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Reversed and Remanded and Majority and = Dissenting=20 Opinions filed October 11, 2007.

 

 

In The

 

Fourteenth=20 Court of Appeals

____________

 

NO.=20 14-06-00962-CV

____________

 

WALGREEN COMPANY, = Appellant

 

V.

 

CYNTHIA HIEGER AND ROY C. HIEGER, BOTH=20 INDIVIDUALLY AND AS NEXT FRIEND OF DAVID C. HIEGER, A MINOR,=20 Appellees

 

 

On Appeal from the = 281st=20 District Court

Harris County, = Texas

Trial Court Cause = No. 2005-79787

 

 

D I S S E=20 N T I N G   O P I N I O N

I respectfully = dissent.=20

This court must = review a trial=20 court=3Ds ruling relative to = the=20 adequacy of an expert report under an abuse of discretion=20 standard.   Am. Transitional Care Ctrs. v. = Palacios, 46=20 S.W.3d 873, 877 (Tex. 2001).  A trial court abuses its = discretion if=20 it acts in an arbitrary or unreasonable manner without reference = to=20 guiding rules or principles.  See Garcia v. Martinez, = 988=20 S.W.2d 219, 222 (Tex. 1999).  When reviewing matters = committed to the=20 trial court=3Ds discretion, we may = not=20 substitute our own judgment for that of the trial court.  = Walker=20 v. Packer, 827 S.W.2d 833, 839 (Tex. 1992).  A trial = court does=20 not abuse its discretion merely because its discretionary decision = is=20 different from what an appellate court=3Ds disposition would = be =20 under similar circumstances.  See Downer v. Aquamarine = Operators,=20 Inc., 701 S.W.2d 238, 241B42 (Tex. 1985).  = The=20 majority acknowledges but refuses to be constrained by this = standard.=20

I. =20 Texas Civil Practice and Remedies Code Section 74.351 =

Pursuant to section = 74.351, a=20 health-care-liability claimant must provide an expert report to = the=20 defendant no later than 120 days after the original petition was=20 filed.  See Tex. Civ.=20 Prac. & Rem. Code Ann. ' 74.351(a) (Vernon = Supp.=20 2006).  If a claimant timely furnishes an expert report, a = defendant=20 may file a motion challenging the adequacy of the report.  = See=20 id.  The trial court shall grant the motion only if it = appears=20 that the report does not represent a good faith effort to comply = with the=20 statutory definition of an expert report.  Tex. Civ. Prac. & Rem. = Code=20 Ann. ' 74.351(l) (Vernon = Supp.=20 2006).  In determining whether the report represents a good = faith=20 effort, the trial court=3Ds inquiry is limited = to the=20 four corners of the report.  See Palacios, 46 S.W.3d = at 878.=20

Under the statute, an = expert=20 report is defined as a written report by an expert that provides a = fair=20 summary of the expert=3Ds opinions as of the = date of=20 the report regarding: (1) applicable standard of care, (2) the = manner in=20 which the care provided failed to meet the standards, and (3) the = causal=20 relationship between that failure and the injury, harm, or damages = claimed.  Tex. Civ. = Prac.=20 & Rem. Code Ann. ' 74.351(r)(6) (Vernon = Supp.=20 2006); Palacios, 46 S.W.3d at 878B79. Although a = plaintiff need=20 not marshal all of her proof, the expert=3Ds report must include = opinions=20 on the three statutory elementsCstandard of care, = breach, and=20 causation.  See Palacios, 46 S.W.3d at = 878B79.  In = compliance with=20 these standards, the plaintiff must incorporate enough information = to=20 fulfill two purposes: (1) inform the defendant of the specific = conduct the=20 plaintiff has called into question, and (2) provide a basis for = the trial=20 court to conclude that the claims have merit.  Id. at=20 879.  A report that merely expresses the expert=3Ds conclusions about = the=20 standard of care, breach, and causation does not fulfill these two = purposes.  Id.   The expert must explain the = basis=20 for his statements and must link his conclusions to the = facts. =20 Bowie Mem=3Dl Hosp. v.=20 Wright, 79=20 S.W.3d 48, 52 (Tex. 2002).  However, to avoid dismissal, a = plaintiff=20 need not present all the evidence necessary to litigate the merits = of her=20 case.  Palacios, 46 S.W.3d at 879. The report may be = informal=20 in that the information need not fulfill the same requirements as = the=20 evidence offered in a summary-judgment proceeding or at = trial. =20 Id.  Moreover, the expert is not required to express = the=20 causal relationship in terms of reasonable medical probability or = other=20 Amagic@ words.  = Wright, 79=20 S.W.3d at 52. 

