Full Opinion

Opinion filed September 24, 2026 In The Eleventh Court of Appeals __________ No. 11-25-00225-CV __________ GEORGE MUNS, Appellant V. KHARVAR DAR, M.D., Appellee On Appeal from the 358th District Court Ector County, Texas Trial Court Cause No. D-22-04-0401-CV MEMORANDUM OPINION This medical malpractice appeal concerns the sufficiency of the amended expert report that Appellant, George Muns, 1 filed in the underlying suit. See TEX. 1 As he did in the trial court, Muns is also proceeding pro se on appeal. Although we liberally construe briefs and other filings that are submitted by pro se parties, we hold pro se litigants to the same standards as licensed attorneys and require them to comply with all applicable laws and rules of procedure and evidence. Mansfield State Bank v. Cohn, 573 S.W.2d 181, 184–85 (Tex. 1978); Barrientos v. Barrientos, 675 S.W.3d 399, 404 n.2 (Tex. App.—Eastland 2023, pet. denied); Aaron v. Fisher, 645 S.W.3d 299, 312 (Tex. App.—Eastland 2022, no pet.). CIV. PRAC. & REM. CODE ANN. § 74.351 (West Supp. 2025). This is our second occasion to address the issue of the sufficiency of an expert report in this case. In the first appeal, we concluded that Muns’s Chapter 74 reports were deficient, and we remanded this cause to the trial court to determine whether Muns was entitled to a thirty-day extension to cure the deficiencies. See Mourning v. Muns, No. 11-22- 00277-CV, 2024 WL 4557799, at *5–6 (Tex. App.—Eastland Oct. 24, 2024, no pet.) (mem. op.) (Muns I). After Muns purportedly cured the report’s deficiencies, he submitted an amended report prepared by David Henderson, M.D. Appellee, Kharvar Dar, M.D., thereafter filed a motion to dismiss the underlying suit contending that the amended expert report was deficient, which the trial court granted. Muns now appeals from the trial court’s order of dismissal. In four issues, Muns argues that the trial court erred when it: (1) failed to apply the proper good faith standard established in Baty v. Futrell, 543 S.W.3d 689 (Tex. 2018); (2) found that the amended report was insufficient because it clearly informed Dr. Dar of the conduct called into question; (3) failed to adequately consider the amended report’s causal relationship analysis; and (4) refused to grant him a second thirty-day extension to further amend his report. We affirm. I. Factual Background On August 24, 2020, Muns was “intubated emergently” at a hospital in Pecos because of respiratory distress. He was subsequently transferred to Odessa Regional Medical Center (ORMC) via air flight transport. Muns later filed the underlying suit against Dr. Dar, ORMC, and others 2 asserting causes of action based on the medical care and treatment that he received at ORMC. Muns alleged in his amended petition that on August 24, 2020, because 2 The only defendant that is a party to this interlocutory appeal is Dr. Dar, who filed the motion to dismiss. 2 of inadequate sedation, he woke up in the critical care unit at ORMC while intubated. He then removed both his orogastric and endotracheal tubes. About ten minutes later, Jodi Bittick, a nurse at ORMC, telephoned Muns’s wife, his medical power of attorney, to inform her that Muns was “sitting up in bed with [a] CPAP on and [was] grabbing at [the] mask, secondary to residual medication in his system, but [was] stable.” However, there is no record that Bittick attempted to obtain consent for Muns to be reintubated. Several minutes later, Muns was reintubated. Muns claimed that, at the time, “[n]o emergency existed and no diagnostic procedures were performed to support the procedure.” He alleged that, instead, the medical staff decided that he should be reintubated because “the providers did not want to have to provide the extra care needed” to prevent him from removing his CPAP mask. Muns further alleged that the following morning, he awoke, restrained, while two nurses performed an IV infusion, which caused him to experience severe burning pain. He claims that he attempted to pull his arm away and began trying to communicate with the staff by using hand gestures. In response, charge nurse Michael Gonzales allegedly told Muns that he should “[l]ay back and shut up.” As Muns continued to gesture, Gonzales allegedly stated that Muns “lost [his] rights” when he removed his intubations and reiterated that Muns would not be released. Minutes into the procedure, Muns claims that he lost control of his gag reflex and vomited into the tubes that were placed in his mouth. The ORMC staff allegedly began “scrambling” to clear his airways while he