FI L ED U.S. COURT OF APPEAL S EL EVENTH CI RCUI T Nov. 30, 2009
THOMAS K. KAH

N CL ERK [DO NOT PUBLISH]

IN THE UN ITED STATES COURT OF APPEALS

FOR THE ELE VENTH CIRCUIT

__ __ __ __ __ __ __ __ __ __ __ __
No. 0 8- 16 00 4

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D.C. Dock et No. 0 6- 00 25 5- CV-1 -SPM -AK

EVELYN ORTIZ, as Pe rs on al Rep res en ta ti ve of t he Est at e o f Raf

ael I. Orti z-Pa ga n,

Pl ai nt iff -Ap pe ll an t,

ve rs us

UNITED STAT ES OF AMERIC A,

Defen da nt -Ap pe ll ee.

__ __ __ __ __ __ __ __ __ __ __ __ App eal fro m

th e Uni te d S ta te s Di st ric t Co ur t fo r th e Nor th ern Dis tri ct of F lo rid a

__ __ __ __ __ __ __ __ __ __ __ __ (No ve m be r 30 , 20 09 )

Befo re BLACK, WILSON and COX, Circ ui t J ud ge s.

COX, Cir cu it Ju dg e:

I. BACKG ROUNDOn Mon da y , Mar ch 17
, 20 03
, Rafa el Orti z-Pa ga n pre se nt ed to th e em erg en cy

ro om at th e Dep art m en t of Vete ran s Affai rs Hos pi ta l in Gain es vi ll e, Fl or id a (“ th e

ho sp it al ” or “ th e V A ” )

. O r ti z was a ch ro ni c pa in pa ti en t an d ha d ov erd os ed on hi s

pa in m ed ic at io n. The em erg en cy ro om ph y si ci an ke pt Orti z in th e em erg en cy ro om

ov ern ig ht an d o rd ered a ps y ch ia try co ns ul t. The ps y ch ia try resi de nt ph y si ci an who

ex am in ed an d in te rv ie wed Orti z in th e la te m or ni ng on Tue sd ay , Mar ch 18
, in vo ke d

The Fl or id a Men ta l Heal th Act to in vo lu nt ari ly co m m it Orti z to th e ps y ch ia tri c ward

of th e h os pi ta l an d p la ced hi m on su ic id e p reca ut io ns

.

Orti z sp en t m

uc h of th e da y on Tue sd ay , Mar ch 18
, on su ic id e pr ecau ti on s, in

th e da y ro om of th e ps y ch ia tri c ward
, un de r co ns ta nt on e-o n

- o n e o b s e rv at io n by a

nu rs e. Dur in g th at ti m e, he was ev al ua te d by a st aff ps y ch ia tri st , Dr. Cam il o Mar ti n.

In th e earl y aft ern oo n, Mar ti n co nc lu de d th at Orti z di d no t req ui re su ic id e pr ecau ti on s

an d do wng rad ed hi s ob se rv at io na l st at us to cl os e ob se rv at io n. On cl os e ob se rv at io n,

pa ti en ts are as si gn ed a ro om an d o bs erv ed by a nu rs e at fif te en -m in ut e in te rv al s.

Dur in g th e aft er n o on of Mar ch 18
, bo th be fo re an d aft er he ha d be en

do wng rad ed to cl os e ob se rv at io n st at us , Orti z vi si te d wit h hi s wife an d s o n s in th e

da y ro om of th e ps y ch ia tri c ward

. Afte r he was ch an ge d to cl os e ob se rv at io n st at us ,

th e nu rs in g st aff ch eck ed o n hi m ev ery fif te en m in ut es

. His fam il y de pa rte d aft er

8: 00 p.m

. Orti z wen t to hi s ro om an d la id i n b e d

. The ro om Orti z oc cu pi ed ha d

2s e v e r a l p at ie nt be ds se pa rat ed by pa rti ti on s. The re were th ree ot he r pa ti en ts in t h e

ro om . Orti z was ass ig ne d t he th ird be d o n t he lef t, a co rn er b ed by a wind ow.

