Santa-Cruz-Bacardi et al v. Metro Pavia Hospital, Inc. et al
Filing
144
OPINION AND ORDER granting 121 motion for summary judgment. Due to the absence of expert testimony and Plaintiffs' inability to show that Dr. Blondet's conduct was sufficiently blatant or patent that a lay person could infer that he was negligent and caused Mr. Santa Cruz-Sigarreta's death, the Court GRANTS Defendants' Motion for Summary Judgment (Docket No. 121 ). Judgment shall be entered accordingly. Signed by Judge Raul M. Arias-Marxuach on 01/15/2020. (dv)
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
JUAN A. SANTA CRUZ BACARDI,
et al.
Plaintiffs
CIVIL NO. 16-2455(RAM)
vs.
METRO PAVIA HOSPITAL, INC, et
al.
Defendants
OPINION AND ORDER
RAÚL M. ARIAS-MARXUACH, District Judge
Pending
before
the
Court
are
Defendant
Máximo
Blondet-
Passalacqua’s Motion for Summary Judgment (“Summary Judgment”)
(Docket No. 121), Statement of Uncontested Facts in Support of
Request
for
Summary
Judgment
(“SUF”)
(Docket
No.
122)
and
a
Memorandum of Law (Docket No. 123).
Having considered the parties’ submissions in response and in
opposition to summary judgment, the Court GRANTS Defendant’s Motion
for Summary Judgment for the reasons set forth below.
I.
FACTUAL BACKGROUND
On August 7, 2016, plaintiffs Mr. Juan A. Santa Cruz-Bacardí
and Mrs. Mireya Santa Cruz-Bacardí (“Plaintiffs”) sued Dr. Gaspar
Fuentes Mejía and Metro Pavía Hospital, Inc. d/b/a/ Hospital Pavia
Santurce
(“Hospital
Pavia”)
for
alleged
medical
malpractice
Civil No. 16-2455 (RAM)
resulting
in
Mr.
Juan
2
Santa
Cruz-Sigarreta’s
(“Santa
Cruz-
Sigarreta”) death. (Docket No. 1 at 5-6). Dr. Blondet was included
as a Defendant in the Second Amended Complaint filed on August 11,
2017 (Docket No. 27). On November 4, 2017, Dr. Blondet filed an
Answer to Second Amended Complaint denying all allegations against
him. (Docket No. 40). 1 Subsequently, on December 10, 2018, he filed
a Motion in Limine requesting that the expert report of Dr. Ian
Cummings be excluded and that the Second Amended Complaint be
dismissed. (Docket No. 64).
On July 26, 2019, the Court granted in part and denied in
part the Motion in Limine. (Docket No. 103). The Court struck Dr.
Ian Cummings’ expert report because it failed to show a national
standard of care and failed to comply with Fed. R. Evid. 702 and
Rule Fed. R. Civ. P. 26. Id. at 14. The claims against Dr. Blondet
were not dismissed at that time because a motion in limine is not
tantamount to a motion for summary judgment. Id. at 15.
On September 17, 2019, the Court denied Plaintiffs’ Motion
for Reconsideration. (Docket Nos. 104 and 118). The Court also
denied Dr. Blondet’s Motion Adopting Expert filed at Docket No.
1
Dr. Blondet is the sole remaining Defendant in the case at bar. Defendant
Metro Santurce, Inc. d/b/a/ Hospital Pavía Santurce was dismissed pursuant to
a voluntary dismissal filed by Plaintiffs at Docket No. 52 and subsequently
granted at Docket No. 53. Defendants Dr. Gaspar Fuentes Mejía and Emergency
Medical Service, Inc. were dismissed from the case pursuant to a voluntary
dismissal filed by Plaintiffs at Docket No. 112 and granted at Docket No. 114.
Civil No. 16-2455 (RAM)
3
95. (Docket No. 120). On October 7, 2019, Dr. Blondet moved for
summary judgment (Docket Nos. 121, 122 and 123).
II.
LEGAL STANDARD
A motion for summary judgment is governed by Fed. R. Civ. P.
56(a). This rule entitles a party to judgment if “the movant shows
[...] no genuine dispute as to any material fact and the movant is
entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a).
A dispute is genuine “if the evidence about the fact is such that
a reasonable jury could resolve the point in the favor of the nonmoving party.” Mercado-Reyes v. City of Angels, Inc., 320 F. Supp.
