LOURDES RIVERA RODRÍGUEZ; MARIA DE LOS ANGELES RAMOS RODRÍGUEZ; and RAFAEL PACHECO RODRÍGUEZ, Plaintiffs, Appellants, v. HOSPITAL SAN CRISTOBAL, INC.; QUALITY HEALTH SERVICES OF PUERTO RICO, INC.; IRIS VÉLEZ GARCÍA; ZACARÍAS A. MATEO MINAYA; BERRIS CASTILLO; and CONJUGAL PARTNERSHIP MATEO-CASTILLO, Defendants, Appellees, FUNDACIÓN SAN CRISTOBAL, INC.; JOHN DOE; CONJUGAL PARTNERSHIP DOE-VÉLEZ; CORPORATIONS A, B, AND C; and UNKNOWN INSURANCE COMPANY, Defendants.
No. 22-1776
United States Court of Appeals For the First Circuit
January 19, 2024
Barron, Chief Judge, Lipez and Montecalvo, Circuit Judges.
David Efron, with whom Law Offices of David Efron, P.C. was on brief, for appellants.
Jose Hector Vivas, with whom Vivas & Vivas was on brief, for appellees Hospital San Cristobal, Inc., and Quality Health Services of Puerto Rico, Inc.
José A. González Villamil, with whom Bufete González Villamil C.S.P. was on brief, for appellees Zacarías A. Mateo Minaya, Berris Castillo, and the Mateo-Castillo conjugal partnership.
Roberto Ruiz Comas and RC Legal & Litigation Services PSC for appellee Iris Vélez García.
BARRON, Chief Judge. Lourdes Rivera Rodríguez, Maria de Los Angeles Ramos Rodríguez, and Rafael Pacheco Rodríguez (collectively, “the plaintiffs“) appeal from the grant of summary judgment against them in this medical malpractice suit. They brought the suit in the United States District Court for the District of Puerto Rico after their mother, Ramona Rodríguez Rivera (“Rodríguez“), passed away while in the care of Hospital San Cristobal (“HSC“). The suit seeks to
I.
A.
We begin with a recitation of the undisputed facts and relevant procedural history.1
On February 29, 2016, Rodríguez visited HSC complaining of pelvic pain. Rodríguez — who was then seventy-one years old and living with several chronic health conditions including hypertension, type 2 diabetes, and asthma — was examined by Dr. Vélez, who had been her regular gynecologist since 2005. Dr. Vélez recommended that Rodríguez undergo a bilateral oophorectomy via laparotomy after a pelvic ultrasound revealed a “complex cystic mass” near Rodríguez‘s right ovary.
Dr. Vélez performed Rodríguez‘s surgery on April 21, 2016, at HSC. During the surgery, Dr. Vélez discovered that Rodríguez had a “frozen pelvis” with multiple “intraabdominal adhesions,” and so she requested a surgical consultation from Dr. Mateo, another gynecologist on HSC‘s staff. Dr. Mateo assisted Dr. Vélez with Rodríguez‘s surgery. On April 25, 2016, Rodríguez was discharged from HSC after HSC staff observed “positive bowel sounds” and Rodríguez reported “positive stool passage.”
Four days later, on April 29, during a scheduled postoperative appointment with Dr. Vélez at HSC, Rodríguez reported that she had been experiencing “nausea, vomiting, and abdominal/pelvic pain since April 26.” Rodríguez was then admitted to HSC‘s emergency department and was diagnosed with a presumed perforated sigmoid colon. Later that day, Rodríguez underwent an emergency exploratory laparotomy to address her presumed perforated colon, during which Dr. Vélez, Dr. Mateo, and one Dr. Ortiz Rosado2 performed a “partial colectomy with Hartman[n] pouch, end colostomy[,] and subtotal hysterectomy.” Rodríguez was subsequently admitted to HSC‘s intensive care unit (“ICU“) in critical condition. She was intubated on a respirator with a nasogastric (“NG“) tube, a colostomy bag, and a Foley catheter.
In HSC‘s ICU, Rodríguez received care from various specialists, including Dr. Vélez and staff from HSC‘s “general surgery, internal medicine, infectious disease, cardiology, pulmonology, nephrology, hematology/oncology, and ENT” departments. Two days after her admission to the ICU, on May 1, Rodríguez was diagnosed with “bacteremia/sepsis.” Then, on May 4, Rodríguez tested positive for pseudomonas bacteria, at which point HSC‘s “infection control program became involved” with her care. HSC‘s epidemiology department recommended several specific disinfection protocols to treat Rodríguez‘s pseudomonas infection, but “[t]here is no documentation that these recommendations were carried out at any time.”
