Batista-Acevedo et al v. Presbyterian Community Hospital, Inc et al

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
AISLYN BATISTA ACEVEDO, et al.,
Plaintiffs,
v.
PRESBYTERIAN COMMUNITY
HOSPITAL INC., et al.,
Defendants.
Civ. No. 22-01468 (MAJ)
OPINION AND ORDER
I. Introduction
On September 27, 2022, Plaintiffs Aislyn Batista Acevedo, Ina Ruth Kessler
Krugman, and minor A.D.S.B. (collectively, “Plaintiffs”) filed the instant suit on behalf of
the late David Suárez (“Suárez”) against Ashford Presbyterian Hospital (“Presby”) and
various other defendants (collectively, “Defendants”). (ECF No. 1).1 From September 29,
2021, until his death on October 23, 2021, Suárez was hospitalized at Presby and Doctors’
Center Hospital Bayamón (“Doctors’”). Plaintiffs allege that, during the time that Suárez
was hospitalized, Defendants failed to properly screen and treat Suárez in violation of the
Emergency Medical Treatment and Labor Act (“EMTALA”). See 42 U.S.C. § 1395.
Plaintiffs also allege that all Defendants are liable under Puerto Rico law for negligence
and medical malpractice. (ECF No. 288). To prove their claims, Plaintiffs intend to
introduce at trial the expert witness testimony of Dr. Dainius Drukteinis (“Dr.
Drukteinis”). Defendants move the Court to rule the proffered testimony of Dr. Drukteinis
1 Plaintiffs filed their Second Amended Complaint, now the operative Complaint, on May 18, 2023.
(ECF No. 288).
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inadmissible. (ECF No. 752). Plaintiffs oppose the motion. (ECF No. 782). For the
reasons provided below, the motion is DENIED.
II. Background
According to the operative complaint,2 Suárez was admitted to the emergency
room at Presby on September 29, 2021. (ECF No. 288 at 16 ¶ 107). At that time, Suárez
was complaining of acute abdominal pain. Id. Medical staff at the hospital ordered “an
abdominal sonogram, some laboratory tests, pain medications and hydration[,]” as well
as “a consultation with internal medicine and surgery services.” (ECF No. 288 at 16 ¶
110).
Early the next day, Suárez was evaluated by Dr. Cuff, a physician specializing in
general surgery. (ECF No. 288 at 5 ¶ 21, 16 ¶ 112). Dr. Cuff determined that Suárez
would need to undergo surgery, yet he decided that Suárez would first have to submit to
an “MRCP” evaluation before surgery would be possible. (ECF No. 288 at 17 ¶ 113). By
disputed means, medical staff at the hospital allegedly determined that Suárez was too
obese to fit in the MRI machine used to conduct MRCP procedures at Presby. (ECF No.
288 at 17 ¶ 115). Accordingly, on September 30, 2021, the physicians treating Suárez
decided to transfer him to another hospital facility. (ECF No. 288 at 18 ¶ 120).
On October 1, 2021, Suárez was transferred to Doctors’. By the next day, medical
staff at that facility allegedly determined that they also would not be able to perform the
necessary procedures on Suárez because their facilities could not accommodate his size.
(ECF No. 288 at 23–24 ¶¶ 155–156). Medical staff at Doctors’ then decided to transfer
Suárez back to Presby. (ECF No. 288 at 24 ¶ 161).
2 The Court recites the following facts from the Complaint for sole purpose of providing background
on the controversy between the parties; the Court does not accept the allegations in the Complaint as true.
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Over the course of the next two days, Suárez’s condition deteriorated. (ECF No.
288 at 25–27 ¶¶ 163–176). On October 4, 2021, Suárez was intubated. (ECF No. 288
at 27 ¶ 176). Several weeks later, on October 23, 2021, Suárez died. (ECF No. 288 at
29–30 ¶ 191).
To prove their negligence claims against Defendants, Plaintiffs intend to introduce
the expert witness testimony of Dr. Drukteinis. Dr. Drukteinis has been practicing
emergency medicine for over twenty years and currently serves as the Attending Physician
at the emergency department of St. Joseph’s Hospital in Tampa, Florida. (ECF No. 782-
9 at 1). He has previously served as an Assistant Professor of Emergency Medicine with
the University of South Florida. (ECF No. 782-9 at 1). In preparing his expert report
and opinion in this case, Dr. Drukteinis reviewed all relevant medical records for Suárez,
the interrogatories exchanged by the parties in this matter, text messages between various
defendants, photographic evidence, over twenty deposition transcripts, as well as the
expert witness reports of two additional expert witnesses retained by Plaintiffs. (ECF No.