3d 344, 347 (D.P.R. 2018) (quotation omitted). A fact is material
if it may determine the outcome of the litigation. See Id.
The moving party, here Dr. Blondet, has “the initial burden
of ‘demonstrat[ing] the absence of a genuine issue of material
fact’ with definite and competent evidence.” Id. (quoting Celotex
Corp. v. Catrett, 477 U.S. 317, 323 (1986)). Once this occurs, the
burden shifts to the nonmovant, here Plaintiffs. The First Circuit
has stated that a non-moving party must “with respect to each issue
on which he has the burden of proof, […] demonstrate that a trier
of fact reasonably could find in his favor.” Woodward v. Emulex
Corp., 714 F.3d 632, 637 (1st Cir. 2013) (quotation omitted).
While a Court will draw all reasonable inferences in favor of
the
non-movant,
allegations.
See
it
will
Johnson
disregard
v.
unsupported
Duxbury,
or
conclusory
Massachusetts,
2019
WL
Civil No. 16-2455 (RAM)
4
3406537, at *2 (1st Cir. 2019). Moreover, the existence of “some
alleged factual dispute between the parties will not affect an
otherwise properly supported motion for summary judgment.” Scott
v. Harris, 550 U.S. 372, 379 (2007) (quotation omitted). Hence, a
court should review the record in its entirety and refrain from
credibility determinations or weighing of the evidence. See Reeves
v. Sanderson Plumbing Products, Inc., 530 U.S. 133, 135 (2000).
Finally, Local Rule 56 also governs summary judgment. See
D.P.R. Civ. R. 56. Per this Rule, a motion for summary judgment
must include “a separate, short, and concise statement of material
facts, set forth in numbered paragraphs, as to which […] there is
no genuine issue of material fact to be tried.” Id. A nonmoving
party must then “admit, deny or qualify the facts supporting the
motion […] by reference to each numbered paragraph of the moving
party’s statement of material facts.” Id. The First Circuit has
highlighted that “[p]roperly supported facts […] shall be deemed
admitted unless controverted in the manner prescribed by the local
rule.” Advanced Flexible Circuits, Inc. v. GE Sensing & Inspection
Techs. GmbH, 781 F.3d 510, 520 (1st Cir. 2015) (quotation omitted).
III. FINDINGS OF FACT
Before discussing the undisputed facts, the Court addresses
several compliance issues regarding Plaintiffs’ Response to Dr.
Blondet’s SUF (Docket No. 127). In general, Plaintiffs admitted,
denied
or
qualified
the
proposed
facts.
However,
while
they
Civil No. 16-2455 (RAM)
5
qualified their response to Defendant’s Facts Nos. 8 and 10 (Docket
No. 127 at 3 ¶¶ 8 and 10), they failed to include a record citation
alongside their response, as required by Local Rule 56. See D.P.R.
Civ. R. 56 (“Unless a fact is admitted, the opposing statement
shall support each denial or qualification by a record citation as
required by this rule.”) Hence, these facts are deemed admitted as
per Local Rule 56(e) and Fed. R. Civ. P. 56(e), the latter of which
states that “[i]f a party fails to properly support an assertion
of fact or fails to properly address another party's assertion of
fact […], the court may […] consider the fact undisputed.”
The First Circuit contends that a “nonmovant can thwart the
motion [for summary judgment] only by showing through materials of
evidentiary quality that a genuine dispute exists about some
material fact.” Acosta v. Ames Dep't Stores, Inc., 386 F.3d 5, 8
(1st Cir. 2004). Therefore, without evidentiary proof and a record
citation showing that the facts in question are, for example,
irrelevant or self-serving, the factual disputes alone are not
enough to surpass a summary judgment motion. See e.g., Baum-Holland
v. El Conquistador P'ship, L.P., S.E., 336 F. Supp. 3d 6, 20
(D.P.R.
2018)
(quoting
Anderson
v.
Liberty
Lobby,
Inc.,
477
U.S.242, 247–248 (1986)) (Finding that the existence “of some
alleged factual dispute between the parties will not affect an
otherwise properly supported motion for summary judgment.”). Here,
Defendant admitted, denied or qualified most of the facts in
Civil No. 16-2455 (RAM)
Plaintiffs’
Statement
6
of
Additional
Material
Facts
(“SAMF”).