II. =20 Analysis

Pursuant to section = 74.351(i),=20 Anothing in this = section shall=20 be construed to mean that a single expert must address all = liability and=20 causation issues with respect to all physicians or health care = providers=20 or with respect to both liability and causation issues for a = physician or=20 health care provider.@  Tex. Civ. Prac. & Rem. = Code=20 Ann. ' 74.351(i) (Vernon = Supp.=20 2006).  Therefore, Ginsburg=3Ds and Dr. = Young=3Ds reports may be read = together=20 to satisfy the expert report requirements.

A.       =20 Diane Ginsburg=3Ds Expert = Report =

The majority = correctly notes=20 that Ginsburg is not qualified under section 74.351 to provide = medical=20 causation opinions.  To render an expert report regarding = causation,=20 the expert must be licensed to practice medicine in one or more of = the=20 states in the United States.  Randalls Food and Drugs v.=20 Kocurek, No. 14B05B01184BCV, 2006 WL 2771872, = at *3=20 (Tex. App.CHouston [14th Dist.] = Sept. 28,=20 2006, no pet.) (mem. op.) (holding expert with an undergraduate = degree and=20 master=3Ds degree in = microbiology and a=20 Ph.D. in toxicology and experimental surgery was not qualified to = render=20 an expert opinion regarding causation because she was not licensed = to=20 practice medicine in the United States).  Here, Ginsburg was = not=20 qualified to give an opinion regarding causation because she is = not=20 licensed to practice medicine in one or more of the states in the = United=20 States.  However, Ginsburg was qualified to give an opinion = regarding=20 the remaining two statutory requirements: standard of care and = breach of=20 standard of care.  She addressed standard of care and breach = of=20 standard of care in her expert report as follows:   

The standard of care applicable to = Walgreens=20 Pharmacy was to ensure that medications are dispensed and = delivered safely=20 and accurately as prescribed by the physician in accordance with = Texas=20 State Board of Pharmacy Rules ' 291.32.C.5. Specifically, the standard = of care=20 obligates the pharmacist to assure that he/she has dispensed the = right=20 drug, in the right dose, and by the right route to the right = patient (the=20 Afour rights@). The pharmacist must systematize the = process in=20 such a way that the Afour rights@ are observed and the drug dispensed to = the=20 patient without error.  The standard of care demands a high = degree of=20 care on the part of the pharmacist, and he/she must check the = medicine and=20 labeling very carefully before dispensing so as to avoid error, = because=20 there can be significant consequences to medication errors.  = In my=20 opinion, Walgreens Pharmacy breached the standards of care in = failing to=20 observe the Afour rights@, failing to accurately fill Ms.=20 Hieger=3Ds prescription, and failed to exercise a = high=20 degree of care in checking the accuracy of the prescription = before =20 dispensing it. 

 

Accordingly, the = Hiegers were=20 required to satisfy their statutory obligation as to the causation = element=20 through Dr. Reed Young=3Ds expert = report

B.       =20 Dr. Reed Young=3Ds Expert = Report =

Walgreen contends Dr. = Young=3Ds report does not = provide a=20 fair summary of the alleged causal relationship between the = incorrectly=20 refilled prescription and Ms. Hieger=3Ds alleged injuries. = The=20 majority concludes that Dr. Young=3Ds report is = insufficient=20 because Dr. Young has expressed Aan opinion on a = possibility,=20 not an ultimate opinion on causation.@  I = disagree.  The=20 relevant portion of Dr. Young=3Ds report is restated = below for=20 clarification and emphasis.

