NUMBER 13-17-00621-CV
COURT OF APPEALS
THIRTEENTH DISTRICT OF TEXAS
CORPUS CHRISTI – EDINBURG
FERNANDO JAVIER OTERO, M.D., Appellant,
v.
RACHEL SALDIVAR AND ROBERTO
GARZA, JR., INDIVIDUALLY AND AS
NEXT FRIENDS OF XXX, A MINOR, Appellees.
On appeal from the 370th District Court
of Hidalgo County, Texas.
MEMORANDUM OPINION
Before Justices Rodriguez, Contreras, and Hinojosa
Memorandum Opinion by Justice Contreras
In this interlocutory appeal, appellant Fernando Javier Otero, M.D., challenges the
denial of his motion to dismiss the health care liability claim of appellees Rachel Saldivar
and Roberto Garza Jr., individually and as next friends of P.G.,1 a minor. See TEX. CIV.
PRAC. & REM. CODE ANN. §§ 51.014(a)(9); 74.351(a), (b) (West, Westlaw through 2017
1st C.S.). By one issue, Dr. Otero argues that the trial court should have dismissed the
health care liability claim because the plaintiffs’ expert report did not adequately address
proximate causation. We affirm.
I. BACKGROUND
On October 8, 2014, Rachel was admitted emergently at 11:45 p.m. to Doctors
Hospital at Renaissance in Edinburg, Texas. Rachel was over thirty-seven weeks
pregnant with P.G. and complained of vaginal bleeding and lower right abdominal pain.
Rachel, however, was not evaluated in person by a physician until almost nine hours after
her admission. During that time, P.G.’s vitals deteriorated and indicated that P.G. was
not receiving enough oxygen. P.G. was eventually delivered via cesarean section at
9:22 a.m. on October 9, 2014, but without a heartbeat, and she was successfully
resuscitated. Subsequent MRI scans showed P.G. sustained hypoxic ischemic
encephalopathy (HIE)—a severe, permanent brain injury caused by a lack of oxygen and
blood flow. P.G. spent forty-six days after birth in neonatal intensive care and was
diagnosed with HIE, epilepsy, bronchiolitis, and uncontrolled seizures.
Two physicians oversaw Rachel’s care from the time she was admitted at the
hospital until P.G. was delivered: (1) Carlos Eduardo Puig, M.D., who was the
obstetrician and gynecologist responsible for Rachel from the beginning of her emergency
care on October 8, 2014 until early the next morning; and (2) Dr. Otero, an obstetrician
and gynecologist, who was called to evaluate Rachel at 8:19 a.m. on October 9, 2014,
1 The plaintiffs’ lawsuit is styled “Rachel Saldivar and Roberto Garza, Jr., individually and as next
friends of XXX, a minor.” However, we will refer to the baby by her initials throughout this memorandum
opinion.
2
evaluated her at 8:31 a.m., and subsequently performed a cesarean section on her at
9:22 a.m. Three hospital nurses also looked after Rachel during this time.
Rachel and Roberto filed suit against Doctors Hospital at Renaissance, Dr. Puig,
and Dr. Otero for negligence resulting in the injuries suffered by P.G.; however, only their
claim against Dr. Otero is relevant for the purpose of this appeal.
Pursuant to the Texas health care liability statute, Rachel and Roberto served
Dr. Otero with an expert report authored by Mark D. Akin, M.D. See id. § 74.351(a).
Dr. Otero filed objections to Dr. Akin’s report and a motion to dismiss, and Rachel and
Roberto then obtained leave from the trial court to file an amended expert report.
According to Dr. Akin’s amended report, Dr. Otero should have ordered a cesarean
section immediately at 8:20 a.m. when he was informed over the phone of Rachel’s
condition and P.G.’s vitals. Instead, Dr. Otero examined Rachel at her bedside at
8:31 a.m. and decided to perform an elective surgery on another patient before
performing Rachel’s cesarean section at 9:22 a.m. Dr. Akin explains Dr. Otero’s actions
resulted in a delay of thirty-two minutes in P.G.’s delivery, after accounting for the thirty-
minute window it takes from “decision to incision.”2 Dr. Otero again filed objections to
Dr. Akin’s report, which were overruled, and a second motion to dismiss, which was
denied. This interlocutory appeal followed.
