Pages-Ramirez v. Hosp. Espanol Auxilio Mutuo de Puerto Rico, Inc.

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO

DILMA PAGES-RAMIREZ, et al.,
Plaintiffs
v.
HOSPITAL ESPAÑOL AUXILIO MUTUO
DE PUERTO RICO, INC., et al.,
Defendants

CIVIL NO. 07-1407 (JP)

OPINION AND ORDER

Before the Court is a motion for summary judgment (No. 52) filed
by Defendant Hospital Español Auxilio Mutuo (“HEAM”) and its insurer,
Admiral Insurance Company (“Admiral”). Also before the Court is
Plaintiffs’ opposition thereto (No. 54). Plaintiffs Dilma
Pagés-Ramírez (“Pagés”), Michael Pietri-Pozzi (“Pietri”), the
conjugal partnership between them, and their child Giovanni
Pietri-Pagés (“Giovanni”) (collectively, “Plaintiffs”), brought the
instant action alleging medical malpractice against Defendants HEAM,
Admiral, Dr. Antonio Ramírez-Gonzalez (“Ramírez”), and Insurers
Syndicate for the Joint Underwriting of Medical-Hospital Professional
Liability Insurance (“SIMED”), pursuant to P.R. Laws Ann. tit. 31,
Sections 5141-5142, and P.R. Laws. Ann. tit. 26, Section 2003, for
the injuries sustained by Giovanni during his birth.
Defendants HEAM and Admiral move the Court for summary judgment
on the grounds that a hospital cannot be held liable for the alleged

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malpractice of its nursing staff when the nurses are simply following
the orders of a physician. Defendants also argue that a hospital
cannot be held liable for the alleged malpractice of a private
physician who merely has privileges at said hospital. For the
reasons stated here, Defendants’ motion (No. 52) is DENIED.1
FACTUAL ALLEGATIONS
I.
On May 19, 2005, Plaintiff Pagés, age thirty-three, arrived at
Defendant HEAM at her thirty-sixth week of pregnancy to deliver her
baby, Plaintiff Giovanni. Defendant Ramírez was the physician in
charge of Plaintiff Pagés’ care during pregnancy, and he was the
attending physician at the birth. During the delivery, Plaintiffs
allege that Giovanni suffered or acquired profound multi-organ
damage, respiratory failure, sepsis, asphyxia, and seizures. Due to
the alleged negligence of Defendants during Plaintiff Pagés’
pre-natal care and delivery, Plaintiff Giovanni was born with severe
birth defects including cerebral palsy. Plaintiff Giovanni remained
hospitalized at HEAM until August 5, 2005, when he was transferred
to San Jorge Children’s Hospital to continue treatment.
Plaintiffs make numerous claims that Defendants departed from
medical standards, including 1) failing to record measurements of the
uterine fundus throughout the birth, 2) failing to elicit a
comprehensive obstetrical history from a high risk patient,

The other Defendants in the case, Ramírez and his insurer, SIMED, did not move
for summary judgment.

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3) failing to estimate the fetal weight and to enter same in the
delivery record, 4) proceeding with labor and delivery with
incomplete prenatal record, 5) attempting a mid-pelvic delivery by
vacuum extraction, especially where the heart monitor showed a
problematic pattern, 6) failing to place an internal fetal heart
monitor, 7) failing to monitor the baby’s heart rate, 8) failing to
timely call for a Cesarean-section delivery, 9) failing to timely
perform a Cesarean-section delivery, and 10) failing to timely
diagnose and treat the baby’s fetal distress.
Plaintiffs allege that, as a result of Defendants’ departures
from medical standards, Plaintiff Giovanni is catastrophically
injured, with severe brain damage and physical abnormalities that are
permanent and incapacitating. This has caused Plaintiffs Pagés and
Pietri to suffer emotional anguish. Due to Plaintiffs’ limited
economic resources, Plaintiff Giovanni allegedly has not been able
to receive sufficient quality medical care or therapy.
Defendant HEAM claims that it complied with the generally
accepted standards for hospital care and that Plaintiffs received the
degree of care that a reasonable and prudent person should provide.
HEAM alleges that its personnel did not breach their duty or engage
in any omission that could be considered as the cause of damages
allegedly suffered by Plaintiffs. Defendants further claim that
Plaintiffs have not provided enough evidence to overcome the heavy
burden of the presumption of appropriate medical attention.

