LEANDRO CARILLO vs PEOPLE OF THE PHILIPPINES which was not immediately life-destructive but which culminated,

G.R. No. 86890, January 21, 1994 in the present case, in the death of a human being three (3) days
later.

In the case at bar, the Court considered that the chain of

Facts: circumstances above noted, namely: (1) the failure of petitioner
Petitioner Dr. Leandro Carillo, an anesthesiologists, seeks review and Dr. Madrid to appreciate the serious post-surgery condition of
of the Decision of the Court of Appeals dated 28 November 1988, their patient and to monitor her condition and provide close
which affirmed his conviction by the Regional Trial Court of the patient care to her; (2) the summons of petitioner by Dr. Madrid
crime of simple negligence resulting in homicide, for the death of and the cardiologist after the patient’s heart attack on the very
his thirteen (13) year old patient Catherine Acosta. evening that the surgery was completed; (3) the low level of care
and diligence exhibited by petitioner in failing to correct Dr.
Madrid’s prescription of Nubain for post-operative pain; (4) the
extraordinary failure or refusal of petitioner and Dr. Madrid to
The deceased, daughter of spouses Domingo and Yolanda Acosta, inform the parents of Catherine Acosta of her true condition after
complained to her father of pains in the lower part of her surgery, in disregard of the requirements of the Code of Medical
abdomen. Catherine was then brought to Dr. Elva Peña. Dra. Peña Ethics; and (5) the failure of petitioner and Dr. Madrid to prove
called for Dr. Emilio Madrid and the latter examined Catherine that they had in fact exercised the necessary and appropriate
Acosta. According to Dr. Madrid, his findings might be degree of care and diligence to prevent the sudden decline in the
appendicitis. Then Dr. Peña told Catherine’s parents to bring the condition of Catherine Acosta and her death three (3) days later,
child to the hospital in Baclaran so that the child will be observed. leads the Court to the conclusion, with moral certainty, that
petitioner and Dr. Madrid were guilty of simple negligence
resulting in homicide.
At the Baclaran General Hospital, a nurse took blood sample form
the child. The findings became known in the afternoon and the
child was scheduled for operation. When brought inside the G.R. No. 86890 January 21, 1994
operating room, the child was feeling very well and they did not
subject the child to ECG (electrocardiogram) and X-ray.The
appellant Dr. Emilio Madrid, a surgeon, operated on Catherine. LEANDRO CARILLO, petitioner, 
He was assisted by appellant, Dr. Leandro Carillo, an vs.
anesthesiologists. PEOPLE OF THE PHILIPPINES, respondent.

Balane, Tamase, Alampay Law Office for petitioner.

It has been established that the deceased was not weighed before
the administration of anesthesia on her. The Solicitor General for the people.

When Catherine remained unconscious until noontime the next

day, a neurologist examined her and she was diagnosed as
FELICIANO, J.:
comatose. Three (3) days later, Catherine died without regaining
consciousness.
Petitioner Dr. Leandro Carillo, an anesthetist, seeks review of the
Decision of the Court of Appeals dated 28 November 1988, which
affirmed his conviction by the Regional Trial Court of the crime
The Court of Appeals held that Catherine had suffered from an
of simple negligence resulting in homicide, for the death of his
overdose of, or an adverse reaction to, anaesthesia, leading to her
thirteen (13) year old patient 
death.
Catherine Acosta. The trial court had sentenced him to suffer the
penalty of arresto mayor in its medium period (four [4] months'
imprisonment), as well as to pay the heirs of his patient an
The Court of Appeals found criminal negligence on the part of indemnity of P30,000.00 for her death, P10,000.00 as
petitioner Dr.Carillo and his co-accused Dr. Madrid, holding that reimbursement for actual expenses incurred, P50,000.00 as moral
both had failed to observe the required standard of diligence in the damages and to pay the costs of the suit.1
examination of Catherine prior to the actual administration of
anaesthesia.
The information filed against petitioner and his co-accused, the
surgeon Dr. Emilio Madrid, alleged the following:

Issue: 
Whether or not Dr.Carillo is guilty of the crime of simple That on or about the 31st of May 1981, in the municipality of
negligence resulting in homicide. Parañaque, Metro Manila, Philippines and within the jurisdiction
of this Honorable Court, the above-named accused, conspiring
and confederating together and mutually helping and aiding with
one another, without taking the necessary care and precaution to
Held: avoid injury to person, did then and there willfully, unlawfully
Yes. Simple negligence, penalized under what is now Article 365 and feloniously operate, in a reckless, careless and imprudent
of the Revised Penal Code,is defined as “a mere lack of prevision manner and neglected to exercise their respective medical
in a situation where either the threatened harm is not immediate or knowhow and tasks and/or departed from the recognized standard
the danger not openly visible.” Put in a slightly different way, the in their treatment, diagnosis of the condition, and operation of the
gravamen of the offense of simple negligence is the failure to patient, one Catherine Acosta, 13 years old, which negligence
exercise the diligence necessitated or called for the situation caused the death of the said Catherine Acosta. 2
Petitioner and Dr. Emilio Madrid entered pleas of not guilty at and 
arraignment and the case proceeded to trail with Judge Job B. X-ray.
Madayag presiding.3
The appellant Dr. Emilio Madrid, a surgeon,
The prosecution presented as its principal evidence the testimony operated on Catherine. He was assisted by
of four (4) witnesses, namely: 1) Yolanda Acosta, Catherine's appellant, Dr. Leandro Carillo, an
mother, who was able to observe the conduct of the accused anesthesiologists.
outside the operating theater before, during and after the
appendectomy procedure carried out on her daughter; 4 2) During the operation, while Yolanda Acosta,
Domingo Acosta, Catherine's father, who corroborated some parts Catherine's mother, was staying outside the
of his wife's  operating room, she "noticed something very
testimony;5 3) Dr. Horacio Buendia, an expert witness who unfamiliar." The three nurses who assisted in
described before the trial court the relationship between a surgeon the operation were going in and out of the
and an anesthetist in the course of a surgical operation, as well as operating room, they were not carrying
define the likelihood of cardiac arrest as a post operative anything, but in going out of the operating
complication;6 and 4) Dr. Nieto Salvador, an expert witness who room, they were already holding something.
analyzed and explained the significance of the results of the
pathological study and autopsy conducted on Catherine's body by
one Dr. Alberto Reyes.7 Yolanda asked one of the nurses if she could
enter the operating room but she was refused.
After the prosecution had rested its case, the defense was granted
leave to file a demurrer to the evidence. 8 After failing to file the At around 6:30 p.m., Dr. Emilio Madrid went
demurrer within the reglementary period, Judge Manuel Yuzon, outside the operating room and Yolanda
who had in the meantime taken over as presiding judge of the sala Acosta was allowed to enter the first door.
where this case was pending, denied the defense motion for
extension of time to file demurrer and declared the case submitted The appendicitis (sic) was shown to them by
for decision.9 Dr. Madrid, because, according to Dr.
Madrid, they might be wondering because he
On 19 September 1985, the trial court promulgated its decision was going to install drainage near the
convicting both the accused of the crime charged. 10 operating (sic) portion of the child.

On appeal, the Court of Appeals affirmed the judgment of When asked, the doctor told them the child
conviction, and specified that the civil liability of the two (2) was already out of danger but the operation
accused was solidary in nature. 11 was not yet finished.

Petitioner Dr. Carillo alone filed the present Petition for Review It has also been established that the deceased
with the Court, seeking reversal of his conviction, or in the was not weighed before the administration of
alternative, the grant of a new trial. Dr. Madrid did not try to anesthesia on her.
appeal further the Court of Appeals Decision. Accordingly, the
judgment of conviction became final insofar as the accused The operation was finished at 7:00 o'clock in
surgeon Dr. Madrid is concerned. the evening and when the child was brought
out from the operating room, she was
The facts of the case as established by the Court of Appeals are as observed to be shivering (nanginginig); her
follows: heart beat was not normal; she was asleep and
did not wake up; she was pale; and as if she
had difficulty in breathing and Dr. Emilio
The deceased, Catherine Acosta, a 13 year old girl, daughter of Madrid suggested that she placed under
spouses Domingo and Yolanda Acosta, complained to her father oxygen tank; that oxygen was administered to
at about 10:30 o'clock in the morning of May 31, 1981 of pains in the child when she was already in the room.
the lower part of her abdomen. Catherine was then brought to Dr.
Elva Peña. Dra. Peña called for Dr. Emilio Madrid and the latter
examined Catherine Acosta. According to Dr. Madrid, his Witness Yolanda Acosta further testified that shortly before the
findings might be appendicitis. Then Dr. Peña told Catherine's child was transferred from the operating room to her room, she
parents to bring the child to the hospital in Baclaran so that the (witness) was requested by the anesthesiologist to go home and
child will be observed. get a blanket. 
A portion of Yolanda Acosta's testimony on what happened when
she returned to the hospital are reproduced hereunder as follows:
At the Baclaran General Hospital, a nurse
took blood sample form the child. The
findings became known at around 3:00 Q What happened afterward?
o'clock in the afternoon and the child was
scheduled for operation at 5:00 o'clock in the A When I arrived in the hospital, my child was being
afternoon. The operation took place at 5:45 transferred to her bed.
p.m. because Dr. Madrid arrived only at that
time. Q What else happened?

When brought inside the operating room, the Q I noticed that the heartbeat of my daughter was not
child was feeling very well and they did not normal. And I noticed that her hospital gown is rising up
subject the child to ECG (electrocardiogram) and down.
Q What transpired after that? A According to them, they will do their best for the child
and that they will call for Dr. Carillo.
A I asked Dr. Madrid why it was like that, that the
heartbeat of my daughter is not normal. Q Did Dr. Carillo arrived?

Q And did the doctor make any reply? A At around 10:30 in the evening.

A The doctor said because of the lesion of the child. Q Did Dr. Carillo do anything when he arrived on 31 May
1981?
Q What else happened?
A When he arrived, he noticed that there were two small
A After they have revived the heartbeat of the child, bottles and big bottles of dextrose which were hanging
Dr. Carillo and Dr.Madrid left. above the bed of the child. Then he said, "What is this?
Christmas tree or what?" He told us that one bottle of
dextrose be removed. And the big one will remain.
Q Now do you remember what time was it when
Dr. Carillo stepped out?
Q What happened after that?
A Only a minute after they have transferred the child to
the bed. A After that we talked to Dr. Carillo and asked him how
did this happen to the child.
Q What happened later on after Dr. Carillo and
Dr. Madrid stepped out of the hospital? Q What did Dr. Carillo reply (sic) to you?

A After 15 or 30 minutes has lapsed at about 7:15 or A He answered "that is nothing, the child will regain
7:30, the child had developed convulsion and stiffening of consciousness and if the child will not regain
the body. consciousness, I will resign (sic) as a doctor."12

Q When you observed convulsion and stiffening of the (Emphasis supplied)

body, did you do anything?
When Catherine remained unconscious until noontime the next
A We requested the nurse who was attending to her to call day, a neurologist examined her and she was diagnosed as
for a doctor. comatose. 13 Three (3) days later, Catherine died without
regaining consciousness.14
Q And the nurse who was attending to the patient called
for a doctor? The Court of Appeals held that Catherine had suffered from an
overdose of, or an adverse reaction to, anesthesia, particularly the
arbitrary administration of Nubain, a pain killer, without benefit
A They called for Dra. Peña, their family physician. of prior weighing of the patient's body mass, which weight
determines the dosage of Nubain which can safely be given to a
Q What transpired afterwards? patient. 15 The Court of Appeals held that this condition triggered
off a heart attack as a post-operative complication, depriving
A What Dra. Peña did was call for Dr. Madrid and the Catherine's brain of oxygen, leading to the brain's
cardiologist. hemorrhage. 16 The Court of Appeals identified such cardiac arrest
as the immediate cause of Catherine's death. 17

Q Did this doctor arrived?

The Court of Appeals found criminal negligence on the part of
petitioner Dr. Carillo and his co-accused Dr. Madrid, holding that
A Yes. both had failed to observe the required standard of diligence in the
examination of Catherine prior to the actual administration of
Q What transpired after the doctor arrived? anesthesia; 18 that it was "a bit rash" on the part of the accused Dr.
Carillo "to have administered Nubain without first weighing
Catherine"; 19 and that it was an act of negligence on the part of
A They examined the child.
both doctors when, (a) they failed to monitor Catherine's heartbeat
after the operation and 
Q After they examined the child, did they inform you of the (b) they left the hospital immediately after reviving Catherine's
result of the examination? heartbeat, depriving the latter of immediate and expert medical
assistance when she suffered a heart attack approximately fifteen
A The cardiologist was the one whom informed us after he (15) to thirty (30) minutes later. 20
stepped out of the room when we followed him. The doctor
told us that she suffered severe infection which went up to Since neither petitioner nor his co-accused presented evidence in
her head. their own behalf, the present Petition seeks to question the
soundness of the factual conclusions drawn by the Court of
Q After you were informed of the result of his examination, Appeals, upon which the affirmance of petitioner's conviction was
what transpired next? based.
Close examination of the instant Petition for Review shows that could not have combined with septicemia and peritonitis in
petitioner's main arguments are two-fold: (1) the Court of Appeals bringing about Catherine's death.
"completely brushed aside" and "misapprehended" Catherine's
death certificate and biopsy report which allegedly showed that What is of critical importance for present purposes is not so much
the cause of death was a ruptured appendix, which led to blood the identification of the "true cause" or "real cause" of Catherine's
poisoning, 21 rather than faulty anesthetic treatment;  death but rather the set of circumstances which both the trial court
and (2) there was no direct evidence of record showing that and the Court of Appeals found constituted simple (as
Nubain was administered to Catherine either during the distinguished from reckless) negligence on the part of the two
appendectomy procedure or after such operation. 22 accused Dr. Madrid and Dr. Carillo leading to the death of
Catherine.
Two (2) related issues are thus posed for the Court's
consideration. The first is whether the Court of Appeals so When the patient was wheeled out of the operating room after
drastically "misapprehended" the relevant, operative facts in this completion of surgery, she manifested signs of medical instability
case as to compel this Court to examine and resolve question(s) of (i.e., shivering, paleness, irregular breathing and weak heart
fact which would have a decisive significance for the disposition beat). 27 She was not brought to a properly equipped recovery
of the case. The rule is too firmly settled to require much room, or intensive care until which the hospital lacked. 28 Such
documentation that only questions of law may be raised before facilities and their professional staffs, of which an anesthetist is
this Court in a petition for review on certiorari, subject to certain commonly a part, are essential for providing close observation
well-known exceptions. 23 After careful scrutiny of petitioner's and patient care while a post-surgery patient is recovering from
contentions before us and the record of this case, we do not the effects of anesthesia and while the normal protective
believe that petitioner has shown "misapprehension of facts" on mechanisms are still dull or obtunded. 29 Instead, the patient was
the part of the Court of Appeals which would require this Court to merely brought to her assigned hospital bed and was provided
overturn the judgment reached by the former. oxygen on the instructions of Dr. Madrid then "revived" her
heartbeat. 30 Both doctors then left their patient and the hospital;
The second issue is whether or not the findings of fact of the approximately fifteen minutes later, she suffered convulsions and
Court of Appeals adequately support the conclusion that petitioner cardiac arrest. 31
Dr. Carillo was, along with Dr. Madrid, guilty of simple
negligence which resulted in homicide. Our review of the record The conduct of Dr. Madrid and of the petitioner constituted
leads us to an affirmative answer. inadequate care of their patient in view of her vulnerable
condition. Both doctors failed to appreciate the serious condition
Petitioner contends that the Court of Appeals seriously erred in of their patient whose adverse physical signs were quite manifest
finding that an overdose of, or an allergic reaction to, the right after surgery. And after reviving her heartbeat, both doctors
anesthetic drug Nubain had led to the death of Catherine Acosta failed to monitor their patient closely or extend further medical
and that the true cause of Catherine's death was that set out in the care to her; such conduct was especially necessary in view of the
death certificate of Catherine: "Septicemia (or blood poisoning) inadequate, 
due to perforated appendix with peritonitis." 24 The concept of post-operative facilities of the hospital. We do not, of course, seek
causation in general, and the cause of death in human beings in to hold petitioner responsible for the inadequate facilities of the
particular, are complex and difficult notions. What is fairly clear Baclaran General Hospital. We consider, however, that the
is that death, understood as a physical condition involving inadequate nature of those facilities did impose a somewhat
cessation of vital signs in the brain and heart, is preceded by a higher standard of professional diligence upon the accused
series of physiological events, any one of which events can, with surgeon and anesthetist personally than would have been called
equal cogency, be described as a "cause of death". The Court of for in a modern fully-equipped hospital.
Appeals found that an overdose of, or an adverse reaction to,
Nubain, an anesthetic or  While Dr. Madrid and a cardiologist were containing the patient's
pain-killing drug the appropriate dose of which depends on the convulsions, and after the latter had diagnosed that infection had
body weight or mass of the patient, had generated or triggered off reached the patient's head, these two (2) apparently after
cardiac arrest, which in  consultation, decided to call-in the petitioner. 32 There is here a
turn led to lack of oxygen in Catherine's brain, which then strong implication that the patient's post-operative condition must
brought about hemorrhaging in the brain. Vital activity in the have been considered by the two (2) doctors as in some way
brain thereupon ceased. The medical evidence presented at the related to the anesthetic treatment she had received from the
trial was quite consistent with the findings of the Court of petitioner either during or after the surgical procedure.
Appeals which concluded that cardiac arrest was the cause of
Catherine's death. 25
Once summoned, petitioner anesthesiologist could not be readily
found. When he finally appeared at 10:30 in the evening, he was
For his part, petitioner insists that cardiac arrest is not the only evidently in a bad temper, commenting critically on the dextrose
cause of oxygen-starvation of the brain, that septicemia with bottles before ordering their removal. 33 This circumstance
peritonitis or severe infection which had "gone up to the head" of indicated he was not disposed to attend to this unexpected call, in
Catherine was an equally efficient cause of deprivation of the violation of the canons of his profession that as a physician, he
brain of oxygen and hence of brain hemorrhage. The medical should serve the interest of his patient "with the greatest of
testimony of the expert witnesses for the prosecution on which solicitude, giving them always his best talent and skill." 34 Indeed,
petitioner relies is also consistent with petitioner's theory that when petitioner finally saw his patient, he offered the
septicemia with peritonitis was, or at least could have been, the unprofessional bluster to the parents of Catherine that he would
cause of Catherine's death. 26 resign if the patient will not regain consciousness. 35 The canons
of medical ethics require a physician to "attend to his patients
Indeed, it appears to the Court that there was no medical proof faithfully and conscientiously." He should secure for them all
submitted to the trial court to show that one or the other "cause" possible benefits that may depend upon his professional skill and
was necessarily an exclusive cause of death in the case of care. As the sole tribunal to adjudge the physician's failure to
Catherine Acosta; that an overdose or allergic reaction to Nubain fulfill his obligation to his patient is, in most cases, his own
conscience, violation of this rule on his part is "discreditable and As early as in People v. Vistan, 48 the Court defined simple
inexcusable". 36 negligence, penalized under what is now Article 365 of the
Revised Penal Code, as "a mere lack of prevision in a situation
Nubain was an experimental drug for anesthesia and post- where either the threatened harm is 
operative pain and the medical literature required that a patient be not immediate or the danger not openly visible." Put in a slightly
weighed first before it is administered and warned that there was different way, the gravamen of the offense of simple negligence is
no (or inadequate) experience relating to the administration the failure to exercise the diligence necessitated or called for the
thereof to a patient less that eighteen (18) ears of age. 37 Yet, the situation which was not immediately 
doctor's order sheet (Exhibit "C") did not contain this precaution life-destructive but which culminated, in the present case, in the
but instead directed a reader to apply the drug only when death of a human being three (3) days later. Such failure to
warranted by the circumstances. 38 During the offer of Exhibit "C" exercise the necessary degree of care and diligence is a negative
by the prosecution, Dr. Madrid admitted that this prescription, ingredient of the offense charged. The rule in such cases is that
which was unsigned, was made in his own handwriting. 39 It must while the prosecution must prove the negative ingredient of the
be observed that the instruction was open-ended in that some offense, it needs only to present the best evidence procurable
other individual still had to determine if circumstances existed under the circumstances, in order to shift the burden of disproving
warranting administration of the drug to the patient. The or countering the proof of the negative ingredient to the accused,
document thus indicated the abdication of medical responsibility provided that such initial evidence establishes at least on a prima
on an extremely critical matter. Sincepetitioner anesthesiologist facie basis the guilt of the accused. 49 This rule is particularly
entered subsequent prescriptions or orders in the same order sheet, applicable where the negative ingredient of the offense is of such
which were signed by him, at 7:15 p.m. on the same evening of a nature or character as, under the circumstances, to be specially
31 May 1981, he was in a position to appreciate the dangers within the knowledge or control of the accused. 50 In the instant
inherent in the prior prescription, which was within his case, the Court is bound to observe that the events which occurred
(petitioner's) area of specialization, and to order measures to during the surgical procedure (including whether or not Nubain
correct this anomaly and protect his patient's well-being. So far as had in fact been administered as an anesthesia immediately before
the condition of the evidence shows, he failed to do so. In sum, or during the surgery) were peculiarly within the knowledge and
only a low level of diligence was exhibited by petitioner and Dr. control of Dr. Carillo and Dr. Madrid. It was, therefore,
Madrid in the prescription of medication for their patient. incumbent upon the two (2) accused to overturn the prima
facie case which the prosecution had established, by reciting the
measures which they had actually taken to prevent or to counter
As noted earlier, petitioner relied heavily in this proceeding on the the obviously serious condition of Catherine Acosta which was
testimony on cross-examination of the expert witnesses for the evident right after surgery. This they failed or refused to do so.
prosecution to show that blood poisoning resulting from a
ruptured appendix could also be responsible for the patient's
death. Still another circumstance of which account must be taken is that
both petitioner and Dr. Madrid failed to inform the parents of their
minor patient of the nature of her illness, or to explain to them
No suggestion has been made that the rupture of the patient's either during the surgery 
occurred prior to surgery. After her blood sample was examined, (if feasible) or at any time after the surgery, the events which
the patient was merely diagnosed as a case of appendicitis, comprised the dramatic deterioration of her condition
without further elaboration. 40 No intensive preoperative immediately after surgery as compared with her pre-surgery
preparations, like the immediate administration of antibiotics, condition. To give a truthful explanation to the parents was a duty
was thereafter undertaken on the patient. This is a standard imposed upon them by the canons of their profession. 51 Petitioner
procedure for patients who are, after being diagnosed, suspected should have explained to Catherine's parents the actual
of suffering from a perforated appendix and consequent circumstances surrounding Catherine's death, how, in other
peritonitis. 41 The mother also testified that petitioner words, a simple appendectomy procedure upon an ambulatory
anesthesiologist merely injected a drug, "pre-anesthesia" intended patient could have led to such fatal consequences.
to put the patient to sleep, into the container of fluids being
administered to her daughter intravenously at her room, prior to
surgery. 42 We note further that the surgeon Dr. Madrid was forty- By way of resume, in the case at bar, we consider that the chain of
five minutes late in arriving at the operating circumstances above noted, namely: (1) the failure of petitioner
theater. 43 Considering that delay in treatment of appendicitis and Dr. Madrid to appreciate the serious post-surgery condition of
increases the morbidity of the patient, 44 Dr. Madrid's conduct can their patient and to monitor her condition and provide close
only be explained by a pre-operative diagnosis on his part that the patient care to her; (2) the summons of petitioner by Dr. Madrid
condition of appendicitis was not yet attended by complications and the cardiologist after the patient's heart attack on the very
(i.e., a ruptured appendix and peritonitis). evening that the surgery was completed; (3) the low level of care
and diligence exhibited by petitioner in failing to correct Dr.
Madrid's prescription of Nubain for post-operative pain; (4) the
The above circumstances do strongly indicate that the rupture of extraordinary failure or refusal of petitioner and Dr. Madrid to
the patient's appendix occurred during the appendectomy inform the parents of Catherine Acosta of her true condition after
procedure, that is, at a time and place — the operating room — surgery, in disregard of the requirements of the Code of Medical
where the two (2) accused were in full control of the situation and Ethics; and (5) the failure of petitioner and Dr. Madrid to prove
could determine decisively what needed to be done in respect of that they had in fact exercised the necessary and appropriate
the patient. 45 This circumstance must be considered in degree of care and diligence to prevent the sudden decline in the
conjunction with other related circumstances which the condition of Catherine Acosta and her death three (3) days later,
prosecution had proven: that the patient was ambulatory when leads the Court to the conclusion, with moral certainty, that
brought to the operating room; 46 that she left the operating room petitioner and Dr. Madrid were guilty of simple negligence
two (2) hours later in obviously serious condition; and that an resulting in homicide.
appendectomy accompanied or followed by sustained antibiotic
treatment is a fairly common and generally accepted medical
procedure for dealing with ruptured appendix and peritonitis, 47 a In addition to the main arguments raised by petitioner earlier, he
fact of which judicial note may be taken. also raised an ancillary, constitutional claim of denial of due
process. He contends that he was deprived of his right to have
competent representation at trial, and to have his cause adequately
heard, because his counsel of record, Atty. Jose B. Puerto, was G.R. No. 118231 July 5, 1996
"incompetent" and exhibited "gross negligence" by manifesting an
intent to file a demurrer to the evidence, in failing to present
evidence in his behalf and in omitting to file a defense DR. VICTORIA L. BATIQUIN and ALLAN
memorandum for the benefit of  BATIQUIN, petitioners, 
Judge Yuzon, after the latter took over the case at the end of trial vs.
and before the Judge rendered his decision. 52Petitioner submits he COURT OF APPEALS, SPOUSES QUEDO D. ACOGIDO
is entitled to a new trial. 53 and FLOTILDE G. VILLEGAS, respondents.

These contentions do not persuade. An examination of the record  

indicates that Atty. Puerto represented petitioner during trial with
reasonable competence. Except for the two hearing sessions when DAVIDE, JR., J.:p
witnesses Domingo Acosta was cross-examined and recross-
examined by Atty. Puerto, petitioner was present during all the Throughout history, patients have consigned their fates and lives
sessions when the other prosecution witnesses were presented and to the skill of their doctors. For a breach of this trust, men have
during which Atty. Puerto extensively cross-examined them in been quick to demand retribution. Some 4,000 years ago, the
behalf of petitioner and Dr. Madrid. This counsel elicited from the Code of Hammurabi1 then already provided: "If a physician make
two (2) expert witnesses for the prosecution testimony favorable a deep incision upon a man with his bronze lancet and cause the
to petitioner and which was relied upon by the latter in this man's death, or operate on the eye socket of a man with his bronze
proceeding. 54 The record further indicates that if petitioner indeed lancet and destroy the man's eyes, they shall cut off his
entertained substantial doubts about the capability of Atty. Puerto, hand." 2 Subsequently, Hippocrates3wrote what was to become
he could have easily terminated the services of that counsel and part of the healer's oath: "I will follow that method of treatment
retained a new one, or sought from the trial court the appointment which according to my ability and judgment, I consider for the
of counsel  benefit of my patients, and abstain from whatever is deleterious
de oficio, during the ample opportunity given from the time Atty. and mischievous. . . . While I continue to keep this oath
Puerto manifested his intent to file a demurrer on 16 October unviolated may it be granted me to enjoy life and practice the art,
1985, to the submission of the case for decision on 25 June 1986 respected by all men at all times but should I trespass and violate
and before the promulgation of judgment on 19 September this oath, may the reverse be my lot." At present, the primary
1986. 55 During all this time, petitioner could have obtained leave objective of the medical profession if the preservation of life and
of court to present evidence in his behalf in lieu of a demurrer, or maintenance of the health of the people. 4
to submit a memorandum for the defense. After promulgation of
the judgment of conviction, petitioner did not seek a new trial, but
permitted Atty. Puerto to obtain leave from the trial court to Needless to say then, when a physician strays from his sacred
continue on bail during the pendency of the proceedings before duty and endangers instead the life of his patient, he must be
the Court of Appeals. 56 Indeed, petitioner replaced  made to answer therefor. Although society today cannot and will
Atty. Puerto as counsel only upon institution of the present not tolerate the punishment meted out by the ancients, neither will
petition. 57 it and this Court, as this case would show, let the act go
uncondemned.
Petitioner's constitutional objection is plainly an afterthought.
The petitioners appeal from the decision 5 of the Court of Appeals
of 11 May 1994 in CA-G.R. CV No. 30851, which reversed the
WHEREFORE, the Decision of the Court of Appeals dated 28 decision6 of 21 December 1990 of Branch 30 of the Regional
November 1988 is hereby AFFIRMED, subject only to the Trial Court (RTC) of Negros Oriental in Civil Case No. 9492.
modification that the indemnity for the death of Catherine Acosta
is hereby increased to P50,000.00, in line with current
jurisprudence. 58 The facts, as found by the trial court, are as follows:

SO ORDERED. Dr. Batiquin was a Resident Physician at the Negros

Oriental Provincial Hospital, Dumaguete City from
January 9, 1978 to September 1989. Between 1987 and
September, 1989 she was also the Actg. Head of the
Department of Obstetrics and Gynecology at the said
Hospital.

Mrs. Villegas is a married woman who submitted to Dr.

Batiquin for prenatal care as the latter's private patient
sometime before September 21, 1988.

In the morning of September 21, 1988 Dr.

Batiquin, with the assistance of Dr. Doris
Teresita Sy who was also a Resident
Physician at the same Hospital, C.I. and O.R.
Nurse Arlene Diones and some student nurses
performed a simple caesarean section on Mrs.
Villegas at the Negros Oriental Provincial
Hospital and after 45 minutes Mrs. Villegas
delivered her first child, Rachel Acogido, at
about 11:45 that morning. Thereafter, Plaintiff
remained confined at the Hospital until
September 27, 1988 during which period of The piece of rubber allegedly found near private respondent
confinement she was regularly visited by Dr. Flotilde Villegas's uterus was not presented in court, and although
Batiquin. On September 28, 1988 Mrs. Dr. Ma. Salud Kho Testified that she sent it to a pathologist in
Villegas checked out of the Hospital. . . and Cebu City for examination,8 it was not mentioned in the
on that same day she paid Dr. Batiquin, thru pathologist's Surgical Pathology Report.9
the latter's secretary, the amount of P1,500.00
as "professional fee". . . . Aside from Dr. Kho's testimony, the evidence which mentioned
the piece of rubber are a Medical Certificate, 10 a Progress
Soon after leaving the Hospital Mrs. Villegas Record,11 an Anesthesia Record,12 a Nurse's Record,13 and a
began to suffer abdominal pains and Physician's Discharge Summary.14 The trial court, however,
complained of being feverish. She also regarded these documentary evidence as mere hearsay, "there
gradually lost her appetite, so she consulted being no showing that the person or persons who prepared them
Dr. Batiquin at the latter's polyclinic who are deceased or unable to testify on the facts therein stated. . . .
prescribed for her certain medicines. . . which Except for the Medical Certificate (Exhibit "F"), all the above
she had been taking up to December, 1988. documents were allegedly prepared by persons other than Dr.
Kho, and she merely affixed her signature on some of them to
In the meantime, Mrs. Villegas was given a express her agreement thereto. . . ." 15 The trial court also refused
Medical Certificate by Dr. Batiquin on to give weight to Dr. Kho's testimony regarding the subject piece
October 31, 1988. . . certifying to her physical of rubber as Dr. Kho "may not have had first-hand knowledge"
fitness to return to her work on November 7, thereof,16 as could be gleaned from her statement, thus:
1988. So, on the second week of November,
1988 Mrs. Villegas returned to her work at the A . . . I have heard
Rural Bank of Ayungon, Negros Oriental. somebody that [sic] says
[sic] there is [sic] a
The abdominal pains and fever kept on foreign body that goes
recurring and bothered Mrs. Villegas no end with the tissues but
despite the medications administered by Dr. unluckily I don't know
Batiquin. When the pains became unbearable where the rubber was. 17
and she was rapidly losing weight she
consulted Dr. Ma. Salud Kho at the Holy The trial court deemed vital Dr. Victoria Batiquin's testimony that
Child's Hospital in Dumaguete City on when she confronted Dr. Kho regarding the piece of rubber, "Dr.
January 20, 1989. Kho answered that there was rubber indeed but that she threw it
away."18 This statement, the trial court noted, was never denied
The evidence of Plaintiffs show that when Dr. nor disputed by Dr. Kho, leading it to conclude:
Ma. Salud Kho examined Mrs. Villegas at the
Holy Child's Hospital on January 20, 1989 There are now two different versions on the
she found Mrs. Villegas to be feverish, pale whereabouts of that offending "rubber" — (1)
and was breathing fast. Upon examination she that it was sent to the Pathologist in Cebu as
felt an abdominal mass one finger below the testified to in Court by Dr. Kho and (2) that
umbilicus which she suspected to be either a Dr. Kho threw it away as told by her to
tumor of the uterus or an ovarian cyst, either Defendant. The failure of the Plaintiffs to
of which could be cancerous. She had an x- reconcile these two different versions serve
ray taken of Mrs. Villegas' chest, abdomen only to weaken their claim against Defendant
and kidney. She also took blood tests of Batiquin.19
Plaintiff. A blood count showed that Mrs.
Villegas had [an] infection inside her All told, the trial court held in favor of the petitioners herein.
abdominal cavity. The results of all those
examinations impelled Dr. Kho to suggest
that Mrs. Villegas submit to another surgery The Court of Appeals reviewed the entirety of Dr. Kho's
to which the latter agreed. testimony and, even without admitting the private respondents'
documentary evidence, deemed Dr. Kho's positive testimony to
definitely establish that a piece of rubber was found near private
When Dr. Kho opened the abdomen of Mrs. respondent Villegas's uterus. Thus, the Court of Appeals reversed
Villegas she found whitish-yellow discharge the decision of the trial court, holding:
inside, an ovarian cyst on each of the left and
right ovaries which gave out pus, dirt and pus
behind the uterus, and a piece of rubber 4. The fault or negligence of appellee Dr. Batiquin is
material on the right side of the uterus established by preponderance of evidence. The trial court
embedded on [sic] the ovarian cyst, 2 inches itself had narrated what happened to appellant Flotilde after
by 3/4 inch in size. This piece of rubber the caesarean operation made by appellee doctor. . . . After
material which Dr. Kho described as a the second operation, appellant Flotilde became well and
"foreign body" looked like a piece of a healthy. Appellant Flotilde's troubles were caused by the
"rubber glove". . . and which is [sic] also infection due to the "rubber" that was left inside her
"rubber-drain like". . . . It could have been a abdomen. Both appellant; testified that after the operation
torn section of a surgeon's gloves or could made by appellee doctor, they did not go to any other
have come from other sources. And this doctor until they finally decided to see another doctor in
foreign body was the cause of the infection of January, 1989 when she was not getting any better under
the ovaries and consequently of all the the care of appellee Dr. Batiquin. . . . Appellee Dr. Batiquin
discomfort suffered by Mrs. Villegas after her admitted on the witness stand that she alone decided when
delivery on September 21, 1988.7 to close the operating area; that she examined the portion
she operated on before closing the same. . . Had she The petitioners contend that the Court of Appeals misappreciated
exercised due diligence, appellee Dr. Batiquin would have the following portion of Dr. Kho's testimony:
found the rubber and removed it before closing the
operating area.20 Q What is the purpose of the examination?

The appellate court then ruled: A Just in case, I was just thinking at the back of my
mind, just in case this would turn out to be a medico-
Appellants' evidence show[s] that they paid a legal
total of P17,000.00 [deposit of P7,100.00 case, I have heard somebody that [sic] says [sic] there 
(Exh. G-1-A) plus hospital and medical is [sic] a
expenses together with doctor's fees in the foreign body that goes with the tissues but unluckily I 
total amount P9,900.00 (Exhs. G and G-2)] don't know where the rubber was. It was not in the
for the second operation that saved her life. Lab, it was not in Cebu. 23 (emphasis supplied)

For the miseries appellants endured for more The petitioners prefer the trial court's interpretation of
than three (3) months, due to the negligence the above testimony, i.e., that Dr. Kho's knowledge of
of appellee Dr. Batiquin they are entitled to the piece of rubber was based on hearsay. The Court of
moral damages in the amount of P100,000.00; Appeals, on the other hand, concluded that the
exemplary damages in the amount of underscored phrase was taken out of context by the trial
P20,000.00 and attorney's fees in the amount court. According to the Court of Appeals, the trial court
of P25,000.00. should have likewise considered the other portions of
Dr. Kho's testimony, especially the following:
The fact that appellant Flotilde can no longer
bear children because her uterus and ovaries Q So you did actually conduct the operation on her?
were removed by Dr. Kho is not taken into
consideration as it is not shown that the A Yes, I did.
removal of said organs were the direct result
of the rubber left by appellee Dr. Batiquin
near the uterus. What is established is that the Q And what was the result?
rubber left by appellee caused infection,
placed the life of appellant Flotilde in A Opening up her abdomen, there was whitish-yellow
jeopardy and caused appellant fear, worry and discharge inside the abdomen, there was an ovarian cyst
anxiety. . . . on the left and side and there was also an ovarian cyst on
the right which, on opening up or freeing it up from the
WHEREFORE, the appealed judgment, uterus, turned out to be pus. Both ovaries turned out. . . to
dismissing the complaint for damages is have pus. And then, cleaning up the uterus, at the back of
REVERSED and SET ASIDE. Another the uterus it was very dirty, it was full of pus. And there
judgment is hereby entered ordering was a [piece of] rubber, we found a [piece of] rubber on
defendants-appellees to pay plaintiffs- the right 
appellants the amounts of P17,000.00 as and side. 24
for actual damages; P100,000.00 as and for
moral damages; P20,000.00 as and for We agree with the Court of Appeals. The phrase relied upon by
exemplary damages; and P25,000.00 as and the trial court does not negate the fact that Dr. Kho saw a piece of
for attorney's fees plus the costs of litigation. rubber in private respondent Villegas's abdomen, and that she sent
it to a laboratory and then to Cebu City for examination by a
SO ORDERED.21 pathologist.25 Not even the Pathologist's Report, although devoid
of any mention of a piece of rubber, could alter what Dr. Kho
saw. Furthermore, Dr. Kho's knowledge of the piece of rubber
From the above judgment, the petitioners appealed to this Court could not be based on other than first-hand knowledge for, as she
claiming that the appellate court: (1) committed grave abuse of asserted before the trial court:
discretion by resorting to findings of fact not supported by the
evidence on record, and (2) exceeded its discretion, amounting to
lack or excess of jurisdiction, when it gave credence to Q But you are sure you have seen [the piece of rubber]?
testimonies punctured with contradictions and falsities.
A Oh yes. I was not the only one who saw it. 26
The private respondents commented that the petition raised only
questions of fact, which were not proper for review by this Court. The petitioners emphasize that the private respondents never
reconciled Dr. Kho's testimony with Dr. Batiquin's claim on the
While the rule is that only questions of law may be raised in a witness stand that when Dr. Batiquin confronted Dr. Kho about
petition for review on certiorari, there are exceptions, among the foreign body, the latter said that there was a piece of rubber
which are when the factual findings of the trial court and the but that she threw it away. Although hearsay, Dr. Batiquin's claim
appellate court conflict, when the appealed decision is clearly was not objected to, and hence, the same is admissible 27 but it
contradicted by the evidence on record, or when the appellate carries no probative value. 28 Nevertheless, assuming otherwise,
court misapprehended the facts.22 Dr. Batiquin's statement cannot belie the fact that Dr. Kho found a
piece of rubber near private respondent Villegas's uterus. And
even if we were to doubt Dr. Kho as to what she did to the piece
After deciphering the cryptic petition, we find that the focal point of rubber, i.e., whether she threw it away or sent it to Cebu City,
of the instant appeal is the appreciation of Dr. Kho's testimony. we are not justified in distrusting her as to her recovery of a piece
of rubber from private respondent Villegas's abdomen. On this
score, it is perfectly reasonable to believe the testimony of a evidence whereby negligence of [the] alleged wrongdoer
witness with respect to some facts and disbelieve his testimony may be inferred from [the] mere fact that [the] accident
with respect to other facts. And it has been aptly said that even happened provided [the] character of [the] accident and
when a witness is found to have deliberately falsified in some circumstances attending it lead reasonably to belief that in
material particulars, it is not required that the whole of his [the] absence of negligence it would not have occurred
uncorroborated testimony be rejected, but such portions thereof and that thing which caused injury is shown to have been
deemed worthy of belief may be credited.29 under [the] management and control of [the] alleged
wrongdoer. . . . Under [this] doctrine
It is here worth noting that the trial court paid heed to the . . . the happening of an injury permits an inference of
following portions of Dr. Batiquin's testimony: that no rubber negligence where plaintiff produces substantial evidence
drain was used in the operation, 30 and that there was neither any that [the] injury was caused by an agency or
tear on Dr. Batiquin's gloves after the operation nor blood smears instrumentality under [the] exclusive control and
on her hands upon removing her gloves.31 Moreover, the trial management of defendant, and that the occurrence [sic]
court pointed out that the absence of a rubber drain was was such that in the ordinary course of things would not
corroborated by Dr. Doris Sy, Dr. Batiquin's assistant during the happen if reasonable care had been used.
operation on private respondent Villegas.32 But the trial court
failed to recognize that the assertions of Drs. Batiquin and Sy x x x           x x x          x x x
were denials or negative testimonies. Well-settled is the rule that
positive testimony is stronger than negative testimony. 33 Of The doctrine of [r]es ipsa loquitur as a rule of
course, as the petitioners advocate, such positive testimony must evidence is peculiar to the law of negligence which
come from a credible source, which leads us to the second recognizes that prima facie negligence may be
assigned error. established without direct proof and furnishes a
substitute for specific proof of negligence. The
While the petitioners claim that contradictions and falsities doctrine is not a rule of substantive law, but merely
punctured Dr. Kho's testimony, a regarding of the said testimony a mode of proof or a mere procedural convenience.
reveals no such infirmity and establishes Dr. Kho as a credible The rule, when applicable to the facts and
witness. Dr. Kho was frank throughout her turn on the witness circumstances of a particular case, is not intended to
stand. Furthermore, no motive to state any untruth was ever and does not dispense with the requirement of proof
imputed against Dr. Kho, leaving her trustworthiness of culpable negligence on the party charged. It
unimpaired.34 The trial court's following declaration shows that merely determines and regulates what shall
while it was critical of the lack of care with which Dr. Kho be prima facie evidence thereof and facilitates the
handled the piece of rubber, it was not prepared to doubt Dr. burden of plaintiff of proving a breach of the duty of
Kho's credibility, thus only supporting our appraisal of Dr. Kho's due care. The doctrine can be invoked when and
trustworthiness: only when, under the circumstances involved, direct
evidence is absent and not readily available. 36
This is not to say that she was less than honest when she
testified about her findings, but it can also be said that she did In the instant case, all the requisites for recourse to the doctrine
not take the most appropriate precaution to preserve that are present. First, the entire proceedings of the caesarean section
"piece of rubber" as an eloquent evidence of what she would were under the exclusive control of Dr. Batiquin. In this light, the
reveal should there be a "legal problem" which she claim[s] to private respondents were bereft of direct evidence as to the actual
have anticipated.35 culprit or the exact cause of the foreign object finding its way into
private respondent Villegas's body, which, needless to say, does
Considering that we have assessed Dr. Kho to be a credible not occur unless through the intersection of negligence. Second,
witness, her positive testimony [that a piece of rubber was indeed since aside from the caesarean section, private respondent
found in private respondent Villega's abdomen] prevails over the Villegas underwent no other operation which could have caused
negative testimony in favor of the petitioners. the offending piece of rubber to appear in her uterus, it stands to
reason that such could only have been a by-product of the
caesarean section performed by Dr. Batiquin. The petitioners, in
As such, the rule of res ipsa loquitur comes to fore. This Court this regard, failed to overcome the presumption of negligence
has had occasion to delve into the nature and operation of this arising from resort to the doctrine of res ipsa loquitur. Dr.
doctrine: Batiquin is therefore liable for negligently leaving behind a piece
of rubber in private respondent Villegas's abdomen and for all the
This doctrine [res ipsa loquitur] is stated thus: adverse effects thereof.
"Where the thing which causes injury is
shown to be under the management of the As a final word, this Court reiterates its recognition of the vital
defendant, and the accident is such as in the role the medical profession plays in the lives of the people, 3 7 and
ordinary course of things does not happen in the State's compelling interest to enact measures to protect the
those who have the management use proper public from "the potentially deadly effects of incompetence and
care, it affords reasonable evidence, in the ignorance in those who would undertake to treat our bodies and
absence of an explanation by the defendant, minds for disease or trauma." 38 Indeed, a physician is bound to
that the accident arose from want of care." Or serve the interest of his patients "with the greatest of solicitude,
as Black's Law Dictionary puts it: giving them always his best talent and skill." 39 Through her
tortious conduct, the petitioner endangered the life of Flotilde
Res ipsa loquitur. The thing speaks for itself. Rebuctable Villegas, in violation of her profession's rigid ethical code and in
presumption or inference that defendant was negligent, contravention of the legal standards set forth for professionals, in
which arises upon proof that [the] instrumentality causing general,40 and members of the medical profession,41 in particular.
injury was in defendant's exclusive control, and that the
accident was one which ordinary does not happen in
absence of negligence. Res ipsa loquitur is [a] rule of
WHEREFORE, the challenged decision of 11 May 1994 of the GARCIA-RUEDA vs. PASCASIO G.R. No. 118141.
Court of Appeals in CA-G.R. CV No. 30851 is hereby September 5, 1997
AFFIRMED in toto.

Costs against the petitioners.

SO ORDERED. FACTS:

Florencio V. Rueda, husband of petitioner Leonila Garcia-Rueda,

underwent surgical operation at the UST hospital for the removal
of a stone blocking his ureter. He was attended by Dr. Domingo
Antonio, Jr. who was the surgeon, while Dr. ErlindaBalatbat-
Reyes was the anaesthesiologist. Six hours after the surgery,
however, Florencio died of complications of “unknown cause,”
according to officials of the UST Hospital.

Not satisfied with the findings of the hospital, petitioner requested

the National Bureau of Investigation (NBI) to conduct an autopsy
on her husband’s body.Consequently, the NBI ruled that
Florencio’s death was due to lack of care by the attending
physician in administeringanaesthesia. Pursuant to its findings,
the NBI recommended that Dr. Domingo Antonio and Dr.
ErlindaBalatbat-Reyes be charged for Homicide through Reckless
Imprudence. The case was initially assigned to Prosecutor
Antonio M. Israel, who had to inhibit himself because he was
related to the counsel of one of the doctors. The case was re-
raffled to Prosecutor Norberto G. Leono who was, however,
disqualified on motion of the petitioner. The case was then
referred to Prosecutor Ramon O. Carisma, who issued a resolution
recommending that only Dr. Reyes be held criminally liable and
that the complaint against Dr. Antonio be dismissed.

Assistant City Prosecutor Josefina Santos Sioson, recommended

that the case be re-raffled on the ground that Prosecutor Carisma
was partial to the petitioner. Thus, the case was transferred to
Prosecutor Leoncia R. Dimagiba, who endorsed that the
complaint against Dr. Reyes be dismissed and instead, a
corresponding information be filed against Dr. Antonio. Petitioner
filed a motion for reconsideration, questioning the findings of
Prosecutor Dimagiba. Pending the resolution of petitioner’s
motion for reconsideration regarding Prosecutor Dimagiba’s
resolution, the investigative “pingpong” continued when the case
was again assigned to another prosecutor, who recommended that
Dr. Reyes be included in the criminal information of Homicide
through Reckless Imprudence. While the recommendation of
Prosecutor Gualberto was pending, the case was transferred to
Senior State Prosecutor Gregorio A. Arizala, who resolved to
exonerate Dr. Reyes from any wrongdoing, a resolution which
was approved by both City Prosecutor Porfirio G. Macaraeg and
City Prosecutor Jesus F. Guerrero.

Aggrieved, petitioner filed graft charges specifically for violation

of Section 3(e) of Republic Act No. 3019 against Prosecutors
Guerrero, Macaraeg, and Arizala for manifest partiality in favor
of Dr. Reyes before the Office of the Ombudsman. However, the
Ombudsman issued the assailed resolution dismissing the
complaint for lack of evidence. In fine, petitioner assails the
exercise of the discretionary power of the Ombudsman to review
the recommendations of the government prosecutors and to
approve and disapprove the same. Petitioner faults the
Ombudsman for, allegedly ingrave abuse of discretion, refusing to
find that there exists probable cause to hold public respondent
City Prosecutors liable for violation of Section 3(e) of R.A. No.
3019.
ISSUE: allegation of negligence is not entirely baseless. Moreover, the
Whether there was negligence on the part of the physicians which NBI deduced that the attending surgeons did not conduct the
resulted to the death of Petitioner’s husband necessary interview of the patient prior to the operation. It appears
that the cause of the death of the victim could have been averted
had the proper drug been applied to cope with the symptoms of
HELD: malignant hyperthermia. Also, we cannot ignore the fact that an
antidote was readily available to counteract whatever deleterious
effect the anaesthesia might produce. Why these precautionary
measures were disregarded must be sufficiently explained.
Yes. No less than the NBI pronounced after conducting an
autopsy that there was indeed negligence on the part of the
attending physicians in administering the anaesthesia

RATIO:
LEONILA GARCIA-RUEDA, Petitioner, v. WILFREDO L.
PASCASIO, RAUL R. ARNAU, ABELARDO L.
The fact of want of competence or diligence is evidentiary in APORTADERA JR., Honorable CONDRADO M.
nature, the veracity of which can best be passed upon after a full- VASQUEZ, all of the Office of the Ombudsman; JESUS F.
blown trial for it is virtually impossible to ascertain the merits of a GUERRERO, PORFIRIO MACARAEG, and GREGORIO
medical negligence case without extensive investigation, research, A. ARIZALA, all of the Office of the City Prosecutor,
evaluation and consultations with medical experts. Clearly, the Manila, Respondents.
City Prosecutors are not in a competent position to pass judgment
on such a technical matter, especially when there are conflicting DECISION
evidence and findings. The bases of a party’s accusation and
defenses are better ventilated at the trial proper than at the ROMERO, J.:
preliminary investigation.

May this Court review the findings of the Office of the

Ombudsman? The general rule has been enunciated in Ocampo v.
There are four elements involved in medical negligence cases:
Ombudsman 1 which states:
duty, breach, injury and proximate causation.

In the exercise of its investigative power, this Court has

consistently held that courts will not interfere with the discretion
Evidently, when the victim employed the services of Dr. Antonio
of the fiscal or the Ombudsman to determine the specificity and
and Dr. Reyes, a physician-patient relationship was created. In
adequacy of the averments of the offense charged. He may
accepting the case, Dr. Antonio and Dr. Reyes in effect
dismiss the complaint forthwith if he finds it to be insufficient in
represented that, having the needed training and skill possessed by
form and substance or if he otherwise finds no ground to continue
physicians and surgeons practicing in the same field, they will
with the inquiry; or he may proceed with the investigation of the
employ such training, care and skill in the treatment of their
complaint if, in his view, it is in due and proper form.
patients.

Does the instant case warrant a departure from the foregoing

general rule? When a patient dies soon after surgery under
They have a duty to use at least the same level of care that any
circumstances which indicate that the attending surgeon and
other reasonably competent doctor would use to treat a condition
anaesthesiologist may have been guilty of negligence but upon
under the same circumstances. The breach of these professional
their being charged, a series of nine prosecutors toss the
duties of skill and care, or their improper performance, by a
responsibility of conducting a preliminary investigation to each
physician surgeon whereby the patient is injured in body or in
other with contradictory recommendations, ping-pong style,
health, constitutes actionable malpractice. Consequently, in the
perhaps the distraught widow is not to be blamed if she finally
event that any injury results to the patient from want of due care
decides to accuse the City Prosecutors at the end of the line for
or skill during the operation, the surgeons may be held answerable
partiality under the Anti-Graft and Corrupt Practices Act. Nor
in damages for negligence.
may she be entirely faulted for finally filing a petition before this
Court against the Ombudsman for grave abuse of discretion in
dismissing her complaint against said City Prosecutors on the
Moreover, in malpractice or negligence cases involving the ground of lack of evidence. Much as we sympathize with the
administration of anaesthesia, the necessity of expert testimony bereaved widow, however, this Court is of the opinion that the
and the availability of the charge of res ipsa loquitur to the general rule still finds application in instant case. In other words,
plaintiff, have been applied in actions against anaesthesiologist to the respondent Ombudsman did not commit grave abuse of
hold the defendant liable for the death or injury of a patient under discretion in deciding against filing the necessary information
excessive or improper anaesthesia. Essentially, it requires two- against public respondents of the Office of the City Prosecutor.
pronged evidence: evidence as to the recognized standards of the
medical community in the particular kind of case, and a showing
The following facts are borne out by the records.
that the physician in question negligently departed from this
standard in his treatment.
Florencio V. Rueda, husband of petitioner Leonila Garcia-Rueda,
underwent surgical operation at the UST hospital for the removal
Causal connection is discernible from the occurrence of the of a stone blocking his ureter. He was attended by Dr. Domingo
victim’s death after the negligent act of the anaesthesiologist in Antonio, Jr. who was the surgeon, while Dr. Erlinda Balatbat-
administering the anesthesia, a fact which, if confirmed, should Reyes was the anaesthesiologist. Six hours after the surgery,
warrant the filing of the appropriate criminal case. To be sure, the however, Florencio died of complications of unknown cause,
according to officials of the UST As protector of the people, the Office of the Ombudsman has the
Hospital.2chanroblesvirtuallawlibrary power, function and duty to act promptly on complaints filed in
any form or manner against public officials and to investigate any
Not satisfied with the findings of the hospital, petitioner requested act or omission of any public official when such act or omission
the National Bureau of Investigation (NBI) to conduct an autopsy appears to be illegal, unjust, improper or
on her husbands body. Consequently, the NBI ruled that inefficient. 5chanroblesvirtuallawlibrary
Florencios death was due to lack of care by the attending
physician in administering anaesthesia. Pursuant to its findings, While the Ombudsman has the full discretion to determine
the NBI recommended that Dr. Domingo Antonio and Dr. Erlinda whether or not a criminal case should be filed, this Court is not
Balatbat-Reyes be charged for Homicide through Reckless precluded from reviewing the Ombudsmans action when there is
Imprudence before the Office of the City Prosecutor. an abuse of discretion, in which case Rule 65 of the Rules of
Court may exceptionally be invoked pursuant to Section I, Article
During the preliminary investigation, what transpired was a VIII of the 1987 Constitution. 6chanroblesvirtuallawlibrary
confounding series of events which we shall try to disentangle.
The case was initially assigned to Prosecutor Antonio M. Israel, In this regard, grave abuse of discretion has been defined as where
who had to inhibit himself because he was related to the counsel a power is exercised in an arbitrary or despotic manner by reason
of one of the doctors. As a result, the case was re-raffled to of passion or personal hostility so patent and gross as to amount to
Prosecutor Norberto G. Leono who was, however, disqualified on evasion of positive duty or virtual refusal to perform a duty
motion of the petitioner since he disregarded prevailing laws and enjoined by, or in contemplation of
jurisprudence regarding preliminary investigation. The case was law. 7chanroblesvirtuallawlibrary
then referred to Prosecutor Ramon O. Carisma, who issued a
resolution recommending that only Dr. Reyes be held criminally From a procedural standpoint, it is certainly odd why the
liable and that the complaint against Dr. Antonio be dismissed. successive transfers from one prosecutor to another were not
sufficiently explained in the Resolution of the Ombudsman. Being
The case took another perplexing turn when Assistant City the proper investigating authority with respect to misfeasance,
Prosecutor Josefina Santos Sioson, in the interest of justice and non-feasance and malfeasance of public officials, the Ombudsman
peace of mind of the parties, recommended that the case be re- should have been more vigilant and assiduous in determining the
raffled on the ground that Prosecutor Carisma was partial to the reasons behind the buckpassing to ensure that no irregularity took
petitioner. Thus, the case was transferred to Prosecutor Leoncia R. place.
Dimagiba, where a volte face occurred again with the
endorsement that the complaint against Dr. Reyes be dismissed Whether such transfers were due to any outside pressure or
and instead, a corresponding information be filed against Dr. ulterior motive is a matter of evidence. One would have expected
Antonio. Petitioner filed a motion for reconsideration, questioning the Ombudsman, however, to inquire into what could hardly
the findings of Prosecutor Dimagiba. qualify as standard operating procedure, given the surrounding
circumstances of the case.
Pending the resolution of petitioners motion for reconsideration
regarding Prosecutor Dimagibas resolution, the investigative While it is true that a preliminary investigation is essentially
pingpong continued when the case was again assigned to another inquisitorial, and is often the only means to discover who may be
prosecutor, Eudoxia T. Gualberto, who recommended that Dr. charged with a crime, its function is merely to determine the
Reyes be included in the criminal information of Homicide existence of probable cause. 8 Probable cause has been defined as
through Reckless Imprudence. While the recommendation of the existence of such fact and circumstances as would excite the
Prosecutor Gualberto was pending, the case was transferred to belief, in a reasonable mind, acting on the facts within the
Senior State Prosecutor Gregorio A. Arizala, who resolved to knowledge of the prosecution, that the person charged was guilty
exonerate Dr. Reyes from any wrongdoing, a resolution which of the crime for which he was
was approved by both City Prosecutor Porfirio G. Macaraeg and prosecuted.9chanroblesvirtuallawlibrary
City Prosecutor Jesus F. Guerrero.
Probable cause is a reasonable ground of presumption that a
Aggrieved, petitioner filed graft charges specifically for violation matter is, or may be, well founded, such a state of facts in the
of Section 3(e) of Republic Act No. 3019 3 against Prosecutors mind of the prosecutor as would lead a person of ordinary caution
Guerrero, Macaraeg, and Arizala for manifest partiality in favor and prudence to believe, or entertain an honest or strong
of Dr. Reyes before the Office of the Ombudsman. However, on suspicion, that a thing is so. The term does not mean actual and
July 11, 1994, the Ombudsman issued the assailed resolution positive cause nor does it import absolute certainty. It is merely
dismissing the complaint for lack of evidence. based on opinion and reasonable belief. Thus, a finding of
probable cause does not require an inquiry into whether there is
In fine, petitioner assails the exercise of the discretionary power sufficient evidence to procure a conviction. It is enough that it is
of the Ombudsman to review the recommendations of the believed that the act or omission complained of constitutes the
government prosecutors and to approve and disapprove the same. offense charged. Precisely, there is a trial for the reception of
Petitioner faults the Ombudsman for, allegedly in grave abuse of evidence of the prosecution in support of the
discretion, refusing to find that there exists probable cause to hold charge.10chanroblesvirtuallawlibrary
public respondent City Prosecutors liable for violation of Section
3(e) of R.A. No. 3019. In the instant case, no less than the NBI pronounced after
conducting an autopsy that there was indeed negligence on the
Preliminarily, the powers and functions of the Ombudsman have part of the attending physicians in administering the
generally been categorized into the following: investigatory anaesthesia. 11 The fact of want of competence or diligence is
powers, prosecutory power, public assistance function, authority evidentiary in nature, the veracity of which can best be passed
to inquire and obtain information, and function to adopt, institute upon after a full-blown trial for it is virtually impossible to
and implement preventive measures. 4chanroblesvirtuallawlibrary ascertain the merits of a medical negligence case without
extensive investigation, research, evaluation and consultations
with medical experts. Clearly, the City Prosecutors are not in a anaesthesia might produce. 19 Why these precautionary measures
competent position to pass judgment on such a technical matter, were disregarded must be sufficiently explained.
especially when there are conflicting evidence and findings. The
bases of a partys accusation and defenses are better ventilated at The City Prosecutors were charged with violating Section 3(e) of
the trial proper than at the preliminary investigation. the Anti-Graft and Corrupt Practices Act which requires the
following facts:
A word on medical malpractice or negligence cases.
1. The accused is a public officer discharging administrative or
In its simplest terms, the type of lawsuit which has been called official functions or private persons charged in conspiracy with
medical malpractice or, more appropriately, medical negligence, them;
is that type of claim which a victim has available to him or her to
redress a wrong committed by a medical professional which has 2. The public officer committed the prohibited act during the
caused bodily harm. performance of his official duty or in relation to his public
position;
In order to successfully pursue such a claim, a patient must prove
that a health care provider, in most cases a physician, either failed 3. The public officer acted with manifest partiality, evident bad
to do something which a reasonably prudent health care provider faith or gross, inexcusable negligence; and
would have done, or that he or she did something that a
reasonably prudent provider would not have done; and that that
failure or action caused injury to the 4. His action caused undue injury to the Government or any
patient.12chanroblesvirtuallawlibrary private party, or gave any party any unwarranted benefit,
advantage or preference to such
parties. 20chanroblesvirtuallawlibrary
Hence, there are four elements involved in medical negligence
cases: duty, breach, injury and proximate causation.
Why did the complainant, petitioner in instant case, elect to
charge respondents under the above law?
Evidently, when the victim employed the services of Dr. Antonio
and Dr. Reyes, a physician-patient relationship was created. In
accepting the case, Dr. Antonio and Dr. Reyes in effect While a party who feels himself aggrieved is at liberty to choose
represented that, having the needed training and skill possessed by the appropriate weapon from the armory, it is with no little
physicians and surgeons practicing in the same field, they will surprise that this Court views the choice made by the complainant
employ such training, care and skill in the treatment of their widow.
patients.13 They have a duty to use at least the same level of care
that any other reasonably competent doctor would use to treat a To our mind, the better and more logical remedy under the
condition under the same circumstances. The breach of these circumstances would have been to appeal the resolution of the
professional duties of skill and care, or their improper City Prosecutors dismissing the criminal complaint to the
performance, by a physician surgeon whereby the patient is Secretary of Justice under the Department of Justices Order No.
injured in body or in health, constitutes actionable 223, 21 otherwise known as the 1993 Revised Rules on Appeals
malpractice.14 Consequently, in the event that any injury results to From Resolutions In Preliminary Investigations/Reinvestigations,
the patient from want of due care or skill during the operation, the as amended by Department Order No. 359, Section 1 of which
surgeons may be held answerable in damages for provides:
negligence.15chanroblesvirtuallawlibrary
Section 1. What May Be Appealed. - Only resolutions of the
Moreover, in malpractice or negligence cases involving the Chief State Prosecutor/Regional State Prosecutor/Provincial or
administration of anaesthesia, the necessity of expert testimony City Prosecutor dismissing a criminal complaint may be the
and the availability of the charge of res ipsa loquitur to the subject of an appeal to the Secretary of Justice except as
plaintiff, have been applied in actions against anaesthesiologists otherwise provided in Section 4 hereof.
to hold the defendant liable for the death or injury of a patient
under excessive or improper anaesthesia.16 Essentially, it requires What action may the Secretary of Justice take on the appeal?
two-pronged evidence: evidence as to the recognized standards of Section 9 of Order No. 223 states: The Secretary of Justice may
the medical community in the particular kind of case, and a reverse, affirm or modify the appealed resolution. On the other
showing that the physician in question negligently departed from hand, He may motu proprio or on motion of the appellee, dismiss
this standard in his treatment.17chanroblesvirtuallawlibrary outright the appeal on specified
grounds. 22chanroblesvirtuallawlibrary
Another element in medical negligence cases is causation which
is divided into two inquiries: whether the doctors actions in fact In exercising his discretion under the circumstances, the
caused the harm to the patient and whether these were the Ombudsman acted within his power and authority in dismissing
proximate cause of the patients injury. 18 Indeed here, a causal the complaint against the Prosecutors and this Court will not
connection is discernible from the occurrence of the victims death interfere with the same.
after the negligent act of the anaesthesiologist in administering the
anesthesia, a fact which, if confirmed, should warrant the filing of
the appropriate criminal case. To be sure, the allegation of WHEREFORE, in view of the foregoing, the instant petition is
negligence is not entirely baseless. Moreover, the NBI deduced DISMISSED, without prejudice to the filing of an appeal by the
that the attending surgeons did not conduct the necessary petitioner with the Secretary of Justice assailing the dismissal of
interview of the patient prior to the operation. It appears that the her criminal complaint by the respondent City Prosecutors. No
cause of the death of the victim could have been averted had the costs.
proper drug been applied to cope with the symptoms of malignant
hyperthermia. Also, we cannot ignore the fact that an antidote was SO ORDERED.
readily available to counteract whatever deleterious effect the
Cruz vs Court of Appeals
GR No. 122445 November 18, 1997

Facts: On March 22, 1991, prosecution witness, Rowena Umali

de Ocampo, accompanied her mother to the Perpetual Help Clinic
and General Hospital situated in Balagtas Street, San Pablo City,
Laguna. They arrived at the said hospital at around 4:30 in the
afternoon of the same day. Prior to March 22, 1991, Lydia was
examined by the petitioner who found a “Myoma” in her uterus,
and scheduled her for a hysterectomy operation on March 23,
1991. Rowena and her mother slept in the clinic on the evening of
March 22, 1991 as the latter was to be operated on the next day at
1pm. According to Rowena, she noticed that the clinic was untidy
and the windows and the floor were very dusty prompting her to
ask the attendant fora rag to wipe the window and floor with.
Prior to the operation, Rowena tried to convince her mother to not
proceed with the operation and even asked petitioner for it to be
postponed, however it still pushed through after the petitioner told
Lydia that operation must be done as scheduled. During the
operation, the assisting doctor of the petitioner, Dr. Ercillo went
out of the operating room and asked that tagmet ampules be
bought which was followed by another instruction to buy a bag of
blood. After the operation, when Lydia came out of the OR,
another bag of blood was requested to be bought, however, the
same was not bought due to unavailability of type A from the
blood bank. Thereafter a person arrived to donate blood which
was later transferred to Lydia. Rowena then noticed her mother,
who was attached to an oxygen tank, gasping for breathe
apparently, the oxygen tank is empty, so her husband and
petitioner’s driver bought an oxygen. Later, without the
knowledge of Lydia’s relatives,she was decided by the doctors to
be transferred to San Pablo District Hospital were she was
supposed to be re-operated. After Lydia experienced shocks, she
died.

Issue: Whether or not petitioner has been negligent which caused

the death of Lydia Umali.

Held: Yes. Whether or not a physician has committed an

“inexcusable lack of precaution” in the treatment of his patient to
be determined according to the standard of care observed by other
members of the profession in good standing under similar
circumstances bearing in mind the advanced state of the
profession at the time of treatment or the present state of medical
science. A doctor in effect represents that, having the needed
training and skill possessed by physicians and surgeons practicing
in the same field, he will employ such training, care and skill in
the treatment of his patients. He therefore has a duty to use at least
the same level of care that any other reasonably competent doctor
would use to treat a condition under the same circumstances. It is
in this aspect of medical malpractice that expert testimony is
essential to establish not only the standard of care of the
profession but also that the physician’s conduct in the treatment
and care falls below such standard. Further, in as much as the
causes of the injuries involved in malpractice actions are
determinable only in the light of scientific knowledge, it has been
recognized that expert testimony is usually necessary to the
conclusion as to causation.

In litigations involving medical negligence, the plaintiff has the

burden of establishing appellant’s negligence and for a reasonable
conclusion of negligence, there must be proof of breach of duty
on the part of the surgeon as well as  causal connection of such
breach and the resulting death of his patient.

In order that there may be recovery for an injury, however, it must

be shown that the injury for which recovery is sought must be
legitimate consequence of the wrong done; the connection the attending anaesthesiologist and surgeon,
between the negligence and the injury must be a direct and natural respectively, did then and there, in a
reference of events, unbroken by intervening efficient causes. In negligence (sic), careless, imprudent, and
other words, the negligence must be the proximate cause of the incompetent manner, and failing to supply or
injury. For negligence, no matter what it consists, cannot create a store sufficient provisions and facilities
right of action unless it is the proximate cause of the injury necessary to meet any and all exigencies apt
complained of and the proximate cause of an injury is that cause, to arise before, during and/or after a surgical
which in natural and continuous sequence, unbroken by any operation causing by such negligence,
efficient intervening cause, produces the injury and without which carelessness, imprudence, and incompetence,
the result would have occurred. and causing by such failure, including the lack
of preparation and foresight needed to avert a
The elements of reckless imprudence are: tragedy, the untimely death of said Lydia
Umali on the day following said surgical
operation. 5
1. That the offender does or fails to do an act;
2. That the doing or the failure to do that act is voluntary;
3. That it be without malice; Trial ensued after both the petitioner and Dr. Lina Ercillo pleaded
4. That material damage results from the reckless not guilty to the above-mentioned charge. On March 4, 1994, the
imprudence; and Municipal Trial Court in Cities (MTCC) of San Pablo City
5. That there is inexcusable lack of precaution on the part rendered a decision, the dispositive portion of which is hereunder
of the offender, taking into consideration his quoted as follows:
employment or occupation, degree of intelligence,
physical condition, and other circumstances regarding WHEREFORE, the court finds the accused
persons, time, and place. Dra. Lina Ercillo not guilty of the offense
charged for insufficiency of evidence while
The possible causes of hemorrhage during an operation are: 1.) her co-accused Dra. Ninevetch Cruz is hereby
the failure of the surgeon to tie or suture a cut blood vessel; 2.) held responsible for the death of Lydia Umali
allowing a cut blood vessel to get out of control; 3.) the on March 24, 1991, and therefore guilty under
subsequent loosening of the tie or suture applied to a cut blood Art. 365 of the Revised Penal Code, and she
vessel; and 4.)and a clotting defect known as DIC. is hereby sentenced to suffer the penalty of 2
months and 1 day imprisonment of arresto
mayor with costs. 6
G.R. No. 122445 November 18, 1997
The petitioner appealed her conviction to the Regional
DR. NINEVETCH CRUZ, petitioner,  Trial Court (RTC) which affirmed in toto the decision
vs. of the MTCC 7 prompting the petitioner to file a petition
COURT OF APPEALS and LYDIA UMALI, respondents. for review with the Court of Appeals but to no avail.
Hence this petition for review on certiorari assailing the
decision promulgated by the Court of Appeals on
October 24, 1995 affirming petitioner's conviction with
FRANCISCO, J.: modification that she is further directed to pay the heirs
of Lydia Umali P50,000.00 as indemnity for her death.8

Doctors are protected by a special rule of law. They are not

guarantors of care. They do not even warrant a good result. They In substance, the petition brought before this Court
are not insurers against mishaps or unusual consequences. raises the issue of whether or not petitioner's conviction
Furthermore they are not liable for honest mistakes of judgment . . of the crime of reckless imprudence resulting in
. 1 homicide, arising from an alleged medical malpractice,
is supported by the evidence on record.

The present case against petitioner is in the nature of a medical

malpractice suit, which in simplest terms is the type of claim First the antecedent facts.
which a victim has available to him or her to redress a wrong
committed by a medical professional which has caused bodily On March 22, 1991, prosecution witness, Rowena Umali De
harm. 2 In this jurisdiction, however, such claims are most often Ocampo, accompanied her mother to the Perpetual Help Clinic
brought as a civil action for damages under Article 2176 of the and General Hospital situated in Balagtas Street, San Pablo City,
Civil Code, 3 and in some instances, as a criminal case under Laguna. They arrived at the said hospital at around 4:30 in the
Article 365 of the Revised Penal Code 4 with which the civil afternoon of the same day. 9 Prior to
action for damages is impliedly instituted. It is via the latter type March 22, 1991, Lydia was examined by the petitioner who found
of action that the heirs of the deceased sought redress for the a "myoma" 10 in her uterus, and scheduled her for a hysterectomy
petitioner's alleged imprudence and negligence in treating the operation on March 23,
deceased thereby causing her death. The petitioner and one Dr. 1991. 11 Rowena and her mother slept in the clinic on the evening
Lina Ercillo who was the attending anaesthesiologist during the of March 22, 1991 as the latter was to be operated on the next day
operation of the deceased were charged with "reckless at 1:00 o'clock in the afternoon. 12 According to Rowena, she
imprudence and negligence resulting to (sic) homicide" in an noticed that the clinic was untidy and the window and the floor
information which reads: were very dusty prompting her to ask the attendant for a rag to
wipe the window and the floor with. 13 Because of the untidy state
That on or about March 23, 1991, in the City of the clinic, Rowena tried to persuade her mother not to proceed
of San Pablo, Republic of the Philippines and with the operation. 14 The following day, before her mother was
within the jurisdiction of this Honorable wheeled into the operating room, Rowena asked the petitioner if
Court, the accused above named, being then the operation could be postponed. The petitioner called Lydia into
her office and the two had a conversation. Lydia then informed medical parlance that the "the abdomen of the
Rowena that the petitioner told her that she must be operated on person is a temple of surprises" because you
as scheduled. 15 do not know the whole thing the moment it
was open (sic) and surgeon must be prepared
Rowena and her other relatives, namely her husband, her sister for any eventuality thereof. The patient (sic)
and two aunts waited outside the operating room while Lydia chart which is a public document was not
underwent operation. While they were waiting, Dr. Ercillo went presented because it is only there that we
out of the operating room and instructed them to buy tagamet could determine the condition of the patient
ampules which Rowena's sister immediately bought. About one before the surgery. The court also noticed in
hour had passed when Dr. Ercillo came out again this time to ask Exh. "F-1" that the sister of the deceased
them to buy blood for Lydia. They bought type "A" blood from wished to postpone the operation but the
the St. Gerald Blood Bank and the same was brought by the patient was prevailed upon by Dra. Cruz to
attendant into the operating room. After the lapse of a few hours, proceed with the surgery. The court finds that
the petitioner informed them that the operation was finished. The Lydia Umali died because of the negligence
operating staff then went inside the petitioner's clinic to take their and carelessness of the surgeon Dra.
snacks. Some thirty minutes after, Lydia was brought out of the Ninevetch Cruz because of loss of blood
operating room in a stretcher and the petitioner asked Rowena and during the operation of the deceased for
the other relatives to buy additional blood for Lydia. evident unpreparedness and for lack of skill,
Unfortunately, they were not able to comply with petitioner's the reason why the patient was brought for
order as there was no more type "A" blood available in the blood operation at the San Pablo City District
bank. Thereafter, a person arrived to donate blood which was later Hospital. As such, the surgeon should answer
transfused to Lydia. Rowena then noticed her mother, who was for such negligence. With respect to Dra. Lina
attached to an oxygen tank, gasping for breath. Apparently the Ercillo, the anaesthesiologist, there is no
oxygen supply had run out and Rowena's husband together with evidence to indicate that she should be held
the driver of the accused had to go to the San Pablo District jointly liable with Dra. Cruz who actually did
Hospital to get oxygen. Lydia was given the fresh supply of the operation. 23
oxygen as soon as it arrived. 16 But at around 10:00 o'clock P.M.
she went into shock and her blood pressure dropped to 60/50. The RTC reiterated the abovementioned findings of the MTCC
Lydia's unstable condition necessitated her transfer to the San and upheld the latter's declaration of "incompetency, negligence
Pablo District Hospital so she could be connected to a respirator and lack of foresight and skill of appellant (herein petitioner) in
and further examined. 17 The transfer to the San Pablo District handling the subject patient before and after the operation." 24 And
Hospital was without the prior consent of Rowena nor of the other likewise affirming the petitioner's conviction, the Court of
relatives present who found out about the intended transfer only Appeals echoed similar observations, thus:
when an ambulance arrived to take Lydia to the San Pablo District
Hospital. Rowena and her other relatives then boarded a tricycle . . . While we may grant that the untidiness
and followed the ambulance. 18 and filthiness of the clinic may not by itself
indicate negligence, it nevertheless shows the
Upon Lydia's arrival at the San Pablo District Hospital, she was absence of due care and supervision over her
wheeled into the operating room and the petitioner and Dr. Ercillo subordinate employees. Did this unsanitary
re-operated on her because there was blood oozing from the condition permeate the operating room? Were
abdominal incision. 19 The attending physicians summoned Dr. the surgical instruments properly sterilized?
Bartolome Angeles, head of the Obstetrics and Gynecology Could the conditions in the OR have
Department of the San Pablo District Hospital. However, when contributed to the infection of the patient?
Dr. Angeles arrived, Lydia was already in shock and possibly Only the petitioner could answer these, but
dead as her blood pressure was already 0/0. Dr. Angeles then she opted not to testify. This could only give
informed petitioner and Dr. Ercillo that there was nothing he rise to the presumption that she has nothing
could do to help save the patient. 20 While the petitioner was good to testify on her defense. Anyway, the
closing the abdominal wall, the patient died. 21 Thus, on March alleged "unverified statement of the
24, 1991, at 3:00 o'clock in the morning, Lydia Umali was prosecution witness" remains unchallenged
pronounced dead. Her death certificate states "shock" as the and unrebutted.
immediate cause of death and "Disseminated Intravascular
Coagulation (DIC)" as the antecedent cause. 22 Likewise undisputed is the prosecution's
version indicating the following facts: that the
In convicting the petitioner, the MTCC found the following accused asked the patient's relatives to buy
circumstances as sufficient basis to conclude that she was indeed Tagamet capsules while the operation was
negligent in the performance of the operation: already in progress; that after an hour, they
were also asked to buy type "A" blood for the
. . . , the clinic was untidy, there was lack of patient; that after the surgery, they were again
provision like blood and oxygen to prepare asked to procure more type "A" blood, but
for any contingency that might happen during such was not anymore available from the
the operation. The manner and the fact that source; that the oxygen given to the patient
the patient was brought to the San Pablo was empty; and that the son-in-law of the
District Hospital for reoperation indicates that patient, together with a driver of the
there was something wrong in the manner in petitioner, had to rush to the San Pablo City
which Dra. Cruz conducted the operation. District Hospital to get the much-needed
There was no showing that before the oxygen. All these conclusively show that the
operation, accused Dra. Cruz had conducted a petitioner had not prepared for any unforeseen
cardio pulmonary clearance or any typing of circumstances before going into the first
the blood of the patient. It was (sic) said in surgery, which was not emergency in nature,
but was elective or pre-scheduled; she had no court on the matter of the standard of care that petitioner should
ready antibiotics, no prepared blood, properly have exercised.
typed and cross-matched, and no sufficient
oxygen supply. All three courts below bewail the inadequacy of the facilities of
the clinic and its untidiness; the lack of provisions such as blood,
Moreover, there are a lot of questions that oxygen, and certain medicines; the failure to subject the patient to
keep nagging Us. Was the patient given any a cardio-pulmonary test prior to the operation; the omission of any
cardio-pulmonary clearance, or at least a form of blood typing before transfusion; and even the subsequent
clearance by an internist, which are standard transfer of Lydia to the San Pablo Hospital and the reoperation
requirements before a patient is subjected to performed on her by the petitioner. But while it may be true that
surgery. Did the petitioner determine as part the circumstances pointed out by the courts below seemed beyond
of the pre-operative evaluation, the bleeding cavil to constitute reckless imprudence on the part of the surgeon,
parameters of the patient, such as bleeding this conclusion is still best arrived at not through the educated
time and clotting time? There is no showing surmises nor conjectures of laymen, including judges, but by the
that these were done. The petitioner just unquestionable knowledge of expert witnesses. For whether a
appears to have been in a hurry to perform the physician or surgeon has exercised the requisite degree of skill
operation, even as the family wanted a and care in the treatment of his patient is, in the generality of
postponement to April 6, 1991. Obviously, cases, a matter of expert opinion. 30 The deference of courts to the
she did not prepare the patient; neither did she expert opinion of qualified physicians stems from its realization
get the family's consent to the operation. that the latter possess unusual technical skills which laymen in
Moreover, she did not prepare a medical chart most instances are incapable of intelligently evaluating. 31 Expert
with instructions for the patient's care. If she testimony should have been offered to prove that the
did all these, proof thereof should have been circumstances cited by the courts below are constitutive of
offered. But there is none. Indeed, these are conduct falling below the standard of care employed by other
overwhelming evidence of recklessness and physicians in good standing when performing the same operation.
imprudence. 25 It must be remembered that when the qualifications of a physician
are admitted, as in the instant case, there is an inevitable
This Court, however, holds differently and finds the foregoing presumption that in proper cases he takes the necessary precaution
circumstances insufficient to sustain a judgment of conviction and employs the best of his knowledge and skill in attending to
against the petitioner for the crime of reckless imprudence his clients, unless the contrary is sufficiently established. 32 This
resulting in homicide. The elements of reckless imprudence are: presumption is rebuttable by expert opinion which is so sadly
(1) that the offender does or fails to do an act; (2) that the doing or lacking in the case at bench.
the failure to do that act is voluntary; (3) that it be without malice;
(4) that material damage results from the reckless imprudence; Even granting arguendo that the inadequacy of the facilities and
and (5) that there is inexcusable lack of precaution on the part of untidiness of the clinic; the lack of provisions; the failure to
the offender, taking into consideration his employment or conduct pre-operation tests on the patient; and the subsequent
occupation, degree of intelligence, physical condition, and other transfer of Lydia to the San Pablo Hospital and the reoperation
circumstances regarding persons, time and place. performed on her by the petitioner do indicate, even without
expert testimony, that petitioner was recklessly imprudent in the
Whether or not a physician has committed an "inexcusable lack of exercise of her duties as a surgeon, no cogent proof exists that any
precaution" in the treatment of his patient is to be determined of these circumstances caused petitioner's death. Thus, the
according to the standard of care observed by other members of absence of the fourth element of reckless imprudence: that the
the profession in good standing under similar circumstances injury to the person or property was a consequence of the reckless
bearing in mind the advanced state of the profession at the time of imprudence.
treatment or the present state of medical science. 26 In the recent
case of Leonila Garcia-Rueda v. Wilfred L. Pascasio, et In litigations involving medical negligence, the plaintiff has the
al., 27 this Court stated that in accepting a case, a doctor in effect burden of establishing appellant's negligence and for a reasonable
represents that, having the needed training and skill possessed by conclusion of negligence, there must be proof of breach of duty
physicians and surgeons practicing in the same field, he will on the part of the surgeon as well as a causal connection of such
employ such training, care and skill in the treatment of his breach and the resulting death of his patient.  33 In Chan Lugay
patients. He therefore has a duty to use at least the same level of v. St. Luke's Hospital, Inc., 34 where the attending physician was
care that any other reasonably competent doctor would use to treat absolved of liability for the death of the complainant's wife and
a condition under the same circumstances. It is in this aspect of newborn baby, this Court held that:
medical malpractice that expert testimony is essential to establish
not only the standard of care of the profession but also that the In order that there may be a recovery for an injury, however, it
physician's conduct in the treatment and care falls below such must be shown that the "injury for which recovery is sought
standard. 28 Further, inasmuch as the causes of the injuries must be the legitimate consequence of the wrong done; the
involved in malpractice actions are determinable only in the light connection between the negligence and the injury must be a
of scientific knowledge, it has been recognized that expert direct and natural sequence of events, unbroken by intervening
testimony is usually necessary to support the conclusion as to efficient causes." In other words, the negligence must be the
causation. 29 proximate cause of the injury. For, "negligence, no matter in
what it consists, cannot create a right of action unless it is the
Immediately apparent from a review of the records of this case is proximate cause of the injury complained of ." And "the
the absence of any expert testimony on the matter of the standard proximate cause of an injury is that cause, which, in natural and
of care employed by other physicians of good standing in the continuous sequence, unbroken by any efficient intervening
conduct of similar operations. The prosecution's expert witnesses cause, produces the injury, and without which the result would
in the persons of Dr. Floresto Arizala and Dr. Nieto Salvador, Jr. not have occurred." 35 (Emphasis supplied.)
of the National Bureau of Investigation (NBI) only testified as to
the possible cause of death but did not venture to illuminate the
Dr. Arizala who conducted an autopsy on the body of the A. Yes, sir.
deceased summarized his findings as follows:
Q. How about the intestines and mesenteries are place
Atty. Cachero: (sic) with blood clots noted between the mesenteric folds,
will you please explain on (sic) this?
Q. You mentioned about your Autopsy Report which has
been marked as Exh. "A-1-b". There appears here a signature A. In the peritoneal cavity, they are mostly perritonial
above the typewritten name Floresto Arizala, Jr., whose blood . . . . . . . .
signature is that?
Q. And what could have caused this blood?
A. That is my signature, sir.
A. Well, ordinarily blood is found inside the blood vessel.
Q. Do you affirm the truth of all the contents of Exh. "A-1- Blood were (sic) outside as a result of the injuries which
b"? destroyed the integrity of the vessel allowing blood to sip
(sic) out, sir.
A. Only as to the autopsy report no. 91-09, the time and
place and everything after the post mortem findings, sir. Q. By the nature of the postmortem findings indicated in
Exh. A-1-B, can you tell the court the cause of death?
Q. You mentioned on your "Post Mortem Findings" about
surgical incision, 14:0 cm., infraumbilical area, anterior A. Yes, sir. The cause of death is: Gross findings are
abdominal area, midline, will you please explain that in your compatible with hemorrhagic shock.
own language?
Q. Can you tell the us what could have caused this
A. There was incision wound (sic) the area just below the hemorrhagic shock?
navel, sir.
A. Well hemorrhagic shock is the result of blood loss.
Q. And the last paragraph of the postmortem findings which
I read: Uterus, pear-shaped and pale measuring 7.5 x 5.5 x Q. What could have the effect of that loss of blood?
5.0 cm. with some surface nodulation of the fundic area
posteriorly. Cut-section shows diffusely pale myometrium
with areas of streak induration. The ovaries and adnexal A. Unattended hemorrhage, sir. 36 (Emphasis supplied.)
structures are missing with the raw surfaces patched with
clotted blood. Surgical sutures were noted on the operative The foregoing was corroborated by Dr. Nieto Salvador:
site.
Q. And were you able to determine the cause of death by
Intestines and mesenteries are pale with blood clots noted virtue of the examination of the specimen submitted by Dr.
between the mesentric folds. Arizala?