On May 6, HSC staff discovered that Rodríguez‘s stоma had become necrotic. Rodríguez consequently underwent a third surgical procedure consisting of “an exploratory
On May 12, nursing and infectious-disease staff noted “the presence of worms and/or maggots in the right nostril of [Rodríguez], where the NG tube was located.” A CT scan of Rodríguez‘s sinuses was ordered, but there was otherwise “little to no documentation of [any] consultations regarding the presence of worms nor any analysis of the source of these worms.”
On May 15, it was “documented that [Rodríguez‘s] fecal collector [was] out of place.” The following day, HSC staff noted that the fecal collector “continue[d] to be displaced and that there [was] abundant fecal material around the site [of the fecal collector] as well as coming from” an “open wound” near the site.
On May 18, two types of bacteria were detected in cultures of fluid taken from Rodríguez‘s abdomen. That same day, HSC staff noted that Rodríguez was “no longer responding to verbal or physical stimuli.” By the following afternoon, HSC staff determined that Rodríguez could not undergo a planned fourth procedure “due to worsening of her condition,” and they obtained a “Do Not Resuscitate” order from Rodríguez‘s family. Rodríguez died later that evening, at 8:48 P.M. on May 19, 2016.
An autopsy determined that Rodríguez‘s cause of death was “peritonitis due to sigmoid colon perforation with associated sepsis and septic shock. Complicating factors were congestive heart failure, bilateral bronchopneumonia, and diabetic ketoacidosis.” The autopsy аlso showed “multiple pressure ulcers” on Rodríguez‘s body.
B.
The plaintiffs filed suit in the District Court on May 11, 2018. The operative complaint named as defendants Quality Health Services of Puerto Rico, Inc., doing business as HSC (“Quality Health/HSC“); Dr. Vélez; Dr. Mateo; Dr. Mateo‘s wife, Berris Castillo; the Mateo-Castillo conjugal partnership; and several other individuals and corporations “whose identities [were] unknown, [but who] by their negligent acts or omissions caused or contributed to the damages claimed.”3
The operative complaint asserted that “[HSC] and [its] personnel, including [Dr. Vélez] and [Dr. Mateo], were practicing below the standard of care in the treatment” that they provided to Rodríguez, and that Rodríguez‘s “premature death . . . was caused by the negligent management of her condition.” The complaint alleged several departures from “medical standards” and instances of “professional negligence” in the defendаnts’ care of Rodríguez which “include[d], but [were] not limited to“:
failure to recognize, appropriately asses[s] and repair damage to any organs involved in or near the operative field prior to closing the abdomen; failure to recognize that Mrs. Rodríguez‘s sigmoid colon was damaged in this circumstance and to perform an appropriate repair procedure to assure sigmoid colon integrity before abdominal closure; failure in the proper management of hygiene by the hospital staff in the care of Mrs. Rodríguez; failure in the documentation
of the findings; failure to manage the infectious processes suffered by the patient; failure to manage the patient‘s pre-existing condition of diabetes which likely exacerbated her condition and accelerated her demise; failure to timely correct the displacement of the fecal сollector[;] and failure to manage the patient‘s care by presenting multiple pressure ulcers at autopsy due to the fact that apparently the staff did not make changes in the patient‘s position in the required time.
The plaintiffs claimed that these alleged deficiencies in the care provided to Rodríguez made the defendants liable for negligence under Puerto Rico law. See
C.
To establish a prima facie case of negligence under Puerto Rico law, “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.” Cortéz-Irizarry v. Corporación Insular de Seguros, 111 F.3d 184, 189 (1st Cir. 1997). In cases of alleged medical malpractice, “Puerto Rico holds heаlth care professionals to a national standard of care.” Id. at 190.
Under Puerto Rico law, “physicians are protected by a presumption to the effect that they have exercised a reasonable degree of care and the treatment provided was adequate.” López Delgado v. Cañizares, 163 P.R. Dec. 119 (2004) (certified translation at Appellant‘s App. 247). Thus, “[a] physician‘s negligence is not presumed from the fact that a patient suffered damages or the treatment was unsuccessful.” Id. Instead, to establish “a breach of a physician‘s duty of care,” a plaintiff “ordinarily must adduce expert testimony to limn the minimum acceptable standard and confirm the defendant doctor‘s failure to meet it.” Cortéz-Irizarry, 111 F.3d at 190.
