FTCA Accrual Starts with Post‑Surgical Complications, Not Later Medical Imaging: The First Circuit’s Objective Discovery Rule in Roldán‑Barrios v. United States

Introduction

In Roldán‑Barrios v. United States, No. 23‑1202 (1st Cir. Oct. 20, 2025) (per curiam) (not for publication), the First Circuit affirmed summary judgment for the United States on statute‑of‑limitations grounds in a Federal Tort Claims Act (FTCA) medical malpractice suit arising from 1995 orthopedic surgery and ensuing infections at the VA Caribbean Healthcare System. The central issue was when the claim “accrued” for limitations purposes under the FTCA’s discovery rule: at the time of post‑surgical complications in 1995, or decades later when the plaintiff received a 2020 MRI identifying “small metallic artifacts” and allegedly learned of causation from an infectious disease specialist in 2018.

The court held that the claim accrued no later than December 2, 1995—upon discharge after a multi‑week hospitalization to treat infection following the removal of intramedullary hardware—because, under an objective standard, a reasonable person was then on notice of both injury and probable cause. Later imaging and retrospective medical opinions did not reset or toll the accrual date. The panel likewise held that any parallel Puerto Rico tort claims were untimely and, in any event, independently barred by sovereign immunity.

Procedurally, the case was decided by a two‑judge panel under 28 U.S.C. § 46(d) following the passing of Judge Selya during pendency.

Summary of the Opinion

The First Circuit reviewed de novo the district court’s grant of summary judgment on limitations grounds and affirmed. It concluded:

Under 28 U.S.C. § 2401(b), an FTCA claim must be presented to the appropriate agency within two years of accrual.
Applying the FTCA discovery rule, accrual occurs when a plaintiff knows or reasonably should know both of the injury and its probable cause; definitive knowledge of negligence is not required.
By December 1995—after infection, readmission, and removal of the intramedullary rod and nail—a reasonable person would have been on notice that the surgery was the probable cause of the leg injuries and complications. The claim thus accrued by that date.
Subsequent events (an alleged 2018 statement by an infectious disease specialist and a 2020 MRI reporting “small metallic artifacts”) did not toll or reset the limitations period, which had long since expired.
Equitable tolling and estoppel were not preserved below and, in any case, were inadequately developed on appeal.
Plaintiff’s Puerto Rico law claims (Articles 1802 and 1803) are untimely under the one‑year statute of limitations; moreover, the United States has not waived sovereign immunity for direct suits under Puerto Rico law, casting doubt on subject‑matter jurisdiction over those claims in any event.

Factual and Procedural Background

January 25, 1995: VA surgeons placed an intramedullary rod and nail to repair right tibia/fibula fractures.
September 1995: Plaintiff presented with fever, pain, redness, warmth in the right leg; diagnosed with cellulitis; the rod and nail were surgically removed at the end of September.
November‑December 1995: Plaintiff returned with similar symptoms; hospitalized and treated for cellulitis; discharged December 2, 1995.
2004–2018: Recurrent infections led to multiple VA visits.
August 8, 2018: Plaintiff presented an FTCA administrative claim; VA denied it two months later as time‑barred.
April 9, 2019: Plaintiff filed suit in the District of Puerto Rico.
February 2020: MRI reported an old, healed tibial fracture with “small metallic artifacts.”
April 2022: CT scan reported “small metallic densities ... probably associated to postsurgical changes.”
Affidavit: Plaintiff stated he was told by an infectious disease specialist in 2018 that infections were caused by the 1995 surgery, and that he first learned of metal in his leg in 2020, which led him to discover a 2012 x‑ray report referencing metallic traces.
District Court: Granted summary judgment for the United States, finding accrual no later than December 2, 1995; no tolling by 2020 MRI or 2018 statement.
Appeal: First Circuit affirmed.

