OPINION
Opinion By
Nеxion Health at Terrell Manor d/b/a Terrell Manor, Inc. and Brenda J. Allen, R.N. bring this interlocutory appeal of the trial court’s order denying their motion to dismiss this medical malpractice case brought by Chad Taylor, Individually and on Behalf of the Estate of Stephen Taylor, Deceased. See Tex. Civ. Prac. & Rem.Code Ann. § 51.014(a)(9) (Vernon 2008). In their sole issue on appeal, appellants assert the trial court abused its discretion in denying their motion to dismiss because appellee failed to serve an adequate expert report. We affirm the trial court’s order.
BACKGROUND
In 2005, Stephen Taylor (Taylor) was a resident of Terrell Manor nursing home, located in Terrell, Texas. On December 5, 2005, Taylor was admitted to the Terrell Medical Center with pneumonia, and he died there on December 20, at the age of fifty-seven. On December 10, 2007, appel-lee sued the nursing home, as well as two doctors and two nurses who practiced there, alleging their negligent care of Taylor resulted in his death. Appellee also alleged that the nursing home’s negligent failure to provide adequate training and guidelines to its staff led to Taylor’s death.
On April 8, 2008, appellee served appellants with an expert report prepared by Dr. David Seignious, M.D. Appellants moved to dismiss the case, arguing the expert report was inadequate. The trial court found the report was inadequate but granted appellee a thirty-day extensiоn to serve appellants with an adequate expert report by Dr. Seignious. After appellee timely served Dr. Seignious’s amended expert report, appellants filed another motion to dismiss, arguing that the amended report was inadequate. After a hearing, the trial court denied the motion to dismiss, and appellants filed their notice of appeal.
STANDARD OF REVIEW AND APPLICABLE LAW
Chapter 74 of the Texas Civil Practice & Remedies Code requires a plaintiff bringing a health care liability claim to serve the defendants with an expert report not later than the 120th day after the date the original petition was filed. Tex. Civ. Prac. & Rem.Code Ann. § 74.351(a) (Vernon Supp. 2008). If the plaintiff fails to timely serve the expert report, the trial court, on the motion of the defendant, must dismiss the claim and award the defendant reasonable attorney’s fees and costs of court. Id. § 74.351(b). If a motion to dismiss is filed and the court determines that an expert report is deficient, the court may grant one 30-day extension to the plaintiff to cure the deficiency. Id. § 74.351(c). The statute defines “expert report” as follows:
“Expert report” means a written report by an expert that provides a fair summary of the expert’s opinions as of the date of the report regarding [1] applicable standards of care, [2] the manner in which the care rendered by the physician or health care provider failed to meet the standards, and [3] the causal relationship betweеn that failure and the injury, harm, or damages claimed.
Id.
§ 74.351(r)(6) (bracketed numbering added). The court must grant a motion
Appellate courts review the trial court’s determination of the adequacy of an expert report for an abuse of discretion.
Jernigan v. Langley,
An expert report under section 74.351(r)(6) of the Texas Civil Practice and Remedies Code must provide enough information to fulfill two purposes if it is to constitute an objеctive, good-faith effort. The report must inform the defendant of the specific conduct the plaintiff has called into question, and the report must provide a basis for the trial judge to conclude the claims have merit.
See Palacios,
Whether the report complies with the requirements of section 74.351(r)(6) is determined by examining only the report itself.
Bowie Mem. Hosp. v. Wright,
[a] plaintiff need not present evidence in the report as if he were actually litigating the merits. 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,
In this case, appellants assert Dr. Seig-nious’s amended report did not adequately
THE EXPERT REPORT
In the amended expert report, Dr. Seig-nious set out his qualifications, which are not challenged, and the evidence he reviewed in forming his conclusions, which consisted of appellee’s original petition and the medical records from the nursing home, where he resided through Decеmber 4, 2005, and Terrell Medical Center, where he was hospitalized from December 5, 2005 until he died on December 20, 2005.