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II. MATERIAL FACTS NOT IN GENUINE ISSUE OR DISPUTE:
The following facts were agreed upon by the parties at the
Initial Scheduling Conference held before the Court on September 14,
2007:

Plaintiffs Pagés and Pietri are the parents of Plaintiff
Giovanni.
Defendant HEAM is a Puerto Rico corporation, with its
principal place of business in Puerto Rico. It owns and
operates a hospital of the same name located in San Juan.
Defendant Ramírez is a medical doctor, married to
co-defendant Jane Doe. Ramírez intervened in the
pre-natal care and labor and delivery of Plaintiff Pagés
and her son Giovanni. Ramírez and his wife are residents
of Puerto Rico.
Defendant Ramírez was Plaintiff Pagés’ obstetrician for
her pregnancy with Giovanni.
Plaintiff Pagés received pre-natal care through her
private physician, Defendant Ramírez.
At all times relevant to this case, Defendant Ramírez was
a duly licensed physician with a speciality in obstetrics
and gynecology, authorized to practice medicine in Puerto
Rico, who had privileges to practice obstetrics and
gynecology at HEAM.

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10.

11.
12.

13.

At all times relevant to this case, Defendant Ramírez had
a medical malpractice policy number PRM-10714 (March 2,
2007 to March 2, 2008, retroactive March 2, 2001), issued
by SIMED, with limits of $100,000.00. Said policy is
subject to its own terms, limits, conditions and
restrictions.
By October 22, 2004, Plaintiff Pagés, then thirty-three
years old, visited Defendant Ramírez’s office for a
prenatal evaluation. She was six weeks pregnant at the
time.
Plaintiff Pagés referred a history of four pregnancies and
one previous abortion to Ramírez.
Plaintiff Pagés was instructed to return for follow-up in
three weeks.
Her estimated due date was set for June 13, 2005.
Plaintiff Pagés visited Defendant Ramírez to receive a
pre-natal check-up on December 17, 2004.
Plaintiff Pagés made subsequent visits to Defendant
Ramírez on February 9, March 14, March 18, April 22 and
May 12, 2005. On her May 12, 2005 visit, Plaintiff Pagés
was said to be thirty-five weeks pregnant. Her expected
due date was changed to June 1, 2005.

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14.

15.

16.

17.

18.

19.

Plaintiff Pagés arrived at HEAM on May 19, 2005, at
2:09 p.m., in active labor, with a diagnosis of
intrauterine pregnancy at thirty-six weeks of gestation.
Laboratory work was performed upon Plaintiff Pagés’
admission to HEAM.
Also on May 19, 2005, at 3:00 p.m., Plaintiff Pagés was
admitted to the labor room. On vaginal examination, the
cervix was ninety percent effaced and six centimeters
dilated with the vertex at the negative two station.
Plaintiff Pagés’ blood pressure was 110/70 and her
contractions were every six minutes.
Also on May 19, 2005, by 4:30 p.m., there had been no
change in the findings on vaginal examination.
Intravenous pitocin was running at a rate of one milli
unit/minute and her contractions were every five minutes.
The membranes were artificially ruptured at 4:45 p.m.,
discharging clear fluid, and epidural anesthesia was
begun.
Also on May 19, 2005, at about 5:37 p.m., the baby’s fetal
heart rate went down. Plaintiff Pagés was placed on her
right side and the baby’s heart rate went up to 120 beats
per minute.
Also on May 19, 2005, at 6:00 p.m., the vaginal
examination revealed the cervix to be 8 centimeters

