Laboy-Irizarry et al v. Hospital Comunitario Buen Samaritano, Inc. et al
Filing
124
AMENDED OPINION AND ORDER (NUNC PRO TUNC). Signed by Judge Raul M. Arias-Marxuach on 7/17/19.(mrr)
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
RAMON LABOY-IRIZARRY, MARIA INES
ACOSTA-IRIZARRY and JOSUE RAMON
LABOY-ACOSTA,
Plaintiffs
CIVIL NO. 17-1362 (RAM)
v.
HOSPITAL COMUNITARIO BUEN
SAMARITANO, INC., et al.,
Defendants
AMENDED OPINION AND ORDER
(NUNC PRO TUNC)
RAÚL M. ARIAS-MARXUACH, District Judge
I. BACKGROUND
Plaintiffs Ramon Laboy-Irizarry (“Mr. Laboy”), Maria Ines
Acosta-Irizarry (“Mrs. Acosta”) and Josue Ramon Laboy-Acosta (“Mr.
Laboy-Acosta”) are respectively the father, mother and brother of
Ileana Laboy-Acosta (“Ileana”). On March 15, 2017, they filed this
action seeking damages arising from alleged medical malpractice.
Specifically, Plaintiffs contend that Ileana’s death due to postpartum hemorrhaging after giving birth to her second child at
Hospital Comunitario Buen Samaritano, Inc. (“the Hospital”) was
the result of medical malpractice. To recover their damages,
Plaintiffs sued the Hospital, four (4) doctors who provided care
Civil No. 17-1362 (RAM)
2
to Ileana, the doctors’ spouses and the conjugal partnerships
between said doctors and their spouses.
Dr. Castillo was Ileana’s Obstetrician and Gynecologist and
had delivered her first child. Dr. Marrero was the anesthesiologist
who provided care to Ileana on the day of her death. Dr. Rivera
was an emergency room doctor who briefly provided care to Ileana
shortly after childbirth. Dr. Samuel Fuentes provided care to
Ileana while she was at the Hospital’s Intensive Care Unit.
On
June
20,
2019,
this
case
was
transferred
to
the
undersigned. At the time of transfer, a jury trial setting of June
26, 2019 was in effect. The Court modified the schedule to provide
for a settlement conference before a Magistrate Judge on June 25,
2019; a final pretrial conference on June 27, 2019; and both jury
selection and the first day of the jury trial on June 28, 2019.
At
the
settlement
conference
with
the
Magistrate
Judge,
co-
defendants Dr. Castillo, Dr. Marrero, and the Hospital, reached a
settlement
agreement
in
which
plaintiffs
released
them
from
liability. This settlement agreement applies to the present case
as well as a related action before the Court of First Instance,
Aguadilla Superior Part (“the State Action”).
Following the final pretrial conference on June 27, 2019, codefendant
Dr.
Rivera
reached
a
settlement
agreement
with
Plaintiffs which also covered this case and the State Action.
Accordingly, partial judgments of dismissal with prejudice were
Civil No. 17-1362 (RAM)
3
entered. Thus, the sole defendant remaining was Dr. Fuentes, who
is in default.
Dr. Fuentes was personally served with process and copy of
the original complaint on April 7, 2017. Default was entered
against Dr. Fuentes on December 7, 2017.
The Court held hearings under Fed. R. Civ. P 55(b) regarding
the claims against Dr. Fuentes on June 28 and July 1, 2019. During
the hearing held on June 28, 2019, Plaintiffs testified as to the
effect Ileana’s death had on them. At the hearing on July 1, 2019,
Plaintiffs presented the testimony of their medical expert Dr.
Jason S. James (“Dr. James”), who testified as to Dr. Fuentes’,
and
the
settling
co-defendants’,
breaches
of
the
applicable
standard of care and their role in causing Ileana’s death.
II. FINDINGS OF FACT
A. Background:
1.
Plaintiffs Ramon Laboy-Irizarry, his wife Maria Ines
Acosta-Irizarry and their son Josue Ramon Laboy-Acosta are the
parents
and
brother,
respectively,
of
deceased
Ileana
Laboy-
Acosta.
2.
Mr. Laboy and Mrs. Acosta have been married for thirty-
six (36) years. They had three (3) daughters and one son, Josue
Laboy-Irizarry.
3.
Ileana was the youngest daughter. Her husband was named
Zuriel Villarrubia Ruiz. They had two (2) sons. The oldest is Dylan
Civil No. 17-1362 (RAM)
4
who is eight (8) years old. The youngest is Elian who was born on
the day of Ileana’s passing.
4. Ileana was twenty-eight (28) years old at the time of
her passing.
5. Following Ileana’s passing, Mr. Laboy and Mrs. Acosta
moved to Gillette, Wyoming to be close to their son Josue.
6. Defendant
Dr.
Samuel
Fuentes
is
a
medical
doctor
specialized in emergency medicine.
7. Hospital Comunitario Buen Samaritano, Inc. is a nonprofit corporation organized and existing under the laws of the
Commonwealth of Puerto Rico which has its principal place of
business in Puerto Rico and which is the owner and/or operator of
a hospital of the same name, located in Aguadilla, Puerto Rico.
