Cody Bernard, Individually and as Representative of the Estate of Paul Bernard And Blake Bernard v. CHI St. Luke's Health – the Woodlands Hospital Yasir Elhawi, M.D. And Heine Ruiz, M.D. ( 2023 )

Reversed and Remanded and Opinion filed April 13, 2023.
In The
Fourteenth Court of Appeals
NO. 14-22-00270-CV
CODY BERNARD, INDIVIDUALLY AND AS REPRESENTATIVE OF
THE ESTATE OF PAUL BERNARD; AND BLAKE BERNARD, Appellants
V.
CHI ST. LUKE’S HEALTH — THE WOODLANDS HOSPITAL; YASIR
ELHAWI, M.D.; AND HEINE RUIZ, M.D., Appellees
On Appeal from the 215th District Court
Harris County, Texas
Trial Court Cause No. 2020-53620
OPINION
Appellants Cody Bernard, individually and as representative of the Estate of
Paul Bernard, and Blake Bernard (together, the “Bernard Appellants”) filed health
care liability claims stemming from the death of their father. Appellees CHI St.
Luke’s Health — The Woodlands Hospital, Yasir Elhawi, M.D., and Heine Ruiz,
M.D. (collectively, “Appellees”) filed motions to dismiss, challenging the
sufficiency of the Bernard Appellants’ expert report. See Tex. Civ. Prac. & Rem.
Code Ann. § 74.351. The trial court granted the motions, dismissed the Bernard
Appellants’ claims with prejudice, and assessed attorney’s fees. For the reasons
below, we reverse these orders and remand the case for further proceedings.
BACKGROUND
Paul Bernard was admitted to St. Luke’s Hospital on August 24, 2018,
complaining of dysuria and abdominal pain. Paul was treated and discharged from
the hospital on September 3, 2018. Two days later, Paul suffered cardiac arrest
and died.
Approximately two years after Paul’s death, the Bernard Appellants sued
CHI St. Luke’s Health — The Woodlands Hospital,1 Memorial Hermann Health
System, Dr. Heine Ruiz, Dr. Yasir Elhawi, and Dr. Alexander Kadin. Asserting
claims stemming from Paul’s death, the Bernard Appellants alleged that the
defendants failed to assess Paul’s risk of pulmonary embolism and failed to
prescribe or administer necessary prophylactic measures. To support their health
care liability claims, the Bernard Appellants served Appellees with Dr. Mark
Murray’s expert report and curriculum vitae. See Tex. Civ. Prac. & Rem. Code
Ann. § 74.351(a).
Appellees filed individual motions to dismiss challenging the sufficiency of
Dr. Murray’s expert report. The Bernard Appellants filed a response and argued
that Dr. Murray’s expert report satisfied the statutory requirements. In the
alternative, the Bernard Appellants requested a 30-day extension to amend the
1
In its original answer, appellee CHI St. Luke’s Health — The Woodlands Hospital
asserted that the Bernard Appellants incorrectly named St. Luke’s Community Health Services
and CHI St. Luke’s Health Baylor College of Medicine Medical Center as defendants. On
appeal, the Bernard Appellants similarly use “CHI St. Luke’s Health — The Woodlands
Hospital” to refer to these entities. Accordingly, this opinion also uses “CHI St. Luke’s Health
— The Woodlands Hospital” to refer to defendants St. Luke’s Community Health Services and
CHI St. Luke’s Health Baylor College of Medicine Medical Center.
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expert report if the trial court concluded it was deficient.
On April 2, 2021, the trial court signed two orders granting the motions to
dismiss filed by CHI St. Luke’s Health — The Woodlands Hospital and Dr.
Elhawi. The trial court signed a third order on April 23, 2021, granting Dr. Ruiz’s
motion to dismiss the Bernard Appellants’ health care liability claim.
Appellees filed individual motions requesting their attorney’s fees and costs.
The Bernard Appellants filed a motion to reconsider the denial of their request for
a 30-day extension to amend Dr. Murray’s report. The trial court held a hearing on
the motions and, afterwards, signed three separate orders granting each Appellee
their fees and costs. The trial court also denied the Bernard Appellants’ request for
a 30-day extension. The Bernard Appellants timely filed a notice of interlocutory
appeal.2 See id. § 51.014(a)(10).
