Jared Bush, Jr. v. Columbia Medical Center of Arlington Subsidiary, L.P. D/B/A Medical City Arlington and Hca Inc.

Supreme Court of Texas
══════════
No. 23-0460
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Jared Bush, Jr.,
Petitioner,

v.

Columbia Medical Center of Arlington Subsidiary, L.P. d/b/a
Medical City Arlington and HCA Inc.,
Respondents

═══════════════════════════════════════
On Petition for Review from the
Court of Appeals for the Second District of Texas
═══════════════════════════════════════

Argued September 12, 2024

JUSTICE HUDDLE delivered the opinion of the Court, in which
Chief Justice Blacklock, Justice Lehrmann, Justice Boyd, Justice Busby,
Justice Young, and Justice Sullivan joined.

JUSTICE BLAND filed a dissenting opinion, in which Justice Devine
joined.

Health care liability claimants must timely serve an adequate
expert report to each defendant. A report is adequate if it “provides a
fair summary of the expert’s opinions.” TEX. CIV. PRAC. & REM. CODE
§ 74.351(r)(6). In this medical malpractice case, the trial court twice
held that a timely served expert report was adequate. The court of
appeals disagreed and ultimately dismissed the plaintiff’s claims
against a hospital with prejudice, concluding that the expert’s amended
report was deficient because his causation opinion was conclusory. We
hold that the trial court did not abuse its discretion in concluding that
the report adequately supported the claim against the hospital.
Accordingly, we reverse the judgment of the court of appeals and remand
to the trial court for further proceedings.
I. Background
As alleged, 35-year-old Ireille Williams-Bush fainted and was
taken by ambulance to Medical City Arlington Hospital. She presented
with symptoms consistent with a pulmonary embolism (a blood clot in
the lungs): chest pain, shortness of breath, and severe fainting. But the
emergency room doctor’s initial impression was that she had suffered a
non-ST-elevated myocardial infarction (a type of heart attack), so the
hospital admitted her under that diagnosis. 1 The consulting cardiologist
performed a cardiac catheterization procedure on Williams-Bush but
never screened her for pulmonary embolism. Williams-Bush was later
discharged in stable condition with instructions to follow up in two
weeks. Three days after her discharge, she was found in bed, struggling
to breathe. She was rushed to the hospital but died that day. An
autopsy revealed clotting in her heart and lungs.

1 Williams-Bush was initially seen by Shalako Bradley, D.O. and was

admitted and eventually discharged by hospitalist Zakari Tanimu, M.D., who
consulted with cardiologist Atif Sohail, M.D.

2
Williams-Bush’s husband, Jared Bush (acting individually and on
behalf of his wife’s estate and their two children), sued Columbia
Medical Center of Arlington Subsidiary, L.P. d/b/a Medical City
Arlington and HCA, Inc. d/b/a HCA Healthcare (together, the Hospital),
as well as the emergency room doctor, the admitting hospitalist, the
consulting cardiologist, and those physicians’ practice groups, for
negligence. We focus on the adequacy of the expert report’s theory of
liability against the Hospital because the claims against the physicians
and their practice groups are not at issue here. With respect to the
Hospital, Bush alleges that “the acts and/or omissions of [the Hospital]
constituted deviations from the applicable standards of care in
numerous respects including,” among other things, “[f]ailure to have
and/or enforce adequate protocols, policies and/or procedures.”
The first report. Bush timely served the Hospital with an expert
report prepared by Dr. Cam Patterson, a board-certified cardiologist
with over twenty years of experience in clinical practice and education.
Dr. Patterson has also served in administrative roles as Chief of the
Division of Cardiology at the University of North Carolina at Chapel
Hill, the physician-in-chief of the UNC Center for Heart and Vascular
Care, and the Executive Director of UNC McAllister Heart Institute.
The Hospital objected to the report and moved to dismiss Bush’s
claims on the grounds that (1) Dr. Patterson was either unqualified to
opine on standards of care for hospital policies or the statements about
his qualifications were conclusory and (2) his opinions about the
Hospital’s breach of the standard of care and about causation were
conclusory. See id. § 74.351(a) (allowing the defendant to object to an

3
expert report’s sufficiency), (b) (requiring dismissal on a defendant’s
motion when “an expert report has not been served”). The trial court
denied the motion, and the Hospital appealed. See id. § 51.014(a)(9).
The court of appeals reversed, holding the report failed to establish
Dr. Patterson’s qualifications to testify about the Hospital’s standard of
care and, alternatively, that his opinions about standard of care, breach,
and causation were conclusory and therefore did not comply with
Chapter 74’s “good-faith” requirement. Columbia Med. Ctr. of Arlington
Subsidiary, L.P. v. J.B. (Bush I), No. 02-20-00190-CV, 2021 WL
5132535, at *8–10 (Tex. App.—Fort Worth Nov. 4, 2021, no pet.).
The court of appeals reasoned that the Hospital’s alleged
violations of the standard of care—the failure to have a proper protocol
to ensure Williams-Bush was properly evaluated and treated and
allowing her to be discharged—“implicate the practice of medicine.” Id.
at *8. It noted that “[a] hospital cannot practice medicine and therefore
cannot be held directly liable for any acts or omissions that constitute
medical functions.” Id. (alteration in original) (quoting Reed v.
Granbury Hosp. Corp., 117 S.W.3d 404, 415 (Tex. App.—Fort Worth
2003, no pet.)). Thus, the court concluded that the expert’s report was
deficient if it did not explain “how his opinions do not implicate the
practice of medicine”:
If such things as establishing administrative polic[i]es on
ordering particular tests and discharging patients aren’t
medical functions, an expert purporting to pin direct rather
than vicarious blame on a hospital for a policy or protocol
failure should reasonably be expected to explain how his
opinions do not implicate the practice of medicine, even at
this preliminary stage.