Detailed Analysis

Precedents Cited and Their Influence

O’Brien v. United States, __ F.4th __, 2025 WL 2621596, at *7 (1st Cir. Sept. 11, 2025): Cited for the general rule that an FTCA claim accrues at the time of injury, subject to the discovery rule in medical malpractice contexts. The panel used O’Brien to anchor the accrual framework before applying the discovery rule refinements.
Sánchez v. United States, 740 F.3d 47, 52 (1st Cir. 2014): Establishes that in FTCA medical malpractice cases, accrual may be delayed until the plaintiff knows or reasonably should know of both injury and its cause. Crucially, Sánchez applies an objective standard. This case provides the doctrinal backbone for the panel’s “should have known” approach.
Morales‑Melecio v. United States (HHS), 890 F.3d 361, 367–69 (1st Cir. 2018): Affirms that a plaintiff need not know the full extent of injury, nor possess definitive knowledge of negligent causation, for accrual. Once aware of the probable cause and existence of injury, a plaintiff bears the burden to seek medical and legal advice. The panel expressly relies on this duty‑to‑investigate principle.
Donahue v. United States, 634 F.3d 615, 624 (1st Cir. 2011): Reinforces the objective standard: what a reasonable plaintiff should have known or discovered. The panel invokes Donahue to frame the inquiry as objective, not subjective.
McCullough v. United States, 607 F.3d 1355, 1360 (11th Cir. 2010): The Eleventh Circuit held that familiar post‑surgical symptoms (pain, swelling, fever) combined with surgery at the locus of pain suffice to alert a reasonable patient to potential negligence. The First Circuit cites McCullough analogically to show that Roldán’s 1995 complications signaled actionable injury and probable cause.
Reilly v. United States, 513 F.2d 147, 150 (8th Cir. 1975): Hospital readmission and subsequent procedures were “extreme and unexpected consequences” adequate to put a plaintiff on notice. Used here to underscore that readmission and hardware removal in 1995 were legally significant notice events.
Mello v. United States, 435 F. Supp. 3d 327, 329 n.1 (D. Mass. 2020): A plaintiff with a large, red blister at the acupuncture site could “hardly disclaim knowledge” of injury and cause. The panel uses Mello for the proposition that visible and localized post‑treatment complications objectively signal causation.
Bradley v. United States by Veterans Admin., 951 F.2d 268, 271 (10th Cir. 1991): A plaintiff cannot wait for a third party to inform him of negligent causation; diligence is required. This authority supports rejecting accrual based on later medical statements or opinions.
Santana‑Concepción v. Centro Médico del Turabo, Inc., 768 F.3d 5, 9 (1st Cir. 2014): Confirms the one‑year statute of limitations for Puerto Rico medical malpractice under Articles 1802 and 1803. The panel applies this rule to conclude the Puerto Rico claims are time‑barred.
United States v. Zannino, 895 F.2d 1, 17 (1st Cir. 1990): Appellate courts need not develop arguments that are merely sketched. Invoked to dispose of undeveloped equitable tolling/estoppel references.
Velázquez‑Rivera v. Danzig, 234 F.3d 790, 795 (1st Cir. 2000), and Mahon v. United States, 742 F.3d 11, 12 (1st Cir. 2014): Together, these cases underscore that the United States has not waived sovereign immunity for direct suits under Puerto Rico law, implicating subject‑matter jurisdiction absent the FTCA framework.

Legal Reasoning

The court’s reasoning proceeds in three steps: the applicable accrual standard, its application to undisputed facts, and the rejection of tolling/reset theories.

Accrual Standard under the FTCA Discovery Rule.
- Section 2401(b) requires presentment within two years after accrual; accrual is generally at injury but, in medical malpractice, may be delayed until the plaintiff knows or reasonably should know of both the injury and its cause.
- Knowledge of negligence is not required; “definitive knowledge” is not the benchmark. What matters is awareness of injury and probable cause, assessed objectively.
- Once on notice, the plaintiff bears the burden to investigate further (Morales‑Melecio), including consulting medical and legal professionals.
Application to the Record (Objective Notice by December 2, 1995).
- In September 1995, after the January surgery, plaintiff experienced fever, pain, redness, and warmth in the same leg; he was diagnosed with cellulitis, and the intramedullary hardware was removed.
- Within weeks, he was readmitted for similar symptoms and hospitalized through December 2, 1995.
- These clustered, serious, and localized post‑surgical complications—culminating in hardware removal—are precisely the type of events that courts view as “extreme and unexpected consequences” (Reilly) and symptoms that should alert a reasonable person to potential causation by the prior surgery (McCullough; Mello).
- Therefore, by discharge on December 2, 1995, a reasonable plaintiff would have known of both injury and probable cause. Accrual thus occurred no later than that date.
Rejection of Later‑Discovery Tolling/Reset Theories.
- 2018 Specialist Statement: A belated medical opinion associating infections with the 1995 surgery does not postpone accrual; plaintiffs cannot wait to be “passively informed” that their injury was negligently inflicted (Bradley).
- 2020 MRI and 2022 CT Imaging: The identification of “small metallic artifacts/densities” probably related to postsurgical changes is not a new injury and does not change the accrual analysis; the clock does not restart when later evidence corroborates what a reasonable person already should have suspected decades earlier.
- Equitable Tolling/Estoppel: Not preserved below; inadequately briefed on appeal (Zannino). Even on the merits, no extraordinary circumstances or misconduct were identified to warrant tolling or estoppel.

