Issue link: https://maltatoday.uberflip.com/i/1535229
A doctor-patient relationship is a contractu- al one and in order to find a doctor responsi- ble for damages, the latter must prove there was a breach of contract. This was held in a judgment delivered by the Court of Appeal on 6 May 2025 in Paul- ine Montebello et vs Public Health Superin- tendent and Principal Medical Officer. The Court was presided by Chief Justice Mark Chetcuti and judges Robert Mangion and Grazio Merceica. The Montebello family filed a negligence case against the Superintendent of Public Health and the Principal Medical Officer following the death of William Montebello, the Plaintiffs' husband and father. He died after being admitted to Mater Dei Hospital on three occasions in August 2020, when he was complaining of chest pains. The Plain- tiffs attributed Montebello's death to misdi- agnosis on the first time he went to Mater Dei Hospital (MDH). The Court of Appeal quoted the judgment of the Court of First Instance. The Plaintiffs argued that the doctors failed to identify the cause of Montebello's distress was heart-re- lated and that the medical team did not consider his family medical history. William Montebello was discharged from hospi- tal on the first occasion because he was no longer in pain. He was eating and drinking and was deemed fit for discharge. However, when he was first admitted he showed the classical signs of a heart attack. The doctor seeing him ordered a Troponin test, which showed to be normal. He was kept in hos- pital to have blood tests. Then an ECG was administered, but again this did not show that Montebello suffered a heart attack. These tests were undertaken in accordance to MDH guidelines. Following these tests Montebello was discharged. Two Troponin tests are taken in order for the medical team not to depend on only one test. The court was presented with a number of guidelines and protocols used in such cases. Guidelines are discretionary, whole proto- cols are mandatory. MDH follows the Eu- ropean Guidance Society Guidelines, which have been drawn up by the best cardiologist experts. According to the medical records of the case, the doctors followed these guide- lines. The doctor who treated Montebello the first time told the court that a cardiol- ogist would have been called in if the test showed that there was a heart issue. The Plaintiffs said that the doctors failed to ask about the family history because Wil- liam Montebello's parents died in their 50s from heart disease. The doctors said that this information is important, but not a de- termining factor. Although it was important to ask on the family history, the treatment of the patient would not have changed. An- other doctor testified and said that in med- icine there is no black and white results. If the tests indicate that there is heart disease then action should be taken. However, in this case, the tests did not show this. As to the legal responsibility of a medi- cal practitioner, that medical practitioner would not be held responsible for the death of a patient if they would have followed gen- eral medical practice. This is an objective test and not subjective. The First Court observed that Montebel- lo was not given the medicine he was pre- scribed. His son argued that the family was informed that the medicine should be given only if the symptoms reappeared. On the second time Montebello was admitted to hospital, treatment was given. After a few days, the doctors recommended to switch off the life support machines, but the Plain- tiffs objected. They accused MDH of being in a hurry to free a bed at ITU. The Plaintiff appealed this judgement on the ground that not all documents were pre- sented in court and that the doctors did not follow the best practice. The Court of Appeal observed that two different guidelines were presented, but for different situations. MDH presented guide- lines which were modern and involved the Troponin test. The Plaintiffs presented guidelines for a suspected cardiac chest pain. Not discharged because of wrong diagnosis The Court of Appeal agreed with the Court of First Instance that although it was impor- tant to ask on the family medical history, this was not the only data required. Mon- tebello underwent tests such as Troponin and ECG, which were sufficient to exclude negligence. Montebello was not discharged because of a wrong diagnosis. All the doc- tors produced as witnesses confirmed that doctors at the emergency followed what was expected from them. The Court of Appeal held that the Civil Code does not provide any specific norms for doctors and therefore, one has to adopt the general terms of responsibility. The Defendants in this case represent the ex- ecutive and the Plaintiffs did not take any action against the individual doctors. There are judgments which base responsibility of doctors on quasi-tort. In the UK a Nation- al Health Service patient may also take ac- tion on quasi-tort, however, if the action is against a private doctor, the relationship with the patient is a contractual relation- ship. In Italy the relationship is always con- tractual. In Malta judgments such as Rose Gauci vs Donald Felice, delivered on 8 Oc- tober 1999 and Vincent Gauci vs Principal Medical Officer and Albert Fenech, decided on 18 June 2019, the courts held that the re- lationship between a doctor and patient is a contractual one. Therefore, the action for damages is a re- sult of a breach of contract. Article 1132 and 1032 of the Civil Code applies in that the Defendant must show that he or she acted as a bonus pater familias (the care of a fa- ther). The diligence a doctor must show is the same a competent professional and uses normal diligence. It is expected that the doc- tor keeps updated with medical advances and applies them as an ordinary profession- al doctor. The defendants proved that they were competent and diligent. Montebello's death cannot be attributed to the Defend- ants. The Court of Appeal then moved to dis- miss the appeal. LAW Law Report The relationship between a doctor and a patient is a contractual relationship LAW REPORT MALCOLM MIFSUD Mifsud & Mifsud Advocates MALCOLM MIFSUD Mifsud & Mifsud Advocates maltatoday | SUNDAY • 11 MAY 2025 8 As to the legal responsibility of a medical practitioner, that medical practitioner would not be held responsible for the death of a patient if they would have followed general medical practice. This is an objective test and not subjective.