continued to struggle against his restraints. According to Muns, Dr. Dar appeared in the room approximately ten minutes later. Standing near Muns’s bedside, Dr. Dar allegedly berated Muns, and repeatedly called him an “a-----e.” Muns asserted that he then feared for his life and began crying. In response, Dr. Dar allegedly told Muns: 3 Ok a**hole, you are going to do exactly what I say a**hole and if you are an a**hole like you were yesterday, I’m going to intubate you, sedate you, and place you on a ventilator for 2 weeks. After Dr. Dar left the room, Muns penned a note asking whose “bright idea” was it to “leave [him] un-sedated,” and that it was “[n]ot [f]unny” to “intubate [him] [and] paralyze [him] for [two] weeks.” Following these events, Muns was extubated and released from ORMC against medical advice. II. Analysis We consider Muns’s first three issues together because they all relate to the sufficiency of an expert report under Chapter 74 and whether the trial court abused its discretion when it found that the amended report is insufficient. A. Standard of Review We review a trial court’s ruling on a motion to dismiss a health care liability claim for an abuse of discretion. Abshire v. Christus Health Se. Tex., 563 S.W.3d 219, 223 (Tex. 2018) (per curiam); Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 877 (Tex. 2001); Daughtery v. Schiessler, 229 S.W.3d 773, 774 (Tex. App.—Eastland 2007, no pet.). A trial court abuses its discretion if it acts without reference to any guiding rules or principles or acts in an arbitrary or unreasonable manner. Daughtery, 229 S.W.3d at 774 (citing Downer v. Aquamarine Operators, Inc., 701 S.W.2d 238, 241–42 (Tex.1985)). In analyzing a Chapter 74 expert report under this standard, we consider only the information contained within the four corners of the report. Abshire, 563 S.W.3d at 223. In doing so, we defer to the trial court’s factual determinations if supported by the evidence but review its legal determinations de novo. Van Ness v. ETMC First Physicians, 461 S.W.3d 140, 142 (Tex. 2015) (per curiam). B. Good Faith Standard under Chapter 74 Chapter 74 provides that a “[trial] court shall grant a motion challenging the adequacy of an expert report only if it appears to the court, after a hearing, that the 4 report does not represent an objective good faith effort to comply with the definition of an expert report.” CIV. PRAC. & REM. § 74.351(l). An “[e]xpert report” is defined as: a written report by an expert that 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. CIV. PRAC. & REM. § 74.351(r)(6). An expert report demonstrates a “good faith effort” when it (1) informs the defendant of the specific conduct that the plaintiff has called into question, and (2) provides a basis for the trial court to conclude that the claims have merit. Bush v. Columbia Med. Ctr. of Arlington Subsidiary, L.P., 714 S.W.3d 536, 543 (Tex. 2024) (citing Baty, 543 S.W.3d at 693–94); Abshire, 563 S.W.3d at 223. “At this threshold stage of the case, the adequacy of an expert report is measured by a ‘lenient standard.’” Bush, 714 S.W.3d at 543 (quoting Scoresby v. Santillan, 346 S.W.3d 546, 549 (Tex. 2011)). However, when evaluating the sufficiency of an expert report, “close calls must go to the trial court.” Walker v. Baptist St. Anthony’s Hosp., 703 S.W.3d 339, 343 (Tex. 2024) (quoting Larson v. Downing, 197 S.W.3d 303, 304 (Tex. 2006)). A report that merely states the expert’s bare conclusions about the basis for asserting a medical malpractice claim—standard of care, breach, and causation— will not suffice. Scoresby, 346 S.W.3d at 556; Palacios, 46 S.W.3d at 879; accord Abshire, 563 S.W.3d at 223. Thus, when a report fails to include information linking the expert’s conclusions to the alleged breach, the trial court may reasonably conclude that the report is conclusory. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 53 (Tex. 2002) (per curiam). Furthermore, “[a]n expert cannot simply opine that the breach caused the injury[,]” because such a statement would “not give the trial court any reasonable basis for concluding that the lawsuit has merit.” See Jelinek v. 5 Casas, 328 S.W.3d 526, 539 (Tex. 2010). Rather, the expert must “explain, to a reasonable degree, how and why the breach caused the injury based on the facts presented.” Id. at 539–40 (emphasis added); see also Columbia Valley Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453, 461 (Tex. 2017). To show “how” and “why” the breach caused the injury, the report “must make a good-faith effort to explain, factually, how