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dilated with the vertex at the negative one station. The
pitocin was running at a rate of two milli units/minute
and the contractions were every three minutes.
Also on May 19, 2005, by 6:45 p.m., the cervix was said to
be fully dilated and the vertex at the positive
two station. Plaintiff Pagés was placed in the lithotomy
position and the peritoneal lavage was affected. An
attempt at vacuum extraction was carried out without
success.
A spinal anesthesia was attempted but changed to general
anesthesia due to unavailability to perform spinal.
Also on May 19, 2005, Plaintiff Giovanni was delivered at
7:55 p.m. by Defendant Ramírez via low transverse Cesarean
section. Giovanni weighed nine pounds and four ounces,
and had an Apgar score of 2/7. Giovanni did not cry, did
not have good muscular tone, was cyanotic, and his heart
rate was 120 beats/minute. He was described as
macrosomic.
Giovanni was assisted by a neonatologist who proceeded to
intubate him and to transfer him to the Hospital’s
neonatal intensive care unit.
When Plaintiff Giovanni was transferred to the Neonatal
Intensive Care Unit, he was placed on a ventilator.

20.

21.

22.

23.

24.

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25.

26.

27.

28.

Plaintiff Giovanni’s umbilical cord was sent to the
laboratory for cord gases and the pH was 6.92, the
bicarbonate was 20.2, the pC0 was ninety-seven and the
2
base excess was -12.6.
After delivery, Plaintiff Pagés developed uterine atony,
requiring the transfusion of 4 units of blood. She
remained hospitalized until May 24, 2005.
Plaintiff Giovanni remained at the Hospital until
August 5, 2005, when he was transferred to San Jorge
Children’s Hospital to continue treatment.
The discharge summary at the Hospital indicates the
following diagnoses for Plaintiff Giovanni:
R/O
Aspiration – Gastric Content
Atelectasis
Birth Asphyxia
Gastroesophogeal reflux
Hypertonia
Hypocalcemia – neonatal
Hypokalemia
Hyponatremia
R/O Inborn Error of Metabolism
Jitteriness
Nutritional Support
Perinatal Depression
Poor Feeder
Psychosocial Intervention
Renal Dysfunction
Respiratory Failure
Respiratory Insufficiency
Seizures
Sepsis-newborn
Term Infant
Urinary Tract Infection-newborn

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29. Defendant HEAM has a professional liability policy with
Admiral Insurance Company, No. 000003905. Said policy has
a self-insured retention of $500,000.00 per claim on a
$1,000,000.00 policy limit, per claim, and $3,000,000.00
aggregate.
The following facts are deemed uncontested by the Court because
they were included in the motion for summary judgment and opposition
and were agreed upon, or they were properly supported by evidence and
not genuinely opposed:
Defendant Ramírez was Plaintiff Pagés’ physician for all
1.
five of her pregnancies, including that with Giovanni, and
therefore Plaintiff Pagés had established a close
relationship with Defendant Ramírez.
On the day of Plaintiff Giovanni’s birth, Plaintiff Pagés
had previously visited Defendant Ramírez’s office prior to
the birth. After examining her, Defendant Ramírez told
Plaintiff Pagés that she could not go back to her home and
that she should go to the hospital for admission thereto.
Defendant Ramírez was present in the labor room throughout
the afternoon.
Dr. Carolyn Crawford (“Dr. Crawford”) has been retained as
one of Plaintiffs’ expert witnesses.

