Misty Jackson, Individually and on Behalf of the Estate of Roger J. Young, And Roger Jackson v. Kindred Hospitals Limited Partnership D/B/A Kindred Hospital Fort Worth , 565 S.W.3d 75 ( 2018 )


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  •                  In the
    Court of Appeals
    Second Appellate District of Texas
    at Fort Worth
    --------------------------------------------
    No. 02-18-00027-CV
    --------------------------------------------
    MISTY JACKSON, INDIVIDUALLY AND ON BEHALF OF
    THE ESTATE OF ROGER J. YOUNG, DECEASED; AND
    ROGER JACKSON, Appellants
    v.
    KINDRED HOSPITALS LIMITED PARTNERSHIP D/B/A
    KINDRED HOSPITAL FORT WORTH, Appellee
    On Appeal from the 141st District Court
    Tarrant County, Texas
    Trial Court No. 141-297189-18
    Before Sudderth, C.J.; Gabriel and Pittman, JJ.
    Opinion by Chief Justice Sudderth
    OPINION
    I. Introduction
    This appeal arises out of an order sustaining Appellee Kindred Hospitals Limited
    Partnership d/b/a Kindred Hospital Fort Worth’s (Kindred) objection to Appellants
    Misty Jackson’s, Individually and on Behalf of the Estate of Roger J. Young, Deceased,
    and Roger Jackson’s section 74.351 expert report. Tex. Civ. Prac. & Rem. Code Ann.
    § 74.351(a) (West 2017). Because we conclude that the trial court abused its discretion
    by sustaining Kindred’s objection, we reverse and remand.
    II. Background
    Roger J. Young, Roger Jackson’s father and Misty Jackson’s father-in-law, was
    79 years old when he was admitted to Kindred—a long-term care facility—in January
    2015. Young stayed at Kindred for a few months before being transferred to Plaza
    Hospital for critical care. Young died six days later on April 16, 2015.
    The Jacksons assert that while Young was at Kindred, he received insufficient
    monitoring from Kindred’s nursing and medical staff and that Kindred’s staff failed to
    adequately treat and report changes in his medical condition, which caused his death.
    Specifically, the Jacksons contend that during Young’s stay at Kindred, he developed
    several pressure ulcers and abscesses on his scrotum and lower back 1 that the Jacksons
    contend caused him to develop sepsis, septic shock, and metabolic encephalopathy.
    Kindred concedes that “[d]espite the nursing staff’s treatment and care,
    1
    Mr. Young developed pressure ulcers and sepsis during his admission period[.]”
    2
    The Jacksons filed a healthcare liability claim (HCLC) against Kindred and
    Dr. Muhammad Naveed Siddiqi—Young’s treating physician—and timely served both
    with separate expert reports from Dr. Manuel Eskildsen. See 
    id. §§ 74.001(a)(13),
    .351(a)
    (West 2017). Kindred and Dr. Siddiqi filed objections to the expert reports. After
    granting Kindred’s objections and allowing the Jacksons to cure the deficiencies, see 
    id. § 74.351(c),
    the Jacksons served amended expert reports.             Kindred again filed
    objections, and the trial court sustained Kindred’s objections and dismissed Kindred
    from the lawsuit; but the trial court ordered that the Jacksons’ lawsuit against Dr. Siddiqi
    could proceed.
    Dr. Siddiqi then filed a motion for leave to designate Kindred as a responsible
    third party.   The Jacksons filed a response and motion to reconsider the order
    dismissing Kindred. After the trial court denied the Jacksons’ motion to reconsider and
    granted Dr. Siddiqi’s motion, the trial court granted the Jacksons’ motion to sever and
    rendered final judgment in favor of Kindred. This appeal followed.
    On appeal, the Jacksons raise two issues: First, that the trial court abused its
    discretion by sustaining Kindred’s objection to Dr. Eskildsen’s expert report, and
    second, that the trial court abused its discretion by denying their motion to reconsider.
