In the
Court of Appeals
Sixth Appellate District of Texas at Texarkana
No. 06-24-00101-CV
ANGELA HILTON, INDIVIDUALLY AND AS THE REPRESENTATIVE
OF THE ESTATE OF BARBARA JACKSON, Appellant
V.
MARK GIBBS, M.D., PARIS ORTHOPEDIC CLINIC, P.A., MARK CAMPBELL, M.D.,
ANDREW FRASER, D.O., PRMC HEALTHCARE GROUP, INC., PIA LIPPINCOTT, M.D.,
PRMC ER GROUP, INC., AND ESSENT PRMC, L.P., D/B/A PARIS REGIONAL HEALTH
F/K/A PARIS REGIONAL MEDICAL CENTER, Appellees
On Appeal from the 6th District Court
Lamar County, Texas
Trial Court No. 92471
Before Stevens, C.J., van Cleef and Rambin, JJ.
Memorandum Opinion by Justice van Cleef
MEMORANDUM OPINION
Angela Hilton, individually and as the representative of the estate of Barbara Jackson
(Hilton), filed a healthcare liability claim against Mark Gibbs, M.D., and the Paris Orthopedic
Clinic, P.A.; Mark Campbell, M.D.; and Pia Lippincott, M.D. (Appellees), maintaining that
Appellees’ management of Ms. Jackson’s medical issues fell below the accepted standard of
care. In accordance with Section 74.351 of the Texas Civil Practice and Remedies Code, Hilton
filed a timely expert report of Vineet Choudhry, M.D. (Report). See TEX. CIV. PRAC. & REM.
CODE ANN. § 74.351. Appellees filed objections and motions to dismiss, arguing that the Report
was deficient as to the element of causation.1 Following a hearing, the trial court granted
Appellees’ motions to dismiss and found that Appellees were entitled to the recovery of
reasonable attorney’s fees and costs of court. Furthermore, the trial court denied Hilton’s request
for an additional thirty days in which to cure any deficiencies in the Report.
Hilton files this interlocutory appeal,2 arguing that the trial court abused its discretion
when it granted Appellees’ motions, and in the alternative, the trial court should have given her
an additional thirty days in which to cure any alleged deficiencies in the Report.
We affirm the trial court’s orders granting Appellees’ motions to dismiss.
1
Dr. Lippincott, who practices anesthesiology, also included in her motion to dismiss an argument that Hilton’s expert lacked qualifications sufficient to opine on the standard of care applicable to anesthesiologists. Because we affirm the trial court’s orders granting Appellees’ motions to dismiss due to the deficiency as to the element of causation, we find it unnecessary to address Dr. Lippincott’s additional issue.
2
“A person may appeal from an interlocutory order” that “grants relief sought by a motion under Section 74.351(l).” TEX. CIV. PRAC. & REM. CODE ANN. § 54.014(a)(10).
2
I. Background3
Barbara Jackson was admitted to Paris Regional Medical Center on March 28, 2022, to
undergo a hip replacement procedure that was to be performed by Dr. Gibbs. The next day, Ms.
Jackson began having abdominal pain and distension. Post-operative medical procedures
revealed a possible ileus. Medical personnel subsequently inserted a nasogastric tube into Ms.
Jackson’s nose, resulting in the removal of “significant amounts of bilious fluid.”
On March 30, 2022, Dr. Andrew Fraser was asked to consult on the ileus, and after
reviewing a computed tomography scan (CT scan) of Ms. Jackson’s abdomen and pelvis, he
concluded that there was “no definitive evidence of a bowel perforation.” As a treatment plan,
Dr. Fraser ordered an enema and electrolyte replacement and placed Ms. Jackson on “n.p.o.”
status (nothing by mouth). On April 4, 2022, Ms. Jackson had an additional test that showed
“dilated small bowel loops concerning for possible distal small bowel obstruction and/or ileus.”
Ms. Jackson underwent another CT scan, which “show[ed] increased bowel gas and fluid within
the [gastrointestinal] tract without evidence of obstruction . . . [that] could be related to mild
ileus or gastroenteritis.”