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According to Dr. Crawford, an obstetrician has to make the
ultimate decision whether to put an internal fetal monitor
instead of an external fetal monitor.
According to Dr. Crawford, in the absence of a hospital
protocol stating otherwise, it is the physician (as
opposed to a nurse) who orders the administration of
pitocin and whether it should be increased.
At 4:30 p.m. on May 19, 2005, Defendant Ramírez ordered
the administration of pitocin to Plaintiff Pagés.
At about 4:45 p.m. on May 19, 2005, the order given by
Defendant Ramírez to administer pitocin was carried out by
Defendant HEAM’s nurse.
III. LEGAL STANDARD FOR A MOTION FOR SUMMARY JUDGMENT
Summary judgment serves to assess the proof to determine if
there is a genuine need for trial. Garside v. Osco Drug, Inc.,
895 F.2d 46, 50 (1st Cir. 1990). Pursuant to Rule 56(c) of the
Federal Rules of Civil Procedure, summary judgment is appropriate
when “the record, including the pleadings, depositions, answers to
interrogatories, admissions on file, and affidavits, viewed in the
light most favorable to the nonmoving party, reveals no genuine issue
as to any material fact and the moving party is entitled to judgment
as a matter of law.” Fed. R. Civ. P. 56(c); see also
Zambrana-Marrero v. Suárez-Cruz, 172 F.3d 122, 125 (1st Cir. 1999)
(stating that summary judgment is appropriate when, after evaluating

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the record in the light most favorable to the non-moving party, the
evidence “fails to yield a trial worthy issue as to some material
fact”); Goldman v. First Nat’l Bank of Boston, 985 F.2d 1113, 1116
(1st Cir. 1993); Canal Ins. Co. v. Benner, 980 F.2d 23, 25
(1st Cir. 1992). The Supreme Court has stated that “only disputes
over facts that might affect the outcome of the suit under the
governing law will properly preclude the entry of summary judgment.
Factual disputes that are irrelevant or unnecessary will not be
counted.” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248,
106 S. Ct. 2505, 2510, 91 L. Ed. 2d 202 (1986). In this way, a fact
is material if, based on the substantive law at issue, it might
affect the outcome of the case. See Mack v. Great Atl. and Pac. Tea
Co., Inc., 871 F.2d 179, 181 (1st Cir. 1989).
On a summary judgment motion, the movant bears the burden of
“informing the district court of the basis for its motion and
identifying those portions of the [record] which it believes
demonstrate the absence of a genuine issue of material fact.”
Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S. Ct. 2548, 2253,
91 L. Ed. 2d 265 (1986). Once the movant meets this burden, the
burden shifts to the opposing party who may not rest upon mere
allegations or denials of the pleadings, but must affirmatively show,
through the filing of supporting affidavits or otherwise, that there
is a genuine issue of material fact for trial. See Anderson,

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477 U.S. at 248, 106 S. Ct. at 2510; Celotex, 477 U.S. at 324,
106 S. Ct. at 2553; Goldman, 985 F.2d at 1116.
IV. ANALYSIS
Plaintiffs brought this tort action for medical malpractice
pursuant to P.R. Laws Ann. tit. 31, Sections 5141-5142, claiming that
Defendants deviated from the standard of care required of medical
professionals, thereby causing Plaintiff Giovanni to be born with
severe birth defects.
Because this action’s jurisdictional basis in federal court is
diversity of citizenship of the parties, Puerto Rico substantive law
applies. Hanna v. Plumer, 380 U.S. 460, 467 (1965); see also Lama
v. Borrás, 16 F.3d 473, 477-78 (1st Cir. 1994). In this
jurisdiction, tort liability for medical malpractice arises under
Article 1802 of the Civil Code of Puerto Rico, P.R. Laws Ann.
tit. 31, Section 5141. Under Puerto Rico law, three elements
comprise a prima facie case of medical malpractice: a party must
establish (1) the duty owed; (2) an act or omission transgressing
that duty; and (3) a sufficient causal nexus between the breach and
the harm. Otero v. United States, 428 F. Supp. 2d 34,
45-46 (D.P.R. 2006) (citing Rivera v. Turabo Med. Ctr. P’ship,
415 F.3d 162, 167 (1st Cir. 2005)).
Relevant case-law focuses on the first and third prongs of the
test set forth by Otero, supra. First turning to a duty owed, Puerto
Rico courts have explained the duty owed to a patient as that level

