IN THE
TENTH COURT OF APPEALS
No. 10-12-00396-CV
HILLCREST BAPTIST MEDICAL CENTER,
Appellant
v.
LURETTA DIXON,
Appellee
From the 414th District Court
McLennan County, Texas
Trial Court No. 2011-5158-5
MEMORANDUM OPINION
In three issues, appellant, Hillcrest Baptist Medical Center (”Hillcrest”),
challenges the trial court’s order denying its motion to dismiss health-care-liability
claims filed by appellee, Luretta Dixon. We affirm.
I. BACKGROUND
In this medical-malpractice case, Dixon alleges that an anesthesiologist
improperly placed a central subclavian line in her artery rather than her vein after
surgery at Hillcrest on October 15, 2009. It is undisputed that Nick Manitzas, M.D.,
inserted the line and “performed anesthesia post-operative evaluation” of Dixon on
October 15, 2009. In his evaluation, Dr. Manitzas requested a single-view chest x-ray to
confirm the proper placement of the line. Jose Watson, M.D., read the x-ray and
allegedly failed to note that the line was improperly placed in an artery rather than a
vein. The line remained in use for ten days until a Hillcrest nurse, Stephanie Markum,
R.N., detected and reported that the line had been misplaced. During those ten days,
Dixon suffered seizures, a heart attack, and a stroke.
On October 25, 2009, a second single-view chest x-ray of Dixon was taken.
Jeffrey Charles Gerik, M.D., read and interpreted the second x-ray. Dr. Gerik allegedly
opined that the line inserted by Dr. Manitzas was properly placed. In any event,
Hillcrest medical personnel ceased using the line at this time.
Dixon filed her original petition in this matter on December 22, 2011, asserting
health-care liability claims against Hillcrest, Dr. Watson, and Dr. Gerik.1 Less than 120
days later, on March 23, 2012, Dixon served Hillcrest with two expert reports—one
drafted by Daniel M. Sykes Jr., M.D., and the other drafted by Julius Danziger, M.D. A
week later, Dixon served Hillcrest with a third expert report compiled by Bethany
Autumn Rankin, R.N.
Hillcrest subsequently objected to Dixon’s expert reports, asserting that the
reports were insufficient. Specifically, Hillcrest alleged that none of Dixon’s expert
reports constituted a good-faith effort to comply with section 74.351 of the Texas Civil
1Though the order is not included in the Clerk’s Record, the docket sheet indicates that the trial
court granted Dixon’s motion to dismiss her claims against Dr. Gerik with prejudice.
Hillcrest Baptist Medical Center v. Dixon Page 2
Practice and Remedies Code because the reports did not adequately address: (1) the
standards of care applicable to Hillcrest; (2) the manner in which Hillcrest allegedly
breached those standards of care; and (3) the causal connection between the alleged
breach and Dixon’s injuries. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6) (West
2011). Essentially, Hillcrest argued that Dixon’s tendered expert reports were no
reports at all within the meaning of Chapter 74. See id. And based on these arguments,
Hillcrest moved to dismiss Dixon’s lawsuit.
Dixon responded to Hillcrest’s objections by arguing that the reports should be
read together, as allowed by section 74.351(i). See id. § 74.351(i). Dixon further argued
that her expert reports constituted a good-faith effort to comply with Chapter 74
because the reports called into question the conduct of Hillcrest employees and
provided the trial court with a basis for concluding that her claims have merit. See id. §
74.351(r)(6). In the alternative, Dixon requested a thirty-day extension to cure any
expert-report defects that may have existed. See id. § 74.351(c).
On June 4, 2012, the trial court granted Dixon’s request for a thirty-day extension.
Subsequently, on June 21, 2012, Dixon served Hillcrest with a supplemental expert
report drafted by Dr. Sykes and an additional copy of Nurse Rankin’s expert report.
Hillcrest once again objected to Dixon’s expert reports raising substantially
similar arguments that were raised in its original objections. Hillcrest also moved to
dismiss Dixon’s lawsuit on the basis that she failed to timely file adequate expert
reports addressing her health-care-liability claims.