In preparation for trial, the District Court ordered the parties to submit a joint pretrial conference memorandum outlining the contours of the case and the evidence that they would present at trial. The plaintiffs indicated in the memorandum that they would rely on the testimony of an expert witness, Dr. Jason S. James (“Dr. James“), to establish the defendants’ negligence. The plaintiffs asserted that Dr. James would
testify as a medical expert in obstetrics, gynecology[,] and general medicine about his professional qualifications, his review of the medical records in this case, the applicable medical standards, his expert report and deposition testimony, the reports of defendants’ experts, his professional opinion as to the departures from the medical standards by defendants in the treatment provided to [Rodríguez] and their causal relationship with [Rodríguez‘s] injuries and premature death[,] and about any applicable medical literature in support of his opinion.
The plaintiffs also “reserve[d] the right to use as their own any expert witness announced by the defendants.”
Dr. Vélez and Dr. Mateo reрresented that they would each call an expert witness of their own, and Quality Health/HSC represented that it would call its own expert witness as well. Dr. Vélez represented that her expert, Dr. Adrián Colón Laracuente, would testify as to Dr. Vélez‘s treatment of Rodríguez “from the gynecological and surgical standpoint . . . and her compliance with the standard of care.” Dr. Mateo represented
Following a pretrial conference, the District Court referred the case to a magistrate judge for mediation. Mediation was unsuccessful, in part because the defendants represented at the settlement conference that they intended to file motions in limine, the resolution of which had the potential to affect the parties’ settlement efforts.
Two separate motions in limine were filed — one by Quality Health/HSC and the other by Dr. Mateo, Berris Castillo, and the Mateo-Castillo conjugal partnership, joined by Dr. Vélez. The motions sought to exclude the expert opinion testimony of the plaintiffs’ expert, Dr. James. Both motions argued that Dr. James‘s testimony must be excluded because his expert report did not comply with
Dr. James‘s expert report first summarized his qualifications as a licensed physician and gynecological specialist “well versed in the current standards of care applicable to the practice of obstetrics and gynecology.” Dr. James‘s report stated that, “[i]n this matter, [his] opinions [were] based on [certain enumerated] medical records and documents . . . and on reliable and accepted scientific principles to a reasonable degree of medical certainty.” The report next stated that Dr. James had
Based on the medical documents submitted, it appears that [Rodríguez] expired from sepsis and septic shock, a condition caused by the perforated sigmoid colon that occurred in the initial surgery on April 21, 2016 performed by Dr. [Vélez] and Dr. [Mateo]. This patient encountered several organisms throughout her various organ systems: Klebsiella pneumonia, Pseudomonas aeruginosa, and Enterococcus faecalis in the blood, in the inguinal and perianal secretions, in the urine, in the colostomy, and in the throat, as noted in the autopsy report. In addition, the most surprising finding was the worms and/or maggots that were noted to be present in the nostril of the patient where the NG tube was placed. There is little room for doubt regarding the inappropriate nature and poor hygiene which was utilized by the hospital personnel in caring for [Rodríguez]. There is poor documentation regarding this unusual discovery and no evidence that appropriate precautions were taken to prevent this occurrence or to remedy the situation once it was realized. There is no evidence of appropriate disinfection of the hospital room, equipment, hospital staff, and the patient herself as recommended by infectious disease and epidemiology. In addition, there appears to be poor management of [Rodríguez‘s] medical comorbidities, such as inadequate care for her diabetes which likely exacerbated her condition and accelerated her demise. It appears that her fecal collector remained out of place for more than 24 hours after discovering it had become dislodged, allowing fecal material to contaminate the stoma as well as the open wound itself. Further, there is evidence on autopsy of multiple pressure
ulcers, which lends further evidence of the substandard care that [Rodríguez] received during her admission at [HSC].
In conclusion, it is my opinion — based upon a reasonable degree of medical certainty — that in the case discussed above there were numerous deviations, failures, аnd departures from acceptable standards of care on the part of Dr. [Vélez], Dr. [Mateo], as well as as on the part of [HSC] and its staff.