II. STANDARD OF REVIEW
We review a trial court’s decision on the sufficiency of an expert’s report and on a
motion to dismiss under the expert-report rule for an abuse of discretion. Jelinek v.
2 Dr. Otero disputes that P.G’s delivery was delayed by thirty-two minutes and instead contends it
was delayed by nineteen minutes. Dr. Otero’s argument is premised on the idea that the delay is measured
from the time when he examined Rachel by her bedside, as opposed to when he first received the phone
call informing him of Rachel’s and P.G.’s conditions. As we explain below, Dr. Akin’s report explains that
the decision to perform a cesarean section should have been made when Dr. Otero was first informed of
the situation during the phone call.
3
Casas, 328 S.W.3d 526, 539 (Tex. 2010); see also TEX. CIV. PRAC. & REM. CODE ANN.
§ 74.351. A court abuses its discretion if it acts in an arbitrary or unreasonable manner
and without reference to any guiding rules or principles. Crawford v. XTO Energy, Inc.,
509 S.W.3d 906, 911 (Tex. 2017). “When reviewing matters committed to the trial court’s
discretion, ‘the reviewing court may not substitute its judgment for that of the trial court.’”
Miller v. JSC Lake Highlands Operations, LP, 536 S.W.3d 510, 512–13 (Tex. 2017)
(quoting Walker v. Packer, 827 S.W.2d 833, 839 (Tex. 1992)).
III. APPLICABLE LAW
Section 74.351 of the Texas Civil Practice and Remedies Code provides that a
plaintiff in a health care liability suit must serve the defendant with a statutorily-compliant
expert report accompanied by the expert’s curriculum vitae. See TEX. CIV. PRAC. & REM.
CODE ANN. § 74.351. If a plaintiff fails to do so within 120 days of filing suit, the statute
provides that the trial court must dismiss the claim with prejudice on the defendant’s
motion. See id. § 74.351(a), (b)(2). The report must include the expert’s opinion on each
of the three elements: standard of care, breach, and causation. Jelinek, 328 S.W.3d at
539. The goal is “to deter frivolous lawsuits by requiring a claimant early in litigation to
produce the opinion of a suitable expert that his claim has merit.” Columbia Valley
Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453, 460 (Tex. 2017) (quoting Scoresby
v. Santillan, 346 S.W.3d 546, 552 (Tex. 2011)). Therefore, “[a]n expert report . . . is a low
threshold a person [bringing a claim] against a health care provider must cross merely to
show that his claim is not frivolous.” Loaisiga v. Cerda, 379 S.W.3d 248, 264 (Tex. 2012).
“A trial court must sustain a challenge to a report’s adequacy if the report does not
represent an objective good faith effort to provide a fair summary of the applicable
standard of care, the defendant’s breach of that standard, and how that breach caused
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the patient’s harm.” Miller, 536 S.W.3d at 513 (internal quotation marks omitted); see
TEX. CIV. PRAC. & REM. CODE. ANN. § 74.351(l), (r)(6). “A good-faith effort must ‘provide
enough information to fulfill two purposes: (1) it must inform the defendant of the specific
conduct the plaintiff has called into question, and (2) it must provide a basis for the trial
court to conclude that the claims have merit.’” Miller, 536 S.W.3d at 513 (quoting Bowie
Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002) (per curiam)). All information
needed for this inquiry is found within the four corners of the expert report, which need
not marshal all of the plaintiff’s proof. Jelinek, 328 S.W.3d at 539 (quoting Am.
Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 879, 879 (Tex. 2011)).
As to the causation element, the expert report must explain how and why the
healthcare provider’s breach proximately caused the plaintiff’s injury. Zamarripa, 526
S.W.3d at 460. “Unquestionably, a plaintiff asserting a health care liability claim based
on negligence, who cannot prove that her injury was proximately caused by the
defendant’s failure to meet applicable standards of care, does not have a meritorious
claim.” Id. There is no requirement that the expert use any particular words, such as
“proximate cause,” “foreseeability,” or “cause in fact”; however, the expert’s explanation
of the plaintiff’s injuries must be more than a mere conclusory assertion. See id. Thus,
“the expert must explain the basis of his statements to link his conclusions to the facts.”