Hemoperitoneum: 300 s.s., A. Without knowledge of the autopsy findings it would be

right paracolic gutter, difficult for me to determine the cause of death, sir.
50 c.c., left paracolic gutter
200 c.c., mesentric area, Q. Have you also examined the post mortem of Dr. Arizala?
100 c.c., right pelvic gutter
stomach empty.
A. Yes, sir, and by virtue of the autopsy report in connection
with your pathology report.
Other visceral organs, pale.,

Q. What could have caused the death of the victim?

will you please explain that on (sic) your own language or
in ordinary. . . . . . . . . . . .
A. This pathologic examination are (sic) compatible with the
person who died, sir.
A. There was a uterus which was not attached to the
adnexal structures namely ovaries which were not present
and also sign of previous surgical operation and there were Q. Will you explain to us the meaning of hemorrhagic
(sic) clotted blood, sir. compatible?

Q. How about the ovaries and adnexal structures? A. It means that a person died of blood loss. Meaning a
person died of non-replacement of blood and so the victim
before she died there was shock of diminish of blood of the
A. They are missing, sir. circulation. She died most probably before the actual
complete blood loss, sir.
Q. You mean to say there are no ovaries?
Court: Is it possible doctor that the loss of the blood was due on
A. During that time there are no ovaries, sir. (sic) operation?

Q. And there were likewise sign of surgical sutures? A. Based on my pathologist finding, sir.
Q. What could have caused this loss of blood? Q. Aside from the DIC what could another causes (sic) that
could be the cause for the hemorrhage or bleeding in a
A. Many, sir. A patient who have undergone surgery. Another patient by an operations (sic)?
may be a blood vessel may be cut while on operation and this
cause (sic) bleeding, or may be set in the course of operation, or A. In general sir, if there was an operations (sic) and it is
may be (sic) he died after the operation. Of course there are possible that the ligature in the suture was (sic) become (sic)
other cause (sic). loose, it is (sic) becomes loose if proven..

Atty. Cachero: x x x           x x x          x x x

Q. Especially so doctor when there was no blood replacement? Q. If the person who performed an autopsy does not find any
untight (sic) clot (sic) blood vessel or any suture that become
A. Yes, sir. 37 (Emphasis supplied.) (sic) loose the cause of the bleeding could not be attributed
to the fault of the subject?
The testimonies of both doctors establish hemorrhage or
hemorrhagic shock as the cause of death. However, as likewise A. Definitely,
testified to by the expert witnesses in open court, hemorrhage or sir. 39 (Emphasis
hemorrhagic shock during surgery may be caused by several supplied.)
different factors. Thus, Dr. Salvador's elaboration on the matter:
According to both doctors, the possible causes of hemorrhage
Atty. Pascual: during an operation are: (1) the failure of the surgeon to tie or
suture a cut blood vessel; (2) allowing a cut blood vessel to get
out of control; (3) the subsequent loosening of the tie or suture
Q. Doctor, among the causes of hemorrhage that you mentioned applied to a cut blood vessel; and (4) and a clotting defect known
you said that it could be at the moment of operation when one as DIC. It is significant to state at this juncture that the autopsy
losses (sic) control of the presence, is that correct? During the conducted by Dr. Arizala on the body of Lydia did not reveal any
operation there is lost (sic) of control of the cut vessel? untied or unsutured cut blood vessel nor was there any indication
that the tie or suture of a cut blood vessel had become loose
A. Yes, sir. thereby causing the hemorrhage. 40 Hence the following pertinent
portion of Dr. Arizala's testimony:
Q. Or there is a failure to ligate a vessel of considerable size?
Q: Doctor, in examining these structures did you know whether
A. Yes, sir. these were sutured ligature or plain ligature

Q. Or even if the vessel were ligated the knot may have slipped A: Ligature, sir.
later on?
Q: We will explain that later on. Did you recall if the cut
A. Yes, sir. structures were tied by first suturing it and then tying a knot or the
tie was merely placed around the cut structure and tied?

Q. And you also mentioned that it may be possible also to

some clotting defect, is that correct? A: I cannot recall, sir.

A. May be (sic). 38 (Emphasis supplied). Q: As a matter of fact, you cannot recall because you did not even
bothered (sic) to examine, is that correct?

Defense witness, Dr. Bu C. Castro also gave the following expert

opinion: A: Well, I bothered enough to know that they were sutured, sir.

Q. Doctor even a patient after an operations (sic) would Q: So, therefore, Doctor, you would not know whether any of the
suffer hemorrage what would be the possible causes of such cut structures were not sutured or tied neither were you able to
hemorrage (sic)? determine whether any loose suture was found in the peritoneal
cavity?

A. Among those would be what we call Intravascular

Coagulation and this is the reason for the bleeding, sir, A: I could not recall any loose sutured (sic), sir. 41
which cannot be prevented by anyone, it will happen to
anyone, anytime and to any persons (sic), sir. On the other hand, the findings of all three doctors do not
preclude the probability that DIC caused the hemorrhage and
COURT: consequently, Lydia's death. DIC which is a clotting defect
creates a serious bleeding tendency and when massive DIC occurs
as a complication of surgery leaving raw surface, major
What do you think of the cause of the bleeding, the cutting or hemorrhage occurs. 42 And as testified to by defense witness, Dr.
the operations done in the body? Bu C. Castro, hemorrhage due to DIC "cannot be prevented, it
will happen to anyone,
A. Not related to this one, the bleeding here is not related to anytime." 43 He testified further:
any cutting or operation that I (sic) have done.
Q. Now, under that circumstance one of the possibility as witness, cannot be attributed to the petitioner's fault or negligence.
you mentioned in (sic) DIC? The probability that Lydia's death was caused by DIC was
unrebutted during trial and has engendered in the mind of this
A. Yes, sir. Court a reasonable doubt as to the petitioner's guilt. Thus, her
acquittal of the crime of reckless imprudence resulting in
homicide. While we condole with the family of Lydia Umali, our
Q. And you mentioned that this cannot be prevented? hands are bound by the dictates of justice and fair dealing which
hold inviolable the right of an accused to be presumed innocent
A. Yes, sir. until proven guilty beyond reasonable doubt. Nevertheless, this
Court finds the petitioner civilly liable for the death of Lydia
Q. Can you even predict if it really happen (sic)? Umali, for while a conviction of a crime requires proof beyond
reasonable doubt, only a preponderance of evidence is required to
establish civil liability. 45
A. Possible, sir.
The petitioner is a doctor in whose hands a patient puts his life
Q. Are there any specific findings of autopsy that will tell and limb. For insufficiency of evidence this Court was not able to
you whether this patient suffered among such things as render a sentence of conviction but it is not blind to the reckless
DIC? and imprudent manner in which the petitioner carried out her
duties. A precious life has been lost and the circumstances leading
A. Well, I did reserve because of the condition of the thereto exacerbated the grief of those left behind. The heirs of the
patient. deceased continue to feel the loss of their mother up to the present
time 46 and this Court is aware that no amount of compassion and
commiseration nor words of bereavement can suffice to assuage
Q. Now, Doctor you said that you went through the
the sorrow felt for the loss of a loved one. Certainly, the award of
record of the deceased Lydia Umali looking for the chart,
moral and exemplary damages in favor of the heirs of Lydia
the operated (sic) records, the post mortem findings on
Umali are proper in the instant case.
the histophanic (sic) examination based on your
examination of record, doctor, can you more or less says
(sic) what part are (sic) concerned could have been the WHEREFORE, premises considered, petitioner DR.
caused (sic) of death of this Lydia Umali? NINEVETCH CRUZ is hereby ACQUITTED of the crime of
reckless imprudence resulting in homicide but is ordered to pay
the heirs of the deceased Lydia Umali the amount of FIFTY
A. As far as the medical record is concern (sic) the caused
THOUSAND PESOS (P50,000.00) as civil liability, ONE
(sic) of death is dessimulated (sic) Intra Vascular Coagulation
HUNDRED THOUSAND PESOS (P100,000.00) as moral
or the DIC which resulted to hemorrhage or bleedings, sir.
damages, and FIFTY THOUSAND PESOS (P50,000.00) as
exemplary damages.
Q. Doctor based on your findings then there is knowing (sic)
the doctor would say whether the doctor her (sic) has been
Let a copy of this decision be furnished to the Professional
(sic) fault?
Regulation Commission (PRC) for appropriate action.

ATTY. MALVEDA:

We will moved (sic) to strike out the (sic) based on finding

they just read the chart as well as the other record.

ATTY. PASCUAL:

Precisely based on this examination.

ATTY. MALVEDA:

Not finding, there was no finding made.

COURT:

He is only reading the record.

ATTY. PASCUAL:

Yes, sir.

A. No, sir, there is no fault on the part of the surgeon, sir. 44

This Court has no recourse but to rely on the expert testimonies

rendered by both prosecution and defense witnesses that
substantiate rather than contradict petitioner's allegation that the
cause of Lydia's death was DIC which, as attested to by an expert
Ramos v. CA before resort to the doctrine may be allowed, the following
Facts: requisites must be satisfactorily shown.
Erlinda Ramos, a 47-year old robust woman, was normal except (1) The accident is of a kind which ordinarily does not occur in
for her experiencing occasional pain due to the presence of stone the absence of someone's negligence;
in her gall bladder. She was advised to undergo an operation for (2) It is caused by an instrumentality within the exclusive control
its removal. The results in the examinations she underwent of the defendant or defendants; and
indicate that she was fit for the operation. She and her husband (3) The possibility of contributing conduct which would make the
Rogelio met Dr. Hosaka, one of the defendants, who advised that plaintiff responsible is eliminated.
she should undergo cholecystectomy. Dr. Hosaka assured them Medical malpractice cases do not escape the application of this
that he will get a good anaesthesiologist. At 7:30 a.m. on the day doctrine. Thus, res ipsa loquitur has been applied when the
of the operation at Delos Santos Medical Center, Herminda Cruz, circumstances attendant upon the harm are themselves of such a
Erlinda’s sister-in-law and the dean of the College of Nursing in character as to justify an inference of negligence as the cause of
Capitol Medical Center, was there to provide moral support. Dr. that harm. Although generally, expert medical testimony is relied
Perfecta Gutierrez was to administer the anaesthesia. Dr. Hosaka upon in malpractice suits to prove that a physician has done a
arrived only at 12:15 p. m. Herminda saw Dr. Gutierrez intubating negligent act or that he has deviated from the standard medical
the patient, and heard the latter say “Ang hirap ma-intubate nito, procedure, when the doctrine of res ipsa loquitur is availed by the
mali yata ang pagkakapasok. O, lumalaki ang tiyan.” Herminda plaintiff, the need for expert medical testimony is dispensed with
saw bluish discoloration of the nailbeds of the patient. She heard because the injury itself provides the proof of negligence. Hence,
Dr. Hosaka issue an order for someone to call Dr. Calderon. The in cases where the res ipsa loquitur is applicable, the court is
doctor arrived and placed the patient in trendelenburg position, permitted to find a physician negligent upon proper proof of
wherein the head of the patient is positioned lower than the feet, injury to the patient, without the aid of expert testimony, where
which indicates a decrease of blood supply in the brain. Herminda the court from its fund of common knowledge can determine the
knew and told Rogelio that something wrong was happening. Dr. proper standard of care. When the doctrine is appropriate, all that
Calderon was able to intubate the patient. Erlinda was taken to the the patient must do is prove a nexus between the particular act or
ICU and became comatose. omission complained of and the injury sustained while under the
Rogelio filed a civil case for damages. The trial court ruled in his custody and management of the defendant without need to
favor, finding Dr. Gutierrez, Dr. Hosaka, and the hospital, guilty produce expert medical testimony to establish the standard of
of negligence, but the Court of Appeals reversed the decision. care. Resort to res ipsa loquitur is allowed because there is no
Hence, petitioner filed a Motion for Reconsideration, which the other way, under usual and ordinary conditions, by which the
Court of Appeals denied for having been filed beyond the patient can obtain redress for injury suffered by him.
reglementary period. However, it was found that the notice of the Res ipsa loquitur is not a rigid or ordinary doctrine to be
decision was never sent to the petitioner’s counsel. Rather, it was perfunctorily used but a rule to be cautiously applied, depending
sent to the petitioner, addressing him as Atty. Rogelio Ramos, as upon the circumstances of each case. A distinction must be made
if he was the legal counsel. The petitioner filed the instant petition between the failure to secure results, and the occurrence of
for certiorari. On the procedural issue, the Supreme Court rules something more unusual and not ordinarily found if the service or
that since the notice did not reach the petitioner’s then legal treatment rendered followed the usual procedure of those skilled
counsel, the motion was filed on time. in that particular practice. The real question, therefore, is whether
Issue: or not in the process of the operation any extraordinary incident or
Whether a surgeon, an anaesthesiologist, and a hospital, should be unusual event outside of the routine performance occurred which
made liable for the unfortunate comatose condition of a patient is beyond the regular scope of customary professional activity in
scheduled for cholecystectomy such operations, which, if unexplained would themselves
Held: reasonably speak to the average man as the negligent cause or
Res Ipsa Loquitor causes of the untoward consequence.
Res ipsa loquitur is a Latin phrase which literally means "the We find the doctrine of res ipsa loquitur appropriate in the case at
thing or the transaction speaks for itself." The phrase "res ipsa bar. Erlinda submitted herself for cholecystectomy and expected a
loquitur'' is a maxim for the rule that the fact of the occurrence of routine general surgery to be performed on her gall bladder. On
an injury, taken with the surrounding circumstances, may permit that fateful day she delivered her person over to the care, custody
an inference or raise a presumption of negligence, or make out a and control of private respondents who exercised complete and
plaintiff's prima facie case, and present a question of fact for exclusive control over her. At the time of submission, Erlinda was
defendant to meet with an explanation. Where the thing which neurologically sound and, except for a few minor discomforts,
caused the injury complained of is shown to be under the was likewise physically fit in mind and body. However, during
management of the defendant or his servants and the accident is the administration of anesthesia and prior to the performance of
such as in ordinary course of things does not happen if those who cholecystectomy she suffered irreparable damage to her brain.
have its management or control use proper care, it affords Thus, without undergoing surgery, she went out of the operating
reasonable evidence, in the absence of explanation by the room already decerebrate and totally incapacitated. Obviously,
defendant, that the accident arose from or was caused by the brain damage, which Erlinda sustained, is an injury which does
defendant's want of care. It is grounded in the superior logic of not normally occur in the process of a gall bladder operation. In
ordinary human experience and on the basis of such experience or fact, this kind of situation does not in the absence of negligence of
common knowledge, negligence may be deduced from the mere someone in the administration of anesthesia and in the use of
occurrence of the accident itself. However, much has been said endotracheal tube. Furthermore, the instruments used in the
thatres ipsa loquitur is not a rule of substantive law and, as such, administration of anesthesia, including the endotracheal tube,
does not create or constitute an independent or separate ground of were all under the exclusive control of private respondents, who
liability. Mere invocation and application of the doctrine does not are the physicians-in-charge. Likewise, petitioner Erlinda could
dispense with the requirement of proof of negligence. It is simply not have been guilty of contributory negligence because she was
a step in the process of such proof, permitting the plaintiff to under the influence of anesthetics which rendered her
present along with the proof of the accident, enough of the unconscious.
attending circumstances to invoke the doctrine, creating an Negligence of the Anaesthesiologist
inference or presumption of negligence, and to thereby place on The pre-operative evaluation of a patient prior to the
the defendant the burden of going forward with the proof. Still, administration of anesthesia is universally observed to lessen the
possibility of anesthetic accidents. Respondent Dra. Gutierrez' act
of seeing her patient for the first time only an hour before the and was in fact over three hours late for the latter's operation.
scheduled operative procedure was, therefore, an act of Because of this, he had little or no time to confer with his
exceptional negligence and professional irresponsibility. Her anesthesiologist regarding the anesthesia delivery. This indicates
failure to follow this medical procedure is, therefore, a that he was remiss in his professional duties towards his patient.
clear indicia of her negligence. Erlinda's case was elective and Thus, he shares equal responsibility for the events which resulted
this was known to respondent Dra. Gutierrez. Thus, she had all in Erlinda's condition.
the time to make a thorough evaluation of Erlinda's case prior to Responsibility of the Hospital
the operation and prepare her for anesthesia. However, she never Hospitals hire, fire and exercise real control over their attending
saw the patient at the bedside. She herself admitted that she had and visiting "consultant" staff. While "consultants" are not,
seen petitioner only in the operating room, and only on the actual technically employees, a point which respondent hospital asserts
date of the cholecystectomy. She negligently failed to take in denying all responsibility for the patient's condition, the control
advantage of this important opportunity. As such, her attempt to exercised, the hiring, and the right to terminate consultants all
exculpate herself must fail. fulfill the important hallmarks of an employer-employee
Opinion of Expert Witness relationship, with the exception of the payment of wages. In
An anesthetic accident caused by a rare drug-induced assessing whether such a relationship in fact exists, the control
bronchospasm properly falls within the fields of anesthesia, test is determining. Accordingly, on the basis of the foregoing, we
internal medicine-allergy, and clinical pharmacology. The rule that for the purpose of allocating responsibility in medical
resulting anoxic encephalopathy belongs to the field of neurology. negligence cases, an employer-employee relationship in effect
While admittedly, many bronchospastic-mediated pulmonary exists between hospitals and their attending and visiting
diseases are within the expertise of pulmonary medicine, Dr. physicians.
Jamora's field, the anesthetic drug-induced, allergic mediated The basis for holding an employer solidarily responsible for the
bronchospasm alleged in this case is within the disciplines of negligence of its employee is found in Article 2180 of the Civil
anesthesiology, allergology and pharmacology. On the basis of Code which considers a person accountable not only for his own
the foregoing transcript, in which the pulmonologist himself acts but also for those of others based on the former's
admitted that he could not testify about the drug with medical responsibility under a relationship of patria potestas. Such
authority, it is clear that the appellate court erred in giving weight responsibility ceases when the persons or entity concerned prove
to Dr. Jamora's testimony as an expert in the administration of that they have observed the diligence of a good father of the
Thiopental Sodium. Generally, to qualify as an expert witness, family to prevent damage. In the instant case, respondent hospital,
one must have acquired special knowledge of the subject matter apart from a general denial of its responsibility over respondent
about which he or she is to testify, either by the study of physicians, failed to adduce evidence showing that it exercised the
recognized authorities on the subject or by practical experience. diligence of a good father of a family in the hiring and supervision
Clearly, Dr. Jamora does not qualify as an expert witness based of the latter. It failed to adduce evidence with regard to the degree
on the above standard since he lacks the necessary knowledge, of supervision which it exercised over its physicians. In
skill, and training in the field of anesthesiology. Oddly, apart from neglecting to offer such proof, or proof of a similar nature,
submitting testimony from a specialist in the wrong field, private respondent hospital thereby failed to discharge its burden under
respondents' intentionally avoided providing testimony by the last paragraph of Article 2180. Having failed to do this,
competent and independent experts in the proper areas. respondent hospital is consequently solidarily responsible with its
Proximate Cause physicians for Erlinda's condition.
Proximate cause has been defined as that which, in natural and Damages
continuous sequence, unbroken by any efficient intervening At current levels, the P8000/monthly amount established by the
cause, produces injury, and without which the result would not trial court at the time of its decision would be grossly inadequate
have occurred. An injury or damage is proximately caused by an to cover the actual costs of home-based care for a comatose
act or a failure to act, whenever it appears from the evidence in individual. The calculated amount was not even arrived at by
the case, that the act or omission played a substantial part in looking at the actual cost of proper hospice care for the patient.
bringing about or actually causing the injury or damage; and that What it reflected were the actual expenses incurred and proved by
the injury or damage was either a direct result or a reasonably the petitioners after they were forced to bring home the patient to
probable consequence of the act or omission. Instead of the avoid mounting hospital bills. And yet ideally, a comatose patient
intended endotracheal intubation what actually took place was an should remain in a hospital or be transferred to a hospice
esophageal intubation. During intubation, such distention specializing in the care of the chronically ill for the purpose of
indicates that air has entered the gastrointestinal tract through the providing a proper milieu adequate to meet minimum standards of
esophagus instead of the lungs through the trachea. Entry into the care. Given these considerations, the amount of actual damages
esophagus would certainly cause some delay in oxygen delivery recoverable in suits arising from negligence should at least reflect
into the lungs as the tube which carries oxygen is in the wrong the correct minimum cost of proper care, not the cost of the care
place. That abdominal distention had been observed during the the family is usually compelled to undertake at home to avoid
first intubation suggests that the length of time utilized in bankruptcy.
inserting the endotracheal tube (up to the time the tube was Our rules on actual or compensatory damages generally assume
withdrawn for the second attempt) was fairly significant. Due to that at the time of litigation, the injury suffered as a consequence
the delay in the delivery of oxygen in her lungs Erlinda showed of an act of negligence has been completed and that the cost can
signs of cyanosis. be liquidated. However, these provisions neglect to take into
Responsibility of the Surgeon account those situations, as in this case, where the resulting injury
As the so-called "captain of the ship," it is the surgeon's might be continuing and possible future complications directly
responsibility to see to it that those under him perform their task arising from the injury, while certain to occur, are difficult to
in the proper manner. Respondent Dr. Hosaka's negligence can be predict. Temperate damages can and should be awarded on top of
found in his failure to exercise the proper authority in not actual or compensatory damages in instances where the injury is
determining if his anesthesiologist observed proper anesthesia chronic and continuing. And because of the unique nature of such
protocols. In fact, no evidence on record exists to show that cases, no incompatibility arises when both actual and temperate
respondent Dr. Hosaka verified if respondent Dra. Gutierrez damages are provided for. The reason is that these damages cover
properly intubated the patient. Furthermore, it does not escape us two distinct phases. As it would not be equitable - and certainly
that respondent Dr. Hosaka had scheduled another procedure in a not in the best interests of the administration of justice - for the
different hospital at the same time as Erlinda's cholecystectomy, victim in such cases to constantly come before the courts and
invoke their aid in seeking adjustments to the compensatory his acts. A mistake, through gross negligence or incompetence or
damages previously awarded - temperate damages are plain human error, may spell the difference between life and
appropriate. The amount given as temperate damages, though to a death. In this sense, the doctor plays God on his patient's fate. 1
certain extent speculative, should take into account the cost of
proper care. In the instant case, petitioners were able to provide In the case at bar, the Court is called upon to rule whether a
only home-based nursing care for a comatose patient who has surgeon, an anesthesiologist and a hospital should be made liable
remained in that condition for over a decade. Having premised for the unfortunate comatose condition of a patient scheduled for
our award for compensatory damages on the amount provided by cholecystectomy. 2
petitioners at the onset of litigation, it would be now much more
in step with the interests of justice if the value awarded for
temperate damages would allow petitioners to provide optimal Petitioners seek the reversal of the decision 3 of the Court of
care for their loved one in a facility which generally specializes in Appeals, dated 29 May 1995, which overturned the decision 4 of
such care. They should not be compelled by dire circumstances to the Regional Trial Court, dated 30 January 1992, finding private
provide substandard care at home without the aid of professionals, respondents liable for damages arising from negligence in the
for anything less would be grossly inadequate. Under the performance of their professional duties towards petitioner
circumstances, an award of P1,500,000.00 in temperate damages Erlinda Ramos resulting in her comatose condition.
would therefore be reasonable.
Petitioner Erlinda Ramos was in her mid-forties when the incident The antecedent facts as summarized by the trial court are
occurred. She has been in a comatose state for over fourteen years reproduced hereunder:
now. The burden of care has so far been heroically shouldered by
her husband and children, who, in the intervening years have been Plaintiff Erlinda Ramos was, until the
deprived of the love of a wife and a mother. Meanwhile, the afternoon of June 17, 1985, a 47-year old
actual physical, emotional and financial cost of the care of (Exh. "A") robust woman (TSN, October 19,
petitioner would be virtually impossible to quantify. Even the 1989, p. 10). Except for occasional
temperate damages herein awarded would be inadequate if complaints of discomfort due to pains
petitioner's condition remains unchanged for the next ten allegedly caused by the presence of a stone in
years. The husband and the children, all petitioners in this case, her gall bladder (TSN, January 13, 1988, pp.
will have to live with the day to day uncertainty of the patient's 4-5), she was as normal as any other woman.
illness, knowing any hope of recovery is close to nil. They have Married to Rogelio E. Ramos, an executive of
fashioned their daily lives around the nursing care of petitioner, Philippine Long Distance Telephone
altering their long term goals to take into account their life with a Company, she has three children whose
comatose patient. They, not the respondents, are charged with the names are Rommel Ramos, Roy Roderick
moral responsibility of the care of the victim. The family's moral Ramos and Ron Raymond Ramos (TSN,
injury and suffering in this case is clearly a real one. For the October 19, 1989, pp. 5-6).
foregoing reasons, an award of P2,000,000.00 in moral damages
would be appropriate.
Finally, by way of example, exemplary damages in the amount of Because the discomforts somehow interfered
P100,000.00 are hereby awarded. Considering the length and with her normal ways, she sought professional
nature of the instant suit we are of the opinion that attorney's fees advice. She was advised to undergo an
valued at P100,000.00 are likewise proper. operation for the removal of a stone in her
WHEREFORE, the decision and resolution of the appellate court gall bladder (TSN, January 13, 1988, p. 5).
appealed from are hereby modified so as to award in favor of She underwent a series of examinations which
petitioners, and solidarily against private respondents the included blood and urine tests (Exhs. "A" and
following: 1) P1,352,000.00 as actual damages computed as of the "C") which indicated she was fit for surgery.
date of promulgation of this decision plus a monthly payment of
P8,000.00 up to the time that petitioner Erlinda Ramos expires or Through the intercession of a mutual friend,
miraculously survives; 2) P2,000,000.00 as moral damages, 3) Dr. Buenviaje (TSN, January 13, 1988, p. 7),
P1,500,000.00 as temperate damages; 4) P100,000.00 each as she and her husband Rogelio met for the first
exemplary damages and attorney's fees; and, 5) the costs of the time Dr. Orlino Hozaka (should be
suit. Hosaka; see TSN, February 20, 1990, p. 3),
one of the defendants in this case, on June 10,
G.R. No. 124354 December 29, 1999 1985. They agreed that their date at the
operating table at the DLSMC (another
defendant), would be on June 17, 1985 at 9:00
ROGELIO E. RAMOS and ERLINDA RAMOS, in their own A.M.. Dr. Hosaka decided that she should
behalf and as natural guardians of the minors, ROMMEL undergo a "cholecystectomy" operation after
RAMOS, ROY RODERICK RAMOS and RON RAYMOND examining the documents (findings from the
RAMOS, petitioners,  Capitol Medical Center, FEU Hospital and
vs. DLSMC) presented to him. Rogelio E.
COURT OF APPEALS, DELOS SANTOS MEDICAL Ramos, however, asked Dr. Hosaka to look
CENTER, DR. ORLINO HOSAKA and DRA. PERFECTA for a good anesthesiologist. Dr. Hosaka, in
GUTIERREZ, respondents. turn, assured Rogelio that he will get a good
anesthesiologist. Dr. Hosaka charged a fee of
  P16,000.00, which was to include the
anesthesiologist's fee and which was to be
KAPUNAN, J.: paid after the operation (TSN, October 19,
1989, pp. 14-15, 22-23, 31-33; TSN, February
27, 1990, p. 13; and TSN, November 9, 1989,
The Hippocratic Oath mandates physicians to give primordial pp. 3-4, 10, 17).
consideration to the health and welfare of their patients. If a
doctor fails to live up to this precept, he is made accountable for
A day before the scheduled date of operation, At about 12:15 P.M., Herminda Cruz, who
she was admitted at one of the rooms of the was inside the operating room with the
DLSMC, located along E. Rodriguez Avenue, patient, heard somebody say that "Dr. Hosaka
Quezon City (TSN, October 19,1989, p. 11). is already here." She then saw people inside
the operating room "moving, doing this and
At around 7:30 A.M. of June 17, 1985 and that, [and] preparing the patient for the
while still in her room, she was prepared for operation" (TSN, January 13, 1988, p. 16). As
the operation by the hospital staff. Her sister- she held the hand of Erlinda Ramos, she then
in-law, Herminda Cruz, who was the Dean of saw Dr. Gutierrez intubating the hapless
the College of Nursing at the Capitol Medical patient. She thereafter heard Dr. Gutierrez
Center, was also there for moral support. She say, "ang hirap ma-intubate nito, mali yata
reiterated her previous request for Herminda ang pagkakapasok. O lumalaki ang tiyan" (id.,
to be with her even during the operation. p. 17). Because of the remarks of Dra.
After praying, she was given injections. Her Gutierrez, she focused her attention on what
hands were held by Herminda as they went Dr. Gutierrez was doing. She thereafter
down from her room to the operating room noticed bluish discoloration of the nailbeds of
(TSN, January 13, 1988, pp. 9-11). Her the left hand of the hapless Erlinda even as
husband, Rogelio, was also with her (TSN, Dr. Hosaka approached her. She then heard
October 19, 1989, p. 18). At the operating Dr. Hosaka issue an order for someone to call
room, Herminda saw about two or three Dr. Calderon, another anesthesiologist (id., p.
nurses and Dr. Perfecta Gutierrez, the other 19). After Dr. Calderon arrived at the
defendant, who was to administer anesthesia. operating room, she saw this anesthesiologist
Although not a member of the hospital staff, trying to intubate the patient. The patient's
Herminda introduced herself as Dean of the nailbed became bluish and the patient was
College of Nursing at the Capitol Medical placed in a trendelenburg position — a
Center who was to provide moral support to position where the head of the patient is
the patient, to them. Herminda was allowed to placed in a position lower than her feet which
stay inside the operating room. is an indication that there is a decrease of
blood supply to the patient's brain (Id., pp. 19-
20). Immediately thereafter, she went out of
At around 9:30 A.M., Dr. Gutierrez reached a the operating room, and she told Rogelio E.
nearby phone to look for Dr. Hosaka who was Ramos "that something wrong was . . .
not yet in (TSN, January 13, 1988, pp. 11-12). happening" (Ibid.). Dr. Calderon was then
Dr. Gutierrez thereafter informed Herminda able to intubate the patient (TSN, July 25,
Cruz about the prospect of a delay in the 1991, p. 9).
arrival of Dr. Hosaka. Herminda then went
back to the patient who asked, "Mindy, wala
pa ba ang Doctor"? The former replied, Meanwhile, Rogelio, who was outside the
"Huwag kang mag-alaala, darating na iyon" operating room, saw a respiratory machine
(Ibid.). being rushed towards the door of the
operating room. He also saw several doctors
rushing towards the operating room. When
Thereafter, Herminda went out of the informed by Herminda Cruz that something
operating room and informed the patient's wrong was happening, he told her (Herminda)
husband, Rogelio, that the doctor was not yet to be back with the patient inside the
around (id., p. 13). When she returned to the operating room (TSN, October 19, 1989, pp.
operating room, the patient told her, "Mindy, 25-28).
inip na inip na ako, ikuha mo ako ng ibang
Doctor." So, she went out again and told
Rogelio about what the patient said (id., p. Herminda Cruz immediately rushed back, and
15). Thereafter, she returned to the operating saw that the patient was still in trendelenburg
room. position (TSN, January 13, 1988, p. 20). At
almost 3:00 P.M. of that fateful day, she saw
the patient taken to the Intensive Care Unit
At around 10:00 A.M., Rogelio E. Ramos was (ICU).
"already dying [and] waiting for the arrival of
the doctor" even as he did his best to find
somebody who will allow him to pull out his About two days thereafter, Rogelio E. Ramos
wife from the operating room (TSN, October was able to talk to Dr. Hosaka. The latter
19, 1989, pp. 19-20). He also thought of the informed the former that something went
feeling of his wife, who was inside the wrong during the intubation. Reacting to what
operating room waiting for the doctor to was told to him, Rogelio reminded the doctor
arrive (ibid.). At almost 12:00 noon, he met that the condition of his wife would not have
Dr. Garcia who remarked that he (Dr. Garcia) happened, had he (Dr. Hosaka) looked for a
was also tired of waiting for Dr. Hosaka to good anesthesiologist (TSN, October 19,
arrive (id., p. 21). While talking to Dr. Garcia 1989, p. 31).
at around 12:10 P.M., he came to know that
Dr. Hosaka arrived as a nurse remarked, Doctors Gutierrez and Hosaka were also
"Nandiyan na si Dr. Hosaka, dumating na asked by the hospital to explain what
raw." Upon hearing those words, he went happened to the patient. The doctors
down to the lobby and waited for the explained that the patient had bronchospasm
operation to be completed (id., pp. 16, 29-30). (TSN, November 15, 1990, pp. 26-27).
Erlinda Ramos stayed at the ICU for a month. and the patient, thereafter, was placed in
About four months thereafter or on November trendelenburg position, because of the
15, 1985, the patient was released from the decrease of blood supply to the patient's brain.
hospital. The evidence further shows that the hapless
patient suffered brain damage because of the
During the whole period of her confinement, absence of oxygen in her (patient's) brain for
she incurred hospital bills amounting to approximately four to five minutes which, in
P93,542.25 which is the subject of a turn, caused the patient to become comatose.
promissory note and affidavit of undertaking
executed by Rogelio E. Ramos in favor of On the part of Dr. Orlino Hosaka, this Court
DLSMC. Since that fateful afternoon of June finds that he is liable for the acts of Dr.
17, 1985, she has been in a comatose Perfecta Gutierrez whom he had chosen to
condition. She cannot do anything. She cannot administer anesthesia on the patient as part of
move any part of her body. She cannot see or his obligation to provide the patient a good
hear. She is living on mechanical means. She anesthesiologist', and for arriving for the
suffered brain damage as a result of the scheduled operation almost three (3) hours
absence of oxygen in her brain for four to five late.
minutes (TSN, November 9, 1989, pp. 21-22).
After being discharged from the hospital, she On the part of DLSMC (the hospital), this
has been staying in their residence, still Court finds that it is liable for the acts of
needing constant medical attention, with her negligence of the doctors in their "practice of
husband Rogelio incurring a monthly expense medicine" in the operating room. Moreover,
ranging from P8,000.00 to P10,000.00 (TSN, the hospital is liable for failing through its
October 19, 1989, pp. 32-34). She was also responsible officials, to cancel the scheduled
diagnosed to be suffering from "diffuse operation after Dr. Hosaka inexcusably failed
cerebral parenchymal damage" (Exh. "G"; see to arrive on time.
also TSN, December 21, 1989,
p. 6). 5
In having held thus, this Court rejects the
defense raised by defendants that they have
Thus, on 8 January 1986, petitioners filed a civil case 6 for acted with due care and prudence in rendering
damages with the Regional Trial Court of Quezon City against medical services to plaintiff-patient. For if the
herein private respondents alleging negligence in the management patient was properly intubated as claimed by
and care of Erlinda Ramos. them, the patient would not have become
comatose. And, the fact that another
During the trial, both parties presented evidence as to the possible anesthesiologist was called to try to intubate
cause of Erlinda's injury. Plaintiff presented the testimonies of the patient after her (the patient's) nailbed
Dean Herminda Cruz and Dr. Mariano Gavino to prove that the turned bluish, belie their claim. Furthermore,
sustained by Erlinda was due to lack of oxygen in her brain the defendants should have rescheduled the
caused by the faulty management of her airway by private operation to a later date. This, they should
respondents during the anesthesia phase. On the other hand, have done, if defendants acted with due care
private respondents primarily relied on the expert testimony of Dr. and prudence as the patient's case was an
Eduardo Jamora, a pulmonologist, to the effect that the cause of elective, not an emergency case.
brain damage was Erlinda's allergic reaction to the anesthetic
agent, Thiopental Sodium (Pentothal). x x x           x x x          x x x

After considering the evidence from both sides, the Regional Trial WHEREFORE, and in view of the foregoing,
Court rendered judgment in favor of petitioners, to wit: judgment is rendered in favor of the plaintiffs
and against the defendants. Accordingly, the
After evaluating the evidence as shown in the latter are ordered to pay, jointly and severally,
finding of facts set forth earlier, and applying the former the following sums of money, to
the aforecited provisions of law and wit:
jurisprudence to the case at bar, this Court
finds and so holds that defendants are liable to 1) the sum of P8,000.00 as actual monthly
plaintiffs for damages. The defendants were expenses for the plaintiff Erlinda Ramos
guilty of, at the very least, negligence in the reckoned from November 15, 1985 or in the
performance of their duty to plaintiff-patient total sum of P632,000.00 as of April 15,
Erlinda Ramos. 1992, subject to its being updated;

On the part of Dr. Perfecta Gutierrez, this 2) the sum of P100,000.00 as reasonable
Court finds that she omitted to exercise attorney's fees;
reasonable care in not only intubating the
patient, but also in not repeating the
administration of atropine (TSN, August 20, 3) the sum of P800,000.00 by way of moral
1991, pp. 5-10), without due regard to the fact damages and the further sum of P200,000,00
that the patient was inside the operating room by way of exemplary damages; and,
for almost three (3) hours. For after she
committed a mistake in intubating [the] 4) the costs of the suit.
patient, the patient's nailbed became bluish
SO ORDERED. 7 A copy of the above resolution was received by Atty. Sillano on
11 April 1996. The next day, or on 12 April 1996, Atty. Sillano
Private respondents seasonably interposed an appeal to the Court filed before this Court a motion for extension of time to file the
of Appeals. The appellate court rendered a Decision, dated 29 present petition for certiorari under Rule 45. The Court granted
May 1995, reversing the findings of the trial court. The decretal the motion for extension of time and gave petitioners additional
portion of the decision of the appellate court reads: thirty (30) days after the expiration of the fifteen-day (15) period
counted from the receipt of the resolution of the Court of Appeals
within which to submit the petition. The due date fell on 27 May
WHEREFORE, for the foregoing premises 1996. The petition was filed on 9 May 1996, well within the
the appealed decision is hereby REVERSED, extended period given by the Court.
and the complaint below against the
appellants is hereby ordered DISMISSED.
The counterclaim of appellant De Los Santos Petitioners assail the decision of the Court of Appeals on the
Medical Center is GRANTED but only following grounds:
insofar as appellees are hereby ordered to pay
the unpaid hospital bills amounting to I
P93,542.25, plus legal interest for justice must
be tempered with mercy. IN PUTTING MUCH RELIANCE ON THE
TESTIMONIES OF RESPONDENTS DRA.
SO ORDERED. 8 GUTIERREZ, DRA. CALDERON AND DR.
JAMORA;
The decision of the Court of Appeals was received on 9 June 1995
by petitioner Rogelio Ramos who was mistakenly addressed as II
"Atty. Rogelio Ramos." No copy of the decision, however, was
sent nor received by the Coronel Law Office, then counsel on IN FINDING THAT THE NEGLIGENCE
record of petitioners. Rogelio referred the decision of the OF THE RESPONDENTS DID NOT
appellate court to a new lawyer, Atty. Ligsay, only on 20 June CAUSE THE UNFORTUNATE
1995, or four (4) days before the expiration of the reglementary COMATOSE CONDITION OF
period for filing a motion for reconsideration. On the same day, PETITIONER ERLINDA RAMOS;
Atty. Ligsay, filed with the appellate court a motion for extension
of time to file a motion for reconsideration. The motion for
reconsideration was submitted on 4 July 1995. However, the III
appellate court denied the motion for extension of time in its
Resolution dated 25 July 1995. 9Meanwhile, petitioners engaged IN NOT APPLYING THE DOCTRINE
the services of another counsel, Atty. Sillano, to replace Atty. OF RES IPSA LOQUITUR. 11
Ligsay. Atty. Sillano filed on 7 August 1995 a motion to admit
the motion for reconsideration contending that the period to file Before we discuss the merits of the case, we shall first dispose of
the appropriate pleading on the assailed decision had not yet the procedural issue on the timeliness of the petition in relation to
commenced to run as the Division Clerk of Court of the Court of the motion for reconsideration filed by petitioners with the Court
Appeals had not yet served a copy thereof to the counsel on of Appeals. In their 
record. Despite this explanation, the appellate court still denied Comment, 12 private respondents contend that the petition should
the motion to admit the motion for reconsideration of petitioners not be given due course since the motion for reconsideration of
in its Resolution, dated 29 March 1996, primarily on the ground the petitioners on the decision of the Court of Appeals was validly
that the fifteen-day (15) period for filing a motion for dismissed by the appellate court for having been filed beyond the
reconsideration had already expired, to wit: reglementary period. We do not agree.

We said in our Resolution on July 25, 1995, A careful review of the records reveals that the reason behind the
that the filing of a Motion for Reconsideration delay in filing the motion for reconsideration is attributable to the
cannot be extended; precisely, the Motion for fact that the decision of the Court of Appeals was not sent to then
Extension (Rollo, p. 12) was denied. It is, on counsel on record of petitioners, the Coronel Law Office. In fact,
the other hand, admitted in the latter Motion a copy of the decision of the appellate court was instead sent to
that plaintiffs/appellees received a copy of the and received by petitioner Rogelio Ramos on 9 June 1995
decision as early as June 9, 1995. wherein he was mistakenly addressed as Atty. Rogelio Ramos.
Computation wise, the period to file a Motion Based on the other communications received by petitioner
for Reconsideration expired on June 24. The Rogelio Ramos, the appellate court apparently mistook him for
Motion for Reconsideration, in turn, was the counsel on record. Thus, no copy of the decision of the
received by the Court of Appeals already on counsel on record. Petitioner, not being a lawyer and unaware of
July 4, necessarily, the 15-day period already the prescriptive period for filing a motion for reconsideration,
passed. For that alone, the latter should be referred the same to a legal counsel only on 20 June 1995.
denied.

It is elementary that when a party is represented by counsel, all

Even assuming admissibility of the Motion notices should be sent to the party's lawyer at his given address.
for the Reconsideration, but after considering With a few exceptions, notice to a litigant without notice to his
the Comment/Opposition, the former, for lack counsel on record is no notice at all. In the present case, since a
of merit, is hereby DENIED. copy of the decision of the appellate court was not sent to the
counsel on record of petitioner, there can be no sufficient notice to
SO ORDERED. 10 speak of. Hence, the delay in the filing of the motion for
reconsideration cannot be taken against petitioner. Moreover,
since the Court of Appeals already issued a second Resolution,
dated 29 March 1996, which superseded the earlier resolution In the above requisites, the fundamental element is the "control of
issued on 25 July 1995, and denied the motion for reconsideration instrumentality" which caused the damage. 22Such element of
of petitioner, we believed that the receipt of the former should be control must be shown to be within the dominion of the
considered in determining the timeliness of the filing of the defendant. In order to have the benefit of the rule, a plaintiff, in
present petition. Based on this, the petition before us was addition to proving injury or damage, must show a situation
submitted on time. where it is applicable, and must establish that the essential
elements of the doctrine were present in a particular incident. 23
After resolving the foregoing procedural issue, we shall now look
into the merits of the case. For a more logical presentation of the Medical malpractice 24 cases do not escape the application of this
discussion we shall first consider the issue on the applicability of doctrine. Thus, res ipsa loquitur has been applied when the
the doctrine of res ipsa loquiturto the instant case. Thereafter, the circumstances attendant upon the harm are themselves of such a
first two assigned errors shall be tackled in relation to the res ipsa character as to justify an inference of negligence as the cause of
loquiturdoctrine. that harm. 25 The application of res ipsa loquitur in medical
negligence cases presents a question of law since it is a judicial
Res ipsa loquitur is a Latin phrase which literally means "the function to determine whether a certain set of circumstances does,
thing or the transaction speaks for itself." The phrase "res ipsa as a matter of law, permit a given inference. 26
loquitur'' is a maxim for the rule that the fact of the occurrence of
an injury, taken with the surrounding circumstances, may permit Although generally, expert medical testimony is relied upon in
an inference or raise a presumption of negligence, or make out a malpractice suits to prove that a physician has done a negligent
plaintiff's prima facie case, and present a question of fact for act or that he has deviated from the standard medical procedure,
defendant to meet with an explanation. 13 Where the thing which when the doctrine of res ipsa loquitur is availed by the plaintiff,
caused the injury complained of is shown to be under the the need for expert medical testimony is dispensed with because
management of the defendant or his servants and the accident is the injury itself provides the proof of negligence. 27 The reason is
such as in ordinary course of things does not happen if those who that the general rule on the necessity of expert testimony applies
have its management or control use proper care, it affords only to such matters clearly within the domain of medical science,
reasonable evidence, in the absence of explanation by the and not to matters that are within the common knowledge of
defendant, that the accident arose from or was caused by the mankind which may be testified to by anyone familiar with the
defendant's want of care. 14 facts. 28 Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has
The doctrine of res ipsa loquitur is simply a recognition of the been treated or operated upon with a reasonable degree of skill
postulate that, as a matter of common knowledge and experience, and care. However, testimony as to the statements and acts of
the very nature of certain types of occurrences may justify an physicians and surgeons, external appearances, and manifest
inference of negligence on the part of the person who controls the conditions which are observable by any one may be given by non-
instrumentality causing the injury in the absence of some expert witnesses. 29 Hence, in cases where the res ipsa loquitur is
explanation by the defendant who is charged with negligence. 15 It applicable, the court is permitted to find a physician negligent
is grounded in the superior logic of ordinary human experience upon proper proof of injury to the patient, without the aid of
and on the basis of such experience or common knowledge, expert testimony, where the court from its fund of common
negligence may be deduced from the mere occurrence of the knowledge can determine the proper standard of care. 30 Where
accident itself. 16 Hence, res ipsa loquitur is applied in common knowledge and experience teach that a resulting injury
conjunction with the doctrine of common knowledge. would not have occurred to the patient if due care had been
exercised, an inference of negligence may be drawn giving rise to
an application of the doctrine of res ipsa loquitur without medical
However, much has been said that res ipsa loquitur is not a rule of evidence, which is ordinarily required to show not only what
substantive law and, as such, does not create or constitute an occurred but how and why it occurred. 31 When the doctrine is
independent or separate ground of liability. 17 Instead, it is appropriate, all that the patient must do is prove a nexus between
considered as merely evidentiary or in the nature of a procedural the particular act or omission complained of and the injury
rule. 18 It is regarded as a mode of proof, or a mere procedural of sustained while under the custody and management of the
convenience since it furnishes a substitute for, and relieves a defendant without need to produce expert medical testimony to
plaintiff of, the burden of producing specific proof of establish the standard of care. Resort to res ipsa loquitur is
negligence. 19 In other words, mere invocation and application of allowed because there is no other way, under usual and ordinary
the doctrine does not dispense with the requirement of proof of conditions, by which the patient can obtain redress for injury
negligence. It is simply a step in the process of such proof, suffered by him.
permitting the plaintiff to present along with the proof of the
accident, enough of the attending circumstances to invoke the
doctrine, creating an inference or presumption of negligence, and Thus, courts of other jurisdictions have applied the doctrine in the
to thereby place on the defendant the burden of going forward following situations: leaving of a foreign object in the body of the
with the proof. 20 Still, before resort to the doctrine may be patient after an operation, 32 injuries sustained on a healthy part of
allowed, the following requisites must be satisfactorily shown: the body which was not under, or in the area, of
treatment, 33 removal of the wrong part of the body when another
part was intended, 34 knocking out a tooth while a patient's jaw
1. The accident is of a kind which ordinarily does not was under anesthetic for the removal of his tonsils, 35 and loss of
occur in the absence of someone's negligence; an eye while the patient plaintiff was under the influence of
anesthetic, during or following an operation for
2. It is caused by an instrumentality within the exclusive appendicitis, 36 among others.
control of the defendant or defendants; and
Nevertheless, despite the fact that the scope of res ipsa
3. The possibility of contributing conduct which would loquitur has been measurably enlarged, it does not automatically
make the plaintiff responsible is eliminated. 21 apply to all cases of medical negligence as to mechanically shift
the burden of proof to the defendant to show that he is not guilty
of the ascribed negligence. Res ipsa loquitur is not a rigid or
ordinary doctrine to be perfunctorily used but a rule to be than to the plaintiff for they had the exclusive control of the
cautiously applied, depending upon the circumstances of each instrumentalities of anesthesia.
case. It is generally restricted to situations in malpractice cases
where a layman is able to say, as a matter of common knowledge Upon all the facts, conditions and circumstances alleged in
and observation, that the consequences of professional care were Count II it is held that a cause of action is stated under the
not as such as would ordinarily have followed if due care had doctrine of res ipsa loquitur. 44
been 
exercised. 37 A distinction must be made between the failure to
secure results, and the occurrence of something more unusual and Indeed, the principles enunciated in the aforequoted case apply
not ordinarily found if the service or treatment rendered followed with equal force here. In the present case, Erlinda submitted
the usual procedure of those skilled in that particular practice. It herself for cholecystectomy and expected a routine general
must be conceded that the doctrine of res ipsa loquitur can have surgery to be performed on her gall bladder. On that fateful day
no application in a suit against a physician or surgeon which she delivered her person over to the care, custody and control of
involves the merits of a diagnosis or of a scientific private respondents who exercised complete and exclusive control
treatment. 38 The physician or surgeon is not required at his peril over her. At the time of submission, Erlinda was neurologically
to explain why any particular diagnosis was not correct, or why sound and, except for a few minor discomforts, was likewise
any particular scientific treatment did not produce the desired physically fit in mind and body. However, during the
result. 39 Thus, res ipsa loquitur is not available in a malpractice administration of anesthesia and prior to the performance of
suit if the only showing is that the desired result of an operation or cholecystectomy she suffered irreparable damage to her brain.
treatment was not accomplished. 40The real question, therefore, is Thus, without undergoing surgery, she went out of the operating
whether or not in the process of the operation any extraordinary room already decerebrate and totally incapacitated. Obviously,
incident or unusual event outside of the routine performance brain damage, which Erlinda sustained, is an injury which does
occurred which is beyond the regular scope of customary not normally occur in the process of a gall bladder operation. In
professional activity in such operations, which, if unexplained fact, this kind of situation does not in the absence of negligence of
would themselves reasonably speak to the average man as the someone in the administration of anesthesia and in the use of
negligent cause or causes of the untoward consequence. 41 If there endotracheal tube. Normally, a person being put under anesthesia
was such extraneous interventions, the doctrine of res ipsa is not rendered decerebrate as a consequence of administering
loquitur may be utilized and the defendant is called upon to such anesthesia if the proper procedure was followed.
explain the matter, by evidence of exculpation, if he could. 42 Furthermore, the instruments used in the administration of
anesthesia, including the endotracheal tube, were all under the
exclusive control of private respondents, who are the physicians-
We find the doctrine of res ipsa loquitur appropriate in the case at in-charge. Likewise, petitioner Erlinda could not have been guilty
bar. As will hereinafter be explained, the damage sustained by of contributory negligence because she was under the influence of
Erlinda in her brain prior to a scheduled gall bladder operation anesthetics which rendered her unconscious.
presents a case for the application of res ipsa loquitur.
Considering that a sound and unaffected member of the body (the
A case strikingly similar to the one before us is Voss brain) is injured or destroyed while the patient is unconscious and
vs. Bridwell, 43 where the Kansas Supreme Court in applying under the immediate and exclusive control of the physicians, we
the res ipsa loquitur stated: hold that a practical administration of justice dictates the
application of res ipsa loquitur. Upon these facts and under these
The plaintiff herein submitted himself for a circumstances the Court would be able to say, as a matter of
mastoid operation and delivered his person common knowledge and observation, if negligence attended the
over to the care, custody and control of his management and care of the patient. Moreover, the liability of the
physician who had complete and exclusive physicians and the hospital in this case is not predicated upon an
control over him, but the operation was never alleged failure to secure the desired results of an operation nor on
performed. At the time of submission he was an alleged lack of skill in the diagnosis or treatment as in fact no
neurologically sound and physically fit in operation or treatment was ever performed on Erlinda. Thus, upon
mind and body, but he suffered irreparable all these initial determination a case is made out for the
damage and injury rendering him decerebrate application of the doctrine of res ipsa loquitur.
and totally incapacitated. The injury was one
which does not ordinarily occur in the process Nonetheless, in holding that res ipsa loquitur is available to the
of a mastoid operation or in the absence of present case we are not saying that the doctrine is applicable in
negligence in the administration of an any and all cases where injury occurs to a patient while under
anesthetic, and in the use and employment of anesthesia, or to any and all anesthesia cases. Each case must be
an endoctracheal tube. Ordinarily a person viewed in its own light and scrutinized in order to be within
being put under anesthesia is not rendered the res ipsa loquitur coverage.
decerebrate as a consequence of administering
such anesthesia in the absence of negligence.
Upon these facts and under these Having in mind the applicability of the res ipsa loquitur doctrine
circumstances a layman would be able to say, and the presumption of negligence allowed therein, the Court now
as a matter of common knowledge and comes to the issue of whether the Court of Appeals erred in
observation, that the consequences of finding that private respondents were not negligent in the care of
professional treatment were not as such as Erlinda during the anesthesia phase of the operation and, if in the
would ordinarily have followed if due care affirmative, whether the alleged negligence was the proximate
had been exercised. cause of Erlinda's comatose condition. Corollary thereto, we shall
also determine if the Court of Appeals erred in relying on the
testimonies of the witnesses for the private respondents.
Here the plaintiff could not have been guilty of contributory
negligence because he was under the influence of anesthetics
and unconscious, and the circumstances are such that the true In sustaining the position of private respondents, the Court of
explanation of event is more accessible to the defendants Appeals relied on the testimonies of Dra. Gutierrez, Dra. Calderon
and Dr. Jamora. In giving weight to the testimony of Dra. x x x           x x x          x x x
Gutierrez, the Court of Appeals rationalized that she was candid
enough to admit that she experienced some difficulty in the ATTY. PAJARES:
endotracheal intubation 45 of the patient and thus, cannot be said
to be covering her negligence with falsehood. The appellate court
likewise opined that private respondents were able to show that Q: From whom did you hear those words
the brain damage sustained by Erlinda was not caused by the "lumalaki ang tiyan"?
alleged faulty intubation but was due to the allergic reaction of the
patient to the drug Thiopental Sodium (Pentothal), a short-acting A: From Dra. Perfecta Gutierrez.
barbiturate, as testified on by their expert witness, Dr. Jamora. On
the other hand, the appellate court rejected the testimony of Dean Q: After hearing the phrase "lumalaki ang tiyan,"
Herminda Cruz offered in favor of petitioners that the cause of the what did you notice on the person of the patient?
brain injury was traceable to the wrongful insertion of the tube
since the latter, being a nurse, was allegedly not knowledgeable in
the process of intubation. In so holding, the appellate court A: I notice (sic) some bluish discoloration on the
returned a verdict in favor of respondents physicians and hospital nailbeds of the left hand where I was at.
and absolved them of any liability towards Erlinda and her family.
Q: Where was Dr. Orlino Ho[s]aka then at that
We disagree with the findings of the Court of Appeals. We hold particular time?
that private respondents were unable to disprove the presumption
of negligence on their part in the care of Erlinda and their A: I saw him approaching the patient during that
negligence was the proximate cause of her piteous condition. time.

In the instant case, the records are helpful in furnishing not only Q: When he approached the patient, what did he
the logical scientific evidence of the pathogenesis of the injury but do, if any?
also in providing the Court the legal nexus upon which liability is
based. As will be shown hereinafter, private respondents' own
A: He made an order to call on the
testimonies which are reflected in the transcript of stenographic
anesthesiologist in the person of Dr. Calderon.
notes are replete of signposts indicative of their negligence in the
care and management of Erlinda.
Q: Did Dr. Calderon, upon being called, arrive
inside the operating room?
With regard to Dra. Gutierrez, we find her negligent in the care of
Erlinda during the anesthesia phase. As borne by the records,
respondent Dra. Gutierrez failed to properly intubate the patient. A: Yes sir.
This fact was attested to by Prof. Herminda Cruz, Dean of the
Capitol Medical Center School of Nursing and petitioner's sister- Q: What did [s]he do, if any?
in-law, who was in the operating room right beside the patient
when the tragic event occurred. Witness Cruz testified to this
A: [S]he tried to intubate the patient.
effect:

Q: What happened to the patient?

ATTY. PAJARES:

A: When Dr. Calderon try (sic) to intubate the

Q: In particular, what did Dra. Perfecta Gutierrez do, if any
patient, after a while the patient's nailbed became
on the patient?
bluish and I saw the patient was placed in
trendelenburg position.
A: In particular, I could see that she was intubating the
patient.
Q: Do you know the reason why the patient was
placed in that trendelenburg position?
Q: Do you know what happened to that intubation process
administered by Dra. Gutierrez?
A: As far as I know, when a patient is in that
position, there is a decrease of blood supply to the
ATTY. ALCERA: brain. 46

She will be incompetent Your Honor. x x x           x x x          x x x

COURT: The appellate court, however, disbelieved Dean Cruz's testimony

in the trial court by declaring that:
Witness may answer if she knows.
A perusal of the standard nursing curriculum
A: As have said, I was with the patient, I was in our country will show that intubation is not
beside the stretcher holding the left hand of the taught as part of nursing procedures and
patient and all of a sudden heard some remarks techniques. Indeed, we take judicial notice of
coming from Dra. Perfecta Gutierrez herself. the fact that nurses do not, and cannot,
She was saying "Ang hirap ma-intubate nito, intubate. Even on the assumption that she is
mali yata ang pagkakapasok. O lumalaki ang fully capable of determining whether or not a
tiyan. patient is properly intubated, witness
Herminda Cruz, admittedly, did not peep into Q: Did you pull away the tube immediately?
the throat of the patient. (TSN, July 25, 1991,
p. 13). More importantly, there is no evidence A: You do not pull the . . .
that she ever auscultated the patient or that
she conducted any type of examination to
check if the endotracheal tube was in its Q: Did you or did you not?
proper place, and to determine the condition
of the heart, lungs, and other organs. Thus, A: I did not pull the tube.
witness Cruz's categorical statements that
appellant Dra. Gutierrez failed to intubate the Q: When you said "mahirap yata ito," what were you
appellee Erlinda Ramos and that it was Dra. referring to?
Calderon who succeeded in doing so clearly
suffer from lack of sufficient factual bases. 47
A: "Mahirap yata itong i-intubate," that was the patient.
In other words, what the Court of Appeals is trying to impress is
that being a nurse, and considered a layman in the process of Q: So, you found some difficulty in inserting the tube?
intubation, witness Cruz is not competent to testify on whether or
not the intubation was a success. A: Yes, because of (sic) my first attempt, I did not see right
away. 51
We do not agree with the above reasoning of the appellate court.
Although witness Cruz is not an anesthesiologist, she can very Curiously in the case at bar, respondent Dra. Gutierrez made the
well testify upon matters on which she is capable of observing haphazard defense that she encountered hardship in the insertion
such as, the statements and acts of the physician and surgeon, of the tube in the trachea of Erlinda because it was positioned
external appearances, and manifest conditions which are more anteriorly (slightly deviated from the normal anatomy of a
observable by any one. 48 This is precisely allowed under the person) 52 making it harder to locate and, since Erlinda is obese
doctrine of res ipsa loquitur where the testimony of expert and has a short neck and protruding teeth, it made intubation even
witnesses is not required. It is the accepted rule that expert more difficult.
testimony is not necessary for the proof of negligence in non-
technical matters or those of which an ordinary person may be
The argument does not convince us. If this was indeed observed,
expected to have knowledge, or where the lack of skill or want of
private respondents adduced no evidence demonstrating that they
care is so obvious as to render expert testimony
proceeded to make a thorough assessment of Erlinda's airway,
unnecessary. 49 We take judicial notice of the fact that anesthesia
prior to the induction of anesthesia, even if this would mean
procedures have become so common, that even an ordinary
postponing the procedure. From their testimonies, it appears that
person can tell if it was administered properly. As such, it would
the observation was made only as an afterthought, as a means of
not be too difficult to tell if the tube was properly inserted. This
defense.
kind of observation, we believe, does not require a medical degree
to be acceptable.
The pre-operative evaluation of a patient prior to the
administration of anesthesia is universally observed to lessen the
At any rate, without doubt, petitioner's witness, an experienced
possibility of anesthetic accidents. Pre-operative evaluation and
clinical nurse whose long experience and scholarship led to her
preparation for anesthesia begins when the anesthesiologist
appointment as Dean of the Capitol Medical Center School at
reviews the patient's medical records and visits with the patient,
Nursing, was fully capable of determining whether or not the
traditionally, the day before elective surgery. 53 It includes taking
intubation was a success. She had extensive clinical experience
the patient's medical history, review of current drug therapy,
starting as a staff nurse in Chicago, Illinois; staff nurse and
physical examination and interpretation of laboratory data. 54 The
clinical instructor in a teaching hospital, the FEU-NRMF; Dean of
physical examination performed by the anesthesiologist is
the Laguna College of Nursing in San Pablo City; and then Dean
directed primarily toward the central nervous system,
of the Capitol Medical Center School of Nursing. 50Reviewing
cardiovascular system, lungs and upper airway. 55 A thorough
witness Cruz' statements, we find that the same were delivered in
analysis of the patient's airway normally involves investigating
a straightforward manner, with the kind of detail, clarity,
the following: cervical spine mobility, temporomandibular
consistency and spontaneity which would have been difficult to
mobility, prominent central incisors, diseased or artificial teeth,
fabricate. With her clinical background as a nurse, the Court is
ability to visualize uvula and the thyromental distance. 56Thus,
satisfied that she was able to demonstrate through her testimony
physical characteristics of the patient's upper airway that could
what truly transpired on that fateful day.
make tracheal intubation difficult should be studied. 57 Where the
need arises, as when initial assessment indicates possible
Most of all, her testimony was affirmed by no less than problems (such as the alleged short neck and protruding teeth of
respondent Dra. Gutierrez who admitted that she experienced Erlinda) a thorough examination of the patient's airway would go
difficulty in inserting the tube into Erlinda's trachea, to wit: a long way towards decreasing patient morbidity and mortality.

ATTY. LIGSAY: In the case at bar, respondent Dra. Gutierrez admitted that she saw
Erlinda for the first time on the day of the operation itself, on 17
Q: In this particular case, Doctora, while you were intubating at June 1985. Before this date, no prior consultations with, or pre-
your first attempt (sic), you did not immediately see the trachea? operative evaluation of Erlinda was done by her. Until the day of
the operation, respondent Dra. Gutierrez was unaware of the
physiological make-up and needs of Erlinda. She was likewise not
DRA. GUTIERREZ: properly informed of the possible difficulties she would face
during the administration of anesthesia to Erlinda. Respondent
A: Yes sir. Dra. Gutierrez' act of seeing her patient for the first time only an
hour before the scheduled operative procedure was, therefore, an
act of exceptional negligence and professional irresponsibility.
The measures cautioning prudence and vigilance in dealing with the short-acting barbiturate. We find the theory of private
human lives lie at the core of the physician's centuries-old respondents unacceptable.
Hippocratic Oath. Her failure to follow this medical procedure is,
therefore, a clear indicia of her negligence. First of all, Dr. Jamora cannot be considered an authority in the
field of anesthesiology simply because he is not an
Respondent Dra. Gutierrez, however, attempts to gloss over this anesthesiologist. Since Dr. Jamora is a pulmonologist, he could
omission by playing around with the trial court's ignorance of not have been capable of properly enlightening the court about
clinical procedure, hoping that she could get away with it. anesthesia practice and procedure and their complications. Dr.
Respondent Dra. Gutierrez tried to muddle the difference between Jamora is likewise not an allergologist and could not therefore
an elective surgery and an emergency surgery just so her failure to properly advance expert opinion on allergic-mediated processes.
perform the required pre-operative evaluation would escape Moreover, he is not a pharmacologist and, as such, could not have
unnoticed. In her testimony she asserted: been capable, as an expert would, of explaining to the court the
pharmacologic and toxic effects of the supposed culprit,
ATTY. LIGSAY: Thiopental Sodium (Pentothal).

Q: Would you agree, Doctor, that it is good medical practice The inappropriateness and absurdity of accepting Dr. Jamora's
to see the patient a day before so you can introduce yourself to testimony as an expert witness in the anesthetic practice of
establish good doctor-patient relationship and gain the trust Pentothal administration is further supported by his own
and confidence of the patient? admission that he formulated his opinions on the drug not from
the practical experience gained by a specialist or expert in the
administration and use of Sodium Pentothal on patients, but only
DRA. GUTIERREZ: from reading certain references, to wit:

A: As I said in my previous statement, it depends on the ATTY. LIGSAY:

operative procedure of the anesthesiologist and in my case,
with elective cases and normal cardio-pulmonary clearance
like that, I usually don't do it except on emergency and on Q: In your line of expertise on pulmonology, did you have any
cases that have an abnormalities (sic). 58 occasion to use pentothal as a method of management?

However, the exact opposite is true. In an emergency procedure, DR. JAMORA:

there is hardly enough time available for the fastidious demands
of pre-operative procedure so that an anesthesiologist is able to A: We do it in conjunction with the anesthesiologist when they
see the patient only a few minutes before surgery, if at all. have to intubate our patient.
Elective procedures, on the other hand, are operative procedures
that can wait for days, weeks or even months. Hence, in these Q: But not in particular when you practice pulmonology?
cases, the anesthesiologist possesses the luxury of time to be at
the patient's beside to do a proper interview and clinical
evaluation. There is ample time to explain the method of A: No.
anesthesia, the drugs to be used, and their possible hazards for
purposes of informed consent. Usually, the pre-operative Q: In other words, your knowledge about pentothal is based
assessment is conducted at least one day before the intended only on what you have read from books and not by your own
surgery, when the patient is relaxed and cooperative. personal application of the medicine pentothal?

Erlinda's case was elective and this was known to respondent Dra. A: Based on my personal experience also on pentothal.
Gutierrez. Thus, she had all the time to make a thorough
evaluation of Erlinda's case prior to the operation and prepare her Q: How many times have you used pentothal?
for anesthesia. However, she never saw the patient at the bedside.
She herself admitted that she had seen petitioner only in the
operating room, and only on the actual date of the A: They used it on me. I went into bronchospasm during my
cholecystectomy. She negligently failed to take advantage of this appendectomy.
important opportunity. As such, her attempt to exculpate herself
must fail. Q: And because they have used it on you and on account of
your own personal experience you feel that you can testify on
Having established that respondent Dra. Gutierrez failed to pentothal here with medical authority?
perform pre-operative evaluation of the patient which, in turn,
resulted to a wrongful intubation, we now determine if the faulty A: No. That is why I used references to support my claims. 61
intubation is truly the proximate cause of Erlinda's comatose
condition.
An anesthetic accident caused by a rare drug-induced
bronchospasm properly falls within the fields of anesthesia,
Private respondents repeatedly hammered the view that the internal medicine-allergy, and clinical pharmacology. The
cerebral anoxia which led to Erlinda's coma was due to resulting anoxic encephalopathy belongs to the field of neurology.
bronchospasm 59 mediated by her allergic response to the drug, While admittedly, many bronchospastic-mediated pulmonary
Thiopental Sodium, introduced into her system. Towards this end, diseases are within the expertise of pulmonary medicine, Dr.
they presented Dr. Jamora, a Fellow of the Philippine College of Jamora's field, the anesthetic drug-induced, allergic mediated
Physicians and Diplomate of the Philippine Specialty Board of bronchospasm alleged in this case is within the disciplines of
Internal Medicine, who advanced private respondents' theory that anesthesiology, allergology and pharmacology. On the basis of
the oxygen deprivation which led to anoxic the foregoing transcript, in which the pulmonologist himself
encephalopathy, 60 was due to an unpredictable drug reaction to admitted that he could not testify about the drug with medical
authority, it is clear that the appellate court erred in giving weight noticed abdominal distention on the body of Erlinda. The
to Dr. Jamora's testimony as an expert in the administration of development of abdominal distention, together with respiratory
Thiopental Sodium. embarrassment indicates that the endotracheal tube entered the
esophagus instead of the respiratory tree. In other words, instead
The provision in the rules of evidence 62 regarding expert of the intended endotracheal intubation what actually took place
witnesses states: was an esophageal intubation. During intubation, such distention
indicates that air has entered the gastrointestinal tract through the
esophagus instead of the lungs through the trachea. Entry into the
Sec. 49. Opinion of expert witness. — The esophagus would certainly cause some delay in oxygen delivery
opinion of a witness on a matter requiring into the lungs as the tube which carries oxygen is in the wrong
special knowledge, skill, experience or place. That abdominal distention had been observed during the
training which he is shown to possess, may be first intubation suggests that the length of time utilized in
received in evidence. inserting the endotracheal tube (up to the time the tube was
withdrawn for the second attempt) was fairly significant. Due to
Generally, to qualify as an expert witness, one must have acquired the delay in the delivery of oxygen in her lungs Erlinda showed
special knowledge of the subject matter about which he or she is signs of cyanosis. 66 As stated in the testimony of Dr. Hosaka, the
to testify, either by the study of recognized authorities on the lack of oxygen became apparent only after he noticed that the
subject or by practical experience. 63Clearly, Dr. Jamora does not nailbeds of Erlinda were already blue. 67 However, private
qualify as an expert witness based on the above standard since he respondents contend that a second intubation was executed on
lacks the necessary knowledge, skill, and training in the field of Erlinda and this one was successfully done. We do not think so.
anesthesiology. Oddly, apart from submitting testimony from a No evidence exists on record, beyond private respondents' bare
specialist in the wrong field, private respondents' intentionally claims, which supports the contention that the second intubation
avoided providing testimony by competent and independent was successful. Assuming that the endotracheal tube finally found
experts in the proper areas. its way into the proper orifice of the trachea, the same gave no
guarantee of oxygen delivery, the hallmark of a successful
Moreover, private respondents' theory, that Thiopental Sodium intubation. In fact, cyanosis was again observed immediately after
may have produced Erlinda's coma by triggering an allergic the second intubation. Proceeding from this event (cyanosis), it
mediated response, has no support in evidence. No evidence of could not be claimed, as private respondents insist, that the second
stridor, skin reactions, or wheezing — some of the more common intubation was accomplished. Even granting that the tube was
accompanying signs of an allergic reaction — appears on record. successfully inserted during the second attempt, it was obviously
No laboratory data were ever presented to the court. too late. As aptly explained by the trial court, Erlinda already
suffered brain damage as a result of the inadequate oxygenation of
her brain for about four to five minutes. 68
In any case, private respondents themselves admit that Thiopental
induced, allergic-mediated bronchospasm happens only very
rarely. If courts were to accept private respondents' hypothesis The above conclusion is not without basis. Scientific studies point
without supporting medical proof, and against the weight of out that intubation problems are responsible for one-third (1/3) of
available evidence, then every anesthetic accident would be an act deaths and serious injuries associated with
of God. Evidently, the Thiopental-allergy theory vigorously anesthesia. 69 Nevertheless, ninety-eight percent (98%) or the vast
asserted by private respondents was a mere afterthought. Such an majority of difficult intubations may be anticipated by performing
explanation was advanced in order to advanced in order to a thorough evaluation of the patient's airway prior to the
absolve them of any and all responsibility for the patient's operation. 70 As stated beforehand, respondent Dra. Gutierrez
condition. failed to observe the proper pre-operative protocol which could
have prevented this unfortunate incident. Had appropriate
diligence and reasonable care been used in the pre-operative
In view of the evidence at hand, we are inclined to believe evaluation, respondent physician could have been much more
petitioners' stand that it was the faulty intubation which was the prepared to meet the contingency brought about by the perceived
proximate cause of Erlinda's comatose condition. anatomic variations in the patient's neck and oral area, defects
which would have been easily overcome by a prior knowledge of
Proximate cause has been defined as that which, in natural and those variations together with a change in technique. 71 In other
continuous sequence, unbroken by any efficient intervening words, an experienced anesthesiologist, adequately alerted by a
cause, produces injury, and without which the result would not thorough pre-operative evaluation, would have had little difficulty
have occurred. 64 An injury or damage is proximately caused by going around the short neck and protruding teeth. 72 Having failed
an act or a failure to act, whenever it appears from the evidence in to observe common medical standards in pre-operative
the case, that the act or omission played a substantial part in management and intubation, respondent Dra. Gutierrez'
bringing about or actually causing the injury or damage; and that negligence resulted in cerebral anoxia and eventual coma of
the injury or damage was either a direct result or a reasonably Erlinda.
probable consequence of the act or omission. 65 It is the dominant,
moving or producing cause. We now determine the responsibility of respondent Dr. Orlino
Hosaka as the head of the surgical team. As the so-called "captain
Applying the above definition in relation to the evidence at hand, of the ship," 73 it is the surgeon's responsibility to see to it that
faulty intubation is undeniably the proximate cause which those under him perform their task in the proper manner.
triggered the chain of events leading to Erlinda's brain damage Respondent Dr. Hosaka's negligence can be found in his failure to
and, ultimately, her comatosed condition. exercise the proper authority (as the "captain" of the operative
team) in not determining if his anesthesiologist observed proper
anesthesia protocols. In fact, no evidence on record exists to show
Private respondents themselves admitted in their testimony that
that respondent Dr. Hosaka verified if respondent Dra. Gutierrez
the first intubation was a failure. This fact was likewise observed
properly intubated the patient. Furthermore, it does not escape us
by witness Cruz when she heard respondent Dra. Gutierrez
that respondent Dr. Hosaka had scheduled another procedure in a
remarked, "Ang hirap ma-intubate nito, mali yata ang
different hospital at the same time as Erlinda's cholecystectomy,
pagkakapasok. O lumalaki ang tiyan." Thereafter, witness Cruz
and was in fact over three hours late for the latter's operation.
Because of this, he had little or no time to confer with his In the instant case, respondent hospital, apart from a general
anesthesiologist regarding the anesthesia delivery. This indicates denial of its responsibility over respondent physicians, failed to
that he was remiss in his professional duties towards his patient. adduce evidence showing that it exercised the diligence of a good
Thus, he shares equal responsibility for the events which resulted father of a family in the hiring and supervision of the latter. It
in Erlinda's condition. failed to adduce evidence with regard to the degree of supervision
which it exercised over its physicians. In neglecting to offer such
We now discuss the responsibility of the hospital in this particular proof, or proof of a similar nature, respondent hospital thereby
incident. The unique practice (among private hospitals) of filling failed to discharge its burden under the last paragraph of Article
up specialist staff with attending and visiting "consultants," 74 who 2180. Having failed to do this, respondent hospital is
are allegedly not hospital employees, presents problems in consequently solidarily responsible with its physicians for
apportioning responsibility for negligence in medical malpractice Erlinda's condition.
cases. However, the difficulty is only more apparent than real.
Based on the foregoing, we hold that the Court of Appeals erred
In the first place, hospitals exercise significant control in the in accepting and relying on the testimonies of the witnesses for
hiring and firing of consultants and in the conduct of their work the private respondents. Indeed, as shown by the above
within the hospital premises. Doctors who apply for "consultant" discussions, private respondents were unable to rebut the
slots, visiting or attending, are required to submit proof of presumption of negligence. Upon these disquisitions we hold that
completion of residency, their educational qualifications; private respondents are solidarily liable for damages under Article
generally, evidence of accreditation by the appropriate board 2176 79 of the Civil Code.
(diplomate), evidence of fellowship in most cases, and references.
These requirements are carefully scrutinized by members of the We now come to the amount of damages due petitioners. The trial
hospital administration or by a review committee set up by the court awarded a total of P632,000.00 pesos (should be
hospital who either accept or reject the application. 75 This is P616,000.00) in compensatory damages to the plaintiff, "subject
particularly true with respondent hospital. to its being updated" covering the period from 15 November 1985
up to 15 April 1992, based on monthly expenses for the care of
After a physician is accepted, either as a visiting or attending the patient estimated at P8,000.00.
consultant, he is normally required to attend clinico-pathological
conferences, conduct bedside rounds for clerks, interns and At current levels, the P8000/monthly amount established by the
residents, moderate grand rounds and patient audits and perform trial court at the time of its decision would be grossly inadequate
other tasks and responsibilities, for the privilege of being able to to cover the actual costs of home-based care for a comatose
maintain a clinic in the hospital, and/or for the privilege of individual. The calculated amount was not even arrived at by
admitting patients into the hospital. In addition to these, the looking at the actual cost of proper hospice care for the patient.
physician's performance as a specialist is generally evaluated by a What it reflected were the actual expenses incurred and proved by
peer review committee on the basis of mortality and morbidity the petitioners after they were forced to bring home the patient to
statistics, and feedback from patients, nurses, interns and avoid mounting hospital bills.
residents. A consultant remiss in his duties, or a consultant who
regularly falls short of the minimum standards acceptable to the And yet ideally, a comatose patient should remain in a hospital or
hospital or its peer review committee, is normally politely be transferred to a hospice specializing in the care of the
terminated. chronically ill for the purpose of providing a proper milieu
adequate to meet minimum standards of care. In the instant case
In other words, private hospitals, hire, fire and exercise real for instance, Erlinda has to be constantly turned from side to side
control over their attending and visiting "consultant" staff. While to prevent bedsores and hypostatic pneumonia. Feeding is done by
"consultants" are not, technically employees, a point which nasogastric tube. Food preparation should be normally made by a
respondent hospital asserts in denying all responsibility for the dietitian to provide her with the correct daily caloric requirements
patient's condition, the control exercised, the hiring, and the right and vitamin supplements. Furthermore, she has to be seen on a
to terminate consultants all fulfill the important hallmarks of an regular basis by a physical therapist to avoid muscle atrophy, and
employer-employee relationship, with the exception of the by a pulmonary therapist to prevent the accumulation of
payment of wages. In assessing whether such a relationship in fact secretions which can lead to respiratory complications.
exists, the control test is determining. Accordingly, on the basis of
the foregoing, we rule that for the purpose of allocating Given these considerations, the amount of actual damages
responsibility in medical negligence cases, an employer-employee recoverable in suits arising from negligence should at least reflect
relationship in effect exists between hospitals and their attending the correct minimum cost of proper care, not the cost of the care
and visiting physicians. This being the case, the question now the family is usually compelled to undertake at home to avoid
arises as to whether or not respondent hospital is solidarily liable bankruptcy. However, the provisions of the Civil Code on actual
with respondent doctors for petitioner's condition. 76 or compensatory damages present us with some difficulties.