4
Id. The court of appeals purported to draw support for its conclusion
from Columbia Valley Healthcare System, L.P. v. Zamarripa, 526
S.W.3d 453 (Tex. 2017). In Zamarripa, a physician ordered a pregnant
woman to be transferred to another hospital in an unhealthy condition,
and the plaintiff’s expert asserted that the hospital was negligent
because its nurses “permitt[ed] and facilitat[ed] her transfer.” Id.
at 457–58. We held the expert’s report was insufficient because it failed
to explain “how [the hospital] had either the right or the means to
persuade [the physician] not to order the transfer or to stop it when he
did.” Id. at 461. Relying on that holding, the court of appeals held that
Dr. Patterson’s report was similarly deficient. Bush I, 2021 WL
5132535, at *9. On this point, the court reasoned that the report did not
explain how the Hospital’s “policies, procedures, and protocols—which
can be implemented only through its nurses and staff—could have
changed what the physician did in ordering tests, making his diagnosis,
and discharging [Williams-Bush].” Id. The court of appeals reversed
and remanded, allowing the trial court to consider whether to grant a
thirty-day extension to cure the report’s deficiencies. Id. at *10; see TEX.
CIV. PRAC. & REM. CODE § 74.351(c).
The amended report. Dr. Patterson filed an amended report
setting forth his qualifications and opinions on standard of care, breach,
and causation. 2 Central to this appeal is Dr. Patterson’s opinion that
“[h]ospitals that treat acute cardiovascular patients are required to have
systems-based polic[i]es, protocols and procedures to ensure patients are

2 The Hospital did not challenge Dr. Patterson’s qualifications as set

forth in the amended report.

5
treated and managed appropriately.” Their purpose, according to
Dr. Patterson, is “to ensure that patients presenting with chest pain,
shortness of breath and severe syncope [i.e., fainting] are properly
evaluated, assessed, tested, treated and diagnosed.” Dr. Patterson
describes the different systems within a hospital that must work
together to provide patient care, and he explains that the standard of
care for this systems-based operation “requires appropriate
development, implementation, training and enforcement of policies and
procedures regarding the evaluation, identification and communication
related to treating acute cardiac patients.” He explains that “every
hospital treating acute cardiovascular patients has a responsibility to
ensure that the systems-based procedures and protocols are
appropriately developed, implemented, and enforced through proper
education and training to providers involved, including nurses, medical
staff and physicians.”
For someone presenting with Williams-Bush’s symptoms and
medical history, i.e., a female in her mid-thirties on oral contraceptives
with no other cardiac risk factors, Dr. Patterson opines that the Hospital
must have “appropriate hospital polic[i]es, protocols and procedures
[that] would have required specific steps be undertaken, such as order
sets for imaging and lab work, to ensure that a massive pulmonary
embolism was ruled out as a life-threat[en]ing etiology of her
symptoms.” Dr. Patterson recounts his experience as a hospital
administrator developing, implementing, and enforcing what he refers
to as “systems-based ‘Triple Rule Out’ protocols to ensure that critical
cardiac pathologies, including aortic dissection, pulmonary embolism

6
and coronary artery disease, are appropriately considered, investigated
and ruled out in every hospital patient presenting with signs and
symptoms similar to those in this matter.” The Triple Rule Out protocol
“requires either a series of test[s] or specific protocol[s] to perform
imaging studies to include or exclude pulmonary embolism as a
diagnosis, such as a protocol for performing [a] CT angiogram, which is
a triple rule out study.” According to the amended report, hospitals
must have and enforce this protocol “to be activated under appropriate
conditions, such as this,” because it “helps clinicians rule out, or in, three
of the most life-threatening critical conditions of chest pain,” including
pulmonary embolism, “in one single scan.” These policies, procedures,
and guidelines “ensure appropriate communication between providers
and interdisciplinary teams involved in individual patient care.”
Dr. Patterson opines that the Hospital breached the standard of
care by failing to adopt and enforce such a protocol and that breach was
a direct and proximate cause of Williams-Bush’s death. His report
states that the failure to “have policies, protocols and procedures in
place, to ensure pulmonary embolism was ruled out as a potential
underlying etiology,” was a violation of the standard of care that led to
“a life-threatening condition” not being “appropriately assessed,
monitored, diagnosed and treated, which greatly increased the risk of a
fatal thromboemboli [i.e., clotting] event, which ultimately occurred.”
As a result of the Hospital’s failure to adopt such a policy, “a proper
workup was never completed[,] which resulted in a lack of appropriate
communication between interdisciplinary providers and the massive
pulmonary embolism was never appropriately ruled out as the

7
underlying etiology of symptoms nor treated prior to discharge.” The
amended report opines that, “[a]s a direct result of these violations of
the standard of care, [Williams-Bush] was discharged without
pulmonary embolism being properly ruled out as her underlying
etiology.”
The Hospital moved to dismiss on the ground that Dr. Patterson’s
amended report was inadequate. The trial court again denied the
motion, but the court of appeals reversed and directed the claims against
the Hospital be dismissed with prejudice. 692 S.W.3d 606, 609 (Tex.
App.—Fort Worth 2023).
In the second appeal, the court of appeals addressed only
causation, and it again deemed the report conclusory. Id. at 612. The
court reasoned that the report “still fails to explain how the mere
presence of standard order sets, policies, procedures, or protocols would
have overridden the actual medical decisions, diagnoses, and treatment
orders of the doctors who were present and deciding how
[Williams-Bush] should be managed.” Id. at 613 (citing Zamarripa,
526 S.W.3d at 461). According to the court of appeals, Dr. Patterson’s
amended report says the policies “would be binding on the medical staff”
but did “not describe how the hospital could enact and enforce such rules
on medical decision making.” Id. (emphasis added). The court of
appeals identified several other so-called “analytical gaps”:
[I]f a doctor evaluates a patient and does not implement
the hospital’s protocol, what happens? Does a nurse or
other hospital employee then have the authority to order
the tests? If not, how does the protocol get implemented?
Does it require invoking a chain of command within the
hospital administration, medical staff, or otherwise? If so,