On or about April 8, 2022,4 Ms. Jackson was once again tested, and the results of that test
showed “persistent diffuse gaseous distention of small bowel loops compatible with ileus or
obstruction.” Also, Ms. Jackson’s chest x-ray from that day “was concerning for interval
development of large volume of intraperitoneal free air, concerning for hollow viscus
3
The factual background is taken from Hilton’s pleadings and the Report.
4
In some instances, Hilton states the test occurred on April 9, 2022.
3
perforation.” Apparently, the radiologist, who read Ms. Jackson’s chest x-ray, attempted to
contact an unidentified physician by telephone to discuss her findings. The radiologist was
unable to reach the physician, so she discussed her findings with a registered nurse who, in turn,
agreed to provide the results of the x-ray to the physician.
In the late hours of April 8 or the early hours of April 9, Dr. Campbell allegedly met with
Ms. Jackson’s family members, informing them that he did not believe surgical intervention was
a potential treatment option for the purpose of stabilizing Ms. Jackson. The family, however,
remained insistent that the doctors move forward with surgery. Around that time, Dr. Campbell
consulted with Dr. Lippincott about possibly performing exploratory surgery on Ms. Jackson.
Dr. Lippincott purportedly agreed with Dr. Campbell’s assessment that Ms. Jackson should not
be subjected to surgery because it was too risky. Dr. Campbell asked Dr. Lippincott to speak
with Ms. Jackson’s family because she was “known for having a calming effect on patients and
families.”5 Pursuant to his request, Dr. Lippincott spoke with the family members, but they
remained unwavering in their position that Ms. Jackson undergo surgery. That same day, Ms.
Jackson’s family asked that she be discharged and then transferred to another hospital.
On April 9, 2022, Ms. Jackson was released from the Paris Regional Medical Center and
transferred to a Dallas hospital6 where, according to Hilton, physicians performed an exploratory
laparotomy, finding that “she had a very large blown-out perforation of both her transverse and
5
Lippincott maintains that her involvement in Ms. Jackson’s case was limited to speaking to the family about the potential risks of Ms. Jackson undergoing an operation in her condition. Hilton asserts that Dr. Lippincott agreed with Dr. Campbell that Ms. Jackson was too unstable to undergo surgery.
6
The Report states that the Dallas hospital’s records showed that Ms. Jackson “was transferred from an outside facility with delayed presentation of perforated abdominal viscus and presented in multisystem organ failure with sepsis related to delayed treatment of perforated viscus.”
4
sigmoid colon.” A few days later, Ms. Jackson had another operation and was then placed in the
intensive care unit, which, according to Appellees, included “ventilator support.”
On April 20, 2022, Ms. Jackson required a tracheostomy tube, presumably as a result of
breathing issues. According to the Report, on April 28, 2022, during a physical therapy session,
the “tracheostomy [tube] became dislodged, and [Ms. Jackson] lost her airway. She coded and
was taken urgently to the OR for replacement of her trach[eostomy tube].” Unfortunately, Ms.
Jackson “did not recover and was transitioned to comfort care.” She passed away on April 28.
II. The Adequacy of Dr. Choudhry’s Expert Report
In her second point of error, Hilton maintains that Dr. Choudhry’s Report adequately
addressed causation and that the trial court erred when it found otherwise. In the alternative,
Hilton contends that the trial court erred when it found that Dr. Choudhry did not make a good
faith effort to comply with Chapter 74 of the Texas Civil Practice and Remedies Code’s statutory
requirements and when it refused to grant a thirty-day extension of time to allow Dr. Choudhry
to cure any deficiencies contained in his Report.
A. Standard of Review
An appellate court reviews a trial court’s decision regarding the adequacy of an expert’s
report for an abuse of discretion. Baty v Futrell, 543 S.W.3d 689, 693 (Tex. 2018) (citing Am.
Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 875 (Tex. 2001)). A trial court
abuses its discretion when it fails to correctly apply the law to the facts or when it fails to apply
the appropriate rules or principles. Palacios, 46 S.W.3d at 875. “Importantly, in determining
whether the report is deficient, [an appellate court] may not draw any inferences; instead, courts
5
must consider only the information contained within the four corners of the report.” Morrison v.