Id. (quoting Earle v. Ratliff, 998 S.W.2d 882, 890 (Tex. 1999)); Jelinek, 328 S.W.3d at
539. In our inquiry, we are precluded from filling gaps in a report by drawing inferences
or guessing as to what the expert likely meant or intended. Fulp v. Miller, 286 S.W.3d
501, 509 (Tex. App.—Corpus Christi 2009, no pet.).
IV. DR. AKIN’S EXPERT REPORT
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By his sole issue, Dr. Otero makes several arguments in support of his claim that
Dr. Akin’s expert report does not adequately address proximate causation. Dr. Otero,
however, does not dispute the applicable standards of care or breaches thereof as
articulated by Dr. Akin. Thus, to aid our analysis and provide context for Dr. Otero’s
argument on appeal, we quote portions of Dr. Akin’s amended report.
A. Standard of Care and Breach of Standard of Care
Dr. Akin’s amended report states:
Dr. Otero was informed by nursing staff of [Rachel’s] admission for
abnormal vaginal bleeding. He had a duty to evaluate the patient with a
pelvic exam and diagnose the cause of her bleeding. His failure to do so
was a violation of the standard of care.
The Standard of Care requires that the physician adequately insure fetal
well-being based upon interpretation of fetal monitoring. This would require
Dr. Otero to recognize:
1) Loss of heart rate variability
2) bradycardia
3) Repetitive late decelerations
His failure to assess fetal well-being was a violation of the standard of care.
The Standard of Care requires that a patient with abnormal uterine bleeding
and evidence of a fetus [in] jeopardy be delivered emergently. His failure
to recognize fetal jeopardy and his lack of due diligence to stay with the
patient and deliver her as soon as possible violates the standard of care.
At 8:20 am Dr. Otero knew that [Rachel] was in active labor with category
III fetal heart rate tracings. He also knew that Rachel had vaginal bleeding
with contractions and high blood pressure readings. Despite this
knowledge, at 8:20 am Dr. Otero did not make any orders or tell the nurses
to be prepared for an emergency C-Section.
At 8:31 am Dr. Otero was at Rachel’s bedside. At this point, it was the
standard of care for Dr. Otero to examine Rachel and recognize the
following:
• The baby has minimal variability and [decelerations], which are
category III tracings.
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• At 08:17 Ochoa, RN starts IV bolus, oxygen 10 liters non rebreather
and turns the patient to the left lateral position. These nursing
interventions to restore oxygenation failed and the baby continued to
have category III tracings.
• The baby is in breech position.
• Rachel has vaginal bleeding.
• Rachel’s contractions began at 3 am the prior day.
• Rachel had a previous C-Section.
• Rachel has insulin dependent diabetes.
• Rachel has pregnancy induced hypertension.
• Rachel has a history of pre-eclampsia.
• Rachel’s blood pressure was 167/98 at 07:30.
Dr. Otero should have recognized that there were category III fetal heart
rate tracings, which are abnormal and convey increased risk for fetal
acidemia. These tracings are associated with increased risk of neonatal
encephalopathy, cerebral palsy, and neonatal acidosis. Considering the
tracings and the failed nursing intervention, and [Rachel’s] conditions listed
above, the standard of care required immediate delivery. Dr. Otero had an
opportunity to recognize the deteriorating fetal status at 0831, but decided
to perform an elective surgery on another patient prior to performing
[Rachel’s] Cesarean section. Dr. Otero should have performed an
immediate C-Section on [Rachel] before the elective surgery. [Rachel’s]
condition and her baby’s condition required immediate delivery. Since the
prior nursing interventions failed, the only way to restore adequate oxygen
to the baby was through delivery via C-Section. Every minute that the baby
does not receive adequate oxygen causes more brain damage. Elective
surgeries are not emergencies. Elective surgeries never take priority over
situations where the mother in active labor is bleeding[], has irregular
contractions, hypertension, diabetes, and high blood pressure and the baby
has strong evidence of fetal distress. The decision to perform the elective
surgery first, and deliver [Rachel’s] baby later, was below the standard of
care.