Impact and Significance

Although nonprecedential, the decision is a strong, practical reaffirmation of the First Circuit’s objective, diligence‑oriented approach to FTCA medical malpractice accrual:

Diligence over diagnostic certainty: Plaintiffs must act when they experience serious, localized, and temporally connected post‑treatment complications. The clock can start even if they do not yet know the full extent of injury, the precise mechanism, or whether negligence occurred.
No reset by later testing or retrospective opinions: New imaging, records discoveries, or provider statements years later do not revive already time‑barred claims when earlier events sufficed to trigger a duty to investigate.
Administrative practice under § 2401(b): Counsel should evaluate accrual at the time of readmission, corrective procedures (e.g., hardware removal), or other significant adverse outcomes, not at later confirmations. Waiting for “smoking‑gun” records is risky.
Puerto Rico overlay: Plaintiffs who try to append Puerto Rico tort claims against the United States face both a stringent one‑year limitations period and the sovereign immunity barrier; the FTCA is ordinarily the exclusive vehicle, subject to its federal limitations regime.
Litigation strategy: The opinion underscores preservation requirements: equitable tolling/estoppel must be raised and developed in the district court and fully briefed on appeal.

Complex Concepts Simplified

Accrual (FTCA): The moment the legal time clock starts. In medical malpractice under the FTCA, accrual happens when a reasonable person would know they are injured and that their treatment probably caused it—even without proof of negligence.
Discovery Rule: A doctrine postponing accrual until the injury and its probable cause are or should be known. It does not wait for perfect certainty; it is about reasonable suspicion triggering a duty to investigate.
Objective Standard: The test is what a reasonable person in the plaintiff’s position should have known, not the plaintiff’s subjective beliefs or the date they actually obtained conclusive proof.
Equitable Tolling vs. Estoppel:
- Equitable tolling pauses a limitations period due to extraordinary circumstances beyond the plaintiff’s control, despite diligence.
- Equitable estoppel prevents a defendant from asserting a time bar if the defendant’s misconduct caused the plaintiff’s delay. Both doctrines are exceptional and must be properly preserved and supported.
Sovereign Immunity and FTCA: The United States can be sued only to the extent it consents. The FTCA is a limited waiver that permits certain tort claims under the “law of the place,” but governed by federal procedures and time limits. Direct Puerto Rico tort claims against the U.S. are not independently authorized.
Summary Judgment on Limitations: Appropriate when, viewing the record favorably to the non‑movant, there is no genuine dispute that the claim is time‑barred under applicable accrual and tolling rules.

Key Takeaways

Significant post‑surgical complications—especially readmission and corrective interventions at the surgical site—are powerful accrual triggers under the FTCA’s discovery rule.
Later imaging (e.g., MRI/CT suggesting postsurgical metallic artifacts) and retrospective opinions do not reset the statute once the plaintiff was objectively on notice decades earlier.
Plaintiffs must act diligently: once on inquiry notice, they carry the burden to seek medical/legal advice and to timely present administrative claims.
Equitable doctrines must be preserved and robustly briefed; mere references on appeal are insufficient.
Puerto Rico tort claims against the United States are both time‑sensitive and, in any event, curtailed by sovereign immunity absent FTCA compliance.

Conclusion

Roldán‑Barrios reinforces a stringent, objective approach to FTCA accrual in medical malpractice cases: the limitations clock begins when a reasonable person would recognize injury and probable cause, not when later records or providers deliver confirmation. The First Circuit’s application of Sánchez, Morales‑Melecio, and Donahue emphasizes inquiry notice and diligence, aligning with inter‑circuit authority that post‑treatment complications and corrective surgery are clear notice events. Although unpublished, the decision offers a practical roadmap for litigants and counsel: evaluate accrual at the time of significant adverse outcomes; do not rely on later testing to revive stale claims; preserve and substantiate any equitable tolling arguments; and recognize the limited path for Puerto Rico tort theories against the United States. In short, the case underscores that FTCA claims are governed as much by reasonableness and timeliness as they are by medical causation.