Expert Causation Testimony Required; Hospital Failed to Prevent Transfer

A 36-year-old woman, pregnant with a third child and midway through the third trimester, was taken by ambulance to the hospital’s labor and delivery emergency room. The woman had been vomiting and was experiencing fever, abdominal pain, and mild contractions. An obstetrician examined the woman and ordered a pain reliever, intravenous antibiotics, a sonogram, and an MRI, as well as a biophysical profile to test the health of the baby. The sonogram was normal and the baby appeared to be healthy, but the woman’s contractions continued. The MRI showed placenta accreta, an abnormal placental attachment to the uterine wall, which is a serious condition that increases the risk of heavy bleeding during delivery. 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.


The obstetrician ordered the woman be transferred to a medical center 159 miles away. The reason, according to medical records, was a “medical necessity upgrade in care,” though there was no emergency. The medical center agreed to accept the transfer. When the ambulance left the hospital to take the woman to the medical center, the woman was diaphoretic and felt pressure pain in the abdomen. Midway through the trip, the woman began to bleed and became anxious and restless. When the ambulance personnel would not stop for ice or to open the vehicle doors, the woman became extremely combative. The ambulance personnel called their employer for permission to divert to another facility so that the woman could be evaluated. The employer instructed the ambulance personnel to continue on. When the ambulance became stuck in a severe traffic jam, the woman began screaming to get to the hospital, then collapsed onto her side in cardiac arrest. The woman was pulseless and apneic, and the ambulance personnel began cardiopulmonary resuscitation. Approximately three hours after leaving the hospital, the ambulance arrived at the medical center. An emergency caesarian section and hysterectomy were immediately performed. The woman was stable at first. Approximately seven hours after the woman arrived at the medical center, the woman died. The woman’s baby girl was stillborn.


The woman’s wrongful death beneficiaries sued the obstetrician at the hospital, the hospital, the obstetrician at the medical center, the medical center, and the ambulance company. The complaint alleged that hospital personnel allowed the woman to be discharged when the woman was not suitable for discharge and that hospital personnel allowed a ground ambulance transfer when the woman should not have been transferred.


The Texas Medical Liability Act imposes a threshold requirement that the plaintiff furnish a statement of opinion by an individual with expertise indicating that the claim asserted has merit. 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.


To satisfy the statutory expert report requirement, the woman’s wrongful death beneficiaries timely served on the hospital two reports. One report was written by a nurse with experience in the labor and delivery setting, as well as the emergency room. The other report was by an obstetrician/gynecologist.


The nurse’s report stated that the hospital’s nurses breached the standard of care by not advocating for additional treatment of preterm labor when the woman’s contractions continued and by not advocating for further investigation and treatment of the woman’s low fibrinogen levels and continued abdominal pain/pressure once the woman was diagnosed with placenta accreta. Additionally, the nurse opined that the hospital nurses breached the standard of care by allowing the woman to be transferred to another facility many miles away while the woman was clearly in preterm labor.


The obstetrician/gynecologist’s report stated that due to the breaches of care by the hospital personnel in permitting and facilitating the transfer, the woman was in an ambulance on the highway when and where timely emergent caesarian section and hysterectomy surgery was not available when the woman began to bleed from the abrupted placenta. The woman’s bleeding caused cardiovascular arrest due to lack of oxygen carried to the heart for sufficient pumping. This collapse led to disseminated intravascular coagulation (DIC), in which small blood clots develop throughout the bloodstream, blocking small blood vessels; the increased clotting depletes the platelets and clotting factors needed to control bleeding, causing excessive bleeding, and the woman’s death.


The hospital objected to the expert reports and moved to dismiss on the ground that the reports were insufficient to show how the hospital caused the woman’s death. Specifically, the hospital argued that it was the obstetrician, not the hospital, who ordered the woman transferred. The trial court overruled the hospital’s objection and denied its motion to dismiss.


The Court of Appeals of Texas, Corpus Christi-Edinburg (13th Dist.), held that the expert report was not required to address proximate cause.


The Supreme Court of Texas reversed. The court held that the wrongful death beneficiaries’ expert report was required to show proximate cause.


The wrongful death beneficiaries’ expert report was required to show proximate cause. Generally, to satisfy the expert report requirement, an expert must explain, based on facts set out in the report, how and why a health care provider’s breach of the standard of care caused the injury. A bare expert opinion that the breach caused the injury will not suffice. Rather, the expert must explain the basis of statements to link the conclusions to the facts. Only the expert obstetrician/gynecologist could testify regarding causation. The expert obstetrician/gynecologist failed to explain how the hospital permitted or facilitated the woman’s transfer or even whether the hospital had any say in the matter. The expert nurse and expert obstetrician/gynecologist did not explain how investigating the woman’s fibrinogen levels and abdominal pain further would have averted the transfer. The expert nurse and expert obstetrician/gynecologist did not explain how the hospital had either the right or the means to persuade the hospital obstetrician not to order the transfer or to stop the transfer after it was ordered. The court concluded the wrongful death beneficiaries’ expert reports did not show how the hospital caused the woman’s death. The court ordered the case remanded to the trial court to consider a 30-day extension to cure deficiencies in the expert report.


The Supreme Court of Texas reversed the appellate court’s affirmation of the trial court’s denial of the hospital’s motion to dismiss on the ground that the expert opinions failed to address causation.


See: Columbia Valley Healthcare System, L.P. d/b/a Valley Regional Medical Center v. Zamarripa, 2017 WL 2492003 (Tex., June 9, 2017) (not designated for publication).


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