Paxil is an antidepressant with = anxiolytic=20 properties.  It is prescribed for rheumatic pain syndromes = and=20 clearly has a central action against pain.  In my own = experience,=20 when Paxil is stopped abruptly, the patient can go through a very=20 uncomfortable period of worse depression, worse pain, and marked = anxiety=20 and hyper activity. 

Ambien, like Halcion, can cause peculiar = side=20 effects if someone takes it and tries to stay awake for awhile;=20 specifically they can act somewhat psychotic.

I was told by the patient that in = October, 2003, a=20 prescription for Paxil was miss-filled (sic) with Ambien and = miss-labeled=20 (sic). As applied to these events, when cynthia = (sic)=20 Hieger suddenly ceased taking her Paxil and began taking Ambien = for=20 daytime use, her complaints of psychosis, hypersensitivity,=20 jitteriness, and increased pain are consistent with the known = side=20 effects of each medication. 

(emphasis = added). =20    

Walgreen argues that = the=20 language Aconsistent = with@ does not demonstrate = a causal=20 connection.  Specifically, Walgreen contends the language = indicating=20 that Ms. Hieger=3Ds symptoms are =20 Aconsistent = with@ the known side = effects of the=20 medications is not the same as stating that the symptoms were in = fact=20 caused by the medication.

However, considering = the four=20 corners of the report, I note that Dr. Young first explained the = side=20 effects resulting from abrupt termination of  treatment with=20 Paxil.  He then explained the side effects of taking Ambien = while=20 trying to stay awake.  The symptoms he described were not the = generally known side effects from taking the medications.  He = also=20 explained the side effects of the medications as applied to these = specific=20 factsCthe abrupt = discontinuation of=20 Paxil and taking Ambien during the day.  Dr. Young wrote,=20 Aas applied to these=20 events@ Ms. = Hieger=3Ds complaints = Aare consistent = with@ the side effects of=20 discontinuing Paxil and taking Ambien during the=20 daytime.         =20

Walgreen argues, by = analogy,=20 that back pain is Aconsistent = with@ a herniated lumbar = disc and=20 that to say back pain is Aconsistent = with@ a herniated lumbar = disc is not=20 the same as opining that the pain was caused by a herniated = disc. =20 However, appellant ignores the fact that Dr. Young described side = effects=20 of the medications as applied to the Ms. Hieger=3Ds particular = complaints=20 immediately before opining that her symptoms were consistent with = those=20 side effects.  Therefore, the words Aconsistent with the = known side=20 effects of each medication@ were not in = isolation or=20 without definition, as in appellant=3Ds analogy.  =

In support of its = argument,=20 Walgreen cites several cases in which other courts of appeals = found=20 language in expert reports conclusory.  However, none of the = cases=20 involved misfilled prescriptions by a  pharmacy.  = Moreover,=20 those courts concluded that various statements regarding causation = contained in expert reports were conclusory because they lacked=20 information linking the expert=3Ds opinion to the=20 defendant=3Ds alleged breach.[1] =20

In contrast to the = cases cited=20 by Walgreen, Dr.  Young explained the side effects of the = medications=20 as applied to these facts and then explained that Ms. = Hieger=3Ds complaints were = Aconsistent = with@ the side effects of = the=20 medications.  He sufficiently explained the basis for his = statements=20 and linked his conclusions to the facts.  See Wright, = 79=20 S.W.3d at 52.  Moreover, his report constituted a good faith = effort=20 to summarize causation because it informed Walgreen of the = specific=20 conduct called into question and provided a basis for the trial = court to=20 conclude that the claims had merit.  See Palacios, 46 = S.W.3d=20 at 879.  Therefore, it is my considered opinion that his = statements=20 were not conclusory. 

For all the reasons = stated=20 above, I would hold that the trial court did not act in an = arbitrary or=20 unreasonable fashion without reference to guiding rules or=20 principles.  Accordingly, I would overrule Walgreen = Co.=3Ds sole issue and = affirm the=20 judgment of the trial court.