(Docket No. 127). Yet, he sometimes failed to include a record
citation in his response or only responded that the fact was selfserving or irrelevant. These include Facts Nos. 8, 31-33, 35, 37,
45, 56, 59, 62-66. (Docket No. 133 ¶¶ 8, 31-33, 35, 37, 45, 56, 59
and 62-66). Accordingly, these facts are deemed admitted.
A review of most of the denials shows that Defendant failed
to oppose the truth of the fact itself. For example, Plaintiffs’
SAMF Facts Nos. 12-18 revolve around an April 29th, 2015 emergency
room
visit
by
Mr.
Santa
Cruz-Sigarreta
wherein
Dr.
Blondet
allegedly visited him and annotated his hospital record. (Docket
No. 127 at 6-7 ¶¶ 12-18). Yet, Dr. Blondet’s responses to the facts
merely state “Irrelevant in the amended complaint filed there are
no allegations regarding April 29, 2015 (Exhibit 3 Second Amended
Complaint).” (Docket No. 133 at 5-8 ¶¶ 12-18). While this may be
true, Dr. Blondet’s responses fail to contradict the proposed
facts. Thus, Facts Nos. 12-18 of the SAMF are admitted. See Marina
de Ponce, Inc. v. Fed. Deposit Ins. Corp., 2018 WL 1061441, at *2
(D.P.R. 2018) (“The denials presented by Plaintiff Marina do not
oppose the truth of the statement offered and are either irrelevant
to the matter at hand, provide additional evidence not related to
the fact in question and/or failed to contradict it.”) This also
applies to Defendant’s responses to Facts Nos. 6, 10-11, 24, 28,
42, 49, 52-53, 55, 58 and 60-61 (Docket Nos. 133 ¶¶ 6, 10-11, 24,
Civil No. 16-2455 (RAM)
7
28, 42, 49, 52-53, 55, 58 and 60-61). Hence, these facts are
admitted as well.
After analyzing the proposed facts as stated in Defendant’s
SUF and/or in Plaintiffs’ SAMF, and only crediting the material
facts properly supported by a record citation in accordance with
Local Rule 56, the Court makes the following findings of facts: 2
1. Dr. Blondet is a pulmonologist. (Docket No. 122 ¶1).
2. Mr. Santa Cruz-Sigarreta was a seventy (70) year-old patient,
who
suffered
from
angina
pectoris,
hypertension,
hyperlipidemia, diabetes mellitus, coronary artery disease
(“CAD”), and Idiopathic Pulmonary Fibrosis (“IPF”). (Docket
No. 127 ¶1).
3. Mr. Santa Cruz-Sigarreta was a private patient of Dr.
Blondet, who treated him for IPF, a chronic pulmonary
condition, since 2012. (Id. ¶2).
4. Mr. Santa Cruz-Sigarreta was diagnosed with IPF in 2012. (Id.
¶3).
5. Mr. Santa Cruz-Sigarreta visited the offices of Dr. Blondet
approximately every six (6) weeks. (Id. ¶4).
6. Dr. Blondet saw Mr. Santa Cruz-Sigarreta twenty-four (24)
times in 148 weeks. (Id. ¶5).
7. During that period, Dr. Blondet provided ongoing care to Mr.
Santa Cruz-Sigarreta for episodic illness related to IPF.
(Id. ¶6).
8. During the three (3) years that Mr. Santa Cruz-Sigarreta was
treated by Dr. Blondet, the patient only suffered three (3)
or four (4) exacerbations of his IPF symptoms. (Id. ¶9).
9. When Mr. Santa Cruz-Sigarreta suffered exacerbations of his
IPF symptoms, Dr. Blondet “would see him (Mr. Santa Cruz)
2
The numbers for the admitted facts do not necessarily coincide with their
respective numbers in the SUF or in the SAMF. Therefore, the Court also includes
a reference to their original paragraph number.
Civil No. 16-2455 (RAM)
8
and would give some steroids and some antibiotics and he
would get better”. (Id. ¶10).
10. Dr. Blondet has been an on-call pulmonologist available for
consultations at Hospital Pavía since 2001. (Id. ¶7).
11. Mr. Santa Cruz-Sigarreta’s IPF progressed very slowly during
the three (3) years he was treated by Dr. Blondet. (Id. ¶11).