At 11 :4 5 p.m ., Ort iz was ob se rv ed in hi s be d

. A t 12 :0 3 a.m . o n W ed ne sd ay ,

Mar ch 19
, 20 03
, a nu rs e fo un d Orti z ha ng in g fro m a be d sh eet at ta ch ed to th e

win do w. He had co m

m it te d s ui ci de

. 1

Or tiz ’ s wid ow (“ Pl ai nt iff

”) br ou gh t th is la wsu it ag ai ns t th e Uni te d St at es un de r

th e Fed eral Tort Cl ai m s Act, 28 U.S.C. §§ 13 46 & 26 71 -8 0, al le gi ng th at th e ho sp it al

st aff ha d be en ne gl ig en t in fai li ng to ad eq ua te ly care fo r an d su pe rv is e Orti z. (R.1 -1 .)

At tri al
, Pl ai nt iff pr es en te d ex pe rt te st im on y fro m Dr. Gary Ja co bs on

. Ja co bs on ha d

rev ie wed Orti z’s m ed ic al reco rd s an d op in ed th at ho sp it al pe rs on ne l br each ed th e

st an da rd of care by ne gl ig en tl y fai li ng to co nc lu de th at Orti z was a su ic id e ris k. He

fu rth er op in ed th at , as a res ul t of th e fai lu re to reco gn iz e Orti z was at ris k fo r su ic id e,

t h e h o s p it al st aff fai le d to m on it or Orti z ad eq ua te ly an d fai le d to pl ace hi m i n a n

en vi ro nm en t th at wou ld pr ev en t hi s su ic id e. The Uni te d S t at es di d no t pr es en t an

in de pe nd en t ex pe rt wit ne ss to reb ut Ja co bs on ’s t es ti m on y . Th e tre at in g ph y si ci an s

an d nu rs es who in te ract ed wit h Orti z on th e ps y ch ia tri c ward te st ifi ed ab ou t th ei r

There was no evidenc e as to how Ortiz attache d the bed sheet to the window, or whether the 1 window was open. The only evidenc e about the phy sical state of the window was: (1) a nurse’ s note that, when he found Ortiz hang ing at 12:03 a.m. on Marc h 19, 2003, “a white sheet

. . . was wra pped around [ Orti z ’s] neck and attached to the t op of t he window.” (R.5 at 33 I NP); and (2) testimony by a nursing assistant on the psy chiatric war d that the window by Ortiz’s bed was big and square and require d a key

for ope ning. ( R.3-82 at 60.)

3ex am in at io ns an d in te ract io ns wit h hi m , th e i r a s se ss m en t of hi s m ed ic al co nd it io n,

an d t he act io ns th ey

to ok du rin g h is ho sp it al st ay

.

The di st ric t co ur t is su ed a m em or an du m of de c is io n. The co ur t reject ed

Ja co bs on ’s op in io ns th at th e ho sp it al st aff ha d br each ed th e st an da rd of care , of feri ng

as an ge ne ral ex pl an at io n: “ Dr. Ja co bs on ’s te st im on y an d hi s co nc lu si on s ab ou t Mr.

Orti z were ba se d en ti rel y up on en tri es in th e m ed i cal reco rd s, so m e of whi ch were

ta ke n ou t of co nt ex t an d whi ch were la te r ex pl ai ne d in m or e de ta il in te st im on y fro m

tre at in g ps y ch ia tri st s an d nu rs es .” (R.1 -7 3 ¶8 0.) The co ur t ga ve sp eci fic ex am pl es

of te st im on y by tre at in g pr of es si on al s fro m whi ch th e co ur t co nclud ed tha t Ja co bson ’ s

op in io ns , ba se d so le ly on th e m ed ic al reco rd , m is in te rp ret ed Orti z’s co nd it io n. ( Id

. ¶¶8 1- 83 .) The co ur t st at ed
, “ Dr. Ja co bs on ’s co nc lu si on th at Mr. Orti z was un de r an

i mm i n en t ris k of su ic id e at th e VA ho sp it al on Mar ch 18
, 20 03
, an d th at th e s t a f f

ne gl ig en tl y fai le d to m on it or hi m is no t co nf irmed by th e te st im on y at tri al or by th e

m ed ic al reco rd s.” (

Id

. ¶8 7.)

Th e c o ur t al so fo un d, “ The reas on s Dr. Mar ti n ga ve fo r rem ov in g Mr. Ort i z

fro m su ic i d e p r ecau ti on s refl ect a reas on ab le m ed ic al as se ss m en t of Mr. Orti z’s

co nd it io n an d hi s tre at m en t ne ed s,” ( id

. ¶8 6)
, an d “ Dr. Mar ti n’s de ci si on to ta ke Mr.