Hillcrest Baptist Medical Center v. Dixon Page 3
The trial court denied Hillcrest’s motion to dismiss and objections to Dixon’s
expert reports. This accelerated, interlocutory appeal followed. See id. § 51.014(a)(9)
(West Supp. 2012) (authorizing an interlocutory appeal from the denial of “all or part of
the relief sought by a motion under Section 74.351(b), except that an appeal may not be
taken from an order granting an extension under Section 74.351 . . . .”).
II. STANDARD OF REVIEW
We review all rulings related to Section 74.351 of the Texas Civil Practice and
Remedies Code under an abuse of discretion standard. Jelinek v. Casas, 328 S.W.3d 526,
538-39 (Tex. 2010); Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 877
(Tex. 2001). Although we defer to the trial court’s factual determinations, we review
questions of law de novo. Haskell v. Seven Acres Jewish Senior Care Servs., Inc., 363
S.W.3d 754, 757 (Tex. App.—Houston [1st Dist.] 2012, no pet.). A trial court has no
discretion in determining what the law is, which law governs, or how to apply the law.
Poland v. Ott, 278 S.W.3d 39, 45 (Tex. App.—Houston [1st Dist.] 2008, pet. denied). An
abuse of discretion occurs if the trial court fails to correctly apply the law to the facts or
if its acts in an arbitrary or unreasonable manner without reference to guiding rules or
principles. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002); see Haskell, 363
S.W.3d at 757 (citing Petty v. Churner, 310 S.W.3d 131, 134 (Tex. App.—Dallas 2010, no
pet.)).
III. APPLICABLE LAW
A plaintiff who asserts a health-care-liability claim, as defined by Chapter 74,
must provide each defendant physician or health-care provider with an expert report
Hillcrest Baptist Medical Center v. Dixon Page 4
which provides “a fair summary of the expert’s opinions” as of the date of the report
regarding the applicable standards of care, the manner in which the care rendered
failed to meet the applicable standards, and the causal relationship between that failure
and the claimed injury. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a), (r)(6). “‘The
purpose of the expert report requirement is to deter frivolous claims, not to dispose of
claims regardless of their merits.’” Loaisiga v. Cerda, 379 S.W.3d 248, 258 (Tex. 2012)
(quoting Scoresby v. Santillan, 346 S.W.3d 546, 554 (Tex. 2011)).
When a plaintiff timely files an expert report and a defendant moves to dismiss
on the basis that the report is insufficient, the trial court must grant the motion only if
the report does not represent a good-faith effort to meet the statutory requirements.
TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(l). To constitute a good-faith effort, a report
“must discuss the standard of care, breach, and causation with sufficient specificity to
inform the defendant of the conduct the plaintiffs has called into question and to
provide a basis for the trial court to conclude that the claims have merit.” Palacios, 46
S.W.3d at 875; see Wright, 79 S.W.3d at 52.
A report cannot merely state the expert’s conclusions about these elements;
instead, the report must explain the basis of the statements and link the conclusions to
the facts. Wright, 79 S.W.3d at 52; see Jelinek, 328 S.W.3d at 539-40. A report that merely
states the expert’s conclusions about the standard of care, breach, and causation is
deficient. Palacios, 46 S.W.3d at 879. Further, a report that omits any of the statutory
elements is likewise deficient. Id. In determining whether the trial court’s ruling on a
motion to dismiss was correct, we review the information contained within the four
Hillcrest Baptist Medical Center v. Dixon Page 5
corners of the report. Wright, 79 S.W.3d at 53. “The report can be informal in that 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.” Palacios, 46 S.W.3d at 879.
IV. ANALYSIS
A. Dixon’s Original Expert Reports
In its first and second issues, Hillcrest alleges that the trial court abused its
discretion in denying Hillcrest’s motion to dismiss and objections to Dixon’s original
expert reports because the reports failed to address causation. As such, Hillcrest asserts
that Dixon’s expert reports were not a good-faith effort and that the trial court abused
its discretion in granting Dixon an extension to cure her expert reports. We disagree.