12. On July 24, 2015, Mr. Santa Cruz-Sigarreta and his wife, Mrs.
Mireya Bacardí-González (hereinafter, “Mrs. Bacardí”),
called Dr. Blondet’s private offices at Instituto Neumológico
de Puerto Rico (“Instituto”) to seek immediate help and
advice
due
to
Mr.
Santa
Cruz-Sigarreta’s
worsening
respiratory problems, severe coughing episodes and copious
production of phlegm. (Id. ¶28).
13. On July 24, 2015, given that Dr. Blondet was not at his
office, the person that took their call at Instituto
instructed them to go to Hospital Pavía’s Emergency Room
(“ER”), so that Dr. Blondet could see Mr. Santa CruzSigarreta, since he was there seeing patients. (Id. ¶30).
14. The person that took their call and referred them to Hospital
Pavía’s ER also told them to request Dr. Blondet once they
got there. Once at the ER, Mrs. Bacardí requested from the
triage nurse to please call Dr. Blondet. (Id. ¶31).
15. According to the office manager and the receptionist at
Instituto, when a patient called requesting the services of
a physician who was not available, and the patient was
referred to Hospital Pavía’s ER due to an emergency
situation, the standard operating procedure in place
throughout 2015 was to call the patient’s physician at his
cellular phone to let him know of the emergency situation.
(Id. ¶32).
16. According to the office manager and the receptionist at
Instituto, in the scenario presented in the previous
paragraph, Instituto’s office personnel would also write down
on a piece of paper the patient’s name and symptoms, and
leave that message at the corresponding physician’s desk.
(Id. at 11 ¶33).
17. On July 24, 2015 Mr. Santa Cruz-Sigarreta and his wife, Mrs.
Bacardí, arrived at Hospital Pavía’s ER. (Id. ¶34).
Civil No. 16-2455 (RAM)
9
18. After Mr. Santa Cruz-Sigarreta was admitted to the ER, Mrs.
Bacardí was informed that calls were placed to Dr. Blondet,
and that they had left him a message. Throughout the time
they spent at the ER, Mrs. Bacardí was not informed whether
Dr. Blondet was reached and told to come see her husband,
which was why they had gone to the ER. (Id. ¶35).
19. Phone records produced by AT&T show multiple calls to Dr.
Blondet’s cellular telephone number from the telephone number
used at the ER to contact physicians. (Id. at 12 ¶37).
20. On the afternoon of July 24, 2015, Dr. Blondet was one of
two (2) on-call pulmonologists available to see patients at
Hospital Pavia. (Id. ¶38).
21. Dr. Blondet was on-call and present at Hospital Pavia until
5:00 pm on July 24, 2015. (Id. ¶39).
22. Since Mr. Santa Cruz-Sigarreta’s initial oxygen saturation
at Hospital Pavia’s ER was 77%, he was admitted to the
emergency room for evaluation and treatment under the
services of Dr. Gaspar Fuentes-Mejía (“Dr. Fuentes”), who
ordered several diagnostic tests (CBC, CMP BNP, ABG, Chest
X-ray, and electrocardiogram). (Id. ¶41).
23. Mrs. Bacardí informed Dr. Fuentes that Mr. Santa CruzSigarreta was Dr. Blondet’s patient and that they had gone
to the hospital to see him. (Id. ¶42).
24. After Dr. Fuentes was informed of the ABG values, he
consulted with Dr. Blondet over telephone concerning the
respiratory condition presented by Mr. Santa Cruz-Sigarreta.
(Id. ¶44). 3
25. According to Dr. Fuentes, “on several occasions … regardless
of whether it be the pulmonologist or the cardiologist”, he
“received patients who are patients of the sub-specialists”,
and he “called that sub-specialist regarding a case [he] had
to deal with regarding those patients.” (Id. ¶45).
26. According to the phone records, Dr. Blondet’s conversation
with Dr. Fuentes on July 24, 2015, apparently occurred at
3 Regarding ABG values, the Cleveland Clinic defines an Arterial Blood Gas Test
as “[a] blood test that measures oxygen and carbon dioxide in the blood.” Heart
&
Vascular
Dictionary,
Cleveland
Clinic,
https://my.clevelandclinic.org/departments/heart/patient-education/dictionary
(last visited Jan. 15, 2020).
Civil No. 16-2455 (RAM)
10
4:25 pm and lasted seventy-eight (78) seconds, which is one
minute and eighteen seconds (1:18). (Id. ¶48).