The basis for holding an employer solidarily responsible for the Well-settled is the rule that actual damages which may be claimed
negligence of its employee is found in Article 2180 of the Civil by the plaintiff are those suffered by him as he has duly proved.
Code which considers a person accountable not only for his own The Civil Code provides:
acts but also for those of others based on the former's
responsibility under a relationship of patria potestas. 77 Such
responsibility ceases when the persons or entity concerned prove Art. 2199. — Except as provided by law or by
that they have observed the diligence of a good father of the stipulation, one is entitled to an adequate
family to prevent damage. 78 In other words, while the burden of compensation only for such pecuniary loss
proving negligence rests on the plaintiffs, once negligence is suffered by him as he has duly proved. Such
shown, the burden shifts to the respondents (parent, guardian, compensation is referred to as actual or
teacher or employer) who should prove that they observed the compensatory damages.
diligence of a good father of a family to prevent damage.
Our rules on actual or compensatory damages generally assume These adjustments entail costs, prosthetic
that at the time of litigation, the injury suffered as a consequence replacements and months of physical and
of an act of negligence has been completed and that the cost can occupational rehabilitation and therapy.
be liquidated. However, these provisions neglect to take into During the lifetime, the prosthetic devise will
account those situations, as in this case, where the resulting injury have to be replaced and readjusted to changes
might be continuing and possible future complications directly in the size of her lower limb effected by the
arising from the injury, while certain to occur, are difficult to biological changes of middle-age, menopause
predict. and aging. Assuming she reaches menopause,
for example, the prosthetic will have to be
In these cases, the amount of damages which should be awarded, adjusted to respond to the changes in bone
if they are to adequately and correctly respond to the injury resulting from a precipitate decrease in
caused, should be one which compensates for pecuniary loss calcium levels observed in the bones of all
incurred and proved, up to the time of trial; and one which would post-menopausal women. In other words, the
meet pecuniary loss certain to be suffered but which could not, damage done to her would not only be
from the nature of the case, be made with certainty. 80 In other permanent and lasting, it would also be
words, temperate damages can and should be awarded on top of permanently changing and adjusting to the
actual or compensatory damages in instances where the injury is physiologic changes which her body would
chronic and continuing. And because of the unique nature of such normally undergo through the years. The
cases, no incompatibility arises when both actual and temperate replacements, changes, and adjustments will
damages are provided for. The reason is that these damages cover require corresponding adjustive physical and
two distinct phases. occupational therapy. All of these
adjustments, it has been documented, are
painful.
As it would not be equitable — and certainly not in the best
interests of the administration of justice — for the victim in such
cases to constantly come before the courts and invoke their aid in x x x           x x x          x x x
seeking adjustments to the compensatory damages previously
awarded — temperate damages are appropriate. The amount A prosthetic devise, however technologically
given as temperate damages, though to a certain extent advanced, will only allow a reasonable
speculative, should take into account the cost of proper care. amount of functional restoration of the motor
functions of the lower limb. The sensory
In the instant case, petitioners were able to provide only home- functions are forever lost. The resultant
based nursing care for a comatose patient who has remained in anxiety, sleeplessness, psychological injury,
that condition for over a decade. Having premised our award for mental and physical pain are inestimable. 83
compensatory damages on the amount provided by petitioners at
the onset of litigation, it would be now much more in step with The injury suffered by Erlinda as a consequence of private
the interests of justice if the value awarded for temperate damages respondents' negligence is certainly much more serious than the
would allow petitioners to provide optimal care for their loved amputation in the Valenzuela case.
one in a facility which generally specializes in such care. They
should not be compelled by dire circumstances to provide Petitioner Erlinda Ramos was in her mid-forties when the incident
substandard care at home without the aid of professionals, for occurred. She has been in a comatose state for over fourteen years
anything less would be grossly inadequate. Under the now. The burden of care has so far been heroically shouldered by
circumstances, an award of P1,500,000.00 in temperate damages her husband and children, who, in the intervening years have been
would therefore be reasonable. 81 deprived of the love of a wife and a mother.

In Valenzuela vs. Court of Appeals, 82 this Court was confronted Meanwhile, the actual physical, emotional and financial cost of
with a situation where the injury suffered by the plaintiff would the care of petitioner would be virtually impossible to quantify.
have led to expenses which were difficult to estimate because Even the temperate damages herein awarded would be inadequate
while they would have been a direct result of the injury if petitioner's condition remains unchanged for the next ten years.
(amputation), and were certain to be incurred by the plaintiff, they
were likely to arise only in the future. We awarded P1,000,000.00
in moral damages in that case. We recognized, in Valenzuela that a discussion of the victim's
actual injury would not even scratch the surface of the resulting
moral damage because it would be highly speculative to estimate
Describing the nature of the injury, the Court therein stated: the amount of emotional and moral pain, psychological damage
and injury suffered by the victim or those actually affected by the
As a result of the accident, Ma. Lourdes victim's condition. 84 The husband and the children, all petitioners
Valenzuela underwent a traumatic amputation in this case, will have to live with the day to day uncertainty of
of her left lower extremity at the distal left the patient's illness, knowing any hope of recovery is close to nil.
thigh just above the knee. Because of this, They have fashioned their daily lives around the nursing care of
Valenzuela will forever be deprived of the full petitioner, altering their long term goals to take into account their
ambulatory functions of her left extremity, life with a comatose patient. They, not the respondents, are
even with the use of state of the art prosthetic charged with the moral responsibility of the care of the victim.
technology. Well beyond the period of The family's moral injury and suffering in this case is clearly a
hospitalization (which was paid for by Li), real one. For the foregoing reasons, an award of P2,000,000.00 in
she will be required to undergo adjustments in moral damages would be appropriate.
her prosthetic devise due to the shrinkage of
the stump from the process of healing. Finally, by way of example, exemplary damages in the amount of
P100,000.00 are hereby awarded. Considering the length and
nature of the instant suit we are of the opinion that attorney's fees the operation on her. The operation was scheduled for June 17,
valued at P100,000.00 are likewise proper. 1985 at 9:00 in the morning at private respondent De Los Santos
Medical Center (DLSMC). Since neither petitioner Erlinda nor
Our courts face unique difficulty in adjudicating medical her husband, petitioner Rogelio, knew of any anesthesiologist, Dr.
negligence cases because physicians are not insurers of life and, Hosaka recommended to them the services of Dr. Gutierrez.
they rarely set out to intentionally cause injury or death to their
patients. However, intent is immaterial in negligence cases Petitioner Erlinda was admitted to the DLSMC the day before the
because where negligence exists and is proven, the same scheduled operation. By 7:30 in the morning of the following day,
automatically gives the injured a right to reparation for the petitioner Erlinda was already being prepared for operation. Upon
damage caused. the request of petitioner Erlinda, her sister-in-law, Herminda
Cruz, who was then Dean of the College of Nursing at the Capitol
Established medical procedures and practices, though in constant Medical Center, was allowed to accompany her inside the
flux are devised for the purpose of preventing complications. A operating room.
physician's experience with his patients would sometimes tempt
him to deviate from established community practices, and he may At around 9:30 in the morning, Dr. Hosaka had not yet arrived so
end a distinguished career using unorthodox methods without Dr. Gutierrez tried to get in touch with him by phone. Thereafter,
incident. However, when failure to follow established procedure Dr. Gutierrez informed Cruz that the operation might be delayed
results in the evil precisely sought to be averted by observance of due to the late arrival of Dr. Hosaka. In the meantime, the patient,
the procedure and a nexus is made between the deviation and the petitioner Erlinda said to Cruz, "Mindy, inip na inip na ako, ikuha
injury or damage, the physician would necessarily be called to mo ako ng ibang Doctor."
account for it. In the case at bar, the failure to observe pre-
operative assessment protocol which would have influenced the By 10:00 in the morning, when Dr. Hosaka was still not around,
intubation in a salutary way was fatal to private respondents' case. petitioner Rogelio already wanted to pull out his wife from the
operating room. He met Dr. Garcia, who remarked that he was
WHEREFORE, the decision and resolution of the appellate court also tired of waiting for Dr. Hosaka. Dr. Hosaka finally arrived at
appealed from are hereby modified so as to award in favor of the hospital at around 12:10 in the afternoon, or more than three
petitioners, and solidarily against private respondents the (3) hours after the scheduled operation.
following: 1) P1,352,000.00 as actual damages computed as of the
date of promulgation of this decision plus a monthly payment of Cruz, who was then still inside the operating room, heard about
P8,000.00 up to the time that petitioner Erlinda Ramos expires or Dr. Hosaka’s arrival. While she held the hand of Erlinda, Cruz
miraculously survives; 2) P2,000,000.00 as moral damages, 3) saw Dr. Gutierrez trying to intubate the patient. Cruz heard Dr.
P1,500,000.00 as temperate damages; 4) P100,000.00 each as Gutierrez utter: "ang hirap ma-intubate nito, mali yata ang
exemplary damages and attorney's fees; and, 5) the costs of the pagkakapasok. O lumalaki ang tiyan." Cruz noticed a bluish
suit. discoloration of Erlinda’s nailbeds on her left hand. She (Cruz)
then heard Dr. Hosaka instruct someone to call Dr. Calderon,
SO ORDERED. another anesthesiologist. When he arrived, Dr. Calderon
attempted to intubate the patient. The nailbeds of the patient
G.R. No. 124354            April 11, 2002 remained bluish, thus, she was placed in a trendelenburg position
– a position where the head of the patient is placed in a position
lower than her feet. At this point, Cruz went out of the operating
ROGELIO E. RAMOS and ERLINDA RAMOS, in their own room to express her concern to petitioner Rogelio that Erlinda’s
behalf and as natural guardians of the minors, ROMMEL operation was not going well.
RAMOS, ROY RODERICK RAMOS, and RON RAYMOND
RAMOS, petitioners, 
vs. Cruz quickly rushed back to the operating room and saw that the
COURT OF APPEALS, DE LOS SANTOS MEDICAL patient was still in trendelenburg position. At almost 3:00 in the
CENTER, DR. ORLINO HOSAKA and DR. PERFECTA afternoon, she saw Erlinda being wheeled to the Intensive Care
GUTIERREZ, respondents. Unit (ICU). The doctors explained to petitioner Rogelio that his
wife had bronchospasm. Erlinda stayed in the ICU for a month.
She was released from the hospital only four months later or on
RESOLUTION November 15, 1985. Since the ill-fated operation, Erlinda
remained in comatose condition until she died on August 3,
KAPUNAN, J.: 1999.1

Private respondents De Los Santos Medical Center, Dr. Orlino Petitioners filed with the Regional Trial Court of Quezon City a
Hosaka and Dr. Perfecta Gutierrez move for a reconsideration of civil case for damages against private respondents. After due trial,
the Decision, dated December 29, 1999, of this Court holding the court a quo rendered judgment in favor of petitioners.
them civilly liable for petitioner Erlinda Ramos’ comatose Essentially, the trial court found that private respondents were
condition after she delivered herself to them for their professional negligent in the performance of their duties to Erlinda. On appeal
care and management. by private respondents, the Court of Appeals reversed the trial
court’s decision and directed petitioners to pay their "unpaid
For better understanding of the issues raised in private medical bills" to private respondents.
respondents’ respective motions, we will briefly restate the facts
of the case as follows: Petitioners filed with this Court a petition for review on certiorari.
The private respondents were then required to submit their
Sometime in 1985, petitioner Erlinda Ramos, after seeking respective comments thereon. On December 29, 1999, this Court
professional medical help, was advised to undergo an operation promulgated the decision which private respondents now seek to
for the removal of a stone in her gall bladder (cholecystectomy). be reconsidered. The dispositive portion of said Decision states:
She was referred to Dr. Hosaka, a surgeon, who agreed to perform
WHEREFORE, the decision and resolution of the B.2 RESPONDENT DOCTOR PERFECTA
appellate court appealed from are hereby modified so as GUTIERREZ HAS SUFFICIENTLY
to award in favor of petitioners, and solidarily against DISCHARGED THE BURDEN OF
private respondents the following: 1) P1,352,000.00 as EVIDENCE BY SUBSTANTIAL PROOF
actual damages computed as of the date of promulgation OF HER HAVING SUCCESSFULLY
of this decision plus a monthly payment of P8,000.00 INTUBATED PATIENT ERLINDA RAMOS
up to the time that petitioner Erlinda Ramos expires or
miraculously survives; 2) P2,000,000.00 as moral C. THE SUPREME COURT MAY HAVE
damages, 3) P1,500,000.00 as temperate damages; 4) INADVERTENTLY PLACED TOO MUCH
P100,000.00 each exemplary damages and attorney’s RELIANCE ON THE TESTIMONY OF
fees; and 5) the costs of the suit.2 PETITIONER’S WITNESS HERMINDA CRUZ,
DESPITE THE EXISTENCE OF SEVERAL
In his Motion for Reconsideration, private respondent Dr. Hosaka FACTUAL CIRCUMSTANCES WHICH RENDERS
submits the following as grounds therefor: DOUBT ON HER CREDIBILITY

I D. THE SUPREME COURT MAY HAVE

INADVERTENTLY DISREGARDED THE EXPERT
THE HONORABLE SUPREME COURT COMMITTED TESTIMONY OF DR. JAMORA AND DRA.
REVERSIBLE ERROR WHEN IT HELD RESPONDENT DR. CALDERON
HOSAKA LIABLE ON THE BASIS OF THE "CAPTAIN-OF-
THE-SHIP" DOCTRINE. E. THE HONORABLE SUPREME COURT MAY
HAVE INADVERTENTLY AWARDED DAMAGES
II TO PETITIONERS DESPITE THE FACT THAT
THERE WAS NO NEGLIGENCE ON THE PART OF
RESPONDENT DOCTOR.4
THE HONORABLE SUPREME COURT ERRED IN HOLDING
RESPONDENT DR. HOSAKA LIABLE DESPITE THE FACT
THAT NO NEGLIGENCE CAN BE ATTRIBUTABLE TO Private respondent De Los Santos Medical Center likewise moves
HIM. for reconsideration on the following grounds:

III I

ASSUMING WITHOUT ADMITTING THAT RESPONDENT THE HONORABLE COURT ERRED IN GIVING DUE
DR. HOSAKA IS LIABLE, THE HONORABLE SUPREME COURSE TO THE INSTANT PETITION AS THE DECISION
COURT ERRED IN AWARDING DAMAGES THAT WERE OF THE HONORABLE COURT OF APPEALS HAD
CLEARLY EXCESSIVE AND WITHOUT LEGAL BASIS.3 ALREADY BECOME FINAL AND EXECUTORY

Private respondent Dr. Gutierrez, for her part, avers that: II

A. THE HONORABLE SUPREME COURT MAY THE HONORABLE SUPREME COURT ERRED IN FINDING
HAVE INADVERTENTLY OVERLOOKED THE THAT AN EMPLOYER-EMPLOYEE [RELATIONSHIP]
FACT THAT THE COURT OF APPEAL’S EXISTS BETWEEN RESPONDENT DE LOS SANTOS
DECISION DATED 29 MAY 1995 HAD ALREADY MEDICAL CENTER AND DRS. ORLINO HOSAKA AND
BECOME FINAL AND EXECUTORY AS OF 25 PERFECTA GUTIERREZ
JUNE 1995, THEREBY DEPRIVING THIS
HONORABLE COURT OF JURISDICTION OVER III
THE INSTANT PETITION;
THE HONORABLE SUPREME COURT ERRED IN FINDING
B. THE HONORABLE SUPREME COURT MAY THAT RESPONDENT DE LOS SANTOS MEDICAL CENTER
HAVE INADVERTENTLY OVERLOOKED IS SOLIDARILY LIABLE WITH RESPONDENT DOCTORS
SEVERAL MATERIAL FACTUAL
CIRCUMSTANCES WHICH, IF PROPERLY IV
CONSIDERED, WOULD INDUBITABLY LEAD TO
NO OTHER CONCLUSION BUT THAT PRIVATE
RESPONDENT DOCTORS WERE NOT GUILTY OF THE HONORABLE SUPREME COURT ERRED IN
ANY NEGLIGENCE IN RESPECT OF THE INCREASING THE AWARD OF DAMAGES IN FAVOR OF
INSTANT CASE; PETITIONERS.5

B.1 RESPONDENT DOCTOR PERFECTA In the Resolution of February 21, 2000, this Court denied the
GUTIERREZ HAS SUFFICIENTLY motions for reconsideration of private respondents Drs. Hosaka
DISCHARGED THE BURDEN OF and Gutierrez. They then filed their respective second motions for
EVIDENCE BY SUBSTANTIAL PROOF reconsideration. The Philippine College of Surgeons filed its
OF HER COMPLIANCE WITH THE Petition-in-Intervention contending in the main that this Court
STANDARDS OF DUE CARE EXPECTED erred in holding private respondent Dr. Hosaka liable under the
IN HER RESPECTIVE FIELD OF captain of the ship doctrine. According to the intervenor, said
MEDICAL SPECIALIZATION. doctrine had long been abandoned in the United States in
recognition of the developments in modern medical and hospital
practice.6 The Court noted these pleadings in the Resolution of pre-operative medications. And following this line at
July 17, 2000.7 the end of the evaluation we usually come up on
writing, documentation is very important as far as when
On March 19, 2001, the Court heard the oral arguments of the we train an anesthesiologist we always emphasize this
parties, including the intervenor. Also present during the hearing because we need records for our protection, well,
were the amicii curiae: Dr. Felipe A. Estrella, Jr., Consultant of records. And it entails having brief summary of patient
the Philippine Charity Sweepstakes, former Director of the history and physical findings pertinent to anesthesia,
Philippine General Hospital and former Secretary of Health; Dr. plan, organize as a problem list, the plan anesthesia
Iluminada T. Camagay, President of the Philippine Society of technique, the plan post operative, pain management if
Anesthesiologists, Inc. and Professor and Vice-Chair for appropriate, special issues for this particular patient.
Research, Department of Anesthesiology, College of Medicine- There are needs for special care after surgery and if it so
Philippine General Hospital, University of the Philippines; and it must be written down there and a request must be
Dr. Lydia M. Egay, Professor and Vice-Chair for Academics, made known to proper authorities that such and such
Department of Anesthesiology, College of Medicine-Philippine care is necessary. And the request for medical
General Hospital, University of the Philippines. evaluation if there is an indication. When we ask for a
cardio-pulmonary clearance it is not in fact to tell them
if this patient is going to be fit for anesthesia, the
The Court enumerated the issues to be resolved in this case as decision to give anesthesia rests on the anesthesiologist.
follows: What we ask them is actually to give us the functional
capacity of certain systems which maybe affected by the
1. WHETHER OR NOT DR. ORLINO HOSAKA anesthetic agent or the technique that we are going to
(SURGEON) IS LIABLE FOR NEGLIGENCE; use. But the burden of responsibility in terms of
selection of agent and how to administer it rest on the
2. WHETHER OR NOT DR. PERFECTA anesthesiologist.10
GUTIERREZ (ANESTHESIOLOGIST) IS LIABLE
FOR NEGLIGENCE; AND The conduct of a preanesthetic/preoperative evaluation prior to an
operation, whether elective or emergency, cannot be dispensed
3. WHETHER OR NOT THE HOSPITAL (DELOS with.11 Such evaluation is necessary for the formulation of a plan
SANTOS MEDICAL CENTER) IS LIABLE FOR of anesthesia care suited to the needs of the patient concerned.
ANY ACT OF NEGLIGENCE COMMITTED BY
THEIR VISITING CONSULTANT SURGEON AND Pre-evaluation for anesthesia involves taking the patient’s medical
ANESTHESIOLOGIST.8 history, reviewing his current drug therapy, conducting physical
examination, interpreting laboratory data, and determining the
We shall first resolve the issue pertaining to private respondent appropriate prescription of preoperative medications as necessary
Dr. Gutierrez. She maintains that the Court erred in finding her to the conduct of anesthesia.12
negligent and in holding that it was the faulty intubation which
was the proximate cause of Erlinda’s comatose condition. The Physical examination of the patient entails not only evaluating the
following objective facts allegedly negate a finding of negligence patient’s central nervous system, cardiovascular system and lungs
on her part: 1) That the outcome of the procedure was a comatose but also the upper airway. Examination of the upper airway would
patient and not a dead one; 2) That the patient had a cardiac in turn include an analysis of the patient’s cervical spine mobility,
arrest; and 3) That the patient was revived from that cardiac temporomandibular mobility, prominent central incisors, deceased
arrest.9 In effect, Dr. Gutierrez insists that, contrary to the finding or artificial teeth, ability to visualize uvula and the thyromental
of this Court, the intubation she performed on Erlinda was distance.13
successful.
Nonetheless, Dr. Gutierrez omitted to perform a thorough
Unfortunately, Dr. Gutierrez’ claim of lack of negligence on her preoperative evaluation on Erlinda. As she herself admitted, she
part is belied by the records of the case. It has been sufficiently saw Erlinda for the first time on the day of the operation itself,
established that she failed to exercise the standards of care in the one hour before the scheduled operation. She auscultated 14 the
administration of anesthesia on a patient. Dr. Egay enlightened patient’s heart and lungs and checked the latter’s blood pressure
the Court on what these standards are: to determine if Erlinda was indeed fit for operation. 15 However,
she did not proceed to examine the patient’s airway. Had she been
x x x What are the standards of care that an able to check petitioner Erlinda’s airway prior to the operation,
anesthesiologist should do before we administer Dr. Gutierrez would most probably not have experienced
anesthesia? The initial step is the preparation of the difficulty in intubating the former, and thus the resultant injury
patient for surgery and this is a pre-operative evaluation could have been avoided. As we have stated in our Decision:
because the anesthesiologist is responsible for
determining the medical status of the patient, In the case at bar, respondent Dra. Gutierrez admitted
developing the anesthesia plan and acquainting the that she saw Erlinda for the first time on the day of the
patient or the responsible adult particularly if we are operation itself, on 17 June 1985. Before this date, no
referring with the patient or to adult patient who may prior consultations with, or pre-operative evaluation of
not have, who may have some mental handicaps of the Erlinda was done by her. Until the day of the operation,
proposed plans. We do pre-operative evaluation because respondent Dra. Gutierrez was unaware of the
this provides for an opportunity for us to establish physiological make-up and needs of Erlinda. She was
identification and personal acquaintance with the likewise not properly informed of the possible
patient. It also makes us have an opportunity to alleviate difficulties she would face during the administration of
anxiety, explain techniques and risks to the patient, anesthesia to Erlinda. Respondent Dra. Gutierrez’ act of
given the patient the choice and establishing consent to seeing her patient for the first time only an hour before
proceed with the plan. And lastly, once this has been the scheduled operative procedure was, therefore, an act
agreed upon by all parties concerned the ordering of of exceptional negligence and professional
irresponsibility. The measures cautioning prudence and Thank you.17
vigilance in dealing with human lives lie at the core of
the physician’s centuries-old Hippocratic Oath. Her What is left to be determined therefore is whether Erlinda’s
failure to follow this medical procedure is, therefore, a hapless condition was due to any fault or negligence on the part of
clear indicia of her negligence.16 Dr. Gutierrez while she (Erlinda) was under the latter’s care. Dr.
Gutierrez maintains that the bronchospasm and cardiac arrest
Further, there is no cogent reason for the Court to reverse its resulting in the patient’s comatose condition was brought about
finding that it was the faulty intubation on Erlinda that caused her by the anaphylactic reaction of the patient to Thiopental Sodium
comatose condition. There is no question that Erlinda became (pentothal).18 In the Decision, we explained why we found Dr.
comatose after Dr. Gutierrez performed a medical procedure on Gutierrez’ theory unacceptable. In the first place, Dr. Eduardo
her. Even the counsel of Dr. Gutierrez admitted to this fact during Jamora, the witness who was presented to support her (Dr.
the oral arguments: Gutierrez) theory, was a pulmonologist. Thus, he could not be
considered an authority on anesthesia practice and procedure and
CHIEF JUSTICE: their complications.19

Mr. Counsel, you started your argument Secondly, there was no evidence on record to support the theory
saying that this involves a comatose patient? that Erlinda developed an allergic reaction to pentothal. Dr.
Camagay enlightened the Court as to the manifestations of an
allergic reaction in this wise:
ATTY. GANA:
DR. CAMAGAY:
Yes, Your Honor.
All right, let us qualify an allergic reaction. In
CHIEF JUSTICE: medical terminology an allergic reaction is
something which is not usual response and it
How do you mean by that, a comatose, a is further qualified by the release of a
comatose after any other acts were done by hormone called histamine and histamine has
Dr. Gutierrez or comatose before any act was an effect on all the organs of the body
done by her? generally release because the substance that
entered the body reacts with the particular
ATTY. GANA: cell, the mass cell, and the mass cell secretes
this histamine. In a way it is some form of
response to take away that which is not mine,
No, we meant comatose as a final outcome of which is not part of the body. So, histamine
the procedure. has multiple effects on the body. So, one of
the effects as you will see you will have
CHIEF JUSTICE: redness, if you have an allergy you will have
tearing of the eyes, you will have swelling,
very crucial swelling sometimes of the
Meaning to say, the patient became comatose
larynges which is your voice box main
after some intervention, professional acts have
airway, that swelling may be enough to
been done by Dr. Gutierrez?
obstruct the entry of air to the trachea and you
could also have contraction, constriction of
ATTY. GANA: the smaller airways beyond the trachea, you
see you have the trachea this way, we brought
Yes, Your Honor. some visual aids but unfortunately we do not
have a projector. And then you have the
smaller airways, the bronchi and then
CHIEF JUSTICE:
eventually into the mass of the lungs you have
the bronchus. The difference is that these
In other words, the comatose status was a tubes have also in their walls muscles and this
consequence of some acts performed by D. particular kind of muscles is smooth muscle
Gutierrez? so, when histamine is released they close up
like this and that phenomenon is known as
ATTY. GANA: bronco spasm. However, the effects of
histamine also on blood vessels are different.
They dilate blood vessel open up and the
It was a consequence of the well, (interrupted) patient or whoever has this histamine release
has hypertension or low blood pressure to a
CHIEF JUSTICE: point that the patient may have decrease blood
supply to the brain and may collapse so, you
An acts performed by her, is that not correct? may have people who have this.20

ATTY. GANA: These symptoms of an allergic reaction were not shown to have
been extant in Erlinda’s case. As we held in our Decision, "no
evidence of stridor, skin reactions, or wheezing – some of the
Yes, Your Honor. more common accompanying signs of an allergic reaction –
appears on record. No laboratory data were ever presented to the
CHIEF JUSTICE: court."21
Dr. Gutierrez, however, insists that she successfully intubated Yes.
Erlinda as evidenced by the fact that she was revived after
suffering from cardiac arrest. Dr. Gutierrez faults the Court for Q         There were two attempts. In the first attempt was
giving credence to the testimony of Cruz on the matter of the the tube inserted or was the laryngoscope only inserted,
administration of anesthesia when she (Cruz), being a nurse, was which was inserted?
allegedly not qualified to testify thereon. Rather, Dr. Gutierrez
invites the Court’s attention to her synopsis on what transpired
during Erlinda’s intubation: A         All the laryngoscope.

12:15 p.m. Patient was inducted with sodium pentothal Q         All the laryngoscope. But if I remember right
2.5% (250 mg) given by slow IV. 02 was started by somewhere in the re-direct, a certain lawyer, you were
mask. After pentothal injection this was followed by IV asked that you did a first attempt and the question was –
injection of Norcuron 4mg. After 2 minutes 02 was did you withdraw the tube? And you said – you never
given by positive pressure for about one minute. withdrew the tube, is that right?
Intubation with endotracheal tube 7.5 m in diameter was
done with slight difficulty (short neck & slightly A         Yes.
prominent upper teeth) chest was examined for breath
sounds & checked if equal on both sides. The tube was Q         Yes. And so if you never withdrew the tube then
then anchored to the mouth by plaster & cuff inflated. there was no, there was no insertion of the tube during
Ethrane 2% with 02 4 liters was given. Blood pressure that first attempt. Now, the other thing that we have to
was checked 120/80 & heart rate regular and normal settle here is – when cyanosis occurred, is it recorded in
90/min. the anesthesia record when the cyanosis, in your
recording when did the cyanosis occur?
12:25 p.m. After 10 minutes patient was cyanotic.
Ethrane was discontinued & 02 given alone. Cyanosis A         (sic)
disappeared. Blood pressure and heart beats stable.

Q         Is it a standard practice of anesthesia that

12:30 p.m. Cyanosis again reappeared this time with whatever you do during that period or from the time of
sibilant and sonorous rales all over the chest. induction to the time that you probably get the patient
D_5%_H20 & 1 ampule of aminophyline by fast drip out of the operating room that every single action that
was started. Still the cyanosis was persistent. Patient you do is so recorded in your anesthesia record?
was connected to a cardiac monitor. Another ampule of
of [sic] aminophyline was given and solu cortef was
given. A         I was not able to record everything I did not
have time anymore because I did that after the, when
the patient was about to leave the operating room. When
12:40 p.m. There was cardiac arrest. Extra cardiac there was second cyanosis already that was the
massage and intercardiac injection of adrenalin was (interrupted)
given & heart beat reappeared in less than one minute.
Sodium bicarbonate & another dose of solu cortef was
given by IV. Cyanosis slowly disappeared & 02 Q         When was the first cyanosis?
continuously given & assisted positive pressure.
Laboratory exams done (see results in chart). A         The first cyanosis when I was (interrupted)

Patient was transferred to ICU for further management. 22 Q         What time, more or less?

From the foregoing, it can be allegedly seen that there was no A         I think it was 12:15 or 12:16.
withdrawal (extubation) of the tube. And the fact that the cyanosis
allegedly disappeared after pure oxygen was supplied through the
Q         Well, if the record will show you started
tube proved that it was properly placed.
induction at 12:15?

The Court has reservations on giving evidentiary weight to the

A         Yes, Your Honor.
entries purportedly contained in Dr. Gutierrez’ synopsis. It is
significant to note that the said record prepared by Dr. Gutierrez
was made only after Erlinda was taken out of the operating room. Q         And the first medication you gave was what?
The standard practice in anesthesia is that every single act that the
anesthesiologist performs must be recorded. In Dr. Gutierrez’ A         The first medication, no, first the patient was
case, she could not account for at least ten (10) minutes of what oxygenated for around one to two minutes.
happened during the administration of anesthesia on Erlinda. The
following exchange between Dr. Estrella, one of the amicii curiae,
Q         Yes, so, that is about 12:13?
and Dr. Gutierrez is instructive:

A         Yes, and then, I asked the resident physician to

DR. ESTRELLA
start giving the pentothal very slowly and that was
around one minute.
Q         You mentioned that there were two (2) attempts
in the intubation period?
Q         So, that is about 12:13 no, 12:15, 12:17?

DR. GUTIERREZ
A         Yes, and then, after one minute another A         I did not say "mali ata ang pinasukan" I never
oxygenation was given and after (interrupted) said that.

Q         12:18? Q         Well, just for the information of the group here

the remarks I am making is based on the documents that
A         Yes, and then after giving the oxygen we start were forwarded to me by the Supreme Court. That is
the menorcure which is a relaxant. After that relaxant why for purposes of discussion I am trying to clarify
(interrupted) this for the sake of enlightenment. So, at what point did
you ever make that comment?
Q         After that relaxant, how long do you wait before
you do any manipulation? A         Which one, sir?

A         Usually you wait for two minutes or three Q         The "mahirap intubate ito" assuming that you
minutes. (interrupted)

Q         So, if our estimate of the time is accurate we are A         Iyon lang, that is what I only said "mahirap
now more or less 12:19, is that right? intubate (interrupted)

A         Maybe. Q         At what point?

Q         12:19. And at that time, what would have been A         When the first attempt when I inserted the
done to this patient? laryngoscope for the first time.

A         After that time you examine the, if there is Q         So, when you claim that at the first attempt you
relaxation of the jaw which you push it downwards and inserted the laryngoscope, right?
when I saw that the patient was relax because that
monorcure is a relaxant, you cannot intubate the patient A         Yes.
or insert the laryngoscope if it is not keeping him relax.
So, my first attempt when I put the laryngoscope on I Q         But in one of the recordings somewhere at the,
saw the trachea was deeply interiorly. So, what I did ask somewhere in the transcript of records that when the
"mahirap ata ito ah." So, I removed the laryngoscope lawyer of the other party try to inquire from you during
and oxygenated again the patient. the first attempt that was the time when "mayroon ba
kayong hinugot sa tube, I do not remember the page
Q         So, more or less you attempted to do an now, but it seems to me it is there. So, that it was on the
intubation after the first attempt as you claimed that it second attempt that (interrupted)
was only the laryngoscope that was inserted.
A         I was able to intubate.
A         Yes.
Q         And this is more or less about what time 12:21?
Q         And in the second attempt you inserted the
laryngoscope and now possible intubation? A         Maybe, I cannot remember the time, Sir.

A         Yes. Q         Okay, assuming that this was done at 12:21 and

looking at the anesthesia records from 12:20 to 12:30
Q         And at that point, you made a remark, what there was no recording of the vital signs. And can we
remark did you make? presume that at this stage there was already some
problems in handling the patient?
A         I said "mahirap ata ito" when the first attempt I
did not see the trachea right away. That was when I A         Not yet.
(interrupted)
Q         But why are there no recordings in the
Q         That was the first attempt? anesthesia record?

A         Yes. A         I did not have time.

Q         What about the second attempt? Q         Ah, you did not have time, why did you not have
time?
A         On the second attempt I was able to intubate
right away within two to three seconds. A         Because it was so fast, I really (at this juncture
the witness is laughing)
Q         At what point, for purposes of discussion
without accepting it, at what point did you make the Q         No, I am just asking. Remember I am not here
comment "na mahirap ata to intubate, mali ata ang not to pin point on anybody I am here just to more or
pinasukan" less clarify certainty more ore less on the record.
A         Yes, Sir. The injury incurred by petitioner Erlinda does not normally
happen absent any negligence in the administration of anesthesia
Q         And so it seems that there were no recording and in the use of an endotracheal tube. As was noted in our
during that span of ten (10) minutes. From 12:20 to Decision, the instruments used in the administration of anesthesia,
12:30, and going over your narration, it seems to me including the endotracheal tube, were all under the exclusive
that the cyanosis appeared ten (10) minutes after control of private respondents Dr. Gutierrez and Dr.
induction, is that right? Hosaka.27 In Voss vs. Bridwell,28 which involved a patient who
suffered brain damage due to the wrongful administration of
anesthesia, and even before the scheduled mastoid operation
A         Yes. could be performed, the Kansas Supreme Court applied the
doctrine of res ipsa loquitur, reasoning that the injury to the
Q         And that is after induction 12:15 that is 12:25 patient therein was one which does not ordinarily take place in the
that was the first cyanosis? absence of negligence in the administration of an anesthetic, and
in the use and employment of an endotracheal tube. The court
A         Yes. went on to say that "[o]rdinarily a person being put under
anesthesia is not rendered decerebrate as a consequence of
administering such anesthesia in the absence of negligence. Upon
Q         And that the 12:25 is after the 12:20? these facts and under these circumstances, a layman would be
able to say, as a matter of common knowledge and observation,
A         We cannot (interrupted) that the consequences of professional treatment were not as such
as would ordinarily have followed if due care had been
exercised."29 Considering the application of the doctrine of res
Q         Huwag ho kayong makuwan, we are just trying
ipsa loquitur, the testimony of Cruz was properly given credence
to enlighten, I am just going over the record ano, kung
in the case at bar.
mali ito kuwan eh di ano. So, ganoon po ano, that it
seems to me that there is no recording from 12:20 to
12:30, so, I am just wondering why there were no For his part, Dr. Hosaka mainly contends that the Court erred in
recordings during the period and then of course the finding him negligent as a surgeon by applying the Captain-of-
second cyanosis, after the first cyanosis. I think that was the-Ship doctrine.30 Dr. Hosaka argues that the trend in United
the time Dr. Hosaka came in? States jurisprudence has been to reject said doctrine in light of the
developments in medical practice. He points out that
anesthesiology and surgery are two distinct and specialized fields
A         No, the first cyanosis (interrupted).23
in medicine and as a surgeon, he is not deemed to have control
over the acts of Dr. Gutierrez. As anesthesiologist, Dr. Gutierrez
We cannot thus give full credence to Dr. Gutierrez’ synopsis in is a specialist in her field and has acquired skills and knowledge
light of her admission that it does not fully reflect the events that in the course of her training which Dr. Hosaka, as a surgeon, does
transpired during the administration of anesthesia on Erlinda. As not possess.31 He states further that current American
pointed out by Dr. Estrella, there was a ten-minute gap in Dr. jurisprudence on the matter recognizes that the trend towards
Gutierrez’ synopsis, i.e., the vital signs of Erlinda were not specialization in medicine has created situations where surgeons
recorded during that time. The absence of these data is do not always have the right to control all personnel within the
particularly significant because, as found by the trial court, it was operating room,32 especially a fellow specialist.33
the absence of oxygen supply for four (4) to five (5) minutes that
caused Erlinda’s comatose condition.
Dr. Hosaka cites the case of Thomas v. Raleigh General
Hospital,34 which involved a suit filed by a patient who lost his
On the other hand, the Court has no reason to disbelieve the voice due to the wrongful insertion of the endotracheal tube
testimony of Cruz. As we stated in the Decision, she is competent preparatory to the administration of anesthesia in connection with
to testify on matters which she is capable of observing such as, the laparotomy to be conducted on him. The patient sued both the
the statements and acts of the physician and surgeon, external anesthesiologist and the surgeon for the injury suffered by him.
appearances and manifest conditions which are observable by any The Supreme Court of Appeals of West Virginia held that the
one.24 Cruz, Erlinda’s sister-in-law, was with her inside the surgeon could not be held liable for the loss of the patient’s voice,
operating room. Moreover, being a nurse and Dean of the Capitol considering that the surgeon did not have a hand in the intubation
Medical Center School of Nursing at that, she is not entirely of the patient. The court rejected the application of the "Captain-
ignorant of anesthetic procedure. Cruz narrated that she heard Dr. of-the-Ship Doctrine," citing the fact that the field of medicine has
Gutierrez remark, "Ang hirap ma-intubate nito, mali yata ang become specialized such that surgeons can no longer be deemed
pagkakapasok. O lumalaki ang tiyan." She observed that the as having control over the other personnel in the operating room.
nailbeds of Erlinda became bluish and thereafter Erlinda was It held that "[a]n assignment of liability based on actual control
placed in trendelenburg position. 25Cruz further averred that she more realistically reflects the actual relationship which exists in a
noticed that the abdomen of Erlinda became distended. 26 modern operating room."35 Hence, only the anesthesiologist who
inserted the endotracheal tube into the patient’s throat was held
The cyanosis (bluish discoloration of the skin or mucous liable for the injury suffered by the latter.
membranes caused by lack of oxygen or abnormal hemoglobin in
the blood) and enlargement of the stomach of Erlinda indicate that This contention fails to persuade.
the endotracheal tube was improperly inserted into the esophagus
instead of the trachea. Consequently, oxygen was delivered not to
That there is a trend in American jurisprudence to do away with
the lungs but to the gastrointestinal tract. This conclusion is
the Captain-of-the-Ship doctrine does not mean that this Court
supported by the fact that Erlinda was placed in trendelenburg
will ipso facto follow said trend. Due regard for the peculiar
position. This indicates that there was a decrease of blood supply
factual circumstances obtaining in this case justify the application
to the patient’s brain. The brain was thus temporarily deprived of
of the Captain-of-the-Ship doctrine. From the facts on record it
oxygen supply causing Erlinda to go into coma.
can be logically inferred that Dr. Hosaka exercised a certain
degree of, at the very least, supervision over the procedure then DR. CAMAGAY:
being performed on Erlinda.
x x x Pre-operative medication has three main
First, it was Dr. Hosaka who recommended to petitioners the functions: One is to alleviate anxiety. Second
services of Dr. Gutierrez. In effect, he represented to petitioners is to dry up the secretions and Third is to
that Dr. Gutierrez possessed the necessary competence and skills. relieve pain. Now, it is very important to
Drs. Hosaka and Gutierrez had worked together since 1977. alleviate anxiety because anxiety is associated
Whenever Dr. Hosaka performed a surgery, he would always with the outpouring of certain substances
engage the services of Dr. Gutierrez to administer the anesthesia formed in the body called adrenalin. When a
on his patient.36 patient is anxious there is an outpouring of
adrenalin which would have adverse effect on
Second, Dr. Hosaka himself admitted that he was the attending the patient. One of it is high blood pressure,
physician of Erlinda. Thus, when Erlinda showed signs of the other is that he opens himself to
cyanosis, it was Dr. Hosaka who gave instructions to call for disturbances in the heart rhythm, which would
another anesthesiologist and cardiologist to help resuscitate have adverse implications. So, we would like
Erlinda.37 to alleviate patient’s anxiety mainly because
he will not be in control of his body there
could be adverse results to surgery and he will
Third, it is conceded that in performing their responsibilities to be opened up; a knife is going to open up his
the patient, Drs. Hosaka and Gutierrez worked as a team. Their body. x x x42
work cannot be placed in separate watertight compartments
because their duties intersect with each other. 38
Dr. Hosaka cannot now claim that he was entirely blameless of
what happened to Erlinda. His conduct clearly constituted a
While the professional services of Dr. Hosaka and Dr. Gutierrez breach of his professional duties to Erlinda:
were secured primarily for their performance of acts within their
respective fields of expertise for the treatment of petitioner
Erlinda, and that one does not exercise control over the other, they CHIEF JUSTICE:
were certainly not completely independent of each other so as to
absolve one from the negligent acts of the other physician. Two other points. The first, Doctor, you were
talking about anxiety, would you consider a
That they were working as a medical team is evident from the fact patient's stay on the operating table for three
that Dr. Hosaka was keeping an eye on the intubation of the hours sufficient enough to aggravate or
patient by Dr. Gutierrez, and while doing so, he observed that the magnify his or her anxiety?
patient’s nails had become dusky and had to call Dr. Gutierrez’s
attention thereto. The Court also notes that the counsel for Dr. DR. CAMAGAY:
Hosaka admitted that in practice, the anesthesiologist would also
have to observe the surgeon’s acts during the surgical process and Yes.
calls the attention of the surgeon whenever necessary 39 in the
course of the treatment. The duties of Dr. Hosaka and those of Dr.
Gutierrez in the treatment of petitioner Erlinda are therefore not as CHIEF JUSTICE:
clear-cut as respondents claim them to be. On the contrary, it is
quite apparent that they have a common responsibility to treat the In other words, I understand that in this
patient, which responsibility necessitates that they call each particular case that was the case, three hours
other’s attention to the condition of the patient while the other waiting and the patient was already on the
physician is performing the necessary medical procedures. operating table (interrupted)

It is equally important to point out that Dr. Hosaka was remiss in DR. CAMAGAY:
his duty of attending to petitioner Erlinda promptly, for he arrived
more than three (3) hours late for the scheduled operation. Yes.
The cholecystectomy was set for June 17, 1985 at 9:00 a.m., but
he arrived at DLSMC only at around 12:10 p.m. In reckless
disregard for his patient’s well being, Dr. Hosaka scheduled two CHIEF JUSTICE:
procedures on the same day, just thirty minutes apart from each
other, at different hospitals. Thus, when the first procedure Would you therefore conclude that the
(protoscopy) at the Sta. Teresita Hospital did not proceed on time, surgeon contributed to the aggravation of the
Erlinda was kept in a state of uncertainty at the DLSMC. anxiety of the patient?

The unreasonable delay in petitioner Erlinda’s scheduled DR. CAMAGAY:

operation subjected her to continued starvation and consequently,
to the risk of acidosis, 40 or the condition of decreased alkalinity of
That this operation did not take place as
the blood and tissues, marked by sickly sweet breath, headache,
scheduled is already a source of anxiety and
nausea and vomiting, and visual disturbances. 41 The long period
most operating tables are very narrow and that
that Dr. Hosaka made Erlinda wait for him certainly aggravated
patients are usually at risk of falling on the
the anxiety that she must have been feeling at the time. It could be
floor so there are restraints that are placed on
safely said that her anxiety adversely affected the administration
them and they are never, never left alone in
of anesthesia on her. As explained by Dr. Camagay, the patient’s
the operating room by themselves specially if
anxiety usually causes the outpouring of adrenaline which in turn
they are already pre-medicated because they
results in high blood pressure or disturbances in the heart rhythm:
may not be aware of some of their movement
that they make which would contribute to and (4) the power to control not only the end to be achieved, but
their injury. the means to be used in reaching such an end.47

CHIEF JUSTICE: DLSMC maintains that first, a hospital does not hire or engage the
services of a consultant, but rather, accredits the latter and grants
In other words due diligence would require a him or her the privilege of maintaining a clinic and/or admitting
surgeon to come on time? patients in the hospital upon a showing by the consultant that he
or she possesses the necessary qualifications, such as
accreditation by the appropriate board (diplomate), evidence of
DR. CAMAGAY: fellowship and references.48 Second, it is not the hospital but the
patient who pays the consultant’s fee for services rendered by the
I think it is not even due diligence it is latter.49 Third, a hospital does not dismiss a consultant; instead, the
courtesy. latter may lose his or her accreditation or privileges granted by the
hospital.50 Lastly, DLSMC argues that when a doctor refers a
CHIEF JUSTICE: patient for admission in a hospital, it is the doctor who prescribes
the treatment to be given to said patient. The hospital’s obligation
is limited to providing the patient with the preferred room
Courtesy. accommodation, the nutritional diet and medications prescribed
by the doctor, the equipment and facilities necessary for the
DR. CAMAGAY: treatment of the patient, as well as the services of the hospital
staff who perform the ministerial tasks of ensuring that the
doctor’s orders are carried out strictly.51
And care.

After a careful consideration of the arguments raised by DLSMC,

CHIEF JUSTICE:
the Court finds that respondent hospital’s position on this issue is
meritorious. There is no employer-employee relationship between
Duty as a matter of fact? DLSMC and Drs. Gutierrez and Hosaka which would hold
DLSMC solidarily liable for the injury suffered by petitioner
DR. CAMAGAY: Erlinda under Article 2180 of the Civil Code.

Yes, Your Honor.43 As explained by respondent hospital, that the admission of a

physician to membership in DLSMC’s medical staff as active or
visiting consultant is first decided upon by the Credentials
Dr. Hosaka's irresponsible conduct of arriving very late for the
Committee thereof, which is composed of the heads of the various
scheduled operation of petitioner Erlinda is violative, not only of
specialty departments such as the Department of Obstetrics and
his duty as a physician "to serve the interest of his patients with
Gynecology, Pediatrics, Surgery with the department head of the
the greatest solicitude, giving them always his best talent and
particular specialty applied for as chairman. The Credentials
skill,"44 but also of Article 19 of the Civil Code which requires a
Committee then recommends to DLSMC's Medical Director or
person, in the performance of his duties, to act with justice and
Hospital Administrator the acceptance or rejection of the
give everyone his due.
applicant physician, and said director or administrator validates
the committee's recommendation.52 Similarly, in cases where a
Anent private respondent DLSMC’s liability for the resulting disciplinary action is lodged against a consultant, the same is
injury to petitioner Erlinda, we held that respondent hospital is initiated by the department to whom the consultant concerned
solidarily liable with respondent doctors therefor under Article belongs and filed with the Ethics Committee consisting of the
2180 of the Civil Code45 since there exists an employer-employee department specialty heads. The medical director/hospital
relationship between private respondent DLSMC and Drs. administrator merely acts as ex-officio member of said
Gutierrez and Hosaka: committee.

In other words, private hospitals, hire, fire and exercise Neither is there any showing that it is DLSMC which pays any of
real control over their attending and visiting its consultants for medical services rendered by the latter to their
"consultant" staff. While "consultants" are not, respective patients. Moreover, the contract between the consultant
technically employees, x x x the control exercised, the in respondent hospital and his patient is separate and distinct from
hiring and the right to terminate consultants all fulfill the contract between respondent hospital and said patient. The
the important hallmarks of an employer-employee first has for its object the rendition of medical services by the
relationship, with the exception of the payment of consultant to the patient, while the second concerns the provision
wages. In assessing whether such a relationship in fact by the hospital of facilities and services by its staff such as nurses
exists, the control test is determining. x x x46 and laboratory personnel necessary for the proper treatment of the
patient.
DLSMC however contends that applying the four-fold test in
determining whether such a relationship exists between it and the Further, no evidence was adduced to show that the injury suffered
respondent doctors, the inescapable conclusion is that DLSMC by petitioner Erlinda was due to a failure on the part of respondent
cannot be considered an employer of the respondent doctors. DLSMC to provide for hospital facilities and staff necessary for
her treatment.
It has been consistently held that in determining whether an
employer-employee relationship exists between the parties, the For these reasons, we reverse the finding of liability on the part of
following elements must be present: (1) selection and engagement DLSMC for the injury suffered by petitioner Erlinda.
of services; (2) payment of wages; (3) the power to hire and fire;
Finally, the Court also deems it necessary to modify the award of died on August 3, 1999.55 In view of this supervening event, the
damages to petitioners in view of the supervening event of award of temperate damages in addition to the actual or
petitioner Erlinda’s death. In the assailed Decision, the Court compensatory damages would no longer be justified since the
awarded actual damages of One Million Three Hundred Fifty actual damages awarded in the Decision are sufficient to cover the
Two Thousand Pesos (P1,352,000.00) to cover the expenses for medical expenses incurred by petitioners for the patient. Hence,
petitioner Erlinda’s treatment and care from the date of only the amounts representing actual, moral and exemplary
promulgation of the Decision up to the time the patient expires or damages, attorney’s fees and costs of suit should be awarded to
survives.53 In addition thereto, the Court awarded temperate petitioners.
damages of One Million Five Hundred Thousand Pesos
(P1,500,000.00) in view of the chronic and continuing nature of WHEREFORE, the assailed Decision is hereby modified as
petitioner Erlinda’s injury and the certainty of further pecuniary follows:
loss by petitioners as a result of said injury, the amount of which,
however, could not be made with certainty at the time of the
promulgation of the decision. The Court justified such award in (1) Private respondent De Los Santos Medical Center is hereby
this manner: absolved from liability arising from the injury suffered by
petitioner Erlinda Ramos on June 17, 1985;
Our rules on actual or compensatory damages generally
assume that at the time of litigation, the injury suffered (2) Private respondents Dr. Orlino Hosaka and Dr. Perfecta
as a consequence of an act of negligence has been Gutierrez are hereby declared to be solidarily liable for the injury
completed and that the cost can be liquidated. However, suffered by petitioner Erlinda on June 17, 1985 and are ordered to
these provisions neglect to take into account those pay petitioners—
situations, as in this case, where the resulting injury
might be continuing and possible future complications (a) P1,352,000.00 as actual damages;
directly arising from the injury, while certain to occur,
are difficult to predict. (b) P2,000,000.00 as moral damages;

In these cases, the amount of damages which should be (c) P100,000.00 as exemplary damages;
awarded, if they are to adequately and correctly respond
to the injury caused, should be one which compensates
for pecuniary loss incurred and proved, up to the time of (d) P100,000.00 as attorney’s fees; and
trial; and one which would meet pecuniary loss certain
to be suffered but which could not, from the nature of (e) the costs of the suit.
the case, be made with certainty. In other words,
temperate damages can and should be awarded on top
SO ORDERED.
of actual or compensatory damages in instances where
the injury is chronic and continuing. And because of the
unique nature of such cases, no incompatibility arises
when both actual and temperate damages are provided
for. The reason is that these damages cover two distinct
phases.

As it would not be equitable—and certainly not in the

best interests of the administration of justice—for the
victim in such cases to constantly come before the
courts and invoke their aid in seeking adjustments to the
compensatory damages previously awarded—temperate
damages are appropriate. The amount given as
temperate damages, though to a certain extent
speculative, should take into account the cost of proper
care.

In the instant case, petitioners were able to provide only

home-based nursing care for a comatose patient who
has remained in that condition for over a decade.
Having premised our award for compensatory damages
on the amount provided by petitioners at the onset of
litigation, it would be now much more in step with the
interests of justice if the value awarded for temperate
damages would allow petitioners to provide optimal
care for their loved one in a facility which generally
specializes in such care. They should not be compelled
by dire circumstances to provide substandard care at
home without the aid of professionals, for anything less
would be grossly inadequate. Under the circumstances,
an award of P1,500,000.00 in temperate damages would
therefore be reasonable.54

However, subsequent to the promulgation of the Decision, the

Court was informed by petitioner Rogelio that petitioner Erlinda
G.R. No. 130547               October 3, 2000 patient was asked by Dr. Blanes whether he had a previous heart
ailment or had suffered from chest pains in the past. Jorge replied
LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and he did not.5 After about 15 minutes, however, Jorge again started
minors LLOYD and KRISTINE, all surnamed REYES, to vomit, showed restlessness, and his convulsions returned. Dr.
represented by their mother, LEAH ALESNA Blanes re-applied the emergency measures taken before and, in
REYES, petitioners,  addition, valium was administered. Jorge, however, did not
vs. respond to the treatment and slipped into cyanosis, a bluish or
SISTERS OF MERCY HOSPITAL, SISTER ROSE purplish discoloration of the skin or mucous membrane due to
PALACIO, DR. MARVIE BLANES, and DR. MARLYN deficient oxygenation of the blood. At around 2:00 a.m., Jorge
RICO, respondents. died. He was forty years old. The cause of his death was
"Ventricular Arrythemia Secondary to Hyperpyrexia and typhoid
fever."
DECISION
On June 3, 1987, petitioners filed before the Regional Trial Court
MENDOZA, J.: of Cebu City a complaint6 for damages against respondents Sisters
of Mercy, Sister Rose Palacio, Dr. Marvie Blanes, Dr. Marlyn
This is a petition for review of the decision 1 of the Court of Rico, and nurse Josephine Pagente. On September 24, 1987,
Appeals in CA-G.R. CV No. 36551 affirming the decision of the petitioners amended their complaint to implead respondent Mercy
Regional Trial Court, Branch IX, Cebu City which dismissed a Community Clinic as additional defendant and to drop the name
complaint for damages filed by petitioners against respondents. of Josephine Pagente as defendant since she was no longer
connected with respondent hospital. Their principal contention
The facts are as follows: was that Jorge did not die of typhoid fever. 7 Instead, his death was
due to the wrongful administration of chloromycetin. They
contended that had respondent doctors exercised due care and
Petitioner Leah Alesna Reyes is the wife of the late Jorge Reyes. diligence, they would not have recommended and rushed the
The other petitioners, namely, Rose Nahdja, Johnny, Lloyd, and performance of the Widal Test, hastily concluded that Jorge was
Kristine, all surnamed Reyes, were their children. Five days suffering from typhoid fever, and administered chloromycetin
before his death on January 8, 1987, Jorge had been suffering without first conducting sufficient tests on the patient’s
from a recurring fever with chills. After he failed to get relief compatibility with said drug. They charged respondent clinic and
from some home medication he was taking, which consisted of its directress, Sister Rose Palacio, with negligence in failing to
analgesic, antipyretic, and antibiotics, he decided to see the provide adequate facilities and in hiring negligent doctors and
doctor. nurses.8

On January 8, 1987, he was taken to the Mercy Community Clinic Respondents denied the charges. During the pre-trial conference,
by his wife. He was attended to by respondent Dr. Marlyn Rico, the parties agreed to limit the issues on the following: (1) whether
resident physician and admitting physician on duty, who gave the death of Jorge Reyes was due to or caused by the negligence,
Jorge a physical examination and took his medical history. She carelessness, imprudence, and lack of skill or foresight on the part
noted that at the time of his admission, Jorge was conscious, of defendants; (2) whether respondent Mercy Community Clinic
ambulatory, oriented, coherent, and with respiratory was negligent in the hiring of its employees; and (3) whether
distress.2 Typhoid fever was then prevalent in the locality, as the either party was entitled to damages. The case was then heard by
clinic had been getting from 15 to 20 cases of typhoid per the trial court during which, in addition to the testimonies of the
month.3 Suspecting that Jorge could be suffering from this disease, parties, the testimonies of doctors as expert witnesses were
Dr. Rico ordered a Widal Test, a standard test for typhoid fever, presented.
to be performed on Jorge. Blood count, routine urinalysis, stool
examination, and malarial smear were also made. 4 After about an
hour, the medical technician submitted the results of the test from Petitioners offered the testimony of Dr. Apolinar Vacalares, Chief
which Dr. Rico concluded that Jorge was positive for typhoid Pathologist at the Northern Mindanao Training Hospital, Cagayan
fever. As her shift was only up to 5:00 p.m., Dr. Rico indorsed de Oro City. On January 9, 1987, Dr. Vacalares performed an
Jorge to respondent Dr. Marvie Blanes. autopsy on Jorge Reyes to determine the cause of his death.
However, he did not open the skull to examine the brain. His
findings9 showed that the gastro-intestinal tract was normal and
Dr. Marvie Blanes attended to Jorge at around six in the evening. without any ulceration or enlargement of the nodules. Dr.
She also took Jorge’s history and gave him a physical Vacalares testified that Jorge did not die of typhoid fever. He also
examination. Like Dr. Rico, her impression was that Jorge had stated that he had not seen a patient die of typhoid fever within
typhoid fever. Antibiotics being the accepted treatment for five days from the onset of the disease.
typhoid fever, she ordered that a compatibility test with the
antibiotic chloromycetin be done on Jorge. Said test was
administered by nurse Josephine Pagente who also gave the For their part, respondents offered the testimonies of Dr. Peter
patient a dose of triglobe. As she did not observe any adverse Gotiong and Dr. Ibarra Panopio. Dr. Gotiong is a diplomate in
reaction by the patient to chloromycetin, Dr. Blanes ordered the internal medicine whose expertise is microbiology and infectious
first five hundred milligrams of said antibiotic to be administered diseases. He is also a consultant at the Cebu City Medical Center
on Jorge at around 9:00 p.m. A second dose was administered on and an associate professor of medicine at the South Western
Jorge about three hours later just before midnight. University College of Medicine in Cebu City. He had treated over
a thousand cases of typhoid patients. According to Dr. Gotiong,
the patient’s history and positive Widal Test results ratio of 1:320
At around 1:00 a.m. of January 9, 1987, Dr. Blanes was called as would make him suspect that the patient had typhoid fever. As to
Jorge’s temperature rose to 41°C. The patient also experienced Dr. Vacalares’ observation regarding the absence of ulceration in
chills and exhibited respiratory distress, nausea, vomiting, and Jorge’s gastro-intestinal tract, Dr. Gotiong said that such
convulsions. Dr. Blanes put him under oxygen, used a suction hyperplasia in the intestines of a typhoid victim may be
machine, and administered hydrocortisone, temporarily easing the microscopic. He noted that since the toxic effect of typhoid fever
patient’s convulsions. When he regained consciousness, the
may lead to meningitis, Dr. Vacalares’ autopsy should have In the present case, there is no doubt that a physician-patient
included an examination of the brain.10 relationship existed between respondent doctors and Jorge Reyes.
Respondents were thus duty-bound to use at least the same level
The other doctor presented was Dr. Ibarra Panopio, a member of of care that any reasonably competent doctor would use to treat a
the American Board of Pathology, examiner of the Philippine condition under the same circumstances. It is breach of this duty
Board of Pathology from 1978 to 1991, fellow of the Philippine which constitutes actionable malpractice. 14 As to this aspect of
Society of Pathologist, associate professor of the Cebu Institute of medical malpractice, the determination of the reasonable level of
Medicine, and chief pathologist of the Andres Soriano Jr. care and the breach thereof, expert testimony is essential.
Memorial Hospital in Toledo City. Dr. Panopio stated that Inasmuch as the causes of the injuries involved in malpractice
although he was partial to the use of the culture test for its greater actions are determinable only in the light of scientific knowledge,
reliability in the diagnosis of typhoid fever, the Widal Test may it has been recognized that expert testimony is usually necessary
also be used. Like Dr. Gotiong, he agreed that the 1:320 ratio in to support the conclusion as to causation.15
Jorge’s case was already the maximum by which a conclusion of
typhoid fever may be made. No additional information may be Res Ipsa Loquitur
deduced from a higher dilution.11 He said that Dr. Vacalares’
autopsy on Jorge was incomplete and thus inconclusive. There is a case when expert testimony may be dispensed with, and
that is under the doctrine of res ipsa loquitur. As held in Ramos v.
On September 12, 1991, the trial court rendered its decision Court of Appeals:16
absolving respondents from the charges of negligence and
dismissing petitioners’ action for damages. The trial court Although generally, expert medical testimony is relied upon in
likewise dismissed respondents’ counterclaim, holding that, in malpractice suits to prove that a physician has done a negligent
seeking damages from respondents, petitioners were impelled by act or that he has deviated from the standard medical procedure,
the honest belief that Jorge’s death was due to the latter’s when the doctrine of res ipsa loquitor is availed by the plaintiff,
negligence. the need for expert medical testimony is dispensed with because
the injury itself provides the proof of negligence. The reason is
Petitioners brought the matter to the Court of Appeals. On July that the general rule on the necessity of expert testimony applies
31, 1997, the Court of Appeals affirmed the decision of the trial only to such matters clearly within the domain of medical science,
court. and not to matters that are within the common knowledge of
mankind which may be testified to by anyone familiar with the
Hence this petition. facts. Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has
been treated or operated upon with a reasonable degree of skill
Petitioners raise the following assignment of errors: and care. However, testimony as to the statements and acts of
physicians and surgeons, external appearances, and manifest
I. THE HONORABLE COURT OF APPEALS conditions which are observable by any one may be given by non-
COMMITTED A REVERSIBLE ERROR WHEN IT expert witnesses. Hence, in cases where the res ipsa loquitur is
RULED THAT THE DOCTRINE OF RES IPSA applicable, the court is permitted to find a physician negligent
LOQUITUR IS NOT APPLICABLE IN THE upon proper proof of injury to the patient, without the aid of
INSTANT CASE. expert testimony, where the court from its fund of common
knowledge can determine the proper standard of care. Where
II. THE HONORABLE COURT OF APPEALS common knowledge and experience teach that a resulting injury
COMMITTED REVERSIBLE ERROR WHEN IT would not have occurred to the patient if due care had been
MADE AN UNFOUNDED ASSUMPTION THAT exercised, an inference of negligence may be drawn giving rise to
THE LEVEL OF MEDICAL PRACTICE IS LOWER an application of the doctrine of res ipsa loquitur without medical
IN ILIGAN CITY. evidence, which is ordinarily required to show not only what
occurred but how and why it occurred. When the doctrine is
appropriate, all that the patient must do is prove a nexus between
III. THE HONORABLE COURT OF APPEALS the particular act or omission complained of and the injury
GRAVELY ERRED WHEN IT RULED FOR A sustained while under the custody and management of the
LESSER STANDARD OF CARE AND DEGREE OF defendant without need to produce expert medical testimony to
DILIGENCE FOR MEDICAL PRACTICE IN ILIGAN establish the standard of care. Resort to res ipsa loquitor is
CITY WHEN IT APPRECIATE[D] NO DOCTOR’S allowed because there is no other way, under usual and ordinary
NEGLIGENCE IN THE TREATMENT OF JORGE conditions, by which the patient can obtain redress for injury
REYES. suffered by him.

Petitioner’s action is for medical malpractice. This is a particular Thus, courts of other jurisdictions have applied the doctrine in the
form of negligence which consists in the failure of a physician or following situations: leaving of a foreign object in the body of the
surgeon to apply to his practice of medicine that degree of care patient after an operation, injuries sustained on a healthy part of
and skill which is ordinarily employed by the profession the body which was not under, or in the area, of treatment,
generally, under similar conditions, and in like surrounding removal of the wrong part of the body when another part was
circumstances.12 In order to successfully pursue such a claim, a intended, knocking out a tooth while a patient’s jaw was under
patient must prove that the physician or surgeon either failed to do anesthetic for the removal of his tonsils, and loss of an eye while
something which a reasonably prudent physician or surgeon the patient was under the influence of anesthetic, during or
would have done, or that he or she did something that a following an operation for appendicitis, among others.17
reasonably prudent physician or surgeon would not have done,
and that the failure or action caused injury to the patient. 13 There
are thus four elements involved in medical negligence cases, Petitioners asserted in the Court of Appeals that the doctrine
namely: duty, breach, injury, and proximate causation. of res ipsa loquitur applies to the present case because Jorge
Reyes was merely experiencing fever and chills for five days and
was fully conscious, coherent, and ambulant when he went to the
hospital. Yet, he died after only ten hours from the time of his as typhoid fever, and immediately prescribed the administration
admission. of the antibiotic chloromycetin;21 and (2) Dr. Marvie Blanes erred
in ordering the administration of the second dose of 500
This contention was rejected by the appellate court. milligrams of chloromycetin barely three hours after the first was
given.22 Petitioners presented the testimony of Dr. Apolinar
Vacalares, Chief Pathologist of the Northern Mindanao Training
Petitioners now contend that all requisites for the application Hospital, Cagayan de Oro City, who performed an autopsy on the
of res ipsa loquitur were present, namely: (1) the accident was of body of Jorge Reyes. Dr. Vacalares testified that, based on his
a kind which does not ordinarily occur unless someone is findings during the autopsy, Jorge Reyes did not die of typhoid
negligent; (2) the instrumentality or agency which caused the fever but of shock undetermined, which could be due to allergic
injury was under the exclusive control of the person in charge; reaction or chloromycetin overdose. We are not persuaded.
and (3) the injury suffered must not have been due to any
voluntary action or contribution of the person injured.18
First. While petitioners presented Dr. Apolinar Vacalares as an
expert witness, we do not find him to be so as he is not a specialist
The contention is without merit. We agree with the ruling of the on infectious diseases like typhoid fever. Furthermore, although
Court of Appeals. In the Ramos case, the question was whether a he may have had extensive experience in performing autopsies, he
surgeon, an anesthesiologist, and a hospital should be made liable admitted that he had yet to do one on the body of a typhoid victim
for the comatose condition of a patient scheduled for at the time he conducted the postmortem on Jorge Reyes. It is also
cholecystectomy.19 In that case, the patient was given anesthesia plain from his testimony that he has treated only about three cases
prior to her operation. Noting that the patient was neurologically of typhoid fever. Thus, he testified that:23
sound at the time of her operation, the Court applied the doctrine
of res ipsa loquitur as mental brain damage does not normally
occur in a gallblader operation in the absence of negligence of the ATTY. PASCUAL:
anesthesiologist. Taking judicial notice that anesthesia procedures
had become so common that even an ordinary person could tell if Q Why? Have you not testified earlier that you have never seen a
it was administered properly, we allowed the testimony of a patient who died of typhoid fever?
witness who was not an expert. In this case, while it is true that
the patient died just a few hours after professional medical A In autopsy. But, that was when I was a resident physician yet.
assistance was rendered, there is really nothing unusual or
extraordinary about his death. Prior to his admission, the patient
already had recurring fevers and chills for five days unrelieved by Q But you have not performed an autopsy of a patient who died of
the analgesic, antipyretic, and antibiotics given him by his wife. typhoid fever?
This shows that he had been suffering from a serious illness and
professional medical help came too late for him. A I have not seen one.

Respondents alleged failure to observe due care was not Q And you testified that you have never seen a patient who died
immediately apparent to a layman so as to justify application of typhoid fever within five days?
of res ipsa loquitur. The question required expert opinion on the
alleged breach by respondents of the standard of care required by A I have not seen one.
the circumstances. Furthermore, on the issue of the correctness of
her diagnosis, no presumption of negligence can be applied to Dr.
Marlyn Rico.As held in Ramos: Q How many typhoid fever cases had you seen while you were in
the general practice of medicine?
. . . . Res ipsa loquitur is not a rigid or ordinary doctrine to be
perfunctorily used but a rule to be cautiously applied, depending A In our case we had no widal test that time so we cannot
upon the circumstances of each case. It is generally restricted to consider that the typhoid fever is like this and like that. And the
situations in malpractice cases where a layman is able to say, as a widal test does not specify the time of the typhoid fever.
matter of common knowledge and observation, that the
consequences of professional care were not as such as would Q The question is: how many typhoid fever cases had you seen in
ordinarily have followed if due care had been exercised. A your general practice regardless of the cases now you practice?
distinction must be made between the failure to secure results, and
the occurrence of something more unusual and not ordinarily
A I had only seen three cases.
found if the service or treatment rendered followed the usual
procedure of those skilled in that particular practice. It must be
conceded that the doctrine of res ipsa loquitur  can have no Q And that was way back in 1964?
application in a suit against a physician or a surgeon which
involves the merits of a diagnosis or of a scientific treatment. The A Way back after my training in UP.
physician or surgeon is not required at his peril to explain why
any particular diagnosis was not correct, or why any particular
Q Clinically?
scientific treatment did not produce the desired result.20

A Way back before my training.

Specific Acts of Negligence

He is thus not qualified to prove that Dr. Marlyn Rico erred in her
We turn to the question whether petitioners have established
diagnosis. Both lower courts were therefore correct in discarding
specific acts of negligence allegedly committed by respondent
his testimony, which is really inadmissible.
doctors.

In Ramos, the defendants presented the testimony of a

Petitioners contend that: (1) Dr. Marlyn Rico hastily and
pulmonologist to prove that brain injury was due to oxygen
erroneously relied upon the Widal test, diagnosed Jorge’s illness
deprivation after the patient had bronchospasms24 triggered by her A I would then think of toxemia, which was toxic meningitis and
allergic response to a drug, 25 and not due to faulty intubation by probably a toxic meningitis because of the high cardiac rate.
the anesthesiologist. As the issue was whether the intubation was
properly performed by an anesthesiologist, we rejected the Q Even if the same patient who, after having given intramuscular
opinion of the pulmonologist on the ground that he was not: (1) an valium, became conscious and coherent about 20 minutes later,
anesthesiologist who could enlighten the court about anesthesia have seizure and cyanosis and rolling of eyeballs and vomitting . .
practice, procedure, and their complications; nor (2) an . and death: what significance would you attach to this
allergologist who could properly advance expert opinion on development?
allergic mediated processes; nor (3) a pharmacologist who could
explain the pharmacologic and toxic effects of the drug allegedly
responsible for the bronchospasms. A We are probably dealing with typhoid to meningitis.

Second. On the other hand, the two doctors presented by Q In such case, Doctor, what finding if any could you expect on
respondents clearly were experts on the subject. They vouched for the post-mortem examination?
the correctness of Dr. Marlyn Rico’s diagnosis. Dr. Peter Gotiong,
a diplomate whose specialization is infectious diseases and A No, the finding would be more on the meninges or covering of
microbiology and an associate professor at the Southwestern the brain.
University College of Medicine and the Gullas College of
Medicine, testified that he has already treated over a thousand Q And in order to see those changes would it require opening the
cases of typhoid fever.26 According to him, when a case of typhoid skull?
fever is suspected, the Widal test is normally used, 27 and if the
1:320 results of the Widal test on Jorge Reyes had been presented
to him along with the patient’s history, his impression would also A Yes.
be that the patient was suffering from typhoid fever. 28 As to the
treatment of the disease, he stated that chloromycetin was the As regards Dr. Vacalares’ finding during the autopsy that the
drug of choice.29 He also explained that despite the measures taken deceased’s gastro-intestinal tract was normal, Dr. Rico explained
by respondent doctors and the intravenous administration of two that, while hyperplasia31 in the payer’s patches or layers of the
doses of chloromycetin, complications of the disease could not be small intestines is present in typhoid fever, the same may not
discounted. His testimony is as follows:30 always be grossly visible and a microscope was needed to see the
texture of the cells.32
ATTY. PASCUAL:
Respondents also presented the testimony of Dr. Ibarra T.
Q If with that count with the test of positive for 1 is to 320, what Panopio who is a member of the Philippine and American Board
treatment if any would be given? of Pathology, an examiner of the Philippine Board of Pathology,
and chief pathologist at the MetroCebu Community Hospital,
Perpetual Succor Hospital, and the Andres Soriano Jr. Memorial
A If those are the findings that would be presented to me, the first Medical Center. He stated that, as a clinical pathologist, he
thing I would consider would be typhoid fever. recognized that the Widal test is used for typhoid patients,
although he did not encourage its use because a single test would
Q And presently what are the treatments commonly used? only give a presumption necessitating that the test be repeated,
becoming more conclusive at the second and third weeks of the
A Drug of choice of chloramphenical. disease.33 He corroborated Dr. Gotiong’s testimony that the danger
with typhoid fever is really the possible complications which
could develop like perforation, hemorrhage, as well as liver and
Q Doctor, if given the same patient and after you have cerebral complications.34 As regards the 1:320 results of the Widal
administered chloramphenical about 3 1/2 hours later, the patient test on Jorge Reyes, Dr. Panopio stated that no additional
associated with chills, temperature - 41 oC, what could possibly information could be obtained from a higher ratio. 35 He also
come to your mind? agreed with Dr. Gotiong that hyperplasia in the payer’s patches
may be microscopic.36
A Well, when it is change in the clinical finding, you have to
think of complication. Indeed, the standard contemplated is not what is actually the
average merit among all known practitioners from the best to the
Q And what will you consider on the complication of typhoid? worst and from the most to the least experienced, but the
reasonable average merit among the ordinarily good
A One must first understand that typhoid fever is toximia. The physicians.37 Here, Dr. Marlyn Rico did not depart from the
problem is complications are caused by toxins produced by the reasonable standard recommended by the experts as she in fact
bacteria . . . whether you have suffered complications to think of observed the due care required under the circumstances. Though
-- heart toxic myocardities; then you can consider a toxic the Widal test is not conclusive, it remains a standard diagnostic
meningitis and other complications and perforations and bleeding test for typhoid fever and, in the present case, greater accuracy
in the ilium. through repeated testing was rendered unobtainable by the early
death of the patient. The results of the Widal test and the patient’s
history of fever with chills for five days, taken with the fact that
Q Even that 40-year old married patient who received medication typhoid fever was then prevalent as indicated by the fact that the
of chloromycetin of 500 milligrams intravenous, after the skin clinic had been getting about 15 to 20 typhoid cases a month,
test, and received a second dose of chloromycetin of 500 were sufficient to give upon any doctor of reasonable skill the
miligrams, 3 hours later, the patient developed chills . . . rise in impression that Jorge Reyes had typhoid fever.
temperature to 41oC, and then about 40 minutes later the
temperature rose to 100oF, cardiac rate of 150 per minute who
appeared to be coherent, restless, nauseating, with seizures: what Dr. Rico was also justified in recommending the administration of
significance could you attach to these clinical changes? the drug chloromycetin, the drug of choice for typhoid fever. The
burden of proving that Jorge Reyes was suffering from any other standard of care and degree of diligence required from physicians
illness rested with the petitioners. As they failed to present expert and surgeons in Iligan City.
opinion on this, preponderant evidence to support their contention
is clearly absent. The standard of extraordinary diligence is peculiar to common
carriers. The Civil Code provides:
Third. Petitioners contend that respondent Dr. Marvie Blanes,
who took over from Dr. Rico, was negligent in ordering the Art. 1733. Common carriers, from the nature of their business and
intravenous administration of two doses of 500 milligrams of for reasons of public policy, are bound to observe extraordinary
chloromycetin at an interval of less than three hours. Petitioners diligence in the vigilance over the goods and for the safety of the
claim that Jorge Reyes died of anaphylactic shock 38 or possibly passengers transported by them, according to the circumstances of
from overdose as the second dose should have been administered each case. . . .
five to six hours after the first, per instruction of Dr. Marlyn Rico.
As held by the Court of Appeals, however:
The practice of medicine is a profession engaged in only by
qualified individuals.1âwphi1 It is a right earned through years of
That chloromycetin was likewise a proper prescription is best education, training, and by first obtaining a license from the state
established by medical authority. Wilson, et. al., in Harrison’s through professional board examinations. Such license may, at
Principle of Internal Medicine, 12th ed. write that chlorampenicol any time and for cause, be revoked by the government. In addition
(which is the generic of chloromycetin) is the drug of choice for to state regulation, the conduct of doctors is also strictly governed
typhoid fever and that no drug has yet proven better in promoting by the Hippocratic Oath, an ancient code of discipline and ethical
a favorable clinical response. "Chlorampenicol (Chloromycetin) is rules which doctors have imposed upon themselves in recognition
specifically indicated for bacterial meningitis, typhoid fever, and acceptance of their great responsibility to society. Given these
rickettsial infections, bacteriodes infections, etc." (PIMS Annual, safeguards, there is no need to expressly require of doctors the
1994, p. 211) The dosage likewise including the first observance of "extraordinary" diligence. As it is now, the practice
administration of five hundred milligrams (500 mg.) at around of medicine is already conditioned upon the highest degree of
nine o’clock in the evening and the second dose at around 11:30 diligence. And, as we have already noted, the standard
the same night was still within medically acceptable limits, contemplated for doctors is simply the reasonable average merit
since the recommended dose of chloromycetin is one (1) gram among ordinarily good physicians. That is reasonable diligence
every six (6) hours. (cf. Pediatric Drug Handbook, 1st Ed., for doctors or, as the Court of Appeals called it, the reasonable
Philippine Pediatric Society, Committee on Therapeutics and "skill and competence . . . that a physician in the same or similar
Toxicology, 1996). The intravenous route is likewise correct. locality . . . should apply."
(Mansser, O’Nick, Pharmacology and Therapeutics) Even if the
test was not administered by the physician-on-duty, the evidence
introduced that it was Dra. Blanes who interpreted the results WHEREFORE, the instant petition is DENIED and the decision
remain uncontroverted. (Decision, pp. 16-17) Once more, this of the Court of Appeals is AFFIRMED.
Court rejects any claim of professional negligence in this regard.
SO ORDERED.
....