    III. Applicable Law
    A.     Section 74.351 Expert Reports
    A plaintiff asserting an HCLC must serve each defendant physician or healthcare
    provider with one or more expert reports and a curriculum vitae of each expert whose
    3
    opinion is offered to substantiate the merits of the HCLC. See 
    id. § 74.351(a),
    (i); TTHR
    Ltd. P’ship v. Moreno, 
    401 S.W.3d 41
    , 42 (Tex. 2013). The statute requires that such a
    report must provide: (1) “a fair summary of the expert’s opinions . . . regarding
    applicable standards of care,” (2) a statement identifying “the manner in which the care
    rendered by the physician or [healthcare] provider failed to meet the standards,” and
    (3) an explanation of “the causal relationship between that failure and the injury, harm,
    or damages claimed.” Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6); see TTHR Ltd.
    
    P’ship, 401 S.W.3d at 44
    . The purpose of the report is to “inform the defendant of the
    specific conduct the plaintiff has called into question,” and to “provide a basis for the
    trial court to conclude that the claims have merit.” Am. Transitional Care Ctrs. of Tex.,
    Inc. v. Palacios, 
    46 S.W.3d 873
    , 879 (Tex. 2001). Thus, the expert report “need not
    marshal every bit of the plaintiff’s evidence,” Jernigan v. Langley, 
    195 S.W.3d 91
    , 93 (Tex.
    2006), but it must “explain, to a reasonable degree, how and why the breach caused the
    injury based on the facts presented.” Jelinek v. Casas, 
    328 S.W.3d 526
    , 539–40 (Tex.
    2010).
    When a defendant timely files a motion to dismiss challenging the adequacy of
    an expert report, the trial court may take one of three actions. If the court concludes
    that the report is adequate, it may deny the motion. See, e.g., Hillery v. Kyle, 
    371 S.W.3d 482
    , 489, 492 (Tex. App.—Houston [1st Dist.] 2012, no pet.). If the trial court
    concludes that the report does not constitute an objective, good-faith effort to comply
    with the statute, it must grant the motion. See Tex. Civ. Prac. & Rem. Code Ann.
    4
    § 74.351(l ); Bowie Mem’l Hosp. v. Wright, 
    79 S.W.3d 48
    , 51–52 (Tex. 2002); see also 
    Jernigan, 195 S.W.3d at 94
    . Finally, if the court concludes that the report is an objective, good-
    faith effort to comply with the statute but is nevertheless deficient in some way, it may
    grant the plaintiff one 30-day extension to cure the deficiency. See Tex. Civ. Prac. &
    Rem. Code Ann. § 74.351(c); Scoresby v. Santillan, 
    346 S.W.3d 546
    , 557 (Tex. 2011).
    A report qualifies as an objective, good-faith effort to comply if it (1) informs
    the defendant of the specific conduct the plaintiff questions, and (2) provides a basis
    for the trial court to conclude that the plaintiff’s claims have merit. Loaisiga v. Cerda,
    
    379 S.W.3d 248
    , 260 (Tex. 2012). The Supreme Court of Texas has held that a trial
    court may look only to the “four corners” of the expert report to determine whether it
    constitutes an objective, good-faith effort to comply. 
    Wright, 79 S.W.3d at 52
    ; 
    Palacios, 46 S.W.3d at 878
    .
    B.     Standard of Review
    We review a trial court’s ruling on a motion to dismiss pursuant to section 74.351
    for an abuse of discretion. 
    Palacios, 46 S.W.3d at 878
    ; See Tenet Hosps., Ltd. v. Garcia, 
    462 S.W.3d 299
    , 304 (Tex. App.—El Paso 2015, no pet.) (“The trial court makes the
    decision whether the report is sufficient. Our role, whether the trial court has approved
    or rejected the report, is to determine if the trial court abused its discretion.”). A trial
    court abuses its discretion if it acts in an arbitrary or unreasonable manner without
    reference to any guiding rules or principles. Walker v. Gutierrez, 
    111 S.W.3d 56
    , 62 (Tex.