B. Proximate Causation
Proximate cause has two components: (1) cause-in-fact and (2) foreseeability.
Zamarripa, 526 S.W.3d at 460. Dr. Otero first argues Dr. Akin’s report is deficient as to
the “cause-in-fact” element. “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
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would not have occurred.” Id. (quoting Rodriguez-Escobar v. Goss, 392 S.W.3d 109, 113
(Tex. 2013) (per curiam)). “This is the causal relationship between breach and injury that
an expert report must explain to satisfy” the Texas health care liability act. Id.
Dr. Otero argues that the damage to P.G.’s brain had already occurred prior to his
decision not to immediately perform a cesarean section, and, therefore, his delay could
not have been a “substantial factor” in bringing about the harm. We find this argument
unpersuasive. In his amended report, Dr. Akin notes that:
If Dr. Otero had not breached the standard of care, [P.G.] would have been
delivered sooner (he was notified at 8:20 but did not deliver[] the baby until
over an hour later) thus substantially decreasing her injuries. Dr. Otero
should have ordered a C-Section at 08:20 am when he was notified of
Rachel and the baby’s conditions. Decision to incision is maximum of 30
minutes. Dr. Otero should have ordered a C-Section at 08:20 am.
Therefore, if Dr. Otero ordered a STAT C-Section at 08:20 then the baby
would have been born by 08:50. However, since Dr. Otero breached the
standard of care by failing to recognize the fetal distress and delayed
delivering the baby until 09:22 am, the baby suffered at least an extra 32
minutes of fetal distress from lack of adequate oxygen. I believe within
reasonable medical probability that each minute of further delay before
09:22 until [P.G.] was delivered increased the extent of her permanent
injuries.
...
Category III tracings were present on the fetal monitor strip before taking
[Rachel] to the OR for cesarean section, and the absence of a fetal heart
beat at birth, within reasonable medical probability, confirms that the fetal
condition was worsening during the delay in delivery. Thus, Dr. Otero’s
unreasonable 32 minute delay caused substantial brain damage to the
baby, which were confirmed by radiological manifestations of HIE after birth.
The actions and inactions of Dr. Otero were a proximate causative effect of
[P.G.’s] brain injury (HIE).
Dr. Akin explains how Dr. Otero’s delay resulted in a prolonged deprivation of oxygen to
P.G. and how prompt treatment would have immediately provided P.G. with the oxygen
needed to prevent further injury to her brain. Therefore, according to Dr. Akin’s expert
opinion, the extent of P.G.’s brain injury would not have occurred but for Dr. Otero’s failure
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to act. See Zamarripa, 526 S.W.3d at 460. Furthermore, even if we were to assume that
Dr. Akin’s opinion could later be proved incorrect, it does not make his report inadequate.
See Fagadau v. Wenkstern, 311 S.W.3d 132, 139 (Tex. App.—Dallas 2010, no pet.) (“The
possibility that facts may later be discovered that prove Dr. Goldman’s opinions on
causation are incorrect is not a basis for holding the report insufficient under section
74.351.”); Methodist Hosp. v. Shepherd-Sherman, 296 S.W.3d 193, 200 (Tex. App.—
Houston [14th Dist.] 2009, no pet.) (noting that although discovery could later prove that
a doctor’s opinion is wrong, that is not a basis for holding report insufficient under chapter
74).
Dr. Otero also argues that his decision could not have been a “substantial factor”
in the injury because Dr. Puig and the hospital were the parties who caused the majority
of the harm suffered by P.G. However, contrary to Dr. Otero’s argument, there can be
more than one proximate cause of an injury. See Lee Lewis Constr., Inc. v. Harrison, 70
S.W.3d 778, 784 (Tex. 2001) (noting that there may be more than one act or omission
that is the proximate cause of an injury); Rodriguez v. Moerbe, 963 S.W.2d 808, 819 (Tex.
