Daniel Walker and Kristen Walker v. Baptist St. Anthony's Hospital and Rhodesia Castillo, M.D.

Supreme Court of Texas
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No. 23-0010
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Daniel Walker and Kristen Walker,
Petitioners,

v.

Baptist St. Anthony’s Hospital and Rhodesia Castillo, M.D.,
Respondents

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On Petition for Review from the
Court of Appeals for the Seventh District of Texas
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PER CURIAM

Justice Bland filed a concurring opinion, in which Justice Boyd
joined.

This case involves preliminary expert reports filed by the Walkers
in their medical negligence suit against defendants Baptist St.
Anthony’s Hospital and Dr. Rhodesia Castillo. The Walkers’ reports
attempt to show that several acts and omissions by Dr. Castillo and the
Hospital nurses in delivering the Walkers’ son, Henry, 1 caused him

1 To protect the child’s identity, we refer to him by a pseudonym.

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permanent neurologic injury. Defendants filed objections to the
Walkers’ reports and a motion to dismiss, challenging the experts’
qualifications and arguing that the reports insufficiently explained the
applicable standards of care, how they were breached, and the causal
link between the alleged breaches and Henry’s resulting injuries.
The trial court overruled Defendants’ objections and denied their
motion, ruling that the reports provided a fair summary of the experts’
opinions regarding the standard of care, breach, and causation, as
required by the Texas Medical Liability Act. See TEX. CIV. PRAC. & REM.
CODE § 74.351(a), (l), (r)(6). The court of appeals reversed, holding the
reports contained conclusory and incomplete language that did not
sufficiently explain the cause of Henry’s brain injury. We conclude that
the reports sufficiently explain causation and that the trial court
correctly rejected Defendants’ other challenges. We therefore reverse
the court of appeals’ judgment and remand this case to the trial court
for further proceedings.
I
Kristen Walker gave birth to her son Henry while under
Dr. Castillo’s care at the Hospital. After delivery, Henry required
resuscitation because he asphyxiated during Kristen’s labor and
allegedly suffered a stroke—specifically, a large subacute infarction
involving the majority of his left cerebral hemisphere and other smaller
infarctions in his right cerebral hemisphere.
The Walkers, individually and on Henry’s behalf, sued the
Hospital and Dr. Castillo for negligence occurring before and during
Henry’s birth. They contend the Hospital and Dr. Castillo caused

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Henry’s neurologic injury, and they supplied three expert reports from
obstetrician Dr. Tappan, neonatologist Dr. Null, and Nurse Beach. The
Hospital and Dr. Castillo objected to the experts’ qualifications and filed
a motion to dismiss challenging the reports’ sufficiency under
Section 74.351 of the Civil Practice and Remedies Code. The parties
then agreed the Walkers could amend the reports so long as they waived
their right to seek a future thirty-day extension to serve another report.
The Walkers filed amended reports for all three experts. Because we
conclude that the reports from Drs. Tappan and Null are sufficient, we
need not address the sufficiency of Nurse Beach’s report or Defendants’
other challenges to that report.
The doctors’ amended reports criticize the Hospital nurses and
Dr. Castillo for failing to measure Henry’s heart rate with a fetal scalp
electrode. They also fault Dr. Castillo for leaving the hospital for over
an hour despite knowing Henry’s heart rate was decelerating,
administering more Pitocin to Kristen despite Henry exhibiting non-
reassuring fetal heart rate patterns, delaying in ordering and
performing a cesarean section, and pushing on Henry’s head rather than
pulling on his feet—also known as reverse breech extraction—when he
was stuck in Kristen’s pelvis during the cesarean section. And they fault
the nurses for failing to contact superiors when Dr. Castillo left the
hospital and failing to discontinue or administer particular medications
in response to certain fetal heart patterns.
The reports also discuss how Dr. Castillo’s and the Hospital
nurses’ negligence caused Henry’s resulting neurologic injury. In
particular, Dr. Tappan opined that “[a]s a result” of the Hospital nurses’

