OPINION
' This case involves a health care liability claim subject to the Texas Medical Liability Act. See Tex. Civ. Peac. & Rem.Code Ann. §§ 74.001-.507. Sandra Bernal and the other plaintiffs sued Tenet Hospitals Limited d/b/a Sierra Medical Center (Tenet) and others over the death of Margarita Medrano. The trial court denied Tenet’s challenge to the preliminary expert reports served by the plaintiffs. The issue in this interlocutory appeal is the adequacy of those expert reports. We reverse and remand.
BACKGROUND 1
On August 26, 2011, Dr. Hector Flores performed surgery at Sierra Medical Center to.repair the mitral valve in Margarita Medrano’s heart.- During the course of the procedure, a Swan-Ganz catheter was placed in Medrano’s left subclavian vein:
Two days later, two Tenet nurses unsuccessfully and repeatedly pulled on the catheter in an attempt to remove it from Medrano". Medrano’s daughter observed Medrano screaming in pain during the attempts. Dr. Flores subsequently examined Medrano and also unsuccessfully attempted to remove the catheter. After Medrano underwent imaging, Dr. Flores determined that another surgery was necessary for the controlled removal-of the catheter.
The next day, August 29, Dr. Flores performed surgery to remove the catheter, which, it was discovered, had been inadvertently sutured in place during the first surgery. Plaintiffs allege that during the second surgery, the anesthesiologist, Dr. James B. Boone, prematurely pulled on the stitched catheter and tore Medrano’s heart, which when coupled with the' ensuing negligence of Dr. Flores in reaction to the crisis, resulted in hemorrhage and multi-organ failure,, leaving Medrano in critical condition.
On September 1, Dr. Robert Santoscoy performed a third surgery on Medrano to repair her torn superior vena cava. The surgery was deemed “technically successful.” However, Medrano died two and one-half months’ later, allegedly due to complications arising from the August 29 surgery.
Plaintiffs brought both wrongful death and survival claims arising from Medrano’s death. Plaintiffs sued Dr. Flores, Dr. San-toscoy, and Tenet, but not the anesthesiologist, Dr. Boone. Plaintiffs alleged that Tenet was vicariously liable for the negligence of Dr. Boone under the theory of ostensible agency and vicariously liable for the negligence of its nurses under the doctrine of respondeat superior.
As required by Chapter 74 of the Texas Civil Practices and Remedies Code, plaintiffs served the expert reports of: (1) Dr. Thomas Jay' Berger, who' addressed' the wrongful death claims arising from the alleged negligence of Dr. Flores and the anesthesiologist Dr. Boone; and (2) Nurse Elisabeth Ridgely, who addressed the survival claims for Medrano’s pain arising from the actions of the Tenet nurses in their attempted removal of the Swan-Ganz catheter. See Tex. Civ. PRac. & Rem.Code Ann. § 74.851(a), (b) (West Supp. 2015). *169 Tenet objected to tbe- expert reports and sought the dismissal of plaintiffs’ claims against it. Tenet contended in part that Nurse Ridgely’s report could not support plaintiffs’ survival claims because she could not opine as to causation. Tenet contended in part .that Dr. Berger’s report could not support plaintiffs’'. -wrongful death claims because his report did not mention the hospital or implicate its behavior. The trial court denied Tenet’s motion to dismiss. -
DISCUSSION
TMLA Requirements for Expert Reports
A plaintiff asserting a health care liability claim must serve an expert report “for each physician or health care provider against whom a liability claim is asserted.” Tex. Civ. Prao. ■ & Rem.Code Ann. § 74.351(a). A valid, expert report under the TMLA must provide: (1) a fair summary of the applicable standards of care; (2)the manner in which the physician or health care provider failed to meet those standards; and (3) the causal relationship between the failure and the
2
harm alleged.
TTHR Ltd. Partnership v. Moreno,
A challenge to the sufficiency of ¿ report must be sustained if the report does not represent an objective good faith effort to comply with the statutory requirements. Tex.: Crv. Prac. •
&
Rem.Code Ann. § 74.351(1). A report is a good faith effort if it (1) provides adequate' information to “inform the defendant of the specific conduct the plaintiff.has called into question,” (2) provides “a basis for the trial court to conclude that the claims have merit,” and (3) “does, not contain a material deficiency.”
Van Ness v. ETMC First Physicians,
Standard of Review
A trial court’s ruling on the sufficiency of an expert’s report is, reviewed for abuse of discretion.