8
who all is involved and how long does it take? While the
decision-making is being reviewed, who handles the
patient’s medical care?
Id. Because Bush previously had an opportunity to amend the report,
the court remanded with instructions to dismiss Bush’s claims against
the Hospital with prejudice. Id. at 609.
Bush petitioned this Court for review, which we granted.
II. Relevant law
The Texas Medical Liability Act requires health care liability
claimants to timely serve an adequate expert report on each defendant.
TEX. CIV. PRAC. & REM. CODE § 74.351(a). The statute imposes a modest
requirement at this early stage of litigation: A report is sufficient if it
“provides a fair summary of the expert’s opinions as of the date of the
report regarding applicable standards of care, the manner in which the
care rendered by the physician or health care provider failed to meet the
standards, and the causal relationship between that failure and the
injury, harm, or damages claimed.” Id. § 74.351(r)(6) (emphasis added).
A court may dismiss the suit if the report is untimely or deficient. Id.
§ 74.351(b). However, a court shall grant a motion challenging the
report’s adequacy “only if it appears to the court, after hearing, that the
report does not represent an objective good faith effort” to provide the
required “fair summary” of the applicable standard of care, the
defendant’s breach, and how that breach caused the ultimate injury. Id.
§ 74.351(l).
A report represents a good-faith effort if it “(1) inform[s] the
defendant of the specific conduct called into question and (2) provid[es]
a basis for the trial court to conclude the claims have merit.” Baty v.

9
Futrell, 543 S.W.3d 689, 693–94 (Tex. 2018). At this threshold stage of
the case, the adequacy of an expert report is measured by a “lenient
standard.” Scoresby v. Santillan, 346 S.W.3d 546, 549 (Tex. 2011); see
Loaisiga v. Cerda, 379 S.W.3d 248, 264 (Tex. 2012) (Hecht, J.,
concurring in part and dissenting in part) (describing the standard as a
“low threshold”). In this context, “good faith effort” “simply means a
report that does not contain a material deficiency.” Samlowski v.
Wooten, 332 S.W.3d 404, 409–10 (Tex. 2011) (plurality op.). An expert
report will meet this standard if it “includes all the required elements,
and . . . explains their connection to the defendant’s conduct in a
non-conclusory fashion.” Id. at 410 (citation omitted). “No particular
words or formality are required, but bare conclusions will not suffice.”
Scoresby, 346 S.W.3d at 556 (footnotes omitted).
At this early stage of litigation, the purpose of this low threshold
is to “weed out frivolous malpractice claims,” not to adjudicate
potentially meritorious claims. Abshire v. Christus Health Se. Tex.,
563 S.W.3d 219, 223 (Tex. 2018) (citing Am. Transitional Care Ctrs. of
Tex., Inc. v. Palacios, 46 S.W.3d 873, 877 (Tex. 2001)). A report is not
required to “marshal all the plaintiff’s proof” to avoid dismissal.
Palacios, 46 S.W.3d at 878. In analyzing a report’s sufficiency, courts
must consider “only the information contained within the four corners
of the report.” Abshire, 563 S.W.3d at 223; see also Bowie Mem’l Hosp.
v. Wright, 79 S.W.3d 48, 52 (Tex. 2002). We review for an abuse of
discretion a trial court’s decision to grant or deny a defendant’s motion
to dismiss based on the adequacy of an expert report. Abshire,
563 S.W.3d at 223. As with many discretionary decisions, “[c]lose calls

10
must go to the trial court.” Larson v. Downing, 197 S.W.3d 303, 304
(Tex. 2006).
This Court has explained that a report “adequately addresses
causation when the expert explains ‘how and why’ breach of the
standard caused the injury in question by ‘explain[ing] the basis of his
statements and link[ing] conclusions to specific facts.’” E.D. v. Tex.
Health Care, P.L.L.C., 644 S.W.3d 660, 664 (Tex. 2022) (alterations in
original) (quoting Abshire, 563 S.W.3d at 224).
To satisfy the causation requirement, “the expert need not prove
the entire case or account for every known fact; the report is sufficient if
it makes ‘a good-faith effort to explain, factually, how proximate cause
is going to be proven.’” Abshire, 563 S.W.3d at 224 (quoting Zamarripa,
526 S.W.3d at 460). Proximate cause includes both cause in fact and
foreseeability. Doe v. Boys Clubs of Greater Dall., Inc., 907 S.W.2d 472,
477 (Tex. 1995). Cause in fact is established by showing “the negligent
‘act or omission was a substantial factor in bringing about injury,’
without which the harm would not have occurred.” Id. (quoting
Prudential Ins. Co. of Am. v. Jefferson Assocs., Ltd., 896 S.W.2d 156, 161
(Tex. 1995)). An “injury is foreseeable if its ‘general character . . . might
reasonably have been anticipated.’” Id. at 478 (omission in original)
(quoting Nixon v. Mr. Prop. Mgmt. Co., 690 S.W.2d 546, 551 (Tex. 1985)).
And though foreseeability must be addressed as a part of proximate
cause, no “magical words” are required. Zamarripa, 526 S.W.3d at 460
(quoting Wright, 79 S.W.3d at 53).
The court’s role with respect to causation “is to determine
whether the expert has explained how the negligent conduct caused the

11
injury,” not whether the expert has proved causation. Abshire, 563
S.W.3d at 226 (emphasis added). The “fair summary” threshold “is not
an evidentiary standard, and at this early stage of the litigation, ‘we do
not require a claimant to present evidence in the report as if it were
actually litigating the merits.’” E.D., 644 S.W.3d at 667 (quoting
Abshire, 563 S.W.3d at 226). Instead, “[t]he ultimate evidentiary value
of the opinions proffered”—that is, whether there actually is a causal
connection—“is a matter to be determined at summary judgment and
beyond.” Id. (alteration in original) (quoting Abshire, 563 S.W.3d
at 226). For this reason, an “adequate” expert report “does not have to
meet the same requirements as the evidence offered in a
summary-judgment proceeding or at trial.” Miller v. JSC Lake
Highlands Operations, LP, 536 S.W.3d 510, 517 (Tex. 2017) (quoting
Palacios, 463 S.W.3d at 879).
The same lenient standard applies to the other elements of the
expert’s report. An expert report adequately articulates the elements of
standard of care and breach when it “set[s] forth specific information
about what the defendant should have done differently; that is, what
care was expected, but not given.” Uriegas v. Kenmar Residential HCS
Servs., Inc., 675 S.W.3d 787, 790 (Tex. 2023) (internal quotation marks
omitted). A hospital’s standard of care “is what an ordinarily prudent
hospital would do under the same or similar circumstances.” Palacios,
46 S.W.3d at 880. 3