27. Dr. Blondet indicated to Dr. Fuentes that the ABG values were
normal for Mr. Santa Cruz-Sigarreta due to his pulmonary
condition and that if the labs turned out well, Dr. Fuentes
should discharge the patient. (Id. ¶49).
28. When Dr. Fuentes spoke with Dr. Blondet, all laboratory
results were still pending, including the BNP, which later
resulted in a “panic value”. (Id. ¶50). 4
29. Dr. Blondet did not personally evaluate Mr. Santa CruzSigarreta on July 24, 2015 after Dr. Fuentes consulted with
him over the phone concerning the respiratory condition
presented by the patient. (Id. ¶51).
30. Instituto’s guidelines require that consultations from a
physician to an Instituto physician must be personally
evaluated as soon as possible. (Id. ¶52).
31. According to Dr. Blondet, the reason he did not go to see
Mr. Santa Cruz-Sigarreta at Hospital Pavía’s ER on July 24,
2015 was because he allegedly did not receive a consultation.
(Id. ¶53).
32. Dr. Blondet’s proffered expert could not answer if it was
prudent for Dr. Blondet not to see his patient on July 24,
2015 at Hospital Pavía’s ER. (Id. ¶55).
33. After being discharged from the ER, Mr. Santa Cruz-Sigarreta
remained in bed at home, with worsening shortness of breath,
continued coughing with phlegm, dizziness, and a feeling of
“pressure” in his chest. (Id. ¶56).
34. On July 27, 2015, Mr. Santa Cruz-Sigarreta became
increasingly ill and was taken by ambulance to Hospital HIMA
San Pablo Fajardo (“Hospital HIMA”). (Id. ¶57).
4
Regarding BNP, Cleveland Clinic defines BNP, or B-type natriuretic peptide,
as a hormone “produced by your heart […] released in response to changes in
pressure inside the heart. […] Levels go[] up when heart failure develops or
gets worse, and […] down when heart failure is stable.” NT-proB-type Natriuretic
Peptide
(BNP),
Cleveland
Clinic,
https://my.clevelandclinic.org/health/diagnostics/16814-nt-prob-typenatriuretic-peptide-bnp (last visited Jan. 15, 2020). In particular, BNP is
“measured as a simple blood test to help diagnose and monitor heart failure.”
Id.
Civil No. 16-2455 (RAM)
11
35. Mr. Santa Cruz-Sigarreta was admitted to Hospital HIMA at
4:43 pm with a principal diagnosis of pneumonia and acute
myocardial infarction. (Id. ¶58).
36. While Mr. Santa Cruz-Sigarreta was admitted at Hospital
HIMA’s Intensive Care Unit (“ICU”), Mrs. Bacardí called Dr.
Blondet’s office, was not able to reach him, and left a
message with a secretary or receptionist. (Id. ¶59).
37. Dr. Blondet called Mrs. Bacardí back. Dr. Blondet responded
that he was not aware of the situation with Mr. Santa CruzSigarreta. (Id. ¶60).
38. During that telephone conversation, Mrs. Bacardí informed
Dr. Blondet that Mrs. Santa Cruz-Sigarreta was at HIMA’s ICU,
that he had had a heart attack, that he was very ill, and
relayed the information that the treating physicians at HIMA
had provided to her. (Id. ¶61).
39. After that conversation with Dr. Blondet, Mrs. Bacardi never
heard from Dr. Blondet again, who never called or visited to
see how his patient was doing. (Id. ¶62).
40. On August 6, 2015, the patient was transferred by air
ambulance from Hospital HIMA to Centro Cardiovascular de
Puerto Rico y del Caribe. (Id. ¶63).
41. Mr. Santa Cruz-Sigarreta died on August 14, 2015 at Centro
Cardiovascular de Puerto Rico y del Caribe. (Id. ¶64).
IV.
ANALYSIS
Dr. Blondet’s request for summary judgment rests on Puerto
Rico Supreme Court case law which holds that expert testimony is
required to prove both a standard of care and causation in medical
malpractice suits. (Docket No. 123 at 12). He posits that since
this Court struck Plaintiff’s sole expert report, the claims
against him cannot survive. As discussed below, this Court agrees
with Dr. Blondet.