    2003). In reviewing the adequacy of an expert report, we bear in mind that “[t]he
    5
    Legislature’s goal was to deter baseless claims, not to block earnest ones.” Gonzalez v.
    Padilla, 
    485 S.W.3d 236
    , 242 (Tex. App.—El Paso 2016, no pet.) (quoting Certified EMS,
    Inc. v. Potts, 
    392 S.W.3d 625
    , 631 (Tex. 2013)).
    IV. Analysis
    A.     In Assessing an Expert Report’s Sufficiency, Courts May Not Look
    Beyond the Expert Report’s “Four Corners”
    We first address the Jacksons’ contention that Kindred violates the “four corners
    rule” by picking and choosing excerpts from Dr. Eskildsen’s reports and juxtaposing
    them in an effort to demonstrate the report addressing Kindred’s actions (the Kindred
    Report) is inadequate. The gravamen of Kindred’s response is that the predicate factual
    statements in Dr. Eskildsen’s report addressing Dr. Siddiqi’s actions (the Siddiqi
    Report) as compared to the factual statements in the Kindred Report “seemingly
    concede[] the [Kindred] nursing staff did, in fact, do what they were supposed to do.”
    Kindred argues that while “[s]tanding alone,” the factual statements in the Kindred
    Report “might be sufficient,” “Dr. Eskildsen’s own report as to Dr. Siddiqi, as well as
    underlying facts, indicate otherwise.”
    But in an HCLC expert-report challenge, a trial court’s job is to be a gatekeeper—
    not to determine the truth or falsity of an expert’s opinion. See Mettauer v. Noble, 
    326 S.W.3d 685
    , 691 (Tex. App.—Houston [1st Dist.] 2010, no pet.). Therefore, even if
    Kindred were correct that the factual statements in the Kindred Report contradicted or
    6
    conflicted with the factual statements in the Siddiqi Report,2 resolving such conflicts
    would require the trial court to go beyond the four corners of the Kindred Report and
    compare it against the Siddiqi Report in order to determine the truth or falsity of the
    Jacksons’ factual statements, which are not for the trial court to adjudicate in a section
    74.351 expert-report determination. See 
    Gonzalez, 485 S.W.3d at 245
    (“There is nothing
    in the statute suggesting that we may consider an expert’s credibility or the data he used
    at this stage of the litigation.”); Christus Health Se. Tex. v. Broussard, 
    306 S.W.3d 934
    , 939
    (Tex. App.—Beaumont 2010, no pet.) (affirming trial court’s order denying medical
    providers’ motion to dismiss following plaintiff’s section 74.351 expert report even
    though the factual statements in report were possibly inconsistent with the statements
    in the plaintiff’s pleading because “the trial court could not look beyond the four
    corners of the report at this stage to determine whether the facts asserted in the pleading
    and the report were false”); Collini v. Pustejovsky, 
    280 S.W.3d 456
    , 462 n.4 (Tex. App.—
    Fort Worth 2009, no pet.) (declining the invitation to go beyond four corners of expert’s
    2
    We disagree with this assessment in any event. A fair reading of the Kindred
    Report reveals allegations that Kindred’s staff provided some notes identifying some
    problems with Young’s skin infection that were sufficient to alert Dr. Siddiqi to follow
    up with his own examination, diagnosis, and treatment plan. Indeed, Dr. Eskildsen
    relied upon some of Kindred’s notes in compiling the Kindred Report. But the Kindred
    Report also alleges that Kindred’s staff was deficient by failing to document the extent
    and increasing severity of Young’s skin infection, failing to properly examine Young,
    failing to try different treatments when one treatment plan did not lead to improvement,
    failing to properly monitor Young after noting his skin infection, failing to notify the
    attending physician of Young’s worsening condition and abnormal lab results, and
    failing to follow up with the attending physician after noting the onset of Young’s skin
    infection.