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deviations from the standard of care, “baby [Henry] was subject to more
than an additional hour of intrauterine hypoxia,” and that “[t]he failure
to meet the standards of care . . . was a substantial factor in causing
injuries suffered by [Henry] Walker.” As to Dr. Castillo, Dr. Tappan
opined that “[h]ad Dr. Castillo decided for cesarean at or about 15:15
and had she atraumatically delivered Baby [Henry] by 15:45 . . . [Henry]
Walker would have been born without neurologic injury.” He also
opined that “[b]ut for Dr. Castillo’s failure to deliver by reverse breech
extraction, [Henry] Walker would not likely have suffered these
complications and injuries,” and that “[i]t was foreseeable to an
ordinarily prudent obstetrician that failure to deliver by reverse breech
extraction might reasonably result in traumatic extraction, physical
craniocerebral deformation, and trauma.” At another point,
Dr. Tappan’s report stated Henry’s MRI scan “suggests the possibility
that [Henry] sustained a perinatal arterial ischemic stroke.”
Dr. Null’s report drew similar conclusions. He opined that
Henry’s “course postdelivery is consistent with an antenatal asphyxia
event . . . [and] [m]ore likely than not had [Henry] been delivered one to
one and a half hours sooner he would not have suffered the degree of
brain injury that he has.”
The Hospital and Dr. Castillo reasserted their challenges to the
amended reports. Among other things, they argued that Dr. Tappan’s
report was speculative and conclusory, stating merely that Henry’s MRI
scan “suggests the possibility” of stroke. And as to Dr. Null, they argued
that his report never explains the basis for his opinions and instead
leaves the reader to draw inferences.

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The trial court overruled the Hospital’s and Dr. Castillo’s
objections and denied their motion to dismiss. The court of appeals
reversed, holding that although there is “[n]o doubt[] something
happened leaving child and parent to suffer the consequences,” the
doctors’ reports provide “less than a fair summary allowing jurists to
reasonably conclude that either [the Hospital] or Castillo caused the
harm suffered by [Henry].” ___ S.W.3d ___, 2022 WL 17324338, at *5
(Tex. App.—Amarillo Nov. 29, 2022). In that court’s view, “though it
may be foreseeable that pushing on a baby’s head during extraction may
cause injury, how and why it did in this particular instance was left
unaddressed . . . . So too do the reports leave one to legitimately ask
how the asphyxia or infarction was reasonably foreseeable from the
alleged defaults other than pushing on [Henry’s] head.” Id. “Whether
asphyxia . . . can lead to such brain injury was left to inference or
speculation.” Id. at *4.

II

The Texas Medical Liability Act requires healthcare liability
claimants to serve a defendant healthcare provider with a timely and
adequate expert report. TEX. CIV. PRAC. & REM. CODE § 74.351(a), (l).
An expert report is adequate if it “represent[s] an objective good faith
effort” to provide a “fair summary of the expert’s opinions . . . 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(l), (r)(6). A report demonstrates a good-
faith effort when it “(1) inform[s] the defendant of the specific conduct