As regards anaphylactic shock, the usual way of guarding against

it prior to the administration of a drug, is the skin test of which,
however, it has been observed: "Skin testing with haptenic drugs
is generally not reliable. Certain drugs cause nonspecific
histamine release, producing a weal-and-flare reaction in normal
individuals. Immunologic activation of mast cells requires a
polyvalent allergen, so a negative skin test to a univalent haptenic
drug does not rule out anaphylactic sensitivity to that drug." (Terr,
"Anaphylaxis and Urticaria" in Basic and Clinical
Immunology, p. 349) What all this means legally is that even if
the deceased suffered from an anaphylactic shock, this, of itself,
would not yet establish the negligence of the appellee-physicians
for all that the law requires of them is that they perform the
standard tests and perform standard procedures. The law cannot
require them to predict every possible reaction to all drugs
administered. The onus probandi was on the appellants to
establish, before the trial court, that the appellee-physicians
ignored standard medical procedure, prescribed and administered
medication with recklessness and exhibited an absence of the
competence and skills expected of general practitioners similarly
situated.39

Fourth. Petitioners correctly observe that the medical profession

is one which, like the business of a common carrier, is affected
with public interest. Moreover, they assert that since the law
imposes upon common carriers the duty of observing
extraordinary diligence in the vigilance over the goods and for the
safety of the passengers,40physicians and surgeons should have the
same duty toward their patients.41 They also contend that the Court
of Appeals erred when it allegedly assumed that the level of
medical practice is lower in Iligan City, thereby reducing the
Ruñez Jr. v. Dr. Jurado A.M. No. 2005-08-SC much less duty-bound, to seek out her patient and continue being
his doctor.

Simple neglect of duty presupposes a task expected of an

Facts: employee. Thus, it cannot be present if there was no expected task
Ruñez, Sr. arrived by himself at the Courts clinic complaining of on her part.
dizziness. His blood pressure and pulse rate were taken by the
reception nurse and were registered at 210/100 mmHg and 112
beats a minute, Dr. Jurado then instructed the nurse to administer A.M. No. 2005-08-SC December 9, 2005
one tablet of Capoten 25mg, an emergency drug that quickly
lowers a patients blood pressure. Dr Jurado informed Ruez, Sr. SAMUEL R. RUÑEZ, JR., Complainant, 
that he will be taken to the hospital, after which she immediately vs.
instructed the ambulance driver, Mr. Jacinto, to stand by for MARYBETH V. JURADO, Respondent.
hospital conduction. Minutes later, after having taken Capoten
and being given a chance to rest, Ruez, Sr. stood up and walked
out saying, Doktora, hanaplang ho ako ng kasama. Dr. Jurado said DECISION
she waited for him to return but he failed to show up.
AZCUNA, J.:

According to Ruez, Jr (son of Ruez Sr.), after being informed of It is unfortunate that this administrative case involves co-workers
his father’s condition, he rushed him to the Manila Doctors in this Court. Complainant, Samuel R. Ruñez, Jr. (Ruñez, Jr.), is
Hospital. The following morning, he suffered a stroke and for a Chief of the Clearance Section, Checks Disbursement Division of
moment was on flat line. the FMO-OCA and is the son of the aggrieved party, Samuel V.
Ruñez, Sr. (Ruñez, Sr.), Driver I for the Motorpool, Property
Division of the OCA. Respondent is Dr. Marybeth V. Jurado (Dr.
On February 15, 2005, Ruez, Jr. filed a letter-complaint with the Jurado), Medical Officer IV of the Medical and Dental Services.
Office of the Chief Justice regarding the alleged lack of attention All three were working for the Court at the time of the incident in
given to his father by Dr. Jurado, he claims that Dr. Jurado merely issue.
advised his father to go to the hospital and then allowed him to
travel to Manila Doctors Hospital despite the availability of an The parties agree that on January 12, 2005, at around 4:20 p.m.,
ambulance at the disposal of the clinic. Ruñez, Sr. arrived by himself at this Court’s clinic complaining of
dizziness. His blood pressure and pulse rate were taken by the
reception nurse and were registered at 210/100 mmHg and 112
Issue: beats a minute, respectively. What transpired next is disputed.
Whether or not Dr. Jurado be held liable for simple neglect of Ruñez, Jr. alleged that despite his father’s medical condition, he
duty. was merely advised to go to a hospital and then allowed to walk
out of the clinic on his own. Dr. Jurado, on the other hand,
maintained that after being informed of Ruñez, Sr.’s blood
pressure and heart rate, she instructed the nurse to administer one
Held:
tablet of Capoten 25mg, an emergency drug that quickly lowers a
No. Simple neglect of duty is defined as failure to give proper
patient’s blood pressure. She then informed Ruñez, Sr. that he
attention to a task expected of an employee resulting from either
will be taken to the hospital, after which she immediately
carelessness or indifference or signifies a disregard of duty
instructed the ambulance driver, Mr. Jacinto, to stand by for
resulting from carelessness or indifference.
hospital conduction. Minutes later, after having
Article II, Section 1 of the Code of Medical Ethics of the Medical
taken Capoten and being given a chance to rest, Ruñez, Sr. stood
Profession in the Philippines states:A physician should attend to
up and walked out saying, "Doktora, hanap lang ho ako ng
his patients faithfully and conscientiously. He should secure for
kasama." Dr. Jurado said she waited for him to return but he
them all possible benefits that may depend upon his professional
failed to show up. She asked Mr. Almarza, a nurse at the clinic, to
skill and care. As the sole tribunal to adjudge the physician’s
look for Ruñez, Sr. but he was unable to locate him.
failure to fulfill his obligation to his patients is, in most cases, his
own conscience, violation of this rule on his part is discreditable
and inexcusable. According to Ruñez, Jr., after being informed of his father’s
condition, he rushed him to the Manila Doctors Hospital. There,
Ruñez, Sr. was treated in the emergency room for approximately
four hours before he was discharged at around 8:30 p.m. and
A doctors duty to his patient is not required to be extraordinary.
allowed to go home. However, prior to reaching their house in
The standard contemplated for doctors is simply the reasonable
Balintawak, Caloocan City, Ruñez, Sr. began experiencing
average merit among ordinarily good physicians, i.e. reasonable
nausea, abnormal palpitation and uneasiness and had to be
skill and competence.Dr. Jurado fulfilled such a standard when
brought back to the hospital.
she treated Ruez, Sr. inside the clinic.
Thus, when Ruez, Sr. failed to show up as of closing time, and
could not be found by the male nurse who looked for him at her Ruñez, Sr. and Ruñez, Jr. 1 arrived at the emergency room of the
instructions, Dr. Jurado had reason to think that he had decided to Manila Doctors Hospital at around 10:00 p.m. after which Ruñez,
disregard her medical advice, which he in fact did when he and Sr. underwent a C.T. Scan. The C.T. Scan revealed a blood clot
Ruez, Jr. decided to go to the hospital on their own. Ruez, Sr., still necessitating him to be admitted for treatment and observation.
of sound mind, had the right to accept or ignore his doctors The following morning he suffered a stroke and for a moment was
recommendation. Dr. Jurado was obligated to care for Ruez, Sr. on flat line. The doctors were able to revive him and thereafter he
when the latter asked for medical treatment, which she did, but was transferred to the intensive care unit. Unfortunately, Ruñez
when he left on his own accord Dr. Jurado was not expected,
Sr. never recovered from his ailment and, on September 12, 2005, The Court does not agree that the acts or omission of Dr. Jurado
he passed away due to medical complications. 2 amount to simple neglect of duty. Simple neglect of duty is
defined as failure to give proper attention to a task expected of an
On February 15, 2005, Ruñez, Jr. filed a letter-complaint with the employee resulting from either carelessness or indifference 4 or
Office of the Chief Justice regarding the alleged lack of attention signifies a disregard of duty resulting from carelessness or
given to his father by Dr. Jurado. Specifically, he claims that Dr. indifference.5 In Philippine Retirement Authority,6 it was stated,
Jurado merely advised his father to go to the hospital and then "The Court has decided the following, inter alia, as constituting
allowed him to travel to Manila Doctors Hospital despite the the less grave offense of Simple Neglect of Duty: delay in the
availability of an ambulance at the disposal of the clinic. Ruñez, transmittal of court records, delay in responding to written
Jr. submits that his father would not have suffered a stroke if not queries, and delay of more than one (1) year and seven (7) months
for the neglect of Dr. Jurado. in furnishing a party with a copy of the court’s decision." In all
the instances cited by the Court, respondents had the duty or were
expected to do certain acts which they failed to do. How do we
The letter-complaint was referred to Atty. Eden T. Candelaria, determine what acts are expected of Dr. Jurado? Atty.
Deputy Clerk of Court and Chief of Administrative Services, for Candelaria’s report cites the applicable yardstick: a physician or
investigation. Atty. Candelaria required Dr. Jurado to submit her surgeon is expected to apply in his practice of medicine that
comment to the letter-complaint. The comment was submitted on degree of care and skill which is ordinarily employed by the
March 18, 2005, together with supporting affidavits from profession, generally, and under similar conditions. 7 Therefore, to
respondent’s witnesses. This was followed by Ruñez, Jr.’s reply find Dr. Jurado liable for simple neglect of duty the Court has to
to the comment on April 12, 2005 and Dr. Jurado’s rejoinder on be convinced that those in the medical profession were also
April 22, 2005.3 expected to act in the manner illustrated by Atty.
Candelaria, i.e., to exert all efforts to determine the whereabouts
Atty. Candelaria submitted her report on June 17, 2005. The of Ruñez, Sr., inform his relatives or turn his case over to a doctor
report gave credence to the account of Dr. Jurado that Ruñez, Sr. who was available after office hours.
was given Capoten, informed that he should be hospitalized and
that the ambulance was placed on standby to take him there. Article II, Section 1 of the Code of Medical Ethics of the Medical
These factual findings of Atty. Candelaria appear to be supported Profession in the Philippines states:
by the affidavits of the clinic’s personnel, including the
ambulance driver, who witnessed the events that happened
between Ruñez, Sr. and Dr. Jurado. "A physician should attend to his patients faithfully and
conscientiously. He should secure for them all possible benefits
that may depend upon his professional skill and care. As the sole
The issue now for the Court to resolve is whether, given the tribunal to adjudge the physician’s failure to fulfill his obligation
accepted facts, there is cause to hold Dr. Jurado administratively to his patients is, in most cases, his own conscience, violation of
liable. Atty. Candelaria is satisfied that Dr. Jurado provided this rule on his part is discreditable and inexcusable."
Ruñez, Sr. proper treatment inside the clinic. However, in her
opinion, Dr. Jurado’s actions after Ruñez, Sr. had left were less
than the required diligence of a good father of a family. We quote A doctor’s duty to his patient is not required to be
below the analysis of Atty. Candelaria: extraordinary.8 The standard contemplated for doctors is simply
the reasonable average merit among ordinarily good
physicians, i.e. reasonable skill and competence.9 We are
. . . Records will clearly show that minutes after Mr. Ruñez, Sr. persuaded that Dr. Jurado fulfilled such a standard when she
left the clinic, Dr. Jurado also left the clinic to go home. This is treated Ruñez, Sr. inside the clinic. But what of Dr. Jurado’s
shown by her time out registered in the Chronolog Machine on conduct after Ruñez, Sr. left the clinic and failed to return?
the said date which was 4:31 p.m. and her inclusion in the list of
passengers of Shuttle Bus No. 6. As an efficient and intelligent
doctor, Dr. Jurado should have at least personally exerted all her It has been held that a patient cannot attribute to a physician
efforts to determine the whereabouts of Mr. Ruñez, Sr. because of damages resulting from his own failure to follow his advice, even
his condition and again at the very least informed his relatives in though he was ignorant of the consequences which would result
the Court in order that they too take the necessary action that very from his failure.10 If a patient leaves the hospital contrary to
moment. Or in the alternative, if indeed, Dr. Jurado may have instructions, the physician is not liable for subsequent
been in a hurry at that time to do some errands, she should have at events.11 There is no expectation from doctors that they track
least[,] again, turned Mr. Ruñez over the a [d]octor who was down each patient who apparently missed their appointments or
willing to be left behind after office hours. These however never force them to comply with their directives. After all, a person is
happened. All that she relied on was the fact that there was an still the master of his own body.12
emergency treatment and an order for hospital conduction but [the
same] didn’t materialize and [she] put [the] blame on Mr. Ruñez, Dr. Jurado may have allowed Ruñez, Sr. to walk out of the clinic
Sr. As admitted by complainant, Mr. Ruñez, Sr., is a mere despite her earlier diagnosis of his condition. By that time Ruñez,
"driver" and perhaps may have no knowledge at all of the Sr.’s condition had temporarily stabilized and she did not have the
consequences of his 210/100 blood pressure and since he sought authority to stop him just as other doctors have no power, save in
refuge from the [c]linic, the clinic, particularly Dr. Jurado[,] certain instances (such as when the law makes treatment
should have made him feel safe and secure in the said place. . . . compulsory due to some communicable disease 13 or when consent
is withheld by a minor but non-treatment would be detrimental or
Atty. Candelaria recommends that Dr. Jurado be held liable for when the court of competent jurisdiction orders the treatment), to
simple neglect of duty and suspended for one (1) month and (1) force patients into staying under their care. Dr. Jurado relied on
day. She further recommends that, in light of what happened, Dr. Ruñez, Sr.’s representation that he would return in order to be
Prudencio Banzon, SC Senior Staff Officer, Medical and Dental brought to the hospital but made no undertaking to wait for him
Services, be directed to prepare a flexi-time schedule (until 5:30 beyond the clinic hours or to look for him if he did not return.
p.m.) for all doctors and nurses in the clinic to enable it to provide Thus, when Ruñez, Sr. failed to show up as of closing time, and
immediate and proper attention in case of any emergency medical could not be found by the male nurse who looked for him at her
situation. instructions, Dr. Jurado had reason to think that he had decided to
disregard her medical advice, which he in fact did when he and
Ruñez, Jr. decided to go to the hospital on their own. Ruñez, Sr., ROGELIO P. NOGALES, vs. CAPITOL MEDICAL
still of sound mind, had the right to accept or ignore his doctor’s CENTER, G.R. No. 142625, December 19, 2006
recommendation. Dr. Jurado was obligated to care for Ruñez, Sr.
when the latter asked for medical treatment, which she did, but
when he left on his own accord Dr. Jurado was not expected,
much less duty-bound, to seek out her patient and continue being
his doctor.
FACTS:
Corazon Nogales (Corazon) was pregnant of her 4th child and
Some people may interpret Dr. Jurado’s inaction as indifference, was under the exclusive prenatal care of Dr. Oscar Estrada (Dr.
while others may view the same as just proper. Some would Estrada). On her last trimester of pregnancy, Dr. Estrada noted an
applaud Dr. Jurado’s dedication had she done all the things increase in Corazon’s blood pressure and development of leg
mentioned by Atty. Candelaria and yet others would see them as edema which may lead to a dangerous complication of pregnancy.
still insufficient. There will always be a divergence of opinions as When Corazon started experiencing mild labor pains, she and his
to how Dr. Jurado should have conducted herself but the Court husband Rogelio opted to see Dr. Estrada for examination, and the
must distinguish between acts that deserve to be emulated or latter advised them to admit Corazon to the Capitol Medical
disdained and those that deserve sanctions. The former is largely a Center (CMC). Short after Corazon’s bag of water ruptured, she
matter of opinion while the latter can only be imposed if there was started to experience convulsions. Dr. Estrada and another
a failure to perform a clear duty, expectation or obligation. People physician in the name of Dr. Villaflor began extracting the baby,
may frown upon certain behaviors and chastise others for having which allegedly torn a piece of cervical tissue of the patient. After
less compassion, but it does not necessarily follow that those acts the baby was taken out of the womb, Corazon began to manifest
translate to neglect of duty, misconduct or negligence. moderate vaginal bleeding which rapidly became profuse. Despite
efforts to revive the patient, Corazon died. The cause of which
Dr. Jurado could have exerted greater efforts by searching all over was “hemorrhage, post-partum.”
the compound for Ruñez, Sr. but the fact remains that these were
not part of her duties nor were they expected from her. Simple
neglect of duty presupposes a task expected of an employee. Rogelio Nogales, et al. (petitioners) filed a complaint for damages
Thus, it cannot be present if there was no expected task on her against CMC, Dr. Estrada, and the other involved medical
part. That said, the Court wishes to exhort Dr. Jurado, and all personnel of the hospital (Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr.
personnel in its clinic, not to be satisfied with merely fulfilling the Lacson, Dr. Espinola, and a certain Nurse J. Dumlao) for the
minimum, but to go for the magis, the best service they can render death of Corazon, charging CMC with negligence in the selection
by way of being exemplars for their fellow workers in the Court. and supervision of defendant physicians and hospital staff.

WHEREFORE, the Court finds no reason to hold Dr. Jurado

liable for simple neglect of duty, and, therefore, DISMISSES the The RTC (Manila) rendered judgment finding Dr. Estrada solely
complaint for lack of merit. As recommended by Atty. Eden T. liable for damages. In ruling the same, the Court finds no legal
Candelaria, Deputy Clerk of Court and Chief of Administrative justification to find the other impleaded physicians and hospital
Services, Dr. Prudencio Banzon, Senior Staff Officer, Medical personnel civilly liable.
and Dental Services, is DIRECTED to prepare a flexi-time
schedule for all doctors and nurses in the clinic to further develop
its capability to provide immediate and proper attention in
Upon appeal, petitioners claimed that aside from Dr. Estrada, the
emergency medical situations, and to submit the same to Atty.
remaining respondents should be held equally liable for
Candelaria in 30 days from receipt of a copy of this decision
negligence, pointing out the extent of each respondent’s alleged
which should be served upon him forthwith.
liability.

SO ORDERED.
The CA affirmed the decision of the trial court and on ruling the
ADOLFO S. AZCUNA same, the Court of Appeals applied the “borrowed servant”
doctrine considering that Dr. Estrada was an independent
contractor who was merely exercising hospital privileges. This
doctrine provides that once the surgeon enters the operating room
and takes charge of the proceedings, the acts or omissions of
operating room personnel, and any negligence associated with
such acts or omissions, are imputable to the surgeon. While the
assisting physicians and nurses may be employed by the hospital,
or engaged by the patient, they normally become the temporary
servants or agents of the surgeon in charge while the operation is
in progress, and liability may be imposed upon the surgeon for
their negligent acts under the doctrine of respondeat superior.
Hence, the petition.

ISSUE:
Whether CMC is vicariously liable for the negligence of Dr.
Estrada.

HELD:
YES. Art. 2180. The obligation imposed by article 2176 is
demandable not only for one’s own acts or omissions, but also for
those of persons for whom one is responsible. G.R. No. 142625             December 19, 2006
x x x x
Employers shall be liable for the damages caused by their
employees and household helpers acting within the scope of their ROGELIO P. NOGALES, for himself and on behalf of the
assigned tasks, even though the former are not engaged in any minors, ROGER ANTHONY, ANGELICA, NANCY, and
business or industry. MICHAEL CHRISTOPHER, all surnamed
x x x x NOGALES, petitioners, 
The responsibility treated of in this article shall cease when the vs.
persons herein mentioned prove that they observed all the CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA,
diligence of a good father of a family to prevent damage. DR. ELY VILLAFLOR, DR. ROSA UY, DR. JOEL
Art. 2176. Whoever by act or omission causes damage to another, ENRIQUEZ, DR. PERPETUA LACSON, DR. NOE
there being fault or negligence, is obliged to pay for the damage ESPINOLA, and NURSE J. DUMLAO, respondents.
done. Such fault or negligence, if there is no pre-existing
contractual relation between the parties, is called a quasi-delict
and is governed by the provisions of this Chapter. DECISION
CARPIO, J.:

In general, a hospital is not liable for the negligence of an The Case

independent contractor-physician. There is, however, an
exception to this principle. The hospital may be liable if the
This petition for review1 assails the 6 February 1998
physician is the “ostensible” agent of the hospital. This is known
Decision2 and 21 March 2000 Resolution3 of the Court of Appeals
as the “doctrine of apparent authority.” In Gilbert v. Sycamore
in CA-G.R. CV No. 45641. The Court of Appeals affirmed in
Municipal Hospital, the Illinois Supreme Court explained the
toto the 22 November 1993 Decision4 of the Regional Trial Court
doctrine of apparent authority in this wise:
of Manila, Branch 33, finding Dr. Oscar Estrada solely liable for
damages for the death of his patient, Corazon Nogales, while
absolving the remaining respondents of any liability. The Court of
[U]nder the doctrine of apparent authority a hospital can be held Appeals denied petitioners' motion for reconsideration.
vicariously liable for the negligent acts of a physician providing
care at the hospital, regardless of whether the physician is an
The Facts
independent contractor, unless the patient knows, or should have
known, that the physician is an independent contractor. The
elements of the action have been set out as follows: Pregnant with her fourth child, Corazon Nogales ("Corazon"),
“For a hospital to be liable under the doctrine of apparent who was then 37 years old, was under the exclusive prenatal care
authority, a plaintiff must show that: (1) the hospital, or its agent, of Dr. Oscar Estrada ("Dr. Estrada") beginning on her fourth
acted in a manner that would lead a reasonable person to conclude month of pregnancy or as early as December 1975. While
that the individual who was alleged to be negligent was an Corazon was on her last trimester of pregnancy, Dr. Estrada noted
employee or agent of the hospital; (2) where the acts of the agent an increase in her blood pressure and development of leg
create the appearance of authority, the plaintiff must also prove edema5 indicating preeclampsia,6 which is a dangerous
that the hospital had knowledge of and acquiesced in them; and complication of pregnancy.7
(3) the plaintiff acted in reliance upon the conduct of the hospital
or its agent, consistent with ordinary care and prudence.” Around midnight of 25 May 1976, Corazon started to experience
x x x x mild labor pains prompting Corazon and Rogelio Nogales
The doctrine of apparent authority essentially involves two factors ("Spouses Nogales") to see Dr. Estrada at his home. After
to determine the liability of an independent-contractor physician: examining Corazon, Dr. Estrada advised her immediate admission
The first factor focuses on the hospital’s manifestations and is to the Capitol Medical Center ("CMC").
sometimes described as an inquiry whether the hospital acted in a
manner which would lead a reasonable person to conclude that the
On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC
individual who was alleged to be negligent was an employee or
after the staff nurse noted the written admission request 8 of Dr.
agent of the hospital. In this regard, the hospital need not make
Estrada. Upon Corazon's admission at the CMC, Rogelio Nogales
express representations to the patient that the treating physician is
("Rogelio") executed and signed the "Consent on Admission and
an employee of the hospital; rather a representation may be
Agreement"9 and "Admission Agreement."10 Corazon was then
general and implied. The second factor focuses on the patient’s
brought to the labor room of the CMC.
reliance. It is sometimes characterized as an inquiry on whether
the plaintiff acted in reliance upon the conduct of the hospital or
its agent, consistent with ordinary care and prudence. Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of
CMC, conducted an internal examination of Corazon. Dr. Uy then
called up Dr. Estrada to notify him of her findings.

Based on the Doctor's Order Sheet, 11 around 3:00 a.m., Dr.

Estrada ordered for 10 mg. of valium to be administered
immediately by intramuscular injection. Dr. Estrada later ordered
the start of intravenous administration of syntocinon admixed
with dextrose, 5%, in lactated Ringers' solution, at the rate of
eight to ten micro-drops per minute.

According to the Nurse's Observation Notes,12 Dr. Joel Enriquez

("Dr. Enriquez"), an anesthesiologist at CMC, was notified at 4:15
a.m. of Corazon's admission. Subsequently, when asked if he
needed the services of an anesthesiologist, Dr. Estrada refused. After more than 11 years of trial, the trial court rendered judgment
Despite Dr. Estrada's refusal, Dr. Enriquez stayed to observe on 22 November 1993 finding Dr. Estrada solely liable for
Corazon's condition. damages. The trial court ruled as follows:

At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of The victim was under his pre-natal care, apparently, his
the CMC. At 6:10 a.m., Corazon's bag of water ruptured fault began from his incorrect and inadequate
spontaneously. At 6:12 a.m., Corazon's cervix was fully dilated. management and lack of treatment of the pre-eclamptic
At 6:13 a.m., Corazon started to experience convulsions. condition of his patient. It is not disputed that he
misapplied the forceps in causing the delivery because it
At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of resulted in a large cervical tear which had caused the
magnesium sulfate. However, Dr. Ely Villaflor ("Dr. Villaflor"), profuse bleeding which he also failed to control with the
who was assisting Dr. Estrada, administered only 2.5 grams of application of inadequate injection of magnesium
magnesium sulfate. sulfate by his assistant Dra. Ely Villaflor. Dr. Estrada
even failed to notice the erroneous administration by
nurse Dumlao of hemacel by way of side drip, instead
At 6:22 a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low of direct intravenous injection, and his failure to consult
forceps to extract Corazon's baby. In the process, a 1.0 x 2.5 cm. a senior obstetrician at an early stage of the problem.
piece of cervical tissue was allegedly torn. The baby came out in
an apnic, cyanotic, weak and injured condition. Consequently, the
baby had to be intubated and resuscitated by Dr. Enriquez and Dr. On the part however of Dra. Ely Villaflor, Dra. Rosa
Payumo. Uy, Dr. Joel Enriquez, Dr. Lacson, Dr. Espinola, nurse
J. Dumlao and CMC, the Court finds no legal
justification to find them civilly liable.
At 6:27 a.m., Corazon began to manifest moderate vaginal
bleeding which rapidly became profuse. Corazon's blood pressure
dropped from 130/80 to 60/40 within five minutes. There was On the part of Dra. Ely Villaflor, she was only taking
continuous profuse vaginal bleeding. The assisting nurse orders from Dr. Estrada, the principal physician of
administered hemacel through a gauge 19 needle as a side drip to Corazon Nogales. She can only make suggestions in the
the ongoing intravenous injection of dextrose. manner the patient maybe treated but she cannot impose
her will as to do so would be to substitute her good
judgment to that of Dr. Estrada. If she failed to correctly
At 7:45 a.m., Dr. Estrada ordered blood typing and cross diagnose the true cause of the bleeding which in this
matching with bottled blood. It took approximately 30 minutes for case appears to be a cervical laceration, it cannot be
the CMC laboratory, headed by Dr. Perpetua Lacson ("Dr. safely concluded by the Court that Dra. Villaflor had the
Lacson"), to comply with Dr. Estrada's order and deliver the correct diagnosis and she failed to inform Dr. Estrada.
blood. No evidence was introduced to show that indeed Dra.
Villaflor had discovered that there was laceration at the
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the cervical area of the patient's internal organ.
Obstetrics-Gynecology Department of the CMC, was apprised of
Corazon's condition by telephone. Upon being informed that On the part of nurse Dumlao, there is no showing that
Corazon was bleeding profusely, Dr. Espinola ordered immediate when she administered the hemacel as a side drip, she
hysterectomy. Rogelio was made to sign a "Consent to did it on her own. If the correct procedure was directly
Operation."13 thru the veins, it could only be because this was what
was probably the orders of Dr. Estrada.
Due to the inclement weather then, Dr. Espinola, who was fetched
from his residence by an ambulance, arrived at the CMC about an While the evidence of the plaintiffs shows that Dr. Noe
hour later or at 9:00 a.m. He examined the patient and ordered Espinola, who was the Chief of the Department of
some resuscitative measures to be administered. Despite Dr. Obstetrics and Gynecology who attended to the patient
Espinola's efforts, Corazon died at 9:15 a.m. The cause of death Mrs. Nogales, it was only at 9:00 a.m. That he was able
was "hemorrhage, post partum."14 to reach the hospital because of typhoon Didang
(Exhibit 2). While he was able to give prescription in
On 14 May 1980, petitioners filed a complaint for damages 15 with the manner Corazon Nogales may be treated, the
the Regional Trial Court16 of Manila against CMC, Dr. Estrada, prescription was based on the information given to him
Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr. Lacson, Dr. Espinola, and by phone and he acted on the basis of facts as presented
a certain Nurse J. Dumlao for the death of Corazon. Petitioners to him, believing in good faith that such is the correct
mainly contended that defendant physicians and CMC personnel remedy. He was not with Dr. Estrada when the patient
were negligent in the treatment and management of Corazon's was brought to the hospital at 2:30 o'clock a.m. So,
condition. Petitioners charged CMC with negligence in the whatever errors that Dr. Estrada committed on the
selection and supervision of defendant physicians and hospital patient before 9:00 o'clock a.m. are certainly the errors
staff. of Dr. Estrada and cannot be the mistake of Dr. Noe
Espinola. His failure to come to the hospital on time
For failing to file their answer to the complaint despite service of was due to fortuitous event.
summons, the trial court declared Dr. Estrada, Dr. Enriquez, and
Nurse Dumlao in default. 17 CMC, Dr. Villaflor, Dr. Uy, Dr. On the part of Dr. Joel Enriquez, while he was present
Espinola, and Dr. Lacson filed their respective answers denying in the delivery room, it is not incumbent upon him to
and opposing the allegations in the complaint. Subsequently, trial call the attention of Dr. Estrada, Dra. Villaflor and also
ensued. of Nurse Dumlao on the alleged errors committed by
them. Besides, as anesthesiologist, he has no authority
to control the actuations of Dr. Estrada and Dra.
Villaflor. For the Court to assume that there were errors
being committed in the presence of Dr. Enriquez would SO ORDERED.18
be to dwell on conjectures and speculations.
Petitioners appealed the trial court's decision. Petitioners claimed
On the civil liability of Dr. Perpetua Lacson, [s]he is a that aside from Dr. Estrada, the remaining respondents should be
hematologist and in-charge of the blood bank of the held equally liable for negligence. Petitioners pointed out the
CMC. The Court cannot accept the theory of the extent of each respondent's alleged liability.
plaintiffs that there was delay in delivering the blood
needed by the patient. It was testified, that in order that On 6 February 1998, the Court of Appeals affirmed the decision
this blood will be made available, a laboratory test has of the trial court.19 Petitioners filed a motion for reconsideration
to be conducted to determine the type of blood, cross which the Court of Appeals denied in its Resolution of 21 March
matching and other matters consistent with medical 2000.20
science so, the lapse of 30 minutes maybe considered a
reasonable time to do all of these things, and not a delay
as the plaintiffs would want the Court to believe. Hence, this petition.

Admittedly, Dra. Rosa Uy is a resident physician of the Meanwhile, petitioners filed a Manifestation dated 12 April
Capitol Medical Center. She was sued because of her 200221 stating that respondents Dr. Estrada, Dr. Enriquez, Dr.
alleged failure to notice the incompetence and Villaflor, and Nurse Dumlao "need no longer be notified of the
negligence of Dr. Estrada. However, there is no petition because they are absolutely not involved in the issue
evidence to support such theory. No evidence was raised before the [Court], regarding the liability of
adduced to show that Dra. Rosa Uy as a resident [CMC]."22 Petitioners stressed that the subject matter of this
physician of Capitol Medical Center, had knowledge of petition is the liability of CMC for the negligence of Dr. Estrada. 23
the mismanagement of the patient Corazon Nogales,
and that notwithstanding such knowledge, she tolerated The Court issued a Resolution dated 9 September
the same to happen. 200224 dispensing with the requirement to submit the correct and
present addresses of respondents Dr. Estrada, Dr. Enriquez, Dr.
In the pre-trial order, plaintiffs and CMC agreed that Villaflor, and Nurse Dumlao. The Court stated that with the filing
defendant CMC did not have any hand or participation of petitioners' Manifestation, it should be understood that they are
in the selection or hiring of Dr. Estrada or his assistant claiming only against respondents CMC, Dr. Espinola, Dr.
Dra. Ely Villaflor as attending physician[s] of the Lacson, and Dr. Uy who have filed their respective comments.
deceased. In other words, the two (2) doctors were not Petitioners are foregoing further claims against respondents Dr.
employees of the hospital and therefore the hospital did Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao.
not have control over their professional conduct. When
Mrs. Nogales was brought to the hospital, it was an The Court noted that Dr. Estrada did not appeal the decision of
emergency case and defendant CMC had no choice but the Court of Appeals affirming the decision of the Regional Trial
to admit her. Such being the case, there is therefore no Court. Accordingly, the decision of the Court of Appeals,
legal ground to apply the provisions of Article 2176 and affirming the trial court's judgment, is already final as against Dr.
2180 of the New Civil Code referring to the vicarious Oscar Estrada.
liability of an employer for the negligence of its
employees. If ever in this case there is fault or Petitioners filed a motion for reconsideration 25 of the Court's 9
negligence in the treatment of the deceased on the part September 2002 Resolution claiming that Dr. Enriquez, Dr.
of the attending physicians who were employed by the Villaflor and Nurse Dumlao were notified of the petition at their
family of the deceased, such civil liability should be counsels' last known addresses. Petitioners reiterated their
borne by the attending physicians under the principle of imputation of negligence on these respondents. The Court denied
"respondeat superior". petitioners' Motion for Reconsideration in its 18 February 2004
Resolution.26
WHEREFORE, premises considered, judgment is
hereby rendered finding defendant Dr. Estrada of The Court of Appeals' Ruling
Number 13 Pitimini St. San Francisco del Monte,
Quezon City civilly liable to pay plaintiffs: 1) By way
of actual damages in the amount of P105,000.00; 2) By In its Decision of 6 February 1998, the Court of Appeals upheld
way of moral damages in the amount of P700,000.00; 3) the trial court's ruling. The Court of Appeals rejected petitioners'
Attorney's fees in the amount of P100,000.00 and to pay view that the doctrine in Darling v. Charleston Community
the costs of suit. Memorial Hospital27 applies to this case. According to the Court
of Appeals, the present case differs from the Darling case since
Dr. Estrada is an independent contractor-physician whereas
For failure of the plaintiffs to adduce evidence to the Darling case involved a physician and a nurse who were
support its [sic] allegations against the other defendants, employees of the hospital.
the complaint is hereby ordered dismissed. While the
Court looks with disfavor the filing of the present
complaint against the other defendants by the herein Citing other American cases, the Court of Appeals further held
plaintiffs, as in a way it has caused them personal that the mere fact that a hospital permitted a physician to practice
inconvenience and slight damage on their name and medicine and use its facilities is not sufficient to render the
reputation, the Court cannot accepts [sic] however, the hospital liable for the physician's negligence. 28 A hospital is not
theory of the remaining defendants that plaintiffs were responsible for the negligence of a physician who is an
motivated in bad faith in the filing of this complaint. independent contractor.29
For this reason defendants' counterclaims are hereby
ordered dismissed. The Court of Appeals found the cases of Davidson v.
Conole30 and Campbell v. Emma Laing Stevens
Hospital31applicable to this case. Quoting Campbell, the Court of
Appeals stated that where there is no proof that defendant scope of their assigned tasks, even though the former
physician was an employee of defendant hospital or that are not engaged in any business or industry.
defendant hospital had reason to know that any acts of
malpractice would take place, defendant hospital could not be xxxx
held liable for its failure to intervene in the relationship of
physician-patient between defendant physician and plaintiff.
The responsibility treated of in this article shall cease
when the persons herein mentioned prove that they
On the liability of the other respondents, the Court of Appeals observed all the diligence of a good father of a family to
applied the "borrowed servant" doctrine considering that Dr. prevent damage.
Estrada was an independent contractor who was merely exercising
hospital privileges. This doctrine provides that once the surgeon
enters the operating room and takes charge of the proceedings, the Art. 2176. Whoever by act or omission causes damage
acts or omissions of operating room personnel, and any to another, there being fault or negligence, is obliged to
negligence associated with such acts or omissions, are imputable pay for the damage done. Such fault or negligence, if
to the surgeon.32 While the assisting physicians and nurses may be there is no pre-existing contractual relation between the
employed by the hospital, or engaged by the patient, they parties, is called a quasi-delict and is governed by the
normally become the temporary servants or agents of the surgeon provisions of this Chapter.
in charge while the operation is in progress, and liability may be
imposed upon the surgeon for their negligent acts under the Similarly, in the United States, a hospital which is the employer,
doctrine of respondeat superior.33 master, or principal of a physician employee, servant, or agent,
may be held liable for the physician's negligence under the
The Court of Appeals concluded that since Rogelio engaged Dr. doctrine of respondeat superior.34
Estrada as the attending physician of his wife, any liability for
malpractice must be Dr. Estrada's sole responsibility. In the present case, petitioners maintain that CMC, in allowing
Dr. Estrada to practice and admit patients at CMC, should be
While it found the amount of damages fair and reasonable, the liable for Dr. Estrada's malpractice. Rogelio claims that he knew
Court of Appeals held that no interest could be imposed on Dr. Estrada as an accredited physician of CMC, though he
unliquidated claims or damages. discovered later that Dr. Estrada was not a salaried employee of
the CMC.35 Rogelio further claims that he was dealing with CMC,
whose primary concern was the treatment and management of his
The Issue wife's condition. Dr. Estrada just happened to be the specific
person he talked to representing CMC.36 Moreover, the fact that
Basically, the issue in this case is whether CMC is vicariously CMC made Rogelio sign a Consent on Admission and Admission
liable for the negligence of Dr. Estrada. The resolution of this Agreement37 and a Consent to Operation printed on the letterhead
issue rests, on the other hand, on the ascertainment of the of CMC indicates that CMC considered Dr. Estrada as a member
relationship between Dr. Estrada and CMC. The Court also of its medical staff.
believes that a determination of the extent of liability of the other
respondents is inevitable to finally and completely dispose of the On the other hand, CMC disclaims liability by asserting that Dr.
present controversy. Estrada was a mere visiting physician and that it admitted
Corazon because her physical condition then was classified an
The Ruling of the Court emergency obstetrics case.38

The petition is partly meritorious. CMC alleges that Dr. Estrada is an independent contractor "for
whose actuations CMC would be a total stranger." CMC
On the Liability of CMC maintains that it had no control or supervision over Dr. Estrada in
the exercise of his medical profession.
Dr. Estrada's negligence in handling the treatment and
management of Corazon's condition which ultimately resulted in The Court had the occasion to determine the relationship between
Corazon's death is no longer in issue. Dr. Estrada did not appeal a hospital and a consultant or visiting physician and the liability
the decision of the Court of Appeals which affirmed the ruling of of such hospital for that physician's negligence in Ramos v. Court
the trial court finding Dr. Estrada solely liable for damages. of Appeals,39 to wit:
Accordingly, the finding of the trial court on Dr. Estrada's
negligence is already final. In the first place, hospitals exercise significant control
in the hiring and firing of consultants and in the conduct
Petitioners maintain that CMC is vicariously liable for Dr. of their work within the hospital premises. Doctors who
Estrada's negligence based on Article 2180 in relation to Article apply for "consultant" slots, visiting or attending, are
2176 of the Civil Code. These provisions pertinently state: required to submit proof of completion of residency,
their educational qualifications; generally, evidence of
accreditation by the appropriate board (diplomate),
Art. 2180. The obligation imposed by article 2176 is evidence of fellowship in most cases, and references.
demandable not only for one's own acts or omissions, These requirements are carefully scrutinized by
but also for those of persons for whom one is members of the hospital administration or by a review
responsible. committee set up by the hospital who either accept or
reject the application. This is particularly true with
xxxx respondent hospital.

Employers shall be liable for the damages caused by After a physician is accepted, either as a visiting or
their employees and household helpers acting within the attending consultant, he is normally required to attend
clinico-pathological conferences, conduct bedside The question now is whether CMC is automatically exempt from
rounds for clerks, interns and residents, moderate grand liability considering that Dr. Estrada is an independent contractor-
rounds and patient audits and perform other tasks and physician.
responsibilities, for the privilege of being able to
maintain a clinic in the hospital, and/or for the privilege In general, a hospital is not liable for the negligence of an
of admitting patients into the hospital. In addition to independent contractor-physician. There is, however, an
these, the physician's performance as a specialist is exception to this principle. The hospital may be liable if the
generally evaluated by a peer review committee on the physician is the "ostensible" agent of the hospital. 44 This
basis of mortality and morbidity statistics, and feedback exception is also known as the "doctrine of apparent
from patients, nurses, interns and residents. A authority."45 In Gilbert v. Sycamore Municipal Hospital,46 the
consultant remiss in his duties, or a consultant who Illinois Supreme Court explained the doctrine of apparent
regularly falls short of the minimum standards authority in this wise:
acceptable to the hospital or its peer review committee,
is normally politely terminated.
[U]nder the doctrine of apparent authority a hospital can
be held vicariously liable for the negligent acts of a
In other words, private hospitals, hire, fire and exercise physician providing care at the hospital, regardless of
real control over their attending and visiting whether the physician is an independent contractor,
"consultant" staff. While "consultants" are not, unless the patient knows, or should have known, that
technically employees, a point which respondent the physician is an independent contractor. The
hospital asserts in denying all responsibility for the elements of the action have been set out as follows:
patient's condition, the control exercised, the hiring,
and the right to terminate consultants all fulfill the
important hallmarks of an employer-employee "For a hospital to be liable under the doctrine of
relationship, with the exception of the payment of apparent authority, a plaintiff must show that: (1) the
wages. In assessing whether such a relationship in hospital, or its agent, acted in a manner that would lead
fact exists, the control test is determining. a reasonable person to conclude that the individual who
Accordingly, on the basis of the foregoing, we rule was alleged to be negligent was an employee or agent of
that for the purpose of allocating responsibility in the hospital; (2) where the acts of the agent create the
medical negligence cases, an employer-employee appearance of authority, the plaintiff must also prove
relationship in effect exists between hospitals and that the hospital had knowledge of and acquiesced in
their attending and visiting physicians.This being the them; and (3) the plaintiff acted in reliance upon the
case, the question now arises as to whether or not conduct of the hospital or its agent, consistent with
respondent hospital is solidarily liable with respondent ordinary care and prudence."
doctors for petitioner's condition.
The element of "holding out" on the part of the hospital
The basis for holding an employer solidarily responsible does not require an express representation by the
for the negligence of its employee is found in Article hospital that the person alleged to be negligent is an
2180 of the Civil Code which considers a person employee. Rather, the element is satisfied if the hospital
accountable not only for his own acts but also for those holds itself out as a provider of emergency room care
of others based on the former's responsibility under a without informing the patient that the care is provided
relationship of patria potestas. x x x 40 (Emphasis by independent contractors.
supplied)
The element of justifiable reliance on the part of the
While the Court in Ramos did not expound on the control test, plaintiff is satisfied if the plaintiff relies upon the
such test essentially determines whether an employment hospital to provide complete emergency room care,
relationship exists between a physician and a hospital based on rather than upon a specific physician.
the exercise of control over the physician as to details.
Specifically, the employer (or the hospital) must have the right to The doctrine of apparent authority essentially involves two factors
control both the means and the details of the process by which the to determine the liability of an independent-contractor physician.
employee (or the physician) is to accomplish his task. 41
The first factor focuses on the hospital's manifestations and is
After a thorough examination of the voluminous records of this sometimes described as an inquiry whether the hospital acted in a
case, the Court finds no single evidence pointing to CMC's manner which would lead a reasonable person to conclude that the
exercise of control over Dr. Estrada's treatment and management individual who was alleged to be negligent was an employee or
of Corazon's condition. It is undisputed that throughout Corazon's agent of the hospital.47 In this regard, the hospital need not
pregnancy, she was under the exclusive prenatal care of Dr. make express representations to the patient that the treating
Estrada. At the time of Corazon's admission at CMC and during physician is an employee of the hospital; rather a
her delivery, it was Dr. Estrada, assisted by Dr. Villaflor, who representation may be general and implied.48
attended to Corazon. There was no showing that CMC had a part
in diagnosing Corazon's condition. While Dr. Estrada enjoyed The doctrine of apparent authority is a species of the doctrine of
staff privileges at CMC, such fact alone did not make him an estoppel. Article 1431 of the Civil Code provides that "[t]hrough
employee of CMC.42 CMC merely allowed Dr. Estrada to use its estoppel, an admission or representation is rendered conclusive
facilities43 when Corazon was about to give birth, which CMC upon the person making it, and cannot be denied or disproved as
considered an emergency. Considering these circumstances, Dr. against the person relying thereon." Estoppel rests on this rule:
Estrada is not an employee of CMC, but an independent "Whenever a party has, by his own declaration, act, or omission,
contractor. intentionally and deliberately led another to believe a particular
thing true, and to act upon such belief, he cannot, in any litigation
arising out of such declaration, act or omission, be permitted to
falsify it."49
In the instant case, CMC impliedly held out Dr. Estrada as a Without any indication in these consent forms that Dr. Estrada
member of its medical staff. Through CMC's acts, CMC clothed was an independent contractor-physician, the Spouses Nogales
Dr. Estrada with apparent authority thereby leading the Spouses could not have known that Dr. Estrada was an independent
Nogales to believe that Dr. Estrada was an employee or agent of contractor. Significantly, no one from CMC informed the Spouses
CMC. CMC cannot now repudiate such authority. Nogales that Dr. Estrada was an independent contractor. On the
contrary, Dr. Atencio, who was then a member of CMC Board of
First, CMC granted staff privileges to Dr. Estrada. CMC extended Directors, testified that Dr. Estrada was part of CMC's surgical
its medical staff and facilities to Dr. Estrada. Upon Dr. Estrada's staff.53
request for Corazon's admission, CMC, through its personnel,
readily accommodated Corazon and updated Dr. Estrada of her Third, Dr. Estrada's referral of Corazon's profuse vaginal bleeding
condition. to Dr. Espinola, who was then the Head of the Obstetrics and
Gynecology Department of CMC, gave the impression that Dr.
Second, CMC made Rogelio sign consent forms printed on CMC Estrada as a member of CMC's medical staff was collaborating
letterhead. Prior to Corazon's admission and supposed with other CMC-employed specialists in treating Corazon.
hysterectomy, CMC asked Rogelio to sign release forms, the
contents of which reinforced Rogelio's belief that Dr. Estrada was The second factor focuses on the patient's reliance. It is
a member of CMC's medical staff.50 The Consent on Admission sometimes characterized as an inquiry on whether the plaintiff
and Agreement explicitly provides: acted in reliance upon the conduct of the hospital or its agent,
consistent with ordinary care and prudence.54
KNOW ALL MEN BY THESE PRESENTS:
The records show that the Spouses Nogales relied upon a
I, Rogelio Nogales, of legal age, a resident of 1974 M. perceived employment relationship with CMC in accepting Dr.
H. Del Pilar St., Malate Mla., being the Estrada's services. Rogelio testified that he and his wife
father/mother/brother/sister/spouse/relative/ guardian/or specifically chose Dr. Estrada to handle Corazon's delivery not
person in custody of Ma. Corazon, and representing only because of their friend's recommendation, but more
his/her family, of my own volition and free will, do importantly because of Dr. Estrada's "connection with a reputable
consent and submit said Ma. Corazon to Dr. Oscar hospital, the [CMC]."55 In other words, Dr. Estrada's relationship
Estrada (hereinafter referred to as Physician) for cure, with CMC played a significant role in the Spouses Nogales'
treatment, retreatment, or emergency measures, that the decision in accepting Dr. Estrada's services as the obstetrician-
Physician, personally or by and through the Capitol gynecologist for Corazon's delivery. Moreover, as earlier stated,
Medical Center and/or its staff, may use, adapt, or there is no showing that before and during Corazon's confinement
employ such means, forms or methods of cure, at CMC, the Spouses Nogales knew or should have known that
treatment, retreatment, or emergency measures as Dr. Estrada was not an employee of CMC.
he may see best and most expedient; that Ma.
Corazon and I will comply with any and all rules, Further, the Spouses Nogales looked to CMC to provide the best
regulations, directions, and instructions of the medical care and support services for Corazon's delivery. The
Physician, the Capitol Medical Center and/or its Court notes that prior to Corazon's fourth pregnancy, she used to
staff; and, that I will not hold liable or responsible and give birth inside a clinic. Considering Corazon's age then, the
hereby waive and forever discharge and hold free the Spouses Nogales decided to have their fourth child delivered at
Physician, the Capitol Medical Center and/or its staff, CMC, which Rogelio regarded one of the best hospitals at the
from any and all claims of whatever kind of nature, time.56 This is precisely because the Spouses Nogales feared that
arising from directly or indirectly, or by reason of said Corazon might experience complications during her delivery
cure, treatment, or retreatment, or emergency measures which would be better addressed and treated in a modern and big
or intervention of said physician, the Capitol Medical hospital such as CMC. Moreover, Rogelio's consent in Corazon's
Center and/or its staff. hysterectomy to be performed by a different physician, namely
Dr. Espinola, is a clear indication of Rogelio's confidence in
x x x x51 (Emphasis supplied) CMC's surgical staff.

While the Consent to Operation pertinently reads, thus: CMC's defense that all it did was "to extend to [Corazon] its
facilities" is untenable. The Court cannot close its eyes to the
reality that hospitals, such as CMC, are in the business of
I, ROGELIO NOGALES, x x x, of my own volition and treatment. In this regard, the Court agrees with the observation
free will, do consent and submit said CORAZON made by the Court of Appeals of North Carolina in Diggs v.
NOGALES to Hysterectomy, by the Surgical Staff and Novant Health, Inc.,57 to wit:
Anesthesiologists of Capitol Medical Center and/or
whatever succeeding operations, treatment, or
emergency measures as may be necessary and most "The conception that the hospital does not undertake to
expedient; and, that I will not hold liable or responsible treat the patient, does not undertake to act through its
and hereby waive and forever discharge and hold free doctors and nurses, but undertakes instead simply to
the Surgeon, his assistants, anesthesiologists, the procure them to act upon their own responsibility, no
Capitol Medical Center and/or its staff, from any and all longer reflects the fact. Present day hospitals, as their
claims of whatever kind of nature, arising from directly manner of operation plainly demonstrates, do far
or indirectly, or by reason of said operation or more than furnish facilities for treatment. They
operations, treatment, or emergency measures, or regularly employ on a salary basis a large staff of
intervention of the Surgeon, his assistants, physicians, nurses and internes [sic], as well as
anesthesiologists, the Capitol Medical Center and/or its administrative and manual workers, and they
staff.52 (Emphasis supplied) charge patients for medical care and treatment,
collecting for such services, if necessary, by legal
action. Certainly, the person who avails himself of
'hospital facilities' expects that the hospital will Dr. Rosa Uy's alleged negligence consisted of her failure (1) to
attempt to cure him, not that its nurses or other call the attention of Dr. Estrada on the incorrect dosage of
employees will act on their own responsibility." x x x magnesium sulfate administered by Dr. Villaflor; (2) to take
(Emphasis supplied) corrective measures; and (3) to correct Nurse Dumlao's wrong
method of hemacel administration.
Likewise unconvincing is CMC's argument that petitioners are
estopped from claiming damages based on the Consent on The Court believes Dr. Uy's claim that as a second year resident
Admission and Consent to Operation. Both release forms consist physician then at CMC, she was merely authorized to take the
of two parts. The first part gave CMC permission to administer to clinical history and physical examination of Corazon. 62 However,
Corazon any form of recognized medical treatment which the that routine internal examination did not ipso facto make Dr. Uy
CMC medical staff deemed advisable. The second part of the liable for the errors committed by Dr. Estrada. Further,
documents, which may properly be described as the releasing petitioners' imputation of negligence rests on their baseless
part, releases CMC and its employees "from any and all claims" assumption that Dr. Uy was present at the delivery room. Nothing
arising from or by reason of the treatment and operation. shows that Dr. Uy participated in delivering Corazon's baby.
Further, it is unexpected from Dr. Uy, a mere resident physician at
The documents do not expressly release CMC from liability for that time, to call the attention of a more experienced specialist, if
injury to Corazon due to negligence during her treatment or ever she was present at the delivery room.
operation. Neither do the consent forms expressly exempt CMC
from liability for Corazon's death due to negligence during such c) Dr. Joel Enriquez
treatment or operation. Such release forms, being in the nature of
contracts of adhesion, are construed strictly against hospitals. Petitioners fault Dr. Joel Enriquez also for not calling the
Besides, a blanket release in favor of hospitals "from any and all attention of Dr. Estrada, Dr. Villaflor, and Nurse Dumlao about
claims," which includes claims due to bad faith or gross their errors.63 Petitioners insist that Dr. Enriquez should have
negligence, would be contrary to public policy and thus void. taken, or at least suggested, corrective measures to rectify such
errors.
Even simple negligence is not subject to blanket release in favor
of establishments like hospitals but may only mitigate liability The Court is not convinced. Dr. Enriquez is an anesthesiologist
depending on the circumstances.58 When a person needing urgent whose field of expertise is definitely not obstetrics and
medical attention rushes to a hospital, he cannot bargain on equal gynecology. As such, Dr. Enriquez was not expected to correct
footing with the hospital on the terms of admission and operation. Dr. Estrada's errors. Besides, there was no evidence of Dr.
Such a person is literally at the mercy of the hospital. There can Enriquez's knowledge of any error committed by Dr. Estrada and
be no clearer example of a contract of adhesion than one arising his failure to act upon such observation.
from such a dire situation. Thus, the release forms of CMC cannot
relieve CMC from liability for the negligent medical treatment of
Corazon. d) Dr. Perpetua Lacson

On the Liability of the Other Respondents Petitioners fault Dr. Perpetua Lacson for her purported delay in
the delivery of blood Corazon needed.64 Petitioners claim that Dr.
Lacson was remiss in her duty of supervising the blood bank staff.
Despite this Court's pronouncement in its 9 September
200259 Resolution that the filing of petitioners' Manifestation
confined petitioners' claim only against CMC, Dr. Espinola, Dr. As found by the trial court, there was no unreasonable delay in the
Lacson, and Dr. Uy, who have filed their comments, the Court delivery of blood from the time of the request until the transfusion
deems it proper to resolve the individual liability of the remaining to Corazon. Dr. Lacson competently explained the procedure
respondents to put an end finally to this more than two-decade old before blood could be given to the patient. 65 Taking into account
controversy. the bleeding time, clotting time and cross-matching, Dr. Lacson
stated that it would take approximately 45-60 minutes before
blood could be ready for transfusion.66 Further, no evidence exists
a) Dr. Ely Villaflor that Dr. Lacson neglected her duties as head of the blood bank.

Petitioners blame Dr. Ely Villaflor for failing to diagnose the e) Dr. Noe Espinola
cause of Corazon's bleeding and to suggest the correct remedy to
Dr. Estrada.60 Petitioners assert that it was Dr. Villaflor's duty to
correct the error of Nurse Dumlao in the administration of Petitioners argue that Dr. Espinola should not have ordered
hemacel. immediate hysterectomy without determining the underlying
cause of Corazon's bleeding. Dr. Espinola should have first
considered the possibility of cervical injury, and advised a
The Court is not persuaded. Dr. Villaflor admitted administering a thorough examination of the cervix, instead of believing outright
lower dosage of magnesium sulfate. However, this was after Dr. Estrada's diagnosis that the cause of bleeding was uterine
informing Dr. Estrada that Corazon was no longer in convulsion atony.
and that her blood pressure went down to a dangerous level. 61 At
that moment, Dr. Estrada instructed Dr. Villaflor to reduce the
dosage of magnesium sulfate from 10 to 2.5 grams. Since Dr. Espinola's order to do hysterectomy which was based on the
petitioners did not dispute Dr. Villaflor's allegation, Dr. Villaflor's information he received by phone is not negligence. The Court
defense remains uncontroverted. Dr. Villaflor's act of agrees with the trial court's observation that Dr. Espinola, upon
administering a lower dosage of magnesium sulfate was not out of hearing such information about Corazon's condition, believed in
her own volition or was in contravention of Dr. Estrada's order. good faith that hysterectomy was the correct remedy. At any rate,
the hysterectomy did not push through because upon Dr.
Espinola's arrival, it was already too late. At the time, Corazon
b) Dr. Rosa Uy was practically dead.
f) Nurse J. Dumlao Professional Services Inc. (PSI) v. Agana, G.R. No. 126297, 31
January 2007.
In Moore v. Guthrie Hospital Inc.,67 the US Court of Appeals, 13DEC
Fourth Circuit, held that to recover, a patient complaining of [SANDOVAL-GUTIERREZ, J.]
injuries allegedly resulting when the nurse negligently injected FACTS:
medicine to him intravenously instead of intramuscularly had to Natividad Agana was rushed to the Medical City General Hospital
show that (1) an intravenous injection constituted a lack of (Medical City Hospital) because of difficulty of bowel movement
reasonable and ordinary care; (2) the nurse injected medicine and bloody anal discharge. After a series of medical
intravenously; and (3) such injection was the proximate cause of examinations, Dr. Miguel Ampil diagnosed her to be suffering
his injury. from “cancer of the sigmoid.” Dr. Ampil, assisted by the medical
staff of the Medical City Hospital, performed an anterior resection
surgery on Natividad. He found that the malignancy in her
In the present case, there is no evidence of Nurse Dumlao's sigmoid area had spread on her left ovary, necessitating the
alleged failure to follow Dr. Estrada's specific instructions. Even removal of certain portions of it. Thus, Dr. Ampil obtained the
assuming Nurse Dumlao defied Dr. Estrada's order, there is no consent of Natividad’s husband, Enrique Agana, to permit Dr.
showing that side-drip administration of hemacel proximately Juan Fuentes, respondent in G.R. No. 126467, to perform
caused Corazon's death. No evidence linking Corazon's death and hysterectomy on her. Thereafter, Dr. Ampil took over, completed
the alleged wrongful hemacel administration was introduced. the operation and closed the incision. However, based on the
Therefore, there is no basis to hold Nurse Dumlao liable for record of the hospital, the attending nurses indicated nota bene
negligence. that 2 sponges were missing. The same was reported to Dr. Ampil
but were not found after “diligent seach”.
On the Award of Interest on Damages After couple of days, Natividad complained of excruciating pain
in her anal region. She consulted both Dr. Ampil and Dr. Fuentes
The award of interest on damages is proper and allowed under about it. They told her that the pain was the natural consequence
Article 2211 of the Civil Code, which states that in crimes and of the surgery. Dr. Ampil then recommended that she consult an
quasi-delicts, interest as a part of the damages may, in a proper oncologist to examine the cancerous nodes which were not
case, be adjudicated in the discretion of the court. 68 removed during the operation. Natividad went to the United States
for four months but she was only declared free of cancer. In
Natividad’s return to the Philippines, her daughter found a piece
WHEREFORE, the Court PARTLY GRANTS the petition. The of gauze protruding from her vagina. Upon being informed about
Court finds respondent Capitol Medical Center vicariously liable it, Dr. Ampil proceeded to her house where he managed to extract
for the negligence of Dr. Oscar Estrada. The amounts of P105,000 by hand a piece of gauze measuring 1.5 inches in width. He then
as actual damages and P700,000 as moral damages should each assured her that the pains would soon vanish. But instead the
earn legal interest at the rate of six percent (6%) per annum pains intensified, prompting Natividad to seek treatment at the
computed from the date of the judgment of the trial court. The Polymedic General Hospital. While confined there, Dr. Ramon
Court affirms the rest of the Decision dated 6 February 1998 and Gutierrez detected the presence of another foreign object in her
Resolution dated 21 March 2000 of the Court of Appeals in CA- vagina — a foul-smelling gauze measuring 1.5 inches in width
G.R. CV No. 45641. which badly infected her vaginal vault. A recto-vaginal fistula had
formed in her reproductive organs which forced stool to excrete
SO ORDERED. through the vagina. Natividad underwent another surgical
operation to remedy the damage. Civil and administrative
complaints, for damages and gross negligence respectively, were
filed against Professional Services Inc., owner of Medical City
Hospital, Dr. Ampil and Dr. Fuentes.
ISSUE(S):
Are the following liable?
(1) Professional Services Inc., based on
(a) “employer-employee relationship”;
(b) “doctrine of apparent authority”;
(c) “corporate negligence”;
(2) Dr. Ampil,
(a) for medical negligence;
(b) under the “captain of the ship doctrine”;
(3) Dr.Fuentes, under the doctrine of res ipsa loquitor;
HELD:
(1)
(a) YES.
[P]rivate hospitals, hire, fire and exercise real control over their
attending and visiting ‘consultant’ staff. While ‘consultants’ are
not, technically employees, x x x, the control exercised, the
hiring, and the right to terminate consultants all fulfill the
important hallmarks of an employer-employee relationship, with
the exception of the payment of wages. In assessing whether such
a relationship in fact exists, the control test is determining.
Accordingly, on the basis of the foregoing, we rule that for the
purpose of allocating responsibility in medical negligence cases,
an employer-employee relationship in effect exists between
hospitals and their attending and visiting physicians.
(b) YES.
Apparent authority, or what is sometimes referred to as the leave; and (4) ordering the closure of the incision. To our mind, it
“holding out” theory, or doctrine of ostensible agency or agency was this act of ordering the closure of the incision
by estoppel, has its origin from the law of agency. It imposes notwithstanding that two pieces of gauze remained unaccounted
liability, not as the result of the reality of a contractual for, that caused injury to Natividad’s body. Clearly, the control
relationship, but rather because of the actions of a principal or an and management of the thing which caused the injury was in the
employer in somehow misleading the public into believing that hands of Dr. Ampil, not Dr. Fuentes.
the relationship or the authority exists. xxx In this case, PSI (3) NO.
publicly displays in the lobby of the Medical City Hospital the The requisites for the applicability of the doctrine of res ipsa
names and specializations of the physicians associated or loquitur are: (1) the occurrence of an injury; (2) the thing which
accredited by it, including those of Dr. Ampil and Dr. Fuentes. caused the injury was under the control and management of the
We concur with the Court of Appeals’ conclusion that it “is now defendant; (3) the occurrence was such that in the ordinary course
estopped from passing all the blame to the physicians whose of things, would not have happened if those who had control or
names it proudly paraded in the public directory leading the management used proper care; and (4) the absence of explanation
public to believe that it vouched for their skill and competence.” by the defendant. Of the foregoing requisites, the most
Indeed, PSI’s act is tantamount to holding out to the public that instrumental is the “control and management of the thing which
Medical City Hospital, through its accredited physicians, offers caused the injury.”
quality health care services. By accrediting Dr. Ampil and Dr. We find the element of “control and management of the thing
Fuentes and publicly advertising their qualifications, the hospital which caused the injury” to be wanting. Hence, the doctrine of res
created the impression that they were its agents, authorized to ipsa loquitur will not lie.
perform medical or surgical services for its patients. As expected, It was duly established that Dr. Ampil was the lead surgeon
these patients, Natividad being one of them, accepted the services during the operation of Natividad. He requested the assistance of
on the reasonable belief that such were being rendered by the Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil)
hospital or its employees, agents, or servants. found that the malignancy in her sigmoid area had spread to her
(c) YES. left ovary. Dr. Fuentes performed the surgery and thereafter
Hospital’s corporate negligence extends to permitting a physician reported and showed his work to Dr. Ampil. The latter examined
known to be incompetent to practice at the hospital. xxx [A] it and finding everything to be in order, allowed Dr. Fuentes to
patient who enters a hospital does so with the reasonable leave the operating room. Dr. Ampil then resumed operating on
expectation that it will attempt to cure him. The hospital Natividad. He was about to finish the procedure when the
accordingly has the duty to make a reasonable effort to monitor attending nurses informed him that two pieces of gauze were
and oversee the treatment prescribed and administered by the missing. A “diligent search” was conducted, but the misplaced
physicians practicing in its premises. In the present case, it was gauzes were not found. Dr. Ampil then directed that the incision
duly established that PSI operates the Medical City Hospital for be closed. During this entire period, Dr. Fuentes was no longer in
the purpose and under the concept of providing comprehensive the operating room and had, in fact, left the hospital.
medical services to the public. Accordingly, it has the duty to
exercise reasonable care to protect from harm all patients
admitted into its facility for medical treatment. Unfortunately, PSI
failed to perform such duty.
(2)
(a) YES.
This is a clear case of medical malpractice or more appropriately,
medical negligence. To successfully pursue this kind of case, a
patient must only prove that a health care provider either failed to
do something which a reasonably prudent health care provider
would have done, or that he did something that a reasonably
prudent provider would not have done; and that failure or action
caused injury to the patient. Simply put, the elements are duty,
breach, injury and proximate causation. Dr, Ampil, as the lead
surgeon, had the duty to remove all foreign objects, such as
gauzes, from Natividad’s body before closure of the incision.
When he failed to do so, it was his duty to inform Natividad about
it. Dr. Ampil breached both duties. Such breach caused injury to
Natividad, necessitating her further examination by American
doctors and another surgery. That Dr. Ampil’s negligence is the
proximate cause of Natividad’s injury could be traced from his act
of closing the incision despite the information given by the
attending nurses that two pieces of gauze were still missing. That
they were later on extracted from Natividad’s vagina established
the causal link between Dr. Ampil’s negligence and the injury.
And what further aggravated such injury was his deliberate
concealment of the missing gauzes from the knowledge of
Natividad and her family.
(b) YES.
Under the “Captain of the Ship” rule, the operating surgeon is the
person in complete charge of the surgery room and all personnel
connected with the operation. Their duty is to obey his orders. As
stated before, Dr. Ampil was the lead surgeon. In other words, he
was the “Captain of the Ship.” That he discharged such role is
evident from his following conduct: (1) calling Dr. Fuentes to
perform a hysterectomy; (2) examining the work of Dr. Fuentes
and finding it in order; (3) granting Dr. Fuentes’ permission to
Republic of the Philippines portions of it. Thus, Dr. Ampil obtained the consent of
SUPREME COURT Natividad’s husband, Enrique Agana, to permit Dr. Juan Fuentes,
Manila respondent in G.R. No. 126467, to perform hysterectomy on her.

FIRST DIVISION After Dr. Fuentes had completed the hysterectomy, Dr. Ampil
took over, completed the operation and closed the incision.
G.R. No. 126297             January 31, 2007
However, the operation appeared to be flawed. In the
PROFESSIONAL SERVICES, INC., Petitioner,  corresponding Record of Operation dated April 11, 1984, the
vs. attending nurses entered these remarks:
NATIVIDAD and ENRIQUE AGANA, Respondents.
"sponge count lacking 2
x-----------------------x
"announced to surgeon searched (sic) done but to no avail
G.R. No. 126467            January 31, 2007 continue for closure."

NATIVIDAD (Substituted by her children MARCELINO On April 24, 1984, Natividad was released from the hospital. Her
AGANA III, ENRIQUE AGANA, JR., EMMA AGANA hospital and medical bills, including the doctors’ fees, amounted
ANDAYA, JESUS AGANA, and RAYMUND AGANA) and to P60,000.00.
ENRIQUE AGANA, Petitioners, 
vs. After a couple of days, Natividad complained of excruciating pain
JUAN FUENTES, Respondent. in her anal region. She consulted both Dr. Ampil and Dr. Fuentes
about it. They told her that the pain was the natural consequence
x- - - - - - - - - - - - - - - - - - - -- - - - x of the surgery. Dr. Ampil then recommended that she consult an
oncologist to examine the cancerous nodes which were not
removed during the operation.
G.R. No. 127590            January 31, 2007
On May 9, 1984, Natividad, accompanied by her husband, went to
MIGUEL AMPIL, Petitioner,  the United States to seek further treatment. After four months of
vs. consultations and laboratory examinations, Natividad was told she
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents. was free of cancer. Hence, she was advised to return to the
Philippines.
DECISION
On August 31, 1984, Natividad flew back to the Philippines, still
SANDOVAL-GUTIERREZ, J.: suffering from pains. Two weeks thereafter, her daughter found a
piece of gauze protruding from her vagina. Upon being informed
Hospitals, having undertaken one of mankind’s most important about it, Dr. Ampil proceeded to her house where he managed to
and delicate endeavors, must assume the grave responsibility of extract by hand a piece of gauze measuring 1.5 inches in width.
pursuing it with appropriate care. The care and service dispensed He then assured her that the pains would soon vanish.
through this high trust, however technical, complex and esoteric
its character may be, must meet standards of responsibility Dr. Ampil’s assurance did not come true. Instead, the pains
commensurate with the undertaking to preserve and protect the intensified, prompting Natividad to seek treatment at the
health, and indeed, the very lives of those placed in the hospital’s Polymedic General Hospital. While confined there, Dr. Ramon
keeping.1 Gutierrez detected the presence of another foreign object in her
vagina -- a foul-smelling gauze measuring 1.5 inches in width
Assailed in these three consolidated petitions for review on which badly infected her vaginal vault. A recto-vaginal fistula had
certiorari is the Court of Appeals’ Decision 2 dated September 6, formed in her reproductive organs which forced stool to excrete
1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198 through the vagina. Another surgical operation was needed to
affirming with modification the Decision 3dated March 17, 1993 of remedy the damage. Thus, in October 1984, Natividad underwent
the Regional Trial Court (RTC), Branch 96, Quezon City in Civil another surgery.
Case No. Q-43322 and nullifying its Order dated September 21,
1993. On November 12, 1984, Natividad and her husband filed with the
RTC, Branch 96, Quezon City a complaint for damages against
The facts, as culled from the records, are: the Professional Services, Inc. (PSI), owner of the Medical City
Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil Case No.
Q-43322. They alleged that the latter are liable for negligence for
On April 4, 1984, Natividad Agana was rushed to the Medical leaving two pieces of gauze inside Natividad’s body and
City General Hospital (Medical City Hospital) because of malpractice for concealing their acts of negligence.
difficulty of bowel movement and bloody anal discharge. After a
series of medical examinations, Dr. Miguel Ampil, petitioner in
G.R. No. 127590, diagnosed her to be suffering from "cancer of Meanwhile, Enrique Agana also filed with the Professional
the sigmoid." Regulation Commission (PRC) an administrative complaint for
gross negligence and malpractice against Dr. Ampil and Dr.
Fuentes, docketed as Administrative Case No. 1690. The PRC
On April 11, 1984, Dr. Ampil, assisted by the medical staff 4 of the Board of Medicine heard the case only with respect to Dr. Fuentes
Medical City Hospital, performed an anterior resection surgery on because it failed to acquire jurisdiction over Dr. Ampil who was
Natividad. He found that the malignancy in her sigmoid area had then in the United States.
spread on her left ovary, necessitating the removal of certain
On February 16, 1986, pending the outcome of the above cases, Resolution5 dated October 29, 1993 granting Dr. Fuentes’ prayer
Natividad died and was duly substituted by her above-named for injunctive relief.
children (the Aganas).
On January 24, 1994, CA-G.R. SP No. 32198 was consolidated
On March 17, 1993, the RTC rendered its Decision in favor of the with CA-G.R. CV No. 42062.
Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable for
negligence and malpractice, the decretal part of which reads: Meanwhile, on January 23, 1995, the PRC Board of Medicine
rendered its Decision6 in Administrative Case No. 1690
WHEREFORE, judgment is hereby rendered for the plaintiffs dismissing the case against Dr. Fuentes. The Board held that the
ordering the defendants PROFESSIONAL SERVICES, INC., prosecution failed to show that Dr. Fuentes was the one who left
DR. MIGUEL AMPIL and DR. JUAN FUENTES to pay to the the two pieces of gauze inside Natividad’s body; and that he
plaintiffs, jointly and severally, except in respect of the award for concealed such fact from Natividad.
exemplary damages and the interest thereon which are the
liabilities of defendants Dr. Ampil and Dr. Fuentes only, as On September 6, 1996, the Court of Appeals rendered its Decision
follows: jointly disposing of CA-G.R. CV No. 42062 and CA-G.R. SP No.
32198, thus:
1. As actual damages, the following amounts:
WHEREFORE, except for the modification that the case against
a. The equivalent in Philippine Currency of defendant-appellant Dr. Juan Fuentes is hereby DISMISSED, and
the total of US$19,900.00 at the rate of with the pronouncement that defendant-appellant Dr. Miguel
P21.60-US$1.00, as reimbursement of actual Ampil is liable to reimburse defendant-appellant Professional
expenses incurred in the United States of Services, Inc., whatever amount the latter will pay or had paid to
America; the plaintiffs-appellees, the decision appealed from is hereby
AFFIRMED and the instant appeal DISMISSED.
b. The sum of P4,800.00 as travel taxes of
plaintiffs and their physician daughter; Concomitant with the above, the petition for certiorari and
prohibition filed by herein defendant-appellant Dr. Juan Fuentes
c. The total sum of P45,802.50, representing in CA-G.R. SP No. 32198 is hereby GRANTED and the
the cost of hospitalization at Polymedic challenged order of the respondent judge dated September 21,
Hospital, medical fees, and cost of the saline 1993, as well as the alias writ of execution issued pursuant thereto
solution; are hereby NULLIFIED and SET ASIDE. The bond posted by the
petitioner in connection with the writ of preliminary injunction
issued by this Court on November 29, 1993 is hereby cancelled.
2. As moral damages, the sum of P2,000,000.00;
Costs against defendants-appellants Dr. Miguel Ampil and
3. As exemplary damages, the sum of P300,000.00; Professional Services, Inc.

4. As attorney’s fees, the sum of P250,000.00; SO ORDERED.

5. Legal interest on items 1 (a), (b), and (c); 2; and 3 Only Dr. Ampil filed a motion for reconsideration, but it was
hereinabove, from date of filing of the complaint until denied in a Resolution7 dated December 19, 1996.
full payment; and
Hence, the instant consolidated petitions.
6. Costs of suit.
In G.R. No. 126297, PSI alleged in its petition that the Court of
SO ORDERED. Appeals erred in holding that: (1) it is estopped from raising the
defense that Dr. Ampil is not its employee; (2) it is solidarily
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal liable with Dr. Ampil; and (3) it is not entitled to its counterclaim
to the Court of Appeals, docketed as CA-G.R. CV No. 42062. against the Aganas. PSI contends that Dr. Ampil is not its
employee, but a mere consultant or independent contractor. As
Incidentally, on April 3, 1993, the Aganas filed with the RTC a such, he alone should answer for his negligence.
motion for a partial execution of its Decision, which was granted
in an Order dated May 11, 1993. Thereafter, the sheriff levied In G.R. No. 126467, the Aganas maintain that the Court of
upon certain properties of Dr. Ampil and sold them for Appeals erred in finding that Dr. Fuentes is not guilty of
P451,275.00 and delivered the amount to the Aganas. negligence or medical malpractice, invoking the doctrine of res
ipsa loquitur. They contend that the pieces of gauze are prima
Following their receipt of the money, the Aganas entered into an facie proofs that the operating surgeons have been negligent.
agreement with PSI and Dr. Fuentes to indefinitely suspend any
further execution of the RTC Decision. However, not long Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of
thereafter, the Aganas again filed a motion for an alias writ of Appeals erred in finding him liable for negligence and
execution against the properties of PSI and Dr. Fuentes. On malpractice sans evidence that he left the two pieces of gauze in
September 21, 1993, the RTC granted the motion and issued the Natividad’s vagina. He pointed to other probable causes, such as:
corresponding writ, prompting Dr. Fuentes to file with the Court (1) it was Dr. Fuentes who used gauzes in performing the
of Appeals a petition for certiorari and prohibition, with prayer for hysterectomy; (2) the attending nurses’ failure to properly count
preliminary injunction, docketed as CA-G.R. SP No. 32198. the gauzes used during surgery; and (3) the medical intervention
During its pendency, the Court of Appeals issued a
of the American doctors who examined Natividad in the United the dangers attendant upon delay, still, it is his legal duty to so
States of America. inform his patient within a reasonable time thereafter by advising
her of what he had been compelled to do. This is in order that she
For our resolution are these three vital issues: first, whether the might seek relief from the effects of the foreign object left in her
Court of Appeals erred in holding Dr. Ampil liable for negligence body as her condition might permit. The ruling in Smith v.
and malpractice; second, whether the Court of Appeals erred in Zeagler10 is explicit, thus:
absolving Dr. Fuentes of any liability; and third, whether PSI may
be held solidarily liable for the negligence of Dr. Ampil. The removal of all sponges used is part of a surgical operation,
and when a physician or surgeon fails to remove a sponge he has
I - G.R. No. 127590 placed in his patient’s body that should be removed as part of the
operation, he thereby leaves his operation uncompleted and
creates a new condition which imposes upon him the legal duty of
Whether the Court of Appeals Erred in Holding Dr. Ampil calling the new condition to his patient’s attention, and
endeavoring with the means he has at hand to minimize and avoid
Liable for Negligence and Malpractice. untoward results likely to ensue therefrom.