Dr. Seignious’s report stated the records showed that Taylor “had a history of Schizophrenia NEC; Uncomplicated Vascular Dementia; Hyperthyroidism; Convulsions; Diabetes Mellitus, SYN; Chronic Airway Obstruction and Hypertension.” The report then observed that on November 6, 2005, Taylor had a cough and a cold and was diagnosed with bronchitis. The next day, Taylor requested cough medicine and was given lOcc of Tussin DM. On November 18, Taylor still had a harsh cough. A nurse again diagnosed bronchitis, “and to rule out pneumonia,” she ordered an X-ray “STAT.” For the rest of November, the nurses’ notes record Taylor continuing to have а cough and a temperature varying between 97.2 and 99 degrees. On November 30, Taylor refused to eat breakfast. A nurse ordered an X-ray, and the nurses’ notes observed he had a cough and was in mild distress. The notes also contain the diagnosis of pneumonia. A nurse ordered a daily dose of 750 mg of Levaquin. That evening, Taylor asked to see the nurse and complained that he was still sick. The next day, December 1, Taylor’s cough continued, and he refused to eat supper. On December 4, the nurses’ notes stated Taylor continued to receive Levaquin for pneumonia, had a temperature of 102.2, had decreased energy and endurance, refused to eat supper, “refused supplement,” and had poor fluid intake. The next day, Taylor was taken to Terrell Medical Center in an ambulance. According to the report, “[u]pon arriving at the hospital his oxygen saturation level was 88 and his condition continued over several hours to decline. Terrell Hospital diagnosed Mr. Taylor with pneumonia and his respiratory status was diminished on the right and left.” The assessment of Taylor in the emergency room was acute respiratory failure requiring emergent intubation, septic shock, and disseminated intravascu-lar coagulation and bibasilar aspiration pneumonia, “among other things.” Taylor was taken to the intensive care unit, where “he was intubated for respiratory failure and exhaustion and his condition was guarded.”
The report stated further,
Mr. Taylor’s medical and health condition was deteriorated to a point beyond treatment and reversal and given his prior health complications, proved to be too much to recover from and he subsequently died. Given proper treatment, Mr. Taylor suffered from a treatable condition; however, without proper treatment, such condition can lead to further complications and death, which was the end result for Mr. Taylor in this case.
If the proper treatment would have been rendered by the Nurses in question, and Dr. Satyu, then there was the possibility of a better outcome for Mr. Taylor. In this case, Mr. Taylor was not given that chance. The nurses in question and Dr. Sаtyu failed to orderthe necessary testing, x-rays, follow-up x-rays, oxygenation monitoring, and a proper course of antibiotic therapy, among others, [sic] then Mr. Taylor could have been afforded a better chance of recovery. He was not given that chance by the nurses in question and Dr. Satyu. Because of their negligence, he was allowed to deteriorate to the point that treatment could not reverse the complications from lack of treatment and he died as a result.
The report listed the nurses’ deviations from the applicable standards of care, including:
• failing to diagnose Taylor as a high risk, especially for respiratory problems, due to his pre-existing illnesses;
• failing to evaluate Taylor’s condition properly and to recognize his clinical course deviated from the expected norm;
• failing to monitor and re-evaluate Taylor’s condition appropriately;
• failing to recognize Taylor’s inappropriate response to antibiotic therapy and to intervene appropriately;
• failing to order X-rays and follow-up X-rays and failing to monitor Taylor’s oxygen-saturation level to determine the status of his lungs and whether the antibiotic treatment was working;
• delaying transporting Taylor to the hospital until his condition reached grave levels;
• failing to keep the physician in charge informed of Taylor’s deteriorаting condition, and if the physician refused or failed to provide appropriate treatment, then the nurses were obligated to follow the nursing home’s chain-of-command policy; and
• failing to consult with the physician in a timely manner.
In discussing the last deviation by the nursing staff, the report stated,
In addition to their independent responsibility for patient care, the nurses were obligated to evaluate Mr. Taylor appropriately and present the collected data to Dr. Satyu via the telephone. Nurses serve as patient advocates on behalf of patients in their interactions with hospitals, nursing homes and physicians. If they felt Dr. Satyufs] response to their concerns over the telephone was inadequate, the nurses arе obligated to insist upon the doctor coming to the nursing home facility and evaluating their patient themselves. If the doctor refuses, the nurses are obligated to institute the nursing home’s chain of command policy, appealing to the charge nurse, then nursing supervisors, or other doctors in charge if necessary. Even without appropriate physician response or care, the nurses had an independent responsibility to Mr. Taylor to ensure he was cared for within the standard of care, and specifically, not ignored and not adequately treated for his medical condition without completely eliminating the possibility of pneumonia, respiratory distress, septic shock, among other conditions. If these standards had been followed, the death of Mr. Taylor would not have occurred.
(Emphasis added.) At the conclusion of the section discussing the nursing staff, the report stated,
All of these failures in combination, lead [sic] to the demise of Mr. Taylor. If M.A. Stewart, RN, FNP and B. Allen, LVN or other personnel at Terrell Man- or had not deviated from the standards of care as outlined above, it is within reasonable medical probability that the medical problems and subsequent death of Mr. Taylor could have been made much less likely and may have been prevented. The Defendant nurses[]negligence was a substantial factor in bringing about the deteriorating health of Mr. Taylor and subsequently the death of Mr. Taylor. The Defеndant nurses should have anticipated the danger to Mr. Taylor when he was not adequately treated for pneumonia for over a month and said nurses should have realized this could lead to the deteriorating health of Mr. Taylor and eventually his death.