Civil No. 16-2455 (RAM)
12
In diversity cases such as this one, the substantive law of
Puerto Rico is controlling. See Rivera-Marrero v. Presbyterian
Cmty. Hosp., Inc., 2016 WL 7670044, at *1 (D.P.R. 2016) (quoting
Summers v. Fin. Freedom Acquisition LLC, 807 F.3d 351, 354 (1st
Cir. 2015))(“Since this is a diversity case, we look to federal
law
for
guidance
on
procedural
matters
(such
as
the
summary
judgment framework) and to state law (here, [Puerto Rico] law) for
the substantive rules of decision.”). Thus, in medical malpractice
cases in Puerto Rico, a plaintiff must assert three main elements:
“(1) the duty owed (i.e., the minimum standard of professional
knowledge and skill required in the relevant circumstances); (2)
an act or omission transgressing that duty; and (3) a sufficient
causal nexus between the breach and the harm.” Laureano Quinones
v.
Nadal
Carrion,
2018
WL
4057264,
at
*2–3
(D.P.R.
2018)
(quoting Marcano Rivera v. Turabo Medical Ctr. P’ship, 415 F.3d
162, 167 (1st Cir. 2005)). The standard of care is based on a
national
standard. See
Rojas-Ithier
v.
Sociedad
Espanola
de
Auxilio Mutuo y Beneficiencia de Puerto Rico, 394 F.3d 40, 43 (1st
Cir. 2005). Further, there is a presumption that “physicians have
‘provided an appropriate level of care.’” Laboy-Irizarry v. Hosp.
Comunitario Buen Samaritano, Inc., 2019 WL 3311270, at *9 (D.P.R.
2019) (quoting Borges ex rel. S.M.B.W. v. Serrano-Insern, 605 F.3d
1, 7 (1st Cir. 2010)). Plaintiffs must refute this presumption by
“adducing evidence sufficient to show both the minimum standard of
Civil No. 16-2455 (RAM)
13
care required and the physician’s failure to achieve it.” Id. Under
Puerto Rico law, causation is judged by the doctrine of “adequate
causation.” An adequate cause “is not every condition without
which a result would not have been produced, but that which
ordinarily produces it according to general experience.” LaboyIrizarry v. Hosp. Comunitario Buen Samaritano, Inc., 2019 WL
3311270, at *9 (D.P.R. 2019) (quoting Cardenas Maxan v. Rodriguez
Rodriguez, 125 P.R. Dec. 702, 710 (1990), P.R. Offic. Trans.); see
also, Ganapolsky v. Boston Mut. Life Inc. Co., 138 F.3d 446, 443
(1st Cir. 1998) (“A condition is an adequate cause if it ordinarily
can be expected to produce the result at issue.”)
Puerto Rico Supreme Court precedent and the First Circuit
have repeatedly held that expert testimony is required to prove
causation in medical malpractice suits and to refute the abovementioned presumption. For example, in Marcano Rivera v. Turabo
Medical Center Partnership, the First Circuit averred that “a
factfinder normally cannot find causation [a breach of the duty
owed] without the assistance of expert testimony to clarify complex
medical and scientific issues that are more prevalent in medical
malpractice
cases
than
in
standard
negligence
cases.” Marcano
Rivera v. Turabo Medical Ctr. P’ship, 415 F.3d 162, 167 (1st Cir.
2005)) (quoting Rojas-Ithier, 394 F.3d at 43); see also CruzVazquez v. Mennonite General Hosp., Inc., 613 F.3d 54, 56 (1st
Cir. 2010); Pages- Ramirez v. Ramirez-Gonzalez, 605 F.3d 109, 113
Civil No. 16-2455 (RAM)
(1st
Cir.
2010);
Cortes-Irizarry
14
v.
Corporacion
Insular
De
Seguros, 111 F.3d 184, 191 (1st Cir. 1997) (“A medical malpractice
plaintiff can—and often does—establish causation through expert
testimony.”) In the same vein, this District has held that expert
testimony is necessary to prove both the applicable standard of
care and a doctor’s failure to meet it. See Vargas-Alicea v. Cont'l
Cas. Co., 2019 WL 1453070, at *1 (D.P.R. 2019) (citing RolónAlvarado v. San Juan, 1 F.3d 74, 78 (1st Cir. 1993)) (“Given that
medical knowledge is critical to demonstrating the parameters of
a health-care provider’s duty, the minimum standard of acceptable
care is almost always a matter of informed opinion.”). See also,
Alers v. Barcelo, 2016 WL 4148237, at *3 (D.P.R. 2016).