ANALYSIS
The Bernard Appellants raise three issues on appeal:
1. Dr. Murray’s expert report satisfies the statutory requirements;
2. if Dr. Murray’s report does not satisfy the statutory requirements, any
deficiencies are curable and the trial court abused its discretion by
denying the Bernard Appellants’ request for a 30-day extension to
amend the report; and
3. the evidence is insufficient to support Appellees’ attorney’s fees
awards.
Appellees each filed an individual appellate response. We consider the Bernard
Appellants’ issues below, beginning with the sufficiency of Dr. Murray’s report.
2
Defendants Memorial Hermann Health System and Dr. Alexander Kadin are not parties
to this appeal.
3
I. Overview of Governing Law and Standard of Review
The Texas Medical Liability Act requires that plaintiffs alleging a health
care liability claim serve each defendant with an expert report. See Tex. Civ. Prac.
& Rem. Code Ann. § 74.351(a); Miller v. JSC Lake Highlands Operations, LP,
536 S.W.3d 510, 511 (Tex. 2017) (per curiam). An adequate expert report
provides a “fair summary” of the expert’s opinions regarding (1) the applicable
standards of care, (2) the manner in which the care rendered failed to meet those
standards, and (3) the causal relationship between that failure and the injury, harm,
or damages claimed. Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6); Abshire v.
Christus Health Se. Tex., 563 S.W.3d 219, 223 (Tex. 2018) (per curiam). In
determining whether an expert’s report makes this showing, we are limited to the
report’s four corners. Jelinek v. Casas, 328 S.W.3d 526, 539 (Tex. 2010); C-HCA,
Inc. v. Cornett, 635 S.W.3d 295, 299 (Tex. App.—Houston [14th Dist.] 2021, no
pet.).
“[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, 563 S.W.3d at 223. Accordingly, it is not necessary
that the expert report marshal all the plaintiff’s proof; rather, an expert report is
adequate if it constitutes a “good faith effort” to comply with the statutory
requirements. Id; see also Tex. Children’s Hosp. v. Knight, 604 S.W.3d 162, 169
(Tex. App.—Houston [14th Dist.] 2020, pet. denied). This requires that the report
“(1) inform[] the defendant of the specific conduct called into question, and
(2) provid[e] a basis for the trial court to conclude the claims have merit.” E.D. v.
Tex. Health Care, P.L.L.C., 644 S.W.3d 660, 664 (Tex. 2022) (per curiam). At
this stage of litigation, “whether the expert’s explanations are ‘believable’ is not
relevant to the analysis of whether the expert’s opinion constitutes a good-faith
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effort to comply” with the Texas Medical Liability Act. Id. (emphasis in original).
We review a trial court’s decision to grant or deny a motion to dismiss based
on the adequacy of an expert report for an abuse of discretion. Abshire, 563
S.W.3d at 223. The trial court abuses its discretion if it acts arbitrarily,
unreasonably, or without reference to guiding rules or principles. Bowie Mem’l
Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002) (per curiam). “[U]nder an abuse of
discretion standard, close calls must go to the trial court.” E.D., 644 S.W.3d at
664.
II. Sufficiency of Dr. Murray’s Report
In the trial court, Appellees raised the same challenge to Dr. Murray’s expert
report and alleged that his collective allegations were not specific enough as to
each individual Appellee with regard to the required elements of standard of care,
breach, and causation. With these complaints in mind, we summarize the law
governing each element before examining whether Dr. Murray’s report met these
requirements.
A. A “Good Faith” Effort to Comply with Statutory Requirements
As set out above, an expert report must provide a fair summary of the
expert’s opinions regarding the applicable standards of care, the manner in which
those standards were breached, and the causal relationship between the breach and
the injury, harm, or damages claimed. See Tex. Civ. Prac. & Rem. Code Ann.
§ 74.351(l), (r)(6); Abshire, 563 S.W.3d at 223.
Standard of care is defined by what an ordinarily prudent physician or health
care provider would have done under the same or similar circumstances. Am.
Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 880 (Tex. 2001);
Naderi v. Ratnarajah, 572 S.W.3d 773, 779 (Tex. App.—Houston [14th Dist.]
5
2019, no pet.). Identifying the standard of care is critical because whether a health
care provider breached a duty of care cannot be determined without specific
information about what the defendant should have done differently. Abshire, 563
S.W.3d at 226; Palacios, 46 S.W.3d at 880. However, the stated standard of care
need not be complicated for it to be sufficient. See Baty v. Futrell, 543 S.W.3d
689, 697 (Tex. 2018); see also Patel v. Baker, No. 14-21-00177-CV, 2022 WL
1633802, at *2 (Tex. App.—Houston [14th Dist.] May 24, 2022, pet. denied)
(mem. op.).
An expert report’s sufficiency as to the breach element is tied to its
sufficiency identifying the applicable standard of care. See Baty, 543 S.W.3d at
697. Based on the facts set out in the report, an expert must explain how and why
a health care provider’s breach of the standard of care caused the injury. Columbia
Valley Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453, 459 (Tex. 2017).
Finally, with respect to causation, a conclusory statement is inadequate;
rather, the expert must explain the basis for his statements and link conclusions to
specific facts. E.D., 644 S.W.3d at 664. Satisfying the “how and why” standard
does not require that the expert prove the entire case or account for every known
fact — rather, a report is sufficient if it makes “a good-faith effort to explain,
factually, how proximate cause is going to be proven.” Id. Proximate cause has
two components: (1) foreseeability, and (2) cause-in-fact. Humble Surgical Hosp.,
LLC v. Davis, 542 S.W.3d 12, 23 (Tex. App.—Houston [14th Dist.] 2017, pet.
denied).
When a plaintiff sues more than one health care provider, the expert report
must set forth the standard of care for each provider and explain the causal
relationship between each provider’s individual acts and the claimed injury.
Golucke v. Lopez, 658 S.W.3d 686, 693 (Tex. App.—El Paso 2022, no pet.);
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Kingwood Pines Hosp., LLC v. Gomez, 362 S.W.3d 740, 748 (Tex. App.—
Houston [14th Dist.] 2011, no pet.). This does not mean, however, that an expert
report concluding that multiple health care providers owed the same standard of
care and breached the standard in the same manner can never constitute a good
faith effort at compliance with the Texas Medical Liability Act. See, e.g., Bailey v.
Amaya Clinic, Inc., 402 S.W.3d 355, 367-68 (Tex. App.—Houston [14th Dist.]
2013, no pet.) (expert report was sufficient even though it “applied the same
standard of care” to the doctor and his staff because it “explain[ed] why” that
standard was appropriate). But if an expert report concluding that different health
care providers are collectively negligent is to constitute a good faith effort, it must
explain why, under the particular circumstances, the providers owed the same
standard of care to the plaintiff and breached that duty in the same manner.
Golucke, 658 S.W.3d at 693; see also Tex. Health Harris Methodist Hosp. Fort
Worth v. Biggers, No. 02-12-00486-CV, 2013 WL 5517887, at *6-7 (Tex. App.—
Fort Worth Oct. 3, 2013, no pet.) (mem. op.); Gray v. CHCA Bayshore L.P., 189
S.W.3d 855, 859 (Tex. App.—Houston [1st Dist.] 2006, no pet.).
B. Content of Dr. Murray’s Report
In his expert report, Dr. Murray states that “[t]he same standard of care
applies to all” Appellees. Continuing on, the report explains: “[Appellees] are
grouped together because these healthcare providers owed the same duties to Paul
Bernard — each individual defendant in this group of [Appellees] is held to the
same standard of care.”
Dr. Murray’s report delineates five standards of care collectively applicable
to Appellees:
• Pulmonary embolism protocol: Dr. Murray opines that Appellees
should have adopted a policy to aid in the identification of patients at
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risk for pulmonary embolism.
• Identification of pulmonary embolism risk factors: According to Dr.
Murray, an appropriate pulmonary embolism risk identification policy
would have incorporated the Caprini risk assessment model.3
• Communication between providers: Dr. Murray’s report states that
Appellees were required to “communicate with each other and work
together as a team in rendering medical care to Paul Bernard.” Dr.