Asamoa, 648 S.W.3d 628, 644 (Tex. App.—Eastland 2022, no pet.) (citing Palacios, 46 S.W.3d
at 879).
B. Discussion
In reaching his opinion, Dr. Choudhry reviewed Ms. Jackson’s medical records from
Paris Regional Medical Center and Texas Health Dallas. He stated in his Report as follows:
The standard of care when taking care of a patient postoperatively with an
ileus is to look for changes in the patient’s condition that may indicate a bowel
perforation. Bowel perforation can be a life-threatening condition that requires a
high index of suspicion. Should there be concern of a possible bowel perforation
on an x-ray, the standard of care requires further imaging, such as a CT scan,
and/or taking the patient for exploratory surgery.
Ms. Jackson began having some worrisome symptoms on 3/29/22 when
she developed abdominal distension. She was diagnosed with a postoperative
ileus and had an NG tube placed. By 4/8/22, additional imaging showed concerns
of hollow viscus perforation and the radiologist called the physician to discuss the
findings, but she was only able to talk with a nurse who said she would relay the
findings. Standard of care would dictate that the nurse would relay those
findings, however, the medical records are silent as to whether the nurse relayed
the information and it is a breach in the standard of care to not relay this
information. Standard of care would dictate that Dr. Fraser or Dr. Campbell order
a CT scan of the abdomen and pelvis upon learning of the results to determine
where the perforation is located. Standard of care at this point would also be
prompt exploratory surgery to locate the perforation and repair the perforation.
Neither of these things occurred.
Drs. Fraser and Campbell breached the standard of care by failing to order
a CT scan of Ms. Jackson’s abdomen on the morning of 4/8/22 when the
radiologist notified the nursing staff of a hollow viscus perforation. They further
breached the standard of care by not offering exploratory surgery on 4/8/22. Due
to these breaches in the standard of care, surgery for Ms. Jackson was delayed,
causing her to have multisystem organ failure with sepsis related to delayed
treatment of perforated viscus.
6
During this period of time, the medical records reflect Dr. Gibbs was the
admitting and attending physician. As such, he was made aware of Ms. Jackson’s
deteriorating condition and had a duty as the attending physician to oversee her
care. The standard of care for Dr. Gibbs would be to order a CT scan on 4/8/22
and insist on exploratory surgery. If the general surgeon was unable or unwilling
to perform exploratory surgery, the standard of care required Dr. Gibbs to initiate
transfer to a facility that would be able to perform exploratory surgery.
On 4/8/22, Dr. Lippincott was consulted to discuss the possibility of
exploratory surgery with Dr. Campell. Standard of care for Dr. Lippincott would
be to recommend a CT scan and recommend prompt exploratory surgery to locate
the perforation and repair the perforation. Dr. Lippincott’s failure to recommend
a CT scan be done, and recommendation to not perform exploratory surgery on
4/8/22 was a breach in the standard of care.
The failure to meet the standard of care by the nurse in reporting the
results, and all physicians, as outlined above, in the treatment of Ms. Jackson’s
bowel perforation led to multisystem organ failure with sepsis. If Ms. Jackson
had a CT scan to identify where the perforation was, and had Ms. Jackson been
taken for exploratory surgery on 4/8/22, her perforation would have been found
and repaired. Bowel perforation causes peritonitis, which can lead to sepsis if left
untreated. The delay in treating the bowel perforation caused Ms. Jackon [sic] to
suffer an infection that progressed to sepsis. An earlier diagnosis and correct
treatment, i.e., surgery to repair the perforation, would have, more likely than not,
prevented the infection from progressing to sepsis.
Dr. Choudhry concluded,
Ms. Jackson had a postoperative ileus diagnosed on 3/29/22 that was
treated with an NG tube. By 4/8/22, she had a recognized bowel perforation on
imaging. Despite this, Drs. Fraser, Campbell, Gibbs, and Lippincott failed to take
any action until the following day on 4/9/22. Had a CT scan and exploratory
surgery been done on 4/8/22, Ms. Jackson, more likely than not, would have had
successful repair of her bowel perforation, and she would not have progressed to
multiorgan failure and sepsis. If surgical intervention had taken place on 4/8/22,
it is more likely than not that Ms. Jackson would have survived.