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of care which, recognizing the modern means of communication and
education, meets the professional requirements generally acknowledged
by the medical profession. Otero, 428 F. Supp. 2d at 46; see also
Rivera v. Turabo Med. Ctr. P’ship, 415 F.3d 162, 167 (1st Cir. 2005)
(citing Lama v. Borrás, 16 F.3d 473, 478 (1st Cir. 1994) (quoting
Oliveros v. Abreu, 1 P.R. Offic. Trans. 293, 101 P.R. Dec. 209,
226 (1973)). The standard is considered national and should
generally be proven through expert testimony. Otero, 428 F. Supp. 2d
at 46.
In terms of the standard of care owed specifically by nurses,
the Puerto Rico Supreme Court has held that a nurse must use a degree
of reasonable care to avoid causing unnecessary harm to the patient,
and such degree of care must be equal to the degree of care exercised
by other nurses in the locality or similar localities. Blas Toledo
y otros v. Hospital Nuestra Señora de la Guadalupe, 146 D.P.R. 267,
307 (1998), (citing Castro v. Municipio de Guánica, 87 D.P.R. 725,
728-729 (1963)). In Puerto Rico, nurses and paramedic personnel have
the unavoidable duty to fulfill medical orders with the required
urgency and in accordance with each patient’s particular
circumstances. Ponce v. Ashford Presbyterian Community Hosp.,
189 F.R.D. 31, 33 (D.P.R. 1999) (internal citations omitted).
Next, turning to the causation element, the law of Puerto Rico
holds that to establish causation, a plaintiff must prove by a
preponderance of the evidence, that “the [medical provider’s]

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negligent conduct was the factor that ‘most probably’ caused harm to
the plaintiff.” Rivera v. Turabo Med. Ctr. P’ship, 415 F.3d 162, 168
(1st Cir. 2005). Causation usually cannot be found based on mere
speculation and conjecture. Expert testimony is generally essential
in order to clarify complicated medical issues that are more
prevalent in medical malpractice cases than in standard negligence
cases. Otero, 428 F. Supp. 2d at 46.
A.
LIABILITY OF DEFENDANT HEAM’S NURSES
Defendants HEAM and Admiral move the Court for summary judgment,
arguing that HEAM’s nurses merely complied with the orders given to
them by Defendant Ramírez, the private physician of Plaintiff Pagés
in charge of the birth. As such, Defendants HEAM and Admiral argue
that Defendant Ramírez is solely responsible for any damages alleged
by Plaintiffs.
While it follows that nurses must comply with a physician’s
commands in order for hospitals to run smoothly, Puerto Rico law
clearly requires nurses to meet certain independent standards of
care. The law requires nurses to use a degree of care to avoid
causing unnecessary harm to their patients. Blas Toledo,
146 D.P.R. at 307. According to Plaintiffs’ expert witnesses,
Dr. Crawford and Dr. Bernard Nathanson (“Dr. Nathanson”), HEAM’s
nurses departed from this standard of care in several ways.
First, Dr. Crawford stated in her report that HEAM’s nurses
failed to discontinue the administration of pitocin, or to notify the

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physician to do so, in the presence of signs of fetal distress.
According to Dr. Crawford, it is the duty of a nurse to monitor the
administration of pitocin and to either stop it herself, or alert the
doctor to do so, when the mother is experiencing frequent
contractions and there is a problematic fetal heart rate. This
occurred during the birth of Plaintiff Giovanni, and Dr. Crawford
reported that there is no indication from the medical records that
HEAM’s nurses adhered to the standard of care required of them with
regard to the administration of pitocin.
Moreover, Dr. Crawford testified in her deposition that, given
the frequency and duration of Plaintiff Pagés’ contractions, the
pitocin should not have been administered to Plaintiff Pagés in the
first place. Dr. Crawford stated that HEAM’s nurses should have
alerted the anesthesiologist or the obstetrician to this fact. If
the physicians did not heed the nurses’ warnings, the nurses could
have continued voicing their concerns up the nursing ladder of
responsibility, an industry guideline for nurses to follow when they
question an order from a commanding physician. Plaintiffs allege
that Defendant HEAM’s nurses did not follow this protocol, and
instead blindly followed the instructions of Defendant Ramírez,
thereby causing irreparable harm to Plaintiffs.
Both Dr. Crawford and Dr. Nathanson, Plaintiffs’ obstetrical
expert, reported that HEAM’s nurses departed from the standards of
care required of them by failing to place an internal heart monitor