Murray identifies three specific components of this communication:
(1) discussing the patient’s chart, test results, and risk factors;
(2) reviewing the patient’s medical history and available medical
records that may indicate pulmonary embolism risk factors; and
(3) communicating a patient’s pulmonary embolism risk factors to all
providers rendering care.
• Proper anticoagulants: According to Dr. Murray, “[o]nce it is
determined that a patient is at high risk for [pulmonary embolism],
proper measures must be taken to reduce the risk both during the stay
and upon discharge.” Dr. Murray identifies two measures that would
have been appropriate to take with respect to Paul’s care:
(1) prescribing and providing a sequential compression device4; and
(2) prescribing and administering chemical anticoagulants, such as
Lovenox at a dosage of 40 milligrams upon discharge and a twice
daily 5 milligram dosage thereafter.
• Patient education: Dr. Murray states that Appellees were required “to
educate their patient Paul Bernard regarding his risk for [pulmonary
embolism] and the life-threatening consequences of developing” a
pulmonary embolism. Specifically, Dr. Murray opines that Appellees
were “required to explain the importance of the proper regimen for
prevention of [pulmonary embolism] and the reasons for the
anticoagulants prescribed.”
With respect to breach, Dr. Murray opines that Appellees collectively failed to
3
Describing the Caprini model, Dr. Murray states that it “assesses a [pulmonary
embolism] risk score based on certain factors,” including advanced age, having been confined to
a bed for at least 72 hours, and sepsis.
4
Dr. Murray describes a sequential compression device as follows: A device “shaped
like sleeves that wrap around the legs and inflate with air one at a time. This imitates walking
and helps prevent blood clots.”
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follow these five standards of care.
Finally, with respect to causation, Dr. Murray describes the following chain
of events:
• Pulmonary embolism is a blockage in one of the pulmonary arteries
found in the lungs. In most cases, a pulmonary embolism is caused by
a blood clot traveling to the lungs from veins in the legs or other parts
of the body.
• “In all reasonable medical probability, a blood clot developed in Paul
Bernard’s legs after he was discharged” by Appellees. The clot
“traveled into his lungs, blocking one of his pulmonary arteries,” and
resulted in “cardiac arrest.”
• “[H]ad [Appellees] followed the appropriate standards of care, this
would not have happened, and Paul would still be alive.” Following
the described standards of care “prevents the formation of blood clots
that travel in the lungs.”
• Specifically, the standards of care “act collectively to preclude
clotting of the blood. The mechanical coagulation methods imitate
walking and ensure that blood is constantly flowing, which precludes
development of clots. The chemical methods reduce the likelihood
that blood will clot. Combined these anticoagulant methods
significantly reduce and can eliminate the development of” pulmonary
embolisms.
• Appellees’ “failure to follow these standards of care proximately
caused Paul’s death.” If Appellees had adhered to the appropriate
standards of care, “in all reasonable medical probability Paul would
not have developed the [pulmonary embolism] that ultimately led to
his death.”
C. Application
We conclude that Dr. Murray’s report provides a fair summary of his
opinions regarding the applicable standards of care, how those standards were
breached, and the causal relationship between the breaches and Paul’s death. See
Tex. Civ. Prac. & Rem. Code Ann. § 74.351(l), (r)(6); Abshire, 563 S.W.3d at 223.
9
Linking conclusions to specific facts, Dr. Murray adequately explained how and
why the alleged breaches caused Paul’s death.
However, the trial court reasonably could have concluded that Dr. Murray’s
expert report failed to adequately tie his conclusions regarding these elements to
the actions of individual health care providers. See Golucke, 658 S.W.3d at 693;
Kingwood Pines Hosp., LLC, 362 S.W.3d at 748. In his report, Dr. Murray states
that the collective allegations are appropriate “because these healthcare providers
owed the same duties to Paul Bernard.” But Dr. Murray’s expert report fails to
explain why these different health care providers owed the same duties and
breached them in the same manner. See Golucke, 658 S.W.3d at 693; Tex. Health
Harris Methodist Hosp. Fort Worth, 2013 WL 5517887, at *6-7; Gray, 189
S.W.3d at 859. This explanation is particularly necessary when, as here, the
Bernard Appellants have asserted claims against different types of health care
providers: a hospital and two physicians.