Orti z of f of su ic id e pr ecau ti on s refl ect s a reas on ab le m ed ic al jud gm en t.” ( Id

. ¶9 1.)

The or de r co nc lu de s, “ Und er th e ev id en ce pr es en te d at tri al I can no t fin d th at th e VA

4m ed ic al st aff was ne gl ig en t in th ei r care an d tre at m en t of Mr. Orti z no r can I fin d th at

an y act of t he VA sta ff was th e p ro xi m at e cau se of h is de at h.” ( Id

. ¶9 0.)

The co ur t en te red jud gm en t fo r th e Uni te d S ta te s. Pl ai nt iff ap pe al s.

II . ISSUE S ON APPEAL AND CONTENTI ONS OF TH E PARTIE S

Pl ai nt iff arg ue s th at th e di st ric t co ur t cl earl y erre d by no t ad op ti ng Ja co bs on ’s

op in io n th at Orti z was su ic id al an d by fin di ng th at th e ho sp it al st aff was no t ne gl ig en t

an d d id no t ca us e Ort iz ’s dea th

. Pl ai nt iff arg ue s th at Ja co bs on ’s t es ti m on y was th e

on ly ex pe rt te st im on y on th e st an da rd of care an d th e br each th ereo f an d th eref or e

sh ou ld ha ve be en acce pt ed by the di st ric t co ur t.

The Uni te d St at es res po nd s th at th e di st r ic t co ur t di d no t co m m it erro r by

reject in g P la in ti ff’s ex pe rt wi tn es s’s op in io ns an d con cl ud in g th at th e ho sp it al st aff

ha d n o t be en ne gl ig en t. The Uni te d St at es arg ue s th at a tri er of fact m ay reject an

ex pe rt’s op in io ns ba se d up on an y ev id en ce in th e reco rd
, whe th er or no t th at ev id en ce

is off ered by ano th er ex pe rt wi tn es s.

II I. STANDARDS OF REVIE W

W e rev ie w th e di st ric t co ur t’s fin di ng s of fact fo r cl ear erro r. W hi tl ey v. Uni te d

St at es , 17 0 F.3 d 10 61
, 10 68 n.1 4 (1 1 t h Ci r. 19 99 ) ( ci ti ng Hor to n v. Reli an ce

St an da rd Li

fe In s. Co

. , 14 1 F.3 d 10 38
, 10 40 (1 1t h Ci r.19 98 ). “ W e can no t fin d cl ear

erro r un le ss ‘w e are le ft wi th a de fin it e an d fi rm co nv ic ti on th at a m is ta ke ha s be en

5co m

m it te d.’” Uni te d St at es v. Cr aw fo rd
, 40 7 F.3 d 11 74
, 1 1 77 (1 1t h Ci r. 20 05 )

( qu ot in g Gl as sr ot h v . Moo re , 33 5 F .3d 12 82 , 12 92 (11 th Cir . 20 03 )).

W e rev ie w a di st ric t co ur t’s ap pl ic at io n o f la w to th e fac ts de no vo

. W hi tl ey ,

17 0 F .3d at 1 06 8 ( ci ti ng

Reic h v . Davi s , 50 F.3d 96 2, 9 64 (11 th Cir . 19 95 )).

IV. DIS CUSSI ON

In act io ns br ou gh t un de r t h e Fed eral Tort Cl ai m s Act, li ab il it y is de te rm in ed

un d er th e la w of th e st at e in whi ch th e al le ge d ne gl ig en ce oc cu rred

. 28 U.S.C. §

13 46 (b )(1 ); F.D.I.C. v. Meyer
, 5 1 0 U

. S

. 47 1, 47 8, 11 4 S. Ct

. 99 6, 10 01 (1 99 4)

.