8. Dr. Ruben Castillo is a medical doctor, specializing in
obstetrics and gynecology, married to codefendant Jane Doe and
together
with
her
constituting
a
conjugal
partnership,
who
provided medical treatment to Ileana, now deceased.
9. Dr. José Marrero is an anesthesiologist who provided
medical treatment to Ileana. Dr. Marrero and his wife are domiciled
in Puerto Rico, where they reside.
10.
Dr. Luis Rivera is a medical doctor specializing in
emergency medicine who provided medical treatment to Ileana. Dr.
Rivera-Rivera and his wife are domiciled in Puerto Rico, where
they reside.
Civil No. 17-1362 (RAM)
5
B. As to Ms. Ileana Laboy-Acosta
11.
Ileana was a twenty-eight (28) year old female with a
history of a prior vaginal delivery in 2011 of an 8-pound 11-ounce
boy delivered by Dr. Castillo.
12.
Ileana’s
previous
pregnancy
was
complicated
by
gestational diabetes.
13.
Her
medical
history
is
significant
for
chronic
hypertension, for which she took Enalapril 2.5 mg daily.
14.
Ileana had a baseline weight of 199 pounds, reported
allergy to aspirin and she began prenatal care with Dr. Castillo
at 7.3 weeks gestation, on October 19, 2015.
15.
Her estimated due date was June 3, 2016.
16.
Her prenatal course is significant for an ER visit in
December 2015 due to chest pains.
17.
She was found to have elevated blood pressure (135/95)
and her obstetrician started her on Apresoline 25 mg twice a daily.
18.
In addition, on February 10, 2016 she was diagnosed with
gestational diabetes via three-hour glucose tolerance test and was
prescribed a 2000 calorie per day diabetic diet.
19.
She had a total weight gain of eight (8) pounds and her
Group B streptococcus (“GBS”) status was negative.
20.
According to the Hospital record, Ileana was evaluated
on May 25, 2016 and scheduled for induction of labor on May 31,
2016.
Civil No. 17-1362 (RAM)
6
C.
As to the care provided to Ileana on May 31, 2016.
21.
The
admission
records
reflect
that
Ileana
(“the
patient”) arrived at the Hospital on May 31, 2016 at 6:40 a.m. for
admission.
22.
She
was
noted
to
be
39.4
weeks
gestation
with
a
temperature of 37.2 degrees Celsius, pulse at 117, respiratory
rate of 19, blood pressure 126/83, and weight of 207 pounds.
23.
On
admission,
her
CBC
is
reported
as:
WBC
14.09,
Hemoglobin 13.30, Hematocrit 38.40, and Platelets 290. Urinalysis
findings: clarity (cloudy), glucose (1,000), WBC (26-50), blood
(25), epithelial cells (many) and bacteria (many). The records
reflect that the patient had intact membranes, and her pain level
was 0.
24.
At 7:00 a.m., the nurse’s notes document that the fetal
heart rate was 130-140 bpm, reactive, with moderate variability
and mild irregular contractions without vaginal bleeding and no
complaints of pain.
25.
At 7:30 a.m., the nurse documented that medications were
administered according to medical order and she was given the first
dose of Cytotec at this time.
26.
The second dose of Cytotec was administered at 11:30
27.
The chart reflects that at 1:37 p.m., Dr. Castillo
a.m.
arrived to evaluate the patient.
Civil No. 17-1362 (RAM)
28.
7
He proceeded to rupture the patient’s membranes, and the
amniotic fluid is documented to be clear and moderate in amount.
29.
At 2:30 p.m., the patient was examined again by Dr.
Castillo and was found to be dilated 4 cm.
30.
At 3:00 p.m. the patient began to vomit.
31.
At 3:15 p.m. the patient was examined by the nurse and
was found to be 8-9 cm dilated, 100% effaced, +2 station.
32.
At 3:20 p.m., this was reported to Dr. Castillo via
speakerphone due to the fact that Dr. Castillo was in a surgical
procedure.
33.
Dr. Castillo replied that as soon as he finished his
procedure, he would come to the labor room.
34.
At 3:25 p.m., Mrs. Figueroa (the supervisor) was called
and informed of the patient’s status and that Dr. Castillo was not
immediately available.
35.
Mrs. Figueroa replied that she would come immediately.
36.
At 3:30 p.m., a fetal heart rate of 70-90 bpm was
documented.
37.
At 3:35 p.m., the nurse administered oxygen at 2 liters
per minute.
38.
At 3:55 p.m., a fetal heart rate of 60-70 bpm was
documented.
39.
At 4:17 p.m., the baby’s head was observed to have
delivered to the level of the neck.
Civil No. 17-1362 (RAM)
40.
8
An umbilical cord loop was observed around the neck,
extremely tight to the point that the nurse could barely detect
any blood in the umbilical cord.
41.
The nurse documents positioning the patient using the Mc
Roberts maneuver to favor descent of the shoulder.
42.
The nurse clamped the umbilical cord twice and cut it.
43.
The
application
of
suprapubic
pressure
to
achieve
expulsion of the baby is documented, with delivery of the anterior
shoulder followed by the remainder of the body.
44.
At 4:20 p.m., the placenta was expelled completely,
using the Schultz method, and the nurse administered intravenous
fluids of Lactated Ringers solution (1000 ml with 20 units of
Pitocin) at 125 cc/hour per orders.