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called into question and (2) provid[es] a basis for the trial court to
conclude the claims have merit.” Abshire v. Christus Health Se. Tex.,
563 S.W.3d 219, 223 (Tex. 2018) (quoting Baty v. Futrell, 543 S.W.3d
689, 693-94 (Tex. 2018)). The purpose of these requirements “is to weed
out frivolous malpractice claims in the early stages of litigation, not to
dispose of potentially meritorious claims.” Id.
“We review a trial court’s decision to grant or deny a motion to
dismiss based on the adequacy of an expert report for an abuse of
discretion.” Id. Accordingly, “close calls must go to the trial court.”
Larson v. Downing, 197 S.W.3d 303, 304 (Tex. 2006). A trial court
abuses its discretion “if it acts in an arbitrary or unreasonable manner
without reference to any guiding rules or principles.” Bowie Mem’l Hosp.
v. Wright, 79 S.W.3d 48, 52 (Tex. 2002). In addressing whether an
expert report meets the Texas Medical Liability Act’s requirements, “it
[i]s incumbent on the trial court . . . to review the report, sort out its
contents, resolve any inconsistencies in it, and decide whether the report
demonstrate[s] a good faith effort to show that the [plaintiff’s] claims
ha[ve] merit.” Van Ness v. ETMC First Physicians, 461 S.W.3d 140, 144
(Tex. 2015). In cases like this one, where more than one expert report
is filed, “we review the adequacy of reports in the aggregate.” Uriegas
v. Kenmar Residential HCS Servs., Inc., 675 S.W.3d 787, 790 (Tex.
2023).
To meet the standard of good-faith effort as to causation, a report
need not use magic words like “proximately caused,” but it must
“explain, to a reasonable degree, how and why the breach caused the
injury.” Jelinek v. Casas, 328 S.W.3d 526, 539-40 (Tex. 2010). Because

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bare conclusions are not enough, a report must “explain, factually, how
proximate cause is going to be proven,” although it “need not prove the
entire case or account for every known fact.” Abshire, 563 S.W.3d at 224
(internal quotation marks omitted).
The court of appeals focused its analysis on Defendants’ challenge
that the reports do not adequately explain proximate cause. Defendants
reassert additional challenges in their merits briefs that the court of
appeals did not reach, arguing that the reports also do not adequately
address either the standard of care or breach. Applying the standards
just discussed to these challenges, we conclude that the amended reports
of Drs. Tappan and Null together explain that breaches of the standard
of care by Dr. Castillo and the nurses caused Henry’s injury.
Dr. Tappan stated in his report that the standard of care during
a C-section requires “expeditious and atraumatic delivery of the baby.”
He explained the difference between pulling on the baby’s feet during
delivery (which he opined Dr. Castillo should have done) and pushing
the baby out (which Dr. Castillo did). The pull method is “quicker to
perform and is associated with a 50% decreased risk for NICU
admissions,” while the push method is “associated with serious fetal
morbidity including a fractured skull.” In his report, Dr. Tappan
concludes that by pushing on Henry during delivery, Dr. Castillo “fell
below the standard of care by failing to deliver baby [Henry] in an
atraumatic fashion.”
Dr. Tappan’s explanation of proximate cause regarding this
breach is clear:
Dr. Castillo’s failure to deliver [by the pull method]
proximately caused traumatic extraction, physical

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craniocerebral deformation, and traumatic injury to the
brain. But for Dr. Castillo’s failure to deliver by [the pull
method], [Henry] would not likely have suffered these
complications and injuries. It was foreseeable to an
ordinarily prudent obstetrician that failure to deliver by
[the pull method] might reasonably result in traumatic
extraction, physical craniocerebral deformation, and
trauma, including the increased risk of arterial ischemic
stroke with injury to the fetal brain.
This explanation, especially coupled with the statistics above regarding
consequences of the push method, sufficiently signals the merit of
plaintiffs’ claims. See Abshire, 563 S.W.3d at 223 (expert reports serve
“to weed out frivolous malpractice claims in the early stages of litigation,
not to dispose of potentially meritorious claims”).
Additional breaches the experts identified were Dr. Castillo’s
delay in ordering and performing the C-section and the Hospital nurses’
failure to monitor and report critical data. 2 Dr. Tappan’s report stated
“non-reassuring fetal tracing is the second most common indication and
requires assessment and prompt treatment to avoid fetal hypoxia and
acidosis.” By failing to use a fetal scalp electrode (which the nurses were
authorized to apply by hospital protocol) or to observe, report, and act
upon Henry’s recurrent heart rate decelerations and the foreseeable
“fetal hypoxia and acidosis” that could result, the Hospital nurses and
Dr. Castillo allowed over an hour to pass before starting the C-section.
During that time, Henry’s heart rate baseline was “tachycardic (165
bpm), the variability was minimal, [and] accelerations were absent,

2 We disagree with the concurrence’s statement that this opinion does

not address whether the reports adequately explain the applicable standard of
care and breach with respect to the nurses.