proximate cause is going to be proven.” Zamarripa, 526 S.W.3d at 460. Proximate cause has two components: (1) foreseeability and (2) cause in fact. Id. To be a “cause in fact” of the injury, “the act or omission must have been a substantial factor in bringing about the harm, and absent the act or omission—i.e., but for the act or omission—the harm would not have occurred.” Id. (quoting Rodriguez-Escobar v. Goss, 392 S.W.3d 109, 113 (Tex. 2013) (per curiam)). Muns focuses primarily on the adequacy of the causation analysis in the amended report—specifically the causal relationship between the failure (1) to administer an anesthetic other than Propofol, which caused him harm “from the failed sedation to the non-consensual re-intubation to the alleged mistreatment during extubation[,]” and (2) to obtain his informed consent. 1. The Use of Propofol Here, the amended report, in addressing causation, reads in part: If Dr. Khavar Dar . . . had considered what Ms. Muns . . . had told multiple providers . . . during the history and physical via telephone, that [Muns] had a history of issues awakening while Propofol was being administered, a different medication should have been used to sedate [Muns]. In doing so, [Muns] would have avoided the episode of awareness emergence as evidenced by unintentional extubation. As stated above, there is an increased amount of unintentional extubation with the use of Propofol in patients. The supreme court in Wright addressed a report that is similar to the amended report provided by Muns. In that case, the plaintiff’s expert report stated that “if the x-rays would have been correctly read and the appropriate medical personnel acted upon 6 those findings then [the plaintiff] would have had the possibility of a better outcome.” Wright, 79 S.W.3d at 52–53. The plaintiff contended that this statement established causation because “if the proper medical personnel at [the hospital] had reviewed the x-rays, [the plaintiff] would have had a chance of diagnosis and treatment of her foot fracture.” Id. at 53. However, the court held that the trial court did not abuse its discretion when it found that the report was insufficient and not a good faith effort to comply with the statute. Id. Applying the well-established standard, we conclude that the trial court did not abuse its discretion when it determined that the amended report was not a good faith effort to address Muns’s claim that the use of Propofol caused his injuries. Like the report in Wright, Dr. Henderson’s amended report merely opined that had the proper medication been given, Muns would not have sustained any injuries. However, and importantly, it does not explain how this omission caused Muns’s alleged injuries. See Gray v. CHCA Bayshore L.P., 189 S.W.3d 855, 860 (Tex. App.—Houston [1st Dist.] 2006, no pet.) (finding an expert’s causation analysis was conclusory when the report “[did] not state with any specificity how [the provider’s] departure from the stated standard of care caused [the injury]” and “provide[d] only the conclusory statement that the failure to monitor caused [the plaintiff’s] injury”). Dr. Henderson’s amended report is in stark contrast to the report that was held to be sufficient in Abshire. In Abshire, the report clearly set forth “how” the breach—the failure “to document a complete and accurate assessment”—caused the plaintiff’s paraplegia. Abshire, 563 S.W.3d at 224–25. It further explained, in factual detail, what would have occurred if the medical providers had complied with the applicable standard of care and, in doing so, administered the proper treatment. See id. For example, the report described how (1) the failure to document an accurate assessment resulted in the delay of obtaining proper imaging and protection of the spine, and (2) if the proper standard had been followed, the plaintiff “could have 7 been admitted to the hospital on absolute bed rest, imaging studies such as a CT or MRI of her back ordered, then treatment started to preserved [sic] the integrity of the spine.” Id. In this case, unlike the clear causal link in Abshire, there is no link in Dr. Henderson’s amended report that connects the conclusion—that Propofol should not have been used—to the alleged injuries Muns sustained because of his self- extubation. Further, in his brief, Muns states that his expert “is not opining that [Muns] would not have awakened with the use of a different anesthesia.” Therefore, we conclude that the trial court did not abuse its discretion when it found this part of the amended report insufficient. 