I render these opinions based on my review of the medical records,
education, training, and experience. I reserve the right to amend or supplement
these opinions as more information becomes available.
7
1. Appellees Required an Adequate Expert Report and Not a Mini-Trial
Hilton argues that Appellees were attempting to convert Dr. Choudhry’s Report into a
mini-trial by arguing that his Report was lacking certainty and detail. Maintaining that Hilton
takes an overly simplified view of the requirements of a Section 74.351 expert report, Appellees
contend that Dr. Choudhry failed to connect the facts of the case to the opinions in his Report.
“A valid expert report has three elements: it must fairly summarize the applicable
standard of care; it must explain how a physician or health care provider failed to meet that
standard; and it must establish the causal relationship between the failure and the harm alleged.”
Certified EMS, Inc. v. Potts, 392 S.W.3d 625, 630 (Tex. 2013) (citing TEX. CIV. PRAC. & REM.
CODE ANN. § 74.351(r)(6)). An expert report that satisfies these requirements, even if only as to
one pleaded liability theory, allows the claimant to proceed with his entire suit against the health
care provider. Id. at 630, 632.
Contrary to Hilton’s contention, the record does not show that Appellees were seeking
something akin to a mini-trial. Instead, they were arguing that the facts contained in Dr.
Choudhry’s Report were inadequate to show that their actions caused Ms. Jackson’s death. In
other words, Appellees chose to argue that Dr. Choudhry’s Report omitted at least one of the
requisite statutory elements of a healthcare liability claim, which they had the right to do.
Accordingly, this Court finds that Hilton’s argument is without merit.7
7
Appellees agree with Hilton that Ms. Jackson underwent exploratory surgery, but they state that the attending physician “discovered perforations of the transverse and sigmoid colons.” However, Hilton does not present a point of error or an argument; instead, Hilton stresses the “Appellees’ failure to act expediently when put on notice of the ileus constituted negligence.” Hilton then states, in part, “Dr. Choudhry’s report guides that if an x-ray shows concern for a bowl [sic] perforation, ‘the standard of care requires further imaging, such as a CT scan, as well as
8
2. Dr. Choudhry’s Expert Report is Insufficient as to Causation
Hilton argues that Dr. Choudhry established in his Report that Appellees breached the
standard of care by delaying treatment and that the delay caused Ms. Jackson “to further decline
and ultimately suffer multisystem organ failure.” In contrast, Appellees argue that Dr.
Choudhry’s Report lacked an adequate explanation regarding causation so “as to be no report at
all.” Furthermore, they maintain that his Report failed to “explain how or why each of the
doctors’ conduct proximately caused [Ms.] Jackson’s injuries or death.”
In 2017, the Texas Supreme Court explained:
The Act’s expert-report requirement seeks “to deter frivolous lawsuits by
requiring a claimant early in litigation to produce the opinion of a suitable expert
that his claim has merit.” Unquestionably, a plaintiff asserting a health care
liability claim based on negligence, who cannot prove that her injury was
proximately caused by the defendant’s failure to meet applicable standards of
care, does not have a meritorious claim. While the plaintiff is not required to
prove her claim with the expert report, the report must show that a qualified
expert is of the opinion she can. The report need not use the words “proximate
cause,” “foreseeability” or “cause in fact.” “[A] report’s adequacy does not
depend on whether the expert uses any particular ‘magical words.’” And merely
incanting words does not suffice. “An expert’s simple ipse dixit is insufficient to
establish a matter; rather, the expert must explain the basis of his statements to
link his conclusions to the facts.” In showing how and why a breach of the
standard of care caused injury, the expert report must make a good-faith effort to
explain, factually, how proximate cause is going to be proven:
Proximate cause has two components: (1) foreseeability and
(2) cause-in-fact. For a negligent act or omission to have been a
cause-in-fact of the harm, the act or omission must have been a
substantial factor in bringing about the harm, and absent the act or
omission—i.e., but for the act or omission—the harm would not
have occurred.
immediate exploratory surgery.’” Because Hilton does not present in this section an argument as to notice or the standard of care, this Court has nothing to discuss or determine.
