# Bush v. Columbia Med. Ctr. of Arlington Subsidiary, L.P.

Supreme Court of Texas, No. 23-0460

**Bush v. Columbia Med. Ctr. of Arlington Subsidiary, L.P., No. 23-0460 (Tex. May 23, 2025). Holding: The trial court did not abuse its discretion in concluding that the amended report adequately summarizes the standard of care, breach, and causation against the Hospital: the report explains "how and why" the Hospital's failure to adopt policies such as a Triple Rule Out protocol led to the missed pulmonary embolism and the patient's death, and the court of appeals erred by requiring the expert to explain why the policies would not amount to the corporate practice of medicine or to close every "analytical gap".**

Practice areas: medical liability

## Key issues

- An amended expert report is an adequate good-faith "fair summary" against a hospital under the Texas Medical Liability Act where it explains how the hospital's failure to adopt policies such as a "Triple Rule Out" protocol foreseeably led to a missed pulmonary embolism and the patient's death; the expert need not explain why the policies would not amount to the corporate practice of medicine or how a physician could be made to follow them.
- A court reviewing a report at the threshold stage may not weigh credibility, demand that the expert anticipate and refute every defensive theory, or identify "analytical gaps" that go to the merits, and close calls go to the trial court.

## Factual History
Thirty-five-year-old Ireille Williams-Bush fainted and was taken by ambulance to Medical City Arlington Hospital with chest pain, shortness of breath, and severe fainting, symptoms consistent with a pulmonary embolism (Opinion, PDF p. 2). The emergency-room doctor's initial impression was a heart attack, so she was admitted on that diagnosis; a consulting cardiologist performed a cardiac catheterization but never screened her for pulmonary embolism, and she was discharged in stable condition (Opinion, PDF p. 2). Three days later she was found struggling to breathe and died that day, and an autopsy revealed clotting in her heart and lungs (Opinion, PDF p. 2).

## Procedural History
Her husband, Jared Bush, Jr., sued Columbia Medical Center of Arlington Subsidiary, L.P., doing business as Medical City Arlington, and HCA Inc. (together, the Hospital), along with the emergency-room doctor, the hospitalist, the cardiologist, and their practice groups, alleging among other things that the Hospital failed to have or enforce adequate protocols and policies (Opinion, PDF p. 3). Bush served an expert report from cardiologist Dr. Cam Patterson, which the trial court held adequate but the court of appeals held deficient on qualifications and, alternatively, on standard of care, breach, and causation, remanding to allow an amended report (Opinion, PDF pp. 3-5). The trial court again denied the Hospital's motion to dismiss, and the court of appeals reversed in a second appeal, holding the amended report conclusory on causation and directing dismissal of the claims against the Hospital with prejudice (Opinion, PDF pp. 8-9). Bush petitioned for review on June 19, 2023, and the Hospital responded on October 11, 2023; the Court requested merits briefing on December 15, 2023, granted the petition on June 21, 2024, heard argument on September 12, 2024, and decided the case on May 23, 2025 (Docket; Opinion, PDF pp. 1, 31).

## Issues Presented
Bush presents whether the court of appeals erred in concluding that his expert's report did not meet the Texas Medical Liability Act's fair-summary requirement for standard of care and causation, and whether a claimant suing a hospital for failing to maintain industry-standard policies must have an expert explain why the claim is not one for negligence in the practice of medicine (Brief on the Merits (Jared Bush, Jr), PDF p. 12; Petition for Review (Jared Bush, Junior), PDF p. 9). The Hospital presents that the court of appeals did not abuse its discretion in concluding that the amended report added no factual explanation of how the alleged breaches caused the death (Brief on the Merits (Columbia Medical Center of Arlington Subsidiary, L.P., et al), PDF p. 14). The Court decided whether the amended report is an adequate good-faith fair summary of the standard of care, breach, and causation against the Hospital (Opinion, PDF pp. 1-2, 29-31).

## Standard(s) of Review
A trial court's ruling on the adequacy of an expert report is reviewed for abuse of discretion, within the four corners of the report, under a lenient standard at this threshold stage in which close calls go to the trial court (Opinion, PDF pp. 10-11).

## Legal Arguments
**Whether the amended report adequately supports causation against the Hospital.**

**Petitioner (Bush):** The Act requires only a fair summary, and Dr. Patterson identified industry-standard policies and protocols, such as a Triple Rule Out protocol, that the Hospital lacked and explained why their absence proximately caused the patient's death; the court of appeals' reasoning would require experts to explain why hospital policies do not constitute the practice of medicine (Brief on the Merits (Jared Bush, Jr), PDF p. 12; Petition for Review (Jared Bush, Junior), PDF p. 9).

**Respondents (the Hospital):** The amended report added no factual explanation to its conclusory causation opinions, because it did not explain how nurses and non-physician staff could act under the protocol to order tests and rule out a pulmonary embolism without engaging in the practice of medicine, which the statute reserves to physicians (Brief on the Merits (Columbia Medical Center of Arlington Subsidiary, L.P., et al), PDF pp. 14, 19; Response to Petition (Columbia Medical Center of Arlington Subsidiary, L.P., et al), PDF p. 17).