3 Our courts of appeals have held that a hospital owes a duty to its

patients “to use reasonable care in formulating the policies and procedures that
govern the hospital’s medical staff and nonphysician personnel.” Reed, 117

12
Importantly, we have never required an expert to “anticipate or
rebut all possible defensive theories that may ultimately be presented
to the trial court” as litigation proceeds. Owens v. Handyside, 478
S.W.3d 172, 187 (Tex. App.—Houston [1st Dist.] 2015, pet. denied)
(citing Wright, 79 S.W.3d at 52). At this early point, whether the
expert’s explanation is credible, reasonable, or believable is irrelevant;
those questions are to be litigated later in the proceedings. See Abshire,
563 S.W.3d at 226 (explaining that courts are not to “weigh the report’s
credibility” or question whether the expert’s “explanation is believable”);
Miller, 536 S.W.3d at 516–17 (providing that the believability of the
expert’s explanations is not at issue). Rather, our inquiry is confined to
the narrow question of whether Dr. Patterson’s amended report has
made a good-faith effort to comply with the statutory requirements.
III. Analysis
The court of appeals held that Dr. Patterson’s amended report
was conclusory as to causation, and therefore deficient under
Chapter 74, because it did not “explain how and why Hospital policies,
procedures, and protocols . . . could have changed what the physician
did in ordering tests, making his diagnosis, and discharging
[Williams-Bush] when she was in stable cardiac condition.” 692 S.W.3d
at 612–13 (quoting Bush I, 2021 WL 5132535, at *9). We disagree.

S.W.3d at 409; see Chesser v. LifeCare Mgmt. Servs., L.L.C., 356 S.W.3d 613,
628–29 (Tex. App.—Fort Worth 2011, pet. denied) (holding sufficient evidence
supported a jury finding that the hospital’s negligence in failing to implement
policies and procedures relating to post-operative patients proximately caused
the plaintiff’s injury).

13
A.
The amended report adequately articulates Dr. Patterson’s
opinions regarding causation because it explains “how and why” the
Hospital’s alleged breach of the articulated standard of care led to the
patient’s death. E.D., 644 S.W.3d at 667. That is, the amended report
“draws a line directly” from the Hospital’s failure to adopt policies or
protocols “regarding the evaluation, identification and communication
related to treating acute cardiac patients” to the physicians’ failure to
identify and treat Williams-Bush’s pulmonary embolism, which led to
the ultimate injury—her death. Abshire, 563 S.W.3d at 225.
With respect to cause in fact, Dr. Patterson explains that, as a
result of the Hospital’s failure to implement the described policies, such
as a Triple Rule Out protocol, “a proper workup was never completed[,]
which resulted in a lack of appropriate communication between
interdisciplinary providers.” Had such a workup been completed, and
“had it been recognized that [Williams-Bush] was experiencing a
bilateral pulmonary embolism, she would have been evaluated by a
cardiac or vascular surgeon and would have immediately been
anticoagulated, possibl[y] thrombolized and admitted for observation.”
(Emphasis added.) The report opines that, as a direct result of these
failures, Williams-Bush suffered from a “pulmonary embolism that
remained undetected and untreated, directly leading to her sudden and
untimely death.”
As to foreseeability, the report opines that Williams-Bush
presented “with symptoms classically associated with pulmonary
embolism” and that such a condition is one of the three “most

14
life-threatening critical conditions of chest pain.” The report explains in
detail the policies and procedures Dr. Patterson believes the Hospital
should have implemented to ensure that patients presenting with
symptoms like Williams-Bush’s are properly screened for certain
common life-threatening conditions and concludes that Williams-Bush’s
condition “could have been easily detected” if such policies had been in
place. The expert report fairly summarizes Dr. Patterson’s opinion as
to how and why the Hospital’s alleged failure to implement policies such
as standing orders to perform appropriate tests for patients presenting
with Williams-Bush’s symptoms “foreseeably led to the delay in
recognizing the need,” E.D., 644 S.W.3d at 667, to treat her for a
pulmonary embolism instead of discharging her.
In sum, Dr. Patterson opines that the Hospital’s failure to adopt
certain policies, such as a standing order to run the Triple Rule Out
protocol for patients presenting with certain symptoms, caused a
misdiagnosis, which caused Williams-Bush to die from a pulmonary
embolism. Because the report adequately explains the links in the
causal chain, Abshire, 563 S.W.3d at 225–26, we hold the amended
report is adequate as to causation.
In concluding otherwise, the court of appeals “exceed[ed] the
scope of the fair-summary standard by impermissibly weighing the
credibility of the expert’s opinions.” E.D., 644 S.W.3d at 667. The court
faulted Dr. Patterson for failing to explain why implementing the
hypothesized policies would not amount to the hospital practicing
medicine, which is prohibited. 692 S.W.3d at 612–13; see, e.g., Drs.
Hosp. at Renaissance, Ltd. v. Andrade, 493 S.W.3d 545, 548 (Tex. 2016)