Dr. Ampil, in an attempt to absolve himself, gears the Court’s Here, Dr. Ampil did not inform Natividad about the missing two
attention to other possible causes of Natividad’s detriment. He pieces of gauze. Worse, he even misled her that the pain she was
argues that the Court should not discount either of the following experiencing was the ordinary consequence of her operation. Had
possibilities: first, Dr. Fuentes left the gauzes in Natividad’s body he been more candid, Natividad could have taken the immediate
after performing hysterectomy; second, the attending nurses erred and appropriate medical remedy to remove the gauzes from her
in counting the gauzes; and third, the American doctors were the body. To our mind, what was initially an act of negligence by Dr.
ones who placed the gauzes in Natividad’s body. Ampil has ripened into a deliberate wrongful act of deceiving his
patient.
Dr. Ampil’s arguments are purely conjectural and without basis.
Records show that he did not present any evidence to prove that This is a clear case of medical malpractice or more appropriately,
the American doctors were the ones who put or left the gauzes in medical negligence. To successfully pursue this kind of case, a
Natividad’s body. Neither did he submit evidence to rebut the patient must only prove that a health care provider either failed to
correctness of the record of operation, particularly the number of do something which a reasonably prudent health care provider
gauzes used. As to the alleged negligence of Dr. Fuentes, we are would have done, or that he did something that a reasonably
mindful that Dr. Ampil examined his (Dr. Fuentes’) work and prudent provider would not have done; and that failure or action
found it in order. caused injury to the patient.11 Simply put, the elements are duty,
breach, injury and proximate causation. Dr, Ampil, as the lead
The glaring truth is that all the major circumstances, taken surgeon, had the duty to remove all foreign objects, such as
together, as specified by the Court of Appeals, directly point to gauzes, from Natividad’s body before closure of the incision.
Dr. Ampil as the negligent party, thus: When he failed to do so, it was his duty to inform Natividad about
it. Dr. Ampil breached both duties. Such breach caused injury to
Natividad, necessitating her further examination by American
First, it is not disputed that the surgeons used gauzes as doctors and another surgery. That Dr. Ampil’s negligence is the
sponges to control the bleeding of the patient during the proximate cause12 of Natividad’s injury could be traced from his
surgical operation. act of closing the incision despite the information given by the
attending nurses that two pieces of gauze were still missing. That
Second, immediately after the operation, the nurses who they were later on extracted from Natividad’s vagina established
assisted in the surgery noted in their report that the the causal link between Dr. Ampil’s negligence and the injury.
‘sponge count (was) lacking 2’; that such anomaly was And what further aggravated such injury was his deliberate
‘announced to surgeon’ and that a ‘search was done but concealment of the missing gauzes from the knowledge of
to no avail’ prompting Dr. Ampil to ‘continue for Natividad and her family.
closure’ x x x.
II - G.R. No. 126467
Third, after the operation, two (2) gauzes were extracted
from the same spot of the body of Mrs. Agana where Whether the Court of Appeals Erred in Absolving
the surgery was performed.
Dr. Fuentes of any Liability
An operation requiring the placing of sponges in the incision is
not complete until the sponges are properly removed, and it is
settled that the leaving of sponges or other foreign substances in The Aganas assailed the dismissal by the trial court of the case
the wound after the incision has been closed is at least prima facie against Dr. Fuentes on the ground that it is contrary to the
negligence by the operating surgeon. 8 To put it simply, such act is doctrine of res ipsa loquitur. According to them, the fact that the
considered so inconsistent with due care as to raise an inference two pieces of gauze were left inside Natividad’s body is a prima
of negligence. There are even legions of authorities to the effect facie evidence of Dr. Fuentes’ negligence.
that such act is negligence per se.9
We are not convinced.
Of course, the Court is not blind to the reality that there are times
when danger to a patient’s life precludes a surgeon from further Literally, res ipsa loquitur means "the thing speaks for itself." It is
searching missing sponges or foreign objects left in the body. But the rule that the fact of the occurrence of an injury, taken with the
this does not leave him free from any obligation. Even if it has surrounding circumstances, may permit an inference or raise a
been shown that a surgeon was required by the urgent necessities presumption of negligence, or make out a plaintiff’s prima facie
of the case to leave a sponge in his patient’s abdomen, because of case, and present a question of fact for defendant to meet with an
explanation.13 Stated differently, where the thing which caused the Until the mid-nineteenth century, hospitals were generally
injury, without the fault of the injured, is under the exclusive charitable institutions, providing medical services to the lowest
control of the defendant and the injury is such that it should not classes of society, without regard for a patient’s ability to
have occurred if he, having such control used proper care, it pay.18 Those who could afford medical treatment were usually
affords reasonable evidence, in the absence of explanation that the treated at home by their doctors. 19 However, the days of house
injury arose from the defendant’s want of care, and the burden of calls and philanthropic health care are over. The modern health
proof is shifted to him to establish that he has observed due care care industry continues to distance itself from its charitable past
and diligence.14 and has experienced a significant conversion from a not-for-profit
health care to for-profit hospital businesses. Consequently,
From the foregoing statements of the rule, the requisites for the significant changes in health law have accompanied the business-
applicability of the doctrine of res ipsa loquitur are: (1) the related changes in the hospital industry. One important legal
occurrence of an injury; (2) the thing which caused the injury was change is an increase in hospital liability for medical malpractice.
under the control and management of the defendant; (3) the Many courts now allow claims for hospital vicarious liability
occurrence was such that in the ordinary course of things, would under the theories of respondeat superior, apparent authority,
not have happened if those who had control or management used ostensible authority, or agency by estoppel. 20
proper care; and (4) the absence of explanation by the defendant.
Of the foregoing requisites, the most instrumental is the "control In this jurisdiction, the statute governing liability for negligent
and management of the thing which caused the injury." 15 acts is Article 2176 of the Civil Code, which reads:

We find the element of "control and management of the thing Art. 2176. Whoever by act or omission causes damage to another,
which caused the injury" to be wanting. Hence, the doctrine of res there being fault or negligence, is obliged to pay for the damage
ipsa loquitur will not lie. done. Such fault or negligence, if there is no pre-existing
contractual relation between the parties, is called a quasi-delict
It was duly established that Dr. Ampil was the lead surgeon and is governed by the provisions of this Chapter.
during the operation of Natividad. He requested the assistance of
Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil) A derivative of this provision is Article 2180, the rule governing
found that the malignancy in her sigmoid area had spread to her vicarious liability under the doctrine of respondeat superior, thus:
left ovary. Dr. Fuentes performed the surgery and thereafter
reported and showed his work to Dr. Ampil. The latter examined ART. 2180. The obligation imposed by Article 2176 is
it and finding everything to be in order, allowed Dr. Fuentes to demandable not only for one’s own acts or omissions, but also for
leave the operating room. Dr. Ampil then resumed operating on those of persons for whom one is responsible.
Natividad. He was about to finish the procedure when the
attending nurses informed him that two pieces of gauze were
missing. A "diligent search" was conducted, but the misplaced x x x x x x
gauzes were not found. Dr. Ampil then directed that the incision
be closed. During this entire period, Dr. Fuentes was no longer in The owners and managers of an establishment or enterprise are
the operating room and had, in fact, left the hospital. likewise responsible for damages caused by their employees in
the service of the branches in which the latter are employed or on
Under the "Captain of the Ship" rule, the operating surgeon is the the occasion of their functions.
person in complete charge of the surgery room and all personnel
connected with the operation. Their duty is to obey his Employers shall be liable for the damages caused by their
orders.16 As stated before, Dr. Ampil was the lead surgeon. In employees and household helpers acting within the scope of their
other words, he was the "Captain of the Ship." That he discharged assigned tasks even though the former are not engaged in any
such role is evident from his following conduct: (1) calling Dr. business or industry.
Fuentes to perform a hysterectomy; (2) examining the work of Dr.
Fuentes and finding it in order; (3) granting Dr. Fuentes’ x x x x x x
permission to leave; and (4) ordering the closure of the incision.
To our mind, it was this act of ordering the closure of the incision
notwithstanding that two pieces of gauze remained unaccounted The responsibility treated of in this article shall cease when the
for, that caused injury to Natividad’s body. Clearly, the control persons herein mentioned prove that they observed all the
and management of the thing which caused the injury was in the diligence of a good father of a family to prevent damage.
hands of Dr. Ampil, not Dr. Fuentes.
A prominent civilist commented that professionals engaged by an
In this jurisdiction, res ipsa loquitur is not a rule of substantive employer, such as physicians, dentists, and pharmacists, are not
law, hence, does not per se create or constitute an independent or "employees" under this article because the manner in which they
separate ground of liability, being a mere evidentiary rule. 17 In perform their work is not within the control of the latter
other words, mere invocation and application of the doctrine does (employer). In other words, professionals are considered
not dispense with the requirement of proof of negligence. Here, personally liable for the fault or negligence they commit in the
the negligence was proven to have been committed by Dr. Ampil discharge of their duties, and their employer cannot be held liable
and not by Dr. Fuentes. for such fault or negligence. In the context of the present case, "a
hospital cannot be held liable for the fault or negligence of a
physician or surgeon in the treatment or operation of patients." 21
III - G.R. No. 126297

The foregoing view is grounded on the traditional notion that the

Whether PSI Is Liable for the Negligence of Dr. Ampil professional status and the very nature of the physician’s calling
preclude him from being classed as an agent or employee of a
The third issue necessitates a glimpse at the historical hospital, whenever he acts in a professional capacity. 22 It has been
development of hospitals and the resulting theories concerning said that medical practice strictly involves highly developed and
their liability for the negligence of physicians. specialized knowledge,23 such that physicians are generally free to
exercise their own skill and judgment in rendering medical residents. A consultant remiss in his duties, or a consultant who
services sans interference.24 Hence, when a doctor practices regularly falls short of the minimum standards acceptable to the
medicine in a hospital setting, the hospital and its employees are hospital or its peer review committee, is normally politely
deemed to subserve him in his ministrations to the patient and his terminated.
actions are of his own responsibility.25
In other words, private hospitals, hire, fire and exercise real
The case of Schloendorff v. Society of New York Hospital 26 was control over their attending and visiting ‘consultant’ staff. While
then considered an authority for this view. The "Schloendorff ‘consultants’ are not, technically employees, x x x, the control
doctrine" regards a physician, even if employed by a hospital, as exercised, the hiring, and the right to terminate consultants all
an independent contractor because of the skill he exercises and the fulfill the important hallmarks of an employer-employee
lack of control exerted over his work. Under this doctrine, relationship, with the exception of the payment of wages. In
hospitals are exempt from the application of the respondeat assessing whether such a relationship in fact exists, the control
superior principle for fault or negligence committed by physicians test is determining. Accordingly, on the basis of the foregoing, we
in the discharge of their profession. rule that for the purpose of allocating responsibility in medical
negligence cases, an employer-employee relationship in effect
However, the efficacy of the foregoing doctrine has weakened exists between hospitals and their attending and visiting
with the significant developments in medical care. Courts came to physicians. "
realize that modern hospitals are increasingly taking active role in
supplying and regulating medical care to patients. No longer were But the Ramos pronouncement is not our only basis in sustaining
a hospital’s functions limited to furnishing room, food, facilities PSI’s liability. Its liability is also anchored upon the agency
for treatment and operation, and attendants for its patients. Thus, principle of apparent authority or agency by estoppel and the
in Bing v. Thunig,27 the New York Court of Appeals deviated doctrine of corporate negligence which have gained acceptance in
from the Schloendorff doctrine, noting that modern hospitals the determination of a hospital’s liability for negligent acts of
actually do far more than provide facilities for treatment. Rather, health professionals. The present case serves as a perfect platform
they regularly employ, on a salaried basis, a large staff of to test the applicability of these doctrines, thus, enriching our
physicians, interns, nurses, administrative and manual workers. jurisprudence.
They charge patients for medical care and treatment, even
collecting for such services through legal action, if necessary. The Apparent authority, or what is sometimes referred to as the
court then concluded that there is no reason to exempt hospitals "holding
from the universal rule of respondeat superior.
out" theory, or doctrine of ostensible agency or agency by
In our shores, the nature of the relationship between the hospital estoppel,29 has its origin from the law of agency. It imposes
and the physicians is rendered inconsequential in view of our liability, not as the result of the reality of a contractual
categorical pronouncement in Ramos v. Court of Appeals 28 that relationship, but rather because of the actions of a principal or an
for purposes of apportioning responsibility in medical negligence employer in somehow misleading the public into believing that
cases, an employer-employee relationship in effect exists between the relationship or the authority exists. 30 The concept is essentially
hospitals and their attending and visiting physicians. This Court one of estoppel and has been explained in this manner:
held:
"The principal is bound by the acts of his agent with the apparent
"We now discuss the responsibility of the hospital in this authority which he knowingly permits the agent to assume, or
particular incident. The unique practice (among private hospitals) which he holds the agent out to the public as possessing. The
of filling up specialist staff with attending and visiting question in every case is whether the principal has by his
"consultants," who are allegedly not hospital employees, presents voluntary act placed the agent in such a situation that a person of
problems in apportioning responsibility for negligence in medical ordinary prudence, conversant with business usages and the
malpractice cases. However, the difficulty is more apparent than nature of the particular business, is justified in presuming that
real. such agent has authority to perform the particular act in
question.31
In the first place, hospitals exercise significant control in the
hiring and firing of consultants and in the conduct of their work The applicability of apparent authority in the field of hospital
within the hospital premises. Doctors who apply for ‘consultant’ liability was upheld long time ago in Irving v. Doctor Hospital of
slots, visiting or attending, are required to submit proof of Lake Worth, Inc.32 There, it was explicitly stated that "there does
completion of residency, their educational qualifications, not appear to be any rational basis for excluding the concept of
generally, evidence of accreditation by the appropriate board apparent authority from the field of hospital liability." Thus, in
(diplomate), evidence of fellowship in most cases, and references. cases where it can be shown that a hospital, by its actions, has
These requirements are carefully scrutinized by members of the held out a particular physician as its agent and/or employee and
hospital administration or by a review committee set up by the that a patient has accepted treatment from that physician in the
hospital who either accept or reject the application. x x x. reasonable belief that it is being rendered in behalf of the hospital,
then the hospital will be liable for the physician’s negligence.
After a physician is accepted, either as a visiting or attending
consultant, he is normally required to attend clinico-pathological Our jurisdiction recognizes the concept of an agency by
conferences, conduct bedside rounds for clerks, interns and implication or estoppel. Article 1869 of the Civil Code reads:
residents, moderate grand rounds and patient audits and perform
other tasks and responsibilities, for the privilege of being able to
maintain a clinic in the hospital, and/or for the privilege of ART. 1869. Agency may be express, or implied from the acts of
admitting patients into the hospital. In addition to these, the the principal, from his silence or lack of action, or his failure to
physician’s performance as a specialist is generally evaluated by a repudiate the agency, knowing that another person is acting on his
peer review committee on the basis of mortality and morbidity behalf without authority.
statistics, and feedback from patients, nurses, interns and
In this case, PSI publicly displays in the lobby of the Medical City The doctrine has its genesis in Darling v. Charleston Community
Hospital the names and specializations of the physicians Hospital.36 There, the Supreme Court of Illinois held that "the jury
associated or accredited by it, including those of Dr. Ampil and could have found a hospital negligent, inter alia, in failing to have
Dr. Fuentes. We concur with the Court of Appeals’ conclusion a sufficient number of trained nurses attending the patient; failing
that it "is now estopped from passing all the blame to the to require a consultation with or examination by members of the
physicians whose names it proudly paraded in the public directory hospital staff; and failing to review the treatment rendered to the
leading the public to believe that it vouched for their skill and patient." On the basis of Darling, other jurisdictions held that a
competence." Indeed, PSI’s act is tantamount to holding out to the hospital’s corporate negligence extends to permitting a physician
public that Medical City Hospital, through its accredited known to be incompetent to practice at the hospital. 37 With the
physicians, offers quality health care services. By accrediting Dr. passage of time, more duties were expected from hospitals,
Ampil and Dr. Fuentes and publicly advertising their among them: (1) the use of reasonable care in the maintenance of
qualifications, the hospital created the impression that they were safe and adequate facilities and equipment; (2) the selection and
its agents, authorized to perform medical or surgical services for retention of competent physicians; (3) the overseeing or
its patients. As expected, these patients, Natividad being one of supervision of all persons who practice medicine within its walls;
them, accepted the services on the reasonable belief that such and (4) the formulation, adoption and enforcement of adequate
were being rendered by the hospital or its employees, agents, or rules and policies that ensure quality care for its patients. 38 Thus,
servants. The trial court correctly pointed out: in Tucson Medical Center, Inc. v. Misevich, 39 it was held that a
hospital, following the doctrine of corporate responsibility, has
x x x regardless of the education and status in life of the patient, the duty to see that it meets the standards of responsibilities for
he ought not be burdened with the defense of absence of the care of patients. Such duty includes the proper supervision of
employer-employee relationship between the hospital and the the members of its medical staff. And in Bost v. Riley, 40 the court
independent physician whose name and competence are certainly concluded that a patient who enters a hospital does so with the
certified to the general public by the hospital’s act of listing him reasonable expectation that it will attempt to cure him. The
and his specialty in its lobby directory, as in the case herein. The hospital accordingly has the duty to make a reasonable effort to
high costs of today’s medical and health care should at least exact monitor and oversee the treatment prescribed and administered by
on the hospital greater, if not broader, legal responsibility for the the physicians practicing in its premises.
conduct of treatment and surgery within its facility by its
accredited physician or surgeon, regardless of whether he is In the present case, it was duly established that PSI operates the
independent or employed."33 Medical City Hospital for the purpose and under the concept of
providing comprehensive medical services to the public.
The wisdom of the foregoing ratiocination is easy to discern. Accordingly, it has the duty to exercise reasonable care to protect
Corporate entities, like PSI, are capable of acting only through from harm all patients admitted into its facility for medical
other individuals, such as physicians. If these accredited treatment. Unfortunately, PSI failed to perform such duty. The
physicians do their job well, the hospital succeeds in its mission findings of the trial court are convincing, thus:
of offering quality medical services and thus profits financially.
Logically, where negligence mars the quality of its services, the x x x PSI’s liability is traceable to its failure to conduct an
hospital should not be allowed to escape liability for the acts of its investigation of the matter reported in the nota bene of the count
ostensible agents. nurse. Such failure established PSI’s part in the dark conspiracy
of silence and concealment about the gauzes. Ethical
We now proceed to the doctrine of corporate negligence or considerations, if not also legal, dictated the holding of an
corporate responsibility. immediate inquiry into the events, if not for the benefit of the
patient to whom the duty is primarily owed, then in the interest of
arriving at the truth. The Court cannot accept that the medical and
One allegation in the complaint in Civil Case No. Q-43332 for the healing professions, through their members like defendant
negligence and malpractice is that PSI as owner, operator and surgeons, and their institutions like PSI’s hospital facility, can
manager of Medical City Hospital, "did not perform the necessary callously turn their backs on and disregard even a mere
supervision nor exercise diligent efforts in the supervision of Drs. probability of mistake or negligence by refusing or failing to
Ampil and Fuentes and its nursing staff, resident doctors, and investigate a report of such seriousness as the one in Natividad’s
medical interns who assisted Drs. Ampil and Fuentes in the case.
performance of their duties as surgeons." 34 Premised on the
doctrine of corporate negligence, the trial court held that PSI is
directly liable for such breach of duty. It is worthy to note that Dr. Ampil and Dr. Fuentes operated on
Natividad with the assistance of the Medical City Hospital’s staff,
composed of resident doctors, nurses, and interns. As such, it is
We agree with the trial court. reasonable to conclude that PSI, as the operator of the hospital,
has actual or constructive knowledge of the procedures carried
Recent years have seen the doctrine of corporate negligence as the out, particularly the report of the attending nurses that the two
judicial answer to the problem of allocating hospital’s liability for pieces of gauze were missing. In Fridena v. Evans, 41 it was held
the negligent acts of health practitioners, absent facts to support that a corporation is bound by the knowledge acquired by or
the application of respondeat superior or apparent authority. Its notice given to its agents or officers within the scope of their
formulation proceeds from the judiciary’s acknowledgment that in authority and in reference to a matter to which their authority
these modern times, the duty of providing quality medical service extends. This means that the knowledge of any of the staff of
is no longer the sole prerogative and responsibility of the Medical City Hospital constitutes knowledge of PSI. Now, the
physician. The modern hospitals have changed structure. failure of PSI, despite the attending nurses’ report, to investigate
Hospitals now tend to organize a highly professional medical staff and inform Natividad regarding the missing gauzes amounts to
whose competence and performance need to be monitored by the callous negligence. Not only did PSI breach its duties to oversee
hospitals commensurate with their inherent responsibility to or supervise all persons who practice medicine within its walls, it
provide quality medical care.35 also failed to take an active step in fixing the negligence
committed. This renders PSI, not only vicariously liable for the
negligence of Dr. Ampil under Article 2180 of the Civil Code, but
also directly liable for its own negligence under Article 2176. In G.R. No. 126297             February 11, 2008
Fridena, the Supreme Court of Arizona held:
PROFESSIONAL SERVICES, INC., petitioner, 
x x x In recent years, however, the duty of care owed to the vs.
patient by the hospital has expanded. The emerging trend is to THE COURT OF APPEALS and NATIVIDAD and
hold the hospital responsible where the hospital has failed to ENRIQUE AGANA, respondents,
monitor and review medical services being provided within its
walls. See Kahn Hospital Malpractice Prevention, 27 De Paul . x- - - - - - - - - - - - - - - - - - - - - - - - - - - - x
Rev. 23 (1977).
G.R. No. 126467             February 11, 2008
Among the cases indicative of the ‘emerging trend’ is Purcell v.
Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972). In Purcell,
the hospital argued that it could not be held liable for the NATIVIDAD (Substituted by her children MARCELINO
malpractice of a medical practitioner because he was an AGANA III, ENRIQUE AGANA, JR., EMMA AGANA
independent contractor within the hospital. The Court of Appeals ANDAYA, JESUS AGANA, and RAYMUND AGANA) and
pointed out that the hospital had created a professional staff ENRIQUE AGANA, petitioners, 
whose competence and performance was to be monitored and vs.
reviewed by the governing body of the hospital, and the court held THE COURT OF APPEALS and JUAN
that a hospital would be negligent where it had knowledge or FUENTES, respondents,
reason to believe that a doctor using the facilities was employing
a method of treatment or care which fell below the recognized x- - - - - - - - - - - - - - - - - - - - - - - - - - - - x
standard of care.
G.R. No. 127590             February 11, 2008
Subsequent to the Purcell decision, the Arizona Court of Appeals
held that a hospital has certain inherent responsibilities regarding MIGUEL AMPIL, petitioner, 
the quality of medical care furnished to patients within its walls vs.
and it must meet the standards of responsibility commensurate THE COURT OF APPEALS and NATIVIDAD AGANA and
with this undertaking. Beeck v. Tucson General Hospital, 18 Ariz. ENRIQUE AGANA, respondents.
App. 165, 500 P. 2d 1153 (1972). This court has confirmed the
rulings of the Court of Appeals that a hospital has the duty of
supervising the competence of the doctors on its staff. x x x. RESOLUTION

x x x x x x SANDOVAL-GUTIERREZ, J.:

In the amended complaint, the plaintiffs did plead that the As the hospital industry changes, so must the laws and
operation was performed at the hospital with its knowledge, aid, jurisprudence governing hospital liability. The immunity from
and assistance, and that the negligence of the defendants was the medical malpractice traditionally accorded to hospitals has to be
proximate cause of the patient’s injuries. We find that such eroded if we are to balance the interest of the patients and
general allegations of negligence, along with the evidence hospitals under the present setting.
produced at the trial of this case, are sufficient to support the
hospital’s liability based on the theory of negligent supervision." Before this Court is a motion for reconsideration filed by
Professional Services, Inc. (PSI), petitioner in G.R. No. 126297,
Anent the corollary issue of whether PSI is solidarily liable with assailing the Court’s First Division Decision dated January 31,
Dr. Ampil for damages, let it be emphasized that PSI, apart from a 2007, finding PSI and Dr. Miguel Ampil, petitioner in G.R. No.
general denial of its responsibility, failed to adduce evidence 127590, jointly and severally liable for medical negligence.
showing that it exercised the diligence of a good father of a family
in the accreditation and supervision of the latter. In neglecting to A brief revisit of the antecedent facts is imperative.
offer such proof, PSI failed to discharge its burden under the last
paragraph of Article 2180 cited earlier, and, therefore, must be
On April 4, 1984, Natividad Agana was admitted at the Medical
adjudged solidarily liable with Dr. Ampil. Moreover, as we have
City General Hospital (Medical City) because of difficulty of
discussed, PSI is also directly liable to the Aganas.
bowel movement and bloody anal discharge. Dr. Ampil diagnosed
her to be suffering from "cancer of the sigmoid." Thus, on April
One final word. Once a physician undertakes the treatment and 11, 1984, Dr. Ampil, assisted by the medical staff 1 of Medical
care of a patient, the law imposes on him certain obligations. In City, performed an anterior resection surgery upon her. During
order to escape liability, he must possess that reasonable degree of the surgery, he found that the malignancy in her sigmoid area had
learning, skill and experience required by his profession. At the spread to her left ovary, necessitating the removal of certain
same time, he must apply reasonable care and diligence in the portions of it. Thus, Dr. Ampil obtained the consent of Atty.
exercise of his skill and the application of his knowledge, and Enrique Agana, Natividad’s husband, to permit Dr. Juan Fuentes,
exert his best judgment. respondent in G.R. No. 126467, to perform hysterectomy upon
Natividad.
WHEREFORE, we DENY all the petitions and AFFIRM the
challenged Decision of the Court of Appeals in CA-G.R. CV No. Dr. Fuentes performed and completed the hysterectomy.
42062 and CA-G.R. SP No. 32198. Afterwards, Dr. Ampil took over, completed the operation and
closed the incision. However, the operation appeared to be
Costs against petitioners PSI and Dr. Miguel Ampil. flawed. In the corresponding Record of Operation dated April 11,
1984, the attending nurses entered these remarks:
SO ORDERED.
sponge count lacking 2 by estoppel;and third, PSI’s failure to supervise Dr. Ampil and
its resident physicians and nurses and to take an active step in
announced to surgeon searched done (sic) but to no order to remedy their negligence rendered it directly liable under
avail continue for closure. the doctrine of corporate negligence.

After a couple of days, Natividad complained of excruciating pain In its motion for reconsideration, PSI contends that the Court
in her anal region. She consulted both Dr. Ampil and Dr. Fuentes erred in finding it liable under Article 2180 of the Civil Code,
about it. They told her that the pain was the natural consequence there being no employer-employee relationship between it and its
of the surgical operation performed upon her. Dr. Ampil consultant, Dr. Ampil. PSI stressed that the Court’s Decision
recommended that Natividad consult an oncologist to treat the in Ramos holding that "an employer-employee relationship in
cancerous nodes which were not removed during the operation. effect exists between hospitals and their attending and visiting
physicians for the purpose of apportioning responsibility" had
been reversed in a subsequent Resolution. 3 Further, PSI argues
On May 9, 1984, Natividad, accompanied by her husband, went to that the doctrine of ostensible agency or agency by
the United States to seek further treatment. After four (4) months estoppelcannot apply because spouses Agana failed to establish
of consultations and laboratory examinations, Natividad was told one requisite of the doctrine, i.e., that Natividad relied on the
that she was free of cancer. Hence, she was advised to return to representation of the hospital in engaging the services of Dr.
the Philippines. Ampil. And lastly, PSI maintains that the doctrine of corporate
negligence is misplaced because the proximate cause of
On August 31, 1984, Natividad flew back to the Philippines, still Natividad’s injury was Dr. Ampil’s negligence.
suffering from pains. Two (2) weeks thereafter, her daughter
found a piece of gauze protruding from her vagina. Dr. Ampil was The motion lacks merit.
immediately informed. He proceeded to Natividad’s house where
he managed to extract by hand a piece of gauze measuring 1.5
inches in width. Dr. Ampil then assured Natividad that the pains As earlier mentioned, the First Division, in its assailed Decision,
would soon vanish. ruled that an employer-employee relationship "in effect" exists
between the Medical City and Dr. Ampil. Consequently, both are
jointly and severally liable to the Aganas. This ruling proceeds
Despite Dr. Ampil’s assurance, the pains intensified, prompting from the following ratiocination in Ramos:
Natividad to seek treatment at the Polymedic General Hospital.
While confined thereat, Dr. Ramon Gutierrez detected the
presence of a foreign object in her vagina -- a foul-smelling gauze We now discuss the responsibility of the hospital in this
measuring 1.5 inches in width. The gauze had badly infected her particular incident. The unique practice (among private
vaginal vault. A recto-vaginal fistula had formed in her hospitals) of filling up specialist staff with attending and
reproductive organ which forced stool to excrete through the visiting "consultants," who are allegedly not hospital
vagina. Another surgical operation was needed to remedy the employees, presents problems in apportioning
situation. Thus, in October 1984, Natividad underwent another responsibility for negligence in medical malpractice
surgery. cases. However, the difficulty is only more apparent
than real.
On November 12, 1984, Natividad and her husband filed with the
Regional Trial Court, Branch 96, Quezon City a complaint for In the first place, hospitals exercise significant control
damages against PSI (owner of Medical City), Dr. Ampil and Dr. in the hiring and firing of consultants and in the
Fuentes. conduct of their work within the hospital premises.
Doctors who apply for "consultant" slots, visiting or
attending, are required to submit proof of completion of
On February 16, 1986, pending the outcome of the above case, residency, their educational qualifications; generally,
Natividad died. She was duly substituted by her above-named evidence of accreditation by the appropriate board
children (the Aganas). (diplomate), evidence of fellowship in most cases, and
references. These requirements are carefully scrutinized
On March 17, 1993, the trial court rendered judgment in favor of by members of the hospital administration or by a
spouses Agana finding PSI, Dr. Ampil and Dr. Fuentes jointly and review committee set up by the hospital who either
severally liable. On appeal, the Court of Appeals, in its Decision accept or reject the application. This is particularly true
dated September 6, 1996, affirmed the assailed judgment with with respondent hospital.
modification in the sense that the complaint against Dr. Fuentes
was dismissed. After a physician is accepted, either as a visiting or
attending consultant, he is normally required to
PSI, Dr. Ampil and the Aganas filed with this Court separate attend clinico-pathological conferences, conduct
petitions for review on certiorari. On January 31, 2007, the Court, bedside rounds for clerks, interns and residents,
through its First Division, rendered a Decision holding that PSI is moderate grand rounds and patient audits and
jointly and severally liable with Dr. Ampil for the following perform other tasks and responsibilities, for the
reasons: first, there is an employer-employee relationship between privilege of being able to maintain a clinic in the
Medical City and Dr. Ampil. The Court relied on Ramos v. Court hospital, and/or for the privilege of admitting
of Appeals,2 holding that for the purpose of apportioning patients into the hospital. In addition to these, the
responsibility in medical negligence cases, an employer-employee physician’s performance as a specialist is generally
relationship in effect exists between hospitals and their attending evaluated by a peer review committee on the basis of
and visiting physicians; second, PSI’s act of publicly displaying mortality and morbidity statistics, and feedback
in the lobby of the Medical City the names and specializations of from patients, nurses, interns and residents. A
its accredited physicians, including Dr. Ampil, estopped it from consultant remiss in his duties, or a consultant who
denying the existence of an employer-employee relationship regularly falls short of the minimum standards
between them under the doctrine of ostensible agency or agency
acceptable to the hospital or its peer review apparent or ostensible agency theory. [King v. Mitchell,
committee, is normally politely terminated. 31 A.D.3rd 958, 819 N.Y. S.2d 169 (2006)].

In other words, private hospitals hire, fire and exercise xxx

real control over their attending and visiting
"consultant" staff. While "consultants" are not, The doctrine of apparent authority essentially involves
technically employees, a point which respondent two factors to determine the liability of an independent
hospital asserts in denying all responsibility for the contractor-physician.
patient’s condition, the control exercised, the hiring,
and the right to terminate consultants all fulfill the
important hallmarks of an employer-employee The first factor focuses on the hospital’s manifestations
relationship, with the exception of the payment of and is sometimes described as an inquiry whether the
wages. In assessing whether such a relationship in hospital acted in a manner which would lead a
fact exists, the control test is determining. reasonable person to conclude that the individual who
Accordingly, on the basis of the foregoing, we rule was alleged to be negligent was an employee or agent of
that for the purpose of allocating responsibility in the hospital. (Diggs v. Novant Health, Inc., 628 S.E.2d
medical negligence cases, an employer-employee 851 (2006) citing Hylton v. Koontz, 138 N.C. App. 629
relationship in effect exists between hospitals and (2000). In this regard, the hospital need not make
their attending and visiting physicians.This being the express representations to the patient that the
case, the question now arises as to whether or not treating physician is an employee of the hospital;
respondent hospital is solidarily liable with respondent rather a representation may be general and
doctors for petitioner’s condition. implied. (Id.)

The basis for holding an employer solidarily responsible The doctrine of apparent authority is a specie of the
for the negligence of its employee is found in Article doctrine of estoppel. Article 1431 of the Civil Code
2180 of the Civil Code which considers a person provides that "[t]hrough estoppel, an admission or
accountable not only for his own acts but also for those representation is rendered conclusive upon the person
of others based on the former’s responsibility under a making it, and cannot be denied or disproved as against
relationship of partia ptetas. the person relying thereon." Estoppel rests on this rule:
"Whether a party has, by his own declaration, act, or
omission, intentionally and deliberately led another to
Clearly, in Ramos, the Court considered the peculiar relationship believe a particular thing true, and to act upon such
between a hospital and its consultants on the bases of certain belief, he cannot, in any litigation arising out of such
factors. One such factor is the "control test" wherein the hospital declaration, act or omission, be permitted to falsify it.
exercises control in the hiring and firing of consultants, like Dr. (De Castro v. Ginete, 137 Phil. 453 [1969], citing Sec.
Ampil, and in the conduct of their work. 3, par. A, Rule 131 of the Rules of Court. See also King
v. Mitchell, 31 A.D.3rd 958, 819 N.Y.S.2d 169 [2006]).
Actually, contrary to PSI’s contention, the Court did not reverse
its ruling in Ramos. What it clarified was that the De Los Santos xxx
Medical Clinic did not exercise control over its consultant, hence,
there is no employer-employee relationship between them. Thus,
despite the granting of the said hospital’s motion for The second factor focuses on the patient’s reliance. It is
reconsideration, the doctrine in Ramos stays, i.e., for the purpose sometimes characterized as an inquiry on whether the
of allocating responsibility in medical negligence cases, an plaintiff acted in reliance upon the conduct of the
employer-employee relationship exists between hospitals and hospital or its agent, consistent with ordinary care and
their consultants. prudence. (Diggs v. Novant Health, Inc.)

In the instant cases, PSI merely offered a general denial of PSI argues that the doctrine of apparent authority cannot apply
responsibility, maintaining that consultants, like Dr. Ampil, are to these cases because spouses Agana failed to establish proof of
"independent contractors," not employees of the hospital. Even their reliance on the representation of Medical City that Dr. Ampil
assuming that Dr. Ampil is not an employee of Medical City, but is its employee.
an independent contractor, still the said hospital is liable to the
Aganas. The argument lacks merit.

In Nograles, et al. v. Capitol Medical Center, et al.,4 through Mr. Atty. Agana categorically testified that one of the reasons why he
Justice Antonio T. Carpio, the Court held: chose Dr. Ampil was that he knew him to be a staff member of
Medical City, a prominent and known hospital.
The question now is whether CMC is automatically
exempt from liability considering that Dr. Estrada is an Q     Will you tell us what transpired in your visit to Dr.
independent contractor-physician. Ampil?

In general, a hospital is not liable for the negligence of A     Well, I saw Dr. Ampil at the Medical City, I know
an independent contractor-physician. There is, however, him to be a staff member there, and I told him about
an exception to this principle. The hospital may be the case of my wife and he asked me to bring my wife
liable if the physician is the "ostensible" agent of the over so she could be examined. Prior to that, I have
hospital. (Jones v. Philpott, 702 F. Supp. 1210 [1988]) known Dr. Ampil, first, he was staying in front of our
This exception is also known as the "doctrine of house, he was a neighbor, second, my daughter was his
apparent authority." (Sometimes referred to as the student in the University of the East School of Medicine
at Ramon Magsaysay; and when my daughter opted to
establish a hospital or a clinic, Dr. Ampil was one of also report to the hospital because you are under the
our consultants on how to establish that hospital. And control and direction of the hospital?
from there, I have known that he was a specialist when
it comes to that illness. A     The hospital already had the record of the two
OS missing, sir.
Atty. Agcaoili
Q     If you place yourself in the position of the
On that particular occasion, April 2, 1984, what was hospital, how will you recover.
your reason for choosing to contact Dr. Ampil in
connection with your wife’s illness? A     You do not answer my question with another
question.
A First, before that, I have known him to be a specialist
on that part of the body as a surgeon; second, I have Q     Did the hospital do anything about the missing
known him to be a staff member of the Medical City gauzes?
which is a prominent and known hospital. And third,
because he is a neighbor, I expect more than the usual
medical service to be given to us, than his ordinary A     The hospital left it up to the surgeon who was
patients.5 doing the operation, sir.

Clearly, PSI is estopped from passing the blame solely to Dr. Q     Did the hospital investigate the surgeon who did
Ampil. Its act of displaying his name and those of the other the operation?
physicians in the public directory at the lobby of the hospital
amounts to holding out to the public that it offers quality medical A     I am not in the position to answer that, sir.
service through the listed physicians. This justifies Atty. Agana’s
belief that Dr. Ampil was a member of the hospital’s staff. It Q     You never did hear the hospital investigating
must be stressed that under the doctrine of apparent the doctors involved in this case of those missing
authority, the question in every case is whether the principal sponges, or did you hear something?
has by his voluntary act placed the agent in such a situation
that a person of ordinary prudence, conversant with business
usages and the nature of the particular business, is justified in xxxxxx
presuming that such agent has authority to perform the
particular act in question.6 In these cases, the circumstances A     I think we already made a report by just saying
yield a positive answer to the question. that two sponges were missing, it is up to the hospital
to make the move.
The challenged Decision also anchors its ruling on the doctrine of
corporate responsibility.7 The duty of providing quality medical Atty. Agana
service is no longer the sole prerogative and responsibility of the
physician. This is because the modern hospital now tends to
Precisely, I am asking you if the hospital did a move,
organize a highly-professional medical staff whose competence
if the hospital did a move.
and performance need also to be monitored by the hospital
commensurate with its inherent responsibility to provide quality
medical care.8 Such responsibility includes the proper A     I cannot answer that.
supervision of the members of its medical staff. Accordingly,
the hospital has the duty to make a reasonable effort to Court
monitor and oversee the treatment prescribed and
administered by the physicians practicing in its premises.
By that answer, would you mean to tell the Court
that you were aware if there was such a move done
Unfortunately, PSI had been remiss in its duty. It did not conduct by the hospital?
an immediate investigation on the reported missing gauzes to the
great prejudice and agony of its patient. Dr. Jocson, a member of
A     I cannot answer that, your honor, because I did
PSI’s medical staff, who testified on whether the hospital
not have any more follow-up of the case that
conducted an investigation, was evasive, thus:
happened until now.9

Q     We go back to the operative technique, this was

The above testimony obviously shows Dr. Jocson’s lack of
signed by Dr. Puruganan, was this submitted to the
concern for the patients. Such conduct is reflective of the
hospital?
hospital’s manner of supervision. Not only did PSI breach its
duty to oversee or supervise all persons who practice medicine
A     Yes, sir, this was submitted to the hospital with within its walls, it also failed to take an active step in fixing
the record of the patient. the negligence committed. This renders PSI, not only vicariously
liable for the negligence of Dr. Ampil under Article 2180 of the
Q     Was the hospital immediately informed about Civil Code, but also directly liable for its own negligence under
the missing sponges? Article 2176.

A     That is the duty of the surgeon, sir. Moreover, there is merit in the trial court’s finding that the failure
of PSI to conduct an investigation "established PSI’s part in the
dark conspiracy of silence and concealment about the gauzes."
Q     As a witness to an untoward incident in the
operating room, was it not your obligation, Dr., to
The following testimony of Atty. Agana supports such findings, prior leave of court and the second motion for reconsideration of
thus: PSI.[7]

Q     You said you relied on the promise of Dr. Ampil Due to paramount public interest, the Court en banc accepted the
and despite the promise you were not able to obtain the referral[8] and heard the parties on oral arguments on one
said record. Did you go back to the record custodian? particular issue: whether a hospital may be held liable for the
negligence of physicians-consultants allowed to practice in its
premises.[9]
A     I did not because I was talking to Dr. Ampil. He
promised me. To recall the salient facts, PSI, together with Dr. Miguel Ampil
(Dr. Ampil) and Dr. Juan Fuentes (Dr. Fuentes), was impleaded
Q     After your talk to Dr. Ampil, you went to the by Enrique Agana and Natividad Agana (later substituted by her
record custodian? heirs), in a complaint[10] for damages filed in the Regional Trial
Court (RTC) of Quezon City, Branch 96, for the injuries suffered
A     I went to the record custodian to get the clinical by Natividad when Dr. Ampil and Dr. Fuentes neglected to
record of my wife, and I was given a portion of the remove from her body two gauzes [11] which were used in the
records consisting of the findings, among them, the surgery they performed on her on April 11, 1984 at the Medical
entries of the dates, but not the operating procedure City General Hospital. PSI was impleaded as owner, operator and
and operative report.10 manager of the hospital.

In a decision[12] dated March 17, 1993, the RTC held PSI

In sum, we find no merit in the motion for reconsideration. solidarily liable with Dr. Ampil and Dr. Fuentes for damages.
[13]
 On appeal, the Court of Appeals (CA), absolved Dr. Fuentes
WHEREFORE, we DENY PSI’s motion for but affirmed the liability of Dr. Ampil and PSI, subject to the right
reconsideration with finality. of PSI to claim reimbursement from Dr. Ampil. [14]

On petition for review, this Court, in its January 31, 2007

SO ORDERED.
decision, affirmed the CA decision. [15] PSI filed a motion for
reconsideration[16] but the Court denied it in a resolution dated
[G.R. No. 126297 : February 02, 2010]  February 11, 2008.[17]

PROFESSIONAL SERVICES, INC., PETITIONER, VS. The Court premised the direct liability of PSI to the Aganas on the
THE COURT OF APPEALS AND NATIVIDAD AND following facts and law:
ENRIQUE AGANA, RESPONDENTS. 
First, there existed between PSI and Dr. Ampil an employer-
[G.R. NO. 126467] employee relationship as contemplated in the December 29, 1999
decision in Ramos v. Court of Appeals[18] that "for purposes of
NATIVIDAD [SUBSTITUTED BY HER CHILDREN allocating responsibility in medical negligence cases, an
MARCELINO AGANA III, ENRIQUE AGANA, JR., EMMA employer-employee relationship exists between hospitals and
AGANA-ANDAYA, JESUS AGANA AND RAYMUND their consultants."[19] Although the Court in Ramos later issued a
AGANA] AND ENRIQUE AGANA, PETITIONERS, VS. Resolution dated April 11, 2002 [20] reversing its earlier finding on
THE COURT OF APPEALS AND JUAN FUENTES, the existence of an employment relationship between hospital and
RESPONDENTS.  doctor, a similar reversal was not warranted in the present case
because the defense raised by PSI consisted of a mere general
[G.R. NO. 127590] denial of control or responsibility over the actions of Dr. Ampil.
[21]

MIGUEL AMPIL, PETITIONER, VS. NATIVIDAD AND

ENRIQUE AGANA, RESPONDENTS. Second, by accrediting Dr. Ampil and advertising his
qualifications, PSI created the public impression that he was its
R E S O L U T I O N  agent.[22] Enrique testified that it was on account of Dr. Ampil's
accreditation with PSI that he conferred with said doctor about his
CORONA, J.: wife's (Natividad's) condition.[23] After his meeting with Dr.
Ampil, Enrique asked Natividad to personally consult Dr. Ampil.
With prior leave of court, [1] petitioner Professional Services, Inc. [24]
 In effect, when Enrigue and Natividad engaged the services of
(PSI) filed a second motion for reconsideration [2] urging referral Dr. Ampil, at the back of their minds was that the latter was a
thereof to the Court en banc and seeking modification of the staff member of a prestigious hospital. Thus, under the doctrine of
decision dated January 31, 2007 and resolution dated February 11, apparent authority applied in Nogales, et al. v. Capitol Medical
2008 which affirmed its vicarious and direct liability for damages Center, et al.,[25] PSI was liable for the negligence of Dr. Ampil.
to respondents Enrique Agana and the heirs of Natividad Agana
(Aganas). Finally, as owner and operator of Medical City General Hospital,
PSI was bound by its duty to provide comprehensive medical
Manila Medical Services, Inc. (MMSI),[3] Asian Hospital, Inc. services to Natividad Agana, to exercise reasonable care to protect
(AHI),[4] and Private Hospital Association of the Philippines her from harm,[26] to oversee or supervise all persons who
(PHAP)[5] all sought to intervene in these cases invoking the practiced medicine within its walls, and to take active steps in
common ground that, unless modified, the assailed decision and fixing any form of negligence committed within its premises.
resolution will jeopardize the financial viability of private [27]
 PSI committed a serious breach of its corporate duty when it
hospitals and jack up the cost of health care. failed to conduct an immediate investigation into the reported
missing gauzes.[28]
The Special First Division of the Court granted the motions for
intervention of MMSI, AHI and PHAP (hereafter intervenors),
[6] 
and referred en consulta to the Court en banc the motion for
PSI is now asking this Court to reconsider the foregoing rulings 2180[35] of the Civil Code or the principle of respondeat
for these reasons: superior. Even when no employment relationship exists but it is
shown that the hospital holds out to the patient that the doctor is
I its agent, the hospital may still be vicariously liable under Article
2176 in relation to Article 1431[36] and Article 1869[37] of the Civil
The declaration in the 31 January 2007 Decision vis-a-vis the 11 Code or the principle of apparent authority. [38] Moreover,
February 2009 Resolution that the ruling in Ramos vs. Court of regardless of its relationship with the doctor, the hospital may be
Appeals (G.R. No. 134354, December 29, 1999) that "an held directly liable to the patient for its own negligence or failure
employer-employee relations exists between hospital and their to follow established standard of conduct to which it should
consultants" stays should be set aside for being inconsistent with conform as a corporation. [39]
or contrary to the import of the resolution granting the hospital's
motion for reconsideration in Ramos vs. Court of Appeals (G.R. This Court still employs the "control test" to determine the
No. 134354, April 11, 2002), which is applicable to PSI since the existence of an employer-employee relationship between hospital
Aganas failed to prove an employer-employee relationship and doctor. In Calamba Medical Center, Inc. v. National Labor
between PSI and Dr. Ampil and PSI proved that it has no control Relations Commission, et al.[40] it held:
over Dr. Ampil. In fact, the trial court has found that there is no
employer-employee relationship in this case and that the doctor's Under the "control test", an employment relationship exists
are independent contractors. between a physician and a hospital if the hospital controls both
the means and the details of the process by which the physician is
II to accomplish his task.

Respondents Aganas engaged Dr. Miguel Ampil as their doctor xx xx xx

and did not primarily and specifically look to the Medical City
Hospital (PSI) for medical care and support; otherwise stated, As priorly stated, private respondents maintained specific work-
respondents Aganas did not select Medical City Hospital (PSI) to schedules, as determined by petitioner through its medical
provide medical care because of any apparent authority of Dr. director, which consisted of 24-hour shifts totaling forty-eight
Miguel Ampil as its agent since the latter was chosen primarily hours each week and which were strictly to be observed under
and specifically based on his qualifications and being friend and pain of administrative sanctions.
neighbor.
That petitioner exercised control over respondents gains light
III from the undisputed fact that in the emergency room, the
operating room, or any department or ward for that matter,
PSI cannot be liable under doctrine of corporate negligence since respondents' work is monitored through its nursing
the proximate cause of Mrs. Agana's injury was the negligence of supervisors, charge nurses and orderlies. Without the
Dr. Ampil, which is an element of the principle of corporate approval or consent of petitioner or its medical director, no
negligence.[29] operations can be undertaken in those areas. For control test
to apply, it is not essential for the employer to actually
In their respective memoranda, intervenors raise parallel supervise the performance of duties of the employee, it being
arguments that the Court's ruling on the existence of an employer- enough that it has the right to wield the power. (emphasis
employee relationship between private hospitals and consultants supplied)
will force a drastic and complex alteration in the long-established
and currently prevailing relationships among patient, physician Even in its December 29, 1999 decision [41] and April 11, 2002
and hospital, with burdensome operational and financial resolution[42] in Ramos, the Court found the control test decisive.
consequences and adverse effects on all three parties. [30]
In the present case, it appears to have escaped the Court's
The Aganas comment that the arguments of PSI need no longer be attention that both the RTC and the CA found no employment
entertained for they have all been traversed in the assailed relationship between PSI and Dr. Ampil, and that the Aganas did
decision and resolution. [31] not question such finding. In its March 17, 1993 decision, the
RTC found "that defendant doctors were not employees of PSI in
After gathering its thoughts on the issues, this Court holds that its hospital, they being merely consultants without any employer-
PSI is liable to the Aganas, not under the principle of respondeat employee relationship and in the capacity of independent
superior for lack of evidence of an employment relationship with contractors."[43] The Aganas never questioned such finding.
Dr. Ampil but under the principle of ostensible agency for the
negligence of Dr. Ampil and, pro hac vice, under the principle of PSI, Dr. Ampil and Dr. Fuentes appealed [44] from the RTC
corporate negligence for its failure to perform its duties as a decision but only on the issues of negligence, agency and
hospital. corporate liability. In its September 6, 1996 decision, the CA
mistakenly referred to PSI and Dr. Ampil as employer-employee,
While in theory a hospital as a juridical entity cannot practice but it was clear in its discussion on the matter that it viewed their
medicine,[32] in reality it utilizes doctors, surgeons and medical relationship as one of mere apparent agency. [45]
practitioners in the conduct of its business of facilitating medical
and surgical treatment.[33] Within that reality, three legal The Aganas appealed from the CA decision, but only to question
relationships crisscross: (1) between the hospital and the doctor the exoneration of Dr. Fuentes.[46] PSI also appealed from the CA
practicing within its premises; (2) between the hospital and the decision, and it was then that the issue of employment, though
patient being treated or examined within its premises and (3) long settled, was unwittingly resurrected.
between the patient and the doctor. The exact nature of each
relationship determines the basis and extent of the liability of the In fine, as there was no dispute over the RTC finding that PSI and
hospital for the negligence of the doctor. Dr. Ampil had no employer-employee relationship, such finding
became final and conclusive even to this Court. [47] There was no
Where an employment relationship exists, the hospital may be reason for PSI to have raised it as an issue in its petition. Thus,
held vicariously liable under Article 2176[34] in relation to Article whatever discussion on the matter that may have ensued was
purely academic.
By such statement, PSI virtually reinforced the public impression
Nonetheless, to allay the anxiety of the intervenors, the Court that Dr. Ampil was a physician of its hospital, rather than one
holds that, in this particular instance, the concurrent finding of the independently practicing in it; that the medications and treatments
RTC and the CA that PSI was not the employer of Dr. Ampil is he prescribed were necessary and desirable; and that the hospital
correct. Control as a determinative factor in testing the employer- staff was prepared to carry them out.
employee relationship between doctor and hospital under which
the hospital could be held vicariously liable to a patient in medical PSI pointed out in its memorandum that Dr. Ampil's hospital
negligence cases is a requisite fact to be established by affiliation was not the exclusive basis of the Aganas' decision to
preponderance of evidence. Here, there was insufficient evidence have Natividad treated in Medical City General Hospital, meaning
that PSI exercised the power of control or wielded such power that, had Dr. Ampil been affiliated with another hospital, he
over the means and the details of the specific process by which would still have been chosen by the Aganas as Natividad's
Dr. Ampil applied his skills in the treatment of Natividad. surgeon.[54]
Consequently, PSI cannot be held vicariously liable for the
negligence of Dr. Ampil under the principle of respondeat The Court cannot speculate on what could have been behind the
superior. Aganas' decision but would rather adhere strictly to the fact that,
under the circumstances at that time, Enrique decided to consult
There is, however, ample evidence that the hospital (PSI) held out Dr. Ampil for he believed him to be a staff member of a
to the patient (Natividad)[48] that the doctor (Dr. Ampil) was its prominent and known hospital. After his meeting with Dr. Ampil,
agent. Present are the two factors that determine apparent Enrique advised his wife Natividad to go to the Medical City
authority: first, the hospital's implied manifestation to the patient General Hospital to be examined by said doctor, and the hospital
which led the latter to conclude that the doctor was the hospital's acted in a way that fortified Enrique's belief.
agent; and second, the patient's reliance upon the conduct of the
hospital and the doctor, consistent with ordinary care and This Court must therefore maintain the ruling that PSI is
prudence.[49] vicariously liable for the negligence of Dr. Ampil as its ostensible
agent.
Enrique testified that on April 2, 1984, he consulted Dr. Ampil
regarding the condition of his wife; that after the meeting and as Moving on to the next issue, the Court notes that PSI made the
advised by Dr. Ampil, he "asked [his] wife to go to Medical City following admission in its Motion for Reconsideration:
to be examined by [Dr. Ampil]"; and that the next day, April 3, he
told his daughter to take her mother to Dr. Ampil. [50] This timeline 51. Clearly, not being an agent or employee of petitioner PSI, PSI
indicates that it was Enrique who actually made the decision on [sic] is not liable for Dr. Ampil's acts during the operation.
whom Natividad should consult and where, and that the latter Considering further that Dr. Ampil was personally engaged as a
merely acceded to it. It explains the testimony of Natividad that doctor by Mrs. Agana, it is incumbent upon Dr. Ampil, as
she consulted Dr. Ampil at the instigation of her daughter. [51]  "Captain of the Ship", and as the Agana's doctor to advise her on
what to do with her situation vis-a-vis the two missing gauzes. In
Moreover, when asked what impelled him to choose Dr. Ampil, addition to noting the missing gauzes, regular check-ups were
Enrique testified: made and no signs of complications were exhibited during her
stay at the hospital, which could have alerted petitioner PSI's
Atty. Agcaoili hospital to render and provide post-operation services to and
tread on Dr. Ampil's role as the doctor of Mrs. Agana. The
On that particular occasion, April 2, 1984, what was your reason absence of negligence of PSI from the patient's admission up
for choosing Dr. Ampil to contact with in connection with your to her discharge is borne by the finding of facts in this case.
wife's illness? Likewise evident therefrom is the absence of any complaint
from Mrs. Agana after her discharge from the hospital which
A. First, before that, I have known him to be a specialist on that had she brought to the hospital's attention, could have alerted
part of the body as a surgeon, second, I have known him to be petitioner PSI to act accordingly and bring the matter to Dr.
a staff member of the Medical City which is a prominent and Ampil's attention. But this was not the case. Ms. Agana
known hospital. And third, because he is a neighbor, I expect complained ONLY to Drs. Ampil and Fuentes, not the
more than the usual medical service to be given to us, than his hospital. How then could PSI possibly do something to fix the
ordinary patients.[52] (emphasis supplied) negligence committed by Dr. Ampil when it was not informed
about it at all.[55](emphasis supplied)
Clearly, the decision made by Enrique for Natividad to consult
Dr. Ampil was significantly influenced by the impression that Dr. PSI reiterated its admission when it stated that had Natividad
Ampil was a staff member of Medical City General Hospital, and Agana "informed the hospital of her discomfort and pain, the
that said hospital was well known and prominent. Enrique looked hospital would have been obliged to act on it."[56]
upon Dr. Ampil not as independent of but as integrally related to
Medical City. The significance of the foregoing statements is critical.

PSI's acts tended to confirm and reinforce, rather than negate, First, they constitute judicial admission by PSI that while it had
Enrique's view. It is of record that PSI required a "consent for no power to control the means or method by which Dr. Ampil
hospital care"[53] to be signed preparatory to the surgery of conducted the surgery on Natividad Agana, it had thepower to
Natividad. The form reads: review or cause the review of what may have irregularly
transpired within its walls strictly for the purpose of determining
Permission is hereby given to the medical, nursing and laboratory whether some form of negligence may have attended any
staff of the Medical City General Hospital to perform such procedure done inside its premises, with the ultimate end of
diagnostic procedures and to administer such medications and protecting its patients.
treatments as may be deemed necessary or advisable by
the physicians of this hospital for and during the confinement of Second, it is a judicial admission that, by virtue of the nature of its
xxx. (emphasis supplied) business as well as its prominence [57] in the hospital industry, it
assumed a duty to "tread on" the "captain of the ship" role of any staff and submitted to its custody, especially when these bear
doctor rendering services within its premises for the purpose of earmarks of a surgery gone awry. Thus, the record taken during
ensuring the safety of the patients availing themselves of its the operation of Natividad which reported a gauze count
services and facilities. discrepancy should have given PSI sufficient reason to initiate a
review. It should not have waited for Natividad to complain.
Third, by such admission, PSI defined the standards of its
corporate conduct under the circumstances of this case, As it happened, PSI took no heed of the record of operation and
specifically: (a) that it had a corporate duty to Natividad even consequently did not initiate a review of what transpired during
after her operation to ensure her safety as a patient; (b) that its Natividad's operation. Rather, it shirked its responsibility and
corporate duty was not limited to having its nursing staff note or passed it on to others - to Dr. Ampil whom it expected to inform
record the two missing gauzes and (c) that its corporate duty Natividad, and to Natividad herself to complain before it took any
extended to determining Dr. Ampil's role in it, bringing the matter meaningful step. By its inaction, therefore, PSI failed its own
to his attention, and correcting his negligence. standard of hospital care. It committed corporate negligence.

And finally, by such admission, PSI barred itself from arguing in It should be borne in mind that the corporate negligence ascribed
its second motion for reconsideration that the concept of corporate to PSI is different from the medical negligence attributed to Dr.
responsibility was not yet in existence at the time Natividad Ampil. The duties of the hospital are distinct from those of the
underwent treatment;[58] and that if it had any corporate doctor-consultant practicing within its premises in relation to the
responsibility, the same was limited to reporting the missing patient; hence, the failure of PSI to fulfill its duties as a hospital
gauzes and did not include "taking an active step in fixing the corporation gave rise to a direct liability to the Aganas distinct
negligence committed."[59] An admission made in the pleading from that of Dr. Ampil.
cannot be controverted by the party making such admission and is
conclusive as to him, and all proofs submitted by him contrary All this notwithstanding, we make it clear that PSI's hospital
thereto or inconsistent therewith should be ignored, whether or liability based on ostensible agency and corporate negligence
not objection is interposed by a party. [60] applies only to this case, pro hac vice. It is not intended to set a
precedent and should not serve as a basis to hold hospitals liable
Given the standard of conduct that PSI defined for itself, the next for every form of negligence of their doctors-consultants under
relevant inquiry is whether the hospital measured up to it. any and all circumstances. The ruling is unique to this case, for
the liability of PSI arose from an implied agency with Dr. Ampil
PSI excuses itself from fulfilling its corporate duty on the ground and an admitted corporate duty to Natividad. [64]
that Dr. Ampil assumed the personal responsibility of informing
Natividad about the two missing gauzes. [61] Dr. Ricardo Jocson, Other circumstances peculiar to this case warrant this ruling,
[65]
who was part of the group of doctors that attended to Natividad,  not the least of which being that the agony wrought upon the
testified that toward the end of the surgery, their group talked Aganas has gone on for 26 long years, with Natividad coming to
about the missing gauzes but Dr. Ampil assured them that he the end of her days racked in pain and agony. Such wretchedness
would personally notify the patient about it. [62] Furthermore, PSI could have been avoided had PSI simply done what was logical:
claimed that there was no reason for it to act on the report on the heed the report of a guaze count discrepancy, initiate a review of
two missing gauzes because Natividad Agana showed no signs of what went wrong and take corrective measures to ensure the
complications. She did not even inform the hospital about her safety of Nativad. Rather, for 26 years, PSI hemmed and hawed at
discomfort.[63] every turn, disowning any such responsibility to its patient.
Meanwhile, the options left to the Aganas have all but dwindled,
The excuses proffered by PSI are totally unacceptable. for the status of Dr. Ampil can no longer be ascertained. [66]

To begin with, PSI could not simply wave off the problem and Therefore, taking all the equities of this case into consideration,
nonchalantly delegate to Dr. Ampil the duty to review what this Court believes P15 million would be a fair and reasonable
transpired during the operation. The purpose of such review liability of PSI, subject to 12% p.a. interest from the finality of
would have been to pinpoint when, how and by whom two this resolution to full satisfaction.
surgical gauzes were mislaid so that necessary remedial measures
could be taken to avert any jeopardy to Natividad's recovery. WHEREFORE, the second motion for reconsideration
Certainly, PSI could not have expected that purpose to be is DENIED and the motions for intervention are NOTED.
achieved by merely hoping that the person likely to have mislaid
the gauzes might be able to retrace his own steps. By its own Professional Services, Inc. is ORDERED pro hac vice to pay
standard of corporate conduct, PSI's duty to initiate the review Natividad (substituted by her children Marcelino Agana III,
was non-delegable. Enrique Agana, Jr., Emma Agana-Andaya, Jesus Agana and
Raymund Agana) and Enrique Agana the total amount of P15
While Dr. Ampil may have had the primary responsibility of million, subject to 12% p.a. interest from the finality of this
notifying Natividad about the missing gauzes, PSI imposed upon resolution to full satisfaction.
itself the separate and independent responsibility of initiating the
inquiry into the missing gauzes. The purpose of the first would No further pleadings by any party shall be entertained in this case.
have been to apprise Natividad of what transpired during her
surgery, while the purpose of the second would have been to Let the long-delayed entry of judgment be made in this case upon
pinpoint any lapse in procedure that led to the gauze count receipt by all concerned parties of this resolution.
discrepancy, so as to prevent a recurrence thereof and to
determine corrective measures that would ensure the safety of SO ORDERED.
Natividad. That Dr. Ampil negligently failed to notify Natividad
did not release PSI from its self-imposed separate responsibility.

Corollary to its non-delegable undertaking to review potential

incidents of negligence committed within its premises, PSI had
the duty to take notice of medical records prepared by its own
Cantre vs Go DR. MILAGROS L. CANTRE, Petitioner, 
GR No. 160889 April 27, 2007 vs.
SPS. JOHN DAVID Z. GO and NORA S. GO, Respondents.
Facts: Petitioner Dr. Milagros L. Cantre is a specialist in
obstetrics and gynecology at the Dr. Jesus Delgado memorial DECISION
Hospital. She was the attending physician of respondent Nora Go,
who was admitted at the said hospital on April 19, 1992. At QUISUMBING, J.:
1:30am of April 20, 1992, Nora gave birth to her fourth child, a
baby boy. However, at around 3:30am Nora suffered profuse
bleeding insider her womb due to some parts of the placenta were For review on certiorari are the Decision 1 dated October 3, 2002
not completely expelled from her womb after delivery and Resolution2 dated November 19, 2003 of the Court of
consequently, Nora suffered hypovolemic shock, resulting in a Appeals in CA-G.R. CV No. 58184, which affirmed with
drop in her blood pressure to 40/0. Petitioner said the assisting modification the Decision3 dated March 3, 1997 of the Regional
resident physician performed various medical procedures to stop Trial Court of Quezon City, Branch 98, in Civil Case No. Q-93-
the bleeding and to restore Nora’s blood pressure. Her blood 16562.
pressure was frequently monitored with the use of a
sphygmamometer. While petitioner was massaging Nora’s uterus The facts, culled from the records, are as follows:
for it to contract and stop bleeding, she ordered a drop light to
warm Nora and her baby. Nora remained unconscious until she Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and
recovered. While in the recovery room, her husband, respondent Gynecology at the Dr. Jesus Delgado Memorial Hospital. She was
John David Z. Go noticed a fresh gasping wound 2 1/2″ x 3 1/2″ the attending physician of respondent Nora S. Go, who was
in the inner portion of her left arm, close to the armpit. He asked admitted at the said hospital on April 19, 1992.
the nurses what caused the injury. He was informed, it was a burn.
An investigation was filed by Nora’s husband and found out from
the petitioner that it was caused by the blood pressure cuff, At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth
however, this was contrary to the findings from a medico-legal child, a baby boy. However, at around 3:30 a.m., Nora suffered
report which stated that it was indeed a burn and that a drop light profuse bleeding inside her womb due to some parts of the
when placed near a skin for about 10mins could cause such burn. placenta which were not completely expelled from her womb
Nora was referred to a plastic surgeon from the hospital and skin after delivery. Consequently, Nora suffered hypovolemic shock,
grafting was done on her and scar revision but both still left a resulting in a drop in her blood pressure to "40" over "0."
mark on Nora’s arm compelling the respondent spouse to file a Petitioner and the assisting resident physician performed various
complaint for damages against petitioner. medical procedures to stop the bleeding and to restore Nora’s
blood pressure. Her blood pressure was frequently monitored with
the use of a sphygmomanometer. While petitioner was massaging
Issue: Whether or not petitioner is liable for the injury referred by Nora’s uterus for it to contract and stop bleeding, she ordered a
Nora. droplight to warm Nora and her baby. 4 Nora remained
unconscious until she recovered.
Held: Yes. The Hippocratic oath mandates physicians to give
primordial consideration to the well-being of their patients. If a While in the recovery room, her husband, respondent John David
doctor fails to live up to his precept, he is accountable for his acts. Z. Go noticed a fresh gaping wound two and a half (2 ½) by three
This is notwithstanding, courts face a unique restraint in and a half (3 ½) inches in the inner portion of her left arm, close
adjudicating medical negligence cases because physicians are not to the armpit.5 He asked the nurses what caused the injury. He
guardians of care and they never set out to intentionally cause was informed it was a burn. Forthwith, on April 22, 1992, John
injury to their patients. However, intent is immaterial in David filed a request for investigation. 6 In response, Dr. Rainerio
negligence cases because where negligence exist and is proven, it S. Abad, the medical director of the hospital, called petitioner and
automatically gives the injured a right to reparation for the the assisting resident physician to explain what happened.
damage caused. Petitioner said the blood pressure cuff caused the injury.

In cases, involving medical negligence, the doctrine of res ipsa On May 7, 1992, John David brought Nora to the National Bureau
liquitor allows the mere existence of an injury to justify a of Investigation for a physical examination, which was conducted
presumption of negligence on the part of the person who controls by medico-legal officer Dr. Floresto Arizala, Jr. 7 The medico-
the instrument causing the injury, provided that the following legal officer later testified that Nora’s injury appeared to be a burn
requisites concur: and that a droplight when placed near the skin for about 10
minutes could cause such burn.8 He dismissed the likelihood that
1. The accident is of a kind which ordinarily does not the wound was caused by a blood pressure cuff as the scar was
occur in the absence of someone’s negligence; not around the arm, but just on one side of the arm.9
2. It is caused by an instrumentality within the exclusive
control of the defendant or defendants; On May 22, 1992, Nora’s injury was referred to a plastic surgeon
3. The possibility of contributing conduct which would at the Dr. Jesus Delgado Memorial Hospital for skin
make the plaintiff responsible is eliminated. grafting.10 Her wound was covered with skin sourced from her
abdomen, which consequently bore a scar as well. About a year
All of these three requisites were present in the case at bar. after, on April 30, 1993, scar revision had to be performed at the
same hospital.11 The surgical operation left a healed linear scar in
Under the the captain of the ship doctrine, the surgeon in charge Nora’s left arm about three inches in length, the thickest portion
of the operation is liable for the negligence of his assistants during rising about one-fourth (1/4) of an inch from the surface of the
the time when those are under the surgeons control. skin. The costs of the skin grafting and the scar revision were
shouldered by the hospital.12
G.R. No. 160889             April 27, 2007
Unfortunately, Nora’s arm would never be the Petitioner’s motion for reconsideration was denied by the Court of
same.1a\^/phi1.net Aside from the unsightly mark, the pain in her Appeals. Hence, the instant petition assigning the following as
left arm remains. When sleeping, she has to cradle her wounded errors and issues:
arm. Her movements now are also restricted. Her children cannot
play with the left side of her body as they might accidentally I.
bump the injured arm, which aches at the slightest touch.
WHETHER OR NOT, THE LOWER COURT, AND THE
Thus, on June 21, 1993, respondent spouses filed a complaint13 for COURT OF APPEALS COMMITTED GRAVE ABUSE OF
damages against petitioner, Dr. Abad, and the hospital. Finding in THEIR DISCRETION WHEN, NOTWITHSTANDING THAT
favor of respondent spouses, the trial court decreed: BOTH PARTIES HAVE RESTED THEIR RESPECTIVE
CASES, THE LOWER COURT ADMITTED THE
In view of the foregoing consideration, judgment is hereby ADDITIONAL EXHIBITS FURTHER OFFERED BY
rendered in favor of the plaintiffs and against the defendants, RESPONDENTS NOT TESTIFIED TO BY ANY
directing the latters, (sic) jointly and severally – WITNESS AND THIS DECISION OF THE LOWER COURT
WAS UPHELD BY THE COURT OF APPEALS LIKEWISE
(a) to pay the sum of Five Hundred Thousand Pesos COMMITTING GRAVE ABUSE OF DISCRETION;
(P500,000.00) in moral damages;
II.
(b) to pay the sum of One Hundred Fifty Thousand
Pesos (P150,000.00) exemplary damages; WHETHER OR NOT THE LOWER COURT COMMITTED
GRAVE ABUSE OF ITS DISCRETION WHEN, CONTRARY
(c) to pay the sum of Eighty Thousand Pesos TO PREPONDERANCE OF EVIDENCE PRESENTED BY
(P80,000.00) nominal damages; THE PETITIONER, IT RULED THAT THE PETITIONER HAS
NOT AMPLY SHOWED THAT THE DROPLIGHT DID NOT
TOUCH THE BODY OF MRS. NORA GO, AND THIS
(d) to pay Fifty Thousand Pesos (P50,000.00) for and as DECISION OF THE LOWER COURT WAS UPHELD BY THE
attorney’s fees; and COURT OF APPEALS LIKEWISE COMMITTING GRAVE
ABUSE OF DISCRETION;
(e) to pay Six Thousand Pesos (P6,000.00) litigation
expenses. III.

SO ORDERED.14 WHETHER OR NOT THE LOWER COURT COMMITTED

GRAVE ABUSE OF ITS DISCRETION WHEN, CONTRARY
Petitioner, Dr. Abad, and the hospital all appealed to the Court of TO PREPONDERANCE OF EVIDENCE PRESENTED BY
Appeals, which affirmed with modification the trial court THE PETITIONER, IT RULED THAT PETITIONER DRA.
decision, thus: CANTRE WAS NOT ABLE TO AMPLY EXPLAIN HOW THE
INJURY (BLISTERS) IN THE LEFT INNER ARM OF
WHEREFORE, in view of all the foregoing, and finding no RESPONDENT MRS. GO CAME ABOUT;
reversible error in the appealed Decision dated March 3, 1997 of
Branch 98 of the Regional Trial Court of Quezon City in Civil IV.
Case No. Q-93-16562, the same is hereby AFFIRMED, with the
following MODIFICATIONS: WHETHER OR NOT THE COURT OF APPEALS
COMMITTED GRAVE ABUSE OF ITS DISCRETION WHEN
1. Ordering defendant-appellant Dra. Milagros [L.] IT MADE A RULING ON THE RESPONDENT’S INJURY
Cantre only to pay plaintiffs-appellees John David Go QUOTING THE TESTIMONY OF SOMEONE WHO WAS
and Nora S. Go the sum of P200,000.00 as moral NOT PRESENT AND HAS NOT SEEN THE ORIGINAL,
damages; FRESH INJURY OF RESPONDENT MRS. NORA GO;

2. Deleting the award [of] exemplary damages, V.

attorney’s fees and expenses of litigation;1awphi1.nét
WHETHER OR NOT THE COURT OF APPEALS GRAVELY
3. Dismissing the complaint with respect to defendants- ABUSING ITS DISCRETION RULED THAT PETITIONER
appellants Dr. Rainerio S. Abad and Delgado Clinic, DRA. CANTRE SHOULD HAVE INTENDED TO INFLICT
Inc.; THE INJURY TO SAVE THE LIFE OF RESPONDENT MRS.
GO;
4. Dismissing the counterclaims of defendants-
appellants for lack of merit; and VI.

5. Ordering defendant-appellant Dra. Milagros [L.] WHETHER OR NOT THE LOWER COURT AND THE
Cantre only to pay the costs. COURT [OF] APPEALS COMMITTED GRAVE ABUSE OF
DISCRETION WHEN, CONTRARY TO THE DETAILED
SO ORDERED.15 PROCEDURES DONE BY PETITIONER, BOTH RULED
THAT THE RESPONDENT WAS LEFT TO THE CARE OF
THE NURSING STAFF;

VII.
WHETHER OR NOT THE LOWER COURT COMMITTED The Hippocratic Oath mandates physicians to give primordial
GRAVE ABUSE OF DISCRETION WHEN, CONTRARY TO consideration to the well-being of their patients. If a doctor fails to
THE MEDICAL PURPOSES OF COSMETIC SURGERY, IT live up to this precept, he is accountable for his acts. This
RULED THAT THE COSMETIC SURGERY MADE THE notwithstanding, courts face a unique restraint in adjudicating
SCARS EVEN MORE UGLY AND DECLARED THE medical negligence cases because physicians are not guarantors of
COSMETIC SURGERY A FAILURE; care and, they never set out to intentionally cause injury to their
patients. However, intent is immaterial in negligence cases
VIII. because where negligence exists and is proven, it automatically
gives the injured a right to reparation for the damage caused. 17
WHETHER OR NOT THE LOWER COURT GRAVELY
ABUSE OF (SIC) DISCRETION WHEN, CONTRARY TO In cases involving medical negligence, the doctrine of res ipsa
RESPONDENTS’ CONTRARY TESTIMONIES AND THE loquitur allows the mere existence of an injury to justify a
ABSENCE OF ANY TESTIMONY, IT RULED THAT THEY presumption of negligence on the part of the person who controls
ARE ENTITLED TO DAMAGES AND WHICH WAS the instrument causing the injury, provided that the following
UPHELD, ALTHOUGH MODIFIED, BY THE COURT OF requisites concur:
APPEALS LIKEWISE ABUSING ITS DISCRETION.16
1. The accident is of a kind which ordinarily does not
Petitioner contends that additional documentary exhibits not occur in the absence of someone’s negligence;
testified to by any witness are inadmissible in evidence because
they deprived her of her constitutional right to confront the 2. It is caused by an instrumentality within the exclusive
witnesses against her. Petitioner insists the droplight could not control of the defendant or defendants; and
have touched Nora’s body. She maintains the injury was due to
the constant taking of Nora’s blood pressure. Petitioner also 3. The possibility of contributing conduct which would
insinuates the Court of Appeals was misled by the testimony of make the plaintiff responsible is eliminated. 18
the medico-legal officer who never saw the original injury before
plastic surgery was performed. Finally, petitioner stresses that
plastic surgery was not intended to restore respondent’s injury to As to the first requirement, the gaping wound on Nora’s arm is
its original state but rather to prevent further complication. certainly not an ordinary occurrence in the act of delivering a
baby, far removed as the arm is from the organs involved in the
process of giving birth. Such injury could not have happened
Respondents, however, counter that the genuineness and due unless negligence had set in somewhere.
execution of the additional documentary exhibits were duly
admitted by petitioner’s counsel. Respondents point out that
petitioner’s blood pressure cuff theory is highly improbable, being Second, whether the injury was caused by the droplight or by the
unprecedented in medical history and that the injury was blood pressure cuff is of no moment. Both instruments are
definitely caused by the droplight. At any rate, they argue, even if deemed within the exclusive control of the physician in charge
the injury was brought about by the blood pressure cuff, petitioner under the "captain of the ship" doctrine. This doctrine holds the
was still negligent in her duties as Nora’s attending physician. surgeon in charge of an operation liable for the negligence of his
assistants during the time when those assistants are under the
surgeon’s control.19 In this particular case, it can be logically
Simply put, the threshold issues for resolution are: (1) Are the inferred that petitioner, the senior consultant in charge during the
questioned additional exhibits admissible in evidence? (2) Is delivery of Nora’s baby, exercised control over the assistants
petitioner liable for the injury suffered by respondent Nora Go? assigned to both the use of the droplight and the taking of Nora’s
Thereafter, the inquiry is whether the appellate court committed blood pressure. Hence, the use of the droplight and the blood
grave abuse of discretion in its assailed issuances. pressure cuff is also within petitioner’s exclusive control.

As to the first issue, we agree with the Court of Appeals that said Third, the gaping wound on Nora’s left arm, by its very nature
exhibits are admissible in evidence. We note that the questioned and considering her condition, could only be caused by something
exhibits consist mostly of Nora’s medical records, which were external to her and outside her control as she was unconscious
produced by the hospital during trial pursuant to a while in hypovolemic shock. Hence, Nora could not, by any
subpoena duces tecum. Petitioner’s counsel admitted the existence stretch of the imagination, have contributed to her own injury.
of the same when they were formally offered for admission by the
trial court. In any case, given the particular circumstances of this
case, a ruling on the negligence of petitioner may be made based Petitioner’s defense that Nora’s wound was caused not by the
on the res ipsa loquitur doctrine even in the absence of such droplight but by the constant taking of her blood pressure, even if
additional exhibits. the latter was necessary given her condition, does not absolve her
from liability. As testified to by the medico-legal officer, Dr.
Arizala, Jr., the medical practice is to deflate the blood pressure
Petitioner’s contention that the medico-legal officer who cuff immediately after each use. Otherwise, the inflated band can
conducted Nora’s physical examination never saw her original cause injury to the patient similar to what could have happened in
injury before plastic surgery was performed is without basis and this case. Thus, if Nora’s wound was caused by the blood pressure
contradicted by the records. Records show that the medico-legal cuff, then the taking of Nora’s blood pressure must have been
officer conducted the physical examination on May 7, 1992, while done so negligently as to have inflicted a gaping wound on her
the skin grafting and the scar revision were performed on Nora on arm,20 for which petitioner cannot escape liability under the
May 22, 1992 and April 30, 1993, respectively. "captain of the ship" doctrine.

Coming now to the substantive matter, is petitioner liable for the Further, petitioner’s argument that the failed plastic surgery was
injury suffered by respondent Nora Go? not intended as a cosmetic procedure, but rather as a measure to
prevent complication does not help her case. It does not negate
negligence on her part.
Based on the foregoing, the presumption that petitioner was ILAO-ORETA vs. RONQUILLOGR
negligent in the exercise of her profession stands unrebutted. In G.R. No. 172406 October 17, 2007
this connection, the Civil Code provides:
Facts:
ART. 2176. Whoever by act or omission causes damage to
another, there being fault or negligence, is obliged to pay for the Despite several years of marriage, Spouses Ronquillo is still
damage done.… childless. They consulted Dr. Concepcion Ilao-Oreta, an
obstetrician gynecologist-consultant at St. Luke’s and Chief of the
ART. 2217. Moral damages include physical suffering, mental Reproductive Endocrinology and Infertility Section. Eva Marie
anguish, fright, serious anxiety, besmirched reputation, wounded agreed to undergo alaparoscopic
feelings, moral shock, social humiliation, and similar injury. procedure where a laparoscope would be inserted through her
Though incapable of pecuniary computation, moral damages may abdominal wall to get a direct view of her internal reproductive
be recovered if they are the proximate result of the defendant’s organ in order to determine the real cause of her infertility.
wrongful act or omission.
The procedure was scheduled on April 5, 1999 at 2 pm. Dr. Ilao-
Clearly, under the law, petitioner is obliged to pay Nora for moral Oreta did not arrive at the schedules time and no prior notice of its
damages suffered by the latter as a proximate result of petitioner’s cancellation was received by the Ronquillos. Dr. Ilao-Oreta was
negligence. on her honeymoon in Hawaii.

We note, however, that petitioner has served well as Nora’s She estimated that she would arrive in Manila in the early
obstetrician for her past three successful deliveries. This is the morning of April5. However, she failed to consider the time
first time petitioner is being held liable for damages due to difference between Hawaii and Philippines. Ronquillos filed a
negligence in the practice of her profession. The fact that complaint against Dr. Ilao-Oreta and St. Luke’s for breach of
petitioner promptly took care of Nora’s wound before infection professional and service contract and for damages.
and other complications set in is also indicative of petitioner’s
good intentions. We also take note of the fact that Nora was RTC: awarded Eva Marie only actual damages upon finding that
suffering from a critical condition when the injury happened, such the doctor’s failure to arrive on time was not intentional
that saving her life became petitioner’s elemental concern.
Nonetheless, it should be stressed that all these could not justify
negligence on the part of petitioner. CA: found Dr. Ilao-Oreta grossly negligent

Hence, considering the specific circumstances in the instant case, Issue:

we find no grave abuse of discretion in the assailed decision and
resolution of the Court of Appeals. Further, we rule that the Court WON Dr. Ilao-Oreta was grossly negligent in not arriving on time
of Appeals’ award of Two Hundred Thousand Pesos (₱200,000) for the scheduled laparoscopy
as moral damages in favor of respondents and against petitioner is
just and equitable.21
Held:

WHEREFORE, the petition is DENIED. The Decision dated

Records show that Dr- Ilao-Oreta left an admitting order with her
October 3, 2002 and Resolution dated November 19, 2003 of the
secretary for one of the spouses to pick up, apprised Eva Marie of
Court of Appeals in CA-G.R. CV No. 58184 are AFFIRMED.
the necessary preparations for the procedure and instructed the
hospital staff to perform pre-operative treatments before leaving
No pronouncement as to costs. for Hawaii. These acts reflect an earnest intention to perform the
procedure on the day and time scheduled.
SO ORDERED.
On realizing that she missed the scheduled procedure, Dr. Ilao
Oreta, upon arrival in Manila, immediately called the hospital and
asked the nurses about Eva Marie. She also wanted to call the
Ronquillos but she didn’t have their number at that time. So the
next morning, she went to

her office to get the Ronquillos contact number, which is written

on Eva Marie’s chart, and called them right away.