45.
The nurse began a uterine massage due to the presence of
profuse vaginal bleeding.
46.
At 4:24 p.m., Dr. Rivera, an emergency room physician,
arrived to evaluate the patient and it was noted that the patient
continues to experience profuse vaginal bleeding.
47.
The nurse administered Methergine 0.2 mg IM per Dr.
Rivera’s verbal order and the intravenous fluids were opened to
full drip. The patient was oriented about the treatment and she
referred to understand.
48.
At
4:55
p.m.,
the
patient
was
evaluated
by
her
obstetrician, Dr. Castillo, who ordered the nurse to administer a
Civil No. 17-1362 (RAM)
9
second dose of Methergine 0.2 mg IM. The patient was oriented about
the purpose of the treatment and she referred to understand.
49.
At
4:58
p.m.,
the
patient
was
transferred
to
the
operating room for an examination under anesthesia as the patient
continued to bleed profusely.
50.
–
5:40
The operative report reflects the following: start time
p.m.;
end
time
–
7:50
p.m.;
preoperative
diagnosis-
postpartum vaginal bleeding; postoperative diagnosis – uterine
atony,
left
paratubal
cyst;
procedure
–
subtotal
abdominal
hysterectomy, left paratubal cystectomy; estimated blood loss –
1000 ml; complications – none; operative findings – cervix without
laceration, no vaginal laceration seen, uterine bleeding continues
even with oxytocin drip, postpartum uterus not involuted- atony.
51.
The operative report documents that the round, broad and
utero-ovarian ligaments were clamped, cauterized, and cut, as were
the uterine arteries.
52.
layers;
The uterus was cut at the low segment and sutured in two
additional
hemostasis
was
performed
with
additional
sutures; no bleeding was seen, and abdomen closed by layers;
estimated blood loss was 1000 cc at the end of the procedure.
53.
An estimated blood loss of 500 cc was noted in the
delivery note written by Dr. Castillo at 8:50 p.m.
Civil No. 17-1362 (RAM)
54.
10
A nursing note issued at 7:00 p.m. documents the blood
transfusions (three (3) units of packed red blood cells) that the
patient received, stable vital signs, and mild vaginal bleeding.
55.
A “late note” added to this note documented that Dr.
Castillo has been notified that the patient continued to bleed and
that he placed some sutures in the vaginal area but that she
continued to bleed.
56.
It was documented that three (3) units of PRBC (“packed
red blood cells”) were administered in OR.
57.
The nurse’s operative notes indicated that the patient
was transferred to the ICU at 8:20 p.m.
58.
Documentation
by
Dr.
Marrero
after
the
operative
procedure indicated that the patient was to be transferred to the
ICU in critical condition, intubated and ventilated by Ambu-bag,
and vital signs were blood pressure 90/60 and pulse at 110.
59.
According to the ICU director, Dr. Luis Rivera-Carpio,
he was called at around 8:30 p.m. in consultation for admission of
the patient due to acute blood loss from uterine atony.
60.
At 8:35 p.m., the patient was received from the OR,
connected to a mechanical ventilator. The patient’s skin was cold
to the touch, pale, no capillary refill in either hand, bluish
coloration and documented light vaginal bleeding.
61.
A note by Dr. Rivera-Carpio reflected that the medical
intern notified him that upon arrival in the ICU, the patient was
Civil No. 17-1362 (RAM)
11
unstable, acutely ill, with blood pressure at 51/40 and pulse at
116.
62.
Dr. Rivera-Carpio instructed aggressive fluid management
and blood transfusions.
63.
After 8:35 p.m., the temperature of the patient was not
measurable.
64.
The patient was placed in Trendelenburg position and a
thermal blanket was placed.
65.
Dr. Fuentes consulted Dr. Rivera-Carpio by telephone
after the patient’s arrival at the ICU.
66.
The Patient’s blood pressure was 51/40. Her pulse was
116 beats per minute and could be palpated.
67.
When
Dr.
Rivera-Carpio
arrived
at
the
hospital
at
approximately 9:10 p.m., the patient had been in cardiorespiratory
arrest for 10 minutes, with the cardiac monitor demonstrating
pulseless electric activity (PEA).
68.
At 9:28 p.m., a neurology evaluation was performed in
the company of Dr. Fuentes. The patient presented pupils reactive
to light, reduced corneal reflex, absent gag, no response to verbal
stimulation, no response to pain and involuntary movements are
observed.
69.
At
9:33
p.m.,
the
ACLS
protocol
was
started
medications were administered per medical order.
70.
A full drip unit was transfused per medical order.
and
Civil No. 17-1362 (RAM)
71.
12
ACLS protocols were continued with participation by the
anesthesiologist for a total of 35 minutes with no response.
72.
The patient was pronounced dead by Dr. Rivera-Carpio at
10:20 p.m.
73.
The pathology report states that Mrs. Laboy “had uterine
atony producing acute blood loss.”
74.
The pathology report demonstrates the uterus weighing
1125 grams, postpartum uterus with decidualized endometrium and
placental
implantation
site;
leiomyoma
(x7),
intramural
subserosal, with hyaline degeneration; paratubal left cyst.