Van Ness,
Nurse Ridgely’s Report
The parties agree that Nurse Ridgely’s report was 'served to support plaintiffs’ survival claims for the pain Me-drano suffered when the Tenet nurses attempted to remove the catheter two days after Medrano’s initial surgery. Tenet contends in part that Nurse Ridgely was
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not qualified to opine as to causation. Plaintiffs recognize' that a nurse is not qualified to opine on medical causation.
See
Tex. Civ. Prac, & Rem.Code Ann. § 74.351(r)(5)(C) (restricting opinions on causation to physicians);
Tenet Hospitals Ltd. v. Barajas,
Plaintiffs argue that no expert opinion was needed on causation. They contend the causal relationship between the nurses’' persistent- pulling ’ on the lodged catheter and the resulting pain is apparent and can be provided by lay testimony. In this regard, plaintiffs rely on the common-law rule that while expert testimony is usually required in medical malpractice cases, lay testimony can establish causation “in those cases in which general experience and common sense will enable a layman to deterrfline, with reasonable probability, the causal relationship between the event and'the condition.”
Jelinek v. Casas, 328
S.W.3d 526, 533 (Tex.2010) (quoting
Morgan v. Compugraphic Corp.,
Plaintiffs’ reliance on
Jelinek
is misplaced. The Supreme Court’s discussion of lay testimony of causation in
Jeli-nek
was made in the context of reviewing,'a jury’s verdict, not in reviewing a pre-trial expert report required under the TMLA.
Id.
at 533-34. Under the TMLA, the basic requirements for what an expert report must contain are dictated by the statute, not by the common law. The TMLA expressly provides that an expert report address not only the applicable standard of care and the breach of those standards, but also “the causal relationship between that failure- and the. injury, harm, or damages claimed.” Tex.- Civ. Prao, & Rbm.Code Ann. § 74.351(r)(6). Because the statute is clear that an expert report must address causation, we cannot ignore that requirement simply because ' lay testimony may sometimes be deemed sufficient to establish causation under the common law.
See Union Carbide Corp. v. Synatzske,
Further, it is questionable whether lay testimony could establish that the nurses’ alleged persistent pulling on the catheter caused Medrano “additional pain and suffering.”
See Jelinek,
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Plaintiffs also argüe that Dr. Berger’s report supplied the causal basis for the resultant pain.
4
In particular, plaintiffs note that Dr. Berger indicated that the catheter had been inadvertently stitched in place and that Dr. Boone’s pulling on it severed Medrano’s heart rhuscle. But, Dr. Berger only mentions that the nurses attempted to remove the catheter, met resistance, and notified Dr. Flores. Nowhere does Dr. Berger criticize the actions of the nurses, nor does he state that their' actions caused Medrano additional pain. Dr. Berger’s opinions on causation relate solely to the actions of Dr.'Boone and Dr. Flores during the August 29 surgery to remove the catheter, which occurred the day after the nurses attempted removal. Essentially, plaintiffs are asking us to infer a causal link from Dr. Berger’s report. But, we cannot infer causation either by filling in missing gaps or by guessing what an expert likely meant or intended.
Tenet Hospitals, Ltd. v. Garcia,
A report does not constitute a good faith effort if it omits any of the statutory requirements.
Palacios,
This does not necessarily mean that the plaintiffs’ survival claims fail, however. Plaintiffs also alleged that Tenet was liable for Medrano’s death because Tenet was vicariously liable for the actions of Dr. Boone in prematurely pulling on the catheter and tearing her heart muscle. When a health care liability claim involves a vicarious liability theory, either alone or in combination with other theories, and there is an expert report sufficient to support that vicarious liability theory, the entire case may proceed.
Certified EMS, Inc.,
Dr. Berger’s Report
Tenet contends that Dr. Berger’s report cannot support plaintiffs’ wrongful death claims against it because the report
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does not mention Tenet or implicate its behavior. Tenet concedes. that Dr; Berger’s report attributes Medrano’s wrongful death in part to the actions of Dr. Boone, and that the plaintiffs alleged that Tenet was vicariously liable for the negligence of Dr.' Boone under the-theory of ostensible agency. Tenet argues, however, that Dr. Berger’s expert report is fatally deficient because it does not address vicarious liability and contains nothing to suggest that Medrano had a reasonable belief Dr. Boone was Tenet’s agent or employee, or that Tenet affirmatively held out Dr. Boone as its agent or .employee un knowingly permitted Dr. Boone to so, hold himself out.