Noel admitted that indeed Dr. Ilao-Oreta called him up after she
arrived in Manila. Although Dr. Ilao-Oreta’s act is not grossly
negligent, she was negligent when she scheduled to perform
professional service at 2 pm without considering the time
difference between Philippines and Hawaii. Having travelled to
the US, where she obtained a fellowship in Reproductive
Endocrinology and Infertility, more than twice, she should have
been mindful of said difference.

The procedure to be conducted on Eva Marie was only elective in

nature thus the situation did not present any clear and apparent
harm or injury that even a careless person may perceive.
In its Answer,4 the St. Luke’s Medical Center contended that the
According to the SC, it bears noting that when Dr. Ilao-Oreta was spouses have no cause of action against it since it performed the
scheduling the date of her performance of the procedure, she had pre-operative procedures without delay, and any cause of action
just gotten married and was preparing for her honeymoon. It is they have would be against Dr. Ilao-Oreta.
common knowledge that excitement attends its preparations. Her
negligence could then be By Decision5 of March 9, 2001, Branch 84 of the Batangas RTC,
partly attributed to human frailty which rules out its finding that the failure of the doctor to arrive on time was not
characterization as gross. intentional, awarded Eva Marie only actual damages in the total
amount of ₱9,939 and costs of suit. It found no adequate proof
G.R. No. 172406               October 11, 2007 that Noel had been deprived of any job contract while attending to
his wife in the hospital.
CONCEPCION ILAO-ORETA, Petitioner, 
vs. On appeal by the spouses, the Court of Appeals, by Decision 6 of
SPOUSES EVA MARIE and BENEDICTO NOEL April 21, 2006, finding Dr. Ilao-Oreta grossly
RONQUILLO, Respondents. negligent,7 modified the trial court’s decision as follows:

DECISION WHEREFORE, the trial Court’s decision dated March 9, 2001 is

affirmed, subject to the modification that the amount of actual
damages, for which both defendants-appellees are jointly and
CARPIO MORALES, J.: severally liable to plaintiffs-appellants, is increased to
P16,069.40. Furthermore, defendant-appellee Dr. Ilao-Oreta is
Respondents, spouses Eva Marie Ronquillo (Eva Marie) and Noel also held liable to pay plaintiff-appellants the following:
Benedicto (Noel) Ronquillo (the Ronquillo spouses or the
spouses), had not been blessed with a child despite several years (a) P50,000.00 as moral damages;
of marriage. They thus consulted petitioner, Dr. Concepcion Ilao-
Oreta (Dr. Ilao-Oreta), an obstetrician-gynecologist-consultant at
the St. Luke’s Medical Center where she was, at the time material (b) P25,000.00 as exemplary damages; and
to the case, the chief of the Reproductive Endocrinology and
Infertility Section. (c) P20,000.00 as attorney’s fees.

Upon Dr. Ilao-Oreta’s advice, Eva Marie agreed to undergo a SO ORDERED.8 (Underscoring supplied)
laparoscopic procedure whereby a laparascope would be inserted
through the patient’s abdominal wall to get a direct view of her Hence, the present Petition for Review9 of Dr. Ilao-Oreta raising
internal reproductive organ in order to determine the real cause of the following arguments:
her infertility.
The court a quo erred in finding petitioner to have acted with
The procedure was scheduled on April 5, 1999 at 2:00 p.m., to be gross negligence and awarding moral damages to respondents. 10
performed by Dr. Ilao-Oreta. At around 7:00 a.m. of said date,
Eva Marie, accompanied by her husband Noel, checked in at the
St. Luke’s Medical Center and underwent pre-operative The court a quo erred in awarding Exemplary Damages to
procedures including the administration of intravenous fluid and respondents.11
enema.
The court a quo [erred] in awarding Attorney’s Fees to
Dr. Ilao-Oreta did not arrive at the scheduled time for the respondents.12
procedure, however, and no prior notice of its cancellation was
received. It turned out that the doctor was on a return flight from The court a quo erred in increasing the award of actual damages
Hawaii to, and arrived at 10:00 p.m. of April 5, 1999 in, Manila. in favor of respondents.13

On May 18, 1999, the Ronquillo spouses filed a "Gross negligence" implies a want or absence of or failure to
complaint1 against Dr. Ilao-Oreta and the St. Luke’s Medical exercise slight care or diligence, or the entire absence of care. It
Center for breach of professional and service contract and for evinces a thoughtless disregard of consequences without exerting
damages before the Regional Trial Court (RTC) of Batangas City. any effort to avoid them. 14 It is characterized by want of even
They prayed for the award of actual damages including alleged slight care, acting or omitting to act in a situation where there is a
loss of income of Noel while accompanying his wife to the duty to act, not inadvertently but willfully and intentionally with a
hospital, moral damages, exemplary damages, the costs of conscious indifference to consequences in so far as other persons
litigation, attorney’s fees, and other available reliefs and may be affected.15
remedies.2
The records show that before leaving for Hawaii, Dr. Ilao-Oreta
In her Answer,3 Dr. Ilao-Oreta gave her side of the case as left an admitting order with her secretary for one of the spouses to
follows: She went on a honeymoon to Hawaii and was scheduled pick up, apprised Eva Marie of the necessary preparations for the
to leave Hawaii at 3:00 p.m. of April 4, 1999 for Manila. Aware procedure, and instructed the hospital staff to perform pre-
that her trip from Hawaii to Manila would take about 12 hours, operative treatments.16 These acts of the doctor reflect an earnest
inclusive of a stop-over at the Narita Airport in Japan, she intention to perform the procedure on the day and time scheduled.
estimated that she would arrive in Manila in the early morning of
April 5, 1999. She thus believed in utmost good faith that she The records also show that on realizing that she missed the
would be back in Manila in time for the scheduled conduct of the scheduled procedure, Dr. Ilao-Oreta, upon arrival in Manila,
laparoscopic procedure. She failed to consider the time difference immediately sought to rectify the same, thus:
between Hawaii and the Philippines, however.
[ATTY SINJAN] Q: So, can you tell us the reason why you service at 2:00 p.m. on April 5, 1999 without considering the time
missed that operation? difference between the Philippines and Hawaii.

[DR. ILAO-ORETA] A: When I scheduled her for the surgery, I The doctor’s act did not, however, reflect gross negligence as
looked at my ticket and so I was to leave Hawaii on April 4 at defined above. Her argument that
around 4:00 o’clock in the afternoon, so I was computing 12
hours of travel including stop-over, then probably I would be in Although petitioner failed to take into consideration the time
Manila early morning of April 5, then I have so much time and I difference between the Philippines and Hawaii, the situation then
can easily do the case at 2:00 o’clock, you know it skipped my did not present any clear and apparent harm or injury that even a
mind the change in time. careless person may perceive. Unlike in situations where the
Supreme Court had found gross negligence to exist, petitioner
Q: So when you arrived at 10:00 [PM] in Manila, what did you could not have been conscious of any foreseeable danger that may
do? occur since she actually believed that she would make it to
the operation that was elective in nature, the only purpose of
A: I called immediately the hospital and I talked with the nurses, I which was to determine the real cause of infertility and not to treat
asked about the patient, Mrs. Ronquillo, and they told me that she and cure a life threatening disease. Thus, in merely fixing the date
has already left at around 7:00. of her appointment with respondent Eva Marie Ronquillo,
petitioner was not in the pursuit or performance of conduct which
any ordinary person may deem to probably and naturally result in
Q: And after calling the hospital, what happened? injury,19 (Underscoring in original)

A: I wanted to call the plaintiffs, but I didn’t have their number at thus persuades.
that time, so in the morning I went to my office early at 8:00 and
looked for her chart, because her telephone number was written in
the chart. So, I called them right away. It bears noting that when she was scheduling the date of her
performance of the procedure, Dr. Ilao-Oreta had just gotten
married and was preparing for her honeymoon, 20 and it is of
Q: Were you able to contact them? common human knowledge that excitement attends its
preparations. Her negligence could then be partly attributed to
A: I was able to reach Mr. Ronquillo. human frailty which rules out its characterization as gross.

Q: In the course of your conversation, what did you tell Mr. The doctor’s negligence not being gross, the spouses are not
Ronquillo? entitled to recover moral damages.

A: I apologized to him, I said I was sorry about the time that I Neither are the spouses entitled to recover exemplary damages in
missed the surgery, and I told him that I can do the case right that the absence of a showing that Dr. Ilao-Oreta acted in a wanton,
same day without Mrs. Ronquillo having to undergo another fraudulent, reckless, oppressive or malevolent manner, 21 nor to
[b]arium enema. award of attorney’s fees as, contrary to the finding of the Court of
Appeals that the spouses "were compelled to litigate and incur
Q: What else did you tell him, if any? expenses to protect their interest," 22 the records show that they did
not exert enough efforts to settle the matter before going to court.
Eva Marie herself testified:
A: I asked him whether I can talk with Mrs. Ronquillo because I
wanted to apologize to her personally.
ATTY. SINJIAN:

Q: And what did he say?

Q: Isn’t it true that before instituting this present case,
you did not make any demand on Dr. Ilao-Oreta
A: I could hear on the background that Mrs. Ronquillo was regarding the claims which you have allegedly incurred,
shouting angrily that she didn’t want to talk to me, and that she because of the failed laparoscopic surgery operation?
didn’t want re-scheduling of the surgery . . .
A [EVA MARIE]: I will tell the truth. Dr. Augusto
ATTY LONTOK: May we move, your Honor, for the striking out Reyes of St. Luke’s . . .
of the answer, this is purely hearsay.
Q: But did you demand?
COURT: Remain on the record.
A: No, I did not demand because…
WITNESS [DR. ILAO-ORETA]: . . . and then Mr. Ronquillo told
me "I’m sorry, Dra., we cannot re-schedule the
surgery."17 (Underscoring supplied) ATTY. SINJIAN: That will be all, your Honor.

Noel admitted that indeed Dr. Ilao-Oreta called him up after she ATTY. LONTOK: The witness is still explaining.
arrived in Manila as related by her.18
WITNESS: I’m explaining first. Dr. Augusto Reyes told
The evidence then shows that Dr. Ilao-Oreta, who had traveled me that he will hold the meeting for me and Dr. Oreta to
more than twice to the United States where she obtained a settle things and reimburse all the money that I spent
fellowship in Reproductive Endocrinology and Infertility was from the hospital, and he even suggested Dr. Oreta to
indeed negligent when she scheduled to perform professional personally talk to me.
ATTY. SINJIAN: The documented claim for hospital and medical expenses of the
spouses is detailed in the Statement of Account issued by the
Q: So it was to Dr. Augusto Reyes that you talked? hospital, the pertinent entries of which read:

A: Yes. xxxx

Q: But you did not demand anything or write to Dr. GROSS HOSPITAL CHARGES 2,416.50
Oreta?
4/5/1999 1699460 DEPOSIT–OFFICIAL
A: No.
RECEIPT (5,000.00)
Q: Before instituting this case? (5,000.00)

A: No.23 (Underscoring supplied)

Finally, Dr. Ilao-Oreta’s prayer for the reduction of actual As extrapolated from the above-quoted entries in the Statement of
damages is well-taken. Article 2201 of the Civil Code provides: Account, ₱2,288.70 (the gross hospital charges of ₱2,416.50 less
the unused medicine in the amount of ₱127.80) was debited from
the ₱5,000 deposit31 to thus leave a balance of the deposit in the
In contracts and quasi-contracts, the damages for which the
amount of ₱2,711.30, which the trial court erroneously
obligor who acted in good faith is liable shall be those which are
denominated as "confinement fee." The remaining balance of
the natural and probable consequences of the breach of the
₱2,711.30 was the amount refundable to the spouses.
obligation, and which the parties have foreseen or could have
reasonably foreseen at the time the obligation was constituted.
Following Eastern Shipping Lines, Inc. v. Court of Appeals,32 this
Court awards interest on the actual damages to be paid by Dr.
In fixing the amount of actual damages, the Court of Appeals and
Ilao-Oreta at the rate of 6% per annum from the time of the filing
the trial court included expenses which the spouses
of the complaint on May 18, 1999, and at 12% per annum from
incurred prior to April 5, 1999 when the breach of contract
the finality of this judgment until its satisfaction.
complained of occurred.24 The Court of Appeals also included the
alleged ₱300 spent on fuel consumption from the spouses’
residence at San Pascual, Batangas to the St. Luke’s Medical WHEREFORE, the petition is GRANTED. The decision
Center in Quezon City and the alleged ₱500 spent on food in the appealed from is MODIFIED in that
hospital canteen, both of which are unsubstantiated by
independent or competent proof.25 The only piece of documentary 1) the award to respondents-spouses Noel and Eva
evidence supporting the food and fuel expenses is an unsigned Marie Ronquillo of actual damages is REDUCED to
listing.26 As the fuel and food expenses are not adequately ₱2,288.70, to bear interest at a rate of 6% per
substantiated, they cannot be included in the computation of the annum from the time of the filing of the complaint on
amount of actual damages. So Premiere Development Bank v. May 18, 1999 and, upon finality of this judgment, at the
Court of Appeals27 instructs: rate of 12% per annum until satisfaction; and

In the instant case, the actual damages were proven through the 2) The award of moral and exemplary damages and
sole testimony of Themistocles Ruguero, the vice president for attorney’s fees is DELETED.
administration of Panacor. In his testimony, the witness affirmed
that Panacor incurred losses, specifically, in terms of training and
SO ORDERED.
seminars, leasehold acquisition, procurement of vehicles and
office equipment without, however, adducing receipts to
substantiate the same. The documentary evidence marked as
Exhibit "W," which was an ordinary private writing allegedly
itemizing the capital expenditures and losses from the failed
operation of Panacor, was not testified to by any witness to
ascertain the veracity of its content. Although the lower court
fixed the sum of P4,520,000.00 as the total expenditures incurred
by Panacor, it failed to show how and in what manner the same
were substantiated by the claimant with reasonable certainty.
Hence, the claim for actual damages should be received with
extreme caution since it is only based on bare assertion without
support from independent evidence. Premiere’s failure to prove
actual expenditure consequently conduces to a failure of its claim.
In determining actual damages, the court cannot rely on mere
assertions, speculations, conjectures or guesswork but must
depend on competent proof and on the best evidence obtainable
regarding the actual amount of loss.28(Underscoring supplied)

The list of expenses cannot replace receipts when they should

have been issued as a matter of course in business
transactions29 as in the case of purchase of gasoline and of
food.1âwphi1
SPOUSES FREDELICTO FLORES (deceased) and
FELICISIMA FLORES, petitioners, vs. SPOUSES These findings lead us to the conclusion that the decision to
DOMINADOR PINEDA and VIRGINIA SACLOLO, and proceed with the D&C operation, notwithstanding Teresita's
FLORENCIO, CANDIDA, MARTA, GODOFREDO, hyperglycemia and without adequately preparing her for the
BALTAZAR and LUCENA, all surnamed PINEDA, as procedure, was contrary to the standards observed by the
heirs of the deceased TERESITA S. PINEDA, and medical profession. Deviation from this standard amounted to
UNITED DOCTORS MEDICAL CENTER, INC., a breach of duty which resulted in the patient's death. Due
respondents. to this negligent conduct, liability must attach to the petitioner
spouses.
Facts:
Teresita was a 51-year old unmarried woman living in Sto. G.R. No. 158996             November 14, 2008
Domingo, Nueva Ecija. She consulted on April 17, 1987 her
townmate, Dr. Fredelicto Flores, regarding her medical
condition. She complained of general body weakness, loss of SPOUSES FREDELICTO FLORES (deceased) and
appetite, frequent urination and thirst, and on-and-off vaginal FELICISIMA FLORES, petitioners, 
bleeding. He advised her to return the following week or to go vs.
to the United Doctors Medical Center (UDMC) in Quezon City SPOUSES DOMINADOR PINEDA and VIRGINIA
for a general check-up. As for her other symptoms, he SACLOLO, and FLORENCIO, CANDIDA, MARTA,
suspected that Teresita might be suffering from diabetes and GODOFREDO, BALTAZAR and LUCENA, all surnamed
told her to continue her medications. PINEDA, as heirs of the deceased TERESITA S. PINEDA,
and UNITED DOCTORS MEDICAL CENTER,
INC., respondents.
They went to United Doctors Medical Center (UDMC) in
Quezon City. Teresita was taken to the operating room. It was
only then that she met Dr. Felicisima, an obstetrician and DECISION
gynecologist. Upon Teresita's complete laboratory examination
results came only on that day . Teresita's urinalysis showed a BRION, J.:
three plus sign (+++) indicating that the sugar in her urine was
very high. She was then placed under the care of Dr. Amado This petition involves a medical negligence case that was elevated
Jorge, an internist. Teresita's condition had worsened. She to this Court through an appeal by certiorari under Rule 45 of the
experienced difficulty in breathing and was rushed to the Rules of Court. The petition assails the Decision 1 of the Court of
intensive care unit. Further tests confirmed that she was Appeals (CA) in CA G.R. CV No. 63234, which affirmed with
suffering from Diabetes Mellitus Type II. Insulin was modification the Decision2 of the Regional Trial Court (RTC) of
administered on the patient, but the medication might have Nueva Ecija, Branch 37 in Civil Case No. SD-1233. The
arrived too late. Due to complications induced by diabetes, dispositive portion of the assailed CA decision states:
Teresita died. Believing that Teresita's death resulted from the
negligent handling of her medical needs, her family
(respondents) WHEREFORE, premises considered, the assailed
Decision of the Regional Trial Court of Baloc, Sto.
Domingo, Nueva Ecija, Branch 37 is hereby
instituted an action for damages against Dr. Fredelicto Flores AFFIRMED but with modifications as follows:
and Dr. Felicisima Flores (collectively referred to as the
petitioner spouses) before the RTC of Nueva Ecija. 1) Ordering defendant-appellants Dr. and Dra.
Fredelicto A. Flores and the United Doctors
Issue: Medical Center, Inc. to jointly and severally
Whether the said doctors can be held liable for negligence? pay the plaintiff-appellees - heirs of Teresita
Pineda, namely, Spouses Dominador Pineda
Held: and Virginia Saclolo and Florencio, Candida,
A medical negligence case is a type of claim to redress a Marta, Godofredo, Baltazar and Lucena, all
wrong committed by a medical professional, that has caused surnamed Pineda, the sum of P400,000.00 by
bodily harm to or the death of a patient. There are four elements way of moral damages;
involved in a medical negligence case, namely: duty, breach,
injury, and proximate causation.
2) Ordering the above-named defendant-
appellants to jointly and severally pay the
We clarify that Dr. Fredelicto's negligence is not solely the above-named plaintiff-appellees the sum
act of ordering an "on call" D&C operation when he was of P100,000.00 by way of exemplary
mainly ananaesthesiologist who had made a very cursory damages;
examination of the patient's vaginal bleeding complaint. Rather,
it was his failure from the very start to identify and confirm,
3) Ordering the above-named defendant-
despite the patient's complaints and his own suspicions, that
appellants to jointly and severally pay the
diabetes was a risk factor that should be guarded against, and his
above-named plaintiff-appellees the sum
participation in the imprudent decision to proceed with the D&C
of P36,000.00 by way of actual and
operation despite his early suspicion and the confirmatory early
compensatory damages; and
laboratory results.

If Dr. Fredelicto believed himself to be incompetent to treat 4) Deleting the award of attorney's fees and
the diabetes, not being an internist or a diabetologist (for costs of suit.
which reason he referred Teresita to Dr. Jorge), he should have
likewise refrained from making a decision to proceed with the SO ORDERED.
D&C operation since he was niether an obstetrician nor a
gynecologist.
While this case essentially involves questions of facts, we opted By April 30, 1987, Teresita's condition had worsened. She
for the requested review in light of questions we have on the experienced difficulty in breathing and was rushed to the
findings of negligence below, on the awarded damages and costs, intensive care unit. Further tests confirmed that she was suffering
and on the importance of this type of ruling on medical practice. 3 from Diabetes Mellitus Type II.10 Insulin was administered on
the patient, but the medication might have arrived too late. Due to
BACKGROUND FACTS complications induced by diabetes, Teresita died in the morning
of May 6, 1987.11
Teresita Pineda (Teresita) was a 51-year old unmarried woman
living in Sto. Domingo, Nueva Ecija. She consulted on April 17, Believing that Teresita's death resulted from the negligent
1987 her townmate, Dr. Fredelicto Flores, regarding her medical handling of her medical needs, her family (respondents) instituted
condition. She complained of general body weakness, loss of an action for damages against Dr. Fredelicto Flores and Dr.
appetite, frequent urination and thirst, and on-and-off vaginal Felicisima Flores (collectively referred to as the petitioner
bleeding. Dr. Fredelicto initially interviewed the patient and asked spouses) before the RTC of Nueva Ecija.
for the history of her monthly period to analyze the probable
cause of the vaginal bleeding. He advised her to return the The RTC ruled in favor of Teresita's family and awarded actual,
following week or to go to the United Doctors Medical Center moral, and exemplary damages, plus attorney's fees and
(UDMC) in Quezon City for a general check-up. As for her other costs.12 The CA affirmed the judgment, but modified the amount
symptoms, he suspected that Teresita might be suffering from of damages awarded and deleted the award for attorney's fees and
diabetes and told her to continue her medications. 4 costs of suit.13

Teresita did not return the next week as advised. However, when Through this petition for review on certiorari, the petitioner
her condition persisted, she went to further consult Dr. Flores at spouses -Dr. Fredelicto (now deceased) and Dr. Felicisima Flores
his UDMC clinic on April 28, 1987, travelling for at least two - allege that the RTC and CA committed a reversible error in
hours from Nueva Ecija to Quezon City with her sister, Lucena finding them liable through negligence for the death of Teresita
Pineda. They arrived at UDMC at around 11:15 a.m.. Lucena later Pineda.
testified that her sister was then so weak that she had to lie down
on the couch of the clinic while they waited for the doctor. When ASSIGNMENT OF ERRORS
Dr. Fredelicto arrived, he did a routine check-up and ordered
Teresita's admission to the hospital. In the admission slip, he
directed the hospital staff to prepare the patient for an "on The petitioner spouses contend that they exercised due care and
call" D&C5 operation to be performed by his wife, Dr. Felicisima prudence in the performance of their duties as medical
Flores (Dr. Felicisima). Teresita was brought to her hospital room professionals. They had attended to the patient to the best of their
at around 12 noon; the hospital staff forthwith took her blood and abilities and undertook the management of her case based on her
urine samples for the laboratory tests 6 which Dr. Fredelicto complaint of an on-and-off vaginal bleeding. In addition, they
ordered. claim that nothing on record shows that the death of Teresita
could have been averted had they employed means other than
what they had adopted in the ministration of the patient.
At 2:40 p.m. of that same day, Teresita was taken to the operating
room. It was only then that she met Dr. Felicisima, an obstetrician
and gynecologist. The two doctors - Dr. Felicisima and Dr. THE COURT'S RULING
Fredelicto, conferred on the patient's medical condition, while the
resident physician and the medical intern gave Dr. Felicisima their We do not find the petition meritorious.
own briefings. She also interviewed and conducted an internal
vaginal examination of the patient which lasted for about 15 The respondents' claim for damages is predicated on their
minutes. Dr. Felicisima thereafter called up the laboratory for the allegation that the decision of the petitioner spouses to proceed
results of the tests. At that time, only the results for the blood with the D&C operation, notwithstanding Teresita's condition and
sugar (BS), uric acid determination, cholesterol determination, and the laboratory test results, amounted to negligence. On the other
complete blood count (CBC) were available. Teresita's BS count hand, the petitioner spouses contend that a D&C operation is the
was 10.67mmol/l7 and her CBC was 109g/l.8 proper and accepted procedure to address vaginal bleeding - the
medical problem presented to them. Given that the patient died
Based on these preparations, Dr. Felicisima proceeded with the after the D&C, the core issue is whether the decision to proceed
D&C operation with Dr. Fredelicto administering the general with the D&C operation was an honest mistake of judgment or
anesthesia. The D&C operation lasted for about 10 to 15 minutes. one amounting to negligence.
By 3:40 p.m., Teresita was wheeled back to her room.
Elements of a Medical Negligence Case
A day after the operation (or on April 29, 1987), Teresita was
subjected to an ultrasound examination as a confirmatory A medical negligence case is a type of claim to redress a wrong
procedure. The results showed that she had an enlarged uterus committed by a medical professional, that has caused bodily harm
and myoma uteri.9 Dr. Felicisima, however, advised Teresita that to or the death of a patient. There are four elements involved in a
she could spend her recovery period at home. Still feeling weak, medical negligence case, namely: duty, breach, injury, and
Teresita opted for hospital confinement. proximate causation.14

Teresita's complete laboratory examination results came only on Duty refers to the standard of behavior which imposes restrictions
that day (April 29, 1987). Teresita's urinalysis showed a three plus on one's conduct.15 The standard in turn refers to the amount of
sign (+++) indicating that the sugar in her urine was very high. competence associated with the proper discharge of the
She was then placed under the care of Dr. Amado Jorge, an profession. A physician is expected to use at least the same level
internist. of care that any other reasonably competent doctor would use
under the same circumstances. Breach of duty occurs when the
physician fails to comply with these professional standards. If
injury results to the patient as a result of this breach, the physician The petitioner spouses countered that, at the time of the operation,
is answerable for negligence.16 there was nothing to indicate that Teresita was afflicted with
diabetes: a blood sugar level of 10.67mmol/l did not necessarily
As in any civil action, the burden to prove the existence of the mean that she was a diabetic considering that this was random
necessary elements rests with the plaintiff. 17 To successfully blood sugar;23 there were other factors that might have caused
pursue a claim, the plaintiff must prove by preponderance of Teresita's blood sugar to rise such as the taking of blood samples
evidence that, one, the physician either failed to do something during lunchtime and while patient was being given intra-venous
which a reasonably prudent health care provider would have dextrose.24 Furthermore, they claim that their principal concern
done, or that he did something that a reasonably prudent was to determine the cause of and to stop the vaginal bleeding.
provider would not have done; and two, the failure or action
caused injury to the patient.18 Expert testimony is therefore The petitioner spouses' contentions, in our view, miss several
essential since the factual issue of whether a physician or surgeon points. First, as early as April 17, 1987, Teresita was already
has exercised the requisite degree of skill and care in the suspected to be suffering from diabetes. 25 This suspicion again
treatment of his patient is generally a matter of expert opinion. 19 arose right before the D&C operation on April 28, 1987 when the
laboratory result revealed Teresita's increased blood sugar
Standard of Care and Breach of Duty level.26 Unfortunately, the petitioner spouses did not wait for the
full medical laboratory results before proceeding with the D&C, a
fact that was never considered in the courts below. Second, the
D&C is the classic gynecologic procedure for the evaluation and petitioner spouses were duly advised that the patient was
possible therapeutic treatment for abnormal vaginal experiencing general body weakness, loss of appetite, frequent
bleeding.20 That this is the recognized procedure is confirmed by urination, and thirst - all of which are classic symptoms of
Drs. Salvador Nieto (Dr. Nieto) and Joselito Mercado (Dr. diabetes.27 When a patient exhibits symptoms typical of a
Mercado), the expert witnesses presented by the respondents: particular disease, these symptoms should, at the very least, alert
the physician of the possibility that the patient may be afflicted
DR. NIETO: [W]hat I know among obstetricians, if with the suspected disease:
there is bleeding, they perform what we call D&C for
diagnostic purposes. Expert testimony for the plaintiff showed that] tests should have been ordered immediately on
admission to the hospital in view of the symptoms presented, and that failure to recognize the

existence of diabetes constitutes negligence.28

xxx xxx xxx

Q: So are you trying to tell the Court that D&C can be a Third, the petitioner spouses cannot claim that their principal
diagnostic treatment? concern was the vaginal bleeding and should not therefore be held
accountable for complications coming from other sources. This is
A: Yes, sir. Any doctor knows this.21 a very narrow and self-serving view that even reflects on their
competence.

Dr. Mercado, however, objected with respect to the time the D&C
operation should have been conducted in Teresita's case. He Taken together, we find that reasonable prudence would have
opined that given the blood sugar level of Teresita, her diabetic shown that diabetes and its complications were foreseeable harm
condition should have been addressed first: that should have been taken into consideration by the petitioner
spouses. If a patient suffers from some disability that increases
the magnitude of risk to him, that disability must be taken
Q: Why do you consider the time of performance of the into account so long as it is or should have been known to the
D&C not appropriate? physician.29 And when the patient is exposed to an increased risk,
it is incumbent upon the physician to take commensurate and
A: Because I have read the record and I have seen the adequate precautions.
urinalysis, [there is] spillage in the urine, and blood
sugar was 10.67 Taking into account Teresita's high blood sugar, 30 Dr. Mendoza
opined that the attending physician should have postponed the
Q: What is the significance of the spillage in the urine? D&C operation in order to conduct a confirmatory test to make a
conclusive diagnosis of diabetes and to refer the case to an
internist or diabetologist. This was corroborated by Dr. Delfin
A: It is a sign that the blood sugar is very high.
Tan (Dr. Tan), an obstetrician and gynecologist, who stated that
the patient's diabetes should have been managed by an
Q: Does it indicate sickness? internist prior to, during, and after the operation.31

A: 80 to 95% it means diabetes mellitus. The blood Apart from bleeding as a complication of pregnancy, vaginal
sugar was 10.67. bleeding is only rarely so heavy and life-threatening that urgent
first-aid measures are required.32 Indeed, the expert witnesses
xxx xxx xxx declared that a D&C operation on a hyperglycemic patient may be
justified only when it is an emergency case - when there is
profuse vaginal bleeding. In this case, we choose not to rely on
COURT: In other words, the operation conducted on the
the assertions of the petitioner spouses that there was profuse
patient, your opinion, that it is inappropriate?
bleeding, not only because the statements were self-serving, but
also because the petitioner spouses were inconsistent in their
A: The timing of [when] the D&C [was] done, based on testimonies. Dr. Fredelicto testified earlier that on April 28, he
the record, in my personal opinion, that D&C should be personally saw the bleeding,33 but later on said that he did not see
postponed a day or two.22 it and relied only on Teresita's statement that she was
bleeding.34 He went on to state that he scheduled the D&C
operation without conducting any physical examination on the dextrose and potassium infusion. Insulin xxx promotes
patient. glucose uptake by the muscle and fat cells while
decreasing glucose production by the liver xxx. The net
The likely story is that although Teresita experienced vaginal effect is to lower blood glucose levels.44
bleeding on April 28, it was not sufficiently profuse to necessitate
an immediate emergency D&C operation. Dr. Tan 35 and Dr. The prudent move is to address the patient's hyperglycemic state
Mendoza36 both testified that the medical records of Teresita immediately and promptly before any other procedure is
failed to indicate that there was profuse vaginal bleeding. The undertaken. In this case, there was no evidence that insulin was
claim that there was profuse vaginal bleeding although this was administered on Teresita prior to or during the D&C operation.
not reflected in the medical records strikes us as odd since the Insulin was only administered two days after the operation.
main complaint is vaginal bleeding. A medical record is the only
document that maintains a long-term transcription of patient care As Dr. Tan testified, the patient's hyperglycemic condition should
and as such, its maintenance is considered a priority in hospital have been managed not only before and during the operation, but
practice. Optimal record-keeping includes all patient inter-actions. also immediately after. Despite the possibility that Teresita was
The records should always be clear, objective, and up-to- afflicted with diabetes, the possibility was casually ignored even
date.37 Thus, a medical record that does not indicate profuse in the post-operative evaluation of the patient; the concern, as the
medical bleeding speaks loudly and clearly of what it does not petitioner spouses expressly admitted, was limited to the
contain. complaint of vaginal bleeding. Interestingly, while the ultrasound
test confirmed that Teresita had a myoma in her uterus, she was
That the D&C operation was conducted principally to diagnose advised that she could be discharged a day after the operation and
the cause of the vaginal bleeding further leads us to conclude that that her recovery could take place at home. This advice implied
it was merely an elective procedure, not an emergency case. In an that a day after the operation and even after the complete
elective procedure, the physician must conduct a thorough pre- laboratory results were submitted, the petitioner spouses still did
operative evaluation of the patient in order to adequately prepare not recognize any post-operative concern that would require the
her for the operation and minimize possible risks and monitoring of Teresita's condition in the hospital.
complications. The internist is responsible for generating a
comprehensive evaluation of all medical problems during the pre- The above facts, point only to one conclusion - that the petitioner
operative evaluation.38 spouses failed, as medical professionals, to comply with their duty
to observe the standard of care to be given to
The aim of pre-operative evaluation is not to screen hyperglycemic/diabetic patients undergoing surgery. Whether this
broadly for undiagnosed disease, but rather to identify breach of duty was the proximate cause of Teresita's death is a
and quantify comorbidity that may impact on the matter we shall next determine.
operative outcome. This evaluation is driven by findings
on history and physical examination suggestive of organ Injury and Causation
system dysfunction…The goal is to uncover problem
areas that may require further investigation or be
amenable to preoperative optimization. As previously mentioned, the critical and clinching factor in a
medical negligence case is proof of the causal
connection between the negligence which the evidence
If the preoperative evaluation uncovers significant established and the plaintiff's injuries; 45 the plaintiff must plead
comorbidity or evidence of poor control of an and prove not only that he had been injured and defendant has
underlying disease process, consultation with an been at fault, but also that the defendant's fault caused the injury.
internist or medical specialist may be required to A verdict in a malpractice action cannot be based on speculation
facilitate the work-up and direct management. In this or conjecture. Causation must be proven within a reasonable
process, communication between the surgeons and the medical probability based upon competent expert testimony. 46
consultants is essential to define realistic goals for this
optimization process and to expedite surgical
management.39 [Emphasis supplied.] The respondents contend that unnecessarily subjecting Teresita to
a D&C operation without adequately preparing her, aggravated
her hyperglycemic state and caused her untimely demise. The
Significantly, the evidence strongly suggests that the pre- death certificate of Teresita lists down the following causes of
operative evaluation was less than complete as the laboratory death:
results were fully reported only on the day following the D&C
operation. Dr. Felicisima only secured a telephone report of the
preliminary laboratory result prior to the D&C. This preliminary Immediate cause: Cardiorespiratory arrest
report did not include the 3+ status of sugar in the patient's
urine40 - a result highly confirmatory of diabetes.
Antecedent cause: Septicemic shock, ketoacidocis
Because the D&C was merely an elective procedure, the patient's
uncontrolled hyperglycemia presented a far greater risk than her Underlying cause: Diabetes Mellitus II
on-and-off vaginal bleeding. The presence of hyperglycemia in a
surgical patient is associated with poor clinical outcomes, and Other significant conditions
aggressive glycemic control positively impacts on morbidity and
mortality.41 Elective surgery in people with uncontrolled contributing to death: Renal Failure - Acute47
diabetes should preferably be scheduled after acceptable glycemic
control has been achieved. 42 According to Dr. Mercado, this is
done by administering insulin on the patient.43
Stress, whether physical or emotional, is a factor that can
aggravate diabetes; a D&C operation is a form of physical stress.
The management approach in  this kind of patients Dr. Mendoza explained how surgical stress can aggravate the
always includes insulin therapy in combination with patient's hyperglycemia: when stress occurs, the diabetic's body,
especially the autonomic system, reacts by secreting hormones These findings lead us to the conclusion that the decision to
which are counter-regulatory; she can have prolonged proceed with the D&C operation, notwithstanding Teresita's
hyperglycemia which, if unchecked, could lead to hyperglycemia and without adequately preparing her for the
death.48 Medical literature further explains that if the blood sugar procedure, was contrary to the standards observed by the medical
has become very high, the patient becomes comatose (diabetic profession. Deviation from this standard amounted to a breach of
coma). When this happens over several days, the body uses its duty which resulted in the patient's death. Due to this negligent
own fat to produce energy, and the result is high levels of waste conduct, liability must attach to the petitioner spouses.
products (called ketones) in the blood and urine (called diabetic
ketoacidiosis, a medical emergency with a significant Liability of the Hospital
mortality).49 This was apparently what happened in Teresita's
case; in fact, after she had been referred to the internist Dr. Jorge,
laboratory test showed that her blood sugar level shot up to In the proceedings below, UDMC was the spouses Flores' co-
14.0mmol/l, way above the normal blood sugar range. Thus, defendant. The RTC found the hospital jointly and severally liable
between the D&C and death was the diabetic complication that with the petitioner spouses, which decision the CA affirmed. In a
could have been prevented with the observance of standard Resolution dated August 28, 2006, this Court however denied
medical precautions. The D&C operation and Teresita's death due UDMC's petition for review on certiorari. Since UDMC's appeal
to aggravated diabetic condition is therefore sufficiently has been denied and they are not parties to this case, we find it
established. unnecessary to delve on the matter. Consequently, the RTC's
decision, as affirmed by the CA, stands.
The trial court and the appellate court pinned the liability for
Teresita's death on both the petitioner spouses and this Court finds Award of Damages
no reason to rule otherwise. However, we clarify that Dr.
Fredelicto's negligence is not solely the act of ordering an "on Both the trial and the appellate court awarded actual damages as
call" D&C operation when he was mainly compensation for the pecuniary loss the respondents suffered. The
an anaesthesiologist who had made a very cursory examination loss was presented in terms of the hospital bills and expenses the
of the patient's vaginal bleeding complaint. Rather, it was his respondents incurred on account of Teresita's confinement and
failure from the very start to identify and confirm, despite the death. The settled rule is that a plaintiff is entitled to be
patient's complaints and his own suspicions, that diabetes was a compensated for proven pecuniary loss. 52This proof the
risk factor that should be guarded against, and his participation in respondents successfully presented. Thus, we affirm the award
the imprudent decision to proceed with the D&C operation of actual damages of P36,000.00 representing the hospital
despite his early suspicion and the confirmatory early laboratory expenses the patient incurred.
results. The latter point comes out clearly from the following
exchange during the trial: In addition to the award for actual damages, the respondent heirs
of Teresita are likewise entitled to P50,000.00 as death
Q: On what aspect did you and your wife consult [with] indemnity pursuant to Article 2206 of the Civil Code, which
each other? states that "the amount of damages for death caused by a
xxx quasi-delict shall be at least three thousand pesos, 53 even
A: We discussed on the finding of the laboratory though there may have been mitigating circumstances xxx." This
[results] because the hemoglobin was below normal, the is a question of law that the CA missed in its decision and which
blood sugar was elevated, so that we have to evaluate we now decide in the respondents' favor.
these laboratory results - what it means.
The same article allows the recovery of moral damages in case of
Q: So it was you and your wife who made the death caused by a quasi-delict and enumerates the spouse,
evaluation when it was phoned in? legitimate or illegitimate ascendants or descendants as the persons
entitled thereto. Moral damages are designed to compensate the
claimant for the injury suffered, that is, for the mental anguish,
A: Yes, sir. serious anxiety, wounded feelings which the respondents herein
must have surely felt with the unexpected loss of their daughter.
Q: Did your wife, before performing D&C ask your We affirm the appellate court's award of P400,000.00 by way
opinion whether or not she can proceed? of moral damages to the respondents.

A: Yes, anyway, she asked me whether we can do D&C We similarly affirm the grant of exemplary damages. Exemplary
based on my experience. damages are imposed by way of example or correction for the
public good.54 Because of the petitioner spouses' negligence in
Q: And your answer was in the positive subjecting Teresita to an operation without first recognizing and
notwithstanding the elevation of blood sugar? addressing her diabetic condition, the appellate court
awarded exemplary damages to the respondents in the amount
of P100,000.00. Public policy requires such imposition to
A: Yes, sir, it was both our disposition to do the suppress the wanton acts of an offender. 55 We therefore affirm the
D&C. [Emphasis supplied.]50 CA's award as an example to the medical profession and to stress
that the public good requires stricter measures to avoid the
If Dr. Fredelicto believed himself to be incompetent to treat the repetition of the type of medical malpractice that happened in this
diabetes, not being an internist or a diabetologist (for which case.
reason he referred Teresita to Dr. Jorge), 51 he should have
likewise refrained from making a decision to proceed with the With the award of exemplary damages, the grant of attorney's fees
D&C operation since he was niether an obstetrician nor a is legally in order.56 We therefore reverse the CA decision
gynecologist. deleting these awards, and grant the respondents the amount
of P100,000.00 as attorney's fees taking into consideration the
legal route this case has taken.
WHEREFORE, we AFFIRM the Decision of the CA dated June
20, 2003 in CA G.R. CV No. 63234 finding petitioner spouses
liable for negligent medical practice. We likewise AFFIRM the
awards of actual and compensatory damages of P36,000.00; moral
damages of P400,000.00; and exemplary damages
of P100,000.00.

We MODIFY the CA Decision by additionally granting an award

of P50,000.00 as death indemnity and by reversing the deletion of
the award of attorney's fees and costs and restoring the award
of P100,000.00 as attorney's fees. Costs of litigation are adjudged
against petitioner spouses.

To summarize, the following awards shall be paid to the family of

the late Teresita Pineda:

1. The sum of P36,000.00 by way of actual and compensatory

damages;

2. The sum of P50,000.00 by way of death indemnity;

3. The sum of P400,000.00 by way of moral damages;

4. The sum of P100,000.00 by way of exemplary damages;

5. The sum of P100,000.00 by way of attorney's fees; and

6. Costs.

SO ORDERED.
FE CAYAO-LASAM, PETITIONER, VS. SPOUSES CLARO interrupted. Had she returned, the respondent could have
AND EDITHA RAMOLETE, RESPONDENTS. examined her thoroughly.

Facts: No negligence can be attributed to the petitioner, the

immediate cause of the accident resulting in Editha's injury
On July 28, 1994, respondent, three months pregnant Editha was her own omission when she did not return for a follow-up
Ramolete (Editha) was brought to the Lorma Medical Center check up, in defiance of petitioner's orders. The immediate cause
(LMC) in San Fernando, La Union due to vaginal bleeding. of Editha's injury was her own act; thus, she cannot recover
Upon advice of petitioner relayed via telephone, Editha was damages from the injury.
admitted to the LMC on the same day. A pelvic sonogram
was then conducted on Editha revealing the fetus' weak cardiac
pulsation. The Decision of the Board of Medicine dated March 4, 1999
exonerating petitioner is AFFIRMED.

The following day, Editha's repeat pelvic sonogram

G.R. No. 159132 December 18, 2008

FE CAYAO-LASAM, petitioner,
showed that aside from the fetus' weak cardiac pulsation, no vs.
fetal movement was also appreciated. Due to persistent and SPOUSES CLARO and EDITHA RAMOLETE,
profuse vaginal bleeding, petitioner advised Editha to undergo a respondents.*
Dilatation and Curettage Procedure (D&C) or "raspa."
DECISION
Petitioner performed the D&C procedure. Editha was discharged
from the hospital the following day. Editha was once again AUSTRIA-MARTINEZ, J.:
brought at the LMC, as she was suffering from vomiting
and severe abdominal pains. Editha was attended by Dr. Before the Court is a Petition for Review on Certiorari under Rule
45 of the Rules of Court filed by Dr. Fe Cayao-Lasam (petitioner)
Beatriz de la Cruz, Dr. Victor B. Mayo and Dr. Juan V.
Komiya. Dr. Mayo allegedly informed Editha that there was seeking to annul the Decision1 dated July 4, 2003 of the Court of
Appeals (CA) in CA-G.R. SP No. 62206.
a dead fetus in the latter's womb. After, Editha underwent
laparotomy, she was found to have a massive intra-abdominal
The antecedent facts:
hemorrhage and a ruptured uterus. Thus, Editha had to
undergo a procedure for hysterectomy and as a result, she
On July 28, 1994, respondent, three months pregnant Editha
has no more chance to bear a child. Editha and her husband
Claro Ramolete (respondents) filed a Complaint for Gross Ramolete (Editha) was brought to the Lorma Medical Center
(LMC) in San Fernando, La Union due to vaginal bleeding. Upon
Negligence and Malpractice against petitioner before the
Professional Regulations Commission (PRC). advice of petitioner relayed via telephone, Editha was admitted to
the LMC on the same day. A pelvic sonogram2 was then
conducted on Editha revealing the fetus’ weak cardiac pulsation.3
Petitioner contended that it was Editha's gross negligence and/or The following day, Editha’s repeat pelvic sonogram4 showed that
omission in insisting to be discharged on such day against aside from the fetus’ weak cardiac pulsation, no fetal movement
doctor's advice and her unjustified failure to return for was also appreciated. Due to persistent and profuse vaginal
check-up as directed by petitioner that contributed to her life- bleeding, petitioner advised Editha to undergo a Dilatation and
threatening condition on September 16, 1994; that Editha's Curettage Procedure (D&C) or "raspa."
hysterectomy was brought about by her very abnormal pregnancy
known as placenta increta, which was an extremely rare and very On July 30, 1994, petitioner performed the D&C procedure.
unusual case of abdominal placental implantation. Editha was discharged from the hospital the following day.

On March 4, 1999, the Board of Medicine (the Board) of On September 16, 1994, Editha was once again brought at the
the PRC rendered a Decision, exonerating petitioner from the LMC, as she was suffering from vomiting and severe abdominal
charges filed against her. On appeal, the PRC rendered a pains. Editha was attended by Dr. Beatriz de la Cruz, Dr. Victor
Decision reversing the findings of the Board and revoking B. Mayo and Dr. Juan V. Komiya. Dr. Mayo allegedly informed
petitioner's authority or license to practice her profession as Editha that there was a dead fetus in the latter’s womb. After,
a physician. Hence, this petition. Editha underwent laparotomy,5 she was found to have a massive
intra-abdominal hemorrhage and a ruptured uterus. Thus, Editha
had to undergo a procedure for hysterectomy6 and as a result, she
Issue:
has no more chance to bear a child.

Whether the petitioner is liable for malpractice? On November 7, 1994, Editha and her husband Claro Ramolete
(respondents) filed a Complaint7 for Gross Negligence and
Held: Malpractice against petitioner before the Professional Regulations
Commission (PRC).
When complainant was discharged on July 31, 1994, herein Respondents alleged that Editha’s hysterectomy was caused by
respondent advised her to return on August 4, 1994 or four (4) petitioner’s unmitigated negligence and professional
days after the D&C. This advise was clear in complainant's incompetence in conducting the D&C procedure and the
Discharge Sheet. However, complainant failed to do so. This petitioner’s failure to remove the fetus inside Editha’s womb.8
being the case, the chain of continuity as required in order that Among the alleged acts of negligence were: first, petitioner’s
the doctrine of proximate cause can be validly invoked was failure to check up, visit or administer medication on Editha
during her first day of confinement at the LMC;9 second,
petitioner recommended that a D&C procedure be performed on Feeling aggrieved, respondents went to the PRC on appeal. On
Editha without conducting any internal examination prior to the November 22, 2000, the PRC rendered a Decision16 reversing the
procedure;10 third, petitioner immediately suggested a D&C findings of the Board and revoking petitioner’s authority or
procedure instead of closely monitoring the state of pregnancy of license to practice her profession as a physician.17
Editha.11
Petitioner brought the matter to the CA in a Petition for Review
In her Answer,12 petitioner denied the allegations of negligence under Rule 43 of the Rules of Court. Petitioner also dubbed her
and incompetence with the following explanations: upon Editha’s petition as one for certiorari18 under Rule 65 of the Rules of
confirmation that she would seek admission at the LMC, Court.
petitioner immediately called the hospital to anticipate the arrival
of Editha and ordered through the telephone the medicines Editha In the Decision dated July 4, 2003, the CA held that the Petition
needed to take, which the nurses carried out; petitioner visited for Review under Rule 43 of the Rules of Court was an improper
Editha on the morning of July 28, 1994 during her rounds; on July remedy, as the enumeration of the quasi-judicial agencies in Rule
29, 1994, she performed an internal examination on Editha and 43 is exclusive.19 PRC is not among the quasi-judicial bodies
she discovered that the latter’s cervix was already open, thus, whose judgment or final orders are subject of a petition for review
petitioner discussed the possible D&C procedure, should the to the CA, thus, the petition for review of the PRC Decision, filed
bleeding become more profuse; on July 30 1994, she conducted at the CA, was improper. The CA further held that should the
another internal examination on Editha, which revealed that the petition be treated as a petition for certiorari under Rule 65, the
latter’s cervix was still open; Editha persistently complained of same would still be dismissed for being improper and premature.
her vaginal bleeding and her passing out of some meaty mass in Citing Section 2620 of Republic Act (R.A.) No. 2382 or the
the process of urination and bowel movement; thus, petitioner Medical Act of 1959, the CA held that the plain, speedy and
advised Editha to undergo D&C procedure which the respondents adequate remedy under the ordinary course of law which
consented to; petitioner was very vocal in the operating room petitioner should have availed herself of was to appeal to the
about not being able to see an abortus;13 taking the words of Office of the President.21
Editha to mean that she was passing out some meaty mass and
clotted blood, she assumed that the abortus must have been Hence, herein petition, assailing the decision of the CA on the
expelled in the process of bleeding; it was Editha who insisted following grounds:
that she wanted to be discharged; petitioner agreed, but she
advised Editha to return for check-up on August 5, 1994, which 1. THE COURT OF APPEALS ERRED ON A QUESTION OF
the latter failed to do. LAW IN HOLDING THAT THE PROFESSIONAL
REGULATION[S] COMMISSION (PRC) WAS EXCLUDED
Petitioner contended that it was Editha’s gross negligence and/or AMONG THE QUASI-JUDICIAL AGENCIES
omission in insisting to be discharged on July 31, 1994 against CONTEMPLATED UNDER RULE 43 OF THE RULES OF
doctor’s advice and her unjustified failure to return for check-up CIVIL PROCEDURE;
as directed by petitioner that contributed to her life-threatening
condition on September 16, 1994; that Editha’s hysterectomy was 2. EVEN ASSUMING, ARGUENDO, THAT PRC WAS
brought about by her very abnormal pregnancy known as placenta EXCLUDED FROM THE PURVIEW OF RULE 43 OF THE
increta, which was an extremely rare and very unusual case of RULES OF CIVIL PROCEDURE, THE PETITIONER WAS
abdominal placental implantation. Petitioner argued that whether NOT PRECLUDED FROM FILING A PETITION FOR
or not a D&C procedure was done by her or any other doctor, CERTIORARI WHERE THE DECISION WAS ALSO ISSUED
there would be no difference at all because at any stage of IN EXCESS OF OR WITHOUT JURISDICTION, OR WHERE
gestation before term, the uterus would rupture just the same. THE DECISION WAS A PATENT NULLITY;

On March 4, 1999, the Board of Medicine (the Board) of the PRC 3. HEREIN RESPONDENTS-SPOUSES ARE NOT ALLOWED
rendered a Decision,14 exonerating petitioner from the charges BY LAW TO APPEAL FROM THE DECISION OF THE
filed against her. The Board held: BOARD OF MEDICINE TO THE PROFESSIONAL
REGULATION[S] COMMISSION;
Based on the findings of the doctors who conducted the
laparotomy on Editha, hers is a case of Ectopic Pregnancy 4. THE COURT OF APPEALS COMMITTED GRAVE ABUSE
Interstitial. This type of ectopic pregnancy is one that is being OF DISCRETION IN DENYING FOR IMPROPER FORUM
protected by the uterine muscles and manifestations may take THE PETITION FOR REVIEW/PETITION FOR CERTIORARI
later than four (4) months and only attributes to two percent (2%) WITHOUT GOING OVER THE MERITS OF THE GROUNDS
of ectopic pregnancy cases. RELIED UPON BY THE PETITIONER;

When complainant Editha was admitted at Lorma Medical Center 5. PRC’S GRAVE OMISSION TO AFFORD HEREIN
on July 28, 1994 due to vaginal bleeding, an ultra-sound was PETITONER A CHANCE TO BE HEARD ON APPEAL IS A
performed upon her and the result of the Sonogram Test reveals a CLEAR VIOLATION OF HER CONSTITUTIONAL RIGHT
morbid fetus but did not specify where the fetus was located. TO DUE PROCESS AND HAS THE EFFECT OF RENDERING
Obstetricians will assume that the pregnancy is within the uterus THE JUDGMENT NULL AND VOID;
unless so specified by the Sonologist who conducted the ultra-
sound. Respondent (Dr. Lasam) cannot be faulted if she was not 6. COROLLARY TO THE FOURTH ASSIGNED ERROR, PRC
able to determine that complainant Editha is having an ectopic COMMITTED GRAVE ABUSE OF DISCRETION,
pregnancy interstitial. The D&C conducted on Editha is necessary AMOUNTING TO LACK OF JURISDICTION, IN
considering that her cervix is already open and so as to stop the ACCEPTING AND CONSIDERING THE MEMORANDUM
profuse bleeding. Simple curettage cannot remove a fetus if the ON APPEAL WITHOUT PROOF OF SERVICE TO HEREIN
patient is having an ectopic pregnancy, since ectopic pregnancy is PETITIONER, AND IN VIOLATION OF ART. IV, SEC. 35 OF
pregnancy conceived outside the uterus and curettage is done only THE RULES AND REGULATIONS GOVERNING THE
within the uterus. Therefore, a more extensive operation needed in REGULATION AND PRACTICE OF PROFESSIONALS;
this case of pregnancy in order to remove the fetus.15
7. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN Moreover, Section 35 of the Rules and Regulations Governing the
REVOKING PETITIONER’S LICENSE TO PRACTICE Regulation and Practice of Professionals cited by petitioner was
MEDICINE WITHOUT AN EXPERT TESTIMONY TO subsequently amended to read:
SUPPORT ITS CONCLUSION AS TO THE CAUSE OF
RESPONDENT EDITHAT [SIC] RAMOLETE’S INJURY; Sec. 35. The complainant/respondent may appeal the order, the
resolution or the decision of the Board within thirty (30) days
8. PRC COMMITTED AN EVEN GRAVER ABUSE OF from receipt thereof to the Commission whose decision shall be
DISCRETION IN TOTALLY DISREGARDING THE FINDING final and executory. Interlocutory order shall not be appealable to
OF THE BOARD OF MEDICINE, WHICH HAD THE the Commission. (Amended by Res. 174, Series of 1990).27
NECESSARY COMPETENCE AND EXPERTISE TO (Emphasis supplied)
ESTABLISH THE CAUSE OF RESPONDENT EDITHA’S
INJURY, AS WELL AS THE TESTIMONY OF THE EXPERT Whatever doubt was created by the previous provision was settled
WITNESS AUGUSTO MANALO, M.D. ;[and] with said amendment. It is axiomatic that the right to appeal is not
a natural right or a part of due process, but a mere statutory
9. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN privilege that may be exercised only in the manner prescribed by
MAKING CONCLUSIONS OF FACTS THAT WERE NOT law.28 In this case, the clear intent of the amendment is to render
ONLY UNSUPPORTED BY EVIDENCE BUT WERE the right to appeal from a decision of the Board available to both
ACTUALLY CONTRARY TO EVIDENCE ON RECORD.22 complainants and respondents.

The Court will first deal with the procedural issues. Such conclusion is bolstered by the fact that in 2006, the PRC
issued Resolution No. 06-342(A), or the New Rules of Procedure
Petitioner claims that the law does not allow complainants to in Administrative Investigations in the Professional Regulations
appeal to the PRC from the decision of the Board. She invokes Commission and the Professional Regulatory Boards, which
Article IV, Section 35 of the Rules and Regulations Governing provides for the method of appeal, to wit:
the Regulation and Practice of Professionals, which provides:
Sec. 1. Appeal; Period Non-Extendible.- The decision, order or
Sec. 35. The respondent may appeal the decision of the Board resolution of the Board shall be final and executory after the lapse
within thirty days from receipt thereof to the Commission whose of fifteen (15) days from receipt of the decision, order or
decision shall be final. Complainant, when allowed by law, may resolution without an appeal being perfected or taken by either the
interpose an appeal from the Decision of the Board within the respondent or the complainant. A party aggrieved by the decision,
same period. (Emphasis supplied) order or resolution may file a notice of appeal from the decision,
order or resolution of the Board to the Commission within fifteen
Petitioner asserts that a careful reading of the above law indicates (15) days from receipt thereof, and serving upon the adverse party
that while the respondent, as a matter of right, may appeal the a notice of appeal together with the appellant’s brief or
Decision of the Board to the Commission, the complainant may memorandum on appeal, and paying the appeal and legal research
interpose an appeal from the decision of the Board only when so fees. x x x29
allowed by law.23 Petitioner cited Section 26 of Republic Act No.
2382 or "The Medical Act of 1959," to wit: The above-stated provision does not qualify whether only the
complainant or respondent may file an appeal; rather, the new
Section 26. Appeal from judgment. The decision of the Board of rules provide that "a party aggrieved" may file a notice of appeal.
Medical Examiners (now Medical Board) shall automatically Thus, either the complainant or the respondent who has been
become final thirty days after the date of its promulgation unless aggrieved by the decision, order or resolution of the Board may
the respondent, during the same period, has appealed to the appeal to the Commission. It is an elementary rule that when the
Commissioner of Civil Service (now Professional Regulations law speaks in clear and categorical language, there is no need, in
Commission) and later to the Office of the President of the the absence of legislative intent to the contrary, for any
Philippines. If the final decision is not satisfactory, the respondent interpretation.30 Words and phrases used in the statute should be
may ask for a review of the case, or may file in court a petition for given their plain, ordinary, and common usage or meaning.31
certiorari.
Petitioner also submits that appeals from the decisions of the PRC
Petitioner posits that the reason why the Medical Act of 1959 should be with the CA, as Rule 4332 of the Rules of Court was
allows only the respondent in an administrative case to file an precisely formulated and adopted to provide for a uniform rule of
appeal with the Commission while the complainant is not allowed appellate procedure for quasi-judicial agencies.33 Petitioner
to do so is double jeopardy. Petitioner is of the belief that the further contends that a quasi-judicial body is not excluded from
revocation of license to practice a profession is penal in nature.24 the purview of Rule 43 just because it is not mentioned therein.34

The Court does not agree. On this point, the Court agrees with the petitioner.

For one, the principle of double jeopardy finds no application in Sec. 1, Rule 43 of the Rules of Court provides:
administrative cases. Double jeopardy attaches only: (1) upon a
valid indictment; (2) before a competent court; (3) after Section 1. Scope. - This Rule shall apply to appeals from
arraignment; (4) when a valid plea has been entered; and (5) when judgments or final orders of the Court of Tax Appeals, and from
the defendant was acquitted or convicted, or the case was awards, judgments, final orders or resolutions of or authorized by
dismissed or otherwise terminated without the express consent of any quasi-judicial agency in the exercise of its quasi-judicial
the accused.25 These elements were not present in the functions. Among these agencies are the Civil Service
proceedings before the Board of Medicine, as the proceedings Commission, Central Board of Assessment Appeals, Securities
involved in the instant case were administrative and not criminal and Exchange Commission, Office of the President, Land
in nature. The Court has already held that double jeopardy does Registration Authority, Social Security Commission, Civil
not lie in administrative cases.26 Aeronautics Board, Bureau of Patents, Trademarks and
Technology Transfer, National Electrification Administration,
Energy Regulatory Board, National Telecommunications
Commission, Department of Agrarian Reform under Republic Act is essential.47 Further, inasmuch as the causes of the injuries
No. 6657, Government Service Insurance System, Employees involved in malpractice actions are determinable only in the light
Compensation Commission, Agricultural Inventions Board, of scientific knowledge, it has been recognized that expert
Insurance Commission, Philippine Atomic Energy Commission, testimony is usually necessary to support the conclusion as to
Board of Investments, Construction Industry Arbitration causation.48
Commission, and voluntary arbitrators authorized by law.
(Emphasis supplied) In the present case, respondents did not present any expert
testimony to support their claim that petitioner failed to do
Indeed, the PRC is not expressly mentioned as one of the agencies something which a reasonably prudent physician or surgeon
which are expressly enumerated under Section 1, Rule 43 of the would have done.
Rules of Court. However, its absence from the enumeration does
not, by this fact alone, imply its exclusion from the coverage of Petitioner, on the other hand, presented the testimony of Dr.
said Rule.35 The Rule expressly provides that it should be applied Augusto M. Manalo, who was clearly an expert on the subject.
to appeals from awards, judgments final orders or resolutions of
any quasi-judicial agency in the exercise of its quasi-judicial Generally, to qualify as an expert witness, one must have acquired
functions. The phrase "among these agencies" confirms that the special knowledge of the subject matter about which he or she is
enumeration made in the Rule is not exclusive to the agencies to testify, either by the study of recognized authorities on the
therein listed.36 subject or by practical experience.49

Specifically, the Court, in Yang v. Court of Appeals,37 ruled that Dr. Manalo specializes in gynecology and obstetrics, authored and
Batas Pambansa (B.P.) Blg. 12938 conferred upon the CA co-authored various publications on the subject, and is a professor
exclusive appellate jurisdiction over appeals from decisions of the at the University of the Philippines.50 According to him, his
PRC. The Court held: diagnosis of Editha’s case was "Ectopic Pregnancy Interstitial
(also referred to as Cornual), Ruptured."51 In stating that the
The law has since been changed, however, at least in the matter of D&C procedure was not the proximate cause of the rupture of
the particular court to which appeals from the Commission should Editha’s uterus resulting in her hysterectomy, Dr. Manalo testified
be taken. On August 14, 1981, Batas Pambansa Bilang 129 as follows:
became effective and in its Section 29, conferred on the Court of
Appeals "exclusive appellate jurisdiction over all final judgments, Atty. Hidalgo:
decisions, resolutions, orders or awards of Regional Trial Courts
and quasi-judicial agencies, instrumentalities, boards or Q: Doctor, we want to be clarified on this matter. The
commissions except those falling under the appellate jurisdiction complainant had testified here that the D&C was the proximate
of the Supreme Court. x x x." In virtue of BP 129, appeals from cause of the rupture of the uterus. The condition which she found
the Professional Regulations Commission are now exclusively herself in on the second admission. Will you please tell us
cognizable by the Court of Appeals.39 (Emphasis supplied) whether that is true or not?

Clearly, the enactment of B.P. Blg. 129, the precursor of the A: Yah, I do not think so for two reasons. One, as I have said
present Rules of Civil Procedure,40 lodged with the CA such earlier, the instrument cannot reach the site of the pregnancy, for
jurisdiction over the appeals of decisions made by the PRC. it to further push the pregnancy outside the uterus. And, No. 2, I
was thinking a while ago about another reason- well, why I don’t
Anent the substantive merits of the case, petitioner questions the think so, because it is the triggering factor for the rupture, it could
PRC decision for being without an expert testimony to support its have–the rupture could have occurred much earlier, right after the
conclusion and to establish the cause of Editha’s injury. Petitioner D&C or a few days after the D&C.
avers that in cases of medical malpractice, expert testimony is
necessary to support the conclusion as to the cause of the Q: In this particular case, doctor, the rupture occurred to have
injury.41 happened minutes prior to the hysterectomy or right upon
admission on September 15, 1994 which is about 1 ½ months
Medical malpractice is a particular form of negligence which after the patient was discharged, after the D&C was conducted.
consists in the failure of a physician or surgeon to apply to his Would you tell us whether there is any relation at all of the D&C
practice of medicine that degree of care and skill which is and the rupture in this particular instance?
ordinarily employed by the profession generally, under similar
conditions, and in like surrounding circumstances.42 In order to A: I don’t think so for the two reasons that I have just
successfully pursue such a claim, a patient must prove that the mentioned- that it would not be possible for the instrument to
physician or surgeon either failed to do something which a reach the site of pregnancy. And, No. 2, if it is because of the
reasonably prudent physician or surgeon would not have done, D&C that rupture could have occurred earlier.52 (Emphases
and that the failure or action caused injury to the patient.43 supplied)

There are four elements involved in medical negligence cases: Clearly, from the testimony of the expert witness and the reasons
duty, breach, injury and proximate causation.44 given by him, it is evident that the D&C procedure was not the
proximate cause of the rupture of Editha’s uterus.
A physician-patient relationship was created when Editha
employed the services of the petitioner. As Editha’s physician, During his cross-examination, Dr. Manalo testified on how he
petitioner was duty-bound to use at least the same level of care would have addressed Editha’s condition should he be placed in a
that any reasonably competent doctor would use to treat a similar circumstance as the petitioner. He stated:
condition under the same circumstances.45 The breach of these
professional duties of skill and care, or their improper Atty. Ragonton:
performance by a physician surgeon, whereby the patient is
injured in body or in health, constitutes actionable malpractice.46 Q: Doctor, as a practicing OB-Gyne, when do you consider that
As to this aspect of medical malpractice, the determination of the you have done a good, correct and ideal dilatation and curettage
reasonable level of care and the breach thereof, expert testimony procedure?
Medical malpractice, in our jurisdiction, is often brought as a civil
A: Well, if the patient recovers. If the patient gets well. action for damages under Article 217654 of the Civil Code. The
Because even after the procedure, even after the procedure you defenses in an action for damages, provided for under Article
may feel that you have scraped everything, the patient stops 2179 of the Civil Code are:
bleeding, she feels well, I think you should still have some
reservations, and wait a little more time. Art. 2179. When the plaintiff’s own negligence was the
immediate and proximate cause of his injury, he cannot recover
Q: If you were the OB-Gyne who performed the procedure on damages. But if his negligence was only contributory, the
patient Editha Ramolete, would it be your standard practice to immediate and proximate cause of the injury being the
check the fetal parts or fetal tissues that were allegedly removed? defendant’s lack of due care, the plaintiff may recover damages,
but the courts shall mitigate the damages to be awarded.
A: From what I have removed, yes. But in this particular case, I
think it was assumed that it was part of the meaty mass which was Proximate cause has been defined as that which, in natural and
expelled at the time she was urinating and flushed in the toilet. So continuous sequence, unbroken by any efficient intervening
there’s no way. cause, produces injury, and without which the result would not
have occurred.55 An injury or damage is proximately caused by
Q: There was [sic] some portions of the fetal parts that were an act or a failure to act, whenever it appears from the evidence in
removed? the case that the act or omission played a substantial part in
bringing about or actually causing the injury or damage; and that
A: No, it was described as scanty scraping if I remember it the injury or damage was either a direct result or a reasonably
right–scanty. probable consequence of the act or omission.56

Q: And you would not mind checking those scant or those little In the present case, the Court notes the findings of the Board of
parts that were removed? Medicine:

A: Well, the fact that it was described means, I assume that it When complainant was discharged on July 31, 1994, herein
was checked, ‘no. It was described as scanty and the color also, I respondent advised her to return on August 4, 1994 or four (4)
think was described. Because it would be very unusual, even days after the D&C. This advise was clear in complainant’s
improbable that it would not be examined, because when you Discharge Sheet. However, complainant failed to do so. This
scrape, the specimens are right there before your eyes. It’s in front being the case, the chain of continuity as required in order that the
of you. You can touch it. In fact, some of them will stick to the doctrine of proximate cause can be validly invoked was
instrument and therefore to peel it off from the instrument, you interrupted. Had she returned, the respondent could have
have to touch them. So, automatically they are examined closely. examined her thoroughly.57 x x x (Emphases supplied)

Q: As a matter of fact, doctor, you also give telephone orders to Also, in the testimony of Dr. Manalo, he stated further that
your patients through telephone? assuming that there was in fact a misdiagnosis, the same would
have been rectified if Editha followed the petitioner’s order to
A: Yes, yes, we do that, especially here in Manila because you return for a check-up on August 4, 1994. Dr. Manalo stated:
know, sometimes a doctor can also be tied-up somewhere and if
you have to wait until he arrive at a certain place before you give Granting that the obstetrician-gynecologist has been misled
the order, then it would be a lot of time wasted. Because if you (justifiably) up to thus point that there would have been ample
know your patient, if you have handled your patient, some of the opportunity to rectify the misdiagnosis, had the patient returned,
symptoms you can interpret that comes with practice. And, I see as instructed for her follow-up evaluation. It was one and a half
no reason for not allowing telephone orders unless it is the first months later that the patient sought consultation with another
time that you will be encountering the patient. That you have no doctor. The continued growth of an ectopic pregnancy, until its
idea what the problem is. eventual rupture, is a dynamic process. Much change in physical
findings could be expected in 1 ½ months, including the
Q: But, doctor, do you discharge patients without seeing them? emergence of suggestive ones.58

A: Sometimes yes, depending on how familiar I am with the It is undisputed that Editha did not return for a follow-up
patient. We are on the question of telephone orders. I am not evaluation, in defiance of the petitioner’s advise. Editha omitted
saying that that is the idle [sic] thing to do, but I think the reality the diligence required by the circumstances which could have
of present day practice somehow justifies telephone orders. I have avoided the injury. The omission in not returning for a follow-up
patients whom I have justified and then all of a sudden, late in the evaluation played a substantial part in bringing about Editha’s
afternoon or late in the evening, would suddenly call they have own injury. Had Editha returned, petitioner could have conducted
decided that they will go home inasmuch as they anticipated that I the proper medical tests and procedure necessary to determine
will discharge them the following day. So, I just call and ask our Editha’s health condition and applied the corresponding treatment
resident on duty or the nurse to allow them to go because I have which could have prevented the rupture of Editha’s uterus. The
seen that patient and I think I have full grasp of her problems. So, D&C procedure having been conducted in accordance with the
that’s when I make this telephone orders. And, of course before standard medical practice, it is clear that Editha’s omission was
giving that order I ask about how she feels.53 (Emphases the proximate cause of her own injury and not merely a
supplied) contributory negligence on her part.

From the foregoing testimony, it is clear that the D&C procedure Contributory negligence is the act or omission amounting to want
was conducted in accordance with the standard practice, with the of ordinary care on the part of the person injured, which,
same level of care that any reasonably competent doctor would concurring with the defendant’s negligence, is the proximate
use to treat a condition under the same circumstances, and that cause of the injury.59 Difficulty seems to be apprehended in
there was nothing irregular in the way the petitioner dealt with deciding which acts of the injured party shall be considered
Editha. immediate causes of the accident.60 Where the immediate cause
of an accident resulting in an injury is the plaintiff’s own act,
which contributed to the principal occurrence as one of its
determining factors, he cannot recover damages for the injury.61
Again, based on the evidence presented in the present case under
review, in which no negligence can be attributed to the petitioner,
the immediate cause of the accident resulting in Editha’s injury
was her own omission when she did not return for a follow-up
check up, in defiance of petitioner’s orders. The immediate cause
of Editha’s injury was her own act; thus, she cannot recover
damages from the injury.

Lastly, petitioner asserts that her right to due process was violated
because she was never informed by either respondents or by the
PRC that an appeal was pending before the PRC.62 Petitioner
claims that a verification with the records section of the PRC
revealed that on April 15, 1999, respondents filed a Memorandum
on Appeal before the PRC, which did not attach the actual registry
receipt but was merely indicated therein.63

Respondents, on the other hand avers that if the original registry

receipt was not attached to the Memorandum on Appeal, PRC
would not have entertained the appeal or accepted such pleading
for lack of notice or proof of service on the other party.64 Also,
the registry receipt could not be appended to the copy furnished to
petitioner’s former counsel, because the registry receipt was
already appended to the original copy of the Memorandum of
Appeal filed with PRC.65

It is a well-settled rule that when service of notice is an issue, the

rule is that the person alleging that the notice was served must
prove the fact of service. The burden of proving notice rests upon
the party asserting its existence.66 In the present case,
respondents did not present any proof that petitioner was served a
copy of the Memorandum on Appeal. Thus, respondents were not
able to satisfy the burden of proving that they had in fact informed
the petitioner of the appeal proceedings before the PRC.

In EDI-Staffbuilders International, Inc. v. National Labor

Relations Commission,67 in which the National Labor Relations
Commission failed to order the private respondent to furnish the
petitioner a copy of the Appeal Memorandum, the Court held that
said failure deprived the petitioner of procedural due process
guaranteed by the Constitution, which could have served as basis
for the nullification of the proceedings in the appeal. The same
holds true in the case at bar. The Court finds that the failure of the
respondents to furnish the petitioner a copy of the Memorandum
of Appeal submitted to the PRC constitutes a violation of due
process. Thus, the proceedings before the PRC were null and
void.

All told, doctors are protected by a special rule of law. They are
not guarantors of care. They are not insurers against mishaps or
unusual consequences68 specially so if the patient herself did not
exercise the proper diligence required to avoid the injury.

WHEREFORE, the petition is GRANTED. The assailed Decision

of the Court of Appeals dated July 4, 2003 in CA-GR SP No.
62206 is hereby REVERSED and SET ASIDE. The Decision of
the Board of Medicine dated March 4, 1999 exonerating petitioner
is AFFIRMED. No pronouncement as to costs.

SO ORDERED.
PETER PAUL PATRICK LUCAS, FATIMA GLADYS his diagnosis and treatment of Peter. This Court has no yardstick
LUCAS, ABBEYGAIL LUCAS AND GILLIAN LUCAS, upon which to evaluate or weigh the attendant facts of this case to
Petitioners, vs. DR. PROSPERO MA. C. TUAÑO, be able to state with confidence that the acts complained of,
indeed, constituted negligence and, thus, should be the subject of
Facts: pecuniary reparation.
Petitioner Peter Paul Patrick Lucas (Peter) contracted "sore
eyes" in his right eye. Upon consultation with Dr. Tuaño, Herein, the burden of proof was clearly upon petitioners, as
Peter narrated that it had been nine (9) days since the problem plaintiffs in the lower court, to establish their case by a
with his right eye began; and that he was already taking preponderance of evidence showing a reasonable connection
Maxitrol to address the problem in his eye. Dr. Tuaño between Dr. Tuaño’s alleged breach of duty and the damage
diagnosed that Peter was suffering from conjunctivitisor "sore sustained by Peter’s right eye. This, they did not do. In
eyes." Dr. Tuaño then prescribed Spersacet-C eye drops for reality, petitioners’ complaint for damages is merely anchored
Peter and told the latter to return for follow-up after one week. As on a statement in the literature of Maxitrol identifying the
instructed, Peter went back to Dr. Tuañ. Upon examination, Dr. risks of its use, and the purported comment of Dr. Agulto –
Tuaño told Peter that the "sore eyes" in the latter’s right eye had another doctor not presented as witness before the RTC –
already cleared up and he could discontinue the Spersacet-C. concerning the prolonged use of Maxitrol for the treatment of
However, the same eye developed Epidemic Kerato EKC.
Conjunctivitis (EKC),a viral infection. To address the new
problem with Peter’s right eye, Dr. Tuaño prescribed to the
former a steroid-based eye drop called Maxitrol, a dosage of It seems basic that what constitutes proper medical treatment
six (6) drops per day. is a medical question that should have been presented to
experts. If no standard is established through expert medical
To recall, Peter had already been using Maxitrol prior to his witnesses, then courts have no standard by which to gauge the
consult with Dr. Tuaño. Peter saw Dr. Tuaño for a follow-up basic issue of breach thereof by the physician or surgeon. The
consultation. After examining both of Peter’s eyes, Dr. RTC and Court of Appeals, and even this Court, could not
Tuaño instructed the former to taper down the dosage of Maxitrol, be expected to determine on its own what medical technique
because the EKC in his right eye had already resolved. Dr. should have been utilized for a certain disease or injury.
Tuaño specifically cautioned Peter that, being a steroid, Absent expert medical opinion, the courts would be dangerously
Maxitrol had to be withdrawn gradually; otherwise, the EKC engaging in speculations.
might recur.

Complaining of feeling as if there was something in his

eyes, Peter returned to Dr. Tuaño for another check-up on . G.R. No. 178763 April 21, 2009
Dr. Tuaño examined Peter’s eyes and found that the right eye had
once more developed EKC. So, Dr. Tuaño instructed Peter to PETER PAUL PATRICK LUCAS, FATIMA GLADYS
resume the use of Maxitrol at six (6) drops per day. Several days LUCAS, ABBEYGAIL LUCAS AND GILLIAN LUCAS,
later, Peter went to see Dr. Tuaño at his clinic, alleging severe eye Petitioners,
pain, feeling as if his eyes were about to "pop-out," a headache vs.
and blurred vision. Dr. Tuaño examined Peter’s eyes and DR. PROSPERO MA. C. TUAÑO, Respondent.
discovered that the EKC was again present in his right eye. As a
result, Dr. Tuaño told Peter to resume the maximum dosage of DECISION
Blephamide.
CHICO-NAZARIO, J.:
Dr. Tuaño saw Peter once more at the former’s clinic. Dr.
Tuaño’s examination showed that only the periphery of In this petition for review on certiorari1 under Rule 45 of the
Peter’s right eye was positive for EKC; hence, Dr. Tuaño Revised Rules of Court, petitioners Peter Paul Patrick Lucas,
prescribed a lower dosage of Blephamide. Fatima Gladys Lucas, Abbeygail Lucas and Gillian Lucas seek
the reversal of the 27 September 2006 Decision2 and 3 July 2007
Upon waking in the morning of 13 December 1988, Peter had no Resolution,3 both of the Court of Appeals in CA-G.R. CV No.
vision in his right eye. Fatima observed that Peter’s right eye 68666, entitled "Peter Paul Patrick Lucas, Fatima Gladys Lucas,
appeared to be bloody and swollen.Thus, spouses Peter and Abbeygail Lucas and Gillian Lucas v. Prospero Ma. C. Tuaño."
Fatima rushed to the clinic of Dr. Tuaño. Peter reported to Dr.
Tuaño that he had been suffering from constant headache in the In the questioned decision and resolution, the Court of Appeals
afternoon and blurring of vision. affirmed the 14 July 2000 Decision of the Regional Trial Court
(RTC), Branch 150, Makati City, dismissing the complaint filed
A civil complaint for damages against Dr. Tuaño on the ground of by petitioners in a civil case entitled, "Peter Paul Patrick Lucas,
Dr. Tuaño’s grossly negligent conduct in prescribing to Peter Fatima Gladys Lucas, Abbeygail Lucas and Gillian Lucas v.
the medicine Maxitrol for a period of three (3) months, Prospero Ma. C. Tuaño," docketed as Civil Case No. 92-2482.

without monitoring Peter’s IOP, as required in cases of From the record of the case, the established factual antecedents of
prolonged use of said medicine, and notwithstanding Peter’s the present petition are:
constant complaint of intense eye pain while using the same.
Sometime in August 1988, petitioner Peter Paul Patrick Lucas
Issue: (Peter) contracted "sore eyes" in his right eye.
Whether Dr. Tuano was negligent?
On 2 September 1988, complaining of a red right eye and swollen
Held: eyelid, Peter made use of his health care insurance issued by
Absent a definitive standard of care or diligence required of Philamcare Health Systems, Inc. (Philamcare), for a possible
Dr. Tuaño under the circumstances, we have no means to consult. The Philamcare Coordinator, Dr. Edwin Oca, M.D.,
determine whether he was able to comply with the same in referred Peter to respondent, Dr. Prospero Ma. C. Tuaño, M.D.
(Dr. Tuaño), an ophthalmologist at St. Luke’s Medical Center, for infractions, in those diseases causing thinning of the cornea or
an eye consult. sclera, perforations have been known to occur with the use of
topical steroids. In acute purulent conditions of the eye, steroids
Upon consultation with Dr. Tuaño, Peter narrated that it had been may mask infection or enhance existing infection. If these
nine (9) days since the problem with his right eye began; and that products are used for 10 days or longer, intraocular pressure
he was already taking Maxitrol to address the problem in his eye. should be routinely monitored even though it may be difficult in
According to Dr. Tuaño, he performed "ocular routine children and uncooperative patients.
examination" on Peter’s eyes, wherein: (1) a gross examination of
Peter’s eyes and their surrounding area was made; (2) Peter’s Employment of steroid medication in the treatment of herpes
visual acuity were taken; (3) Peter’s eyes were palpated to check simplex requires great caution.
the intraocular pressure of each; (4) the motility of Peter’s eyes
was observed; and (5) the ophthalmoscopy4 on Peter’s eyes was xxxx
used. On that particular consultation, Dr. Tuaño diagnosed that
Peter was suffering from conjunctivitis5 or "sore eyes." Dr. Tuaño ADVERSE REACTIONS:
then prescribed Spersacet-C6 eye drops for Peter and told the
latter to return for follow-up after one week. Adverse reactions have occurred with steroid/anti-infective
combination drugs which can be attributed to the steroid
As instructed, Peter went back to Dr. Tuaño on 9 September 1988. component, the anti-infective component, or the combination.
Upon examination, Dr. Tuaño told Peter that the "sore eyes" in Exact incidence figures are not available since no denominator of
the latter’s right eye had already cleared up and he could treated patients is available.
discontinue the Spersacet-C. However, the same eye developed
Epidemic Kerato Conjunctivitis (EKC),7 a viral infection. To Reactions occurring most often from the presence of the anti-
address the new problem with Peter’s right eye, Dr. Tuaño infective ingredients are allergic sensitizations. The reactions due
prescribed to the former a steroid-based eye drop called to the steroid component in decreasing order to frequency are
Maxitrol,8 a dosage of six (6) drops per day.9 To recall, Peter had elevation of intra-ocular pressure (IOP) with possible
already been using Maxitrol prior to his consult with Dr. Tuaño. development of glaucoma, infrequent optic nerve damage;
posterior subcapsular cataract formation; and delayed wound
On 21 September 1988, Peter saw Dr. Tuaño for a follow-up healing.
consultation. After examining both of Peter’s eyes, Dr. Tuaño
instructed the former to taper down10 the dosage of Maxitrol, Secondary infection: The development of secondary has occurred
because the EKC in his right eye had already resolved. Dr. Tuaño after use of combination containing steroids and antimicrobials.
specifically cautioned Peter that, being a steroid, Maxitrol had to Fungal infections of the correa are particularly prone to develop
be withdrawn gradually; otherwise, the EKC might recur.11 coincidentally with long-term applications of steroid. The
possibility of fungal invasion must be considered in any persistent
Complaining of feeling as if there was something in his eyes, corneal ulceration where steroid treatment has been used.
Peter returned to Dr. Tuaño for another check-up on 6 October
1988. Dr. Tuaño examined Peter’s eyes and found that the right Secondary bacterial ocular infection following suppression of host
eye had once more developed EKC. So, Dr. Tuaño instructed responses also occurs.
Peter to resume the use of Maxitrol at six (6) drops per day.
On 26 November 1988, Peter returned to Dr. Tuaño’s clinic,
On his way home, Peter was unable to get a hold of Maxitrol, as it complaining of "feeling worse."14 It appeared that the EKC had
was out of stock. Consequently, Peter was told by Dr. Tuano to spread to the whole of Peter’s right eye yet again. Thus, Dr.
take, instead, Blephamide12 another steroid-based medication, Tuaño instructed Peter to resume the use of Maxitrol. Petitioners
but with a lower concentration, as substitute for the unavailable averred that Peter already made mention to Dr. Tuaño during said
Maxitrol, to be used three (3) times a day for five (5) days; two visit of the above-quoted warning against the prolonged use of
(2) times a day for five (5) days; and then just once a day.13 steroids, but Dr. Tuaño supposedly brushed aside Peter’s concern
as mere paranoia, even assuring him that the former was taking
Several days later, on 18 October 1988, Peter went to see Dr. care of him (Peter).
Tuaño at his clinic, alleging severe eye pain, feeling as if his eyes
were about to "pop-out," a headache and blurred vision. Dr. Petitioners further alleged that after Peter’s 26 November 1988
Tuaño examined Peter’s eyes and discovered that the EKC was visit to Dr. Tuaño, Peter continued to suffer pain in his right eye,
again present in his right eye. As a result, Dr. Tuaño told Peter to which seemed to "progress," with the ache intensifying and
resume the maximum dosage of Blephamide. becoming more frequent.