D. As to the Expert Testimony:
75.
At the hearing, plaintiffs presented the testimony of
Dr. Jason S. James.
76.
Dr.
James
is
Board
certified
in
Obstetrics
and
Gynecology since January of 2006.
77.
Dr. James is a Fellow of the American Congress of
Obstetricians and Gynecologists since May of 2006.
78.
Dr.
James
holds
a
Medical
Doctor
Degree
from
the
Gynecology
and
University of Miami.
79.
He
did
his
medical
residency
in
Obstetrics at the Long Island Jewish Medical Center and has been
engaged in the practice of Obstetrics and Gynecology for 16 years.
Civil No. 17-1362 (RAM)
80.
To
reach
13
his
opinions,
Dr.
James
reviewed
Ileana’s
records kept by Dr. Castillo and the Hospital’s records from her
admission at the Hospital for her delivery.
81.
Dr.
James
also
reviewed
the
death
certificate
and
witness depositions, other experts’ reports and the Hospital’s
protocols.
82.
According to Dr. James, several deviations from the
standard of care by the various physicians, the nursing staff
employed by the Hospital, doctor staff, as well as the Hospital
itself
resulted
in
the
medical
complications
that
eventually
resulted in Ileana’s death.
83.
According to Dr. James, Doctor Fuentes was the last
physician involved in Ileana’s care that had the opportunity to
save her life. However, because of inaction, delay in evaluating
and treating Ileana, and failure to use the appropriate treatments,
Dr. Fuentes unfortunately allowed Ileana to pass.
84.
Patients who lose a lot of blood usually undergo a
process called consumptive coagulopathy. This means that they use
up their clotting factors and continue to bleed.
85.
Consumptive
coagulopathy
results
in
Disseminated
Intravascular Coagulopathy where the body has a difficult time
clotting blood. This condition can be addressed by transfusing
clotting factors.
Civil No. 17-1362 (RAM)
86.
The
requests
14
for
blood
transfusions
sent
to
the
Hospital’s Blood Bank indicate that only PRBCs were requested.
87.
The blood bank’s request for blood transfusion forms
indicate that platelets, plasma, and other products could be
requested.
88.
Blood products such as Fresh Frozen Plasma (FFP) and
cryoprecipitate contain clotting factors, which according to the
Hospital’s hemorrhage plan, should have been transfused to Ileana
to help stem the bleeding.
89.
Hospitals routinely have plans and/or protocols that
recognize the need to transfuse clotting factors in addition to
packed red blood cells when hemorrhaging occurs.
90.
When Ileana was transferred to the ICU, Dr. Fuentes
should have transfused the appropriate ratios of blood products
that would have not only replaced lost blood volume, but also
helped stem further bleeding by replacing clotting factors.
91.
According to Dr. James, if Dr. Fuentes had done the
appropriate and timely evaluation and treatment, Ileana had a very
high likelihood of surviving.
92.
As Ileana’s obstetrician and gynecologist, who also
delivered her first child, Dr. Castillo was aware of her medical
conditions and thus knew that she was a high-risk patient due to
being diagnosed with high blood pressure, gestational diabetes and
obesity.
Civil No. 17-1362 (RAM)
93.
15
Despite scheduling Ileana’s induction of labor for a
specific date in advance, Dr. Castillo did not coordinate to be
present at her delivery or, in the alternative, arrange for another
obstetrician to provide coverage in case of an emergency.
94.
Even after the nursing staff called for Dr. Castillo
once Ileana was 8 to 9 cm dilated, he was not readily available
for over an hour nor did he successfully coordinate for another
obstetrician to go in his place.
95.
This led to Ileana going in to labor without the benefit
of having an obstetrician present, even though she was a high-risk
patient.
96.
recorded
Dr.
Castillo’s
Ileana’s
notes
estimated
also
blood
show
loss
that
during
he
erroneously
birth
as
500
milliliters. According to Dr. James, although 500 milliliters is
the average blood loss during pregnancy, this is incompatible with
the
multiple
notes
throughout
the
medical
record
reiterating
Ileana’s profuse bleeding.
97.
Dr.
Rivera
evaluated
and
treated
Ileana
for
approximately half an hour before Dr. Castillo was able to evaluate
her.
98.
During this time, Dr. Rivera ordered that Ileana be
administered Methergine, 0.2 milligrams intramuscularly. Despite
being
the
correct
dosage,
this
medication
indicated for hypertensive patients.
is
generally
not
Civil No. 17-1362 (RAM)
99.
16
Nevertheless, in his testimony, Dr. James indicated that
this was not a factor that led to Ileana’s death.
100. Dr. Marrero transferred Ileana to the ICU when she was
unstable, tachycardic and hypertensive. However, Dr. Marrero’s
note indicates that Ileana was to be transferred to the ICU in
critical condition, intubated and ventilated.
101. The Hospital, and specifically its nursing staff, did
not
follow
the
established
protocols
regarding
post-partum
hemorrhaging. Specifically, no member of the Hospital’s staff
requested
or
recommended
that
Ileana
receive
blood
clotting
factors.
102. The
detailed
hospital
records
reflect
that
during
Ileana’s labor, the nursing staff only called Dr. Castillo once,
at 3:20 p.m., to inform him that Ileana became dilated 8 to 9 cm.