A similarly-deficient report was examined in Golucke, in which the plaintiff
filed suit after she fell while recuperating from knee replacement surgery. 658
S.W.3d at 690. The plaintiff asserted health care liability claims against multiple
defendants, including five health care entities and four individual nurses. Id. The
plaintiff’s expert report identified multiple standards of care that were breached,
including completion of a thorough nursing assessment of the level of fall risk,
provision of a safe environment to prevent accidents, and use of a “wheelchair” or
“bed” alarm to alert nurses to assist the plaintiff if she attempted to get out of bed.
Id. at 694-95. The expert report applied these standards of care uniformly across
all the defendants without specifying which actions or omissions each entity or
nurse was responsible for. Id. at 694, 700.
One of the nurses challenged the sufficiency of the expert report and the trial
10
court denied her motion to dismiss. Id. at 691. Reversing the denial, the appellate
court held that the report lacked “an explanation on what [the nurse] herself did
wrong or failed to do, such as to indicate how she breached the standard of care
applicable to her individually.” Id. at 696. Continuing on, the court noted that the
expert report “fails to explain, identify, or describe any specific conduct that is
attributable to [the nurse]. Instead, the report leaves us attempting to infer which
individual was involved in the breaches identified.” Id. at 697. “Without
explaining what [the nurse] was doing, what she should have been doing, or how
she was connected to the care and monitoring of [the plaintiff], the report fails to
make a causal connection between any individual act of [the nurse] and [the
plaintiff’s] injury sustained from falling.” Id. at 700; see also Tex. Health Harris
Methodist Hosp. Fort Worth, 2013 WL 5517887, at *6 (the expert’s report was
inadequate because it “fail[ed] 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”).
Here too, Dr. Murray’s expert report did not specifically implicate any
individual Appellee’s acts or omissions in the care provided to Paul. Likewise, in
its discussion of the applicable standards of care, breaches, and causal relationship,
the expert report only refers to the Appellees collectively — it does not assign any
specific acts or omissions to any individual Appellee. Nor does the report explain
why it is appropriate to group the Appellees in this manner, leaving us to speculate
as to each Appellee’s involvement. See Golucke, 658 S.W.3d at 694-700.
Because of this deficiency with respect to the collective allegations in Dr.
Murray’s report, the trial court did not abuse its discretion in granting Appellees’
motions to dismiss the Bernard Appellants’ claims. See E.D., 644 S.W.3d at 664;
Abshire, 563 S.W.3d at 223. We overrule the Bernard Appellants’ first issue.
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III. Entitlement to a 30-Day Extension
In their second issue, the Bernard Appellants assert that any deficiencies in
Dr. Murray’s expert report are curable and, therefore, the trial court abused its
discretion by denying their request for a 30-day extension to amend the report.
If the plaintiff asserting a health care liability claim timely serves an expert
report and the trial court concludes the report represents an objective good faith
effort to comply with the applicable statutes but nevertheless is deficient in some
way, the trial court has the discretion to grant the plaintiff one 30-day extension to
cure the deficiencies. Tex. Civ. Prac. & Rem. Code Ann. § 74.351(c). We review
the trial court’s ruling on a motion for an extension to cure a deficient expert report
for an abuse of discretion. Henry v. Kelly, 375 S.W.3d 531, 535 (Tex. App.—
Houston [14th Dist.] 2012, pet. denied).
The trial court “must grant an extension if a report’s deficiencies are
curable.” Columbia Valley Healthcare Sys., L.P., 526 S.W.3d at 461. The Texas
Supreme Court established a “minimal” standard for determining whether a
deficient report is curable: “a 30-day extension to cure deficiencies in an expert
report may be granted if the report is served by the statutory deadline, if it contains
the opinion of an individual with expertise that the claim has merit, and if the
defendant’s conduct is implicated.” Scoresby v. Santillan, 346 S.W.3d 546, 557
(Tex. 2011); Univ. of Tex. Health Sci. Ctr. at Houston v. Joplin, 525 S.W.3d 772,
782 (Tex. App.—Houston [14th Dist.] 2017, pet. denied); see also Samlowski v.