9
Zamarripa, 526 S.W.3d at 460 (alteration in original) (footnotes omitted) (citations omitted)
(quoting Rodriguez-Escobar v. Goss, 392 S.W.3d 109, 113 (Tex. 2013) (per curiam)). “This is
the causal relationship between breach and injury that an expert report must explain to satisfy the
Act[’s]” requirements. Id. If a plaintiff fails to provide an adequate expert report, one in which
one or more elements are found deficient, the trial court “shall . . . enter an order that: (1) awards
to the affected physician . . . reasonable attorney’s fees and costs of court incurred by the
physician . . . and (2) dismisses the claim with respect to the [defendant], with prejudice to
refiling the claim.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(b); see Scoresby v. Santillan,
346 S.W.3d 546, 553–54 (Tex. 2011).
Dr. Choudhry was not required to prove the entire case or to set out every known fact, but
he was required to explain, factually, how Appellees’ conduct caused Ms. Jackson’s injuries,
which in turn caused her death. The Texas Supreme Court explained in Jelinek v. Casas, 328
S.W.3d 526 (Tex. 2010),
When the only evidence of a vital fact is circumstantial, the expert cannot merely
draw possible inferences from the evidence and state that “in medical probability”
the injury was caused by the defendant’s negligence. The expert must explain
why the inferences drawn are medically preferable to competing inferences that
are equally consistent with the known facts. Thus, when the facts support several
possible conclusions, only some of which establish that the defendant’s
negligence caused the plaintiff’s injury, the expert must explain to the fact finder
why those conclusions are superior based on verifiable medical evidence, not
simply the expert’s opinion.
Id. at 536. Therefore, “expert testimony that the event is a possible cause of a condition cannot
ordinarily be treated as evidence of reasonable medical probability except when, in the absence
of other reasonable causal explanations, it becomes more likely than not that the condition did
10
not result from the evidence.” Id. (quoting Lenger v. Physician’s Gen. Hosp., Inc., 455 S.W.2d
703, 707 (Tex. 1970)). Furthermore,
[t]he burden of proof is on the plaintiff to show that the injury was negligently
caused by the defendant and it is not enough to show the injury together with the
expert opinion that it might have occurred from the doctor’s negligence and from
other causes not the fault of the doctor. Such evidence has no tendency to show
that negligence did cause the injury.
Id. (quoting Hart v. Van Zandt, 399 S.W.2d 791, 792 (Tex. 1965)). That is exactly what we have
in this case.
In his opinion, under a section entitled “Standard of Care, Breach in the Standard of Care,
and Causation,” Dr. Choudhry states that by April 8, 2022, “additional imaging showed concerns
of hollow viscus perforation.” He then explains that the radiologist called the physician to
discuss her concerns, “but she was only able to talk with a nurse who said she would relay the
findings,” presumably to the physician. Dr. Choudhry adds that the “[s]tandard of care would
dictate that the nurse would relay those findings, however, the medical records are silent as to
whether the nurse relayed the information and it is a breach in the standard of care to not relay
this information.” He then turns to Drs. Fraser or Campbell’s standard of care, stating, “Standard
of care would dictate that Dr. Fraser or Dr. Campbell order a CT scan of the abdomen and pelvis
upon learning of the results to determine where the perforation is located.” Dr. Choudhry opines
further, “Standard of care at this point would also be prompt exploratory surgery to locate the
perforation and repair the perforation. Neither of these things occurred.” Dr. Choudhry reasons
that had exploratory surgery taken place on April 8, rather than on April 9, Ms. Jackson would
have avoided the injuries that eventually caused her death.