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during the delivery of Plaintiff Giovanni. According to these
experts, it is the role of a nurse to monitor the baby’s heart rate
during delivery. If the heart rate shows a problematic pattern, the
nurse should place an internal heart monitor, or ask the physician
to do so. When a pattern of fetal heart distress has been found
using an external device, an internal monitor should be placed to
obtain a more consistent recording. Here, Dr. Crawford and
Dr. Nathanson stated in their reports that the external monitor
showed that Plaintiff Giovanni was experiencing fetal distress, yet
there is no evidence in the record that the nurses either 1) placed
an internal heart monitor, or 2) asked the physician to do so.
Dr. Crawford also reported a departure from the standards of
care on the part of both the nurses and the anesthesiologist. The
2
departure stemmed from a failure to follow-up on the epidural
anesthesia given to Plaintiff Pagés. It is the joint responsibility
of the anesthesiologist and the nurses to monitor a patient’s
response after an epidural has been administered. If it is observed
that a baby’s heart rate drops, the mother should be turned onto her
left side and fluids should be increased. These two steps are part
of the resuscitation process that is the duty of the nurses.
Additionally, it is the joint responsibility of the anesthesiologist
and the nurses to administer a bolus of fluids prior to the placement

The anesthesiologist is not a party to the lawsuit. It is also not clear from
the record whether he was on HEAM’s staff, or whether he was a private
physician with privileges at HEAM.

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of the epidural. Dr. Crawford stated in her report that HEAM’s
nurses and anesthesiologist departed from the standard of care by
failing to administer the bolus of fluids to Plaintiff Pagés prior
to the epidural, and failing to take the required follow-up steps
after the epidural had been placed.
The Court agrees with Plaintiffs that the law does not treat
nurses as “robots” in the hospital setting, and holds that Defendants
HEAM and Admiral cannot escape liability by resting on the argument
that the nurses were only following the orders of Defendant Ramírez.
Thus, as to the liability imputed on Defendants HEAM and Admiral as
a result of the acts or omissions of the nursing staff, the Court
denies Defendants’ motion for summary judgment.
B.
HOSPITAL AND PRIVATE PHYSICIAN LIABILITY
Defendants HEAM and Admiral further argue that a hospital cannot
be held liable for the exclusive negligence of Defendant Ramírez, an
unsalaried physician with hospital privileges who was first and
foremost entrusted with the Plaintiff Pagés’ health.
With regard to a hospital’s liability towards its patients, the
Supreme Court of Puerto Rico has firmly established that hospitals
owe their patients that degree of care that would be exercised by a
reasonable and prudent person in the same conditions and
circumstances.
Martínez-Rosado,
v.
Márquez-Vega
See

116 P.R. Dec. 397, 404-405 (1985) (internal quotations omitted).
Puerto Rico courts have held a hospital liable to its patients for