15
(explaining that health care institutions can provide health care but
only licensed doctors can provide medical care); TEX. CIV. PRAC. & REM.
CODE § 74.001(a)(19) (defining “[m]edical care” as “any act defined as
practicing medicine under Section 151.002, Occupations Code,
performed or furnished . . . by one licensed to practice medicine”); TEX.
OCC. CODE § 151.002(a)(13) (defining “[p]racticing medicine” as “the
diagnosis, treatment, or offer to treat” a medical condition). The court
fashioned a hurdle that is neither statutorily nor judicially mandated:
“[A]n expert purporting to pin direct rather than vicarious blame on a
hospital for a policy or protocol failure should reasonably be expected to
explain how his opinions do not implicate the practice of medicine, even
at this preliminary stage.” 692 S.W.3d at 613 (quoting Bush I, 2021 WL
5132535, at *8). This requirement impermissibly raises the standard by
which the adequacy of an expert report is measured in two ways.
First, adopting the court of appeals’ reasoning would essentially
force experts to anticipate and refute potential defensive theories in
reports they author pre-litigation. But nothing in Chapter 74’s text
contemplates such a requirement, and our precedents eschew it. This is
not to say that we agree with Dr. Patterson’s theory of the case. Indeed,
the evidence adduced later in the litigation process, at summary
judgment or trial, may ultimately demonstrate that policies of the type
Dr. Patterson describes would run afoul of the law prohibiting the
corporate practice of medicine. Or the evidence may demonstrate that
the standard of care does not require such policies for some reason
having nothing to do with the prohibition on the corporate practice of
medicine. But these possibilities do not undermine our conclusion that

16
Dr. Patterson’s amended report satisfies the modest requirement that
governs at this stage of the litigation, which is only that he provide a
good-faith explanation regarding the challenged elements of the
plaintiff’s claim. See E.D., 644 S.W.3d at 667 (emphasizing that the “fair
summary” threshold “is not an evidentiary standard, and . . . ‘we do not
require a claimant to present evidence in the report as if it were actually
litigating the merits’” of the case (quoting Abshire, 563 S.W.3d at 226));
Miller, 536 S.W.3d at 517 (noting that our inquiry at this stage is not
“[w]hether each defendant is liable . . . ; that will be answered further in
the litigation process”); Palacios, 46 S.W.3d at 878 (explaining that “[a]
report need not marshal all the plaintiff’s proof” to avoid dismissal); id.
at 879 (“[T]he information in the report does not have to meet the same
requirements as the evidence offered in a summary-judgment
proceeding or at trial.”); Owens, 478 S.W.3d at 187 (noting that an expert
report “need not anticipate or rebut all possible defensive theories that
may ultimately be presented to the trial court” to avoid dismissal).
Rather, “[t]he ultimate evidentiary value of the opinions proffered”—
that is, whether there actually is a causal connection between the
alleged breach and the injury—“is a matter to be determined at
summary judgment and beyond.” E.D., 644 S.W.3d at 667 (alteration in
original) (quoting Abshire, 563 S.W.3d at 226).
Second, imposing this requirement presumes that the Hospital’s
implementation of the policies and protocols Dr. Patterson describes
would constitute the unlawful practice of medicine. But while
Dr. Patterson’s report contemplates policies of various types, it nowhere
suggests that any Hospital policy would or should usurp or even

17
encroach on the role of the physicians, the only actors who may diagnose
and exercise judgment to determine the proper treatment for patients.
See TEX. OCC. CODE § 151.002(a)(13) (defining “[p]racticing medicine” as
“the diagnosis, treatment, or offer to treat a mental or physical disease
or disorder or . . . injury”). Hospital policies may guide or suggest
treatment paths without mandating them or running afoul of the
prohibition on the corporate practice of medicine. See Marsillo v.
Dunnick, 683 S.W.3d 387, 389–90 (Tex. 2024) (describing a claim based
on a physician’s adherence to the hospital’s snakebite-treatment
protocol); Pediatrix Med. Grp., Inc. v. Robinson, 352 S.W.3d 879, 886
(Tex. App.—Dallas 2011, no pet.) (reviewing an expert report referring
to a hospital’s NICU policies and procedures). Indeed, several Texas
courts and the Legislature have recognized the propriety of “standing
orders” through which physicians can delegate certain tasks to
non-physician staff. See TEX. OCC. CODE § 157.005 (“A person to whom
a physician delegates the performance of a medical act is not considered
to be practicing medicine without a license by performing the medical
act . . . .”); id. § 157.054 (stating the conditions under which a medical
facility can have standing orders and protocols); id. § 157.003
(authorizing delegation of medical acts to properly qualified and
certified persons in an emergency); Mercy Hosp. of Laredo v. Rios,
776 S.W.2d 626, 634–35 (Tex. App.—San Antonio 1989, writ denied)
(describing claimed breaches of a hospital’s “standing orders”).
El Paso Healthcare System, Ltd. v. Monsivais, No. 08-18-00043-
CV, 2019 WL 5616973 (Tex. App.—El Paso Oct. 31, 2019, pet. denied),
illustrates that a non-physician may undertake specified medical acts

18
when authorized by a standing order despite the fact that his taking the
same action in the absence of that order might constitute the
unauthorized practice of medicine. The expert in that case opined the
hospital breached the standard of care because it did not have its nurses
and emergency medical technicians “order diagnostic tests,” “admit” a
patient to the hospital, “properly diagnose” the malady, or correctly
“treat” the condition. Id. at *4 (emphases added). The court concluded
that adherence to the espoused standard of care would cause these
non-physician staff to unlawfully practice medicine without a license.
Id. at *5–6. But the court contrasted this type of conduct from “standing
orders” or “protocols,” which do not necessarily involve the unauthorized
practice of medicine:
[W]e do not overlook that hospital medical staff might have
“standing orders” or “protocols” that they are required to
follow that might preauthorize them to conduct specified
tests or administer treatments. The Occupations Code
itself allows physicians to delegate authority in certain
defined circumstances to other health care providers. . . .
[A] person to whom a proper delegation was made is not
considered to be practicing medicine without a license.
Thus, it would hardly be a surprise for a person presenting
at a hospital with complaints of chest pain and shortness
of breath to have the staff initiate an immediate ECG
before ever seeing a physician. In such a case, the hospital
staff has not diagnosed a medical condition such as a heart
attack—they have merely followed a directive developed by
appropriately licensed and trained practitioners.
Id. at *6 (citations omitted). 4

4 Our dissenting colleagues point out that Dr. Patterson’s report
nowhere uses the term “standing orders.” Post at 16 (Bland, J., dissenting).
But “standing order” merely means “procedure,” a term Dr. Patterson’s report