11
As can be seen above, a significant amount of Dr. Choudhry’s analysis, and his resulting
conclusion, was driven by a series of events in which (1) an unnamed radiologist was unable to
speak to an unnamed physician on the telephone about “the very concerning nature of th[o]se
findings” from Ms. Jackson’s chest x-ray and KUB,8 so (2), the unnamed radiologist spoke with
a named registered nurse about “the very concerning nature of th[o]se findings,” and (3) the
same named registered nurse promised the unnamed radiologist that she would relay the findings
to the unnamed physician, but (4) Dr. Choudhry concedes that the nurse may or may not have
relayed the “concerning” findings to the unnamed physician.
Whether the named nurse, the unnamed radiologist, or the unnamed physician actually
conveyed the additional information to Appellees before they made their allegedly negligent
decisions (no further scans, no exploratory surgery) is simply not known, even according to Dr.
Choudhry’s own Report.9 Despite that, he relied on those unknown facts to conclude that
Appellees breached the standard of care. Simply put, Dr. Choudhry opined, without knowing the
relevant facts, that Appellees should have ordered a CT scan of Ms. Jackson’s abdominal area or
performed exploratory surgery “upon learning of the results.” (Emphasis added). He then
concluded that because Appellees failed to do either of those things, Ms. Jackson passed away.
And while this Court is aware that this case was in its initial phase at the time he prepared his 8
A “KUB” refers to a type of X-ray. “A kidney, ureter, and bladder (KUB) x-ray may be performed to assess the abdominal area for causes of abdominal pain, or to assess the organs and structures of the urinary and/or gastrointestinal (GI) system.” Kidney, Ureter, and Bladder X-ray, JOHN HOPKINS MEDICINE, http://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/kidney-ureter-and-bladder-xray (last visited December 15, 2025).
9
In his Report, Dr. Choudhry refers to the nurse’s standard of care in regard to the delivery of the unnamed radiologist’s message to the unnamed physician. He stated, “Standard of care would dictate that the nurse would relay those findings, however, the medical records are silent as to whether the nurse relayed the information and it is a breach in the standard of care to not relay this information.”
12
Report, incorporating incomplete factual assertions in the Report did not lend weight to Dr.
Choudhry’s final conclusion.
Notably, Hilton accuses Appellees of making negligent decisions that resulted in Ms.
Jackson’s sepsis, which then caused her death. However, Dr. Choudhry’s statement as to when
Ms. Jackson was diagnosed with sepsis differs from Hilton’s claim in her petition. In his Report,
Dr. Choudhry states as follows:
It appears Ms. Jackson would not have been transferred but for her family being
concerned that there was no plan for surgery.
At 0033 on 4/9/22, Ms. Jackson was admitted to Texas Health Dallas. It is
noted in the records that Ms. Jackson was transferred from an outside facility with
delayed presentation of perforated abdominal viscus and presented in multisystem
organ failure with sepsis related to delayed treatment of perforated viscus.
Yet, Hilton averred in her petition the following:
That same day [April 9, 2022], . . . Ms. Jackson was discharged and
admitted to a subsequent facility. Upon admission, Ms. Jackson underwent an
exploratory laparotomy where it was discovered both her transverse and sigmoid
colon were perforated. Ms. Jackson was then diagnosed with sepsis and
multisystem organ failure related to delayed treatment of perforated viscus. . . .
On or about April 28, 2022, Ms. Jackson passed away as a result of a perforated
abdominal viscus, acute respiratory failure and septic shock.
Simply stated, Dr. Choudhry opines that Ms. Jackson developed sepsis before she left Paris
Regional Medical Center while Hilton’s petition states that, after her exploratory surgery at
Texas Health Dallas, she was then diagnosed with sepsis. The difference between these two
versions of events is of material importance if Dr. Choudhry claims the sepsis was, at least in
significant part, the cause of Ms. Jackson’s death.
13
Along the same lines, Dr. Choudhry opines that there is a direct link between Ms.
Jackson’s March 28 hip replacement surgery, which resulted in Appellees’ allegedly negligent
medical advice on April 9, and Ms. Jackson’s death on April 28, an entire month later. Dr.