    7
    report and instead “constrain[ing] our review of the report’s adequacy at this
    preliminary stage in the proceedings to the specific information and allegations
    contained within it”); Tenet Hosps., Ltd. v. Boada, 
    304 S.W.3d 528
    , 542 (Tex. App.—
    El Paso 2009, pet. denied) (“Whether an expert’s opinions are correct is an issue for
    summary judgment, not a motion to dismiss under Chapter 74.”).
    Because the trial court could only look to the four corners of the Kindred Report,
    it was impermissible for the trial court to compare a separate expert report related to a
    different healthcare provider to negate the factual assertions in the Kindred Report.3
    
    Wright, 79 S.W.3d at 52
    ; 
    Palacios, 46 S.W.3d at 878
    . Accordingly, we hold that to the
    extent the trial court sustained Kindred’s objection by looking beyond the four corners
    of the Kindred Report and acting as a factfinder, the trial court abused its discretion.
    3
    We recognize that when a plaintiff sues multiple defendants for an HCLC, as in
    this case, the plaintiff may need to file multiple expert reports, in which case courts may
    read the reports together for certain purposes. See Abilene Reg’l Med. Ctr. v. Allen, 
    387 S.W.3d 914
    , 918 (Tex. App.—Eastland 2012, pets. denied) (“[A] plaintiff may serve
    multiple reports by separate experts regarding different defendants, different claims,
    and different issues, as long as the reports, read together, provide a fair summary of the
    standard of care, breach, and causation.”). We understand this to mean a trial court
    may “stack” a plaintiff’s expert reports in order to determine if the plaintiff has provided
    the defendants with fair notice of the allegations of duty, breach, and causation, but not
    that a trial court may juxtapose factual statements in two separate expert reports in
    order to make factual determinations. See 
    Gonzalez, 485 S.W.3d at 245
    (“Appellants’
    points on apparent conflicts between the medical records and the assumptions [the
    expert] makes are well-taken. But ‘[w]hether an expert’s opinions are correct is an issue
    for summary judgment, not a motion to dismiss under Chapter 74.’” (quoting Tenet
    Hosps., 
    Ltd., 304 S.W.3d at 542
    )). That is to say, multiple section 74.351 expert reports
    can be combined to satisfy all of the report requirements as to one healthcare provider.
    But nothing in the statute or case law authorizes the trial court to pit one report as to
    one healthcare provider against another report as to a different healthcare provider.
    8
    B.     The Expert Report Satisfies the Statutory Requirements
    Having held that the trial court could not act as a factfinder by comparing the
    two reports, we still must examine the four corners of the Kindred Report to determine
    if it “include[d] opinions on the three statutory elements—standard of care, breach, and
    causation.” Walgreen Co. v. Hieger, 
    243 S.W.3d 183
    , 188 (Tex. App.—Houston [14th
    Dist.] 2007, pet. denied).
    1.     Standards of Care and Breaches
    The Kindred Report is not required to provide Kindred with “litigation-ready
    evidence,” Certified 
    EMS, 392 S.W.3d at 631
    , or to “meet the same requirements as the
    evidence offered in a summary-judgment proceeding,” 
    Palacios, 46 S.W.3d at 879
    . To
    satisfy the notice requirements for Kindred’s standards of care and alleged breaches
    thereof, the report must only fairly “set out what care was expected, but not given.” 
    Id. at 880.
    Dr. Eskildsen opines in the Kindred Report that Kindred’s general standard of
    care “requires that the medical facility provide that level of care and treatment that a
    reasonable, prudent, similar facility would provide under the same or similar
    circumstances based on the known medical needs of the resident at issue.” See Birchfield
    v. Texarkana Mem’l Hosp., 
    747 S.W.2d 361
    , 366 (Tex. 1987) (holding the standard of care
    for a hospital is what an ordinarily prudent hospital would do under the same or similar
    circumstances). Dr. Eskildsen then provided nine more specific standards of care
    regarding Young’s skin infection:
    9
    • that Kindred assess his skin and any related rashes or breakdown properly.