 

 

/s/       =20 Charles W. Seymore

Justice

 

Judgment rendered and = Majority=20 and Dissenting Opinions filed October 11, 2007.

Panel consists of = Justices=20 Yates, Frost, and Seymore. (Yates, J., majority).

 


[1]  See Wright, 79 S.W.3d at = 51 (=20 AI do believe that it is reasonable to = believe that=20 if the x-rays would have been correctly read . . . [patient] would = have=20 had the possibility of a better outcome@); Logino v. Crosswhite, 183 = S.W.3d 913,=20 917B18 (Tex. App.CTexarkana 2006, no pet.) (language that=20 Athis prolonged symptomatology was a = cause of=20 [patient=3Ds] significant and permanent = neurological=20 injuries@ only stated that delay in diagnosis = caused=20 significant and permanent neurological injuries without explaining = basis=20 for conclusion); Gray v. CHCA Bayshore, 189 S.W.3d = 855, 859=20 (Tex. App.CHouston [1st Dist.] 2006, no pet.) = (expert report=20 only indicated doctors failed to monitor the plaintiff=3Ds knee properly during his surgery = without=20 explaining how the departure from standard of care caused=20 patient=3Ds injury); Pisasale v. Ensign Group, = Inc.,=20 No. 11-05-00196-CV, 2006 WL 2567400, at *4 (Tex. App.CEastland Sept. 7, 2006, pet. denied) = (mem. op.)=20 (language that AI think their negligence was a proximate = cause@ was speculative and conclusory because = it did=20 not  eliminate preexisting conditions); Martinez v. = Riegel,=20 No. 04B5-00336-CV, 2006 WL 1748442, at *4 (Tex. = App.CSan Antonio June 28, 2006, no pet.) = (mem. op.)=20 (language that  Aanesthetic agents@ irritated Athe already inflamed lung = tissue@ did not adequately explain causal = relationship=20 between surgery and injuries); Northeast Med. Ctr. v. = Crooks, No.=20 06-05-00149-CV, 2006 WL 1358361, at *6 (Tex. App.CTexarkana May 19, 2006, no pet.) (mem. = op.)=20 (report did not draw a causal connection between nursing home=20 patient=3Ds fall, which resulted in broken hip, = and his=20 death); Lopez v. Monetemayor, 131 S.W.3d 54, 59B60 (Tex. App.CSan Antonio 2003, pet. denied) (language = that=20 Ait is the aspiration of the bridge = section which=20 caused and precipitated the medical circumstances leading to the=20 patient=3Ds demise@  did not link dentist=3Ds failure to perform an x-ray to=20 patient=3Ds death); Hardy v. Marsh, 170 = S.W.3d 865,=20 869B70 (Tex. App.CTexarkana 2005, no pet.) (language that=20 Aif this patient . . . had had more = immediate=20 treatment that a salvage of his right leg would have been more=20 probable@ was not sufficiently specific establish = causation); Costello v. Christus Santa Rosa Health Care = Corp., 141=20 S.W.3d 245, 249 (Tex. App.CSan Antonio 2004, no pet.) (language = that=20 A[i]f this patient would have been = appropriately=20 triaged and evaluated, then in all reasonable medical probability = she=20 would have survived@ failed to state the medical basis or = reasoning or=20 explain how failure to act was a substantial factor in bringing = about=20 patient=3Ds death); Barko v. Genzel, 123 = S.W.3d 457,=20 460 (Tex. App.CEastland 2003, no pet.) (language that = the=20 Aviolations of the standards of emergency = medical=20 practice were a proximate cause in this patient=3Ds injury@ did not indicate that patient would = have=20 satisfactorily recovered from the back injury but for = doctor=3Ds negligence); Villa v. Hargrove, = 110=20 S.W.3d 74, 78 (Tex. App.CSan Antonio 2003, pet. denied) (language = that=20 Ahad either of these defendants provided = the=20 appropriate care, to an overwhelming probability, [patient] would = be alive=20 and well today@ did not link  actions of doctors = to=20 patient=3Ds death).

 

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