Choudhry focuses on his conclusion, but he disregards other critical events that occurred
between those two dates. For example, during those three to four weeks, Ms. Jackson was a
patient in two different hospitals; underwent two invasive surgeries under a general anesthetic in
both of those hospitals; was cared for by countless healthcare workers with varying degrees of
knowledge; was subjected to a myriad of different tests, treatments, and procedures; required
intensive care and ventilator support following a medical procedure that took place “a few days”
after April 9; and received a tracheostomy on April 20. On April 28, her tracheostomy was
dislodged by an unnamed source and/or in an unidentified manner during physical therapy and,
on that same day, Ms. Jackson passed away. It is difficult, if not impossible, to determine which
person or persons were negligent if, in fact, any of them were.
Dr. Choudhry also failed to include a considerable amount of relevant information in his
Report. By way of example, Dr. Choudhry explains that Ms. Jackson had hip replacement
surgery on March 28 at Paris Regional Medical Center, and within a day of the surgery, she
developed “some abdominal distension.” However, Dr. Choudhry did not identify the person
who determined that Ms. Jackson developed “some abdominal distension,” how that person
came to that conclusion, or what type of healthcare worker made that determination.
Furthermore, Dr. Choudhry stated that due to that diagnosis, a KUB was ordered. Again, he did
not identify the person who ordered the KUB, what position that person held, or the position of
14
the person who interpreted the results. That type of information is critical in a case where a
myriad of healthcare workers, with varying degrees of knowledge and different standards of
care, are responsible for a patient’s well-being for a significant amount of time, yet, a specific
person (or persons) is named as the negligent party.
Here, Dr. Choudhry opined that Appellees’ single recommendation to follow a more
conservative treatment plan—as opposed to immediately proceeding with exploratory surgery—
resulted in Ms. Jackson’s death weeks later. Likewise, he made that determination regardless of
the fact that many other healthcare workers were responsible for Ms. Jackson’s care and were
responsible for making countless decisions regarding her health concerns both before and well
after Appellees made their allegedly negligent recommendation.
The most obvious example of this took place on the day Ms. Jackson passed away. Yet,
Dr. Choudhry’s Report practically disregards the incident as if it were of no consequence to his
analysis. He did, however, direct the reader to April 28, 2022, simply explaining that Ms.
Jackson’s tracheostomy was dislodged. From the record, we learn that at some point, an
unidentified healthcare professional, other than Appellees, determined that Ms. Jackson required
a tracheostomy, which was placed on April 20. We do not know who made that decision, what
type of healthcare professional that person was, or the reasoning behind the decision because it
was not included in Dr. Choudhry’s Report. Dr. Choudhry did refer to the date of April 28,
2022, in his Report. On that day, an unidentified healthcare professional, other than Appellees,
determined that Ms. Jackson should participate in physical therapy despite her condition or
perhaps because of her condition. Dr. Choudhry’s Report did not say. Dr. Choudhry did explain
15
that during her physical therapy session that day, Ms. Jackson’s tracheostomy “became
dislodged, and she lost her airway.” There is no information in Dr. Choudhry’s Report regarding
the circumstances surrounding that unfortunate event. Sadly, Ms. Jackson “coded and was taken
urgently to the OR for replacement of her trach[eostomy tube].” Unfortunately, she did not
recover and passed away several hours later. Yet, there is no information in Dr. Choudhry’s
Report as to what happened to cause Ms. Jackson to die mere hours after she received another
tracheostomy. Yet, despite that relevant event, he concluded in his Report that “[h]ad a CT scan
and exploratory surgery been done on 4/8/22, Ms. Jackson, more likely than not, would have had
successful repair of her bowel perforation, and she would not have progressed to multiorgan
failure and sepsis.” He then concludes, “If surgical intervention had taken place on 4/8/22, it is
more likely than not that Ms. Jackson would have survived.” He reached that conclusion despite
the fact that Ms. Jackson had exploratory surgery at Texas Health Dallas just hours after
Appellees made their allegedly negligent recommendation to Ms. Jackson’s family. Dr.
Choudhry did not address how the several hours of delay in surgery was detrimental to Ms.
Jackson’s health, much less the cause of her death.