The nurses did not call Dr. Castillo again to notify that Ileana
needed urgent medical assistance.
103. The records also show that the nurses treating Ileana
did call Mrs. Figueroa, their supervisor, and eventually Dr.
Rivera, an emergency room physician. However, considering Ileana’s
profuse bleeding, calling another obstetrician or surgeon for
assistance was the proper course of action.
104. Likewise, when Ileana was being transferred from the
Operating Room to the Intensive Care Unit, there is no note in the
Civil No. 17-1362 (RAM)
record
describing
the
17
nursing
staff
calling
Dr.
Fuentes
and
informing him of Ileana’s need for immediate medical attention.
E. As to plaintiff Josue Laboy-Acosta’s Damages:
105. Mr. Laboy-Acosta is Ileana’s brother. He is nine (9)
months older than Ileana and married. His oldest son is four (4)
months older than Ileana’s oldest son Dylan.
106. Ileana was his trusted confidant and counselor to the
extent that he talked to her about matters he felt he could not
share with his wife.
107. Though Mr. Laboy-Acosta moved to Gillette, Wyoming for
work-related reasons in 2012, his relationship with Ileana did not
change. They continued to keep in touch by telephone and met during
Josue’s vacations.
108. One of those vacations took them and their families to
Colorado and South Dakota.
109. Mr. Laboy-Acosta feels that he cannot visit these places
anymore because of the association with Ileana.
110. Mr.
Laboy-Acosta
did
not
testify
about
any
ongoing
medical or psychological treatment.
F.
As to Plaintiff Maria Ines Acosta-Irizarry Damages:
111. Mrs. Acosta described Ileana as an exceptional daughter
and mother. She was attentive to detail, kind and made sure the
family stayed together by organizing gatherings.
Civil No. 17-1362 (RAM)
18
112. Mrs. Acosta also described Ileana as an exceptional
student. Mrs. Acosta postponed completion of her college studies
for various circumstances and eventually graduated with Ileana
from the University of Puerto Rico’s Aguadilla Campus in 2010.
113. Mrs. Acosta was at the Hospital when Ileana was taken
into surgery and when she left the operating room. Mrs. Acosta was
informed that Ileana was going to be taken to the ICU, instead of
a hospital room, and received an update on her daughter’s medical
condition.
114. Mrs. Acosta was at the Hospital when her daughter died.
She received the news of Ileana’s passing from Dr. Castillo.
115. Mrs. Acosta felt she would go mad after Ileana’s death
and she sought the aid of a psychologist in Puerto Rico prior to
her daughter’s funeral.
116. After
Ileana’s
death,
every
time
she
sees
a
young
pregnant woman she experiences fear and anxiety.
117. Following Ileana’s untimely death, Mr. Laboy and Mrs.
Acosta had to resort to mediation to enforce their right to visit
Ileana’s children because Zuriel would cancel commitments and not
allow them to visit the children.
118. Zuriel is now in a relationship with another woman.
While she understands that Ileana’s husband is a young man and it
was inevitable that he would move on, it is painful for Mrs. Acosta
Civil No. 17-1362 (RAM)
19
Irizarry to know that he is in a new relationship and that Ileana’s
two young sons call Zuriel’s new romantic partner “mom”.
119. When
she
moved
to
Wyoming,
Mrs.
Acosta
sought
the
services of a psychologist there.
120. Mrs. Acosta visits the psychologist in Wyoming every
three weeks. She does not want to burden her husband or children
with
her
sadness
and
thus
she
shares
her
feelings
with
the
psychologist and not with them.
G. As to plaintiff Ramon Laboy-Irizarry:
121. Mr. Laboy described Ileana in the same terms as his wife.
To him, Ileana was the spark of life at family gatherings.
122. Mr. Laboy also had a close relationship with Ileana. He
would pick up Ileana’s oldest son from school to help her.
123. At the time of Ileana’s death, Mr. Laboy was at the
Puerto
Rico
Medical
Center
in
Rio
Piedras,
Puerto
Rico,
accompanying and supporting Ileana’s husband as new-born Elian had
been transferred to the Intensive Care Unit there for treatment.
124. He made it back to Aguadilla to see his daughter’s corpse
at the Hospital. On the way to Aguadilla from Rio Piedras, it fell
upon him to break the news of Ileana’s passing to Ileana’s husband,
Zuriel. Zuriel did not want to see Ileana’s corpse.
125. Following Ileana’s death, Mr. Laboy and his wife went to
Gillette, Wyoming to assist their son Josue and his wife with the
Civil No. 17-1362 (RAM)
20
birth of their second child. They returned to Puerto Rico to assist
their youngest daughter who was also pregnant.
126. He and his wife moved permanently to Wyoming after
Ileana’s death because they began to experience “a lot of anguish”
when they started to realize that Ileana was no longer with them.
127. Every time he sees a young pregnant woman he also
experiences fear.
128. Mr. Laboy was diagnosed with bipolar disorder in 2006.
129. He
takes
the
three
(3)
medications
to
manage
his
condition: Lithium, Zyprexa and Lamotrigine.