19
Unlike the report found deficient in El Paso Healthcare System,
Dr. Patterson’s report asserts that the Hospital failed to develop
policies, protocols, and procedures that would have ensured specified
tests were run on a patient presenting with symptoms like
Williams-Bush’s. The report does not contend that the hospital staff,
based on their own initiative and authority, should have ordered and
run those tests. Nor does it suggest that hospital staff—as opposed to a
physician—would interpret the test results. To the contrary, the report
explains that proper lab work and imaging was not run due to the
Hospital’s failure to implement appropriate policies. This “resulted in a
lack of appropriate communication between interdisciplinary providers
and the massive pulmonary embolism was never appropriately ruled out
as the underlying etiology of symptoms nor treated prior to discharge.”
(Emphasis added.) As Dr. Patterson’s report does not call for the
Hospital or non-physician staff to “diagnose” or “treat,” the court of
appeals erred by faulting Dr. Patterson for not refuting the claim that it

uses ad nauseum. See Standing Order, Merriam-Webster.com Dictionary,
https://www.merriam-webster.com/dictionary/standing%20order (last visited
May 19, 2025) (“an instruction or prescribed procedure in force permanently or
until changed or canceled”); 22 TEX. ADMIN. CODE § 169.1(12) (defining
“[s]tanding delegation order” as “[w]ritten instructions, orders, rules, or
procedures designed for a patient population with specific . . . sets of
symptoms” and “provid[ing] a general set of conditions and circumstances
when action can be instituted prior to being examined or evaluated by a
physician”); see also TEX. R. CIV. P. 3a (referencing local rules, forms, and
standing orders). In any event, as all agree, “it is the substance of the opinions,
not the technical words used, that constitutes compliance with the statute.”
Hickory Trail Hosp., L.P. v. Webb, No. 05-16-00663-CV, 2017 WL 677828, at *3
(Tex. App.—Dallas Feb. 21, 2017, no pet.) (quoting Baylor Univ. Med. Ctr. v.
Rosa, 240 S.W.3d 565, 570 (Tex. App.—Dallas 2007, pet. denied)).

20
would. See Fortner v. Hosp. of the Sw., LLP, 399 S.W.3d 373, 382–83
(Tex. App.—Dallas 2013, no pet.) (holding an expert report adequate
where the expert opined the hospital could be liable for breaching a
standard of care based on hospital-implemented policies and procedures
directed at non-physician staff); see also Tex. Child.’s Hosp. v. Knight,
604 S.W.3d 162, 178–79 (Tex. App.—Houston [14th Dist.] 2020, pet.
denied) (holding an expert report sufficient when it opined that a
hospital breached the standard of care for failing to have applicable
policies and procedures governing post-operative assessment of surgical
patients); Methodist Richardson Med. Ctr. v. Cellars, No. 05-19-00378-
CV, 2019 WL 6486246, at *5 (Tex. App.—Dallas Dec. 3, 2019, no pet.)
(deeming adequate an expert report that opined the defendant hospital
was “required to involve itself in the transfer decision (at least
indirectly) by adopting and enforcing appropriate policies and
procedures”).
For similar reasons, we disagree with the court of appeals’
reliance on Zamarripa for the proposition that “an expert’s failure to
explain how a hospital could have countermanded a doctor’s transfer
orders rendered the expert’s opinion mere ipse dixit and insufficient.”
692 S.W.3d at 612. The court faulted the amended report for “fail[ing]
to explain how the mere presence of standard order sets, policies,
procedures, or protocols would have overridden the actual medical
decisions, diagnoses, and treatment orders of the doctors who were
present and deciding how [Williams-Bush] should be managed.” Id.
at 613 (emphasis added) (citing Zamarripa, 526 S.W.3d at 461). It erred
in doing so.

21
In Zamarripa, a patient suffered a fatal injury while being
transferred from the hospital after a physician ordered the transfer. The
expert report asserted “only that by ‘permitting and facilitating the
transfer,’ [the hospital] caused [the patient] to be in an ambulance”
when she suffered a fatal injury. Zamarripa, 526 S.W.3d at 461. We
held the expert’s report to be conclusory, and therefore deficient, because
it lacked any factual explanation of “how [the hospital] permitted or
facilitated [the patient’s] transfer, or even whether [the hospital] had
any say in the matter.” Id.
The expert report in this case does not suffer from the same faults.
Dr. Patterson’s amended report explains how enforcing the proffered
policies would have averted the harmful result: If the Triple Rule Out
protocol had been in place, the treating physician would have received
Williams-Bush’s diagnostic results, which “would have confirmed the
presence of the massive bilateral pulmonary embolism while [she] was
in the hospital and at a time when appropriate and life-saving
intervention could have easily been undertaken, such as blood thinning
medication, thrombolytic and/or surgical intervention.” The amended
report does not call for the Hospital to countermand a physician’s
decisions; rather, it opines that the Hospital could have changed the
outcome by adopting and enforcing policies, such as standing orders to
run specified tests on patients presenting with Williams-Bush’s
symptoms, that would have communicated vital diagnostic information
to her doctors. According to Dr. Patterson, had appropriate protocols
been in place, Williams-Bush’s physicians would have had the necessary

22
information to make an accurate diagnosis and provide timely
treatment, avoiding her death.
We expressly recognized the potential merit of such a claim in
Zamarripa. Although we concluded the expert report was deficient, we
remanded to allow amendment of the report, leaving open the possibility
that the hospital may have breached the standard of care “in not
providing [the physician] information that would have persuaded him to
change his mind” about the transfer. Id. Here, Dr. Patterson similarly
claims that the Hospital’s failure to implement appropriate policies
breached the standard of care and caused Williams-Bush’s death
because her physicians were not provided information that might have
persuaded them to change their minds about her diagnosis and ultimate
discharge.
The report in Zamarripa failed to explain how the hospital “had
either the right or the means to persuade [the physician] not to order
the transfer or to stop it when he did.” Id. By contrast, Dr. Patterson’s
report explains how the Hospital had “the means” to avoid this harmful
result—not by persuading her physicians not to discharge her but by
adopting protocols to ensure appropriate tests were run and results
communicated to her doctors. The test results would have provided the
physicians with the critical information needed to accurately diagnose
and treat Williams-Bush. As a result of the Hospital’s failure to
implement such policies, “a proper workup was never completed[,] which
resulted in a lack of appropriate communication between
interdisciplinary providers.” The amended report is a “fair summary” of
Dr. Patterson’s opinion that the Hospital breached a standard of care by