Wooten, 332 S.W.3d 404, 416 (Tex. 2011) (Guzman, J., concurring) (“[i]n order to
preserve the highest number of meritorious claims, trial courts should err on the
side of granting claimants’ extensions”); Samlowski, 332 S.W.3d at 411 (plurality
op.) (agreeing with the concurrence that the trial court should err on the side of
granting an extension).
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Here, Dr. Murray’s report satisfies this standard. First, the report was served
by the statutory deadline. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(a).
Second, the report contains the opinion of a person with expertise that the claim
has merit, i.e., Dr. Murray. Dr. Murray’s curriculum vitae (which was included
with the expert report) demonstrates that he has expertise in the areas implicated by
the facts of this case. Dr. Murray received his medical degree in 1993 and
completed a residency in internal medicine. Dr. Murray spent five years serving as
an active-duty physician in the United States Air Force and, thereafter, worked as
an emergency room physician. Dr. Murray currently is affiliated with several
health care groups and health systems. This experience provides a foundation
sufficient to support Dr. Murray’s opinion that the Bernard Appellants’ health care
liability claims have merit. See Scoresby, 346 S.W.3d at 557.
Finally, Dr. Murray’s report implicates Appellees’ conduct in Paul Bernard’s
death. As set forth above, Dr. Murray’s report provides a fair summary of his
opinions regarding the applicable standards of care, the alleged breaches of those
standards, and the consequences thereof. Dr. Murray sufficiently explained how
and why the alleged breaches caused Paul Bernard’s death. The only deficiency in
Dr. Murray’s report stems from the collective nature of the allegations — Dr.
Murray failed to specifically assign certain acts or omissions to the individual
Appellees or explain why they are subject to the same standards. See Golucke, 658
S.W.3d at 694-700. But this deficiency does not render his report incurable. See
Scoresby, 346 S.W.3d at 557.
Given the Supreme Court’s minimal standard and the Bernard Appellants’
objective good faith efforts to comply with the statutory requirements governing
expert reports, we cannot say that Dr. Murray’s expert report was incurable.
Therefore, we hold that the trial court abused its discretion by denying the Bernard
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Appellants’ request for a 30-day extension to cure Dr. Murray’s expert report. See,
e.g., Guerrero v. Karkoutly, No. 13-20-00053-CV, 2020 WL 5056511, at *3-4
(Tex. App.—Corpus Christi Aug. 27, 2020, pet. denied) (mem. op.); Curnel v.
Houston Methodist Hosp.-Willowbrook, 562 S.W.3d 553, 569-70 (Tex. App.—
Houston [1st Dist.] 2018, no pet.); Wheeler v. Methodist Richardson Med. Ctr.,
No. 05-17-00332-CV, 2017 WL 6048153, at *3-4 (Tex. App.—Dallas Dec. 7,
2017, pet. denied) (mem. op.). We sustain the Bernard Appellants’ second issue.
IV. Attorney’s Fees
When a plaintiff fails to file an expert report as to a health care liability
defendant, the trial court has no discretion but to dismiss the claims asserted
against that defendant with prejudice and award the defendant costs and attorney’s
fees. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(b). Here, after the trial
court granted Appellees’ motions to dismiss, it awarded each Appellee its costs and
fees.
Because we conclude the trial court abused its discretion by denying the
Bernard Appellants’ request for a 30-day extension, we likewise reverse the trial
court’s orders awarding Appellees their costs and fees. We sustain the Bernard
Appellants’ third issue.
CONCLUSION
We reverse the trial court’s (1) April 2, 2021 orders granting the motions to
dismiss filed by CHI St. Luke’s Health — The Woodlands Hospital and Dr.
Elhawi, and (2) April 23, 2021 order granting Dr. Ruiz’s motion to dismiss. We
also reverse the trial court’s denial of the Bernard Appellants’ request for a 30-day
extension to cure their expert report and its orders awarding Appellees their fees
14
and costs. We remand this case with instructions for the trial court to grant a 30-
day extension under Texas Civil Practice and Remedies Code section 74.351(c).
/s/ Meagan Hassan
Justice
Panel consists of Justices Bourliot, Hassan, and Poissant.
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