See Baptist Memorial Hosp. Sys. v. Sampson,
In this regard; Tenet relies on the Texas Supreme Court’s decision in In re McAllen Medical Ctr., Inc., in which the Supreme Court indicated that an expert report subject'to the TMLA is required to address both the physician’s conduct and the hospital’s alleged vicarious liability for that conduct:
[Tjhe plaintiffs pleaded that Dr. Braca-montes was < the hospital’s agent, and thus was vicariously liable for his negligence. This claim is viable only if the doctor was negligent, so it too is a health care liability, claim and must be .supported by an expert report. But nothing in [the expert’s] reports suggest the hospital controlled the details of his medical tasks (a requirement for hospital liability),- and -the plaiñtiffs do not argue "otherwise on appeal-.
On the other hand, plaintiffs rely on Gardner v. U.S. Imaging, Inc., in which— four months after In re McAllen—the Supreme Court again addressed this issue, but this time indicated that when the hospital’s negligence- is purely vicarious, the expert report need only address the underlying actions, of its “agents or employees”:
SADI 6 additionally, contends it was not served with an expert report because the report that was served does not mention SADI or implicate its behavior. The Gardners respond that because SADl’s alleged liability is purely vicarious in nature, the report as to Dr. Kesz-ler was ■ sufficient. To the extent the allegátions against SADI are based upon respondeat superior, .we agree with the Gardners. When a party’s alleged health -care liability is purely vicarious, a report that adequately implicates the actions of that party’s agents or employees is sufficient.
Tenet argues that
Gardner
must be read narrowly, and that
Gardner
does not apply because Tenet .contested plaintiffs’ allegation that it was vicariously liable for .Dr. Boone’s actions. Tenet notes that there is no record in
Gardner
that SADI, the facility .where the doctor performed the procedure, contested the employment relation
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ship underlying plaintiffs vicarious liability claim. We agree that neither the decision of the Supreme Court nor the decision of the court of appeals in
Gardner
indicates that SADI was contesting its alleged employment relationship .with the negligent doctor.
See Gardner,
Our conclusion is informed in part by the Supreme Court’s subsequent decisions implicitly recognizing the holding in Gardner, and the corresponding lack of Supreme Court decisions applying the holding in In re McAllen that an expert report must address the plaintiffs theory of vicarious liability.
For example, in
Certified EMS, Inc. v. Potts,
the plaintiff alleged both direct and vicarious liability theories against the defendant. The Supreme Court concluded that the TMLA does not require an expert report to address each liability theory pleaded against a defendant, and held that the plaintiff secured “her right to have the entire case move forward,” because she “demonstrated to the trial court that at least one of her alleged theories — vicarious liability — had expert support.”
We recognize' that in
Certified EMS, Inc.
the defendant had not challenged the adequacy of the expert report as to its vicarious liability.
Id.
at 626. However, in a case 'decided less than two months’ later, the defendant hospital did not concede that it was vicariously liable.for the doctors’ actions.
TTHR Ltd. Partnership v. Moreno,
Further, there is nothing, in the record before us rebutting plaintiffs’ allegation that Dr. Boone was acting as Tenet’s ostensible agent. In
Loaisiga v. Cerda,
We recognize Tenet’s concern that by the “artful pleading” of vicarious liability, a plaintiff could avoid early dismissal and impermissibly prolong a medical malpractice case in contravention of the TMLA’s purpose to summarily dispense with cases that are without merit. But, there are other remedies already provided by Texas law to address allegations of vicarious liability that are frivolous or made in bad faith. See Tex, Civ. Prac. & Rem.Code Ann. §§ 9.001-.014 (West 2002) (providing for sanctions, including the striking of pleadings, when a pleading is determined to be groundless and brought in bad faith); Tex. Civ. PraC. & Rem.Code Ann. §§ 10.001-,006 (West 2002) (providing for monetary sanctions when a pleading is filed without evi-dentiary' support or is unlikely to have such support after reasonable discovery); Tex.R. Civ. P. 13 (providing for an appropriate sanction under Rule 215 for pleadings brought in bad faith or that are groundless and brought for purposes of harassment), Tex.R. Civ. P. 91a (providing for the dismissal of causes of action hawing no basis in law or fact).
In fact, Tenet filed special exceptions to plaintiffs’ allegations that it was vicariously
*175
liable for Dr. Boone’s negligence under the theory of ostensible agency. The record does not reflect whether Tenet presented those exceptions to the trial court. But, we note that had those special exceptions been sustained by the court, and plaintiffs failed -to amend after being given an opportunity to replead, their wrongful death claims may have been subject to dismissal for failure to state a claim.