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malpractice “on account of a negligent act on the part of the
institution’s employees; consequently, the hospital’s liability has
been predicated on the vicarious liability doctrine.” Márquez-Vega,
116 P.R. Dec. at 405.
When a patient goes directly to a hospital for care and the
hospital provides the patient with a physician, Puerto Rico courts
have held that the hospital and the physician are jointly liable for
any act of malpractice that may ensue. Id. at 406-407. However, the
situation is different when a defendant physician is not an employee
of the defendant hospital, but rather is granted the privilege of
using the hospital’s facilities for his private patients. When a
patient goes directly to her physician’s private office for care,
agrees with him as to the care she is going to receive, and proceeds
to a given hospital on the physician’s recommendation merely because
the doctor has admitting privileges at this hospital, the hospital
cannot be held liable for the exclusive negligence of an non-employee
doctor, who was first and foremost entrusted with the patient’s
health. Id., at 408-409.
However, even under the circumstances described above, the
hospital has the continuous obligation to protect the health of its
patients by: (a) carefully selecting the physicians who are granted
the privilege of using its facilities; (b) requiring that said
physicians keep up-to-date through professional advancement studies;
(c) monitoring the labor of said physicians and taking action, when

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possible, in the face of an obvious act of malpractice; (d)
discontinuing the privilege granted in the face of the repeated or
crass acts of malpractice on the part of one of those physicians; and
(e) keeping reasonably up-to-date on current technological
breakthroughs. Id., at 409-410 (internal quotations omitted). That
is, a hospital cannot turn its back once a physician is granted
privileges there; rather, it has an obligation to maintain and
enforce high standards of practice for the physicians granted the
right to use its facilities.
Also, the United States Court of Appeals for the First Circuit
has held that when a hospital grants staff privileges to a physician
and shares in the profits earned by that physician at the hospital,
the hospital is also responsible for acts of malpractice committed
by the physician. Suárez-Matos v. Ashford Presbyterian Community
Hosp., 4 F.3d 47, 52 (1st Cir. 1993) (emphasis added). In that
situation, as matter of law the hospital is a joint actor in a joint
enterprise. Id.
In its motion for summary judgment, Defendant HEAM argues that
Plaintiffs cannot make a showing of malpractice against HEAM because
HEAM is not liable for the medical negligence allegedly incurred by
Defendant Ramírez, who is not an employee of HEAM, but merely holds
privileges to use its facilities for the benefit of his private

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patients. HEAM further claims that it complied with its obligations
3
to protect the health of its patients and that its personnel did not
deviate from the applicable standards of care.
The parties have stipulated that Defendant Ramírez was Plaintiff
Pagés’ private physician with admitting privileges at Defendant HEAM.
However, the inquiry into HEAM’s liability does not end there. The
Court must determine whether HEAM complied with its obligations,
including monitoring its physicians with privileges, to ensure the
health of its patients.
In a medical malpractice action, issues of deviations from the
medical standard of care are questions of fact that must be decided
by the jury. See Cortés-Irizarry v. Corporación Insular de Seguros,
111 F.3d 184, 189 (1st Cir. 1997). Plaintiffs, through their
complaint and the expert testimony that followed, have raised several
questions of fact regarding whether Defendant HEAM complied with its
obligations to protect the health of its patients. For example,
Plaintiffs’ expert, Dr. Crawford, opined in her report that a delay
in the administration of anesthesia to Plaintiff Pagés by Defendant
HEAM’s anesthesiologist unnecessarily prolonged the birthing process,
thereby contributing to Plaintiff Giovanni’s injuries. Dr. Crawford
also stated in her report that Plaintiff Pagés was not administered
a bolus of fluids prior to the administration of epidural anesthesia,

The Court is not aware of any information on the record pertaining to the
profit-sharing structure of Defendants HEAM and Ramírez.

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which caused a significant drop in her blood pressure and affected
Plaintiff Giovanni’s oxygen flow. As such, Plaintiffs have shown
that there are genuine issues of material fact for a jury to consider
at trial that require the Court to deny Defendants’ motion for
summary judgment.
CONCLUSION
V.
In conclusion, the Court DENIES Defendants HEAM and Admiral’s
motion for summary judgment.
IT IS SO ORDERED.
In San Juan, Puerto Rico, this 4 day of April, 2008.
th

s/Jaime Pieras, Jr.
JAIME PIERAS, JR.
U.S. SENIOR DISTRICT JUDGE