Und er Fl or id a la w, a ho sp it al m ay be li ab le fo r th e de at h of a in pa ti en t who co m m it s

su ic id e. Pad

do ck v. Ch ac ko
, 52 2 So .2d 41 0, 4 1 7 ( F l a. 5t h DCA 19 88 ) (“ W he re a

pa ti en t ha s su rren de red hi m se l f t o th e cu st od y , care an d tre at m en t of a ps y ch ia tri c

ho sp it al an d it s st aff, l i a b i li ty m ay be pr ed ic at ed up on th e ho sp it al ’s fai lu re to ta ke

pr ot ect iv e m eas ur es to pr ev en t th e pa ti en t fro m in juri ng hi m se lf.” ) As in al l m ed ic al

m al pr act ic e cas es , [T]he cl ai m an t sh al l ha ve th e bu rd en of pr ov in g by th e gr eat er weig ht of

ev id en ce th at th e al le ge d act io ns of th e he al th care pr ov id er rep res en te d

a br each of th e pr ev ai li ng pr of es si on al st an da rd of care fo r th at he a l t h

care pr ov id er. The pr ev ai li ng pr of es si on al st an da rd of care fo r a g iv en he al th c a r e pr ov id er sh al l be th at le ve l of care , sk il l, an d tre at m en t whi ch
, in li gh t of al l rel ev an t su rro un di ng ci rcu m st an ces , is reco gn iz ed

as acce pt ab le an d ap pr op ria te by reas on ab ly pr ud en t si m il ar he al th care pr ov id ers

.

Fl a. St at . Ann . § 7 66 .10 2( 1)

.

6In th is cas e, Ja co bs on ga ve an ex pe rt op in io n th at th e ho sp it al st aff sh ou ld ha ve

reco gn iz ed Orti z was at acu te ris k of su ic id e. (R.2 -8 1 at 47 -4 8.) Ja co bs on ’s op in io n

th at th e ho sp it al br each ed th e st an da rd of care by fai li ng to di ag no se Orti z as su ic id al

was ba se d up on h i s r e v i e w of m ed ic al reco rd s th at th e VA m ai nt ai ne d on Orti z,

in cl ud in g ou tp at i en t cl in ic
, em erg en cy ro om , an d in pa ti en t ho sp it al reco rd s. ( Id

. at

48 .)

The Uni te d St at es di d no t pr es en t an ex pe rt wit ne ss to op in e as to th e st an da rd

o f c a r e

. The Uni te d St at es cal le d th e do ct or s an d nu rs in g st aff m em be rs w h o

in te ract ed wit h Orti z to ex pl ai n th ei r m ed ic al no te s an d tre at m en t of Orti z du rin g hi s

Mar c h 2 0 0 3 s t ay in th e ho sp it al

. Fro m th at te st im on y , th e di st ric t co ur t co nc lu de d

th at Ja co bs on ha d m is in te rp ret ed no te s in th e m ed ic al reco rd
, th e on ly in fo r m at io n

ab ou t Orti z up on whi ch Ja co bs on ba se d hi s op in io ns

. ( Se e R.1 -7 3 ¶¶ 80 -8 3.) And
,

fo r th at reas on , th e di st ric t co ur t reject ed Ja co bs on ’s ex pe rt op in io n of m is di ag no si s.
( Id

. ¶ 87 (“ Dr. Ja co bs on ’s c on cl us io n th at Mr. Orti z was un de r an im m in en t ris k of

su ic id e at th e VA ho sp it al on Mar ch 18
, 20 03
, . . . is no t co nf irmed by th e te st im on y

at tri al or b y

th e m ed ic al reco rd s.”) )

The co ur t di d no t cl earl y err. It was wit hi n th e co ur t’s pr ov in ce as fact fin de r

to co nc lu de th at Ja co bs on ’s o pi ni on th at th e ho sp it al st aff br each ed th e st an da rd of

care in fai li ng to reco gn iz e Orti z as su ic id al sh ou ld no t be cred it ed

. Mims v. Uni te d

7St at es , 37 5 F.2 d 13 5, 14 3 (5 th Ci r. 19 67 ) (“ [E]xpe rt op i n i o n ev id en ce m ay be

reb ut te d by sh owi ng th e in co rrec tn es s or in ad eq ua cy of th e fact ua l as su m pt io ns on

whi ch th e op in io n is ba se d

. . . ” ); Eas ko ld v. Rho de s , 6 14 So .2d 49 5, 49 7- 98 (Fl a. 2

19 93 ) (jury m ay di sr eg ard a m ed ic al ex pe rt’s op in io n, ev en in th e ab se nc e of ex pe rt

te st im on y to th e c o n t r a r y, if it fin ds th at th e m ed ic al reco rd up on whi ch th e ex pe rt

op in io n was ba se d is in co m pl et e); se e a l

s o Fl a. St d. Ju ry In st r. (Ci v.) 2.2 (b ) (“ You

m ay acce pt [ex pe rt] op in io n te st im on y , reject it
, or gi ve it t h e weig ht y ou th in k it

de se rv es , co ns id eri ng th e kn owl ed ge , sk il l, ex pe rie nc e, tra in in g, or ed uc at io n of th e

wit ne ss , th e reas on s gi ve n by th e wit ne ss fo r th e op in io n ex pr es se d, an d al l th e ot he r

ev id en ce i n t he cas e.”) (e m ph as is ad de d)

.