130. After Ileana’s death, his lithium dosage was increased
from 1,800 to 2,000 milligrams a day. He was also instructed to
take an extra dose of 300 milligrams of lithium if he experiences
depression, anxiety or sleeplessness.
131. He also had to increase the frequency of his visits to
the VA Clinic for treatment of his bipolar depression. Prior to
Ileana’s death, he had a standing appointment once every quarter.
Now, he visits the VA Clinic every two months.
132. Despite
Ileana’s
death,
he
has
been
able
to
avoid
hospitalization for bipolar depression for 11 years.
III. CONCLUSIONS OF LAW
A. Default Hearing Under Fed. R. Civ. P. 55(b):
Fed. R. Civ. P. 55(b) provides in turn that when judgment is
not for a sum certain, the Court “may conduct hearings or make
Civil No. 17-1362 (RAM)
21
referrals—preserving any federal statutory right to a jury trial
[…] (B) to determine the amount of damages; (C) the truth of any
allegation by evidence; or (D) investigate any other matter.”
This Rule “preserves the trial by jury when and as required by any
statute of the United States.” Henry v. Sneiders, 490 F.2d 315,
317 (9th Cir. 1974), cert. denied 419 U.S. 832 (1974) (quotations
omitted).
See also
Wright, Miller & Kane Federal Practice &
Procedure: Civil 3d § 2688 (2019). The only federal statute
providing
for
a
jury
trial
that
the
Court
is
aware
of
is
inapplicable in this case. See 28 U.S.C. § 1874 (actions on bonds
and specialties). Moreover, there is no constitutional right to a
jury trial upon entry of default “since the Seventh Amendment right
to trial by jury does not survive a default judgment.” Henry v.
Sneiders, 490 F.2d at 318. See also Adriana Inter. Corp. v.
Thoeren, 913 F.2d 1406, 1414 (9th Cir. 1990); Eisler v. Stritzler,
535 F.2d 148, (1st Cir. 1976) (“Since plaintiffs’ claims were not
for unliquidated damages and defendant had made an appearance, a
hearing, although not a jury trial was required.”)
“After an entry of default, a court may examine a plaintiff’s
complaint to determine whether it alleges a cause of action. In
making that determination it must assume that all well pleaded
factual
allegations
are
true.”
Quirindongo
Pacheco
v.
Rolon
Morales, 953 F.2d 15, 16 (1st Cir. 1992) (citations omitted).
Civil No. 17-1362 (RAM)
22
Pursuant to Fed. R. Civ. P. 55(b)(2), a court, in an exercise
of its discretion, “may hold a hearing to establish the truth of
any averment in the complaint.” Id. (internal quotations omitted).
The First Circuit has held that before holding such a hearing, the
Court must provide adequate notice and make its requirements known
to plaintiff. Id. (citing McGinty v. Berenger Volkswagen, Inc.,
633 F.2d 226, 229 (1st Cir.1980)).
The Court complied with this notice requirement by directing
Plaintiffs to present evidence of their damages and evidence as to
the
co-defendants’
liability
in
order
to
be
in
position
to
apportion it.
B. Medical Malpractice under Puerto Rico Law:
Puerto Rico’s General Tort Statute Article 1802 of the Puerto
Rico Civil Code provides that “[a] person who by an act or omission
causes damage to another through fault or negligence shall be
obliged to repair the damage so done.” P.R. Laws Ann. tit. 31, §
5141 (1991).
To prove medical malpractice in Puerto Rico, a plaintiff must
establish: “(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
claimed harm.” Torres-Lazarini v. United States, 523 F.3d 69, 72
(1st Cir. 2008) (quoting Cortés-Irizarry v. Corporacion Insular De
Civil No. 17-1362 (RAM)
23
Seguros, 111 F.3d 184, 189 (1st Cir. 1997)).
1. As to the duty owed:
According to the First Circuit, “[t]he general parameters of
the duty of care that a physician owes to a patient under Puerto
Rico law are uncontroversial.” Borges ex rel. S.M.B.W. v. SerranoIsern, 605 F.3d 1,7 (2010). Specifically, physicians practicing in
Puerto Rico “must employ a level of care consistent with that set
by
the
medical
profession
nationally.”
Id.
(citing
Cortés–
Irizarry, 111 F.3d at 190.)
Under
Puerto
Rico
law,
there
exists
a
presumption
that
physicians have “provided an appropriate level of care.” Id. Thus,
plaintiffs have the “obligation to refute this presumption by
adducing evidence sufficient to show both the minimum standard of
care required and the physician’s failure to achieve it.” Id.
Ordinarily,
expert
testimony
is
required
to
prove
the
applicable standard of care and the doctor’s failure to meet it
“[b]ecause
medical
knowledge
and
training
are
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.” Rolon-Alvarado v. Municipality of San Juan, 1
F.3d
74,
78
(1st
Cir.
1993).
See
also
Santiago
v.
Hospital
Cayetano, Coll y Toste, 260 F.Supp. 2d 373 (D.P.R. 2003).
Turning to hospitals, they may be held liable: (a) when the
hospital’s
employees,
medical
staff,
or
agents
have
acted
Civil No. 17-1362 (RAM)
24
negligently; (b) for the negligent acts of a physician who was
granted the privilege of using the hospital’s facilities for their
private patients; and (c) when a patient comes to a hospital in
search of help and they believe, or are given the impression, that
all the medical staff treating them is employed by the hospital,
regardless of whether or not it is true. See Casillas Sanchez v.