(Emphasis added.)
Concerning Terrell Manor, the report stated that a nursing home’s nurses are the agents of the nursing home and that Terrell Manor is responsible for errors by its nurses. The report also stated Terrell Manor deviated from the standards of care by:
• failing to provide adequate or competent nursing staff and qualified supervision of the staff;
• failing to provide adequate policies and procedures for the evaluation of patients like Taylоr;
• failing to have policies allowing the nurses to follow a chain of command and insist that a patient be evaluated by a doctor; and
• failing to educate the nursing staff appropriately.
The report stated, “The nurses in questions [sic], as well as, other nursing staff at Terrell Manor did not recognize the symptoms of pneumonia in Mr. Taylor, even given his medical history and did not render the proper treatment to Mr. Taylor, leading to his demise.” The report also indicated, “If there was no chain of command for the nurses to call upon, then this directly contributed to the harms done to Mr. Taylor and his subsequent death.” In discussing the adequacy and competence of the nursing staff, the report stated, “Had Terrell Manor had adequate or competent nursing staff, Mr. Taylor’s health would not have reached such grave conditions and subsequently his death.” “The nurses in question, as employees of the nursing home facility, failed to provide adequate care for Mr. Taylor and failed to follow any proper chain of command, if any, to ensure the proper care of Mr. Taylor, resulting in his demise.”
Dr. Seignious concluded the substantive portion of his report, 1 stating,
If Terrell Manor and their employees, the nurses in question, had not deviated from the standards of care as outlined above, it is probable that the medical problems and subsequent death of Mr. Taylor could have been made much less likely. It is my opinion that Dr. Satyu as the physician for Terrell Manor, deviаted from the standards of care, the nurses in question, that were employed by Terrell Manor and Terrell Manor, as mentioned above which led to the demise of Mr. Taylor, [sic] The Defendant Terrell Manor and its employees, the nurses in question, should have anticipated the danger to Mr. Taylor when he was not adequately treated for pneumonia for over a month and said nurses, and Terrell Manor should have realized this could lead to the deteriorating health of Mr. Taylor and eventually his death.
ANALYSIS
Judicial Admission Concerning Causation
Appellants first argue that appel-lee judicially admitted during the hearing
He clearly states at the bottom of ten, that Terrell Manor and their employees, the nurses in question did not deviate from the standard of care as outlined above, it’s probably that the medical problems and subsequent death of Mr. Taylor could have been much less likely. That’s causation, that’s it. And, this is not based on reasonable medical probability. Now, in depоsition or in summary judgement hearing when they’re arguing about whether or not he states the four reasons and one of them being pneumonia the other being other complications. I think at that point, that’s a separate issue and we don’t know yet because we haven’t done any discovery. We’re just trying to pursuant to the statue [sic], give notice as to what the claims are in the allegations that Terrell Manor failed to do what they should have done and based on that we are here. So, I think that the report is adequate as to that. We don’t have to base it on reasonable medical probability at this stage of the litigation.
Appellants assert this argument constituted a judicial admission that Dr. Seignious did not know the cause of Taylor’s death and that he could not link Taylor’s death to any breach of a standard of care by appellants.
A judicial admission is a formal waiver of proof usually found in pleadings or stipulations.
Mendoza v. Fid. & Guar. Ins. Underwriters, Inc.,
Causation Information Within the Four Corners of the Report
Appellants also assert that, for several reasons, the information within the four corners of Dr. Seignious’s report does not establish causation. We disagree.
Report’s Failure to Identify Exact Cause of Death
In claiming the report is deficient as to causation, appellants focus first on
Appellants cite
Perez v. Daughters of Charity Health Services,
No. 03-08-00200-CV,
Failing to discover declining neurological status timely and failure to report any decline in neurological status delayed treatment ultimately causing death. Failing to ascertain a complete history and physical and formulate a plan of care led to substandard care contributing to the death of Ms. Shap-pee.
Id. at *2. The court of appeals found this causation statement insufficient:
[W]e find the two sentences on the causation element insufficient. The report does not link the hospital’s actions to Shappee’s death or any cause of death. Nor does it identify any specific injury that would have been prevented had the hospital complied with the standаrd of care.
Id. at *4.
In this case, however, the report indicated that with the proper antibiotics, Taylor’s condition was treatable, but the nursing staff failed to observe, or failed to notify the physician, that Taylor was not responding appropriately to the current treatment. Further, the report indicated that Taylor’s treatment was not changed, and his condition deteriorated to the point that the complications from the lack of appropriate treatment resulted in his death. Thus, unlike the report in Perez, the report in this case linked appellants’ alleged failures to follow the applicable standards of care to Taylor’s death.