This Court struck Plaintiffs’ sole expert’s report because it
failed to articulate a national standard of care, an essential
element needed to prove negligence in medical malpractice suits.
(Docket No. 103). Moreover, this Court denied Plaintiffs’ Motion
for Reconsideration on this same issue. (Docket No. 118). Another
Judge in this District in a similar case granted summary judgment
after determining that preclusion of expert testimony made it
difficult for a party to establish a Defendant’s duty of care or
a breach of said duty necessary to prove causation. In Gonzalez
Rivera v. Hosp. HIMA-Caguas, this District noted:
Without the expert testimony of Dr. Lasalle and Dr.
Hausknecht, Plaintiff is unable to present any expert
opinion sufficient to establish either the Defendants'
Civil No. 16-2455 (RAM)
15
duty of care or a breach of the duty owed. The expert
testimony of Dr. Hausknecht is essential to Plaintiff’s
case. The preclusion of Dr. Hausknecht “although
technically not a dismissal of [Plaintiff’s] case,
[would] effectively amounted to one.”
Gonzalez Rivera v. Hosp. HIMA-Caguas, 2018 WL 4676925, at *5
(D.P.R. 2018), aff'd sub nom. Gonzalez-Rivera v. Centro Medico Del
Turabo, Inc., 931 F.3d 23 (1st Cir. 2019) (internal citations
omitted) (quoting Esposito v. Home Depot, U.S.A., Inc., 590 F.3d
72, 78 (1st Cir. 2009)). Thus, this Court believes that as in
Gonzalez-Rivera, summary judgment is proper here because without
expert testimony, Plaintiffs cannot establish Dr. Blondet’s breach
of a duty of care. Without establishing this breach, Plaintiffs
also cannot establish sufficient causation to link Dr. Blondet’s
alleged
death.
actions
or
Plaintiffs
omissions
failed
to
with
Mr.
proffer
to
Santa
the
Cruz-Sigarreta’s
Court
sufficient
material facts which show that Dr. Blondet’s actions contributed
to Mr. Santa Cruz-Sigarreta’s death three weeks after Dr. Blondet
allegedly failed to visit him. Therefore, Plaintiffs are missing
all three elements required to prevail in a medical malpractice
case as without expert testimony they cannot show: (1) the duty
that Dr. Blondet owed to the deceased; (2) an act or omission on
his part breaching that duty; and (3) a sufficient causal nexus
between the breach and the patient’s death. See Rolón-Alvarado v.
San Juan, 1 F.3d 74, 77 (1st Cir. 1993).
Civil No. 16-2455 (RAM)
16
The Court notes that very narrow exceptions exist where a
Court may find that expert testimony is not necessary to prove
causation in medical malpractice suits. These include “situations
where common knowledge and experience are all that is necessary to
comprehend a defendant's negligence […], or where negligence is
grossly apparent, […] or where a doctor's conduct violates a set
standard.” Rolón-Alvarado, 1 F.3d at 79. This means that the
exceptions must encompass “only those few situations in which the
claimed medical malpractice is sufficiently blatant or patent that
lay persons, relying on common knowledge and experience, can
legitimately recognize or infer negligence.” Id. However, none of
these exceptions are applicable to the present case.
A review of
the Docket shows that Plaintiffs fail to show that Dr. Blondet’s
conduct was “sufficiently blatant or patent that [a] lay person[]”
could infer that his negligence caused Mr. Santa Cruz-Sigarreta’s
death. Id.
The
First
Circuit’s
ruling
in
Rodriguez-Diaz
v.
Seguros
Triple-S, Inc. regarding the exclusion of expert testimony and
exceptions to the rule is instructive. See Rodriguez-Diaz v.
Seguros Triple-S, Inc., 636 F.3d 20, 24 (1st Cir. 2011). In
Rodriguez-Diaz,
the
First
Circuit
upheld
a
district
court’s
granting of summary judgment in defendant’s favor because expert
medical testimony was required to prove a physician’s negligence
and the lower court had already excluded the expert’s report.