Ryder Memorial Hospital, Inc., 960 F.Supp. 2d 362, 365 (D.P.R.
2013)(citing Marquez Vega v. Martinez Rosado, 16 P.R. Offic. Trans.
487 (1985)).
2. As to causation:
Pursuant to Puerto Rico law, causation is judged by the
“adequate
cause”
doctrine.
The
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.” Cardenas Maxan v. Rodriguez Rodriguez, 125 P.R. Dec.
702, 710 (1990), P.R. Offic. Trans. See 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.”)
To establish causation under Puerto Rico law, plaintiffs
“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.” Marcano Rivera v. Turabo Medical
Center Partnership, 415 F.3d 162. 168 (1st Cir. 2005) (quoting
Civil No. 17-1362 (RAM)
25
Lama v. Borras, 16 F.3d 473, 478 (1st Cir. 1994)).
Although this causation standard “does not require all other
causes of damage to be eliminated […] expert testimony is generally
essential.” Id. This is due to the need to “clarify complicated
medical issues that are more prevalent in medical malpractice cases
than in standard negligence cases.” Pages-Ramirez v. Hosp. Espanol
Auxilio Mutuo De Puerto Rico, Inc., 547 F. Supp. 2d 141, 149
(D.P.R. 2008) (citing Otero v. United States, 428 F.Supp.2d 34,
45–46 (D.P.R.2006)).
3. The case at bar:
Pursuant to Fed. R. Civ. P. 55(b), the Court heard expert
testimony
relevant
to
plaintiffs’
allegations
of
malpractice
against Dr. Fuentes and the settling co-defendants.
Based on his testimony and his Curriculum Vitae, the Court
found that Dr. Jason S. James was qualified to testify as an expert
in Gynecology & Obstetrics because he possessed the requisite
knowledge, skill, experience, training, and education.1 See Fed.
R. Evid. 702.
Based upon Plaintiffs’ expert’s unopposed expert testimony
which the Court finds credible, the Hospital and the doctors
breached the standard of care and those breaches were the adequate
cause of Ms. Ileana Laboy-Irizarry’s death on May 31, 2016.
1
It is worth noting that none of the settling defendants presented a motion
in limine questioning the admissibility of Dr. James’ testimony.
Civil No. 17-1362 (RAM)
26
In general terms, Dr. Fuentes, Dr. Castillo, Dr. Marrero, and
the Hospital’s staff all breached the applicable standard of care
by
deviating
from
the
Hospital’s
post-partum
hemorrhaging
protocols. In summary, Dr. Fuentes did not timely evaluate Ileana
when she was transferred to the ICU in critical condition and
failed to transfuse clotting factors in addition to blood to
control her profuse blood loss. Dr. Castillo did not recognize
that Ileana was a high-risk patient that required his attention,
or that of another obstetrician, and failed to plan accordingly.
Dr. Marrero transferred Ileana to the ICU while she was still
unstable. Lastly, the Hospital’s nursing staff repeatedly failed
to
adequately
communicate
Ileana’s
dire
condition
to
various
doctors and they did not contact another obstetrician when Dr.
Castillo was not available. On the other hand, the Court finds
that Dr. Rivera did not incur in medical malpractice given the
limited scope of the treatment he provided to Ileana. Furthermore,
pursuant to Plaintiffs’ own expert testimony, the fact that he
ordered Ileana be administered Methergine did not contribute to
her death.
C. Apportionment of liability:
In Puerto Rico, when more than one person’s tortious acts
and/or omissions have caused a harm, “each of the tortfeasors is
solidarily liable to the plaintiff for the harm done.” See Ortiz
v. Cybex, 345 F.Supp. 3d 107, 122 (D.P.R. 2018) (citing Tokyo
Civil No. 17-1362 (RAM)
27
Marine and Fire Ins. Co., Ltd. v. Pérez & Cía., de Puerto Rico,
Inc., 142 F.3d 1, 8 (1st Cir. 1998)). “However, solidarity does
not presuppose that the scope or source of liability is identical
for each solidary debtor.” Tokyo Marine and Fire Ins. Co., Ltd.,
142 F.3d 1,6 (1st Cir. 1998). Moreover, “solidary debtors may be
obligated to different degrees.” Id. Likewise, the Puerto Rico
Supreme Court has held that “joint tortfeasors are solidarily
liable to the injured party, but the onerous effect between the
joint tortfeasors should be distributed in proportion to their
respective degree of negligence.” Szendrey v. Hospicare, Inc., 158
P.R. Dec. 648 (2003), P.R. Offic. Trans.
Courts in Puerto Rico are generally guided by “the principle
that no one should or may unjustly enrich himself by receiving
double compensation for the same accident.” Villarini-Garcia v.