782-9 at 1–4). In addition, Dr. Drukteinis relied on numerous scholarly publications
focused on matters of emergency medicine and patient transfers. (ECF No. 782-9 at 9–
12 n.1–n.12).
On May 16, 2025, Dr. Drukteinis produced an expert report setting forth his
opinions regarding this case. (ECF No. 782-9). The report contains a detailed narrative
of the facts of the case. (ECF No. 782-9 at 4–7). The report also carefully set forth the
entire “Chain of Responsibility for [Suárez]” between the time that Suárez was first
admitted into the emergency room at Presby until the time that he was transferred back
to that facility from Doctors’, listing each responsible physician and the specific times at
which they were involved in the treatment of Suárez. (ECF No. 782-9 at 7–9). Further,
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the report contains a section entitled “Standard of Care” in which Dr. Drukteinis set forth
the standards of care applicable in this case. (ECF No. 782-9 at 9–12) (providing
applicable standards of care with respect to patient transfers, medical intervention for
patients presenting with choledocholithiasis, and patient handoffs in the emergency room
context). The report also includes a section entitled “Lack of Conformity with the
Standard of Care” in which Dr. Drukteinis provides a detailed account of his medical
opinion that the physicians and staff at both Presby and Doctors’ breached the prevailing
standard of care by failing to perform an MRCP or ERCP procedure, conducting poor
transitions of care between medical providers during the time that Suárez was
hospitalized, and transferring Suárez to another hospital facility when there was no valid
reason to do so. (ECF No. 782-9 at 12–15).
III. Legal Standard
Federal Rule of Evidence 702 provides that a qualified expert may testify in the
form of an opinion if: “(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 has reliably applied the principles and
methods to the facts of the case.” FED. R. EVID. 702.
Before a party may admit testimony from a retained expert witness, however, Rule
26 of the Federal Rules of Civil Procedure requires that the party submit a written report
containing, in relevant part, “a complete statement of all opinions the witness will express
and the basis and reasons for them[,]” as well as “the facts or data considered by the
witness in forming them[.]” FED. R. CIV. P. 26(a)(2)(B). Where a party fails to comply with
the mandatory disclosure requirements of Rule 26(a) and their failure was not
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Civ. No. 22-01468 (MAJ) Page 5
“substantially justified or . . . harmless[,]” that “party is not allowed to use that
information or witness to supply evidence . . . at a trial[.]” FED. R. CIV. P. 37(c)(1). The
admissibility of expert witness testimony is thus contingent upon whether the parties
“make explicit and detailed expert disclosures” that demonstrate the reliability and rigor
of the proffered opinion. Santiago-Díaz v. Laboratorio Clínico y de Referencia del Este,
456 F.3d 272, 276 (1st Cir. 2006); see also Clemente-Vizcarrondo v. United States, Civ.
No. 17-1144, 2020 WL 748840, at *2 (D.P.R. Feb. 14, 2020); Rivera-Marrero v.
Presbyterian Cmty. Hosp., 255 F. Supp. 3d 290, 296 (D.P.R. 2017) (“[E]xpert-related
disclosures are insufficient when they consist of sketchy and vague descriptions of
anticipated opinions or areas of anticipated testimony.”) (quotations omitted).
To determine whether the testimony proffered in an expert witness report is
admissible, the trial judge performs a “gatekeeping function” by ensuring that the
proffered expert testimony satisfies the admissibility criteria of Federal Rule of Evidence
