Marcela and Jose Bustamante, as Next Friends of D.B. v. Enrique N. Ponte, Jr., M.D. and Pediatrix Medical Services, Inc., 529 S.W.3d 447

Background

D.B., born at ~23–24 weeks weighing 600g, developed severe retinopathy of prematurity (ROP) and is blind in the right eye with severely impaired vision in the left.
Plaintiffs (Bustamantes as next friends) sued the NICU neonatologist (Dr. Ponte), the ophthalmologist (Dr. Llamas), and their employers for negligent screening, delayed diagnosis/treatment, and allegedly inadequate laser therapy; Del Sol (hospital) settled pretrial; Llamas later settled on appeal.
At first eye exam (July 4, 2005) notes were ambiguous (transcription dispute: "complete" vs "incomplete" vascularization); follow-up was scheduled four weeks later contrary to 2001 joint ROP screening guidance and ETROP-informed practice favoring earlier follow-up for high-risk infants.
On August 1 the ophthalmologist found advanced ROP (stage 3, plus disease, vitreous hemorrhage) and recommended immediate laser; treatment occurred August 4 after a 3-day delay and the right retina later detached.
Plaintiff experts (Drs. Good and Phelps) testified that earlier/more frequent screening and earlier laser (pre-threshold) would, more likely than not, have produced a sighted life for D.B.; defense experts disagreed on causation and treatment adequacy.
A jury apportioned liability (45% Ponte, 45% Llamas, 10% hospital) and awarded damages; the court of appeals reversed for legally insufficient causation evidence; the Texas Supreme Court granted review as to Dr. Ponte and his association.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Sufficiency of proximate-cause evidence in medical-malpractice context	Plaintiffs: experts provided reasonable-medical-probability opinions (more likely than not) that delayed/insufficient screening and delayed treatment caused D.B.’s blindness	Ponte: expert opinions were conclusory, relied improperly on epidemiological studies (ETROP/Havner), and failed to show but-for causation for Ponte alone	Court held evidence legally sufficient under the substantial-factor/"reasonable medical probability" standard; causation established as more likely than not attributable to defendants’ combined negligence
Proper causation standard when multiple actors contributed	Plaintiffs: substantial-factor test applies because screening/treatment is collaborative between neonatologist and ophthalmologist	Ponte: court of appeals applied stricter but-for analysis (must show each act alone caused injury)	Court held substantial-factor test controls where multiple actors jointly affect outcome; court of appeals erred applying stringent but-for test
Use of ETROP/epidemiological data and statistical evidence	Plaintiffs: ETROP and other studies, plus clinicians’ case-specific review, support likelihood that earlier treatment reduces unfavorable outcomes	Ponte: Havner requires showing similarity to study population and "doubling of risk"; ETROP cannot show D.B.-specific causation	Court held Havner’s epidemiological rule does not displace clinical expert testimony here; ETROP and other studies were admissible supporting evidence when combined with clinicians’ case-specific analysis
Whether experts’ testimony was impermissibly conclusory or failed to exclude alternative causes	Plaintiffs: experts tied opinions to records, photos, clinical exams, and experience and addressed alternative explanations (risk factors, neurological causes)	Ponte: experts merely opined generally that earlier care would help, without quantifying or ruling out other plausible causes	Court held experts provided factual bases and explained how/why negligence produced the harm; they addressed and rejected alternative causes sufficiently for legal sufficiency review

Key Cases Cited

Havner v. Merrell Dow Pharm., Inc., 953 S.W.2d 706 (Tex. 1997) (epidemiological-study guidance requiring plaintiffs relying solely on studies to show similarity and rule out other causes)
Jelinek v. Casas, 328 S.W.3d 526 (Tex. 2010) (medical-malpractice experts must explain why their causation opinion is medically preferable when facts support multiple equally likely causes)
Kramer v. Lewisville Mem’l Hosp., 858 S.W.2d 397 (Tex. 1993) (plaintiff must show "reasonable medical probability"—more likely than not—that negligence caused injury)
City of Keller v. Wilson, 168 S.W.3d 802 (Tex. 2005) (legal-sufficiency standard: consider evidence in the light most favorable to verdict and allow reasonable inferences)
Providence Health Ctr. v. Dowell, 262 S.W.3d 324 (Tex. 2008) (proximate-cause analysis where acts were too attenuated to be substantial factor in plaintiff’s suicide)
Transcontinental Ins. Co. v. Crump, 330 S.W.3d 211 (Tex. 2010) (expert need not disprove every possible cause absent record evidence of other plausible causes)
Arkoma Basin Expl. Co. v. FMF Assocs., 249 S.W.3d 380 (Tex. 2008) (expert testimony is not conclusory if it includes an explanation tying opinion to facts even if not perfectly articulated)
Wal-Mart Stores, Inc. v. Merrell, 313 S.W.3d 837 (Tex. 2010) (expert must exclude other plausible causes when they are supported by evidence; failure can render opinion speculative)
Park Place Hosp. v. Estate of Milo, 909 S.W.2d 508 (Tex. 1995) (describes "reasonable medical probability" standard for causation)
Del Lago Partners, Inc. v. Smith, 307 S.W.3d 762 (Tex. 2010) (recognizes multiple proximate causes and the role of substantial-factor causation)