As is evident in this case, the facts contained in Dr. Choudhry’s Report support several
potential conclusions. Dr. Choudhry was required to demonstrate in his Report that he believed
that Hilton could prove that Ms. Jackson died because of Appellees’ allegedly negligent actions
or omissions. However, it was not enough to show that Ms. Jackson’s death might have
occurred from Appellees’ alleged negligence and from other causes not the fault of Appellees.
16
Moreover, Dr. Choudhry’s Report does not adequately support a conclusion that, absent
Appellees’ allegedly negligent actions, Ms. Jackson would still be alive.
We overrule Hilton’s first point of error.
III. Hilton’s Alternative Argument
Hilton argues, in the alternative, that the trial court erred when it refused to grant a thirtyday extension of time to allow Dr. Choudhry to cure any deficiencies contained in his Report.
Section 74.351(c) confers upon a trial court the discretion to give a plaintiff an additional
thirty days to cure a deficiency in an expert report in certain circumstances. Scoresby, 346
S.W.3d at 549 (citing TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c)). A trial court may grant
a thirty-day extension if the report was served by the statutory deadline, contains an expert’s
opinion that the plaintiff’s claim has merit, and the defendant’s conduct is implicated. Id. at 557.
A trial court’s discretion under Section 74.351(c) is based on the need to dispose of frivolous
claims and the need to preserve meritorious ones. Id. at 554. “A court may not provide
opportunities to cure, however, when an expert report is ‘absent’ as opposed to deficient. If an
expert report fails to address all required elements of a claim, the trial court may not consider an
extension.” Hollingsworth v. Springs, 353 S.W.3d 506, 524 (Tex. App.—Dallas 2011, no pet.)
(citing Samlowski v. Wooten, 332 S.W.3d 404, 417–18 (Tex. 2011)). “In making that
determination, a trial court may sometimes err and dismiss a claim when the report could have
been cured.” Samlowski, 332 S.W.3d at 411. “A reasonable error in judgment, however, is not
an abuse of discretion.” Id. (citing Walker v. Packer, 827 S.W.2d 833, 839–40 (Tex. 1992))
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(“noting that reviewing court may not substitute its judgment as to factual matters committed to
trial court’s discretion”).
We have previously required experts to explain the causal relationship between alleged
breaches of the standard of care and medical outcomes that happened later, following intervening
events:
[Dr. Chand’s expert report] faults Parmar for untimely postoperative diagnosis of
a perforation. Yet, Chand does not explain what injuries, if any, could have been
avoided had Parmar diagnosed the esophageal perforation earlier. The report fails
to state whether, had the perforation been found after the first CT on April 18,
Colburn could have avoided either the thoracotomy to repair the esophageal
perforation or the other procedures performed by Kim [beginning on April 27]. It
does not address whether Colburn, whose condition worsened after Kim’s
surgery, would have had a better outcome absent any negligence by Parmar . . . .
Parmar v. Colburn, No. 06-20-00093-CV, 2021 WL 1799867, at *7 (Tex. App.—Texarkana
May 6, 2021, no pet.) (mem. op.). “There can be no analytical gap between a breach of the
standard of care and the ultimate harm.” Tenet Hosps., Ltd. v. Barnes, 329 S.W.3d 537, 543
(Tex. App.—El Paso 2010, no pet.).
As we explained above, Dr. Choudhry’s Report failed to consider other significant risk
factors and other equally plausible causes of Ms. Jackson’s death. Because Dr. Choudhry’s
Report included an “analytical gap” between Appellees’ alleged breach and Ms. Jackson’s death
that could not be cured without considering impermissible inferences, we find no abuse of
discretion in the trial court’s determination that a thirty-day extension of time to cure the
causation defect would be in vain.
Accordingly, we overrule Hilton’s alternative argument and affirm the trial court’s denial
of her request for a thirty-day extension to cure the defects in Dr. Choudhry’s Report.
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V. Conclusion
We affirm the trial court’s orders granting Dr. Mark Campbell’s motion to dismiss;
granting Dr. Mark Gibbs and Paris Orthopedic Clinic, P.A.’s, motion to dismiss; and granting
Dr. Pia Lippincott’s motion to dismiss.
Charles van Cleef
Justice
Date Submitted: June 25, 2025
Date Decided: December 19, 2025
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