See Massey v. Armco Steel Co.,
Tenet also contends that Dr. Berger’s report was conclusory as to causation and contained an analytical 'gap in tying the alleged negligence occurring in the August 29 surgery with Medrano’s death two and one-half months’ later. Dr. Berger’s report states that Dr. Boone’s premature attempt to remove the catheter proximately caused a massive hemorrhage when the stitch holding the catheter tore through the superior-vena-cava/right-atri-um junction, and proximately caused “subsequent sequellae of the hemorrhage including shock, multiorgan system failure and death.” Dr.‘Berger, explains how Dr. Flores’s actions in spending almost an hour attempting to repair the tear without cardiopulmonary bypass caused Medrano to experience further low blood pressure and anoxic injury to her organs. And, Dr. Berger addresses how Dr. Flores’s failure to cannulate in such a way to permit an accurate and safe repair of the tear led to a complete obstruction to the superior vena cava and SVC syndrome, which required Medrano’s third surgery' by Dr. Santoscoy- to repair her SVC. Dr. Berger’s report states that although Dr. Santoscoy’s procedure “was technically successful, Ms. Medrano continued to deteriorate and died on 11/16/11.” The report concludes that: “Each of the,above deviations was a proximate cause of Ms. Medrano’s death.” We agree with Tenet tiíát Dr. Berger’s report is deficient as to causation, in particular because it does not adequately explain how the conditions arising from the August 29 surgery caused'Medrano’s death two and one-half months’'later.
We faced a similar situation in
Clapp v. Perez,
In the present case, however, the plaintiffs have not been given an opportunity to cure any deficiencies in Dr. Berger’s report. in
Gardner,
the expert report stated' only that the plaintiffs meningitis and hearing loss were “directly related” to the lumbar epidural procedure.
Gardner,
Likewise, while Dr. Berger’s report is .deficient as to causation, it is not so deficient as , to constitute no report at all. Accordingly, we remand this case to the trial court to consider granting a thirty-day • extension to cure.
9
See Scoresby v. Santillan,
CONCLUSION
We: reverse the trial court’s order denying Tenet’s motion "to dismiss and remand for further proceedings consistent with this opinion.
Larsen, J. (Senior Judge), sitting by as: signment
Notes
. We take this background information from the petition and the expert reports-in issue, noting that the-factual claims have riot yet been .proven. ■
. The trial court also denied Dr, Flores’s motion to dismiss, but granted Dr. Santoscoy’s motion and dismissed the claims against him.
. Ultimately
in Jelinek,
the Supreme Court held that the lay opinion testimony could not support a finding that the hospital’s negli
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gence caused the plaintiff additional pain and ¿offering. ■
. Expert reports can be considered together in determining whether the plaintiff in a health care liability claim has provided adequate expert opinion regarding the standard of care, breach, and causation.
See
Tex. Civ. Prac. & Rem. Code Ann. § 74.351(i);
Salais v. Texas Dep’t of Aging & Disability Servs.,
. We do not reach Tenet’s contention that Nurse Ridgely’s report contained unsupported assumptions concerning the training and qualification of the Tenet nurses.
. SADI was the facility where jhe. physician, Dr, Keszler, had performed the lumbar epidural procedure the Gardners alleged was negligent.
. Both SADI’s response and brief argue that the plaintiff's expert report “does not place any representative or employee of SADI in Mr. Gardner’s operating room at any time before, during, or after the procedure,” “does not identity what role SADI had in Mr. Gardner’s post-operative care,” and "does not provide any information linking” the expert’s "conclusions to the conduct of SADI, as opposed to the conduct of Dr. Keszler[J” SADI Response to Petition for Review at 3; SADI Brief on Merits at 6-7.- These documents are available on the Texas Supreme Court website, www.txcourts.gov//supfeme.aspx. Appeal No. 08-0268, Case Information, Appellate Briefs.
. In TTHR Ltd. Partnership, the Supreme Court noted that the hospital had acknowledged that whether it could be vicariously liable for the doctors’ actions "is not a question to be determined in this appeal.” Id. at 44, n, 4. It can be inferred that the reason the validity of the vicarious liability theory was not an issue to be determined in the appeal.was because the TMLA does not require an expert report to address the validity of a vicarious liability theory.
. Tenet also contends, that Dr, Berger's qualifications were “stale” and he was not qualified to establish the standard of care for the anesthesiologist, Dr. Boone, and that Dr. Berger's report was speculative and conclusory as to breach. We do not address these deficiencies because they would also be subject to a cure on remand.
See Gardner,