Appellants also compare this case to
Northeast Medical Center, L.P. v. Crooks,
No. 06-05-00149-CV,
The statute requires that the report “provide a fair summary of the expert’s opinions ... regarding ... the causal relationship” between appellants’ alleged failure to meet the applicable standards of care and Taylor’s death, and we conclude the trial court did not abuse its discretion in deciding the report articulated the required causal relationship, even though the report did not identify the precise cause of Taylor’s death. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6).
Report’s Failure to Address Taylor’s Preexisting Conditions
Appellants аlso argue the report is insufficient because it “made no attempt to address or explain the other numerous conditions from which Mr. Taylor was suffering, and their impact on his ultimate death.” However, as this Court has observed, “Nothing in section 74.351 suggests the preliminary report is required to rule out every possible cause of the injury, harm, or damages claimed, especially given that section 74.351(s) limits discovery before a medical expert’s report is filed.”
Wallace,
We conclude section 74.351 does not require at this early stage of the litigation that the report rule out each preexisting condition as a cause of, or factor contributing to, Taylor’s death. Moreover,
Sufficiency of Report’s Assertions of Untimely Treatment
Appellants argue the report failed to establish a causal link between Taylor’s death and appellee’s claims of “untimely” treatment and other conduct because the report did not define when the treatment would have been “timely” or when the conduct became “untimely.” In support of this argument, appellants rely on
McMenemy v. Holden,
No. 14-07-00365-CV,
Whether the Report’s Conclusions Rise Above Mere Conjecture
Appellants also argue that the conclusions in the report couched in terms of “possibility” and “chance” failed to rise above mere conjecture. In
Bowie Memorial Hospital v. Wright,
In this case, appellants point to similar language in Dr. Seignious’s reрort, including:
• “If the proper treatment would have been rendered by the Nurses in question, and Dr. Satyu, then there was the possibility of a better outcome for Mr. Taylor. In this case, Mr. Taylor was not given that chance.”
• “In addition, it is the possibility that the Terrell Manor has more direct responsibility in this case.... ”
• “If M.A. Stewart, RN, FNP and B. Allen, LVN or other personnel at Terrell Manor had not deviated from the standards of care as outlined above, it is within reasonable medical probability that the medical problems and subsequent death of Mr. Taylor could have been made much less likely and may have been prevented.”
Dr. Seignious’s report, however, contains other statements that are not based on “chance” or “possibility” linking appellants’ alleged deviations from the applicable standards of care to Taylor’s death, including:
• “Given proper treatment, Mr. Taylor suffered from a treatable condition; however, without proper treatment, such condition can lead to further complications and death, which was the end result for Mr. Taylor in this case.”
• “Because of [the nurses’ and Dr. Sa-tyu’s] negligence, he was allowed to deteriorate to the point that treatment could not reverse the complications from lack of treatment and he died as a result.”
• “If these standards had been followed, the death of Mr. Taylor would not have occurred.”
• “The Defendant nurses[’] negligence was a substantial factor in bringing about the deteriorating health of Mr. Taylor and subsequently the death of Mr. Taylor. The Defendant nurses should have anticipated the danger to Mr. Taylor when he was not adequately treated for pneumonia for over a month and said nurses should have realized this could lead to the deteriorating health of Mr. Taylor and eventually his death.”
• “It is my opinion that M.A. Stewart, RN, FNP and B. Allen, LVN, as nurses presumably employed by the Terrell Manor, deviated from the standards of care mentioned above which lead [sic] to the demise of Mr. Taylor.”
• “The specific deviations from the standard of care for Terrell Manor including the following, as well as the fact that Terrell Manor, nursing home nurses work as the agents of the nursing homes [sic]; and therefore the Terrell Manor is responsible for errors by its nurses.”
• “Had Terrell Manor had adequate or competent nursing staff, Mr. Taylor’s health would not have reached such grave conditions and subsequently his death.”
Thus, unlike the expert report in Bowie Memorial Hospital, the report in this case contains statements that rise above mere conjecture and articulate a causal relationship between appellants’ alleged failure to meet the applicable standards of care and Taylor’s death. We conclude these statements permitted the trial court to determine, without abusing its discretion, that Dr. Seignious’s report articulated a causal relationship between appеllants’ alleged failure to meet the applicable standards of care and Taylor’s death.
CONCLUSION
We conclude appellants have not shown the trial court abused its discretion in denying appellants’ motion to dismiss this case for failure to serve an adequate expert report as required by section 74.351 of the civil practice and remedies code. We resolve appellants’ sole issue against them.
We affirm the trial court’s order.
Notes
. The report also included deviations from the applicable standards of care by the physician, Dr. Satyu. Dr. Satyu is not a party to this appeal, so we need not consider the sufficiency of the report as to him.
. The opinion states that 9:40 p.m. was “just over three hours after the vision loss.”
McMenemy,