Dr. Tuaño saw Peter once more at the former’s clinic on 4 Upon waking in the morning of 13 December 1988, Peter had no
November 1988. Dr. Tuaño’s examination showed that only the vision in his right eye. Fatima observed that Peter’s right eye
periphery of Peter’s right eye was positive for EKC; hence, Dr. appeared to be bloody and swollen.15 Thus, spouses Peter and
Tuaño prescribed a lower dosage of Blephamide. Fatima rushed to the clinic of Dr. Tuaño. Peter reported to Dr.
Tuaño that he had been suffering from constant headache in the
It was also about this time that Fatima Gladys Lucas (Fatima), afternoon and blurring of vision.
Peter’s spouse, read the accompanying literature of Maxitrol and
found therein the following warning against the prolonged use of Upon examination, Dr. Tuaño noted the hardness of Peter’s right
such steroids: eye. With the use of a tonometer16 to verify the exact intraocular
pressure17 (IOP) of Peter’s eyes, Dr. Tuaño discovered that the
WARNING: tension in Peter’s right eye was 39.0 Hg, while that of his left was
17.0 Hg.18 Since the tension in Peter’s right eye was way over the
Prolonged use may result in glaucoma, with damage to the optic normal IOP, which merely ranged from 10.0 Hg to 21.0 Hg,19
nerve, defects in visual acuity and fields of vision, and posterior, Dr. Tuaño ordered20 him to immediately discontinue the use of
subcapsular cataract formation. Prolonged use may suppress the Maxitrol and prescribed to the latter Diamox21 and
host response and thus increase the hazard of secondary ocular Normoglaucon, instead.22 Dr. Tuaño also required Peter to go for
daily check-up in order for the former to closely monitor the
pressure of the latter’s eyes. Zeiss gonioscopy35 revealed basically open angles both eyes with
occasional PAS,36 OD.
On 15 December 1988, the tonometer reading of Peter’s right eye
yielded a high normal level, i.e., 21.0 Hg. Hence, Dr. Tuaño told Rolly, I feel that Peter Lucas has really sustained significant
Peter to continue using Diamox and Normoglaucon. But upon glaucoma damage. I suggest that we do a baseline visual fields
Peter’s complaint of "stomach pains and tingling sensation in his and push medication to lowest possible levels. If I may suggest
fingers,"23 Dr. Tuaño discontinued Peter’s use of Diamox.24 further, I think we should prescribe Timolol37 BID38 OD in lieu
of Normoglaucon. If the IOP is still inadequate, we may try
Peter went to see another ophthalmologist, Dr. Ramon T. D’epifrin39 BID OD (despite low PAS). I’m in favor of retaining
Batungbacal (Dr. Batungbacal), on 21 December 1988, who Diamox or similar CAI.40
allegedly conducted a complete ophthalmological examination of
Peter’s eyes. Dr. Batungbacal’s diagnosis was Glaucoma25 If fields show further loss in say – 3 mos. then we should consider
O.D.26 He recommended Laser Trabeculoplasty27 for Peter’s trabeculoplasty.
right eye.
I trust that this approach will prove reasonable for you and
When Peter returned to Dr. Tuaño on 23 December 1988,28 the Peter.41
tonometer measured the IOP of Peter’s right eye to be 41.0 Hg,29
again, way above normal. Dr. Tuaño addressed the problem by Peter went to see Dr. Tuaño on 31 December 1988, bearing Dr.
advising Peter to resume taking Diamox along with Agulto’s aforementioned letter. Though Peter’s right and left eyes
Normoglaucon. then had normal IOP of 21.0 Hg and 17.0 Hg, respectively, Dr.
Tuaño still gave him a prescription for Timolol B.I.D. so Peter
During the Christmas holidays, Peter supposedly stayed in bed could immediately start using said medication. Regrettably,
most of the time and was not able to celebrate the season with his Timolol B.I.D. was out of stock, so Dr. Tuaño instructed Peter to
family because of the debilitating effects of Diamox.30 just continue using Diamox and Normoglaucon in the meantime.

On 28 December 1988, during one of Peter’s regular follow-ups Just two days later, on 2 January 1989, the IOP of Peter’s right
with Dr. Tuaño, the doctor conducted another ocular routine eye remained elevated at 21.0 Hg,42 as he had been without
examination of Peter’s eyes. Dr. Tuaño noted the recurrence of Diamox for the past three (3) days.
EKC in Peter’s right eye. Considering, however, that the IOP of
Peter’s right eye was still quite high at 41.0 Hg, Dr. Tuaño was at On 4 January 1989, Dr. Tuaño conducted a visual field study43 of
a loss as to how to balance the treatment of Peter’s EKC vis-à-vis Peter’s eyes, which revealed that the latter had tubular vision44 in
the presence of glaucoma in the same eye. Dr. Tuaño, thus, his right eye, while that of his left eye remained normal. Dr.
referred Peter to Dr. Manuel B. Agulto, M.D. (Dr. Agulto), Tuaño directed Peter to religiously use the Diamox and
another ophthalmologist specializing in the treatment of Normoglaucon, as the tension of the latter’s right eye went up
glaucoma.31 Dr. Tuaño’s letter of referral to Dr. Agulto stated even further to 41.0 Hg in just a matter of two (2) days, in the
that: meantime that Timolol B.I.D. and D’epifrin were still not
available in the market. Again, Dr. Tuaño advised Peter to come
Referring to you Mr. Peter Lucas for evaluation & possible for regular check-up so his IOP could be monitored.
management. I initially saw him Sept. 2, 1988 because of
conjunctivitis. The latter resolved and he developed EKC for Obediently, Peter went to see Dr. Tuaño on the 7th, 13th, 16th and
which I gave Maxitrol. The EKC was recurrent after stopping 20th of January 1989 for check-up and IOP monitoring.
steroid drops. Around 1 month of steroid treatment, he noted
blurring of vision & pain on the R. however, I continued the In the interregnum, however, Peter was prodded by his friends to
steroids for the sake of the EKC. A month ago, I noted iris seek a second medical opinion. On 13 January 1989, Peter
atrophy, so I took the IOP and it was definitely elevated. I stopped consulted Dr. Jaime Lapuz, M.D. (Dr. Lapuz), an
the steroids immediately and has (sic) been treating him ophthalmologist, who, in turn, referred Peter to Dr. Mario V.
medically. Aquino, M.D. (Dr. Aquino), another ophthalmologist who
specializes in the treatment of glaucoma and who could undertake
It seems that the IOP can be controlled only with oral Diamox, the long term care of Peter’s eyes.
and at the moment, the EKC has recurred and I’m in a fix whether
to resume the steroid or not considering that the IOP is still According to petitioners, after Dr. Aquino conducted an extensive
uncontrolled.32 evaluation of Peter’s eyes, the said doctor informed Peter that his
eyes were relatively normal, though the right one sometimes
On 29 December 1988, Peter went to see Dr. Agulto at the latter’s manifested maximum borderline tension. Dr. Aquino also
clinic. Several tests were conducted thereat to evaluate the extent confirmed Dr. Tuaño’s diagnosis of tubular vision in Peter’s right
of Peter’s condition. Dr. Agulto wrote Dr. Tuaño a letter eye. Petitioners claimed that Dr. Aquino essentially told Peter that
containing the following findings and recommendations: the latter’s condition would require lifetime medication and
follow-ups.
Thanks for sending Peter Lucas. On examination conducted
vision was 20/25 R and 20/20L. Tension curve 19 R and 15 L at In May 1990 and June 1991, Peter underwent two (2) procedures
1210 H while on Normoglaucon BID OD & Diamox ½ tab every of laser trabeculoplasty to attempt to control the high IOP of his
6h po. right eye.

Slit lamp evaluation33 disclosed subepithelial corneal defect outer Claiming to have steroid-induced glaucoma45 and blaming Dr.
OD. There was circumferential peripheral iris atrophy, OD. The Tuaño for the same, Peter, joined by: (1) Fatima, his spouse46; (2)
lenses were clear. Abbeygail, his natural child47; and (3) Gillian, his legitimate
child48 with Fatima, instituted on 1 September 1992, a civil
Funduscopy34 showed vertical cup disc of 0.85 R and 0.6 L with complaint for damages against Dr. Tuaño, before the RTC,
temporal slope R>L.
Branch 150, Quezon City. The case was docketed as Civil Case detected, which meant that there was no increase in the tension or
No. 92-2482. IOP, a possible side reaction to the use of steroid medications; and
(3) it was only on 13 December 1988 that Peter complained of a
In their Complaint, petitioners specifically averred that as the headache and blurred vision in his right eye, and upon measuring
"direct consequence of [Peter’s] prolonged use of Maxitrol, [he] the IOP of said eye, it was determined for the first time that the
suffered from steroid induced glaucoma which caused the IOP of the right eye had an elevated value.
elevation of his intra-ocular pressure. The elevation of the intra-
ocular pressure of [Peter’s right eye] caused the impairment of his But granting for the sake of argument that the "steroid treatment
vision which impairment is not curable and may even lead to total of [Peter’s] EKC caused the steroid induced glaucoma,"59 Dr.
blindness."49 Tuaño argued that:

Petitioners additionally alleged that the visual impairment of [S]uch condition, i.e., elevated intraocular pressure, is temporary.
Peter’s right eye caused him and his family so much grief. As soon as the intake of steroids is discontinued, the intraocular
Because of his present condition, Peter now needed close medical pressure automatically is reduced. Thus, [Peter’s] glaucoma can
supervision forever; he had already undergone two (2) laser only be due to other causes not attributable to steroids, certainly
surgeries, with the possibility that more surgeries were still not attributable to [his] treatment of more than three years ago x x
needed in the future; his career in sports casting had suffered and x.
was continuing to suffer;50 his anticipated income had been
greatly reduced as a result of his "limited" capacity; he From a medical point of view, as revealed by more current
continually suffered from "headaches, nausea, dizziness, heart examination of [Peter], the latter’s glaucoma can only be long
palpitations, rashes, chronic rhinitis, sinusitis,"51 etc.; Peter’s standing glaucoma, open angle glaucoma, because of the large
relationships with his spouse and children continued to be C:D ratio. The steroids provoked the latest glaucoma to be
strained, as his condition made him highly irritable and sensitive; revealed earlier as [Peter] remained asymptomatic prior to steroid
his mobility and social life had suffered; his spouse, Fatima, application. Hence, the steroid treatment was in fact beneficial to
became the breadwinner in the family;52 and his two children had [Peter] as it revealed the incipient open angle glaucoma of [Peter]
been deprived of the opportunity for a better life and educational to allow earlier treatment of the same.60
prospects. Collectively, petitioners lived in constant fear of Peter
becoming completely blind.53 In a Decision dated 14 July 2000, the RTC dismissed Civil Case
No. 92-2482 "for insufficiency of evidence."61 The decretal part
In the end, petitioners sought pecuniary award for their supposed of said Decision reads:
pain and suffering, which were ultimately brought about by Dr.
Tuaño’s grossly negligent conduct in prescribing to Peter the Wherefore, premises considered, the instant complaint is
medicine Maxitrol for a period of three (3) months, without dismissed for insufficiency of evidence. The counter claim (sic) is
monitoring Peter’s IOP, as required in cases of prolonged use of likewise dismissed in the absence of bad faith or malice on the
said medicine, and notwithstanding Peter’s constant complaint of part of plaintiff in filing the suit.62
intense eye pain while using the same. Petitioners particularly
prayed that Dr. Tuaño be adjudged liable for the following The RTC opined that petitioners failed to prove by preponderance
amounts: of evidence that Dr. Tuaño was negligent in his treatment of
Peter’s condition. In particular, the record of the case was bereft
1. The amount of ₱2,000,000.00 to plaintiff Peter Lucas as and by of any evidence to establish that the steroid medication and its
way of compensation for his impaired vision. dosage, as prescribed by Dr. Tuaño, caused Peter’s glaucoma. The
trial court reasoned that the "recognized standards of the medical
2. The amount of ₱300,000.00 to spouses Lucas as and by way of community has not been established in this case, much less has
actual damages plus such additional amounts that may be proven causation been established to render [Tuaño] liable."63 According
during trial. to the RTC:

3. The amount of ₱1,000,000.00 as and by way of moral damages. [Petitioners] failed to establish the duty required of a medical
practitioner against which Peter Paul’s treatment by defendant can
4. The amount of ₱500,000.00 as and by way of exemplary be compared with. They did not present any medical expert or
damages. even a medical doctor to convince and expertly explain to the
court the established norm or duty required of a physician treating
5. The amount of ₱200,000.00 as and by way of attorney’s fees a patient, or whether the non taking (sic) by Dr. Tuaño of Peter
plus costs of suit.54 Paul’s pressure a deviation from the norm or his non-discovery of
the glaucoma in the course of treatment constitutes negligence. It
In rebutting petitioners’ complaint, Dr. Tuaño asserted that the is important and indispensable to establish such a standard
"treatment made by [him] more than three years ago has no causal because once it is established, a medical practitioner who departed
connection to [Peter’s] present glaucoma or condition."55 Dr. thereof breaches his duty and commits negligence rendering him
Tuaño explained that "[d]rug-induced glaucoma is temporary and liable. Without such testimony or enlightenment from an expert,
curable, steroids have the side effect of increasing intraocular the court is at a loss as to what is then the established norm of
pressure. Steroids are prescribed to treat Epidemic Kerato duty of a physician against which defendant’s conduct can be
Conjunctivitis or EKC which is an infiltration of the cornea as a compared with to determine negligence.64
result of conjunctivitis or sore eyes."56 Dr. Tuaño also clarified
that (1) "[c]ontrary to [petitioners’] fallacious claim, [he] did The RTC added that in the absence of "any medical evidence to
NOT continually prescribe the drug Maxitrol which contained the contrary, this court cannot accept [petitioners’] claim that the
steroids for any prolonged period"57 and "[t]he truth was the use of steroid is the proximate cause of the damage sustained by
Maxitrol was discontinued x x x as soon as EKC disappeared and [Peter’s] eye."65
was resumed only when EKC reappeared"58; (2) the entire time
he was treating Peter, he "continually monitored the intraocular Correspondingly, the RTC accepted Dr. Tuaño’s medical opinion
pressure of [Peter’s eyes] by palpating the eyes and by putting that "Peter Paul must have been suffering from normal tension
pressure on the eyeballs," and no hardening of the same could be glaucoma, meaning, optic nerve damage was happening but no
elevation of the eye pressure is manifested, that the steroid PROVE THEIR CLAIM FOR MEDICAL NEGLIGENCE
treatment actually unmasked the condition that resulted in the AGAINST THE RESPONDENT; AND
earlier treatment of the glaucoma. There is nothing in the record
to contradict such testimony. In fact, plaintiff’s Exhibit ‘S’ even III.
tends to support them."
THE COURT OF APPEALS COMMITTED GRAVE
Undaunted, petitioners appealed the foregoing RTC decision to REVERSIBLE ERROR IN NOT FINDING THE RESPONDENT
the Court of Appeals. Their appeal was docketed as CA-G.R. CV LIABLE TO THE PETITIONERS’ FOR ACTUAL, MORAL
No. 68666. AND EXEMPLARY DAMAGES, ASIDE FROM
ATTORNEY’S FEES, COSTS OF SUIT, AS A RESULT OF
On 27 September 2006, the Court of Appeals rendered a decision HIS GROSS NEGLIGENCE.69
in CA-G.R. CV No. 68666 denying petitioners’ recourse and
affirming the appealed RTC Decision. The fallo of the judgment A reading of the afore-quoted reversible errors supposedly
of the appellate court states: committed by the Court of Appeals in its Decision and Resolution
would reveal that petitioners are fundamentally assailing the
WHEREFORE, the Decision appealed from is AFFIRMED.66 finding of the Court of Appeals that the evidence on record is
insufficient to establish petitioners’ entitlement to any kind of
The Court of Appeals faulted petitioners because they – damage. Therefore, it could be said that the sole issue for our
resolution in the Petition at bar is whether the Court of Appeals
[D]id not present any medical expert to testify that Dr. Tuano’s committed reversible error in affirming the judgment of the RTC
prescription of Maxitrol and Blephamide for the treatment of that petitioners failed to prove, by preponderance of evidence,
EKC on Peter’s right eye was not proper and that his palpation of their claim for damages against Dr. Tuaño.
Peter’s right eye was not enough to detect adverse reaction to
steroid. Peter testified that Dr. Manuel Agulto told him that he Evidently, said issue constitutes a question of fact, as we are
should not have used steroid for the treatment of EKC or that he asked to revisit anew the factual findings of the Court of Appeals,
should have used it only for two (2) weeks, as EKC is only a viral as well as of the RTC. In effect, petitioners would have us sift
infection which will cure by itself. However, Dr. Agulto was not through the evidence on record and pass upon whether there is
presented by [petitioners] as a witness to confirm what he sufficient basis to establish Dr. Tuaño’s negligence in his
allegedly told Peter and, therefore, the latter’s testimony is treatment of Peter’s eye condition. This question clearly involves
hearsay. Under Rule 130, Section 36 of the Rules of Court, a a factual inquiry, the determination of which is not within the
witness can testify only to those facts which he knows of his own ambit of this Court’s power of review under Rule 45 of the 1997
personal knowledge, x x x. Familiar and fundamental is the rule Rules Civil Procedure, as amended.70
that hearsay testimony is inadmissible as evidence.67
Elementary is the principle that this Court is not a trier of facts;
Like the RTC, the Court of Appeals gave great weight to Dr. only errors of law are generally reviewed in petitions for review
Tuaño’s medical judgment, specifically the latter’s explanation on certiorari criticizing decisions of the Court of Appeals.
that: Questions of fact are not entertained.71

[W]hen a doctor sees a patient, he cannot determine whether or Nonetheless, the general rule that only questions of law may be
not the latter would react adversely to the use of steroids, that it raised on appeal in a petition for review under Rule 45 of the
was only on December 13, 1989, when Peter complained for the Rules of Court admits of certain exceptions, including the
first time of headache and blurred vision that he observed that the circumstance when the finding of fact of the Court of Appeals is
pressure of the eye of Peter was elevated, and it was only then that premised on the supposed absence of evidence, but is contradicted
he suspected that Peter belongs to the 5% of the population who by the evidence on record. Although petitioners may not explicitly
reacts adversely to steroids.68 invoke said exception, it may be gleaned from their allegations
and arguments in the instant Petition.1avvphi1.zw+
Petitioners’ Motion for Reconsideration was denied by the Court
of Appeals in a Resolution dated 3 July 2007. Petitioners contend, that "[c]ontrary to the findings of the
Honorable Court of Appeals, [they] were more than able to
Hence, this Petition for Review on Certiorari under Rule 45 of the establish that: Dr. Tuaño ignored the standard medical procedure
Revised Rules of Court premised on the following assignment of for ophthalmologists, administered medication with recklessness,
errors: and exhibited an absence of competence and skills expected from
him."72 Petitioners reject the necessity of presenting expert
I. and/or medical testimony to establish (1) the standard of care
respecting the treatment of the disorder affecting Peter’s eye; and
THE COURT OF APPEALS COMMITTED GRAVE (2) whether or not negligence attended Dr. Tuaño’s treatment of
REVERSIBLE ERROR IN AFFIRMING THE DECISION OF Peter, because, in their words –
THE TRIAL COURT DISMISSING THE PETITIONERS’
COMPLAINT FOR DAMAGES AGAINST THE That Dr. Tuaño was grossly negligent in the treatment of Peter’s
RESPONDENT ON THE GROUND OF INSUFFICIENCY OF simple eye ailment is a simple case of cause and effect. With mere
EVIDENCE; documentary evidence and based on the facts presented by the
petitioners, respondent can readily be held liable for damages
II. even without any expert testimony. In any case, however, and
contrary to the finding of the trial court and the Court of Appeals,
THE COURT OF APPEALS COMMITTED GRAVE there was a medical expert presented by the petitioner showing
REVERSIBLE ERROR IN DISMISSING THE PETITIONERS’ the recklessness committed by [Dr. Tuaño] – Dr. Tuaño himself.
COMPLAINT FOR DAMAGES AGAINST THE [Emphasis supplied.]
RESPONDENT ON THE GROUND THAT NO MEDICAL
EXPERT WAS PRESENTED BY THE PETITIONERS TO They insist that Dr. Tuaño himself gave sufficient evidence to
establish his gross negligence that ultimately caused the
impairment of the vision of Peter’s right eye,73 i.e., that general neighborhood and in the same general line of practice
"[d]espite [Dr. Tuaño’s] knowledge that 5% of the population ordinarily possess and exercise in like cases.
reacts adversely to Maxitrol, [he] had no qualms whatsoever in
prescribing said steroid to Peter without first determining whether Even so, proof of breach of duty on the part of the attending
or not the (sic) Peter belongs to the 5%."74 physician is insufficient, for there must be a causal connection
between said breach and the resulting injury sustained by the
We are not convinced. The judgments of both the Court of patient. Put in another way, in order that there may be a recovery
Appeals and the RTC are in accord with the evidence on record, for an injury, it must be shown that the "injury for which recovery
and we are accordingly bound by the findings of fact made is sought must be the legitimate consequence of the wrong done;
therein. the connection between the negligence and the injury must be a
direct and natural sequence of events, unbroken by intervening
Petitioners’ position, in sum, is that Peter’s glaucoma is the direct efficient causes";81 that is, the negligence must be the proximate
result of Dr. Tuaño’s negligence in his improper administration of cause of the injury. And the proximate cause of an injury is that
the drug Maxitrol; "thus, [the latter] should be liable for all the cause, which, in the natural and continuous sequence, unbroken
damages suffered and to be suffered by [petitioners]."75 Clearly, by any efficient intervening cause, produces the injury, and
the present controversy is a classic illustration of a medical without which the result would not have occurred.82
negligence case against a physician based on the latter’s
professional negligence. In this type of suit, the patient or his Just as with the elements of duty and breach of the same, in order
heirs, in order to prevail, is required to prove by preponderance of to establish the proximate cause [of the injury] by a
evidence that the physician failed to exercise that degree of skill, preponderance of the evidence in a medical malpractice action,
care, and learning possessed by other persons in the same [the patient] must similarly use expert testimony, because the
profession; and that as a proximate result of such failure, the question of whether the alleged professional negligence caused
patient or his heirs suffered damages. [the patient’s] injury is generally one for specialized expert
knowledge beyond the ken of the average layperson; using the
For lack of a specific law geared towards the type of negligence specialized knowledge and training of his field, the expert’s role
committed by members of the medical profession, such claim for is to present to the [court] a realistic assessment of the likelihood
damages is almost always anchored on the alleged violation of that [the physician’s] alleged negligence caused [the patient’s]
Article 2176 of the Civil Code, which states that: injury.83

ART. 2176. Whoever by act or omission causes damage to From the foregoing, it is apparent that medical negligence cases
another, there being fault or negligence, is obliged to pay for the are best proved by opinions of expert witnesses belonging in the
damage done. Such fault or negligence, if there is no pre-existing same general neighborhood and in the same general line of
contractual relation between the parties, is called a quasi-delict practice as defendant physician or surgeon. The deference of
and is governed by the provisions of this Chapter. courts to the expert opinion of qualified physicians [or surgeons]
stems from the former’s realization that the latter possess unusual
In medical negligence cases, also called medical malpractice suits, technical skills which laymen in most instances are incapable of
there exist a physician-patient relationship between the doctor and intelligently evaluating;84 hence, the indispensability of expert
the victim. But just like any other proceeding for damages, four testimonies.
essential (4) elements i.e., (1) duty; (2) breach; (3) injury; and (4)
proximate causation,76 must be established by the plaintiff/s. All In the case at bar, there is no question that a physician-patient
the four (4) elements must co-exist in order to find the physician relationship developed between Dr. Tuaño and Peter when Peter
negligent and, thus, liable for damages. went to see the doctor on 2 September 1988, seeking a consult for
the treatment of his sore eyes. Admittedly, Dr. Tuaño, an
When a patient engages the services of a physician, a physician- ophthalmologist, prescribed Maxitrol when Peter developed and
patient relationship is generated. And in accepting a case, the had recurrent EKC. Maxitrol or neomycin/polymyxin B
physician, for all intents and purposes, represents that he has the sulfates/dexamethasone ophthalmic ointment is a multiple-dose
needed training and skill possessed by physicians and surgeons anti-infective steroid combination in sterile form for topical
practicing in the same field; and that he will employ such training, application.85 It is the drug which petitioners claim to have
care, and skill in the treatment of the patient.77 Thus, in treating caused Peter’s glaucoma.
his patient, a physician is under a duty to [the former] to exercise
that degree of care, skill and diligence which physicians in the However, as correctly pointed out by the Court of Appeals, "[t]he
same general neighborhood and in the same general line of onus probandi was on the patient to establish before the trial court
practice ordinarily possess and exercise in like cases.78 Stated that the physicians ignored standard medical procedure,
otherwise, the physician has the duty to use at least the same level prescribed and administered medication with recklessness and
of care that any other reasonably competent physician would use exhibited an absence of the competence and skills expected of
to treat the condition under similar circumstances. general practitioners similarly situated."86 Unfortunately, in this
case, there was absolute failure on the part of petitioners to
This standard level of care, skill and diligence is a matter best present any expert testimony to establish: (1) the standard of care
addressed by expert medical testimony, because the standard of to be implemented by competent physicians in treating the same
care in a medical malpractice case is a matter peculiarly within condition as Peter’s under similar circumstances; (2) that, in his
the knowledge of experts in the field.79 treatment of Peter, Dr. Tuaño failed in his duty to exercise said
standard of care that any other competent physician would use in
There is breach of duty of care, skill and diligence, or the treating the same condition as Peter’s under similar
improper performance of such duty, by the attending physician circumstances; and (3) that the injury or damage to Peter’s right
when the patient is injured in body or in health [and this] eye, i.e., his glaucoma, was the result of his use of Maxitrol, as
constitutes the actionable malpractice.80 Proof of such breach prescribed by Dr. Tuaño. Petitioners’ failure to prove the first
must likewise rest upon the testimony of an expert witness that element alone is already fatal to their cause.
the treatment accorded to the patient failed to meet the standard
level of care, skill and diligence which physicians in the same Petitioners maintain that Dr. Tuaño failed to follow in Peter’s case
the required procedure for the prolonged use of Maxitrol. But
what is actually the required procedure in situations such as in the action cannot be based on speculation or conjecture. Causation
case at bar? To be precise, what is the standard operating must be proven within a reasonable medical probability based
procedure when ophthalmologists prescribe steroid medications upon competent expert testimony.93
which, admittedly, carry some modicum of risk?
The causation between the physician’s negligence and the
Absent a definitive standard of care or diligence required of Dr. patient’s injury may only be established by the presentation of
Tuaño under the circumstances, we have no means to determine proof that Peter’s glaucoma would not have occurred but for Dr.
whether he was able to comply with the same in his diagnosis and Tuaño’s supposed negligent conduct. Once more, petitioners
treatment of Peter. This Court has no yardstick upon which to failed in this regard.
evaluate or weigh the attendant facts of this case to be able to
state with confidence that the acts complained of, indeed, Dr. Tuaño does not deny that the use of Maxitrol involves the risk
constituted negligence and, thus, should be the subject of of increasing a patient’s IOP. In fact, this was the reason why he
pecuniary reparation. made it a point to palpate Peter’s eyes every time the latter went
to see him -- so he could monitor the tension of Peter’s eyes. But
Petitioners assert that prior to prescribing Maxitrol, Dr. Tuaño to say that said medication conclusively caused Peter’s glaucoma
should have determined first whether Peter was a "steroid is purely speculative. Peter was diagnosed with open-angle
responder."87 Yet again, petitioners did not present any glaucoma. This kind of glaucoma is characterized by an almost
convincing proof that such determination is actually part of the complete absence of symptoms and a chronic, insidious course.94
standard operating procedure which ophthalmologists should In open-angle glaucoma, halos around lights and blurring of
unerringly follow prior to prescribing steroid medications. vision do not occur unless there has been a sudden increase in the
intraocular vision.95 Visual acuity remains good until late in the
In contrast, Dr. Tuaño was able to clearly explain that what is course of the disease.96 Hence, Dr. Tuaño claims that Peter’s
only required of ophthalmologists, in cases such as Peter’s, is the glaucoma "can only be long standing x x x because of the large
conduct of standard tests/procedures known as "ocular routine C:D97 ratio," and that "[t]he steroids provoked the latest
examination,"88 composed of five (5) tests/procedures – glaucoma to be revealed earlier" was a blessing in disguise "as
specifically, gross examination of the eyes and the surrounding [Peter] remained asymptomatic prior to steroid application."
area; taking of the visual acuity of the patient; checking the
intraocular pressure of the patient; checking the motility of the Who between petitioners and Dr. Tuaño is in a better position to
eyes; and using ophthalmoscopy on the patient’s eye – and he did determine and evaluate the necessity of using Maxitrol to cure
all those tests/procedures every time Peter went to see him for Peter’s EKC vis-à-vis the attendant risks of using the same?
follow-up consultation and/or check-up.
That Dr. Tuaño has the necessary training and skill to practice his
We cannot but agree with Dr. Tuaño’s assertion that when a chosen field is beyond cavil. Petitioners do not dispute Dr.
doctor sees a patient, he cannot determine immediately whether Tuaño’s qualifications – that he has been a physician for close to a
the latter would react adversely to the use of steroids; all the decade and a half at the time Peter first came to see him; that he
doctor can do is map out a course of treatment recognized as has had various medical training; that he has authored numerous
correct by the standards of the medical profession. It must be papers in the field of ophthalmology, here and abroad; that he is a
remembered that a physician is not an insurer of the good result of Diplomate of the Philippine Board of Ophthalmology; that he
treatment. The mere fact that the patient does not get well or that a occupies various teaching posts (at the time of the filing of the
bad result occurs does not in itself indicate failure to exercise due present complaint, he was the Chair of the Department of
care.89 The result is not determinative of the performance [of the Ophthalmology and an Associate Professor at the University of
physician] and he is not required to be infallible.90 the Philippines-Philippine General Hospital and St. Luke’s
Medical Center, respectively); and that he held an assortment of
Moreover, that Dr. Tuaño saw it fit to prescribe Maxitrol to Peter positions in numerous medical organizations like the Philippine
was justified by the fact that the latter was already using the same Medical Association, Philippine Academy of Ophthalmology,
medication when he first came to see Dr. Tuaño on 2 September Philippine Board of Ophthalmology, Philippine Society of
1988 and had exhibited no previous untoward reaction to that Ophthalmic Plastic and Reconstructive Surgery, Philippine
particular drug. 91 Journal of Ophthalmology, Association of Philippine
Ophthalmology Professors, et al.
Also, Dr. Tuaño categorically denied petitioners’ claim that he
never monitored the tension of Peter’s eyes while the latter was It must be remembered that when the qualifications of a physician
on Maxitrol. Dr. Tuaño testified that he palpated Peter’s eyes are admitted, as in the instant case, there is an inevitable
every time the latter came for a check-up as part of the doctor’s presumption that in proper cases, he takes the necessary
ocular routine examination, a fact which petitioners failed to precaution and employs the best of his knowledge and skill in
rebut. Dr. Tuaño’s regular conduct of examinations and tests to attending to his clients, unless the contrary is sufficiently
ascertain the state of Peter’s eyes negate the very basis of established.98 In making the judgment call of treating Peter’s
petitioners’ complaint for damages. As to whether Dr. Tuaño’s EKC with Maxitrol, Dr. Tuaño took the necessary precaution by
actuations conformed to the standard of care and diligence palpating Peter’s eyes to monitor their IOP every time the latter
required in like circumstances, it is presumed to have so went for a check-up, and he employed the best of his knowledge
conformed in the absence of evidence to the contrary. and skill earned from years of training and practice.

Even if we are to assume that Dr. Tuaño committed negligent acts In contrast, without supporting expert medical opinions,
in his treatment of Peter’s condition, the causal connection petitioners’ bare assertions of negligence on Dr. Tuaño’s part,
between Dr. Tuaño’s supposed negligence and Peter’s injury still which resulted in Peter’s glaucoma, deserve scant credit.
needed to be established. The critical and clinching factor in a
medical negligence case is proof of the causal connection between Our disposition of the present controversy might have been vastly
the negligence which the evidence established and the plaintiff’s different had petitioners presented a medical expert to establish
injuries.92 The plaintiff must plead and prove not only that he has their theory respecting Dr. Tuaño’s so-called negligence. In fact,
been injured and defendant has been at fault, but also that the the record of the case reveals that petitioners’ counsel recognized
defendant’s fault caused the injury. A verdict in a malpractice the necessity of presenting such evidence. Petitioners even gave
an undertaking to the RTC judge that Dr. Agulto or Dr. Aquino
would be presented. Alas, no follow-through on said undertaking SO ORDERED.
was made.1avvphi1

The plaintiff in a civil case has the burden of proof as he alleges

the affirmative of the issue. However, in the course of trial in a
civil case, once plaintiff makes out a prima facie case in his favor,
the duty or the burden of evidence shifts to defendant to
controvert plaintiff’s prima facie case; otherwise, a verdict must
be returned in favor of plaintiff.99 The party having the burden of
proof must establish his case by a preponderance of evidence.100
The concept of "preponderance of evidence" refers to evidence
which is of greater weight or more convincing than that which is
offered in opposition to it;101 in the last analysis, it means
probability of truth. It is evidence which is more convincing to the
court as worthy of belief than that which is offered in opposition
thereto.102 Rule 133, Section 1 of the Revised Rules of Court
provides the guidelines for determining preponderance of
evidence, thus:

In civil cases, the party having the burden of proof must establish
his case by a preponderance of evidence. In determining where
the preponderance or superior weight of evidence on the issues
involved lies the court may consider all the facts and
circumstances of the case, the witnesses’ manner of testifying,
their intelligence, their means and opportunity of knowing the
facts to which they are testifying, the nature of the facts to which
they testify, the probability or improbability of their testimony,
their interest or want of interest, and also their personal credibility
so far as the same legitimately appear upon the trial. The court
may also consider the number of witnesses, though the
preponderance is not necessarily with the greater number.

Herein, the burden of proof was clearly upon petitioners, as

plaintiffs in the lower court, to establish their case by a
preponderance of evidence showing a reasonable connection
between Dr. Tuaño’s alleged breach of duty and the damage
sustained by Peter’s right eye. This, they did not do. In reality,
petitioners’ complaint for damages is merely anchored on a
statement in the literature of Maxitrol identifying the risks of its
use, and the purported comment of Dr. Agulto – another doctor
not presented as witness before the RTC – concerning the
prolonged use of Maxitrol for the treatment of EKC.

It seems basic that what constitutes proper medical treatment is a

medical question that should have been presented to experts. If no
standard is established through expert medical witnesses, then
courts have no standard by which to gauge the basic issue of
breach thereof by the physician or surgeon. The RTC and Court of
Appeals, and even this Court, could not be expected to determine
on its own what medical technique should have been utilized for a
certain disease or injury. Absent expert medical opinion, the
courts would be dangerously engaging in speculations.

All told, we are hard pressed to find Dr. Tuaño liable for any
medical negligence or malpractice where there is no evidence, in
the nature of expert testimony, to establish that in treating Peter,
Dr. Tuaño failed to exercise reasonable care, diligence and skill
generally required in medical practice. Dr. Tuaño’s testimony,
that his treatment of Peter conformed in all respects to standard
medical practice in this locality, stands unrefuted. Consequently,
the RTC and the Court of Appeals correctly held that they had no
basis at all to rule that petitioners were deserving of the various
damages prayed for in their Complaint.

WHEREFORE, premises considered, the instant petition is

DENIED for lack of merit. The assailed Decision dated 27
September 2006 and Resolution dated 3 July 2007, both of the
Court of Appeals in CA-G.R. CV No. 68666, are hereby
AFFIRMED. No cost.
Bontilao vs Gerona tube. The doctrine of res ipsa liquitor allows the mere existence
GR No. 176675 September 15, 2010 of an injury to justify a presumption of negligence or the part of
the person who controls the instrument causing the injury,
Facts: On December 28, 1991, respondent Dr. Carlos Gerona, an provided that the following requisites concur:
orthopedic surgeon at the Vicente Gullas Memorial Hospital,
treated petitioner’s son, 8 y/o Allen Roy Bontilao, for a fractured 1. The accident is of a kind which ordinarily does not
right wrist. Respondent administered a “U-spint” and immobilized occur in the absence of someone’s negligence;
Allen’s wrist with a cast, then sent Allen home. On June 4, 1992, 2. It is caused by an instrumentality within the exclusive
Alen re-fractured the same wrist and was brought back to the control of the defendant or co-defendants;
hospital. The x-ray examination showed a complete fractured and 3. The possibility of contributing conduct which would
displacement bone, with the fragments overlapping each other. make the plaintiff responsible is eliminated.
Respondent performed a closed reduction procedure, with Dr.
Vicente Jabagat as the anesthesiologist. Then he placed Allen’s
arm in a plaster cast to immobilize it. He allowed Allen to go
home after the post reduction x-ray showed that the bones were G.R. No. 176675 : September 15, 2010]
properly aligned, but advised Allen’s mother, petitioner Sherlina
Bontilao, to bring Allen back for re-tightening of the cast not later SPS. ALFREDO BONTILAO AND SHERLINA BONTILAO,
than June 15, 1992. Allen was however, only brought back after PETITIONERS, VS. DR. CARLOS GERONA,
the said date. By then, because the cast had not be re-tightened, a RESPONDENT.
rotational deformity had developed in Allen’s arm. The x-ray
examination showed that the deformity was caused by a re- DECISION
displacement of the bone fragments, so it was agreed that an open
reduction surgery will be conducted on June 24, 1992 by the VILLARAMA, JR., J.:
respondent, again with Dr. Jabagat as the anesthesiologist. On the
said date, Sherlina was allowed to observe the operation behind a Before us is a petition for review on certiorari[1] under Rule 45 of
glass panel. Dr. Jabagat failed to intubate the patient after 5 the 1997 Rules of Civil Procedure, as amended, assailing the June
attempts so anesthesia was administered through a gas mask. 28, 2006 Decision[2] and January 19, 2007 Resolution[3] of the
Respondent asked Dr. Jabagat if the operation should be Court of Appeals (CA) in CA-G.R. CV No, 00201. The CA had
postponed given the failure to intubate, but Dr. Jabagat said that it reversed the March 23, 2004 Decision[4] of the Regional Trial
was alright to proceed. Respondent verified that Allen was Court (RTC) of Cebu City, Branch 6 and dismissed petitioners'
breathing properly before proceeding with the surgery. As complaint in Civil Case No. CEB-17822.
respondent was about to finish the suturing, Sherlina decided to
go out of the operating room to make a telephone call and wait for The facts are as follows:
her son. Later, she was informed that her son died on the
operating table. The cause of death was asphyxia due to the On December 28, 1991, respondent Dr. Carlos Gerona, an
congestion and edema of the epiglottis. Hence, a criminal, orthopedic surgeon at the Vicente Gullas Memorial Hospital,
administrative and civil case was filed by the parents of Allen treated petitioners' son, eight (8)-year-old Allen Key Bontilao
against the doctors for the negligence that caused Allen’s death. (Allen), for a fractured right wrist. Respondent administered a
"U-splint" and immobilized Allen's wrist with a cast, then sent
Issue: Whether or not respondent is liable for medical negligence Allen home. On June 4, 1992, Allen re-fractured the same wrist
due to the death of Allen. and was brought back to the hospital. The x-ray examination
showed a complete fracture and displacement of the bone, with
Held: No. The trial court erred in applying the doctrine of res the fragments overlapping each other. Respondent performed a
ipsa liquitor to pin liability on respondent for Allen’s death. Res closed reduction procedure, with Dr. Vicente Jabagat (Dr.
ipsa liquitor is a rebuttable presumption or influence that the Jabagat) as the anesthesiologist. Then he placed Allen's arm in a
defendant was negligent. The presumption only arises upon proof plaster cast to immobilize it. He allowed Allen to go home after
that the instrumentality causing injury was in the defendant’s the post reduction x-ray showed that the bones were properly
exclusive control, and that the accident was one which ordinarily aligned, but advised Allen's mother, petitioner Sherlina Bontilao
does not happen in the absence of negligence. It is a rule of (Sherlina), to bring Allen back for re-tightening of the cast not
evidence whereby negligence of the alleged wrong does may be later than June 15, 1992.
inferred from the mere fact that the accident happened, provided
that the character of the accident and circumstances attending it Allen, however, was brought back to the hospital only on June
lead reasonably to the belief that in the absence of negligence it 1992. By then, because the cast had not been re-tightened, a
would not have occurred and that the thing which caused injury is rotational deformity had developed in Allen's arm. The x-ray
shown to have been under the management and control of the examination showed that the deformity was caused by a re-
alleged wrong doer. displacement of the bone fragments, so it was agreed that an open
reduction surgery will be conducted on June 24, 1992 by
respondent, again with Dr. Jabagat as the anesthesiologist.
Res ipsa liquitor is not a rigid or ordinary doctrine to be
perfunctorily used but a rule to be cautiously applied defending On the said date, Sherlina was allowed to observe the operation
upon the circumstances of each case. In malpractice case, the behind a glass panel. Dr. Jabagat failed to intubate the patient
doctrine is generally restricted to situations where a layman is after five (5) attempts so anesthesia was administered through a
able to say, as a matter of common knowledge and observation, gas mask. Respondent asked Dr. Jabagat if the operation should
that the consequence of professional care were not as such as be postponed given the failure to intubate, but Dr. Jabagat said
would ordinarily have followed if due care had been exercised. that it was alright to proceed. Respondent verified that Allen was
breathing properly before proceeding with the surgery.[5] As
Moreover, we note that in the instant case, the instrument which respondent was about to finish the suturing, Sherlina decided to
caused the injury or damage was not even within respondent’s go out of the operating
exclusive control and management as Dr. Jabagat was exclusively
in control and management of the anesthesia and endotracheal
room to make a telephone call and wait for her son. Later, she was
informed that her son had died on the operating table. The cause Petitioners filed the present petition on the following grounds:
of death was "asphyxia due to congestion and edema of the
epiglottis."[6] [1] THE COURT OF APPEALS ERRED IN REVERSING THE
DECISION OF THE REGIONAL TRIAL COURT BY
Aside from criminal and administrative cases, petitioners filed a DISMISSING THE COMPLAINT IN SO FAR AS THE
complaint for damages against both respondent and Dr. Jabagat in
the RTC of Cebu City alleging negligence and incompetence on SURGEON, DR. CARLOS GERONA IS CONCERNED
the part of the doctors. The documentary evidence and [AFTER] CONCLUDING THAT HE IS NOT SOLIDARILY
testimonies of several witnesses presented in the criminal LIABLE WITH HIS CO-DEFENDANT, DR. VICENTE
proceedings were offered and admitted in evidence at the RTC. JABAGAT, THE ANESTHESIOLOGIST, IN THE ABSENCE
OF ANY NEGLIGENT ACT ON HIS PART.
On March 23, 2004, the RTC decided in favor of the petitioners.
It held that the doctrine of res ipsa loquitur was applicable in [2] THE COURT OF APPEALS ERRED WHEN IT
establishing respondent's liability. According to the RTC, MISAPPRECIATED ESSENTIAL FACTS OF THE CASE
asphyxia or cardiac arrest does not normally occur in an operation THAT LED TO ITS FINDINGS THAT DOCTRINE OF RES
on a fractured bone in the absence of negligence in the IPSA LOQUITfUJR AS APPLIED IN THE RAMOS CASE IS
administration of anesthesia and the use of an endotracheal tube. NOT APPLICABLE IN THE INSTANT CASE.[10]
Also, the instruments used in the administration of anesthesia
were all under the exclusive control of respondent and Dr. Essentially, the issue before us is whether respondent is liable for
Jabagat, and neither Allen nor his mother could be said to be damages for Allen's death.
guilty of contributory negligence. Thus, the trial court held that
respondent and Dr. Jabagat were solidarity liable for they failed to Petitioners argued that the doctrine of res ipsa loquitur applies to
prove that they were not negligent. The trial court likewise said the present case because Allen was healthy, fully conscious,
that respondent cannot shift the blame solely to Dr. Jabagat as the coherent, and ambulant when he went to the hospital to correct a
fault of the latter is also the fault of the former, respondent being deformed arm. Yet, he did not survive the operation, which was
the attending physician and being equally in care, custody and not even an emergency surgery but a corrective one. They
control of Allen.[7] contend that respondent, being the lead surgeon, should be held
liable for the negligence of the physicians and nurses working
Aggrieved, respondent appealed the trial court's decision to the with him during the operation.
CA. Dr. Jabagat, for his part, no longer appealed the decision.
On the other hand, respondent posited that he should not be held
On June 28, 2006, the CA reversed the RTC's ruling. It held that solidarity liable with Dr. Jabagat as they were employed
the doctrine of res ipsa loquitur does not apply for it must be independently from each other and their services were divided as
satisfactorily shown that (1) the accident is of a kind which their best judgment dictated. He insisted that the captain-of-the-
ordinarily does not occur in the absence of someone's negligence; ship doctrine had long been abandoned especially in this age of
(2) the plaintiff was not guilty of contributory conduct; and (3) the specialization. An anesthesiologist and a surgeon are specialists
instrumentality which caused the accident was within the control in their own field and neither one (1) could dictate upon the other.
of the defendant. The CA was correct in finding that the Ramos case does not apply
to respondent. Dr. Jabagat was contracted separately from
The CA held that while it may be true that an Open Reduction and respondent and was chosen by petitioner Sherlina. Respondent
Internal Fixation or ORIF could not possibly lead to a patient's was only a few minutes late from the operation and he waited for
death unless somebody was negligent, still what was involved in the signal of the anesthesiologist to start the procedure. He also
this case was a surgical procedure with all risks attendant, determined the condition of Allen before and after the operation.
including death. As explained by the expert testimony,
unexplained death and mal-occurrence is a possibility in surgical We affirm the assailed CA decision.
procedures especially those involving the administration of
general anesthesia. It had also been established in both the The trial court erred in applying the doctrine of res ipsa loquitur to
criminal and administrative cases against respondent that Allen's pin liability on respondent for Allen's death. Res ipsa loquitur is a
death was the result of the anesthesiologist's negligence and not rebuttable presumption or inference that the defendant was
his.[8] negligent. The presumption only arises upon proof that the
instrumentality causing injury was in the defendant's exclusive
The CA added that the trial court erred in applying the "captain of control, and that the accident was one (1) which ordinarily does
the ship" doctrine to make respondent liable even though he was not happen in the absence of negligence. It is a rule of evidence
the lead surgeon. The CA noted that unlike in Ramos v. Court of whereby negligence of the alleged wrongdoer may be inferred
Appeals,[9] relied upon by the trial court, the anesthesiologist was from the mere fact that the accident happened, provided that the
chosen by petitioners and no specific act of negligence was character of the accident and circumstances attending it lead
attributable to respondent. The alleged failure to perform a skin reasonably to the belief that in the absence of negligence it would
test and a tracheotomy does not constitute negligence. not have occurred and that the thing which caused injury is shown
Tracheotomy is an emergency procedure, and its performance is a to have been under the management and control of the alleged
judgment call of the attending physician as it is another surgical wrongdoer.[11]
procedure done during instances of failure of intubation. On the
other hand, a skin test for a patient's possible adverse reaction to Under this doctrine, the happening of an injury permits an
the anesthesia to be administered is the anesthesiologist's inference of negligence where the plaintiff produces substantial
decision. The CA also noted that the same anesthesia was evidence that the injury was caused by an agency or
previously administered to Allen and he did not manifest any instrumentality under the exclusive control and management of
allergic reaction to it. Finally, unlike in the Ramos case, the defendant, and that the injury was such that in the ordinary
respondent arrived only a few minutes late for the surgery and he course of things would not happen if reasonable care had been
was able to complete the procedure within the estimated time used.[12]
frame of less than an hour.
However, res ipsa loquitur is not a rigid or ordinary doctrine to be trial court's ruling. Petitioners failed to present substantial proof
perfunctorily used but a rule to be cautiously applied, depending that intubation was an indispensable prerequisite for the operation
upon the circumstances of each case.[13] In malpractice cases, and that it would be grave error for any surgeon to continue with
the doctrine is generally restricted to situations where a layman is the operation under such circumstances. In fact, the testimony of
able to say, as a matter of common knowledge and observation, the expert witness presented by the prosecution in the criminal
that the consequences of professional care were not as such as proceedings and admitted into evidence at the RTC, was even to
would ordinarily have followed if due care had been exercised. In the effect that the anesthesia could be administered by alternative
other words, as held in Ramos v. Court of Appeals,[14] the real means such as a mask and that the operation could proceed even
question is whether or not in the process of the operation, any without intubation.[17]
extraordinary incident or unusual event outside of the routine
performance occurred which is beyond the regular scope of There was also no indication in the records that respondent saw or
professional activity in such operations, and which, if should have seen that something was wrong as to prompt him to
unexplained, would themselves reasonably speak to the average act differently than he did in this case. The anesthesia used in the
man as the negligent cause or causes of the untoward operation was the same anesthesia used in the previous closed
consequence. reduction procedure, and Allen did not register any adverse
reaction to it. In fact, respondent knows the anesthesia Ketalar to
Here, we find that the CA correctly found that petitioners failed to be safe for children. Dr. Jabagat was also a specialist and more
present substantial evidence of any specific act of negligence on competent than respondent to determine whether the patient has
respondent's part or of the surrounding facts and circumstances been properly anesthetized for the operation, all things
which would lead to the reasonable inference that the untoward considered. Lastly, it appears that Allen started experiencing
consequence was caused by respondent's negligence. In fact, difficulty in breathing only after the operation, when respondent
under the established facts, respondent appears to have observed was already about to jot down his post-operation notes in the
the proper amount of care required under the circumstances. adjacent room. Respondent was called back to the operating
Having seen that Dr. Jabagat failed in the intubation, respondent room after Dr. Jabagat failed to appreciate a heartbeat on the
inquired from the latter, who was the expert on the matter of patient.[18] He acted promptly and called for other doctors to
administering anesthesia, whether the surgery should be assist and revive Allen, but to no avail.
postponed considering the failure to intubate. Respondent
testified, Moreover, we note that in the instant case, the instrument which
caused the damage or injury was not even within respondent's
WITNESS: exclusive management and control as Dr. Jabagat was exclusively
in control and management of the anesthesia and the endotracheal
A- tube. The doctrine of res ipsa loquitur allows the mere existence
Actually sir, if I may cut short, I'm sorry. I don't know what is the of an injury to justify a presumption of negligence on the part of
term of this sir. But what actually, what we had was that Dr. the person who controls the instrument causing the injury,
Jabagat failed in the intubation. He was not able to insert the tube. provided that the following requisites concur:

ATTY. PADILLA: 1. The accident is of a kind which ordinarily does not occur in the
absence of someone's negligence:
Q-
And you noticed that he failed? 2. It is caused by an instrumentality within the exclusive control
A- of the defendant or defendants; and
Yes, sir.
3. The possibility of contributing conduct which would make the
xxxx plaintiff responsible is eliminated.[19]

ATTY. PADILLA: Here, the respondent could only supervise Dr. Jabagat to make
sure that he was performing his duties. But respondent could not
Q- dictate upon Dr. Jabagat the particular anesthesia to administer,
And you noticed that he failed and still you continued the surgery, the dosage thereof, or that it be administered in any particular way
Dr. Gerona? not deemed appropriate by Dr. Jabagat. Respondent's
A- specialization not being in the field of anesthesiology, it would be
Yes, I continued the surgery. dangerous for him to substitute his judgment for Dr. Jabagat's
decisions in matters that fall appropriately within the scope of Dr.
xxxx Jabagat's expertise.

COURT: Under the above circumstances, although the Court commiserates

with the petitioners on their infinitely sorrowful loss, the Court
Q- cannot properly declare that respondent failed to exercise the
Did not Dr. Jabagat advise you not to proceed with the operation required standard of care as lead surgeon as to hold him liable for
because the tube cannot be inserted? damages for Allen's death.
A-
No, sir. In fact, I was the one who asked him, sir, the tube is not In civil cases, the burden of proof to be established by
inserted, shall we postpone this for another date? He said, it's preponderance of evidence is on the plaintiff who is asserting the
alright.[15] affirmative of an issue.20 Unless the party asserting the
affirmative of an issue sustains the burden of proof, his or her
Respondent further verified that Allen was still breathing by cause will not succeed.
looking at his chest to check that there was excursion before
proceeding with the surgery.[16] That respondent decided to WHEREFORE, the petition is DENIED. The Decision dated June
continue with the surgery even though there was a failure to 28, 2006 and Resolution dated January 19, 2007 of the Court of
intubate also does not tend to establish liability, contrary to the Appeals in CA-G.R. CV No. 00201 are AFFIRMED.
Dr Li vs Sps Soliman gravamen in an informed consent case requires the plaintiff
to point to significant undisclosed information relating to the
Facts: treatment which would have altered her decision to undergo it.

This case involved the death of Angelica Soliman, There was adequate disclosure of material risk inherent in the
respondents’ 11-year old daughter. Previously, Angelica was chemotherapy procedure performed with the consent of
diagnosed withosteosarcoma, osteoblastic type, a highly Angelica’s parents. [The parents] could not have been
malignant cancer of the [thigh] bone. To remove the tumor, her unaware in the course of initial treatment and amputation of
right leg was amputated. And to eliminate any remaining cancer Angelica’s lower extremity, that her immune system was already
cells and minimize the chances of recurrence and prevent the weak on account of the malignant tumor in her knee. When
disease from spreading to other parts of her body [the doctor] informed the [parents] beforehand of the side
(metastasis), she subsequently underwent chemotherapy. The effects of chemotherapy[,] which includes lowered counts of
chemotherapy was administered by petitioner Dr. Rubi Li, an white and red blood cells, decrease in blood platelets,
oncologist at St. Luke’s Medical Center (SLMC) upon possible kidney or heart damage and skin darkening, there is
consent by her parents, herein respondents. Angelica died just reasonable expectation on the part of the doctor that the
eleven days after the administration of the first cycle of the parents understood very well that the severity of these side
chemotherapy regimen. effects will not be the same for all patients undergoing the
procedure.
The parents of the child thereafter sued the doctor for
damages before the RTC, charging the latter (along with other
doctors and the SLMC itself) with negligence in causing
Angelica’s untimely demise. It was specifically averred in the As a physician, petitioner can reasonably expect the parents
complaint that the doctor assured the parents that Angelica to have considered the variables in the
would recover in view of 95% chance of healing with recommended treatment for their daughter afflicted with a life-
chemotherapy (“Magiging normal na ang anak nyo basta ma- threatening illness. On the other hand, it is difficult to give
chemo. 95% ang healing”), and when asked regarding the credence to respondent’s claim that petitioner told them of 95%
side effects, petitioner mentioned only slight vomiting, hair chance of recovery for their daughter, as it was unlikely for
loss and weakness (“Magsusuka ng kaunti. Malulugas ang doctors like petitioner who were dealing with grave conditions
buhok. Manghihina”). The parents thus claimed that they would such as cancer to have falsely assured patients of
not have given their consent to chemotherapy had the doctor not chemotherapy’s success rate. Besides, informed consent laws
falsely assured them of its side effects. in other countries generally require only a reasonable
explanation of potential harms, so specific disclosures such as
statistical data, may not be legally necessary.
The trial court however dismissed the case. It found that the
doctor was not liable for damages as she
observed the best known procedures and employed her The element of ethical duty to disclose material risks in the
highest skill and knowledge in the proposed medical treatment cannot thus be reduced to one
administration of chemotherapy drugs on Angelica [though] simplistic formula applicable in all instances. Further, in a
despite all efforts said patient died. medical malpractice action based on lack of informed consent,
the plaintiff must prove both the duty and the breach of that duty
through expert testimony. Such expert testimony must show
The parents appealed to the Court of Appeals (CA). While the customary standard of care of physicians in the same
concurring with the trial court’s finding that there was no practice as that of the defendant doctor.
negligence committed by the petitioner in the administration of
chemotherapy treatment to Angelica, the CA found that the
doctor failed to fully explain to the parents of the patient all In this case, the testimony of Dr. Balmaceda [witness for the girl’s
the known side effects of chemotherapy. The CA thus adjudged parents] who is not an oncologist but a Medical Specialist of
the doctor liable for damages. the DOH’s Operational and Management Services charged
with receiving complaints against hospitals, does not qualify
as expert testimony to establish the standard of care in
The doctor then appealed to the Supreme Court (SC), raising obtaining consent for chemotherapy treatment. In the absence
the following issue: Under the facts, can she be held liable [of of expert testimony in this regard, the Court felt hesitant
failing] to fully disclose serious side effects of chemotherapy to defining the scope of mandatory disclosure in cases of
the parents of her patient despite the absence of finding that she malpractice based on lack of
was negligent in administering the said treatment. informed consent, much less set a standard of disclosure
that, even in foreign jurisdictions, has been noted to be an
Issue: evolving one.
G.R. No. 165279 June 7, 2011
Whether or not there is malpractice
DR. RUBI LI, Petitioner,
vs.
Held: SPOUSES REYNALDO and LINA SOLIMAN, as parents/heirs
of deceased Angelica Soliman, Respondents.
As indicated above, Justice Villarama ruled that there are four
essential elements a plaintiff must prove in a malpractice action DECISION
based upon the doctrine of informed consent: (1) the
physician had a duty to disclose material risks; (2) he failed to VILLARAMA, JR., J.:
disclose or inadequately disclosed those risks; (3) as a direct and
proximate result of the failure to disclose, the patient consented to Challenged in this petition for review on certiorari is the
treatment she otherwise would not have consented to; and (4) Decision1 dated June 15, 2004 as well as the Resolution2 dated
plaintiff was injured by the proposed treatment. The September 1, 2004 of the Court of Appeals (CA) in CA-G.R. CV
No. 58013 which modified the Decision3 dated September 5, (cachexia) and functionally in the form of lower resistance of the
1997 of the Regional Trial Court of Legazpi City, Branch 8 in body to combat infection. Such infection becomes uncontrollable
Civil Case No. 8904. and triggers a chain of events (sepsis or septicemia) that may lead
to bleeding in the form of Disseminated Intravascular Coagulation
The factual antecedents: (DIC), as what the autopsy report showed in the case of Angelica.

On July 7, 1993, respondents’ 11-year old daughter, Angelica Since the medical records of Angelica were not produced in court,
Soliman, underwent a biopsy of the mass located in her lower the trial and appellate courts had to rely on testimonial evidence,
extremity at the St. Luke’s Medical Center (SLMC). Results principally the declarations of petitioner and respondents
showed that Angelica was suffering from osteosarcoma, themselves. The following chronology of events was gathered:
osteoblastic type,4 a high-grade (highly malignant) cancer of the
bone which usually afflicts teenage children. Following this On July 23, 1993, petitioner saw the respondents at the hospital
diagnosis and as primary intervention, Angelica’s right leg was after Angelica’s surgery and discussed with them Angelica’s
amputated by Dr. Jaime Tamayo in order to remove the tumor. As condition. Petitioner told respondents that Angelica should be
adjuvant treatment to eliminate any remaining cancer cells, and given two to three weeks to recover from the operation before
hence minimize the chances of recurrence and prevent the disease starting chemotherapy. Respondents were apprehensive due to
from spreading to other parts of the patient’s body (metastasis), financial constraints as Reynaldo earns only from ₱70,000.00 to
chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo ₱150,000.00 a year from his jewelry and watch repairing
referred Angelica to another doctor at SLMC, herein petitioner business.9 Petitioner, however, assured them not to worry about
Dr. Rubi Li, a medical oncologist. her professional fee and told them to just save up for the
medicines to be used.
On August 18, 1993, Angelica was admitted to SLMC. However,
she died on September 1, 1993, just eleven (11) days after the Petitioner claimed that she explained to respondents that even
(intravenous) administration of the first cycle of the chemotherapy when a tumor is removed, there are still small lesions
regimen. Because SLMC refused to release a death certificate undetectable to the naked eye, and that adjuvant chemotherapy is
without full payment of their hospital bill, respondents brought needed to clean out the small lesions in order to lessen the chance
the cadaver of Angelica to the Philippine National Police (PNP) of the cancer to recur. She did not give the respondents any
Crime Laboratory at Camp Crame for post-mortem examination. assurance that chemotherapy will cure Angelica’s cancer. During
The Medico-Legal Report issued by said institution indicated the these consultations with respondents, she explained the following
cause of death as "Hypovolemic shock secondary to multiple side effects of chemotherapy treatment to respondents: (1) falling
organ hemorrhages and Disseminated Intravascular hair; (2) nausea and vomiting; (3) loss of appetite; (4) low count
Coagulation."5 of white blood cells [WBC], red blood cells [RBC] and platelets;
(5) possible sterility due to the effects on Angelica’s ovary; (6)
On the other hand, the Certificate of Death6 issued by SLMC damage to the heart and kidneys; and (7) darkening of the skin
stated the cause of death as follows: especially when exposed to sunlight. She actually talked with
respondents four times, once at the hospital after the surgery,
Immediate cause : a. Osteosarcoma, Status Post AKA twice at her clinic and the fourth time when Angelica’s mother
called her through long distance.10 This was disputed by
Antecedent cause : b. (above knee amputation) respondents who countered that petitioner gave them assurance
that there is 95% chance of healing for Angelica if she undergoes
Underlying cause : c. Status Post Chemotherapy chemotherapy and that the only side effects were nausea,
vomiting and hair loss.11 Those were the only side-effects of
On February 21, 1994, respondents filed a damage suit7 against chemotherapy treatment mentioned by petitioner.12
petitioner, Dr. Leo Marbella, Mr. Jose Ledesma, a certain Dr.
Arriete and SLMC. Respondents charged them with negligence On July 27, 1993, SLMC discharged Angelica, with instruction
and disregard of Angelica’s safety, health and welfare by their from petitioner that she be readmitted after two or three weeks for
careless administration of the chemotherapy drugs, their failure to the chemotherapy.
observe the essential precautions in detecting early the symptoms
of fatal blood platelet decrease and stopping early on the On August 18, 1993, respondents brought Angelica to SLMC for
chemotherapy, which bleeding led to hypovolemic shock that chemotherapy, bringing with them the results of the laboratory
caused Angelica’s untimely demise. Further, it was specifically tests requested by petitioner: Angelica’s chest x-ray, ultrasound of
averred that petitioner assured the respondents that Angelica the liver, creatinine and complete liver function tests.13 Petitioner
would recover in view of 95% chance of healing with proceeded with the chemotherapy by first administering hydration
chemotherapy ("Magiging normal na ang anak nyo basta ma- fluids to Angelica.14
chemo. 95% ang healing") and when asked regarding the side
effects, petitioner mentioned only slight vomiting, hair loss and The following day, August 19, petitioner began administering
weakness ("Magsusuka ng kaunti. Malulugas ang buhok. three chemotherapy drugs – Cisplatin,15 Doxorubicin16 and
Manghihina"). Respondents thus claimed that they would not Cosmegen17 – intravenously. Petitioner was supposedly assisted
have given their consent to chemotherapy had petitioner not by her trainees Dr. Leo Marbella18 and Dr. Grace Arriete.19 In
falsely assured them of its side effects. his testimony, Dr. Marbella denied having any participation in
administering the said chemotherapy drugs.20
In her answer,8 petitioner denied having been negligent in
administering the chemotherapy drugs to Angelica and asserted On the second day of chemotherapy, August 20, respondents
that she had fully explained to respondents how the chemotherapy noticed reddish discoloration on Angelica’s face.21 They asked
will affect not only the cancer cells but also the patient’s normal petitioner about it, but she merely quipped, "Wala yan. Epekto ng
body parts, including the lowering of white and red blood cells gamot."22 Petitioner recalled noticing the skin rashes on the nose
and platelets. She claimed that what happened to Angelica can be and cheek area of Angelica. At that moment, she entertained the
attributed to malignant tumor cells possibly left behind after possibility that Angelica also had systemic lupus and consulted
surgery. Few as they may be, these have the capacity to compete Dr. Victoria Abesamis on the matter.23
for nutrients such that the body becomes so weak structurally
On the third day of chemotherapy, August 21, Angelica had Respondents claimed that Angelica passed about half a liter of
difficulty breathing and was thus provided with oxygen inhalation blood through her anus at around seven o’clock that evening,
apparatus. This time, the reddish discoloration on Angelica’s face which petitioner likewise denied.
had extended to her neck, but petitioner dismissed it again as
merely the effect of medicines.24 Petitioner testified that she did On August 30, Angelica continued bleeding. She was restless as
not see any discoloration on Angelica’s face, nor did she notice endotracheal and nasogastric tubes were inserted into her
any difficulty in the child’s breathing. She claimed that Angelica weakened body. An aspiration of the nasogastric tube inserted to
merely complained of nausea and was given ice chips.251avvphi1 Angelica also revealed a bloody content. Angelica was given
more platelet concentrate and fresh whole blood, which petitioner
On August 22, 1993, at around ten o’clock in the morning, upon claimed improved her condition. Petitioner told Angelica not to
seeing that their child could not anymore bear the pain, remove the endotracheal tube because this may induce further
respondents pleaded with petitioner to stop the chemotherapy. bleeding.35 She was also transferred to the intensive care unit to
Petitioner supposedly replied: "Dapat 15 Cosmegen pa iyan. avoid infection.
Okay, let’s observe. If pwede na, bigyan uli ng chemo." At this
point, respondents asked petitioner’s permission to bring their The next day, respondents claimed that Angelica became
child home. Later in the evening, Angelica passed black stool and hysterical, vomited blood and her body turned black. Part of
reddish urine.26 Petitioner countered that there was no record of Angelica’s skin was also noted to be shredding by just rubbing
blackening of stools but only an episode of loose bowel cotton on it. Angelica was so restless she removed those gadgets
movement (LBM). Petitioner also testified that what Angelica attached to her, saying "Ayaw ko na"; there were tears in her eyes
complained of was carpo-pedal spasm, not convulsion or epileptic and she kept turning her head. Observing her daughter to be at the
attack, as respondents call it (petitioner described it in the point of death, Lina asked for a doctor but the latter could not
vernacular as "naninigas ang kamay at paa"). She then requested answer her anymore.36 At this time, the attending physician was
for a serum calcium determination and stopped the chemotherapy. Dr. Marbella who was shaking his head saying that Angelica’s
When Angelica was given calcium gluconate, the spasm and platelets were down and respondents should pray for their
numbness subsided.27 daughter. Reynaldo claimed that he was introduced to a
pediatrician who took over his daughter’s case, Dr. Abesamis who
The following day, August 23, petitioner yielded to respondents’ also told him to pray for his daughter. Angelica continued to have
request to take Angelica home. But prior to discharging Angelica, difficulty in her breathing and blood was being suctioned from her
petitioner requested for a repeat serum calcium determination and stomach. A nurse was posted inside Angelica’s room to assist her
explained to respondents that the chemotherapy will be breathing and at one point they had to revive Angelica by
temporarily stopped while she observes Angelica’s muscle pumping her chest. Thereafter, Reynaldo claimed that Angelica
twitching and serum calcium level. Take-home medicines were already experienced difficulty in urinating and her bowel
also prescribed for Angelica, with instructions to respondents that consisted of blood-like fluid. Angelica requested for an electric
the serum calcium test will have to be repeated after seven days. fan as she was in pain. Hospital staff attempted to take blood
Petitioner told respondents that she will see Angelica again after samples from Angelica but were unsuccessful because they could
two weeks, but respondents can see her anytime if any immediate not even locate her vein. Angelica asked for a fruit but when it
problem arises.28 was given to her, she only smelled it. At this time, Reynaldo
claimed he could not find either petitioner or Dr. Marbella. That
However, Angelica remained in confinement because while still night, Angelica became hysterical and started removing those
in the premises of SLMC, her "convulsions" returned and she also gadgets attached to her. At three o’clock in the morning of
had LBM. Angelica was given oxygen and administration of September 1, a priest came and they prayed before Angelica
calcium continued.29 expired. Petitioner finally came back and supposedly told
respondents that there was "malfunction" or bogged-down
The next day, August 24, respondents claimed that Angelica still machine.37
suffered from convulsions. They also noticed that she had a fever
and had difficulty breathing.30 Petitioner insisted it was carpo- By petitioner’s own account, Angelica was merely irritable that
pedal spasm, not convulsions. She verified that at around 4:50 that day (August 31). Petitioner noted though that Angelica’s skin was
afternoon, Angelica developed difficulty in breathing and had indeed sloughing off.38 She stressed that at 9:30 in the evening,
fever. She then requested for an electrocardiogram analysis, and Angelica pulled out her endotracheal tube.39 On September 1,
infused calcium gluconate on the patient at a "stat dose." She exactly two weeks after being admitted at SLMC for
further ordered that Angelica be given Bactrim,31 a synthetic chemotherapy, Angelica died.40 The cause of death, according to
antibacterial combination drug,32 to combat any infection on the petitioner, was septicemia, or overwhelming infection, which
child’s body.33 caused Angelica’s other organs to fail.41 Petitioner attributed this
to the patient’s poor defense mechanism brought about by the
By August 26, Angelica was bleeding through the mouth. cancer itself.42
Respondents also saw blood on her anus and urine. When Lina
asked petitioner what was happening to her daughter, petitioner While he was seeking the release of Angelica’s cadaver from
replied, "Bagsak ang platelets ng anak mo." Four units of platelet SLMC, Reynaldo claimed that petitioner acted arrogantly and
concentrates were then transfused to Angelica. Petitioner called him names. He was asked to sign a promissory note as he
prescribed Solucortef. Considering that Angelica’s fever was high did not have cash to pay the hospital bill.43
and her white blood cell count was low, petitioner prescribed
Leucomax. About four to eight bags of blood, consisting of Respondents also presented as witnesses Dr. Jesusa Nieves-
packed red blood cells, fresh whole blood, or platelet concentrate, Vergara, Medico-Legal Officer of the PNP-Crime Laboratory
were transfused to Angelica. For two days (August 27 to 28), who conducted the autopsy on Angelica’s cadaver, and Dr.
Angelica continued bleeding, but petitioner claimed it was lesser Melinda Vergara Balmaceda who is a Medical Specialist
in amount and in frequency. Petitioner also denied that there were employed at the Department of Health (DOH) Operations and
gadgets attached to Angelica at that time.34 Management Services.