702. United States v. Sepulveda, 15 F.3d 1161, 1183 (1st Cir. 1993); Pages-Ramírez v.
Ramírez-González, 605 F.3d 109, 113 (1st Cir. 2010). This requires the Court to determine
whether the expert’s “scientific, technical, or other specialized knowledge . . . will assist
the trier better to understand a fact in issue[,]” as well as to “ensure that [their] testimony
both rests on a reliable foundation and is relevant to the task at hand.” Pages-Ramírez,
605 F.3d at 113 (quotations and citations omitted); Daubert v. Merrell Dow
Pharmaceuticals, Inc., 509 U.S. 579, 589 (1993) (providing that under Federal Rule of
Evidence 702 “the trial judge must ensure that any and all scientific testimony or evidence
admitted is not only relevant, but reliable”). This is a “flexible inquiry” that requires the
Court to gauge the “overall reliability” of a proffered expert witness testimony as well as
its “special relevancy” to the issues to be presented to the jury:
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Along with the reliability requirement, the Daubert Court imposed a special
relevancy requirement. To be admissible, expert testimony must be relevant not
only in the sense that all evidence must be relevant, but also in the incremental
sense that the expert’s proposed opinion, if admitted, likely would assist the trier
of fact to understand or determine a fact in issue.
Ruiz-Troche v. Pepsi Cola of P.R. Bottling Co., 161 F.3d 77, 81 (1st Cir. 1998); Cummings
v. Standard Register Co., 265 F.3d 56, 64 (1st Cir. 2001) (reliability of expert witness
testimony under Daubert is contingent upon “whether the proposed testimony . . . rests
on a reliable foundation and is relevant to the facts of the case.”) (citations omitted). “The
party seeking to introduce the evidence has the burden of establishing both its reliability
and its relevance.” Milward v. Rust-Oleum Corp., 820 F.3d 469, 473 (1st Cir. 2016).
Under Rule 702, the Court must focus on the “principles and methodology” of the
proffered expert opinion, “not on the conclusions that they generate.” Daubert, 509 U.S.
at 595. “So long as an expert’s scientific testimony rests upon good grounds . . . it should
be tested by the adversarial process[.]” López-Ramírez v. Toledo-González, 32 F.4th 87,
94 (1st Cir. 2022) (quotations omitted). As the First Circuit has previously explained,
“[t]here is an important difference between what is unreliable support and what a trier of
fact may conclude is insufficient support for an expert's conclusion.” Milward v. Acuity
Specialty Prods. Grp., Inc., 639 F.3d 11, 15 (1st Cir. 2011). Where the factual basis for an
expert opinion is merely “weak”—rather than fundamentally unreliable or irrelevant—the
expert’s opinion is to be weighed by the jury. López-Ramírez, 32 F.4th at 94. On the other
hand, the Court is not required “to admit opinion evidence that is connected to existing
data only by the ipse dixit of the expert” and instead may rule the evidence inadmissible
where “there is simply too great an analytical gap between the data and the opinion
proffered.” Gen. Elec. Co. v. Joiner, 522 U.S. 136, 146 (1997).
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IV. Analysis
Puerto Rico law 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.” 31
L.P.R.A. § 10801.3 “Within this rubric, three elements coalesce to make up a prima facie
case for medical malpractice . . . a plaintiff must establish [1] the duty owed, [2] the
occurrence of an act or omission constituting a breach of that duty, and [3] a sufficient
causal nexus between the breach and some resultant harm.” Martínez-Serrano v. Quality
Health Servs. of P.R., Inc., 568 F.3d 278, 285 (1st Cir. 2009).
In medical malpractice cases, establishing the minimum standard of care owed by
a physician to a patient usually requires the assistance of an expert. Rivera Rodríguez v.
Quality Health Servs. of P.R., Civ. No. 18-1287, 2022 WL 3445348, at *3 (D.P.R. Aug. 4,
2022) (citing Cortés Irizarry v. Corporación Insular de Seguros, 111 F.3d 184, 190 (1st
Cir. 1997)). Likewise, it is well-established that, “in a medical malpractice case under
Puerto Rico law[,] a factfinder normally cannot find causation without the assistance of
expert testimony.” Martinez-Serrano v. Quality Health Servs. of P.R., Inc., 568 F.3d 278,
286 (1st Cir. 2009) (noting that expert testimony is ordinarily required to establish
causation because in medical malpractice cases “the issues tend to be scientifically driven
and more nuanced than in most tort cases”) (citations and quotations omitted). Against
this backdrop, Plaintiff seeks to admit the expert witness testimony of Dr. Drukteinis.