In his report, Dr. Sykes stated the following, in relevant part:
I have reviewed the medical records of Luretta Dixon from her
admission to Hillcrest Baptist Medical Center in Waco, Texas, from
October 15, 2009, through November 2, 2009.
....
Dr. Manitzas placed a central subclavian line. In order to confirm proper
placement of the line, Dr. Manitzas requested a single-view chest x-ray. In
my opinion, by requesting the single-view chest x-ray of Ms. Dixon
immediately following her surgery in order to confirm proper placement
of the line, Dr. Manitzas satisfied the applicable standard of care.
Although his placement of the central subclavian line was improper, being
in the artery rather than the vein.
....
Both Dr. Watson and Dr. Gerik failed to note that the central subclavian
line had been improperly placed, being in the artery rather than the vein.
The records confirm that for a period of at least ten (10) days the central
subclavian line was placed in the artery rather than the vein, and during
that ten (10) days the line was used to inject medications, was periodically
Hillcrest Baptist Medical Center v. Dixon Page 6
flushed, and was periodically used for sampling blood. The records
confirm that during the course of this ten (10) days Ms. Dixon suffered
seizures, a myocardial infarction or “heart attack,” and a cerebrovascular
accident or “stroke,” all of which are extremely serious and adverse events
with respect to Ms. Dixon’s physical condition.
Any arterial cannulation, including cannulation of the subclavian
artery, can by itself result in catastrophic consequences for a patient such
as Ms. Dixon. Cannulation of the subclavian artery by Dr. Manitzas with
respect to Ms. Dixon in reasonable medical probability caused or
contributed to the seizures, myocardial infarction or “heart attack,” and
cerebrovascular accident or “stroke” suffered by Ms. Dixon during the
course of her hospitalization. Injection of medications using this line,
blood sampling using this line, and high pressure flushing of this line in
reasonable medical probability also caused or contributed to the seizures,
myocardial infarction or “heart attack,” and cerebrovascular accident or
“stroke” suffered by Ms. Dixon during the course of her hospitalization.
The mere act of frequently injecting medications or flushing the line can
also cause the adverse health events suffered by Ms. Dixon in this case,
and in reasonable medical probability the frequent injecting of
medications and flushing of the line also caused or contributed to the
seizures, myocardial infarction or “heart attack,” and cerebrovascular
accident or “stroke” suffered by Ms. Dixon during the course of her
hospitalization.
(Emphasis in original). Dr. Danziger’s report addressed the standard of care and breach
elements. Nurse Rankin’s report cannot be used to establish the causation prong
required by section 74.351(r)(6). See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(5)(C),
74.403(a); Benish v. Grottie, 281 S.W.3d 184, 205 (Tex. App.—Fort Worth 2009, pet.
denied) (“Consequently, a nurse cannot offer an opinion in a statutory expert report on
causation.”); see also Hillcrest Baptist Med. Ctr. v. Payne, No. 10-11-00191-CV, 2011 Tex.
App. LEXIS 9182, at **20-21 (Tex. App.—Waco Nov. 16, 2011, pet. denied) (mem. op.).
Therefore, the focus of our analysis is on Dr. Sykes’s expert report.
Hillcrest Baptist Medical Center v. Dixon Page 7
When an expert report has not been served within the required time frame
because elements of the report are deficient, the trial court may grant one thirty-day
extension to cure the deficiency. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c); see
also Ortiz v. Patterson, 378 S.W.3d 667, 676 (Tex. App.—Dallas 2012, no pet.). The Texas
Supreme Court has stated the trial court should err on the side of granting additional
time to cure any deficiencies in expert reports. See Scoresby, 346 S.W.3d at 554 (“[T]rial
courts should be lenient in granting thirty-day extensions and must do so if deficiencies
in an expert report can be cured within the thirty-day period.”); Samlowski v. Wooten,
332 S.W.3d 404, 411 (Tex. 2011) (plurality op.) (“A trial court should therefore grant an
extension when a deficient report can readily be cured and deny the extension when it
cannot.”); Ogletree v. Matthews, 262 S.W.3d 316, 320 (Tex. 2007). However, in both
Scoresby and Samlowski, the Court reaffirmed that the thirty-day extension is only
available where the report was timely served but deficient. See Scoresby, 346 S.W.3d at
549; see also Samlowski, 332 S.W.3d at 411.