    Properly documented skin assessment would allow the staff to assay any
    improvement in his affected areas of skin;
    • that Kindred assess Young’s condition and continue to change his treatment on
    ongoing bases until signs of healing occurred;
    • that Kindred clearly document its monitoring, assessing, and treating of Young’s
    infection in the medical record;
    • that Kindred evaluate and closely monitor Young’s skin for any signs and
    symptoms of infection and implement interventions to address risks of further
    infection;
    • that Kindred develop plans of care documenting the implemented interventions
    designed to minimize any infection;
    • that the facility properly treat any infections that Young had upon admission or
    developed during his residency at the facility by following all physician orders
    and evaluating the outcome of those orders;
    • that the facility treat any infection with the appropriate antibiotics as ordered by
    the physician, monitor the infection to determine if the treatment plan was
    successfully treating the infection, obtain laboratory testing of the infection to
    determine the effectiveness of the treatments, and continually monitor Young
    until all laboratory testing confirmed that the infection was fully treated;
    • that the staff monitor Young’s vital signs during each shift until all of his
    infection symptoms had resolved and the antibiotic treatment plan was
    completed; and
    • that the facility perform continuing assessments of Young, including an
    evaluation by a physician to establish a baseline, clearly document in the medical
    record a specific diagnosis of the infection, develop and document a treatment
    and care plan to address the infection, document a list of medications prescribed
    to treat the infection, develop a plan to reassess the condition with a specific
    timetable, and document any additional treatment notes or requirements needed
    to address the specific condition.
    10
    The Kindred Report identified two ways that Kindred breached the standard of
    care and then provided numerous specific examples under each heading. Dr. Eskildsen
    also broadly stated the two identified breaches:
    Kindred failed to ensure Mr. Young received the necessary medical care
    and treatment to maintain his skin integrity and failed to ensure that the
    signs and symptoms of infection and abscess exhibited by Mr. Young were
    assessed by his physician[; and]
    ....
    . . . Kindred failed to timely and properly treat Mr. Young’s infection prior
    to the infection progressing to him going into septic shock and developing
    endocarditis.
    Under the first alleged breach, Dr. Eskildsen further elaborated that
    • Kindred did not write new orders after Young developed an abrasion and
    drainage on his penis;
    • Young had a scrotal excoriation and abscess, which Kindred left uncovered and
    untreated; and
    • Kindred did not order antibiotics to treat Young’s urinary tract infection.
    Regarding the second alleged breach, Dr. Eskildsen asserted more specifically
    that
    there continued to be no attempt by Kindred’s nurses and clinical staff to
    address [Young’s] scrotal abscess. Kindred’s nurses did not make any
    documentation or any attempts to notify the attending physician that
    Mr. Young needed skin and scrotal assessment and at the very least,
    further orders and diagnostic testing to rule out his abscess as the causative
    factor causing his change of condition and infection.
    11
    In its appellate brief, Kindred acknowledges that “[s]tanding alone”
    Dr. Eskildsen’s identified breaches of the standards of care “might be sufficient,” but
    that “Dr. Eskildsen’s own report [as] to Dr. Siddiqi, as well as underlying facts, indicate
    otherwise.” If indeed the Kindred Report is sufficient “[s]tanding alone,” then it is
    sufficient pursuant to section 74.351.4 As explained above, it is an abuse of discretion
    for a trial court or a reviewing court to act as a factfinder and look beyond the four
    corners of the expert report. See 
    Gonzalez, 485 S.W.3d at 244
    (rejecting defendant’s
    invitation to look “beyond the four corners of the report and consider extrinsic
    evidence, or at the very least the actual records [the expert] relied on, to determine if
    his opinion is worthy of credence”).
    Kindred also asserts that the Kindred Report does not provide standards of care
    related to Young’s specific injuries because Dr. Eskildsen does not provide a standard
    of care for wound care “despite his criticisms [that] the staff failed to properly cover
    the scrotal wound, which Dr. Eskildsen opines led to infection.” The Jacksons argue
    that such a level of specificity is not required by section 74.351.