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. . . all signs consistent of ongoing fetal hypoxia.” Dr. Tappan concluded
that “[h]ad Dr. Castillo decided for cesarean delivery [sooner,]
. . . [Henry] would have been born without” his injury. Dr. Tappan also
concluded that during the hour before the C-section, the Hospital nurses
and Dr. Castillo should have administered terbutaline, a drug commonly
given in this situation that “would have arrested contractions and
helped to restore oxygenated blood to the baby.”
Dr. Null’s report further supports Dr. Tappan’s causation
conclusions as to these breaches. He explained that Henry’s infarction—
“swelling over the left parietal and occipital areas [of the brain] with a
7 cm circular dark bruising over the swelling with central skin
breakdown”—is “consistent with [a pre-birth] asphyxia event.” Dr. Null
concluded “more likely than not had [Henry] been delivered . . . sooner
he would not have suffered the degree of brain injury that he has.”
Together, Drs. Tappan and Null’s reports sufficiently explain the causal
relationship between delaying a necessary C-section operation, failing
to administer terbutaline, and fetal hypoxia.
Later in his report, Dr. Tappan stated that Henry’s resulting
injury “suggests the possibility that [Henry] sustained a perinatal
arterial ischemic stroke.” The Hospital and Dr. Castillo argue that the
phrase “suggests the possibility” is “generic” and insufficiently explains
how or why their misconduct caused Henry’s resulting injury. Although
“suggests the possibility” by itself would not be enough to explain
causation, it does not cancel out Drs. Tappan and Null’s conclusions that
do. Uriegas, 675 S.W.3d at 790 (“[W]e review the adequacy of reports in
the aggregate.”); see also Van Ness, 461 S.W.3d at 144 (“[T]he appeals

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court did not fully credit all of Dr. Jaffee’s factual statements and
opinions.”).
The court of appeals concluded that the reports did not causally
link Henry’s asphyxia or hypoxia with his permanent resulting injury.
But regardless of the precise physical connection between fetal hypoxia
and a large subacute infarction, the reports sufficiently state that
Henry’s long-term neurologic deficits at birth would have been averted
had the Defendants performed proper fetal heart rate monitoring, an
atraumatic delivery, an earlier C-section, and proper drug
administration. Abshire, 563 S.W.3d at 224 (reports must “explain,
factually, how proximate cause is going to be proven,” but “need not
prove the entire case or account for every known fact”). Because an
expert report need only address one theory of liability to meet the Texas
Medical Liability Act’s requirements, we do not discuss any other
theories mentioned in the experts’ reports. See Certified EMS, Inc. v.
Potts, 392 S.W.3d 625, 630 (Tex. 2013).
As an alternative basis for affirmance, Defendants also renew
their challenges to the qualifications of Dr. Tappan—an obstetrician-
gynecologist with experience managing fetal heart rate problems, head
impaction, and associated risks of brain injury due to hypoxia—to opine
about the cause of Henry’s neurological injuries, and the qualifications
of Dr. Null—a neonatologist with extensive experience managing
patients with birth asphyxia—to opine regarding the standard of care
for nurses and the causes of such asphyxia. The court of appeals did not
reach this issue. Having reviewed the record in the interest of judicial
economy and considered this issue on the merits, we conclude the trial

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court did not abuse its discretion in overruling Defendants’ objections to
the experts’ qualifications. Further discussion of this issue would not
add to the jurisprudence of the State.
The concurrence takes the view that we have not provided a
sufficient explanation supporting our resolution of this issue. But
nothing in the appellate rules holds this Court to a particular
explanatory standard when we are carrying out our discretionary review
function. 3 As stewards of scarce judicial resources, we have previously
declined to provide reasons regarding our disposition of certain issues
when we conclude that no error requires reversal and further discussion
is not important to the jurisprudence of the State. See, e.g., Virlar v.
Puente, 664 S.W.3d 53, 66 (Tex. 2023); Columbia Valley Healthcare Sys.,
L.P. v. A.M.A. ex rel. Ramirez, 654 S.W.3d 135, 141 n.3 (Tex. 2022);
Regent Care of San Antonio, L.P. v. Detrick, 610 S.W.3d 830, 839 & n.9
(Tex. 2020); cf. TEX. R. APP. P. 56.1(b)(1). 4