Based on our reading of Dixon’s originally-submitted expert reports, we cannot
say that Dr. Sykes’s original report was so deficient that the trial court was precluded
from granting a thirty-day extension to cure any defects.2 See Scoresby, 346 S.W.3d at
549-50; but see Ortiz, 378 S.W.3d at 676 (“However, when the expert report is absent,
2 Reports may be considered together in determining whether a health-care-liability claimant
provided a report meeting the statutory requirements. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i)
(West 2011); see also Salais v. Tex. Dep’t of Aging & Disability Servs., 323 S.W.3d 527, 534 (Tex. App.—Waco
2010, pet. denied). 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.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i). But read together, the reports must
provide a “fair summary” of the experts’ opinions. Id. § 74.351(r)(6); see Barber v. Mercer, 303 S.W.3d 786,
791 (Tex. App.—Fort Worth 2009, no pet.); Walgreen Co. v. Hieger, 243 S.W.3d 183, 187 n.2 (Tex. App.—
Houston [1st Dist.] 2007, pet. denied).
Hillcrest Baptist Medical Center v. Dixon Page 8
rather than deficient, the trial court may not consider an extension.”) (citing Samlowski,
332 S.W.3d at 404; Hollingsworth v. Springs, 353 S.W.3d 506, 524 (Tex. App.—Dallas 2011,
no pet.)). We do not believe that the aforementioned language contained in Dr. Sykes’s
original report is so utterly devoid of substantive content as to disqualify the document
as an expert report. See Scoresby, 346 S.W.3d at 549. Furthermore, this report was
served by the statutory deadline and contains the opinion of an individual with
expertise—Dr. Sykes—that the claim has merit and implicates conduct occurring while
Dixon was a patient at Hillcrest. See id. at 557 (“We conclude that a thirty-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.”). Therefore, we cannot
say that Dixon’s expert reports are so deficient as to not constitute an expert report at
all.
And with regard Hillcrest’s complaints about the causation element, we believe
that Dr. Sykes’s timely-served original report is, at worst, deficient and eligible for the
thirty-day extension proscribed in section 74.351(c). See TEX. CIV. PRAC. & REM. CODE
ANN. § 74.351(c); see also Scoresby, 346 S.W.3d at 549. Therefore, based on the foregoing,
we cannot conclude that the trial court abused its discretion in denying Hillcrest’s initial
objections and motion to dismiss and granting Dixon a thirty-day extension to cure any
defects in her expert reports. See Jelinek, 328 S.W.3d at 538-39; Palacios, 46 S.W.3d at 879.
Accordingly, we overrule Hillcrest’s first two issues.
Hillcrest Baptist Medical Center v. Dixon Page 9
B. Dixon’s Supplemental Expert Report
In its third issue, Hillcrest contends that the trial court abused its discretion in
denying Hillcrest’s motion to dismiss and objections to Dixon’s supplemental expert
report because the report does not sufficiently address causation. Once again, we
disagree.
In his supplemental report, Dr. Sykes opined, in relevant part, that:
It is critical to confirm proper placement of a central line (Internal
Jugular or Subclavian) and to confirm placement in the vein rather than
the artery, because placement of the central line (Internal Jugular or
Subclavian) in the artery rather than the vein can result in catastrophic
consequences for the patient, particularly if the line is to be periodically
used to inject medications, and periodically flushed, and periodically used
for sampling blood. Vasospasm, ischemia, thrombosis, embolism, and
cerebral air embolism can all occur as a direct result of radial artery
cannulation, injection, blood sampling, and high pressure flushing.
Similar complications can occur with any arterial cannulation, including
cannulation of the subclavian artery. All of these potential problems and
complications are well known to me and to any reasonably competent
anesthesiologist in Texas . . . .
I have reviewed the medical records of Luretta Dixon from her
admission to Hillcrest Baptist Medical Center in Waco, Texas, from
October 15, 2009, through November 2, 2009. A central subclavian line
was placed immediately following her surgery. Unfortunately, placement
of the central subclavian line was improper, being in the artery rather than
the vein.