## Stated Reasons the Court Should Take the Case
Bush argued that the court of appeals and others have defined "practicing medicine" to include any acts or omissions that constitute medical functions, which would expose non-physician hospital staff to liability and effectively immunize health-care institutions from liability for failing to maintain industry-standard policies (Petition for Review (Jared Bush, Junior), PDF p. 9). The Hospital responded that Bush raised issues not presented to the trial court on remand, challenged the first appeal's opinion and not the second, and that the court of appeals did not hold that any act outside the statutory definition is the practice of medicine (Response to Petition (Columbia Medical Center of Arlington Subsidiary, L.P., et al), PDF pp. 12, 17).

## Practice Area Tags
medical-liability

## Procedural Posture/Vehicle
Petition for review from the Second Court of Appeals in an interlocutory appeal from the denial of a motion to dismiss for an inadequate expert report; argued September 12, 2024, and decided May 23, 2025, with a dissent (Opinion, PDF pp. 1, 8-9, 31).

## Amicus Involvement
None. The docket shows no amicus filings.

## Holding
The trial court did not abuse its discretion in concluding that the amended report adequately summarizes the standard of care, breach, and causation against the Hospital: the report explains "how and why" the Hospital's failure to adopt policies such as a Triple Rule Out protocol led to the missed pulmonary embolism and the patient's death, and the court of appeals erred by requiring the expert to explain why the policies would not amount to the corporate practice of medicine or to close every "analytical gap" (Opinion, PDF pp. 13-31).

## Court's Reasoning
**The statutory standard.** A report is adequate if it provides a fair summary of the expert's opinions on the standard of care, the manner in which the care failed to meet it, and the causal relationship to the injury, and a court may grant a motion to dismiss only if the report does not represent an objective good-faith effort to do so (Opinion, PDF p. 9). The standard is lenient at this threshold stage and the court looks only within the report's four corners; a report meets it if it informs the defendant of the specific conduct called into question and provides a basis to conclude the claims have merit, and it need not marshal all the proof or meet summary-judgment requirements (Opinion, PDF pp. 9-12). Causation is adequately addressed when the expert explains "how and why" the breach caused the injury, and courts may not weigh credibility or require the expert to anticipate and rebut all defensive theories (Opinion, PDF pp. 11-13).

**The amended report.** Dr. Patterson opined that hospitals treating acute cardiovascular patients must have systems-based policies and protocols, including a Triple Rule Out protocol to rule out pulmonary embolism, that the Hospital's failure to adopt them meant a proper workup was never completed, and that had the embolism been recognized, she would have been anticoagulated and admitted (Opinion, PDF pp. 5-8). The Court held that the report draws a line directly from the failure to adopt such policies to the physicians' failure to identify and treat the embolism, addressing both cause in fact and foreseeability (Opinion, PDF pp. 14-15).

**The court of appeals' errors.** Requiring the expert to explain how his opinions do not implicate the practice of medicine would force experts to anticipate defensive theories, and it presumes that the policies would constitute the unlawful practice of medicine, although the report suggests no policy that would usurp the physicians' role and standing orders and protocols are recognized in the Occupations Code (Opinion, PDF pp. 15-20). *Zamarripa* is distinguishable because the report there did not explain how the hospital had any say in the transfer decision, whereas Dr. Patterson explains that the policies would have ensured tests were run and results communicated to the physicians, not that the Hospital would countermand their decisions (Opinion, PDF pp. 21-23). The claim rests on administrators' failure to adopt policies, so the report need not identify individual employees' conduct, and the "analytical gaps" the court of appeals identified go to matters for discovery, summary judgment, or cross-examination, though the Hospital may later show the link is too attenuated or that the policies would unlawfully practice medicine (Opinion, PDF pp. 23-27). The Court also held, in the interest of judicial economy, that the report adequately summarizes the standard of care and breach (Opinion, PDF pp. 29-30).

**Dissent (Justice Bland, joined by Justice Devine).** She would hold that a Chapter 74 report seeking to hold a hospital liable must identify conduct by a hospital employee that contributed to the injury, and that this report instead attributes the harm to an independent-contractor physician's misdiagnosis, so it seeks to impose vicarious liability through the Hospital's alleged lack of policies, contrary to *Dow Chemical v. Bright* and *Hoechst-Celanese v. Mendez* (Bland, J., dissenting, PDF pp. 1-2, 7-10). She also said the report never mentions "standing orders," and she warned that experts will testify in every case that a hospital policy could have prevented a doctor's negligence, turning hospitals into guarantors of nonemployee conduct (Bland, J., dissenting, PDF pp. 2, 11-17).

## Disposition
The Court reversed the court of appeals' judgment and remanded the case to the trial court for further proceedings (Opinion, PDF p. 31).

## Vote Breakdown
Justice Huddle delivered the opinion of the Court, joined by Chief Justice Blacklock and Justices Lehrmann, Boyd, Busby, Young, and Sullivan; Justice Bland filed a dissenting opinion, joined by Justice Devine (Opinion, PDF p. 1).


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Source: The SCOTX Report, https://scotxreport.com/cases/23-0460. AI-generated summary of the Court's opinion, orders and the parties' briefs, with pin cites to the page of each document; verify against the Court's own documents at search.txcourts.gov.