23
failing to develop and implement appropriate policies, which caused
Williams-Bush’s death because an appropriate policy could have
ensured vital information was communicated among the providers of
Williams-Bush’s care in time to treat the pulmonary embolism and avoid
her death.
The dissenting justices fault the report for not identifying a
specific Hospital employee’s conduct that contributed to the harm. Post
at 1–2 (Bland, J., dissenting). But this misunderstands the nature of
the allegations. The claim against the Hospital at issue here is based
on the asserted failure of the Hospital, acting through its management
or administrators, to adopt policies that would have prompted Hospital
employees responsible for treating Williams-Bush to run the Triple Rule
Out protocol or similar tests. That claim is predicated on the action or
inaction of administrators rather than the conduct of a nurse or other
medical care provider involved in treating Williams-Bush.
In short, because Bush’s claim is premised on the theory that
Hospital administrators breached a standard of care by failing to adopt
the specified policies, the expert report did not need to identify any
additional alleged negligence on the part of Hospital employees
responsible for treating Williams-Bush. Here, the expert opined that
the absence of appropriate policies and procedures resulted in “a lack of
appropriate communication” between the Hospital’s employees and the
treating physicians such that “the massive pulmonary embolism was
never appropriately ruled out.” There is no requirement to identify
those specific employees who allegedly should have but failed to adopt
policies the claimant theorizes were required. Indeed, at this stage of

24
the litigation, the expert would not be expected to know the names or
titles of those employees in the Hospital’s administration with
responsibility for developing the policies or procedures the expert
asserts were needed.
We similarly disagree with the dissenting justices’ attempt to
recast Bush’s claim against the Hospital as an attempt to impose
vicarious liability based on the doctor’s alleged negligence. We of course
agree that, had Bush sought to hold the Hospital vicariously liable for
the alleged negligence of Dr. Sohail—an independent contractor—that
claim would fail. See Dow Chem. Co. v. Bright, 89 S.W.3d 602, 609 (Tex.
2002) (holding that an employer’s “failure to implement . . . a safety rule
is not actual control” over its independent contractor’s employees
sufficient to impose vicarious liability). But that is not what is
happening here. The expert report opines that the Hospital breached
its duty to implement policies that govern the work of non-physicians.
The Hospital directs and participates in a patient’s care, and the expert
opines that it should have had “policies or procedures in place[] to ensure
the safety of patients.” By not implementing certain protocols and
directing its non-physician employees to follow them, the expert opines
that the Hospital itself was negligent and caused a lack of
communication that resulted in Williams-Bush’s misdiagnosis. While
an independent-contractor physician, in the exercise of independent
medical judgment, could conceivably “opt out” of the protocol or
disregard information the Hospital’s employees provide and thereby
impact causation in a case in which the Hospital had adopted such a

25
protocol, the expert need not rule out every potential defense to
causation. 5 See E.D., 644 S.W.3d at 667; Abshire, 563 S.W.3d at 226.
Citing “analytical gaps in causation,” the court of appeals
required Dr. Patterson to provide a level of detail beyond this “fair
summary” standard. 692 S.W.3d at 613. We conclude the court erred
by “improperly examin[ing] the merits of the expert’s claims when it
identified what it deemed an ‘analytical gap.’” Abshire, 563 S.W.3d
at 226. The purported “gaps” go to facts not before the expert; indeed,
the court of appeals faulted the amended report for failing to explain
how the Hospital could implement the proposed procedures if a
physician hypothetically were to refuse to implement them. This may
be fertile ground for cross-examination, but at this early stage of the
litigation, “[o]ur inquiry is not so exacting.” Miller, 536 S.W.3d at 516.
At this preliminary stage, an expert report is not required to designate
every detail for implementing a protocol or policy that the expert

5 The dissenting justices cite two cases for the proposition that Texas

courts deem a report conclusory when the expert fails to explain how a policy
would realistically be enforced. Post at 11–12 n.35 (Bland, J., dissenting)
(citing Hendrick Med. Ctr. v. Conger, 298 S.W.3d 784 (Tex. App.—Eastland
2009, no pet.), and Webb, 2017 WL 677828). Neither expert in those cases
provided any detail beyond the bare assertion that policies would have
prevented the harm. See Conger, 298 S.W.3d at 789–90 (opining that a policy
would have “reduced the likelihood that mistakes will be made”); Webb, 2017
WL 677828, at *7 (holding a report conclusory because it “fail[ed] to state how
the absence of the listed policies would have kept this particular incident from
happening”). Here, by contrast, we have explained how Dr. Patterson’s report
goes beyond bare assertions by adequately explaining how and why the
presence of the Triple Rule Out protocol would have avoided Williams-Bush’s
death: following the protocol would have identified the pulmonary embolism
from which she suffered at a time when life-saving interventions could have
been taken.

