OPINION In this appeal from the denial of motions to dismiss health care liability claims, the defendant health care providers present two primary questions. First, if a patient died from injuries sustained when the ambulance transporting him on an emergency basis was involved in a motor-vehicle accident, are his survivors’ claims against the ambulance driver and her employer health care liability claims? And if so, are the survivors’ expert reports sufficient on the issue of causation if (a) an expert paramedic opines that the ambulance driver breached the standard of care by failing to activate the siren and that the investigating police officer cited this failure as the only contributing factor in the crash, and (b) a physician opines that the collision proximately caused the fatal injuries? We need not address the first question. Assuming, without deciding, that these are health care liability claims, we conclude that the expert reports are sufficient. We affirm the trial court’s order denying the health care defendants’ motions to dismiss. Background When Donald Willis presented to Matagorda Regional Medical Center complaining of chest pain, left arm numbness, shortness of breath, dizziness, and nausea, his medical history included three prior myocardial infarctions and seven cardiac stents. He was diagnosed with “unstable angina,” and a few hours after he was admitted to the hospital, his physician determined that Willis would have an “improved possibility of retaining life or limb” if he were transferred to the University of Texas Medical Branch at Galveston for specialized treatment and for invasive or radiologic procedures and tests that were not available at the Matagorda facility. Willis’s physician stated in the “memorandum of transfer” that Willis was stable at the time of transfer and that emergency medical services (EMS)[1] personnel were needed for the transport. In the ambulance, Willis remained connected to a cardiac monitor and he received heparin intravenously through a transport pump. While paramedic Robert Smith cared for Willis in the patient compartment, emergency medical technician (EMT) Nicole Marina Mirza drove the ambulance. Mirza activated the ambulance’s emergency lights, but not its siren. On approaching an intersection where the vehicles in front of her were stopped for a red light, Mirza avoided the waiting traffic by steering the ambulance into the left-turn lane, then proceeding forward through the intersection. While at this intersection, Smith assessed Willis’s vitals. Smith leaned forward to push the “acquire BP” (presumably, blood pressure) button on the monitor, and as he sat back, he saw through a side window that the ambulance was traversing the first lane of the cross-traffic, and a truck approaching the intersection in the next lane was not slowing down. The truck—a Ford F250 driven by Dexter Buchanan Fernil—struck the passenger side of the ambulance, knocking it onto its left side. The resulting blunt- force trauma lacerated Willis’s spleen, and he lost nearly two liters of blood into his abdomen. He died from his injuries. Willis’s parents and children (the Willis Parties) sued Mirza and her employer, Bluebird Medical Enterprises, LLC d/b/a Allegiance Mobile Health. Bluebird provides 911 emergency medical services in Texas. It owns Lonestar Ambulance 1 LLC, a licensed emergency medical services provider, and it owns the ambulance Mirza was driving that day.[2] The Willis Parties served two expert reports to Bluebird and Mirza (the Ambulance Parties). The Ambulance Parties objected and moved to dismiss on the ground that the reports were deficient. On the morning of the hearing, the Willis Parties filed a response in which they argued there was no evidence that their claims had any of the characteristics of a health care liability claim (HCLC) and that, as a matter of law, the Texas Medical Liability Act (the Act) does not apply to ambulance collisions. They maintained that their claims were not HCLCs at all, and thus, the Act’s expert-report requirements were inapplicable. In the alternative, they argued that their expert reports satisfied the Act’s requirements. At the hearing, the Ambulance Parties requested and were granted leave to supplement their briefing to “address the points that were made for the first time in the response that was filed this morning.” They timely filed a “supplemental and amended reply brief” with supporting evidence. The trial court overruled the Ambulance Parties’ objections and denied their motions to dismiss. In this interlocutory appeal, the Ambulance Parties argue that (1) the Willis Parties’ claims against them are HCLCs, and (2) the expert reports are deficient. For us to reverse the trial court’s order, the Ambulance Parties must prevail on both issues. For the purpose of this appeal, we assume, without deciding, that the Willis Parties’ claims are HCLCs. Analysis A claimant asserting a health care liability claim is required to serve on each defendant physician or health care provider an expert report providing a fair summary of the expert’s opinion regarding the applicable standard of care, the manner in which the defendant breached the standard of care, and the causal relationship between that failure and the injury, harm, or damages claimed. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a), (r)(6). If the claimant fails to serve the expert report by the 120th day after the defendant answers the suit, the trial court must, on the defendant’s motion, dismiss the claim with prejudice and award the defendant reasonable attorney’s fees and costs of court. Id. § 74.351(a), (b). The Act requires expert reports so that the trial court can “expeditiously weed out claims that have no merit.” Loaisiga v. Cerda, 379 S.W.3d 248, 263 (Tex. 2012). To that end, an expert report must present “a fair summary of the expert’s opinions about the applicable standard of care, the manner in which the care failed to meet that standard, and the causal relationship between that failure and the claimed injury.” Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 878 (Tex. 2001). Taken together, the expert reports must address each of these three elements. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002). In determining the sufficiency of the expert reports, courts consider only the content of the reports. Id. We will reverse a trial court’s ruling on the sufficiency of expert reports only if the ruling constituted an abuse of discretion. See Van Ness v. ETMC First Physicians, 461 S.W.3d 140, 142 (Tex. 2015) (per curiam). A trial court abuses its discretion if it rules without reference to guiding rules or principles. Id. Robert Krause, Ed.D.’s Report on the Standard of Care and Its Breach Robert Krause, who has been a practicing paramedic for nearly four decades, offered his expert opinion on the applicable standard of care and its breach. First, he described the factual background of the claims as follows: Donald Willis was hospitalized in Bay City, Texas for a heart condition. Medical personnel arranged for Willis to be transferred to the University of Texas Medical Branch Hospital in Galveston, Texas. To achieve this transport, Bluebird Medical Enterprises (dba Allegiance Mobile Health) was engaged. Bluebird dispatched an ambulance that had assigned Nicole Mirza to the ambulance crew. Nicole Mirza was driving the ambulance, with Willis as a passenger on the rear stretcher, on FM 2004 in Brazoria County. Mirza approached a red light at the intersection of FM 2004 and State Highway 288B. Mirza entered the left-hand turn lane to pass other vehicles waiting at the red light, and she pulled into the intersection using only emergency lights with no audible siren. A pickup truck struck the ambulance, causing it to overturn. Shortly thereafter, Willis collapsed and could not be resuscitated. In the crash, Willis sustained blunt force injuries with laceration of the spleen and massive internal injuries, and the blunt force trauma caused his death. The driver of the pickup truck had a green light and did not hear any siren activated on the ambulance. Three eyewitnesses at the scene confirmed that Mirza had not activated the ambulance siren by the time of the collision. The investigating police officer cited Mirza’s failure to activate the siren as the only contributing factor in the crash. He then identified the different standards of care applicable to “routine” transports and to “true emergencies,” and although he asserted that Willis’s transport “was not an emergency,” he opined that Mirza breached both standards of care. The Ambulance Parties argue that the trial court erred in overruling their objection that Krause’s report is conclusory because he stated in the report, “Because this was not an emergency, the standard of care, which Ms. Mirza breached, called for obeying the red light and not attempting to navigate past other stopped vehicles.”[3] Krause offered no explanation for his statement that Willis’s transport was not an emergency. We agree with the Ambulance Parties’ objection that this statement is conclusory. See Columbia Valley Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453, 461 (Tex. 2017) (reports that are nothing more than ipse dixit of an expert are insufficient). On the other hand, we disagree that the overruling of that objection was reversible error. In a civil case, an error of law is reversible only if it probably caused the rendition of an improper judgment or probably prevented the appellant from properly presenting the case to the court of appeals. TEX. R. APP. P. 44.1(a). It is not probable that overruling the objection led to either such result because Krause’s report as a whole is not deficient. This is so because he also opined that Mirza breached the standard of care applicable to emergency transports by failing to activate the audible siren. Cf. Certified EMS, Inc. v. Potts, 392 S.W.3d 625, 632 (Tex. 2013) (expert report need only adequately address a single pleaded liability theory). He then noted that the investigating police officer cited this failure as the only contributing factor in the crash. Because the Ambulance Parties do not complain that Krause inadequately addressed the emergency-transport standard of care or its breach, we conclude that the trial court’s overruling of the objection to an unrelated conclusory statement was harmless. Marc Krouse, M.D.’s Report on Causation Under the Act, only a physician may opine “about the causal relationship between the injury, harm, or damages claimed and the alleged departure from the applicable standard of care.