....
Any arterial cannulation, including cannulation of the subclavian
artery, can by itself result in catastrophic consequences for a patient such
as Ms. Dixon. Cannulation of the subclavian artery with respect to Ms.
Dixon in reasonable medical probability caused or contributed to the
seizures, myocardial infarction or “heart attack,” and cerebrovascular
accident or “stroke” suffered by Ms. Dixon during the course of her
hospitalization.
Hillcrest Baptist Medical Center v. Dixon Page 10
Injection of medications using this line, blood sampling using this
line, and flushing of this line by the nursing staff at Hillcrest Baptist
Medical Center in reasonable medical probability also caused or
contributed to the seizures, myocardial infarction or “heart attack,” and
cerebrovascular accident or “stroke” suffered by Ms. Dixon during the
course of her hospitalization. The mere act of frequently injecting
medications or flushing of the line can cause the adverse health events
suffered by Ms. Dixon in this case, and in reasonable medical probability
the frequent injecting of medications and flushing of the line also caused
or contributed to the seizures, myocardial infarction or “heart attack,” and
cerebrovascular accident or “stroke” suffered by Ms. Dixon during the
course of her hospitalization. As indicated, all of these actions were
performed, during the course of Ms. Dixon’s hospitalization, by the
nursing staff at Hillcrest Baptist Medical Center (injection of medications
using the line, blood sampling using the line, flushing of the line). By
using the central line to inject medications and to sample blood, and by
flushing the line, the nursing staff at Hillcrest Baptist Medical Center in
reasonable medical probability caused or contributed to the seizures,
myocardial infarction or “heart attack,” and cerebrovascular accident or
“stroke” suffered by Ms. Dixon during the course of her hospitalization.
By failing to observe, detect, and promptly report to a treating physician
the improper placement of the central line (i.e. that the line appeared to be
placed in an artery rather than a vein), the nursing staff at Hillcrest Baptist
Medical Center delayed action to correct the improper placement of the
central line, and this delay—particularly for a period of ten days—in
reasonable medical probability caused or contributed to the seizures,
myocardial infarction or “heart attack,” and cerebrovascular accident or
“stroke” suffered by Ms. Dixon during the course of her hospitalization.
(Emphasis in original). In his report, Dr. Sykes also implicated Dr. Watson’s conduct,
and recounted additional nursing information contained in Nurse Rankin’s report that
also implicated Hillcrest.
Confining our review to the four corners of Dixon’s expert reports, see Wright, 79
S.W.3d at 53, we believe that Dr. Sykes adequately articulated a causal link between
Dixon’s care at Hillcrest and the seizures, heart attack, and stroke she suffered as a
result of the improper placement of the subclavian line. See id. at 52; see also Jelinek, 328
Hillcrest Baptist Medical Center v. Dixon Page 11
S.W.3d at 539-40; Earle v. Ratliff, 998 S.W.2d 882, 890 (Tex. 1999). Accordingly, we
conclude that Dixon’s expert reports informed Hillcrest of the specific conduct called
into question and provided a basis for the trial judge to conclude that the claims have
merit. See Palacios, 46 S.W.3d at 879. And as such, we hold that Dixon’s expert reports
constitute a good-faith effort to comply with section 74.351 of the Texas Civil Practice
and Remedies Code. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6); see also
Palacios, 46 S.W.3d at 875; Wright, 79 S.W.3d at 52. Therefore, based on the foregoing,
we cannot conclude that the trial court clearly abused its discretion in denying
Hillcrest’s objections and motion to dismiss. See Jelinek, 328 S.W.3d at 538-39; Palacios,
46 S.W.3d at 877. We overrule Hillcrest’s third issue.
V. CONCLUSION
Having overruled all three of appellant’s issues, we affirm the order of the trial
court.
AL SCOGGINS
Justice
Before Chief Justice Gray,
Justice Davis, and
Justice Scoggins
Affirmed
Opinion delivered and filed July 11, 2013
[CV06]
Hillcrest Baptist Medical Center v. Dixon Page 12