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  • Writer's pictureVidal, Nieves & Bauzá LLC

Puerto Rico Supreme Court finds hospital liable for damages.

Puerto Rico Supreme Court finds hospital liable for damages due to its failure to oversee its admitting staff physician and for not adopting clinical protocols and guidelines for certain hospital medical procedures.

Vol. 36 - September 2022 | ©2022 by Vidal, Nieves & Bauzá, LLC. All rights reserved.

In a recent opinion decided on September 2, 2022, the Supreme Court of Puerto Rico expanded on prior precedents holding that hospitals in Puerto Rico may be found liable for a breach of their professional duties in caring for patients admitted to their facilities by their staff physicians. The case, A. Cruz Flores, et al v. Hospital Ryder Memorial, et al (2022 TSPR 112), the Court found that the parents of an infant born in the hospital, --but who subsequently passed away from health complications resulting from her premature birth at the hospital--, were entitled to damages from the hospital due to its failure to ascertain that the admitting staff physician had obtained the mother’s informed consent for both inducing labor resulting in a premature birth, as well as for administering Misoprostol, a medication which is administered to induce labor. Additionally, the hospital was found liable for failing to adopt clinical protocols and guidelines governing the induction of labor and the administration of Misoprostol at its facilities.

Under the unfortunate facts of the case, the admitting staff physician, --an OB-GYN--, decided to admit his 36-month pregnant patient to the hospital, --a full month before the expectant mother was due--, for no apparent valid medical reason and, as the court highlights, because the physician was leaving on vacation. After being admitted, her doctor decided to induce labor, proceeded to artificially rupture the amniotic membrane and to administer what turned out to be three-times the recommended dose of Misoprostol.

Immediately thereafter, the doctor noticed the presence of meconium (a green

substance lining the intestines and stomach of a developing fetus) and clear signs of fetal distress. He ordered an immediate C-Section. The baby girl was born prematurely and placed in the hospital’s Intensive Neonatal Unit as she exhibited multiple health conditions and was critically ill. Twelve days later, after being transferred to another hospital facility, the newborn passed away.

The parents subsequently filed a lawsuit seeking damages against the admitting staff physician, the hospital and other parties. The case reached the Puerto Rico Supreme Court on appeal. The Court´s opinion included a recitation of the black letter law established in the Puerto Rico Civil Code with respect to tort liability generally, including personal liability and vicarious liability, the principles of medical and hospital professional liability, the so-called “doctrine of corporate liability” which applies to hospitals with respect to the hospital’s staff physicians, as well as the hospital’s personal liability, the doctrine of informed consent and other legal principles. The Court next proceed to apply this legal framework and court precedents to the specific facts before the Court.

In doing so, the Court reminded hospitals that hospital institutions and their governing boards have the duty of overseeing that the mechanisms used with respect to patients are established in a safe manner and are zealously protected. That is, the duty to care for a patient does not only belong to the patient’s doctor, but to the hospital as an institution. (Translation ours).

Regarding the hospital’s liability for staff physicians with admitting privileges that are not employed by a hospital, the Court went on to point out that a hospital may be liable if it does not comply with the adequate standard of attention due to a patient in guaranteeing such patient’s security and welfare while at the hospital … and, further, that a hospital must lookout for the welfare of its patients by supervising or monitoring the work of such physicians and by intervening, whenever possible, when facing an evident act of professional liability committed by them. (Our translation; emphasis in the original).

After examining the lower court’s findings and the testimony of the expert witnesses in the case, the Court determined that the hospital in this case had been negligent and was liable to the parents for their newborn infant’s death. It held that the hospital did not review the patient’s records to confirm that the mother had given her informed consent in accordance with best medical practice to the medical procedure through which labor was induced and by not confirming the mother´s consent to the administration of Misoprostol to induce such labor. It further held that in failing to maintain medical protocols for the induction of labor and use of Misoprostol, the hospital had not displayed the degree of care which a prudent and reasonable person should exhibit under the circumstances and, in so doing, had breached its continuing obligation to oversee the health of its patient when such patient is within its facilities. (Our translation).

With respect to the adoption of clinical protocols for certain hospital procedures and the hospital’s duty to oversee the care of patients, the Court clarified that such duty does not imply that a hospital must adopt clinical protocols and guidelines for all possible risks within its institutions related to the activities of admitting physicians having hospital privileges.

It instead noted that this should be the result of a determination taken by the hospital based on the foreseeability of a particular risk in light of the best prevailing medical practices with respect to a given procedure.

Finally, in her concurring opinion (and dissenting regarding the percentage of liability attributed to the hospital vis-à-vis the intervening physician), the Chief Justice of the Court, Maite Oronoz Rodríguez, denounced the facts of the case as a manifestation of “obstetric violence” against women and made a poignant and strongly worded plea in favor of recognizing these situations, generally, and directed at the need to eradicate the same from the medical profession, specifically. She noted that, although not having a clear definition, “obstetric violence”,--a manifestation of violence against women generally--, is the sum of elements and conducts which de-value and de-legitimize the reproductive processes of women. (Our translation). The Chief Justice further indicated that with respect to the facts present in the case, it is disingenuous to think that this matter is not centered on paternalistic conceptions of health. It happens to be that the lack of a gender perspective and of the care and diligence needed in a medical area intrinsically related to women, is being paid with our lives and that of our babies. It is reprehensible that a woman needs to experience such a dehumanizing process during her pregnancy, birth and/or post-birth due to the absence of the minimum required care from the health professionals upon whom patients deposit their trust. (Translation ours).

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