Court of Appeals of Texas, Thirteenth District, Corpus Christi-Edinburg
appeal from the 138th District Court of Cameron County,
Justices Rodriguez, Benavides, and Longoria
V. RODRIGUEZ Justice
interlocutory appeal, appellant Ahmad Karkoutly, M.D.
challenges the denial of his motion to dismiss the health
care liability claim of appellee Maria Guerrero. We reverse
filed suit for medical negligence against two hospital
entities and nine physicians, including Dr. Karkoutly.
Guerrero's petition alleged that on October 9, 2013, her
mother Maria Otilia Estrada was admitted to Valley Regional
Medical Center, a hospital in Brownsville, Texas. She
complained of abdominal pain, nausea, and vomiting, and had a
history of colon ailments. Various defendants treated her for
several weeks, including multiple surgeries. However, Estrada
died, allegedly because the defendants' substandard care
caused Estrada to suffer septic shock and respiratory
support her claim against Dr. Karkoutly, Guerrero filed an
expert report authored by David H. Miller, M.D. Guerrero did
not file expert reports concerning any other defendant, and
Dr. Karkoutly became the only defendant remaining in the
Karkoutly filed a motion to dismiss Guerrero's claims,
asserting that Dr. Miller's report did not satisfy the
requirements of the Texas Medical Liability Act (TMLA).
See Tex. Civ. Prac. & Rem. Code Ann. §
74.351 (West, Westlaw through 2017 1st C.S.). Dr. Karkoutly
objected to multiple aspects of Dr. Miller's report,
including the objection that is the subject of this appeal:
conclusory statements and logical inconsistencies in Dr.
Miller's opinions on causation. Following a hearing, the
trial court denied Dr. Karkoutly's motion to dismiss.
This interlocutory appeal followed.
sole issue on appeal, Dr. Karkoutly contends that Dr.
Miller's report is fatally inadequate under the TMLA. In
particular, Dr. Karkoutly asserts that the report
inadequately addresses the causation element of
Guerrero's health care liability claim, offering only a
conclusory and internally inconsistent account of how Dr.
Karkoutly's acts and omissions caused Estrada's
Dr. Miller's Report
Miller began his report by summarizing Estrada's medical
records. According to Dr. Miller's report, Estrada
presented to the hospital with a history of diverticulitis-a
condition of the colon-along with chronic "hypovolemia,
" nausea, and vomiting. Estrada's initial screening
revealed apparent signs of infection to the point of sepsis,
which included an elevated heart rate, respiratory rate, and
white blood cell count. Dr. Miller explained that upon her
admission to the hospital, Estrada met the criteria for
systemic inflammatory response syndrome or "SIRS, "
which meant that she was already septic or in danger of
developing severe sepsis.
was diagnosed with a likely "stricture" in her
colon, and on October 15, 2013, she underwent surgery to
remove a portion of her colon, with an "ileostomy"
(which Dr. Miller described as draining the colon using a
tube) and "anastomosis" (which he described as
reconnection of the remaining colon). Following her surgery,
Estrada was admitted to the intensive care unit under the
care of Dr. Karkoutly, who diagnosed her with SIRS. Dr.
Karkoutly treated her with antibiotics and noted her
continuing signs of sepsis, which worsened in the following
read his report, Dr. Miller discussed three potential causes
of Estrada's infection. In his opinion, the two
"likely" causes of her infection were a rupture of
the colon or the failure of the surgical reconnection of her
colon following her initial operation. Another
"possibl[e]" cause was the perforation of her colon
during her pre-operative colonoscopy. Out of these three, Dr.
Miller felt that it was "fairly clear from Dr.
Karkoutly's daily charting that something" had gone
wrong with the surgical reconnection of the colon-i.e., that
the reconnection had failed and was leaking fecal matter into
the surrounding tissue, causing infection. Beyond his
statement that the source was ...