    We agree with Kindred’s observation that the standard for wound care recited
    by Dr. Eskildsen is not extremely detailed. For example, Dr. Eskildsen generally states
    that Kindred was required to “properly treat” any infections that Young had upon
    The very premise of Kindred’s argument requires that we look beyond the four
    4
    corners of the Kindred Report itself; thus, on its face Kindred’s argument invites us to
    misapply the applicable standard.
    12
    admission or that may have developed during his stay at Kindred.                Likewise,
    Dr. Eskildsen alleges that Kindred was required to administer “appropriate” antibiotics
    as ordered by the physician, “monitor the infection,” and “determine if the treatment
    plan was successfully treating the infection.” However, “[a] ‘fair summary’ of the
    standard of care is ‘something less than a full statement of the applicable standard of
    care and how it was breached.’” Fagadau v. Wenkstern, 
    311 S.W.3d 132
    , 138 (Tex. App.—
    Dallas 2010, no pet.) (quoting 
    Palacios, 46 S.W.3d at 880
    ); see also Certified 
    EMS, 392 S.W.3d at 630
    (“A report need not cover every alleged liability theory to make the
    defendant aware of the conduct that is at issue.”). Though lacking in painstaking details,
    the Kindred Report has sufficiently notified Kindred of the applicable standard of care
    and the conduct at issue—Kindred failed to assess Young’s condition, administer
    appropriate antibiotics, monitor the infection, determine if its treatment plan was
    succeeding and alter it if necessary, and properly document and notify the attending
    physician of changes in Young’s condition that would require additional diagnostic
    testing and orders. As to identifying the standard of care and the conduct at issue, the
    Kindred Report need not do more.
    Therefore, we hold that the Kindred Report satisfied the requirement that it
    identify the applicable standards of care and conduct for which they seek to hold
    Kindred liable. See 
    Gonzalez, 485 S.W.3d at 250
    (affirming denial of motion to dismiss
    HCLC because “this case involves the treatment of infection and wounds, which are
    subjects common to all areas of medicine, and it involves an alleged complete failure to
    13
    coordinate a treatment plan between doctors,” “the level of technical detail needed
    to . . . determine if a case is frivolous is less than that needed to determine if a suit
    involving a highly complex procedure like a surgery is frivolous”).
    Regarding breach, the Kindred Report avers that Kindred failed to write new
    orders, failed to order antibiotics, failed to attempt to notify the attending physician that
    Young needed a skin and scrotal assessment, and failed to make further orders and
    diagnostic testing when Young’s condition had worsened. We hold that this provided
    Kindred with a fair summary of how Kindred breached the standards of care. See
    
    Gonzalez, 485 S.W.3d at 252
    (affirming denial of HCLC motion to dismiss for duty and
    breach elements of wound-care case when expert alleged that defendant doctor failed
    to create and enforce an adequate follow-up plan); Trisun Healthcare, LLC v. Lopez,
    No. 13-13-00238-CV, 
    2014 WL 3050350
    , at *3 (Tex. App.—Corpus Christi July 3,
    2014, no pet.) (mem. op.) (affirming trial court’s denial of HCLC motion to dismiss
    when expert report stated that medical facility “fail[ed] to immediately notify the
    deceased’s physician of the deterioration of the wound on his hand and fail[ed] to
    recognize and treat the deteriorating wound on the deceased’s hand [which] caused the
    infection to progress and worsen”).
    2.     Causation
    “To satisfy the required element of causation under chapter 74, an expert report
    must include a fair summary of the expert’s opinion regarding the causal relationship
    between the breach of the standard of care and the injury, harm, or damages claimed.”
    14
    Whisenant v. Arnett, 
    339 S.W.3d 920
    , 923 (Tex. App.—Dallas 2011, no pet.). To provide
    fair notice of causation, “[a]n expert is required to link his or her conclusions to the
    facts, but no ‘magical words’ are required.” SCC Partners, Inc v. Ince, 
    496 S.W.3d 111
    ,
    118 (Tex. App.—Fort Worth 2016, pet. dism’d).