In their motions to exclude Dr. James‘s expert testimony under
Alternatively, the defendants argued that Dr. James‘s testimony should be “excluded as speculative” under
The plaintiffs opposed the defendants’ motions to exclude Dr. James‘s testimony. The plaintiffs did not request, however, that the District Court hold a hearing on the merits of the motions at which Dr. James could testify. Nor did they request leave to supplement Dr. James‘s expert report. Instead, the plaintiffs argued that the entirety of Dr. Jamеs‘s proposed testimony was admissible based on the expert report itself.
The District Court granted the defendants’ motions to exclude Dr. James‘s testimony. In so ruling, the District Court relied entirely on
As to Dr. Vélez‘s and Dr. Mateo‘s motion under
As to Quality Health/HSC‘s motion under
At the same time that the District Court granted the defendants’ motions to exclude Dr. James‘s testimony under
The plaintiffs opposed both motions for summary judgment, arguing that even if Dr. James‘s testimony were excluded, they could rely on the testimony of the defendants’ expert witnesses to prove their case. In the alternative, the plaintiffs asked the District Court to reconsider its ruling excluding Dr. James‘s expert testimony, as they contended that the defendants were not entitled to summary judgment if Dr. James‘s testimony were not excluded.
The District Court denied the plaintiffs’ request for reconsideration, granted the defendants’ motions for summary judgment, dismissed the plaintiffs’ claims with prejudice, and entered judgment in favor
II.
We first address the plaintiffs’ challenge to the District Court‘s grant оf summary judgment to Dr. Vélez and Dr. Mateo. “‘To defeat a motion for summary judgment, the nonmoving party must demonstrate the existence of a trialworthy issue as to some material fact, i.e., a fact that ‘potentially could affect the suit‘s outcome.‘” López-Ramírez v. Toledo-González, 32 F.4th 87, 97 (1st Cir. 2022) (quoting Cortéz-Irizarry, 111 F.3d at 187). To make this showing, a plaintiff “must affirmatively point to specific facts that demonstrate the existence of an authentic dispute.” Feliciano-Muñoz v. Rebarber-Ocasio, 970 F.3d 53, 62 (1st Cir. 2020) (quoting McCarthy v. Nw. Airlines, Inc., 56 F.3d 313, 315 (1st Cir. 1995)). Our review of the summary judgment ruling here is de novo. See Milward v. Rust-Oleum Corp. (Milward II), 820 F.3d 469, 472-73 (1st Cir. 2016).
The District Court based its ruling that Drs. Mateo and Vélez were entitled to summary judgment in part on its decision to exclude Dr. James‘s expert testimony under
overturn the summary judgment ruling even if the District Court‘s
A.
To assess the plaintiffs’ challenge to the summary judgment ruling at issue, it helps to focus first on the aspect of that challenge that concerns the District Court‘s ruling excluding Dr. James‘s testimony under
1.
A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if the proponent demonstrates to the court that it is more likely than not that: (a) the expert‘s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue;
(b) the testimony is based on sufficient facts or data;
(c) the testimony is the product of reliable principles and methods; and
(d) the expert‘s opinion reflects a reliable application of the principles and methods to the facts of the case.6
As a result, the present version of
Moreover, in applying
At the same time, “nothing in either Daubert or the
We note that “[t]he party seeking to introduce the evidence has the burden of establishing both its reliability and its relevance,” Milward II, 820 F.3d at 473 (citing Daubert, 509 U.S. at 593 n.10), and that we review a district court‘s ruling on the admissibility of expert testimony under
2.
In its ruling under
Notably, by excluding all of Dr. James‘s expert testimony as to those two defendants, the District Court excluded Dr. James‘s testimony concerning his opinion that, “[b]ased on the medical documents submitted, it appears that [Rodriguez] expired from sepsis and septic shock, a condition caused by the perforated sigmoid colon that occurred in the initial surgery on April 21, 2016 performed by [Dr. Velez and Dr. Mateo].” The District Court appears to have done so because it treated Dr. James‘s opinion in that regard as if it were a “conclu[sion] as a matter of fact that Dr. Velez and Dr. Mateo ‘perforated‘” Rodriguez‘s sigmoid colon during the April 21 surgery. Rivera Rodriguez v. Quality Health Servs. P.R., Civ. No. 18-1287 (PAD), 2022 WL 3445348, at *4 (D.P.R. Aug. 4, 2022).