26
contends the standard of care required. See Abshire, 563 S.W.3d at 227
(explaining a report that did not “designate a specific documentary
procedure that should have been used” was not deficient regarding
standard of care because such detail “is simply not required at this stage
of the proceedings” (quoting Baty, 543 S.W.3d at 697)). The “gaps”
identified by the court of appeals go to issues that cannot be answered
without discovery. The Hospital might successfully establish on
summary judgment or later that the causal link between Dr. Patterson’s
policies and Williams-Bush’s death is too attenuated or that the
Hospital could not implement the described policies without unlawfully
practicing medicine. But those questions need not be answered
definitively at this point as the only inquiry before us is whether the
amended report is a “fair summary” of Dr. Patterson’s opinions. To
satisfy Chapter 74, an expert’s report must only make a “good faith
effort” to identify the breach of the standard of care and its causal
relationship to the injury so the court can determine if the claim has
potential merit. TEX. CIV. PRAC. & REM. CODE § 74.351(l). The amended
report achieves that goal. See Baty, 543 S.W.3d at 697 (“Additional
detail is simply not required at this stage of the proceedings.”); Fortner,
399 S.W.3d at 383 (holding adequate an expert report that opined the
defendant-hospital’s breach in failing to adopt policies and procedures
caused a patient’s blindness and rejecting the hospital’s contrary
arguments as “demand[ing] too much from the expert report”).
We conclude that the amended report satisfies the statutory
requirements. It states that the Hospital’s alleged breach was a factor
that contributed to Williams-Bush’s misdiagnosis “at a time when

27
appropriate and life-saving intervention could have easily been
undertaken.” It explained that the Hospital’s alleged breach—“failing
to have appropriate polic[i]es, protocols and procedures in place, [and]
failing to appropriately train providers and interdisciplinary teams”—
delayed timely diagnosis and proper treatment, which in turn caused
Williams-Bush to die from a pulmonary embolism before it could be
identified and treated.
To be sure, it is possible that the evidence at summary judgment
or beyond may demonstrate that something about the manner, or
timing, of Williams-Bush’s presentation or test results made it
unnecessary to rule out a pulmonary embolism. The evidence may also
show that, due to some fact not yet known to Dr. Patterson, a pulmonary
embolism could not have been detected before Williams-Bush was
discharged. Or the Hospital may proffer evidence that the standard of
care does not require the creation and implementation of these policies,
as Dr. Patterson claims. But those are evidentiary matters to be
developed during discovery and resolved at a later time. For today, all
we need decide is whether the report sufficiently informs the Hospital of
the specific conduct at issue and provides a basis for the trial court to
conclude that the plaintiff’s claims are not frivolous. Because the report
does so, no more is required. See Methodist Hosps. of Dall. v. Yates,
No. 05-21-00039-CV, 2022 WL 202988, at *6–7 (Tex. App.—Dallas
Jan. 24, 2022, no pet.) (finding adequate a report faulting a hospital for
failure to implement a policy that would have required scans to rule out
a medical condition prior to discharge); Methodist Richardson Med. Ctr.,
2019 WL 6486246, at *6 (finding report adequate because it is not

28
frivolous to suggest the extent to which the defendant hospital adopted
appropriate policies would have influenced a physician’s medical
decision). We hold that the amended expert report was sufficient with
respect to causation, and the court of appeals erred by holding to the
contrary.
B.
The court of appeals reversed based on causation without
reaching the Hospital’s remaining challenges to Dr. Patterson’s
amended report. Rather than remand for the court of appeals to do so,
we will address these issues in the interest of judicial economy. See
Baty, 543 S.W.3d at 697–98 (addressing the issues of breach and
causation when the court of appeals only considered standard of care);
see generally Reid Rd. Mun. Util. Dist. No. 2 v. Speedy Stop Food Stores,
Ltd., 337 S.W.3d 846, 855 (Tex. 2011) (“The court of appeals did not
address this issue, but rather than remanding to the court of appeals for
it to do so, we address it in the interest of judicial economy.”); TEX. R.
APP. P. 53.4 (allowing parties to raise, and the Court to consider, issues
briefed but not decided in the court of appeals).
For many of the same reasons discussed above, we conclude the
amended report contains an adequate summary of Dr. Patterson’s
opinions regarding the applicable standard of care and the Hospital’s
alleged breach thereof. The report “expressly references the ‘specific
conduct the plaintiff has called into question.’” Baty, 543 S.W.3d at 695
(quoting Palacios, 46 S.W.3d at 879). Here, Dr. Patterson’s amended
report opines that the applicable standard of care “requires appropriate
development, implementation, training and enforcement of policies and

29
procedures regarding the evaluation, identification and communication
related to treating acute cardiac patients.” Dr. Patterson opines that
the standard of care required the Hospital to “have systems-based
polic[i]es, protocols and procedures to ensure patients are treated and
managed appropriately.” In his opinion, based on Williams-Bush’s
clinical presentation, “appropriate hospital polic[i]es, protocols and
procedures would have required specific steps be undertaken, such as
order sets for imaging and lab work, to ensure that a massive pulmonary
embolism was ruled out as a life-threat[en]ing etiology of her
symptoms.” The amended report further opines that the standard of
care required the Hospital to “have and enforce the Triple Rule Out
protocol to be activated under appropriate conditions,” such as when a
patient presents with the same clinical presentation as Williams-Bush
did.
The amended report also adequately describes the alleged breach
of the relevant standard of care: Dr. Patterson opines that the Hospital
“violated the standard of care by not having appropriate policies,
procedures, guidelines or protocols in place to ensure proper evaluation,
assessment, testing, treatment and diagnosis.” The report additionally
explains that the Hospital “violated the standard of care by not having,
and/or enforcing compliance with, appropriate clinical pathways to
ensure appropriate testing is conducted to rule out medical emergencies,
such as pulmonary embolism.”
We hold that the amended report satisfies Chapter 74’s
requirement to provide a fair summary of Dr. Patterson’s opinions
regarding the standard of care and alleged breach. Having addressed

30
all the Hospital’s challenges to the amended expert report, we conclude
that the trial court did not abuse its discretion by denying the Hospital’s
motion to dismiss.
IV. Conclusion
The question at this early stage of the litigation is not whether
the Hospital may ultimately be held liable for Williams-Bush’s death.
Rather, we need only answer whether Dr. Patterson’s amended expert
report provides a fair summary of his opinions regarding the applicable
standard of care, the Hospital’s alleged failure to meet that standard,
and the causal relationship between that alleged failure and
Williams-Bush’s death. We conclude that it did, and the trial court did
not abuse its discretion in overruling the Hospital’s objections to the
amended report and denying the Hospital’s motion to dismiss. For these
reasons, we reverse the court of appeals’ judgment and remand this case
to the trial court.

Rebeca A. Huddle
Justice

OPINION DELIVERED: May 23, 2025

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