2. Informed Consent Dr. Henderson’s amended report continues: If Dr. Khavar Dar, MD discussed consent with Mrs. Muns, POA, informing her of the risk of intubation, to include awakening during the procedure, and had no information to provide benefits for reintubation, then consent would not have been given per interview with Mrs. Muns, due to [Muns’s] history of “fear and awakening during procedures involving anesthesia.” When a plaintiff’s cause of action is based on the failure of a medical provider to “disclose or adequately disclose the risks and hazards involved in the medical care or surgical procedure rendered[,]” there must be a causal connection showing that the risks complained of “could have influenced a reasonable person in making a decision to give or withhold consent.” See CIV. PRAC. & REM. § 74.101 (West 2017) (emphasis added). Thus, the standard is not whether the plaintiff or someone else would have consented to treatment had they been adequately informed, but rather whether a reasonable person would have. See id.; Greenberg v. Gillen, 257 S.W.3d 281, 283 (Tex. App.—Dallas 2008, pet. dism’d). In Greenberg, the Fifth Court of Appeals analyzed a similar expert report in an informed consent context. In that case, the report contained no discussion about 8 “whether the alleged undisclosed information would have influenced a reasonable person in deciding whether to give or withhold consent.” Greenberg, 257 S.W.3d at 283. Without this, there was no showing that “the alleged negligence in failing to obtain informed consent caused [the plaintiff’s] injury or damage.” Id. As such, the court held that the report did not constitute a good faith effort to comply with the requirements of Chapter 74. Id. Like the report in Greenberg, Dr. Henderson’s amended report contains no reference as to whether possessing the requisite information would have influenced a reasonable person to withhold consent. Instead, his report only references whether Muns’s wife would have withheld consent. See Sanchez v. Martin, 378 S.W.3d 581, 589–90 (Tex. App.—Dallas 2012, no pet.) (finding a report to be deficient when it contains no opinions about what a reasonable person “could have been influenced to decide to give or withhold consent by being informed of the risks or hazards that were not disclosed”). Given the absence of any discussion or connection as to what a reasonable person would have done under the circumstances, we conclude that the amended report’s causation analysis regarding Muns’s informed consent complaint does not constitute a good faith effort to comply with Chapter 74. Because the trial court did not abuse its discretion when it found that Dr. Henderson’s amended report does not satisfy the requirements of Chapter 74, it did not err when it granted Dr. Dar’s motion to dismiss. Accordingly, we overrule Muns’s first, second, and third issues. C. Thirty-Day Extension Section 74.351(c) provides in relevant part: If an expert report has not been served within the period specified by Subsection (a) because elements of the report are found [to be] deficient, the [trial] court may grant one 30-day extension to the claimant in order to cure the deficiency. 9 CIV. PRAC. & REM. § 74.351(c) (emphasis added). Muns contends that he should be granted another extension to cure the deficiencies in the amended report. Dr. Dar argues, and we agree, that Muns is not entitled to a second extension because Section 74.351 only provides for one. Despite Muns’s contention, the statute is clear—a claimant is allowed only “one” thirty-day extension. See id.; MCH Pro. Care v. Zubia, No. 11-19-00338-CV, 2021 WL 4313212, at *8 (Tex. App.—Eastland Sept. 23, 2021, pet. denied) (mem. op.). While Muns attempts to point to the statute’s legislative history—that the purpose of the extension is to allow meritorious claims to go forward while screening frivolous ones—to justify his assertion that he is entitled to an additional extension, legislative history will not overcome the plain and unambiguous meaning of the statute. See City of Rockwall v. Hughes, 246 S.W.3d 621, 626 (Tex. 2008) (“When a statute’s language is clear and unambiguous, it is inappropriate to resort to rules of construction or extrinsic aids to construe the language.”). Thus, we decline to construe the statute in the manner advanced by Muns. Accordingly, we overrule Muns’s fourth issue. III. This Court’s Ruling We affirm the order of the trial court. W. STACY TROTTER JUSTICE September 24, 2026 Panel consists of: Bailey, C.J., Trotter, J., and Williams, J. 10