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Columbia Valley Healthcare System, L.P. v. Zamarripa

Supreme Court of Texas

June 9, 2017

Columbia Valley Healthcare System, L.P. d/b/a Valley Regional Medical Center, Petitioner,
Maria Zamarripa, as Guardian of the Estates of R.F.R. and R.J.R., Minors, Respondent

          Argued March 21, 2017

         On Petition for Review from the Court of Appeals for the Thirteenth District of Texas



         This is a health care liability claim for the tragic death of Yolanda Iris Flores. The Texas Medical Liability Act ("the Act")[1] imposes a threshold requirement that the plaintiff furnish what we have described as "a statement of opinion by an individual with expertise indicating that the claim asserted . . . has merit."[2] This expert report must address, in part, "the causal relationship" between a health care provider's failure to meet applicable standards of care and the claimed injury.[3]The plaintiff here argues, and the court of appeals agreed, that "an expert report is not required to address 'proximate cause'".[4] We disagree and conclude that the plaintiff's expert reports do not show how the defendants before us caused Flores's death. Accordingly, we reverse the court of appeals' judgment and remand the case to the trial court for further proceedings.


         Flores, 36, pregnant with her third child and midway through the third trimester, was taken by ambulance to the Valley Regional Medical Center ("Valley Regional")[6] labor and delivery emergency room in Brownsville, Texas, early on a Tuesday morning. She had been vomiting and was experiencing fever, abdominal pain, and mild contractions. Dr. Patrick Ellis saw her and ordered a pain reliever, intravenous antibiotics, a sonogram, and an MRI, as well as a biophysical profile to test the health of her baby. The sonogram was normal and the baby appeared to be healthy, but Flores's contractions continued, and the MRI showed placenta accreta, an abnormal placental attachment to the uterine wall. Placenta accreta is a serious condition that increases the risk of heavy bleeding during delivery.[7] The MRI did not show a placental abruption-a detachment of the placenta from the uterus which can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother.[8]

         Midmorning, Dr. Ellis ordered Flores transferred to the Corpus Christi Medical Center - Bay Area ("Bay Area") 159 miles away.[9] The reason, according to medical records, was a "medical necessity upgrade in care, " though there was no emergency. Dr. Whitney Gonsoulin, a Bay Area physician, agreed to accept the transfer. A Hidalgo County Emergency Medical Service ("EMS") ambulance left Valley Regional with Flores at 1:22 p.m. Flores was diaphoretic and felt "pressure" pain in her abdomen. Midway through the trip, she began to bleed and became anxious and restless, and when EMS would not stop for ice or to open the vehicle doors, she became extremely combative. An EMS medic called Bay Area for permission to divert to another facility so that Flores could be evaluated but was instructed to continue on. When the ambulance became stuck in a severe traffic jam, Flores began screaming to get to the hospital, then collapsed onto her side in cardiac arrest. She was pulseless and apneic, and the medics began cardiopulmonary resuscitation. Shortly after 4:00 p.m., the ambulance arrived at Bay Area. An emergency cesarian section and hysterectomy were immediately performed, and Flores was stable at first. But tragically, she died at 11:02 p.m. Her baby girl was stillborn.

         Maria Zamarripa, guardian of Flores's two minor children, sued Ellis, Gonsoulin, Valley Regional, Bay Area, EMS, and others.[10] Against Valley Regional, Zamarripa alleges that its "[n]urses allowed [Flores] to be discharged . . . when she was not suitable for discharge", and that "[p]ersonnel . . . allowed a ground ambulance transfer . . . when [Flores] should not have been transferred", as well as "[o]ther acts/omissions of negligence" unspecified. To satisfy the Act's expert-report requirement, Zamarripa timely served on Valley Regional two reports, one by Grace Spears, a nurse with experience in the labor and delivery setting as well as the emergency room, and the other by Dr. Frederick Harlass, an obstetrician/gynecologist.

         An expert report required by the Act must address the applicable standards of care, the failure of a health care provider to meet them, and the causal relationship between that failure and the injury, harm, or damages claimed.[11] We focus here on Valley Regional's argument that the expert reports do not adequately show causation. Spears's report stated that Valley Regional nurses breached the standard of care:

• "by not advocating for":
• "additional treatment of [preterm labor] when [Flores's] contractions . . . continued . . .";
• "further investigation and treatment of [Flores's] low fibrinogen levels";
• "further investigation of [Flores's] continued abdominal pain/pressure with diagnosis of placenta accreta";
• "[Flores] to remain at [Valley Regional] rather than permitting and facilitating her transfer across Texas to [Bay Area] by ground ambulance"; and
• "by allowing [Flores] to be transferred to another facility many miles away while she [was] clearly in [preterm labor] . . .".

         Spears's report did not, of course, address how these breaches caused Flores's death because under the Act, only physicians can be experts on causation.[12] Harlass's report stated that

due [to] the breaches of care by the [Valley Regional] personnel in permitting and facilitating the transfer, . . . Flores was in a location (ambulance on the highway) when and where timely emergent c-section and hysterectomy surgery was not available when she began to bleed from the abrupted placenta. Her bleeding caused her cardiovascular arrest due to lack of oxygen carried to the heart for sufficient pumping. This collapse led to DIC[13] and her death.

         Valley Regional objected to the reports and moved to dismiss, in part, on the ground that they were insufficient to show how Valley Regional caused Flores's death when it was Dr. Ellis, not the hospital, who ordered Flores transferred. The trial court overruled Valley Regional's objection and denied its motion to dismiss. Valley Regional appealed the interlocutory order, and the court of appeals affirmed.[14]

         We granted Valley Regional's petition for review.[15]


         After briefing was completed, and six days before oral argument, Zamarripa argued for the first time that an interlocutory appeal is permitted from the denial of a motion to dismiss under the Act only when an expert report is untimely, not when it is inadequate. The argument goes as follows:

• Section 51.014(a)(9), [16] the interlocutory appeal authority invoked by Valley Regional, allows an appeal from an order denying relief sought by motion "under" Section 74.351(b).[17]
• Section 74.351(b) permits a motion to dismiss a health care liability claim when an expert report has not been served within the prescribed period.[18]
• A motion under Section 74.351(b) is thus one that complains a report is untimely, not that it is deficient.
• Even if deficient, Zamarripa's reports qualified as expert reports because each "contains a statement of opinion by an individual with expertise indicating that the claim asserted by the plaintiff ...

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