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(5)(C); see also id. § 74.403(a). Forensic pathologist Marc Krouse stated in his report that before Willis was transported in the ambulance driven by Mirza, Willis “had been hospitalized for ill-defined myocardial ischemia, but only myocardial enzymes and liver enzymes were out of normal range.” Shortly after the crash, Willis collapsed and could not be resuscitated. After reviewing the hospital records, the crash report, the report of the police investigation of the crash, and the autopsy report, Krouse concluded that Willis did not die from his pre-existing heart condition but from “blunt force trauma in the ambulance crash, with large splenic laceration and loss of nearly two liters of blood in his abdominal cavity.” The Ambulance Parties argue that Krouse’s report does not establish a causal link between a breach of the standard care and Willis’s death, because rather than opining that Mirza’s breach of the standard of care caused Willis’s fatal injuries, Krouse opined only that the crash caused Willis’s injuries and death. We conclude that, taken together, the two expert reports are sufficient. A claimant can satisfy the Act’s expert-report requirement by serving reports of separate experts regarding issues of liability and of causation. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i). Krause opined that Mirza breached the standard of care and explained that the investigating officer cited Mirza’s failure to activate the siren as the only factor contributing to the crash. Krouse’s report picks up from there; he opined that the crash caused blunt force trauma, which, in turn, caused Willis’s death. The Ambulance Parties maintain that, to satisfy the Act’s expert-report requirements, a physician must opine that Mirza’s breach of the standard of care caused the motor-vehicle accident. We disagree. A physician needed to opine on the cause of “the injury, harm, or damages claimed,” not on the cause of the crash. See id. § 74.351(r)(5)(C). Krouse did so. Moreover, when referring to expert reports in an HCLC against a health care provider, the Act defines “expert,” to mean only a person qualified to testify “regarding whether a health care provider departed from accepted standards of health care” or a physician qualified to opine “about the causal relationship between the injury, harm, or damages claimed and the alleged departure from the applicable standard of care.” Id. § 74.351(r)(5)(B) and (C). It follows from these definition of “expert” that (1) a person qualified to testify about the cause of a motor-vehicle accident is not an “expert” for the purpose of an expert report; and (2) such a person’s written opinion about the cause of the crash is not itself an “expert report” that the Act requires to be served. An expert may perhaps be needed at trial to testify about the cause of the accident, but at the expert-report stage, claimants are not required to prove their claims; it is enough that an expert is of the opinion that the claimants can do so. See Zamarripa, 526 S.W.3d at 460. Taken together, the expert reports describe a chain of causation in which (1) Mirza breached the standard of care by failing to activate the siren, (2) the failure to do so was the only factor contributing to the accident, and (3) the accident caused Willis blunt-force injuries from which he died. This is sufficient for the reports to “explain, based on facts set out in the report, how and why a health care provider’s breach of the standard of care caused the injury.” Zamarripa, 526 S.W.3d at 459–60 (quoting Van Ness, 461 S.W.3d at 142) (cleaned up). We conclude that the trial court did not abuse its discretion in overruling the Ambulance Parties’ objection that Krouse failed to causally link Mirza’s alleged breach of the standard of care to Willis’s injury and death. We overrule the Ambulance Parties’ second issue, which renders it unnecessary to address their first issue. Conclusion Assuming, without deciding, that the Willis Parties’ claims are HCLCs, their expert reports satisfy the requirements of the Texas Medical Liability Act. We accordingly affirm the trial court’s orders denying the Ambulance Parties’ motions to dismiss. /s/ Tracy Christopher Chief Justice Panel consists of Chief Justice Christopher and Justices Zimmerer and Wilson.