To support that aspect of the
There is some force to the plaintiffs’ contention that the District Court erred in this aspect of its ruling under
Moreover, the District Court appears to have understood that Dr. James‘s testimony would set forth the opinion that Dr. Velez and Dr. Mateo perforated the colon during the surgery on April 21, rather than merely that the colon was perforated during that surgery. While the District Court explained its reasons for concluding that testimony by Dr. James that those defendants perforated the colon at that time was not admissible under
Dr. James‘s expert report, however, opines only that the perforation of Rodriguez‘s sigmoid colon occurred in the initial surgery on April 21. It does not assert at any point that the perforation occurred due to any action that either Dr. Mateo or Dr. Velez took at that time -- or, for that matter, at any other time. Indeed, in that respect, the report accords with the plaintiffs’ operative complaint, which also does not allege at any point that Dr. Velez or Dr. Mateo acted negligently by perforating Rodriguez‘s colon. Instead, the operative complaint alleges that their negligence lay in their “failure to recognize, appropriately assess and repair damage to any organs involved in or near the operative field prior to closing the abdomen” and their “failure to recognize that [Rodriguez‘s] sigmoid colon was damaged in this circumstance and to perform an appropriate repair procedure to assure sigmoid colon integrity before abdominal closure.”
Despite these potential problems with the District Court‘s analysis of the admissibility of this specific portion of Dr. James‘s expert testimony under
The question that now remains, with respect to the plaintiffs’ challenge to the grant of summary judgment to Dr. Velez and Dr. Mateo, is whether that challenge has merit, given that the District Court properly excluded Dr. James‘s conclusion that Drs. Velez and Mateo deviated from acceptable standards of care. As we will
3.
To be sure, as we have explained, it may be that testimony from Dr. James that Rodriguez‘s colon was perforated during the April 21 surgery was wrongly excluded under
We recognize that the plaintiffs do contend that the District Court‘s grant of summary judgment was in error because, even without Dr. James‘s opinion as to Dr. Velez‘s and Dr. Mateo‘s negligence, the plaintiffs could have relied at trial on the testimony of the defendants’ expert witnesses to “help the jury to determine both the proper standards of care and the causal nexus between [the] defendants’ negligence and [the plaintiffs’ damages.” To support this contention, the plaintiffs point out that none of the defendants’ expert witnesses’ reports expressly refutes Dr. James‘s conclusion that Rodriguez “expired from sepsis and septic shock, a condition caused by the perforated sigmoid colon that occurred in the initial surgery on April 21, 2016.”
In granting the defendants’ motions for summary judgment, however, the District Court determined that it was “irrelevant whether [the] defendants’ experts’ reports . . . refute Dr. James‘[s] conclusion” that Rodriguez‘s sigmoid colon was perforated during her initial surgery.7 As the District Court noted, all of the defendants’ experts opined that the “defendants’ actions did not deviate from the standards of care.” As such, the District Court concluded that the defense experts’ trial testimony would not “align . . . with [the] plaintiffs’ legal theories or otherwise lend any support to their case.” And, upon a thorough review of the evidentiary record, we find no basis on which to disagree with the determination that Dr. Velez and Dr. Mateo were entitled to summary judgment.
None of the defendants’ experts’ reports sets forth any opinion that would support the plaintiffs’ theory that any negligent act or omission by Dr. Velez or Dr. Mateo caused Rodriguez‘s decline and/or her premature death. In his report, Dr. Mateo‘s proffered expert, Dr. Alfredo S. Colon Martinez, concluded that Dr. Mateo‘s “involvement in this complicated case [did] not dеviate[] from the standards of care” applicable to the procedures in which he participated. And Dr. Velez‘s proffered expert, Dr. Adrian Colon Laracuente, concluded in his report that Dr. Velez “did not deviate from the standard of care in her treatment” of Rodriguez.
True, if the District Court had admitted Dr. James‘s opinion that Rodriguez‘s sigmoid colon was perforated during the April
Thus, the reсord in this case contains no “expert testimony to limn the minimum acceptable standard and confirm the defendant doctor[s‘] failure to meet it,” as is required to “establish[] a breach of a physician‘s duty of care” under Puerto Rico‘s negligence statute. Cortez-Irizarry, 111 F.3d at 190. Accordingly, we affirm the District Court‘s grant of summary judgment to Dr. Velez and Dr. Mateo.