    The Kindred Report asserted that
    [a]s a direct result of Kindred’s breaches of the above standards of care,
    Mr. Young developed an infection prior to his myocardial infarction on
    April 10, 2015. Specifically, the nurses’ failure to properly treat his
    abscessed wound, which did not heal, thus allowing a mode of
    transmission for the bacteria to proliferate and spread the infection in
    Mr. Young’s body. His endocarditis was caused by sepsis. The onset of
    sepsis occurs only after an infection. Between January 29, 2015 and April
    10, 2015, Mr. Young developed a serious infection that showed symptoms
    of infection by delivering pus from his scrotum which had created an
    abscess. This is further confirmed by blood cultures that confirmed
    Mr. Young had Enterococcus faecalis bacteria, which are found in wound
    infections and is a cause of endocarditis.
    Had Kindred properly monitored and assessed Mr. Young during
    this period of time, clinical findings would have indicated signs and
    symptoms of an ongoing infection process. Specifically, had the nurses
    informed Mr. Young’s attending physician of the changes to his condition,
    and his abnormal lab results in a timely manner, this would have provided
    a window of opportunity in which assessment and treatment could have,
    and based on reasonable medical probability would have, been
    implemented before sepsis developed. Thus, had Kindred properly
    evaluated, assessed, and monitored Mr. Young from January 29, 2015
    through April 10, 2015, Mr. Young would have received treatment for his
    infection. Unfortunately, these opportunities were missed due to
    Kindred’s failure to ensure he was timely assessed and treated. As a direct
    result of not identifying and receiving timely treatment for his infection,
    Mr. Young developed bacterial endocarditis as a result of infection in his
    blood (sepsis), had an acute myocardial infarction and cardiogenic shock
    resulting in his untimely death on April 16, 2015.
    15
    Similar to Kindred’s assertions regarding the standard of care and breach, its
    assertions concerning causation center on Kindred’s belief that Dr. Eskildsen’s
    statements are “contradicted by the facts and Dr. Eskildsen’s own report” as to
    Dr. Siddiqi. And just as we explained in those instances, it is not proper for the trial
    court or a reviewing court to act as a factfinder by going outside of the four corners of
    the expert report.
    The allegations within the four corners of the Kindred Report provided fair
    notice to Kindred of the Jacksons’ allegations that Kindred’s staff’s failure to assess,
    monitor, and treat Young’s infection and failure to notify the attending physician of
    Young’s changed condition and abnormal lab results, caused sepsis, leading to
    endocarditis, an acute myocardial infarction and cardiogenic shock, and Young’s death.
    Accordingly, we hold that the Kindred Report satisfied section 74.351’s requirement of
    providing Kindred with fair notice of its specific breaches of the applicable standards
    of care and how those breaches were linked to Young’s injuries and death. 
    Allen, 387 S.W.3d at 923
    (rejecting appellants’ contention that the expert’s “opinion on causation
    is insufficient because it conflicts with matters contained in other expert reports and
    the facts in the case” because “[t]he inquiry at the report stage focuses on whether the
    information within the four corners of the report meets the good faith requirement of
    the statute” and “[i]f the facts do not support a plaintiff’s claim, summary judgment
    procedures provide a remedy”).
    16
    Thus, in limiting our review to the allegations in the four corners of the Kindred
    Report, we hold that the report satisfied the fair-notice requirements of section 74.351
    and that the trial court abused its discretion by sustaining Kindred’s objection. We
    sustain the Jacksons’ first issue.5
    V. Conclusion
    Having held that the trial court abused its discretion by sustaining Kindred’s
    objections to the Jacksons’ expert report and dismissing their claims, we reverse the
    trial court’s judgment and remand for further consistent proceedings. See Tex. R. App.
    P. 43.2(d), 43.3.
    /s/ Bonnie Sudderth
    Bonnie Sudderth
    Chief Justice
    Delivered: November 1, 2018
    5
    Because we sustain the Jacksons’ first issue, we need not address their second
    issue concerning their motion to reconsider. See Tex. R. App. P. 47.1.
    17