App.—San Antonio 1998, pet. denied) (“Proximate cause does not necessarily mean the
last cause, or the act immediately preceding the injury.”); see also Taylor v. Christus
Spohn Health Sys., 169 S.W.3d 241, 244 (Tex. App.—Corpus Christi 2004, no pet.)
(noting that, in a health care liability suit against multiple defendants, an expert report
must provide an explanation of how each defendant specifically breached the standard
and how that breach caused or contributed to the cause of injury). Thus, even if part of
the injury had occurred prior to Dr. Otero’s involvement, Dr. Akin’s report makes it clear
that Dr. Otero’s delay resulted in part of the injury sustained by P.G., and “but for” his
decision to postpone the cesarean section, P.G. would not have suffered some of her
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injury. See Zamarripa, 526 S.W.3d at 460. Dr. Otero urges us to look at Dr. Akin’s
original report to find that Dr. Akin initially blamed Dr. Puig and the nurses for P.G.’s injury.
While Dr. Akin’s first report may have been deficient as to causation in regard to Dr. Otero,
neither the original report nor the amended report indicate that Dr. Puig’s and the
hospital’s failures were the sole cause of P.G.’s injury. Accordingly, we reject Dr. Otero’s
arguments that Dr. Akin’s report was deficient as to the cause-in-fact element.
Next, Dr. Otero argues that Dr. Akin’s report does not rule out any other possible
causes for P.G.’s injury and diagnoses. However, an expert does not need to disprove
or discredit every possible cause and need not speculate about other possible unknown
causes and then disprove them. See Bustamante v. Ponte, 529 S.W.3d 447, 457 (Tex.
2017); Nexion Health v. Taylor, 294 S.W.3d 787, 797 (Tex. App.—Dallas 2009, no pet.).
Thus, this argument is also without merit.
Finally, Dr. Otero argues that Dr. Akin’s report is conclusory and fails to adequately
explain how his delay in performing a cesarean section proximately caused P.G.’s injury.
Here, Dr. Akin explains in scientific principles how the delay by Dr. Otero in performing
Rachel’s cesarean section resulted in some of the harm suffered by P.G. In addition to
the text previously quoted, Dr. Akin explains that a baby is dependent upon its mother for
oxygen, and the longer the baby goes without adequate oxygen, the more brain cells die.
He also explains the medical conditions and symptoms exhibited by Rachel and P.G. and
how they indicated that P.G. was suffering from a life-threatening lack of oxygen. He
states in his report “[e]very minute that the baby does not receive adequate oxygen
causes more brain damage.” Dr. Akin goes on to state, “[t]herefore, in reasonable medical
probability, the 32 minute delay was more time wherein the baby lacked adequate
oxygen, which caused more brain cells to die”, and “I believe within reasonable medical
10
probability that each minute of further delay before 09:22 until [P.G.] was delivered
increased the extent of her permanent injuries.” Thus, Dr. Akin explained the basis of his
statements and linked his conclusions to the facts. See Zamarripa, 526 S.W.3d at 460.
The trial court could have reasonably concluded that the detailed opinions in the
report informed Dr. Otero of the conduct called into question and provided a basis to show
the claim’s merit. See Jelinek, 328 S.W.3d at 529. It was not arbitrary or unreasonable
for the trial court to conclude that the report constituted a good faith effort to provide a fair
summary of the expert’s opinion on causation. See id.; see also Crawford, 509 S.W.3d
at 911. Therefore, we find no abuse of discretion in the denial of Dr. Otero’s motion to
dismiss. See Jelinek, 328 S.W.3d at 539.3
We overrule Dr. Otero’s sole issue.
V. CONCLUSION
We affirm the ruling of the trial court.
DORI CONTRERAS
Justice
Delivered and filed the
24th day of May, 2018.
3Because we find no abuse of discretion in the trial court’s denial of Dr. Otero’s motion to dismiss,
we need not address Dr. Otero’s argument that the trial court erred in not awarding him attorney’s fees
upon the dismissal of the claim. See TEX. R. APP. P. 47.4.
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