Hosp. del Maestro, 112 F.3d 5, 8 (1st Cir. 1997) (quotations
omitted). Thus, when a plaintiff liberates a settling tortfeasor
from
all
liability
tortfeasor’s
share
and
of
the
the
court
determines
responsibility,
the
said
settling
non-settling
tortfeasors are entitled to an offset. See Gomez v. RodriguezWilson, 819 F.3d 18, 22 (1st Cir. 2016). In other words, because
non-settling tortfeasors may not seek contribution against any
liberated settling tortfeasor, “a proportionate setoff in which
the
portion
of
responsibility
attributed
to
the
settling
tortfeasor is deducted from an award against the non-settling
Civil No. 17-1362 (RAM)
28
tortfeasor is proper in order to prevent unjust enrichment.” Id.
at
n.
4.
It
is
worth
noting
that
in
the
context
of
joint
tortfeasors, Puerto Rico case law requires proportional offsets
over dollar-for-dollar setoffs. See Rio Mar Assocs., LP, SE v. UHS
of Puerto Rico, Inc., 522 F.3d 159, 165-167 (1st Cir. 2008) (citing
Szendrey v. Hospicare, 158 P.R. Dec. 648 (2003). See also Gomez,
819 F.3d at 22-23 (1st Cir. 2016) (citing Sagardía de Jesús v.
Hosp. Auxilio Mutuo, 177 P.R. Dec. 484 (2009)).
As a prerequisite for a proportionate offset, plaintiffs
and/or non-settling defendants must present evidence regarding the
settling tortfeasor’s degree of responsibility. See Gomez, 819
F.3d at 21-23. (Non-settling doctor was held liable for the
entirety of the jury award because he did not ask the jury to
apportion responsibility). With regards to what evidence is needed
to apportion liability, the First Circuit has validated the use of
expert testimony, documents and circumstantial evidence as proof
of negligence. See Marcano Rivera, 415 F.3d at 171 (The First
Circuit rejected a hospital’s claim that circumstantial evidence
and expert testimony was insufficient evidence to support a jury
finding that it was liable for 47% of the damages).
Based
on
plaintiffs’
expert’s
unopposed
testimony
and
Ileana’s medical records that were submitted into evidence, the
Court apportions liability in this case among Dr. Fuentes and the
settling defendants as follows:
Civil No. 17-1362 (RAM)
29
A. Hospital Comunitario Buen Samaritano: 50%
B. Dr. Samuel Fuentes: 20%
C. Dr. Ruben Castillo-Rivera: 25%
D. Dr. Jose Marrero-Russe: 5%
E. Dr. Luis Rivera-Rivera: 0%
Because
the
Court
has
apportioned
liability
between
the
settling co-defendants and Dr. Fuentes, he is entitled to a
proportionate offset of the settling tortfeasors’ liability. In
other words, Dr. Fuentes is only liable to plaintiffs for twenty
percent (20%) of the total they proved during the Fed. R. Civ. P.
55(b) hearing.
D. Mental Anguish Damages under Puerto Rico Law:
In Puerto Rico tort law cases, including medical malpractice,
“relatives
are
entitled
to
compensation
for
the
sufferings,
emotional distress, or mental anguish experienced as a consequence
of
the
material
or
other
damages
caused
directly
to
their
relatives.” Santana-Concepción v. Centro Medico Del Turabo, Inc.,
768 F.3d 5, 10 (1st Cir. 2014)(internal quotations omitted).
In evaluating plaintiffs’ evidence of damages, the Court was
mindful of the following admonitions by the Puerto Rico Supreme
Court. First, while the Court acknowledges that “human sorrow and
physical pain are not similar or financially assessable”, it also
finds that “if money does not suffice to redress this type of
damage, an insufficient compensation for the victim would be better
Civil No. 17-1362 (RAM)
30
than none.” Riley v. Rodriguez de Pacheco, 19 P.R. Offic. Trans.
806, 848 (1987). When attempting to measure intangible emotions,
it
is
possible
for
mental
suffering
to
“be
quantified
ad
infinitum.” Id. at 849. However, “[w]ithout reasonable limits,
compensation would no longer bear the characteristics of a redress,
but would rather become punitive.” Id.
Based on the above findings of fact, derived from plaintiffs’
unopposed testimony, and the applicable law, the Court values
plaintiffs’ total past, present and future mental anguish damages
as follows:
1. Ramon Laboy-Irizarry in the amount of $250,000;
2. Maria Ines Acosta-Irizarry in the amount of $250,000;
3. Josue Laboy-Irizarry in the amount of $100,000.
IV. ORDER
For the foregoing reasons, the Court awards damages against
Dr. Samuel Fuentes as follows:
A. Compensatory damages for the past, present and future
mental anguish of Ramon Laboy-Irizarry in the amount
of $50,000;
B. Compensatory damages for the past, present and future
mental anguish of Maria Ines Acosta-Irizarry in the
amount of $50,000;
Civil No. 17-1362 (RAM)
31
C. Compensatory damages for the past, present and future
mental anguish of Josue Laboy-Acosta in the amount of
$20,000;
D. Plaintiffs are further entitled to costs and postjudgment interest as prevailing parties, pursuant to
Puerto Rico Rules of Civil Procedure 44.1 and 44.3.
Judgment shall be entered accordingly.
IT IS SO ORDERED.
In San Juan, Puerto Rico, this 17th day of July 2019.
s/Raúl M. Arias-Marxuach
_ _
RAÚL M. ARIAS-MARXUACH
UNITED STATES DISTRICT JUDGE
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