3 “Article 1802 of the Puerto Rico Civil Code of 1930, Puerto Rico's previous tort statute, was replaced
by Article 1536 when the new Puerto Rico Civil Code was enacted in November 2020. However, Articles
1802 and 1536 have provisions that are extremely similar and thus can be used interchangeably. Courts in
this district accordingly apply caselaw analyzing Article 1802 to claims arising under Article 1536.” Forde
v. Concho Corp., Civ. No. 23-01052, 2025 WL 320683, at *3 n.3 (D.P.R. Jan. 28, 2025) (quotations and
citations omitted).
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Defendants raise two arguments as to why the proffered testimony of Dr.
Drukteinis should be ruled inadmissible at trial. First, Defendants assert that the expert
witness report of Dr. Drukteinis fails “to identify the national standard of care” as to each
of the seventeen Defendants involved in the treatment of Suárez. (ECF No. 752 at 2).
Second, Defendants argue that the expert witness report of Dr. Drukteinis also fails to
provide any opinion as to causation. (ECF No. 752 at 2). The Court will address each
issue in turn.
A. The expert report of Dr. Drukteinis reliably identifies a standard of
care applicable to Defendants.
Invoking Rule 702 of the Federal Rules of Evidence, Defendants argue that the
expert witness opinion of Dr. Drukteinis is lacking in relevance and reliability because it
assigns the same standards of care as to all seventeen medical practitioners sued by
Plaintiffs: “[n]otwithstanding the gamut of specialties involved in this case,” Defendants
argue, “Dr. Drukteinis’ report does not identify the specific standard of care applicable to
each physician . . . specialist, . . . nurse practitioner, . . . professional service [corporation],
or [hospital.]” (ECF No. 752 at 3).4
4 The Court notes that Defendants raise an additional argument for the exclusion of Dr. Drukteinis’
opinion on the applicable standard of care: according to Defendants, the expert report submitted by Dr.
Drukteinis ostensibly “lacks any statement that the unspecified standards of care [in question] . . . are
nationally used.” (ECF No. 752 at 12). This argument is without merit. For one, it is well-recognized that,
in order to set forth a sufficiently reliable national standard of care, an expert witness report need not
explicitly use the magic words “national standard of care.” Cortes-Irizarry v. Corporación Insular De
Seguros, 111 F.3d 184, 190 (1st Cir. 1997) (holding that references to a “prevailing medical standard” used
by the “average gynecologist” was sufficient to establish a standard of care). Second, far from offering
“unspecified” conclusions or remaining “conspicuously silent” on the issue of the national standard of care
– as Defendants inaccurately argue (ECF No. 752 at 12) – Dr. Drukteinis’ expert report presents a detailed
account of three distinct standards of care that he attests are directly applicable to the conduct of
Defendants. (ECF No. 782-9 at 9–12). In his explanation of those standards, Dr. Drukteinis cites to a
dozen relevant medical publications. (ECF No. 782-9 at 9–12 n.1–n.12). A cursory review of those
publications suggests that they are not Puerto Rico focused, but rather address standards of medical
practice that apply nationally. See Vargas-Alicea v. Cont’l Cas. Co., Civ. No. 15-1941, 2019 WL 1453070, at
*2 (D.P.R. March 31, 2019) (holding that an expert may establish the national standard of care with
“reliance on peer-reviewed literature (i.e. journals, textbooks, and treatises).”). Moreover, beyond broadly
addressing the scholarship cited by Dr. Drukteinis with skepticism, Defendants never attempt to explain
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Defendants’ argument is belied by the content of the report, which expressly sets
forth three standards of care broadly applicable to all physicians who were responsible
for the care of Suárez, (ECF No. 782-9 at 9–12), in addition to documenting in acute
detail a narrative of the facts of this case and an account of the entire “Chain of
Responsibility for [Suárez]” between the time that Suárez was first admitted into the
emergency room at Presby until the time that he was transferred back to that facility from
Doctors’, listing each responsible physician, as well as the specific times at which they
were involved in the treatment of Suárez. (ECF No. 782-9 at 4–9). It is therefore
unclear why Defendants would argue that the expert report is deficient; indeed, the report
specifically identifies each Defendant physician in an account of the “chain of
responsibility,” and identifies three specific standards of care applicable to all of them.