Civil No. 16-2455 (RAM)
17
Moreover, plaintiffs had not presented any evidence apart from the
expert testimony which could “establish that the care afforded did
not meet minimal standards”. Id. at 23. The Rodriguez-Diaz Court
held that:
Absent an expert witness, […] it would be hard for the
jury to know anything about relative urgency or any need
for differentiation on some other basis—let alone how
the patient's specific symptoms or the slide results in
this case might bear upon the question. […] [T]he appeal
fails because there is a legal rule requiring expert
testimony in a case of this character, and possible
exceptions [such as the jury using common sense to close
the gap] to the rule have not been shown to apply.
Id. at 24.
Lastly, the opinion in Mercado-Velilla v. Asociacion Hosp.
del
Maestro
determined
also
that
shows
the
a
case
similar
did
not
scenario
fall
wherein
within
the
the
Court
exceptions
exemplified in Rolón-Alvarado. In that case, the Court explained
that as “the average layperson does not know how much Prednisone
must
be
consumed
for
an
individual
to
suffer
long-term
consequences.” Mercado-Velilla v. Asociacion Hosp. del Maestro,
902 F. Supp. 2d 217, 239 (D.P.R. 2012). Thus, to determine if a
given medication caused injuries when it was prescribed is the
typical
‘complex
medical
and
scientific
issue[
]
that
[is]
prevalent in medical malpractice cases’” and which requires expert
testimony. Id. (internal quotations omitted).
Here, a similar situation occurs. Plaintiffs simply stating
that Dr. Blondet’s negligence is “grossly apparent,” without more,
Civil No. 16-2455 (RAM)
18
is insufficient for the exceptions articulated in Rolón-Alvarado
to apply. (Docket No. 126 at 16 ¶45). Just because negligent
conduct seems “apparent” does not mean that a layperson can “close
the gap” and conclude that Dr. Blondet’s purported actions or
omissions resulted in the patient’s death. See Prince v. Hosp.
Hima San Pablo Caguas, 2014 WL 2475611, at *6 (D.P.R. 2014)
(quoting Lama v. Borras, 16 F.3d 473, 478 (1st Cir. 1994)) (“To
prevail […] “[a] plaintiff must prove, by a preponderance of the
evidence, that the physician's negligent conduct was the factor
that ‘most probably’ caused harm to the plaintiff.”).
At all relevant times, Mr. Santa Cruz-Sigarreta received
medical care from physicians other than Dr. Blondet. Mr. Santa
Cruz-Sigarreta during his July 24, 2015 visit to Hospital Pavia’s
ER was under the care of Dr. Fuentes. (Docket No. 127 ¶41).
Moreover, between July 27, 2015 and his passing eighteen (18) days
after on August 14, 2005, Mr. Santa Cruz-Sigarreta was under the
care of physicians at Hospital HIMA and Centro Cardiovascular de
Puerto
Rico
intervention
y
of
del
Caribe.
multiple
Id.
¶¶
57-64.
physicians,
and
In
light
Mr.
Santa
of
the
Cruz-
Sigarreta’s pre-existing cardiac condition, this Court finds that
it cannot infer for purposes of summary judgment that Dr. Blondet’s
purported negligence was an adequate cause of Mr. Santa CruzSigarreta’s
death.
As
the
First
Circuit
has
cautioned,
“an
inference is reasonable only if it can be derived from the evidence
Civil No. 16-2455 (RAM)
19
without resort to speculation.” Hidalgo v. Overseas Ins. Agency,
120 F.3d 328, 332 (1st Cir. 1997).
The Court notes that there are some remaining factual disputes
between the parties. However, they are not material in nature and
cannot thwart summary judgment. “[T]he requirement is that there
be no genuine issue of material fact.” Scott, 550 U.S. at 380
(quoting Anderson, 477 U.S. at 247-48). Here, Plaintiffs failed to
create a genuine issue of material fact.
Hence, summary judgment is GRANTED dismissing WITH PREJUDICE
all of Plaintiffs’ pending claims including the direct action
against insurers under 26 L.P.R.A. §2003.
V.
Due
to
the
absence
of
CONCLUSION
expert
testimony
and
Plaintiffs’
inability to show that Dr. Blondet’s conduct was sufficiently
blatant or patent that a lay person could infer that he was
negligent and caused Mr. Santa Cruz-Sigarreta’s death, the Court
GRANTS Defendants' Motion for Summary Judgment (Docket No. 121).
Judgment shall be entered accordingly.
IT IS SO ORDERED.
In San Juan Puerto Rico, this 15th day of January 2020.
S/ RAÚL M. ARIAS-MARXUACH
United States District Judge
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