The ot he r op in io ns Ja co bs on of fere d reg ard in g br each es of th e st an da rd of care

co nc ern th e st an da rd of care fo r pa ti en ts who are su ic id al

. Ja co bs on te st ifi ed th at th e

st an da rd of care fo r pr ot ect in g a su ic id al pa ti en t “ is to ob se rv e th at pa ti en t freq ue nt ly

en ou gh th at th ey

are n ot ab le to m ak e [s ui ci de ] at te m pt s .

. . in a ho sp it al .” (R.2 -8 1

at 51 .) Ja co bs on te st ifi ed th at m on it or in g a su ic id al pa ti en t at fi f t e e n -m in ut e

in crem en ts was in ad eq ua te

. ( Id

. ) He al so te st ifi ed t h a t a h o s pi ta l ha s a du ty to

pr ov id e a sa fe en vi ro nm en t, in cl ud in g pr ov id in g an en vi ro nm en t in whi ch “ th ere’s no

I n Bonner v. City of Pri ch a rd
, 661 F.2d 1206, 1209 (11th Cir. 1981) (en banc)
, this court 2 adopted as binding prec edent all decisions of the former Fifth Circuit handed down prior to close of business on September 30, 1981.

8m ean s or th e m ean s are as li m it ed as po ss ib le to ha rm on es el f.” (R.2 -8 1 at 54 -5 5.)

He te st ifi ed th at , pa ire d wi th in ad eq ua te m on it or in g, p la ci ng a su ic id al pa ti en t in a

ro om wit h a win do w th at op en s so as to al lo w at ta c h men t o f a m ean s of ha ng in g

wou ld be a br each of t he st an da rd of c are. (R .2-8 1 a t 5 5- 56 .)

Hav in g reject ed Ja co bs on ’s op in io n th at th e ho sp it al st aff ne gl ig en tl y fai le d to

di ag no s e O r t i z as su ic id al
, th e di st ric t co ur t di d no t err in di sr eg ard in g Ja co bs on ’s

op in io ns th a t t h e ho sp it al st aff br each ed th e st an da rd s of care fo r ob se rv at io n an d

pl acement of a su ic id al pa ti en t. Tho se op in io ns be cam e ir rel ev an t on ce th e di st ric t

co ur t de te rm in ed th at th e ho sp it al st aff act ed reas on ab ly in co nc lu di ng th at Orti z was

no t an acu te ris k fo r su ic id e. And
, th e di st ric t co ur t pr op erl y di sr eg ard ed Ja co bs on ’s

op in io ns ab ou t ph y si cal as pe ct s of th e ro om i n w h i c h Orti z was pl aced fo r an ot he r

reas on

. The re was no ev id en ti ary ba si s fo r Ja co bs on ’s op in io n th at , whe n pa ire d wit h

m on it or in g at fif

te en -m in ut e in te rv al s, pl aci ng Or t i z i n a ro om wit h a win do w th at

op en ed was a br each of th e st an da rd of care

. As st at ed ab ov e, th ere was no ev id en ce

th at th e win do w was op en , on ly th at th e be d sh eet wit h whi ch Orti z hu ng hi m se lf was

at ta ch ed to th e to p o f th e win do w.

V. CONCLUSIO N

The co ur t pe rm iss ibl y re

j ec te d Ja co bson’ s op in io n te st im on y , th e on ly ev id en ce

P l a i n t i f f pr es en te d th at th e act io ns of th e VA h os pi ta l st aff br each ed th e pr ev ai li ng

9pr of

es si on al st an da rd s of care

. Fo r th at reas on , Pl ai nt iff di d no t pr ov e he r ne gl ig en ce

cas e. And , th e co ur t d id no t er r in gra nt in g ju dg m en t t o t he Uni te d S ta te s.

AFFIR MED.

10