Moreover, Defendants identify no legal authority holding that, in multi-defendant
medical malpractice cases, an expert report must set forth its conclusions regarding the
standard of care with particularity as to each respective defendant. Nor do Defendants
explain why the fact that the conclusions adopted by Dr. Drukteinis are broadly applicable
to various Defendants would render those opinions any less reliable or relevant under
Rule 702. Most importantly, Defendants fail to explain why they believe that the
standards of care set forth in Dr. Drukteinis’ report cannot logically apply to all
defendants alike. For example, Defendants do not articulate why a standard regarding
proper transitions of care between medical providers would differ depending on the
medical specialty of each respective doctor. Defendants have thus failed to persuade the
how the citations in the report fail to establish a national standard of care. See, e.g., (ECF No. 752 at 12)
(arguing that the report “does not correlate how the content of the publications cited in [the] report . . .
establish whether the relevant course of treatment is followed nationally[.]”) (citing Baker v. Chevron USA,
Inc., 680 F. Supp. 2d 865, 878 (S.D. Ohio 2010)). The Court therefore rejects this argument.
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Court that the expert witness testimony of Dr. Drukteinis is lacking reliability or
relevance. The Court therefore declines to exclude the proffered testimony of Dr.
Drukteinis on this basis.5
B. Defendants fail to identify any additional legal grounds for the
exclusion of the proffered testimony of Dr. Drukteinis.
Next, Defendants move the Court to exclude Dr. Drukteinis as a witness for
“fail[ing] to provide opinions regarding causation vis a vis each physician Defendant[.]”
(ECF No. 752 at 13). “In a multi-defendant case such as this,” Defendants insist, “the
expert’s opinions must delineate the duty breached and causation as to each defendant.”
Id. On that basis, Defendants invoke Daubert and move the Court to exclude Dr.
Drukteinis from testifying at trial as an expert witness.6 (ECF No. 752 at 2, 15).
However, in advancing this argument, Defendants fundamentally misapprehend the
purpose of Rule 702 and the role of expert witnesses in federal court.
Defendants are incorrect when they claim that an expert witnesses in a medical
malpractice case “must” articulate an opinion regarding causation in order to testify.
(ECF No. 752 at 13). Dr. Drukteinis is not a party to this case and does not bear the
burden to prove anything; instead, in civil litigation it is the plaintiff who bears the burden
to prove all three elements of a negligence claim. Rule 702 provides civil litigants with the
means to introduce expert witness testimony in order to prove the elements of their legal
claims. See FED. R. EVID. 702. And Daubert requires that any such expert witness
5 The Court also notes that, to the extent Dr. Drukteinis seeks to offer an opinion at trial as to how
the standards of care identified in his report apply to the conduct of any individual Defendant in this case,
an expert witness may reasonably supplement, explain, or elaborate on the material set forth in their Rule
26 report. Gay v. Stonebridge Life Ins. Co., 660 F.3d 58, 64 (1st Cir. 2011).
6 To be clear, with respect to the issue of causation in Dr. Drukteinis’ report, Defendants do not raise
any arguments arising under Rule 26 of the Federal Rules of Civil Procedure. The Court therefore addresses
only the requirements of Rule 702 of the Federal Rules of Evidence.
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testimony be sufficiently reliable and relevant before it is admitted into evidence.
Daubert, 509 U.S. at 589. Even assuming for the sake of argument that Defendants are
correct that Dr. Drukteinis provides no opinion regarding causation in his expert witness
report – a conclusion that the Court does not adopt – Defendants fail to explain why that
would render his proffered testimony relating to the duty and breach elements of
Plaintiffs’ negligence claim unreliable. The Court finds that it would not. Accordingly, the
Court declines to exclude the testimony of Dr. Drukteinis from evidence.
V. Conclusion
For the reasons set forth above, the Court finds that the proffered expert witness
testimony of Dr. Drukteinis will assist the trier of fact. See FED. R. EVID. 702. Indeed, the
opinions set forth in the expert witness report of Dr. Drukteinis are both reliable and
relevant. Accordingly, Defendants’ Motion in Limine is DENIED.
IT IS SO ORDERED.
In San Juan, Puerto Rico, this 10th day of February, 2026.
/s/ María Antongiorgi-Jordán
MARIA ANTONGIORGI-JORDAN
UNITED STATES DISTRICT JUDGE
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