3 See TEX. R. APP. P. 53.1, 56.1(a), 63. In contrast, the rules require
courts of appeals to provide reasons on every necessary issue. See id. 47.1, 47.4
(specifying that court of appeals opinions must “address[] every issue raised
and necessary to final disposition of the appeal” and “advise the parties of the
basic reasons for [the court’s decision]”). Even under those rules, however, a
majority of this Court recently held that courts of appeals declining to exercise
discretionary review over permissive appeals may comply by—at most—
stating their conclusion that the governing legal standard was not met. See
Indus. Specialists, LLC v. Blanchard Ref. Co., 652 S.W.3d 11, 19 (Tex. 2022)
(plurality opinion of Boyd, J.); id. at 23 (Blacklock, J., concurring) (concluding
discretionary decision need not be explained).
4 Similarly, we have summarily reversed or vacated judgments upon

concluding that the case is controlled by a recent decision of this Court without
explaining that decision’s application. E.g., Hannah v. Thompson, 694 S.W.3d
772 (Tex. 2024); Mitchell v. Methodist Hosp., 335 S.W.3d 610 (Tex. 2011);
Escalante v. Rowan, 332 S.W.3d 365, 366 (Tex. 2011); City of Palestine v. Davis,

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The concurrence suggests that a fulsome explanation should
nevertheless be provided in this case because the court of appeals did
not address the qualification challenges. In this situation, “[w]e have
the alternatives of (1) examining the points not considered by the court
of appeals in order to determine whether any will support affirmance of
that court’s judgment, or (2) remanding the cause to the court of appeals
for it to pass on those points.” Roark v. Allen, 633 S.W.2d 804, 811 (Tex.
1982); see TEX. R. APP. P. 53.4. We agree with our concurring colleagues
that the first option best serves judicial and litigant economy here.
Thus, we have examined the qualification challenges not considered by
the court of appeals and determined that they will not support
affirmance. That is all our rules and precedent require.

III

We hold the trial court did not abuse its discretion in overruling
the Hospital’s and Dr. Castillo’s objections and denying their motion to
dismiss under the Texas Medical Liability Act. The reports of
Drs. Tappan and Null provide a fair summary of their opinions as to the
causal relationship between Dr. Castillo’s and the Hospital nurses’
deviations from the standard of care and Henry’s resulting neurologic

977 S.W.2d 328 (Tex. 1998); Eckles v. City of Lubbock, 846 S.W.2d 825 (Tex.
1992); Bacon v. Gen. Devices, Inc., 830 S.W.2d 106 (Tex. 1992). And even
without granting relief, we have directed trial courts to reconsider rulings in
light of new authority without discussing the applicability of that authority.
E.g., In re Parks, 631 S.W.3d 700 (Tex. 2021); In re Liberty County Mut. Ins.
Co., 624 S.W.3d 796 (Tex. 2021); Gulf Chem. & Metallurgical Corp. v. Miner
Dederick Constr., LLP, 455 S.W.3d 164 (Tex. 2015); D.Y. v. Floyd, 893 S.W.2d
536 (Tex. 1995); Clements v. Spears, 851 S.W.2d 192 (Tex. 1993); Brown-
Forman Corp. v. Westergren, 819 S.W.2d 800 (Tex. 1991).

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injury. Accordingly, without hearing oral argument, we reverse the
court of appeals’ judgment and remand the cause to the trial court for
further proceedings. See TEX. R. APP. P. 59.1.

OPINION DELIVERED: December 13, 2024

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