III.
Having affirmed the District Court‘s grant of summary judgment to defendants Dr. Velez and Dr. Mateo, we now must address the plaintiffs’ challenge to the District Court‘s grant of summary judgment to Quality Health/HSC. Here, too, the plaintiffs base their challenge both on a contention that the District Court erred in excluding under Rule 702 the expert testimony of Dr. James and, in the alternative, on the ground that the District Court erred in granting summary judgment to Quality Health/HSC even assuming that such testimony was properly excluded.
In pressing their challenge to this summary judgment ruling, the plaintiffs appear to be advancing two distinct theories by which their claim of negligеnce against Quality Health/HSC may survive that defendant‘s motion for summary judgment. One of these theories is predicated on HSC staff‘s alleged failure to utilize proper hygiene in their care of Rodriguez. The other is predicated on HSC staff‘s alleged failure to properly manage Rodriguez‘s comorbidity of diabetes. We address each of these theories of liability separately, addressing, with respect to each, both the plaintiffs’ challenge to the relevant Rule 702 ruling as to Dr. James‘s testimony and their contention that, even assuming the Rule 702 ruling was sound, the grant of summary judgment to Quality Health/HSC was not.
A.
Insofar as the plaintiffs premise their challenge to the grant of summary judgment in favor of Quality Health/HSC on HSC staff‘s alleged hygiene-related failures, they do so in part by challenging the District Court‘s decision to exclude Dr. James‘s testimony under Rule 702. The plaintiffs argue that Dr. James‘s expert report “clearly express[ed]” multiplе “deficiencies” in HSC staff‘s treatment of Rodriguez. And it is true that several of those alleged deficiencies relate to the plaintiffs’ allegation that HSC staff utilized “inappropriate and poor hygiene at [HSC] and in the care of [Rodriguez].” In that regard, the plaintiffs refer to several facts that Dr. James asserts in his expert report leave “little room for doubt regarding the inappropriate nature and poor hygiene which was utilized by [HSC] personnel in caring for [Rodriguez]” -- such as the presence of “several organisms throughout her various organ systems” and “worms and/or maggots” in her nostril, the lack of “evidence of appropriate disinfection of the hospital room, equipment, hospital staff, and the patient herself,” and the fact that Rodriguez‘s “fecal collector remained out of place for more than 24 hours.”
Nothing in Dr. James‘s report purports to opine, however, thаt any of these hygiene-related failures caused Rodriguez‘s
That being so, we do not see how the plaintiffs’ challenge to the District Court‘s ruling to exclude Dr. James‘s testimony under
B.
We turn, then, to the plaintiffs’ remaining contention as to their challenge to the grant of summary judgment to Quality Health/HSC -- a contention that rests on the theory that HSC staff‘s failure to properly manage Rodriguez‘s comorbidity of diabetes led to her decline and premature death. Here, too, the plaintiffs contend in part that the District Court erred in excluding Dr. James‘s report under
With respect to the plaintiffs’ challenge to the
Nonetheless, the District Court determined that this opinion must be excluded because “nowhere in the report does Dr. James identify the standard of care that [HSC] staff should have adhered to” in their management of Rodriguez‘s diabetes; “where that standard comes from; and how the staff deviated from that standard.” We agree.
In the absence of both an articulated standard of care and any specifiс allegations of acts or omissions by HSC staff that deviated from that standard of care, we cannot see that Dr. James‘s opinion that HSC staff‘s management of Rodriguez‘s diabetes was “poor” and “inadequate” is “the product of reliable principles and methods,” as
None of the defendants’ expert witnesses opines that HSC staff‘s management of Rodriguez‘s diabetes deviated from any applicable standard of care. On the contrary, Quality Health/HSC‘s proffered expert witness, internist Dr. Anibelle Altieri Ramirez, opines in her expert report that “at all times relevant to the [operative] Complaint, [HSC] personnel acted diligently, prudently[,] and reasonably and did not incurred in [sic] negligent acts.” Thus, without the existence in the record of “expert testimony to limn the minimum acceptable standard and confirm the defendant doctor[s‘] failure to meet it,” Cortez-Irizarry, 111 F.3d at 190, we affirm the District Court‘s determination that Quality Health/HSC was entitled to summary judgment in its favor on the plaintiffs’ claim of medical malpractice.
IV.
For these reasons, the judgment of the District Court is affirmed.