On August 29, Angelica developed ulcers in her mouth, which Testifying on the findings stated in her medico-legal report, Dr.
petitioner said were blood clots that should not be removed. Vergara noted the following: (1) there were fluids recovered from
the abdominal cavity, which is not normal, and was due to efforts said patient died. It cited the testimony of Dr. Tamayo who
hemorrhagic shock secondary to bleeding; (2) there was testified that he considered petitioner one of the most proficient in
hemorrhage at the left side of the heart; (3) bleeding at the upper the treatment of cancer and that the patient in this case was
portion of and areas adjacent to, the esophagus; (4) lungs were afflicted with a very aggressive type of cancer necessitating
heavy with bleeding at the back and lower portion, due to chemotherapy as adjuvant treatment. Using the standard of
accumulation of fluids; (4) yellowish discoloration of the liver; negligence laid down in Picart v. Smith,47 the trial court declared
(5) kidneys showed appearance of facial shock on account of that petitioner has taken the necessary precaution against the
hemorrhages; and (6) reddishness on external surface of the adverse effect of chemotherapy on the patient, adding that a
spleen. All these were the end result of "hypovolemic shock wrong decision is not by itself negligence. Respondents were
secondary to multiple organ hemorrhages and disseminated ordered to pay their unpaid hospital bill in the amount of
intravascular coagulation." Dr. Vergara opined that this can be ₱139,064.43.48
attributed to the chemical agents in the drugs given to the victim,
which caused platelet reduction resulting to bleeding sufficient to Respondents appealed to the CA which, while concurring with the
cause the victim’s death. The time lapse for the production of DIC trial court’s finding that there was no negligence committed by
in the case of Angelica (from the time of diagnosis of sarcoma) the petitioner in the administration of chemotherapy treatment to
was too short, considering the survival rate of about 3 years. The Angelica, found that petitioner as her attending physician failed to
witness conceded that the victim will also die of osteosarcoma fully explain to the respondents all the known side effects of
even with amputation or chemotherapy, but in this case chemotherapy. The appellate court stressed that since the
Angelica’s death was not caused by osteosarcoma. Dr. Vergara respondents have been told of only three side effects of
admitted that she is not a pathologist but her statements were chemotherapy, they readily consented thereto. Had petitioner
based on the opinion of an oncologist whom she had interviewed. made known to respondents those other side effects which gravely
This oncologist supposedly said that if the victim already had DIC affected their child -- such as carpo-pedal spasm, sepsis, decrease
prior to the chemotherapy, the hospital staff could have detected in the blood platelet count, bleeding, infections and eventual death
it.44 -- respondents could have decided differently or adopted a
different course of action which could have delayed or prevented
On her part, Dr. Balmaceda declared that it is the physician’s duty the early death of their child.
to inform and explain to the patient or his relatives every known
side effect of the procedure or therapeutic agents to be The CA thus declared:
administered, before securing the consent of the patient or his
relatives to such procedure or therapy. The physician thus bases Plaintiffs-appellants’ child was suffering from a malignant
his assurance to the patient on his personal assessment of the disease. The attending physician recommended that she undergo
patient’s condition and his knowledge of the general effects of the chemotherapy treatment after surgery in order to increase her
agents or procedure that will be allowed on the patient. Dr. chances of survival. Appellants consented to the chemotherapy
Balmaceda stressed that the patient or relatives must be informed treatment because they believed in Dr. Rubi Li’s representation
of all known side effects based on studies and observations, even that the deceased would have a strong chance of survival after
if such will aggravate the patient’s condition.45 chemotherapy and also because of the representation of appellee
Dr. Rubi Li that there were only three possible side-effects of the
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on treatment. However, all sorts of painful side-effects resulted from
Angelica’s lower extremity, testified for the defendants. He the treatment including the premature death of Angelica. The
explained that in case of malignant tumors, there is no guarantee appellants were clearly and totally unaware of these other side-
that the ablation or removal of the amputated part will completely effects which manifested only during the chemotherapy treatment.
cure the cancer. Thus, surgery is not enough. The mortality rate of This was shown by the fact that every time a problem would take
osteosarcoma at the time of modern chemotherapy and early place regarding Angelica’s condition (like an unexpected side-
diagnosis still remains at 80% to 90%. Usually, deaths occur from effect manifesting itself), they would immediately seek
metastasis, or spread of the cancer to other vital organs like the explanation from Dr. Rubi Li. Surely, those unexpected side-
liver, causing systemic complications. The modes of therapy effects culminating in the loss of a love[d] one caused the
available are the removal of the primary source of the cancerous appellants so much trouble, pain and suffering.
growth and then the residual cancer cells or metastasis should be
treated with chemotherapy. Dr. Tamayo further explained that On this point therefore, [w]e find defendant-appellee Dr. Rubi Li
patients with osteosarcoma have poor defense mechanism due to negligent which would entitle plaintiffs-appellants to their claim
the cancer cells in the blood stream. In the case of Angelica, he for damages.
had previously explained to her parents that after the surgical
procedure, chemotherapy is imperative so that metastasis of these xxxx
cancer cells will hopefully be addressed. He referred the patient to
petitioner because he felt that petitioner is a competent oncologist. WHEREFORE, the instant appeal is hereby GRANTED.
Considering that this type of cancer is very aggressive and will Accordingly, the assailed decision is hereby modified to the
metastasize early, it will cause the demise of the patient should extent that defendant-appellee Dr. Rubi Li is ordered to pay the
there be no early intervention (in this case, the patient developed plaintiffs-appellants the following amounts:
sepsis which caused her death). Cancer cells in the blood cannot
be seen by the naked eye nor detected through bone scan. On 1. Actual damages of P139,064.43, plus P9,828.00 for funeral
cross-examination, Dr. Tamayo stated that of the more than 50 expenses;
child patients who had osteogenic sarcoma he had handled, he
thought that probably all of them died within six months from 2. Moral damages of P200,000.00;
amputation because he did not see them anymore after follow-up;
it is either they died or had seen another doctor.46 3. Exemplary damages of P50,000.00;

In dismissing the complaint, the trial court held that petitioner was 4. Attorney’s fee of P30,000.00.
not liable for damages as she observed the best known procedures
and employed her highest skill and knowledge in the SO ORDERED.49 (Emphasis supplied.)
administration of chemotherapy drugs on Angelica but despite all
Petitioner filed a motion for partial reconsideration which the provider would have done, or that he or she did something that a
appellate court denied. reasonably prudent provider would not have done; and that that
failure or action caused injury to the patient.51
Hence, this petition.
This Court has recognized that medical negligence cases are best
Petitioner assails the CA in finding her guilty of negligence in not proved by opinions of expert witnesses belonging in the same
explaining to the respondents all the possible side effects of the general neighborhood and in the same general line of practice as
chemotherapy on their child, and in holding her liable for actual, defendant physician or surgeon. The deference of courts to the
moral and exemplary damages and attorney’s fees. Petitioner expert opinion of qualified physicians stems from the former’s
emphasized that she was not negligent in the pre-chemotherapy realization that the latter possess unusual technical skills which
procedures and in the administration of chemotherapy treatment laymen in most instances are incapable of intelligently evaluating,
to Angelica. hence the indispensability of expert testimonies.52

On her supposed non-disclosure of all possible side effects of In this case, both the trial and appellate courts concurred in
chemotherapy, including death, petitioner argues that it was finding that the alleged negligence of petitioner in the
foolhardy to imagine her to be all-knowing/omnipotent. While the administration of chemotherapy drugs to respondents’ child was
theoretical side effects of chemotherapy were explained by her to not proven considering that Drs. Vergara and Balmaceda, not
the respondents, as these should be known to a competent doctor, being oncologists or cancer specialists, were not qualified to give
petitioner cannot possibly predict how a particular patient’s expert opinion as to whether petitioner’s lack of skill, knowledge
genetic make-up, state of mind, general health and body and professional competence in failing to observe the standard of
constitution would respond to the treatment. These are obviously care in her line of practice was the proximate cause of the
dependent on too many known, unknown and immeasurable patient’s death. Furthermore, respondents’ case was not at all
variables, thus requiring that Angelica be, as she was, constantly helped by the non-production of medical records by the hospital
and closely monitored during the treatment. Petitioner asserts that (only the biopsy result and medical bills were submitted to the
she did everything within her professional competence to attend court). Nevertheless, the CA found petitioner liable for her failure
to the medical needs of Angelica. to inform the respondents on all possible side effects of
chemotherapy before securing their consent to the said treatment.
Citing numerous trainings, distinctions and achievements in her
field and her current position as co-director for clinical affairs of The doctrine of informed consent within the context of physician-
the Medical Oncology, Department of Medicine of SLMC, patient relationships goes far back into English common law. As
petitioner contends that in the absence of any clear showing or early as 1767, doctors were charged with the tort of "battery" (i.e.,
proof, she cannot be charged with negligence in not informing the an unauthorized physical contact with a patient) if they had not
respondents all the side effects of chemotherapy or in the pre- gained the consent of their patients prior to performing a surgery
treatment procedures done on Angelica. or procedure. In the United States, the seminal case was
Schoendorff v. Society of New York Hospital53 which involved
As to the cause of death, petitioner insists that Angelica did not unwanted treatment performed by a doctor. Justice Benjamin
die of platelet depletion but of sepsis which is a complication of Cardozo’s oft-quoted opinion upheld the basic right of a patient to
the cancer itself. Sepsis itself leads to bleeding and death. She give consent to any medical procedure or treatment: "Every
explains that the response rate to chemotherapy of patients with human being of adult years and sound mind has a right to
osteosarcoma is high, so much so that survival rate is favorable to determine what shall be done with his own body; and a surgeon
the patient. Petitioner then points to some probable consequences who performs an operation without his patient’s consent, commits
if Angelica had not undergone chemotherapy. Thus, without an assault, for which he is liable in damages."54 From a purely
chemotherapy, other medicines and supportive treatment, the ethical norm, informed consent evolved into a general principle of
patient might have died the next day because of massive infection, law that a physician has a duty to disclose what a reasonably
or the cancer cells might have spread to the brain and brought the prudent physician in the medical community in the exercise of
patient into a coma, or into the lungs that the patient could have reasonable care would disclose to his patient as to whatever grave
been hooked to a respirator, or into her kidneys that she would risks of injury might be incurred from a proposed course of
have to undergo dialysis. Indeed, respondents could have spent as treatment, so that a patient, exercising ordinary care for his own
much because of these complications. The patient would have welfare, and faced with a choice of undergoing the proposed
been deprived of the chance to survive the ailment, of any hope treatment, or alternative treatment, or none at all, may
for life and her "quality of life" surely compromised. Since she intelligently exercise his judgment by reasonably balancing the
had not been shown to be at fault, petitioner maintains that the CA probable risks against the probable benefits.55
erred in holding her liable for the damages suffered by the
respondents.50 Subsequently, in Canterbury v. Spence56 the court observed that
the duty to disclose should not be limited to medical usage as to
The issue to be resolved is whether the petitioner can be held arrogate the decision on revelation to the physician alone. Thus,
liable for failure to fully disclose serious side effects to the respect for the patient’s right of self-determination on particular
parents of the child patient who died while undergoing therapy demands a standard set by law for physicians rather than
chemotherapy, despite the absence of finding that petitioner was one which physicians may or may not impose upon themselves.57
negligent in administering the said treatment. The scope of disclosure is premised on the fact that patients
ordinarily are persons unlearned in the medical sciences.
The petition is meritorious. Proficiency in diagnosis and therapy is not the full measure of a
physician’s responsibility. It is also his duty to warn of the
The type of lawsuit which has been called medical malpractice or, dangers lurking in the proposed treatment and to impart
more appropriately, medical negligence, is that type of claim information which the patient has every right to expect. Indeed,
which a victim has available to him or her to redress a wrong the patient’s reliance upon the physician is a trust of the kind
committed by a medical professional which has caused bodily which traditionally has exacted obligations beyond those
harm. In order to successfully pursue such a claim, a patient must associated with armslength transactions.58 The physician is not
prove that a health care provider, in most cases a physician, either expected to give the patient a short medical education, the
failed to do something which a reasonably prudent health care disclosure rule only requires of him a reasonable explanation,
which means generally informing the patient in nontechnical or the underlying cancer itself, immediately or sometime after the
terms as to what is at stake; the therapy alternatives open to him, administration of chemotherapy drugs, is a risk that cannot be
the goals expectably to be achieved, and the risks that may ensue ruled out, as with most other major medical procedures, but such
from particular treatment or no treatment.59 As to the issue of conclusion can be reasonably drawn from the general side effects
demonstrating what risks are considered material necessitating of chemotherapy already disclosed.
disclosure, it was held that experts are unnecessary to a showing
of the materiality of a risk to a patient’s decision on treatment, or As a physician, petitioner can reasonably expect the respondents
to the reasonably, expectable effect of risk disclosure on the to have considered the variables in the recommended treatment
decision. Such unrevealed risk that should have been made known for their daughter afflicted with a life-threatening illness. On the
must further materialize, for otherwise the omission, however other hand, it is difficult to give credence to respondents’ claim
unpardonable, is without legal consequence. And, as in that petitioner told them of 95% chance of recovery for their
malpractice actions generally, there must be a causal relationship daughter, as it was unlikely for doctors like petitioner who were
between the physician’s failure to divulge and damage to the dealing with grave conditions such as cancer to have falsely
patient.60 assured patients of chemotherapy’s success rate. Besides,
informed consent laws in other countries generally require only a
Reiterating the foregoing considerations, Cobbs v. Grant61 reasonable explanation of potential harms, so specific disclosures
deemed it as integral part of physician’s overall obligation to such as statistical data, may not be legally necessary.65
patient, the duty of reasonable disclosure of available choices with
respect to proposed therapy and of dangers inherently and The element of ethical duty to disclose material risks in the
potentially involved in each. However, the physician is not proposed medical treatment cannot thus be reduced to one
obliged to discuss relatively minor risks inherent in common simplistic formula applicable in all instances. Further, in a
procedures when it is common knowledge that such risks inherent medical malpractice action based on lack of informed consent,
in procedure of very low incidence. Cited as exceptions to the rule "the plaintiff must prove both the duty and the breach of that duty
that the patient should not be denied the opportunity to weigh the through expert testimony.66 Such expert testimony must show the
risks of surgery or treatment are emergency cases where it is customary standard of care of physicians in the same practice as
evident he cannot evaluate data, and where the patient is a child or that of the defendant doctor.67
incompetent.62 The court thus concluded that the patient’s right
of self-decision can only be effectively exercised if the patient In this case, the testimony of Dr. Balmaceda who is not an
possesses adequate information to enable him in making an oncologist but a Medical Specialist of the DOH’s Operational and
intelligent choice. The scope of the physician’s communications Management Services charged with receiving complaints against
to the patient, then must be measured by the patient’s need, and hospitals, does not qualify as expert testimony to establish the
that need is whatever information is material to the decision. The standard of care in obtaining consent for chemotherapy treatment.
test therefore for determining whether a potential peril must be In the absence of expert testimony in this regard, the Court feels
divulged is its materiality to the patient’s decision.63 hesitant in defining the scope of mandatory disclosure in cases of
malpractice based on lack of informed consent, much less set a
Cobbs v. Grant further reiterated the pronouncement in standard of disclosure that, even in foreign jurisdictions, has been
Canterbury v. Spence that for liability of the physician for failure noted to be an evolving one.
to inform patient, there must be causal relationship between
physician’s failure to inform and the injury to patient and such As society has grappled with the juxtaposition between personal
connection arises only if it is established that, had revelation been autonomy and the medical profession's intrinsic impetus to cure,
made, consent to treatment would not have been given. the law defining "adequate" disclosure has undergone a dynamic
evolution. A standard once guided solely by the ruminations of
There are four essential elements a plaintiff must prove in a physicians is now dependent on what a reasonable person in the
malpractice action based upon the doctrine of informed consent: patient’s position regards as significant. This change in
"(1) the physician had a duty to disclose material risks; (2) he perspective is especially important as medical breakthroughs
failed to disclose or inadequately disclosed those risks; (3) as a move practitioners to the cutting edge of technology, ever
direct and proximate result of the failure to disclose, the patient encountering new and heretofore unimagined treatments for
consented to treatment she otherwise would not have consented currently incurable diseases or ailments. An adaptable standard is
to; and (4) plaintiff was injured by the proposed treatment." The needed to account for this constant progression. Reasonableness
gravamen in an informed consent case requires the plaintiff to analyses permeate our legal system for the very reason that they
"point to significant undisclosed information relating to the are determined by social norms, expanding and contracting with
treatment which would have altered her decision to undergo it.64 the ebb and flow of societal evolution.

Examining the evidence on record, we hold that there was As we progress toward the twenty-first century, we now realize
adequate disclosure of material risks inherent in the chemotherapy that the legal standard of disclosure is not subject to construction
procedure performed with the consent of Angelica’s parents. as a categorical imperative. Whatever formulae or processes we
Respondents could not have been unaware in the course of initial adopt are only useful as a foundational starting point; the
treatment and amputation of Angelica’s lower extremity, that her particular quality or quantity of disclosure will remain
immune system was already weak on account of the malignant inextricably bound by the facts of each case. Nevertheless, juries
tumor in her knee. When petitioner informed the respondents that ultimately determine whether a physician properly informed a
beforehand of the side effects of chemotherapy which includes patient are inevitably guided by what they perceive as the
lowered counts of white and red blood cells, decrease in blood common expectation of the medical consumer—"a reasonable
platelets, possible kidney or heart damage and skin darkening, person in the patient’s position when deciding to accept or reject a
there is reasonable expectation on the part of the doctor that the recommended medical procedure."68 (Emphasis supplied.)
respondents understood very well that the severity of these side
effects will not be the same for all patients undergoing the WHEREFORE, the petition for review on certiorari is
procedure. In other words, by the nature of the disease itself, each GRANTED. The Decision dated June 15, 2004 and the
patient’s reaction to the chemical agents even with pre-treatment Resolution dated September 1, 2004 of the Court of Appeals in
laboratory tests cannot be precisely determined by the physician. CA-G.R. CV No. 58013 are SET ASIDE.
That death can possibly result from complications of the treatment
The Decision dated September 5, 1997 of the Regional Trial
Court of Legazpi City, Branch 8, in Civil Case No. 8904 is
REINSTATED and UPHELD. No costs. SO ORDERED.
Atienza vs Board of Medicine Rico Rommel Atienza (Atienza), which, in turn, assailed the
GR No. 177407 February 9, 2011 Orders2 issued by public respondent Board of Medicine (BOM)
in Administrative Case No. 1882.
Facts: Due to her Lumbar parts, private respondent Editha Sioson
went to Rizal Medical Center (RMC) for check-up on February 4, The facts, fairly summarized by the appellate court, follow.
1995. Sometime in 1999, due to the same problem, she was
referred to Dr. Pedro Lantin III of RMC who, accordingly, Due to her lumbar pains, private respondent Editha Sioson went
ordered several diagnostic laboratory tests. The tests revealed that to Rizal Medical Center (RMC) for check-up on February 4,
her right kidney is normal. It was ascertained, however, that her 1995. Sometime in 1999, due to the same problem, she was
left kidney is non-functioning and non-visualizing. This, she referred to Dr. Pedro Lantin III of RMC who, accordingly,
underwent kidney operation in 1999, September. On February 18, ordered several diagnostic laboratory tests. The tests revealed that
2000, private respondents husband Romeo Sioson, filed a her right kidney is normal. It was ascertained, however, that her
complaint for gross negligence and/or incompetence before the left kidney is non-functioning and non-visualizing. Thus, she
board of medicine against the doctors who allegedly participated underwent kidney operation in September, 1999.
in the fateful kidney operation. It was alleged in the complaint
that the gross negligence and/or incompetence committed by the On February 18, 2000, private respondent’s husband, Romeo
said doctors, including petitioner, consists of the removal of Sioson (as complainant), filed a complaint for gross negligence
private respondents fully functional right kidney, instead of the and/or incompetence before the [BOM] against the doctors who
left non-functioning and non-visualizing kidney. Among the allegedly participated in the fateful kidney operation, namely: Dr.
evidence presented are certified photocopy of the results of the Judd dela Vega, Dr. Pedro Lantin, III, Dr. Gerardo Antonio
ultrasound and X-ray conducted to Editha with the interpretation Florendo and petitioner Rico Rommel Atienza.
that both of her kidneys are in their proper anatomical location.
It was alleged in the complaint that the gross negligence and/or
incompetence committed by the said doctors, including petitioner,
Issue: Whether or not the doctors who conducted the kidney consists of the removal of private respondent’s fully functional
operation are liable for gross negligence despite the evidence right kidney, instead of the left non-functioning and non-
presented were mere photocopies. visualizing kidney.

Held: Yes. To begin with, it is a well settled rule that the rules of The complaint was heard by the [BOM]. After complainant
evidence are not strictly applied in proceedings before Romeo Sioson presented his evidence, private respondent Editha
administrative bodies such as the Board of Medicine. It is the Sioson, also named as complainant there, filed her formal offer of
safest policy  to be liberal, not rejecting them on doubtful or documentary evidence. Attached to the formal offer of
technical grounds, but admitting them unless plainly irrelevant, documentary evidence are her Exhibits "A" to "D," which she
immaterial or incompetent, for the reason that their rejection offered for the purpose of proving that her kidneys were both in
places them beyond the consideration of the court, if they are their proper anatomical locations at the time she was operated.
thereafter found relevant or competent; on the other hand, their She described her exhibits, as follows:
admission, if they turn out later to be irrelevant or incompetent,
can easily be remedied by completely discarding them or ignoring "EXHIBIT ‘A’ – the certified photocopy of the X-ray Request
them. form dated December 12, 1996, which is also marked as Annex
‘2’ as it was actually originally the Annex to x x x Dr. Pedro
Unquestionably, the rules of evidence are merely the means for Lantin, III’s counter affidavit filed with the City Prosecutor of
ascertaining the truth respecting a matter of fact. This, they Pasig City in connection with the criminal complaint filed by
likewise provide for some facts which are established and need [Romeo Sioson] with the said office, on which are handwritten
not be proved, such as those covered by judicial notice, both entries which are the interpretation of the results of the ultrasound
mandatory and discretionary. Laws of nature involving the examination. Incidentally, this exhibit happens to be the same as
physical sciences, specifically biology include the structural or identical to the certified photocopy of the document marked as
make-up and composition of living things such as human beings. Annex ‘2’ to the Counter-Affidavit dated March 15, 2000, filed
In this case, we may take judicial notice that Editha’s kidneys by x x x Dr. Pedro Lantin, III, on May 4, 2000, with this
before, and after the time of her operation, as with most human Honorable Board in answer to this complaint;
beings, were in their proper anatomical locations.
"EXHIBIT ‘B’ – the certified photo copy of the X-ray request
form dated January 30, 1997, which is also marked as Annex ‘3’
as it was actually likewise originally an Annex to x x x Dr. Pedro
Lantin, III’s counter-affidavit filed with the Office of the City
Prosecutor of Pasig City in connection with the criminal
G.R. No. 177407 February 9, 2011 complaint filed by the herein complainant with the said office, on
which are handwritten entries which are the interpretation of the
RICO ROMMEL ATIENZA, Petitioner, results of the examination. Incidentally, this exhibit happens to be
vs. also the same as or identical to the certified photo copy of the
BOARD OF MEDICINE and EDITHA SIOSON, Respondents. document marked as Annex ‘3’ which is likewise dated January
30, 1997, which is appended as such Annex ‘3’ to the counter-
DECISION affidavit dated March 15, 2000, filed by x x x Dr. Pedro Lantin,
III on May 4, 2000, with this Honorable Board in answer to this
NACHURA, J.: complaint.

Before us is a petition for review on certiorari under Rule 45 of "EXHIBIT ‘C’ – the certified photocopy of the X-ray request
the Rules of Court, assailing the Decision1 dated September 22, form dated March 16, 1996, which is also marked as Annex ‘4,’
2006 of the Court of Appeals (CA) in CA-G.R. SP No. 87755. on which are handwritten entries which are the interpretation of
The CA dismissed the petition for certiorari filed by petitioner the results of the examination.
WHETHER THE COURT OF APPEALS COMMITTED
"EXHIBIT ‘D’ – the certified photocopy of the X-ray request GRAVE REVERSIBLE ERROR AND DECIDED A
form dated May 20, 1999, which is also marked as Annex ‘16,’ on QUESTION OF SUBSTANCE IN A WAY NOT IN
which are handwritten entries which are the interpretation of the ACCORDANCE WITH LAW AND THE APPLICABLE
results of the examination. Incidentally, this exhibit appears to be DECISIONS OF THE HONORABLE COURT WHEN IT
the draft of the typewritten final report of the same examination UPHELD THE ADMISSION OF INCOMPETENT AND
which is the document appended as Annexes ‘4’ and ‘1’ INADMISSIBLE EVIDENCE BY RESPONDENT BOARD,
respectively to the counter-affidavits filed by x x x Dr. Judd dela WHICH CAN RESULT IN THE DEPRIVATION OF
Vega and Dr. Pedro Lantin, III in answer to the complaint. In the PROFESSIONAL LICENSE – A PROPERTY RIGHT OR
case of Dr. dela Vega however, the document which is marked as ONE’S LIVELIHOOD.4
Annex ‘4’ is not a certified photocopy, while in the case of Dr.
Lantin, the document marked as Annex ‘1’ is a certified We find no reason to depart from the ruling of the CA.
photocopy. Both documents are of the same date and typewritten
contents are the same as that which are written on Exhibit ‘D.’ Petitioner is correct when he asserts that a petition for certiorari is
the proper remedy to assail the Orders of the BOM, admitting in
Petitioner filed his comments/objections to private respondent’s evidence the exhibits of Editha. As the assailed Orders were
[Editha Sioson’s] formal offer of exhibits. He alleged that said interlocutory, these cannot be the subject of an appeal separate
exhibits are inadmissible because the same are mere photocopies, from the judgment that completely or finally disposes of the
not properly identified and authenticated, and intended to case.5 At that stage, where there is no appeal, or any plain,
establish matters which are hearsay. He added that the exhibits are speedy, and adequate remedy in the ordinary course of law, the
incompetent to prove the purpose for which they are offered. only and remaining remedy left to petitioner is a petition for
certiorari under Rule 65 of the Rules of Court on the ground of
Dispositions of the Board of Medicine grave abuse of discretion amounting to lack or excess of
jurisdiction.
The formal offer of documentary exhibits of private respondent
[Editha Sioson] was admitted by the [BOM] per its Order dated However, the writ of certiorari will not issue absent a showing
May 26, 2004. It reads: that the BOM has acted without or in excess of jurisdiction or
with grave abuse of discretion. Embedded in the CA’s finding that
"The Formal Offer of Documentary Evidence of [Romeo Sioson], the BOM did not exceed its jurisdiction or act in grave abuse of
the Comments/Objections of [herein petitioner] Atienza, [therein discretion is the issue of whether the exhibits of Editha contained
respondents] De la Vega and Lantin, and the Manifestation of in her Formal Offer of Documentary Evidence are inadmissible.
[therein] respondent Florendo are hereby ADMITTED by the
[BOM] for whatever purpose they may serve in the resolution of Petitioner argues that the exhibits formally offered in evidence by
this case. Editha: (1) violate the best evidence rule; (2) have not been
properly identified and authenticated; (3) are completely hearsay;
"Let the hearing be set on July 19, 2004 all at 1:30 p.m. for the and (4) are incompetent to prove their purpose. Thus, petitioner
reception of the evidence of the respondents. contends that the exhibits are inadmissible evidence.

"SO ORDERED." We disagree.

Petitioner moved for reconsideration of the abovementioned To begin with, it is well-settled that the rules of evidence are not
Order basically on the same reasons stated in his strictly applied in proceedings before administrative bodies such
comment/objections to the formal offer of exhibits. as the BOM.6 Although trial courts are enjoined to observe strict
enforcement of the rules of evidence,7 in connection with
The [BOM] denied the motion for reconsideration of petitioner in evidence which may appear to be of doubtful relevancy,
its Order dated October 8, 2004. It concluded that it should first incompetency, or admissibility, we have held that:
admit the evidence being offered so that it can determine its
probative value when it decides the case. According to the Board, [I]t is the safest policy to be liberal, not rejecting them on
it can determine whether the evidence is relevant or not if it will doubtful or technical grounds, but admitting them unless plainly
take a look at it through the process of admission. x x x.3 irrelevant, immaterial or incompetent, for the reason that their
rejection places them beyond the consideration of the court, if
Disagreeing with the BOM, and as previously adverted to, they are thereafter found relevant or competent; on the other hand,
Atienza filed a petition for certiorari with the CA, assailing the their admission, if they turn out later to be irrelevant or
BOM’s Orders which admitted Editha Sioson’s (Editha’s) Formal incompetent, can easily be remedied by completely discarding
Offer of Documentary Evidence. The CA dismissed the petition them or ignoring them.8
for certiorari for lack of merit.
From the foregoing, we emphasize the distinction between the
Hence, this recourse positing the following issues: admissibility of evidence and the probative weight to be accorded
the same pieces of evidence. PNOC Shipping and Transport
I. PROCEDURAL ISSUE: Corporation v. Court of Appeals9 teaches:

WHETHER PETITIONER ATIENZA AVAILED OF THE Admissibility of evidence refers to the question of whether or not
PROPER REMEDY WHEN HE FILED THE PETITION FOR the circumstance (or evidence) is to be considered at all. On the
CERTIORARI DATED 06 DECEMBER 2004 WITH THE other hand, the probative value of evidence refers to the question
COURT OF APPEALS UNDER RULE 65 OF THE RULES OF of whether or not it proves an issue.
COURT TO ASSAIL THE ORDERS DATED 26 MAY 2004
AND 08 OCTOBER 2004 OF RESPONDENT BOARD. Second, petitioner’s insistence that the admission of Editha’s
exhibits violated his substantive rights leading to the loss of his
II. SUBSTANTIVE ISSUE: medical license is misplaced. Petitioner mistakenly relies on
Section 20, Article I of the Professional Regulation Commission (b) When the original is in the custody or under the control of the
Rules of Procedure, which reads: party against whom the evidence is offered, and the latter fails to
produce it after reasonable notice;
Section 20. Administrative investigation shall be conducted in
accordance with these Rules. The Rules of Court shall only apply (c) When the original consists of numerous accounts or other
in these proceedings by analogy or on a suppletory character and documents which cannot be examined in court without great loss
whenever practicable and convenient. Technical errors in the of time and the fact sought to be established from them is only the
admission of evidence which do not prejudice the substantive general result of the whole; and
rights of either party shall not vitiate the proceedings.10
(d) When the original is a public record in the custody of a public
As pointed out by the appellate court, the admission of the officer or is recorded in a public office.
exhibits did not prejudice the substantive rights of petitioner
because, at any rate, the fact sought to be proved thereby, that the The subject of inquiry in this case is whether respondent doctors
two kidneys of Editha were in their proper anatomical locations at before the BOM are liable for gross negligence in removing the
the time she was operated on, is presumed under Section 3, Rule right functioning kidney of Editha instead of the left non-
131 of the Rules of Court: functioning kidney, not the proper anatomical locations of
Editha’s kidneys. As previously discussed, the proper anatomical
Sec. 3. Disputable presumptions. – The following presumptions locations of Editha’s kidneys at the time of her operation at the
are satisfactory if uncontradicted, but may be contradicted and RMC may be established not only through the exhibits offered in
overcome by other evidence: evidence.

xxxx Finally, these exhibits do not constitute hearsay evidence of the

anatomical locations of Editha’s kidneys. To further drive home
(y) That things have happened according to the ordinary course of the point, the anatomical positions, whether left or right, of
nature and the ordinary habits of life. Editha’s kidneys, and the removal of one or both, may still be
established through a belated ultrasound or x-ray of her
The exhibits are certified photocopies of X-ray Request Forms abdominal area.
dated December 12, 1996, January 30, 1997, March 16, 1996, and
May 20, 1999, filed in connection with Editha’s medical case. In fact, the introduction of secondary evidence, such as copies of
The documents contain handwritten entries interpreting the results the exhibits, is allowed.15 Witness Dr. Nancy Aquino testified
of the examination. These exhibits were actually attached as that the Records Office of RMC no longer had the originals of the
annexes to Dr. Pedro Lantin III’s counter affidavit filed with the exhibits "because [it] transferred from the previous building, x x x
Office of the City Prosecutor of Pasig City, which was to the new building."16 Ultimately, since the originals cannot be
investigating the criminal complaint for negligence filed by produced, the BOM properly admitted Editha’s formal offer of
Editha against the doctors of Rizal Medical Center (RMC) who evidence and, thereafter, the BOM shall determine the probative
handled her surgical procedure. To lay the predicate for her case, value thereof when it decides the case.
Editha offered the exhibits in evidence to prove that her "kidneys
were both in their proper anatomical locations at the time" of her WHEREFORE, the petition is DENIED. The Decision of the
operation. Court of Appeals in CA-G.R. SP No. 87755 is AFFIRMED. Costs
against petitioner.
The fact sought to be established by the admission of Editha’s
exhibits, that her "kidneys were both in their proper anatomical SO ORDERED.
locations at the time" of her operation, need not be proved as it is
covered by mandatory judicial notice.11

Unquestionably, the rules of evidence are merely the means for

ascertaining the truth respecting a matter of fact.12 Thus, they
likewise provide for some facts which are established and need
not be proved, such as those covered by judicial notice, both
mandatory and discretionary.13 Laws of nature involving the
physical sciences, specifically biology,14 include the structural
make-up and composition of living things such as human beings.
In this case, we may take judicial notice that Editha’s kidneys
before, and at the time of, her operation, as with most human
beings, were in their proper anatomical locations.

Third, contrary to the assertion of petitioner, the best evidence

rule is inapplicable.1awphil Section 3 of Rule 130 provides:

1. Best Evidence Rule

Sec. 3. Original document must be produced; exceptions. – When

the subject of inquiry is the contents of a document, no evidence
shall be admissible other than the original document itself, except
in the following cases:

(a) When the original has been lost or destroyed, or cannot be

produced in court, without bad faith on the part of the offeror;
Dr Jarcia vs Bastan simple negligence. The elements thereof were not proved by the
prosecution beyond reasonable doubt It can be gleaned from the
Facts: testimony of Dr. Tacata that a thorough examination was not
Belinda Santiago (Mrs. Santiago) lodged a complaint with the performed on Roy Jr. As residents on duty at the emergency
National Bureau of Investigation (NBI) against the petitioners, room, Dr. Jarcia and Dr. Bastan were expected to know the
Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou Bastan medical protocol in treating leg fractures and in attending to
(Dr. Bastan), for their alleged neglect of professional duty victims of car accidents. There was, however, no precise
which caused her son, Roy Alfonso Santiago (Roy Jr.), to evidence and scientific explanation pointing to the fact that
suffer serious physical injuries. Upon investigation, the NBI the delay in the application of the cast to the patient’s
found that Roy Jr. was hit by a taxicab; that he was rushed to the fractured leg because of failure to immediately
Manila Doctors Hospital for an emergency medical treatment; that
an X-ray of the victim’s ankle was ordered; that the X-ray result diagnose the specific injury of the patient, prolonged the pain of
showed no fracture as read by Dr. Jarcia; that Dr. Bastan entered the child or aggravated his condition or even caused further
the emergency room (ER) and, after conducting her own complications. Any person may opine that had patient Roy
examination of the victim, informed Mrs. Santiago that since Jr. been treated properly and given the extensive X-ray
it was only the ankle that was hit, there was no need to examination, the extent and severity of the injury, spiral
examine the upper leg; that eleven (11) days later, Roy Jr. fracture of the mid-tibial part or the bigger bone of the leg,
developed fever, swelling of the right leg and misalignment of the could have been detected early on and the prolonged pain
right foot; that Mrs. Santiago brought him back to the hospital; and suffering of Roy Jr. could have been prevented. But
and that the X-ray revealed a right mid-tibial fracture and a linear still, that opinion, even how logical it may seem would not,
hairline fracture in the shaft of the bone. and could not, be enough basis to hold one criminally liable; thus,
a reasonable doubt as to the petitioners’ guilt.
On June 14, 2005, the RTC found the petitioners guilty beyond
reasonable doubt of the crime of Simple Imprudence Resulting to The Court, nevertheless, finds the petitioners civilly liable for
Serious Physical Injuries. The Court believes that accused are their failure to sufficiently attend to Roy Jr.’s medical needs
negligent when both failed to exercise the necessary and when the latter was rushed to the ER, for while a criminal
reasonable prudence in ascertaining the extent of injury of conviction requires proof beyond reasonable doubt, only a
Alfonso Santiago, Jr. However, the negligence exhibited by preponderance of evidence is required to establish civil liability.
the two doctors does not approximate negligence of a reckless Taken into account also was the fact that there was no bad faith
nature but merely amounts to simple imprudence. Simple on their part.Dr. Jarcia and Dr. Bastan cannot pass on the
imprudence consists in the lack of precaution displayed in those liability to the taxi driver who hit the victim. It may be
cases in which the damage impending to be caused is not the true that the actual, direct, immediate, and proximate cause
immediate nor the danger clearly manifest. The elements of of the injury (fracture of the leg bone or tibia) of Roy Jr.
simple imprudence are as follows. was the vehicular accident when he was hit by a taxi. The
petitioners, however, cannot simply invoke such fact alone to
1. that there is lack of precaution on the part of the excuse themselves from any liability. If this would be so, doctors
offender; and would have a ready defense should they fail to do their job in
2. that the damage impending to be caused is not attending to victims of hit-and-run, maltreatment, and other
immediate of the danger is not clearly crimes of
manifest. violence in which the actual, direct, immediate, and proximate
cause of the injury is indubitably the act of the perpetrator/s. In
Issue: failing to perform an extensive medical examination to determine
the extent of Roy Jr.’s injuries, Dr. Jarcia and Dr. Bastan
were remiss of their duties as members of the medical
Whether or not the Petitioners are guilty of negligence profession. Assuming for the sake of argument that they did
not have the capacity to make such thorough evaluation at
that stage, they should have referred the patient to another
Held: doctor with sufficient training and experience instead of assuring
The Supreme Court reversed the decision of the lower court and him and his mother that everything was all right. If these doctors
the CA. The totality of the evidence on record clearly points to knew from the start that they were not in the position to
the negligence of the petitioners. At the risk of being attend to Roy Jr., a vehicular accident victim, with the
repetitious, the Court, however, is not satisfied that Dr. Jarcia degree of diligence and commitment expected of every
and Dr. Bastan are criminally negligent in this case. doctor in a case like this, they should have not made a
baseless assurance that everything was all right. By doing
Negligence is defined as the failure to observe for the so, they deprived Roy Jr. of adequate medical attention that
protection of the interests of another person that degree of placed him in a more dangerous situation than he was already in.
care, precaution, and vigilance which the circumstances justly What petitioners should have done, and could have done, was to
demand, whereby such other person suffers injury. Reckless refer Roy Jr. to another doctor who could competently and
imprudence consists of voluntarily doing or failing to do, without thoroughly examine his injuries.
malice, an act from which material damage results by reason
of an inexcusable lack of precaution on the part of the
person performing or failing to perform such act.

The elements of simple negligence are:

(1) that there is lack of precaution on the part of the
offender, and
(2) that the damage impending to be caused is not
immediate or the danger is not clearly manifest.

In this case, the Court is not convinced with moral certainty

that the petitioners are guilty of reckless imprudence or
3,850.00 representing medical expenses without subsidiary
imprisonment in case of insolvency and to pay the costs.
G.R. No. 187926 February 15, 2012
It appearing that Dr. Pamittan has not been apprehended nor
Dr. EMMANUEL JARCIA, Jr. and Dr. MARILOU voluntarily surrendered despite warrant issued for her arrest, let
BASTAN, Petitioners, warrant be issued for her arrest and the case against her be
vs. ARCHIVED, to be reinstated upon her apprehension.
PEOPLE OF THE PHILIPPINES, Respondent.
SO ORDERED.6
DECISION
The RTC explained:
MENDOZA, J.:
After a thorough and in depth evaluation of the evidence adduced
Even early on, patients have consigned their lives to the skill of by the prosecution and the defense, this court finds that the
their doctors. Time and again, it can be said that the most evidence of the prosecution is the more credible, concrete and
important goal of the medical profession is the preservation of life sufficient to create that moral certainty in the mind of the Court
and health of the people. Corollarily, when a physician departs that accused herein [are] criminally responsible. The Court
from his sacred duty and endangers instead the life of his patient, believes that accused are negligent when both failed to exercise
he must be made liable for the resulting injury. This Court, as this the necessary and reasonable prudence in ascertaining the extent
case would show, cannot and will not let the act go unpunished.1 of injury of Alfonso Santiago, Jr.

This is a petition for review under Rule 45 of the Rules of Court However, the negligence exhibited by the two doctors does not
challenging the August 29, 2008 Decision2 of the Court of approximate negligence of a reckless nature but merely amounts
Appeals (CA), and its May 19, 2009 Resolution3 in CA-G.R. CR to simple imprudence. Simple imprudence consists in the lack of
No. 29559, dismissing the appeal and affirming in toto the June precaution displayed in those cases in which the damage
14, 2005 Decision4 of the Regional Trial Court, Branch 43, impending to be caused is not the immediate nor the danger
Manila (RTC), finding the accused guilty beyond reasonable clearly manifest. The elements of simple imprudence are as
doubt of simple imprudence resulting to serious physical injuries. follows.

THE FACTS 1. that there is lack of precaution on the part of the offender; and

Belinda Santiago (Mrs. Santiago) lodged a complaint with the 2. that the damage impending to be caused is not immediate of the
National Bureau of Investigation (NBI) against the petitioners, Dr. danger is not clearly manifest.
Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou Bastan (Dr.
Bastan), for their alleged neglect of professional duty which Considering all the evidence on record, The Court finds the
caused her son, Roy Alfonso Santiago (Roy Jr.), to suffer serious accused guilty for simple imprudence resulting to physical
physical injuries. Upon investigation, the NBI found that Roy Jr. injuries. Under Article 365 of the Revised Penal Code, the penalty
was hit by a taxicab; that he was rushed to the Manila Doctors provided for is arresto mayor in its minimum period.7
Hospital for an emergency medical treatment; that an X-ray of the
victim’s ankle was ordered; that the X-ray result showed no Dissatisfied, the petitioners appealed to the CA.
fracture as read by Dr. Jarcia; that Dr. Bastan entered the
emergency room (ER) and, after conducting her own examination As earlier stated, the CA affirmed the RTC decision in toto. The
of the victim, informed Mrs. Santiago that since it was only the August 29, 2008 Decision of the CA pertinently reads:
ankle that was hit, there was no need to examine the upper leg;
that eleven (11) days later, Roy Jr. developed fever, swelling of This Court holds concurrently and finds the foregoing
the right leg and misalignment of the right foot; that Mrs. circumstances sufficient to sustain a judgment of conviction
Santiago brought him back to the hospital; and that the X-ray against the accused-appellants for the crime of simple imprudence
revealed a right mid-tibial fracture and a linear hairline fracture in resulting in serious physical injuries. The elements of imprudence
the shaft of the bone. are: (1) that the offender does or fails to do an act; (2) that the
doing or the failure to do that act is voluntary; (3) that it be
The NBI indorsed the matter to the Office of the City Prosecutor without malice; (4) that material damage results from the
of Manila for preliminary investigation. Probable cause was found imprudence; and (5) that there is inexcusable lack of precaution
and a criminal case for reckless imprudence resulting to serious on the part of the offender, taking into consideration his
physical injuries, was filed against Dr. Jarcia, Dr. Bastan and Dr. employment or occupation, degree of intelligence, physical
Pamittan,5 before the RTC, docketed as Criminal Case No. 01- condition, and other circumstances regarding persons, time and
196646. place.

On June 14, 2005, the RTC found the petitioners guilty beyond Whether or not Dr. Jarcia and Dr. Bastan had committed an
reasonable doubt of the crime of Simple Imprudence Resulting to "inexcusable lack of precaution" in the treatment of their patient is
Serious Physical Injuries. The decretal portion of the RTC to be determined according to the standard of care observed by
decision reads: other members of the profession in good standing under similar
circumstances, bearing in mind the advanced state of the
WHEREFORE, premises considered, the Court finds accused DR. profession at the time of treatment or the present state of medical
EMMANUEL JARCIA, JR. and DR. MARILOU BASTAN science. In the case of Leonila Garcia-Rueda v. Pascasio, the
GUILTY beyond reasonable doubt of the crime of SIMPLE Supreme Court stated that, in accepting a case, a doctor in effect
IMPRUDENCE RESULTING TO SERIOUS PHYSICAL represents that, having the needed training and skill possessed by
INJURIES and are hereby sentenced to suffer the penalty of ONE physicians and surgeons practicing in the same field, he will
(1) MONTH and ONE (1) DAY to TWO (2) MONTHS and to employ such training, care and skill in the treatment of his
indemnify MRS. BELINDA SANTIAGO the amount of ₱ patients. He therefore has a duty to use at least the same level of
care that any other reasonably competent doctor would use to treat
a condition under the same circumstances. A: Yes, sir.

In litigations involving medical negligence, the plaintiff has the Q: What did you [tell] her?
burden of establishing accused-appellants’ negligence, and for a
reasonable conclusion of negligence, there must be proof of A: I told her, sir, while she was cleaning the wounds of my son,
breach of duty on the part of the physician as well as a causal are you not going to x-ray up to the knee because my son was
connection of such breach and the resulting injury of his patient. complaining pain from his ankle up to the middle part of the right
The connection between the negligence and the injury must be a leg.
direct and natural sequence of events, unbroken by intervening
efficient causes. In other words, the negligence must be the Q: And what did she tell you?
proximate cause of the injury. Negligence, no matter in what it
consists, cannot create a right of action unless it is the proximate A: According to Dra. Bastan, there is no need to x-ray because it
cause of the injury complained of. The proximate cause of an was the ankle part that was run over.
injury is that cause which, in natural and continuous sequence,
unbroken by any efficient intervening cause, produces the injury Q: What did you do or tell her?
and without which the result would not have occurred.
A: I told her, sir, why is it that they did not examine[x] the whole
In the case at bench, the accused-appellants questioned the leg. They just lifted the pants of my son.
imputation against them and argued that there is no causal
connection between their failure to diagnose the fracture and the Q: So you mean to say there was no treatment made at all?
injury sustained by Roy.
A: None, sir.
We are not convinced.
xxx xxx xxx
The prosecution is however after the cause which prolonged the
pain and suffering of Roy and not on the failure of the accused- xxx xxx xxx
appellants to correctly diagnose the extent of the injury sustained
by Roy. A: I just listened to them, sir. And I just asked if I will still return
my son.
For a more logical presentation of the discussion, we shall first
consider the applicability of the doctrine of res ipsa loquitur to the xxx xxx xxx
instant case. Res ipsa loquitur is a Latin phrase which literally
means "the thing or the transaction speaks for itself. The doctrine xxx xxx xxx
of res ipsa loquitur is simply a recognition of the postulate that, as
a matter of common knowledge and experience, the very nature of Q: And you were present when they were called?
certain types of occurrences may justify an inference of
negligence on the part of the person who controls the A: Yes, sir.
instrumentality causing the injury in the absence of some
explanation by the accused-appellant who is charged with Q: And what was discussed then by Sis. Retoria?
negligence. It is grounded in the superior logic of ordinary human
experience and, on the basis of such experience or common A: When they were there they admitted that they have mistakes,
knowledge, negligence may be deduced from the mere occurrence sir.
of the accident itself. Hence, res ipsa loquitur is applied in
conjunction with the doctrine of common knowledge. Still, before resort to the doctrine may be allowed, the following
requisites must be satisfactorily shown:
The specific acts of negligence was narrated by Mrs. Santiago
who accompanied her son during the latter’s ordeal at the 1. The accident is of a kind which ordinarily does not occur in the
hospital. She testified as follows: absence of someone’s negligence;

Fiscal Formoso: 2. It is caused by an instrumentality within the exclusive control

of the defendant or defendants; and
Q: Now, he is an intern did you not consult the doctors, Dr. Jarcia
or Dra. Pamittan to confirm whether you should go home or not? 3. The possibility of contributing conduct which would make the
plaintiff responsible is eliminated.
A: Dra. Pamittan was inside the cubicle of the nurses and I asked
her, you let us go home and you don’t even clean the wounds of In the above requisites, the fundamental element is the "control of
my son. the instrumentality" which caused the damage. Such element of
control must be shown to be within the dominion of the accused-
Q: And what did she [tell] you? appellants. In order to have the benefit of the rule, a plaintiff, in
addition to proving injury or damage, must show a situation
A: They told me they will call a resident doctor, sir. where it is applicable and must establish that the essential
elements of the doctrine were present in a particular incident. The
xxx xxx xxx early treatment of the leg of Roy would have lessen his suffering
if not entirely relieve him from the fracture. A boy of tender age
Q: Was there a resident doctor [who] came? whose leg was hit by a vehicle would engender a well-founded
belief that his condition may worsen without proper medical
A: Yes, Sir. Dra. Bastan arrived. attention. As junior residents who only practice general surgery
and without specialization with the case consulted before them,
Q: Did you tell her what you want on you to be done? they should have referred the matter to a specialist. This omission
alone constitutes simple imprudence on their part. When Mrs. and we find application of the doctrine of res ipsa loquitur to be in
Santiago insisted on having another x-ray of her child on the order.
upper part of his leg, they refused to do so. The mother would not
have asked them if they had no exclusive control or prerogative to WHEREFORE, in view of the foregoing, the appeal in this case is
request an x-ray test. Such is a fact because a radiologist would hereby DISMISSED and the assailed decision of the trial court
only conduct the x-ray test upon request of a physician. finding accused-appellants guilty beyond reasonable doubt of
simple imprudence resulting in serious physical injuries is hereby
The testimony of Mrs. Santiago was corroborated by a bone AFFIRMED in toto.
specialist Dr. Tacata. He further testified based on his personal
knowledge, and not as an expert, as he examined himself the child SO ORDERED.8
Roy. He testified as follows:
The petitioners filed a motion for reconsideration, but it was
Fiscal Macapagal: denied by the CA in its May 19, 2009 Resolution.

Q: And was that the correct respon[se] to the medical problem Hence, this petition.
that was presented to Dr. Jarcia and Dra. Bastan?
The petitioners pray for the reversal of the decision of both the
A: I would say at that stage, yes. Because they have presented the RTC and the CA anchored on the following
patient and the history. "At sabi nila, nadaanan lang po ito." And
then, considering their year of residency they are still junior GROUNDS-
residents, and they are not also orthopedic residents but general
surgery residents, it’s entirely different thing. Because if you are 1. IN AFFIRMING ACCUSED-PETITIONERS’ CONVICTION,
an orthopedic resident, I am not trying to say…but if I were an THE COURT OF APPEALS ERRED IN NOT HOLDING THAT
orthopedic resident, there would be more precise and accurate THE ACTUAL, DIRECT, IMMEDIATE, AND PROXIMATE
decision compare to a general surgery resident in so far as CAUSE OF THE PHYSICAL INJURY OF THE PATIENT
involved. (FRACTURE OF THE LEG BONE OR TIBIA), WHICH
REQUIRED MEDICAL ATTENDANCE FOR MORE THAN
Q: You mean to say there is no supervisor attending the THIRTY (30) DAYS AND INCAPACITATED HIM FROM
emergency room? PERFORMING HIS CUSTOMARY DUTY DURING THE
SAME PERIOD OF TIME, WAS THE VEHICULAR
A: At the emergency room, at the Manila Doctor’s Hospital, the ACCIDENT WHERE THE PATIENT’S RIGHT LEG WAS HIT
supervisor there is a consultant that usually comes from a family BY A TAXI, NOT THE FAILURE OF THE ACCUSED-
medicine. They see where a certain patient have to go and then if PETITIONERS TO SUBJECT THE PATIENT’S WHOLE LEG
they cannot manage it, they refer it to the consultant on duty. Now TO AN X-RAY EXAMINATION.
at that time, I don’t [know] why they don’t….Because at that
time, I think, it is the decision. Since the x-rays…. 2. THE COURT OF APPEALS ERRED IN DISREGARDING
ESTABLISHED FACTS CLEARLY NEGATING
Ordinarily, only physicians and surgeons of skill and experience PETITIONERS’ ALLEGED NEGLIGENCE OR
are competent to testify as to whether a patient has been treated or IMPRUDENCE. SIGNIFICANTLY, THE COURT OF
operated upon with a reasonable degree of skill and care. APPEALS UNJUSTIFIABLY DISREGARDED THE OPINION
However, testimony as to the statements and acts of physicians, OF THE PROSECUTION’S EXPERT WITNESS, DR. CIRILO
external appearances, and manifest conditions which are TACATA, THAT PETITIONERS WERE NOT GUILTY OF
observable by any one may be given by non-expert witnesses. NEGLIGENCE OR IMPRUDENCE COMPLAINED OF.
Hence, in cases where the res ipsa loquitur is applicable, the court
is permitted to find a physician negligent upon proper proof of 3. THE COURT OF APPEALS ERRED IN HOLDING THAT
injury to the patient, without the aid of expert testimony, where THE FAILURE OF PETITIONERS TO SUBJECT THE
the court from its fund of common knowledge can determine the PATIENT’S WHOLE LEG TO AN X-RAY EXAMINATION
proper standard of care. Where common knowledge and PROLONGED THE PAIN AND SUFFERING OF THE
experience teach that a resulting injury would not have occurred PATIENT, SUCH CONCLUSION BEING UNSUPPORTED
to the patient if due care had been exercised, an inference of BY, AND EVEN CONTRARY TO, THE EVIDENCE ON
negligence may be drawn giving rise to an application of the RECORD.
doctrine of res ipsa loquitur without medical evidence, which is
ordinarily required to show not only what occurred but how and 4. ASSUMING ARGUENDO THAT THE PATIENT
why it occurred. In the case at bench, we give credence to the EXPERIENCED PROLONGED PAIN AND SUFFERING, THE
testimony of Mrs. Santiago by applying the doctrine of res ipsa COURT OF APPEALS ERRED IN NOT HOLDING THAT THE
loquitur. ALLEGED PAIN AND SUFFERING WERE DUE TO THE
UNJUSTIFIED FAILURE OF THE PATIENT’S MOTHER, A
Res ipsa loquitur is not a rigid or ordinary doctrine to be NURSE HERSELF, TO IMMEDIATELY BRING THE
perfunctorily used but a rule to be cautiously applied, depending PATIENT BACK TO THE HOSPITAL, AS ADVISED BY THE
upon the circumstances of each case. It is generally restricted to PETITIONERS, AFTER HE COMPLAINED OF SEVERE PAIN
situations in malpractice cases where a layman is able to say, as a IN HIS RIGHT LEG WHEN HE REACHED HOME AFTER HE
matter of common knowledge and observation, that the WAS SEEN BY PETITIONERS AT THE HOSPITAL. THUS,
consequences of professional care were not as such as would THE PATIENT’S ALLEGED INJURY (PROLONGED PAIN
ordinarily have followed if due care had been exercised. A AND SUFFERING) WAS DUE TO HIS OWN MOTHER’S
distinction must be made between the failure to secure results and ACT OR OMISSION.
the occurrence of something more unusual and not ordinarily
found if the service or treatment rendered followed the usual 5. THE COURT OF APPEALS ERRED IN NOT HOLDING
procedure of those skilled in that particular practice. The latter THAT NO PHYSICIAN-PATIENT RELATIONSHIP EXISTED
circumstance is the primordial issue that confronted this Court BETWEEN PETITIONERS AND PATIENT ALFONSO
SANTIAGO, JR., PETITIONERS NOT BEING THE LATTER’S
ATTENDING PHYSICIAN AS THEY WERE MERELY exclusive control of the person in charge; and (3) the injury
REQUESTED BY THE EMERGENCY ROOM (ER) NURSE suffered must not have been due to any voluntary action or
TO SEE THE PATIENT WHILE THEY WERE PASSING BY contribution of the person injured.12
THE ER FOR THEIR LUNCH.
In this case, the circumstances that caused patient Roy Jr.’s injury
6. THE COURT OF APPEALS GRAVELY ERRED IN NOT and the series of tests that were supposed to be undergone by him
ACQUITTING ACCUSED-PETITIONERS OF THE CRIME to determine the extent of the injury suffered were not under the
CHARGED."9 exclusive control of Drs. Jarcia and Bastan. It was established that
they are mere residents of the Manila Doctors Hospital at that
The foregoing can be synthesized into two basic issues: [1] time who attended to the victim at the emergency room.13 While
whether or not the doctrine of res ipsa loquitur is applicable in this it may be true that the circumstances pointed out by the courts
case; and [2] whether or not the petitioners are liable for criminal below seem doubtless to constitute reckless imprudence on the
negligence. part of the petitioners, this conclusion is still best achieved, not
through the scholarly assumptions of a layman like the patient’s
THE COURT’S RULING mother, but by the unquestionable knowledge of expert
witness/es. As to whether the petitioners have exercised the
The CA is correct in finding that there was negligence on the part requisite degree of skill and care in treating patient Roy, Jr. is
of the petitioners. After a perusal of the records, however, the generally a matter of expert opinion.
Court is not convinced that the petitioners are guilty of criminal
negligence complained of. The Court is also of the view that the As to Dr. Jarcia and Dr. Bastan’s negligence
CA erred in applying the doctrine of res ipsa loquitur in this
particular case. The totality of the evidence on record clearly points to the
negligence of the petitioners. At the risk of being repetitious, the
As to the Application of The Doctrine of Res Ipsa Loquitur Court, however, is not satisfied that Dr. Jarcia and Dr. Bastan are
criminally negligent in this case.
This doctrine of res ipsa loquitur means "Where the thing which
causes injury is shown to be under the management of the Negligence is defined as the failure to observe for the protection
defendant, and the accident is such as in the ordinary course of of the interests of another person that degree of care, precaution,
things does not happen if those who have the management use and vigilance which the circumstances justly demand, whereby
proper care, it affords reasonable evidence, in the absence of an such other person suffers injury.14
explanation by the defendant, that the accident arose from want of
care." The Black's Law Dictionary defines the said doctrine. Thus: Reckless imprudence consists of voluntarily doing or failing to
do, without malice, an act from which material damage results by
The thing speaks for itself. Rebuttable presumption or inference reason of an inexcusable lack of precaution on the part of the
that defendant was negligent, which arises upon proof that the person performing or failing to perform such act.15
instrumentality causing injury was in defendant's exclusive
control, and that the accident was one which ordinarily does not The elements of simple negligence are: (1) that there is lack of
happen in absence of negligence. Res ipsa loquitur is a rule of precaution on the part of the offender, and (2) that the damage
evidence whereby negligence of the alleged wrongdoer may be impending to be caused is not immediate or the danger is not
inferred from the mere fact that the accident happened provided clearly manifest.16
the character of the accident and circumstances attending it lead
reasonably to belief that in the absence of negligence it would not In this case, the Court is not convinced with moral certainty that
have occurred and that thing which caused injury is shown to the petitioners are guilty of reckless imprudence or simple
have been under the management and control of the alleged negligence. The elements thereof were not proved by the
wrongdoer. Under this doctrine, the happening of an injury prosecution beyond reasonable doubt.
permits an inference of negligence where plaintiff produces
substantial evidence that the injury was caused by an agency or The testimony of Dr. Cirilo R. Tacata (Dr. Tacata), a specialist in
instrumentality under the exclusive control and management of pediatric orthopedic, although pointing to some medical
defendant, and that the occurrence was such that in the ordinary procedures that could have been done by Dr. Jarcia and Dr.
course of things would not happen if reasonable care had been Bastan, as physicians on duty, was not clear as to whether the
used.10 injuries suffered by patient Roy Jr. were indeed aggravated by the
petitioners’ judgment call and their diagnosis or appreciation of
The doctrine of res ipsa loquitur as a rule of evidence is unusual the condition of the victim at the time they assessed him. Thus:
to the law of negligence which recognizes that prima facie
negligence may be established without direct proof and furnishes Q: Will you please tell us, for the record, doctor, what is your
a substitute for specific proof of negligence. The doctrine, specialization?
however, is not a rule of substantive law, but merely a mode of
proof or a mere procedural convenience. The rule, when A: At present I am the chairman department of orthopedic in UP-
applicable to the facts and circumstances of a given case, is not PGH and I had special training in pediatric orthopedic for two (2)
meant to and does not dispense with the requirement of proof of years.
culpable negligence on the party charged. It merely determines
and regulates what shall be prima facie evidence thereof and helps Q: In June 1998, doctor, what was your position and what was
the plaintiff in proving a breach of the duty. The doctrine can be your specialization at that time?
invoked when and only when, under the circumstances involved,
direct evidence is absent and not readily available.11 A: Since 1980, I have been specialist in pediatric orthopedic.

The requisites for the application of the doctrine of res ipsa Q: When Alfonso Santiago, Jr. was brought to you by his mother,
loquitur are: (1) the accident was of a kind which does not what did you do by way of physicians as first step?
ordinarily occur unless someone is negligent; (2) the
instrumentality or agency which caused the injury was under the
A: As usual, I examined the patient physically and, at that time as medicine. They see where a certain patient have to go and then if
I have said, the patient could not walk so I [began] to suspect that they cannot manage it, they refer it to the consultant on duty. Now
probably he sustained a fracture as a result of a vehicular accident. at that time, I don’t why they don’t … Because at that time, I
So I examined the patient at that time, the involved leg, I don’t think, it is the decision. Since the x-rays…
know if that is left or right, the involved leg then was swollen and
the patient could not walk, so I requested for the x-ray of [the] xxx
lower leg.
Q: You also said, Doctor, that Dr. Jarcia and Dra. Bastan are not
Q: What part of the leg, doctor, did you request to be examined? even an orthopedic specialist.

A: If we refer for an x-ray, usually, we suspect a fracture whether A: They are general surgeon residents. You have to man[x] the
in approximal, middle or lebistal tinial, we usually x-ray the entire emergency room, including neurology, orthopedic, general
extremity. surgery, they see everything at the emergency room.

Q: And what was the result? xxxx

A: Well, I can say that it was a spiral fracture of the mid-tibial, it Q: But if initially, Alfonso Santiago, Jr. and his case was
is the bigger bone of the leg. presented to you at the emergency room, you would have
subjected the entire foot to x-ray even if the history that was given
Q: And when you say spiral, doctor, how long was this fracture? to Dr. Jarcia and Dra. Bastan is the same?

A: When we say spiral, it is a sort of letter S, the length was about A: I could not directly say yes, because it would still depend on
six (6) to eight (8) centimeters. my examination, we cannot subject the whole body for x-ray if we
think that the damaged was only the leg.
Q: Mid-tibial, will you please point to us, doctor, where the tibial
is? Q: Not the entire body but the entire leg?

(Witness pointing to his lower leg) A: I think, if my examination requires it, I would.

A: The tibial is here, there are two bones here, the bigger one is Q: So, you would conduct first an examination?
the tibial and the smaller one is the fibula. The bigger one is the
one that get fractured. A: Yes, sir.

Q: And in the course of your examination of Alfonso Santiago, Jr. Q: And do you think that with that examination that you would
did you ask for the history of such injury? have conducted you would discover the necessity subjecting the
entire foot for x-ray?
A: Yes, actually, that was a routine part of our examination that
once a patient comes in, before we actually examine the patient, A: It is also possible but according to them, the foot and the ankle
we request for a detailed history. If it is an accident, then, we were swollen and not the leg, which sometimes normally happens
request for the exact mechanism of injuries. that the actual fractured bone do not get swollen.

Q: And as far as you can recall, Doctor, what was the history of xxxx
that injury that was told to you?
Q: Doctor, if you know that the patient sustained a fracture on the
A: The patient was sideswiped, I don’t know if it is a car, but it is ankle and on the foot and the history that was told to you is the
a vehicular accident. region that was hit is the region of the foot, will the doctor subject
the entire leg for x-ray?
Q: Who did you interview?
A: I am an orthopedic surgeon, you have to subject an x-ray of the
A: The mother. leg. Because you have to consider the kind of fracture that the
patient sustained would you say the exact mechanism of injury.
Q: How about the child himself, Alfonso Santiago, Jr.? For example spiral, "paikot yung bale nya," so it was possible that
the leg was run over, the patient fell, and it got twisted. That’s
A: Normally, we do not interview the child because, usually, at why the leg seems to be fractured.17 [Emphases supplied]
his age, the answers are not accurate. So, it was the mother that I
interviewed. It can be gleaned from the testimony of Dr. Tacata that a thorough
examination was not performed on Roy Jr. As residents on duty at
Q: And were you informed also of his early medication that was the emergency room, Dr. Jarcia and Dr. Bastan were expected to
administered on Alfonso Santiago, Jr.? know the medical protocol in treating leg fractures and in
attending to victims of car accidents. There was, however, no
A: No, not actually medication. I was informed that this patient precise evidence and scientific explanation pointing to the fact
was seen initially at the emergency room by the two (2) that the delay in the application of the cast to the patient’s
physicians that you just mentioned, Dr. Jarcia and Dra. Bastan, fractured leg because of failure to immediately diagnose the
that time who happened to be my residents who were [on] duty at specific injury of the patient, prolonged the pain of the child or
the emergency room. aggravated his condition or even caused further complications.
Any person may opine that had patient Roy Jr. been treated
xxxx properly and given the extensive X-ray examination, the extent
and severity of the injury, spiral fracture of the mid-tibial part or
A: At the emergency room, at the Manila Doctor’s Hospital, the the bigger bone of the leg, could have been detected early on and
supervisor there is a consultant that usually comes from a family the prolonged pain and suffering of Roy Jr. could have been
prevented. But still, that opinion, even how logical it may seem obligation to use at least the same level of care that any other
would not, and could not, be enough basis to hold one criminally reasonably competent physician would use to treat the condition
liable; thus, a reasonable doubt as to the petitioners’ guilt. under similar circumstances."

Although the Court sympathizes with the plight of the mother and Indubitably, a physician-patient relationship exists between the
the child in this case, the Court is bound by the dictates of justice petitioners and patient Roy Jr. Notably, the latter and his mother
which hold inviolable the right of the accused to be presumed went to the ER for an immediate medical attention. The
innocent until proven guilty beyond reasonable doubt. The Court, petitioners allegedly passed by and were requested to attend to the
nevertheless, finds the petitioners civilly liable for their failure to victim (contrary to the testimony of Dr. Tacata that they were, at
sufficiently attend to Roy Jr.’s medical needs when the latter was that time, residents on duty at the ER).21 They obliged and
rushed to the ER, for while a criminal conviction requires proof examined the victim, and later assured the mother that everything
beyond reasonable doubt, only a preponderance of evidence is was fine and that they could go home. Clearly, a physician-patient
required to establish civil liability. Taken into account also was relationship was established between the petitioners and the
the fact that there was no bad faith on their part. patient Roy Jr.

Dr. Jarcia and Dr. Bastan cannot pass on the liability to the taxi To repeat for clarity and emphasis, if these doctors knew from the
driver who hit the victim. It may be true that the actual, direct, start that they were not in the position to attend to Roy Jr., a
immediate, and proximate cause of the injury (fracture of the leg vehicular accident victim, with the degree of diligence and
bone or tibia) of Roy Jr. was the vehicular accident when he was commitment expected of every doctor in a case like this, they
hit by a taxi. The petitioners, however, cannot simply invoke such should have not made a baseless assurance that everything was all
fact alone to excuse themselves from any liability. If this would right. By doing so, they deprived Roy Jr. of adequate medical
be so, doctors would have a ready defense should they fail to do attention that placed him in a more dangerous situation than he
their job in attending to victims of hit-and-run, maltreatment, and was already in. What petitioners should have done, and could
other crimes of violence in which the actual, direct, immediate, have done, was to refer Roy Jr. to another doctor who could
and proximate cause of the injury is indubitably the act of the competently and thoroughly examine his injuries.
perpetrator/s.
All told, the petitioners were, indeed, negligent but only civilly,
In failing to perform an extensive medical examination to and not criminally, liable as the facts show.
determine the extent of Roy Jr.’s injuries, Dr. Jarcia and Dr.
Bastan were remiss of their duties as members of the medical Article II, Section 1 of the Code of Medical Ethics of the Medical
profession. Assuming for the sake of argument that they did not Profession in the Philippines states:
have the capacity to make such thorough evaluation at that stage,
they should have referred the patient to another doctor with A physician should attend to his patients faithfully and
sufficient training and experience instead of assuring him and his conscientiously. He should secure for them all possible benefits
mother that everything was all right. that may depend upon his professional skill and care. As the sole
tribunal to adjudge the physician’s failure to fulfill his obligation
This Court cannot also stamp its imprimatur on the petitioners’ to his patients is, in most cases, his own conscience, violation of
contention that no physician-patient relationship existed between this rule on his part is discreditable and inexcusable.22
them and patient Roy Jr., since they were not his attending
physicians at that time. They claim that they were merely Established medical procedures and practices, though in constant
requested by the ER nurse to see the patient while they were instability, are devised for the purpose of preventing
passing by the ER for their lunch. Firstly, this issue was never complications. In this case, the petitioners failed to observe the
raised during the trial at the RTC or even before the CA. The most prudent medical procedure under the circumstances to
petitioners, therefore, raise the want of doctor-patient relationship prevent the complications suffered by a child of tender age.
for the first time on appeal with this Court. It has been settled that
"issues raised for the first time on appeal cannot be considered As to the Award of Damages
because a party is not permitted to change his theory on appeal.
To allow him to do so is unfair to the other party and offensive to While no criminal negligence was found in the petitioners’ failure
the rules of fair play, justice and due process."18 Stated to administer the necessary medical attention to Roy Jr., the Court
differently, basic considerations of due process dictate that holds them civilly liable for the resulting damages to their patient.
theories, issues and arguments not brought to the attention of the While it was the taxi driver who ran over the foot or leg of Roy
trial court need not be, and ordinarily will not be, considered by a Jr., their negligence was doubtless contributory.
reviewing court.19
It appears undisputed that the amount of ₱ 3,850.00, as expenses
Assuming again for the sake of argument that the petitioners may incurred by patient Roy Jr., was adequately supported by receipts.
still raise this issue of "no physician–patient relationship," the The Court, therefore, finds the petitioners liable to pay this
Court finds and so holds that there was a "physician–patient" amount by way of actual damages.
relationship in this case.
The Court is aware that no amount of compassion can suffice to
In the case of Lucas v. Tuaño,20 the Court wrote that "[w]hen a ease the sorrow felt by the family of the child at that time.
patient engages the services of a physician, a physician-patient Certainly, the award of moral and exemplary damages in favor of
relationship is generated. And in accepting a case, the physician, Roy Jr. in the amount of ₱ 100,000.00 and ₱ 50,000.00,
for all intents and purposes, represents that he has the needed respectively, is proper in this case.
training and skill possessed by physicians and surgeons practicing
in the same field; and that he will employ such training, care, and It is settled that moral damages are not punitive in nature, but are
skill in the treatment of the patient. Thus, in treating his patient, a designed to compensate and alleviate in some way the physical
physician is under a duty to exercise that degree of care, skill and suffering, mental anguish, fright, serious anxiety, besmirched
diligence which physicians in the same general neighborhood and reputation, wounded feelings, moral shock, social humiliation,
in the same general line of practice ordinarily possess and and similar injury unjustly inflicted on a person. Intended for the
exercise in like cases. Stated otherwise, the physician has the restoration of the psychological or emotional status quo ante, the
award of moral damages is designed to compensate emotional
injury suffered, not to impose a penalty on the wrongdoer.23

The Court, likewise, finds the petitioners also liable for exemplary
damages in the said amount.1âwphi1 Article 2229 of the Civil
Code provides that exemplary damages may be imposed by way
of example or correction for the public good.

WHEREFORE, the petition is PARTLY GRANTED. The

Decision of the Court of Appeals dated August 29, 2008 is
REVERSED and SET ASIDE. A new judgment is entered
ACQUITTING Dr. Emmanuel Jarcia, Jr. and Dr. Marilou Bastan
of the crime of reckless imprudence resulting to serious physical
injuries but declaring them civilly liable in the amounts of:

(1) ₱ 3,850.00 as actual damages;

(2) ₱ 100,000.00 as moral damages;

(3) ₱ 50,000.00 as exemplary damages; and

(4) Costs of the suit.

with interest at the rate of 6% per annum from the date of the
filing of the Information. The rate shall be 12% interest per
annum from the finality of judgment until fully paid.

SO ORDERED.
MARITER MENDOZA vs. ADRIANO CASUMPANG et. al WHEREFORE, the Court entirely AFFIRMS the decision of the
G.R. No. 197987 March 19, 2012 Court of Appeals dated March 18, 2011 with the
MODIFICATION ordering petitioner Mariter Mendoza to
FACTS: pay respondents Adriano, Jennifer Adriane and John
On February 13, 1993 Josephine underwent hysterectomy and Andre, all surnamed Casumpang, an additional P50,000.00
myomectomy that Dr. Mendoza performed on her at the as exemplary damages, additional P30,000.00 as attorney’s fees
Iloilo Doctors’ Hospital. After her operation, Josephine and civil indemnity arising from death in the amount of
experienced recurring fever, nausea, and vomiting. Three months P50,000.00.
after the operation, she noticed while taking a bath something
protruding from her genital. She tried calling Dr. Mendoza to
report it but the latter was unavailable. Josephine instead went to G.R. No. 197987 March 19, 2012
see another physician, Dr. Edna Jamandre-Gumban, who
extracted a foul smelling, partially expelled rolled gauze from her MARITER MENDOZA, Petitioner,
cervix. The discovery of the gauze and the illness she went vs.
through prompted Josephine to file a damage suit against Dr. ADRIANO CASUMPANG, JENNIFER ADRIANE and
Mendoza before the RTC of Iloilo City. Because Josephine died JOHN ANDRE, all surnamed CASUMPANG, Respondents.
before trial could end, her husband and their children substituted
her in the case. She was a housewife and 40 years old when she DECISION
died.
On March 7, 2005 the RTC rendered judgment, finding Dr. ABAD, J.:
Mendoza guilty of neglect that caused Josephine’s illness and
eventual death and ordering her to pay plaintiff’s heirs actual Josephine Casumpang, substituted by her respondent husband
damages of P50,000.00, moral damages of P200,000.00, and Adriano and their children Jennifer Adriane and John Andre, filed
attorney’s fees of P20,000.00 plus costs of suit. On motion for an action for damages against petitioner Dr. Mariter Mendoza in
reconsideration, however, the RTC reversed itself and dismissed 1993 before the Regional Trial Court (RTC) of Iloilo City.
the complaint in an order dated June 23, 2005.
On appeal, the Court of Appeals (CA) rendered a decision on On February 13, 1993 Josephine underwent hysterectomy and
March 18, 2011, reinstating the RTC’s original decision. The CA myomectomy that Dr. Mendoza performed on her at the Iloilo
held that Dr. Mendoza committed a breach of her duty as a Doctors’ Hospital. After her operation, Josephine experienced
physician when a gauze remained in her patient’s body after recurring fever, nausea, and vomiting. Three months after the
surgery. The CA denied her motion for reconsideration on July operation, she noticed while taking a bath something protruding
18, 2011, prompting her to file the present petition. from her genital. She tried calling Dr. Mendoza to report it but the
latter was unavailable. Josephine instead went to see another
ISSUE: physician, Dr. Edna Jamandre-Gumban, who extracted a foul
Whether or not there is medical negligence on the part of the smelling, partially expelled rolled gauze from her cervix.
doctor.
The discovery of the gauze and the illness she went through
HELD: prompted Josephine to file a damage suit against Dr. Mendoza
Petitioner claims that no gauze or surgical material was left in before the RTC of Iloilo City. Because Josephine died before trial
Josephine’s body after her surgery as evidenced by the surgical could end, her husband and their children substituted her in the
sponge count in the hospital record. But she raises at this Court’s case. She was a housewife and 40 years old when she died.
level a question of fact when parties may raise only questions of
law before it in petitions On March 7, 2005 the RTC rendered judgment, finding Dr.
for review on certiorari from the CA. With few exceptions, the Mendoza guilty of neglect that caused Josephine’s illness and
factual findings of the latter court are generally binding. None of eventual death and ordering her to pay plaintiff’s heirs actual
those exceptions applies to this case. damages of ₱50,000.00, moral damages of ₱200,000.00, and
attorney’s fees of ₱20,000.00 plus costs of suit.
As the RTC pointed out,
Josephine did not undergo any other surgical operation. And it On motion for reconsideration, however, the RTC reversed itself
would be much unlikely for her or for any woman to inject a roll and dismissed the complaint in an order dated June 23, 2005.
of gauze into her cervix. The Court notes, however, that neither
the CA nor the RTC awarded exemplary damages against Dr. On appeal, the Court of Appeals (CA) rendered a decision on
Mendoza when, under Article 2229 of the Civil Code, March 18, 2011,1 reinstating the RTC’s original decision. The CA
exemplary damages are imposed by way of example or correction held that Dr. Mendoza committed a breach of her duty as a
for the public good, in addition to moral damages. Exemplary physician when a gauze remained in her patient’s body after
damages may also be awarded in cases of gross negligence. surgery. The CA denied her motion for reconsideration on July
18, 2011, prompting her to file the present petition.
A surgical operation is the responsibility of the surgeon
performing it. He must personally ascertain that the counts of Petitioner claims that no gauze or surgical material was left in
instruments and materials used before the surgery and prior to Josephine’s body after her surgery as evidenced by the surgical
sewing the patient up have been correctly done. To provide an sponge count in the hospital record.
example to the medical profession and to stress the need for
constant vigilance in attending to a patient’s health, the award of But she raises at this Court’s level a question of fact when parties
exemplary damages in this case is in order. Further, in view of may raise only questions of law before it in petitions for review
Josephine’s death resulting from petitioner’s negligence, on certiorari from the CA. With few exceptions, the factual
civil indemnity under Article 2206 of the Civil Code should be findings of the latter court are generally binding. None of those
given to respondents as heirs. The amount of P50,000.00 is fixed exceptions applies to this case.2
by prevailing jurisprudence for this kind.
As the RTC pointed out, Josephine did not undergo any other
surgical operation. And it would be much unlikely for her or for
any woman to inject a roll of gauze into her cervix. As the Court
held in Professional Services, Inc. v. Agana:3

An operation requiring the placing of sponges in the incision is

not complete until the sponges are properly removed, and it is
settled that the leaving of sponges or other foreign substances in
the wound after the incision has been closed is at least prima facie
negligence by the operating surgeon. To put it simply, such act is
considered so inconsistent with due care as to raise an inference
of negligence.1âwphi1 There are even legions of authorities to the
effect that such act is negligence per se.

The Court notes, however, that neither the CA nor the RTC
awarded exemplary damages against Dr. Mendoza when, under
Article 2229 of the Civil Code, exemplary damages are imposed
by way of example or correction for the public good, in addition
to moral damages. Exemplary damages may also be awarded in
cases of gross negligence.4

A surgical operation is the responsibility of the surgeon

performing it. He must personally ascertain that the counts of
instruments and materials used before the surgery and prior to
sewing the patient up have been correctly done. To provide an
example to the medical profession and to stress the need for
constant vigilance in attending to a patient’s health, the award of
exemplary damages in this case is in order.

Further, in view of Josephine’s death resulting from petitioner’s

negligence, civil indemnity under Article 22065 of the Civil Code
should be given to respondents as heirs. The amount of
₱50,000.00 is fixed by prevailing jurisprudence for this kind.6
1âwphi1

The Court also deems it just and equitable under Article 2208 of
the Civil Code to increase the award of attorney’s fees from
₱20,000.00 to ₱50,000.00.

WHEREFORE, the Court entirely AFFIRMS the decision of the

Court of Appeals dated March 18, 2011 with the
MODIFICATION ordering petitioner Mariter Mendoza to pay
respondents Adriano, Jennifer Adriane and John Andre, all
surnamed Casumpang, an additional ₱50,000.00 as exemplary
damages, additional ₱30,000.00 as attorney’s fees and civil
indemnity arising from death in the amount of ₱50,000.00.

SO ORDERED.
AQUINO V. HEIRS OF RAYMUNDA CALAYAG DECISION
G.R. No. 158461
Facts:
ABAD, J.:
When Raymunda Calayag went into labor, her husband Rodrigo
brought her to St. Michael’s Clinic. There, its owner, Dr. Unite These cases involve the liability of the surgeon, the
after an examination told the couple that Raymunda would have anesthesiologist, and the hospital owner arising from a botched
to undergo a caesarian operation but she has to be transferred to caesarean section that resulted in the patient going into a coma.
Sacred Heart Hospital. There, Dr. Aquino applied a preliminary
anesthesia and an anesthesia on her spine. After the operation, The Facts and the Case
Raymunda had a stillborn eight-month-old baby. Suddenly, the
medical team noticed that Raymunda is turning blue and her vital When his wife Raymunda went into labor pains and began
signs were gone, but they were able to bleeding on November 13, 1990, respondent Rodrigo Calayag
(Rodrigo)[1] brought her to St. Michael's Clinic of petitioner Dr.
Divinia Unite (Dr. Unite) at Malolos, Bulacan. After initial
restore these.Dr. Unite said to Rodrigo that Raymunda’s turning
examination, the doctor told Rodrigo that Raymunda had to have
blue is just normal since she had anesthesia and everything will
a caesarean section for her baby but this had to be done at the
return to normal after eight hours. However, this never happened.
better-equipped Sacred Heart Hospital (SHH), owned and
Upon referral to an internist, it was discovered that Raymunda
operated by petitioner Dr. Alberto Reyes (Dr. Reyes).
suffered a cardiac arrest during the operation. Thereafter, the
internist ordered Raymunda’s move to a better hospital.
SHH admitted Raymunda at 2:16 p.m. of the same day.[2] To
prepare her, the attending anesthesiologist, petitioner Dr. Eduardo
Raymunda was then admitted to Medical Center Manila where the Aquino (Dr. Aquino), injected her at about 2:30 p.m. with a
attending neurologist declared Raymunda to be in “vegetative preliminary "Hipnotic."[3] At 2:48 p.m., he administered an
state” because there was lack of oxygen coming to the brain anesthesia on her spine.[4] A few minutes later, at 2:53 p.m.,[5]
caused by the cardiac arrest. She never recovered. She died Dr. Unite delivered a stillborn eight-month-old baby.[6]
eventually.Now, the heirs of Raymunda Calayag, namely Rodrigo
and their seven children sued Dr. Unite, Dr. Aquino and Dr. A few minutes later or at around 3:00 p.m., the operating team[7]
Reyes, owner of Sacred Heart Hospital for medical malpractice. noticed that Raymunda had become cyanotic.[8] Her blood
They allege that Dr. Aquino and Dr. Unite were grossly negligent darkened for lack of oxygen and, all of a sudden, her vital signs
while Dr. Reyes was remiss in his duty of supervision. were gone.[9] The team worked on her for about 5 to 7 minutes
until these were restored.[10]
Issue:
Rodrigo claimed that when he saw Raymunda after the operation,
Whether or not the three doctors are negligent in their respective her skin appeared dark ("nangingitim ang katawan") and the white
duties resulting in the death of Raymunda Calayag. of her eyes showed ("nakatirik ang mata"). When he asked Dr.
Unite why his wife did not look well, she replied that this was
Held: merely the effect of the anesthesia and that she would regain
Inordertoobtainaconvictionformedicalmalpractice,theHeirsofRay consciousness in about eight hours.
mundaCalayagshould establish these: (1) duty; (2) breach; (3)
injury; and (4) proximate causation. The Heirs have successfully When Raymunda's condition did not improve after a day, Dr.
proven the breach of duty committed by Dr. Aquino and Dr. Unite Unite referred her to Dr. Farinas, an internist, who found that she
since the former have presented the attending neurologist where suffered a cardiac arrest during the operation, which explained her
his expert testimony outlined before the trial court the cause of comatose state. Dr. Farinas referred Raymunda to a neurologist
Raymunda being a “vegetable”. Moreover, this witness clearly who advised Rodrigo to move her to a better-equipped hospital.
pointed the blame to the doctors present in Raymunda’s operation [11] SHH discharged her on November 16, 1990, four days after
for failing to monitor the vital signs during the operation. her admission.
Furthermore, the testimony of the neurologist outlined what
should usually happen and what happened here being an Raymunda was directly moved to Medical Center Manila (MCM)
anesthetic accident since Dr. Aquino administered the anesthesia where Dr. Rogelio Libarnes (Dr. Libarnes), a neurologist,
at the wrong site. This notwithstanding, Dr. Unite cannot escape examined her. He found Raymunda in a "vegetative state,"[12]
liability. Since she is the surgeon in charge, she should not have having suffered from an anoxic injury[13] due to cardio-
allowed Dr. Aquino inside because he is sick. As a last point, the respiratory arrest during operation.[14] Dr. Libarnes was
trial court found out that there was no notation in the records of reluctant, however, to further proceed without consulting Dr.
Raymunda’s operation regarding the cardiac arrest. The absence Unite, Raymunda's surgeon, and Dr. Aquino, the anesthesiologist.
of this notation spelled the difference because if the surgeons had
this notation, they have 6 to 8 minutes from the time of cardiac On November 23, 1990 Dr. Unite went to MCM to remove the
arrest to save Raymunda. The absence clearly marked the stitches from Raymunda's surgical wound. Dr. Unite noted that
negligence of Dr. Unite and Dr. Aquino. the wound had dried with slight lochial discharge.[15] Later that
day, however, Raymunda's wound split open, causing part of her
However, the liability of Dr. Reyes was not proven since Dr. intestines to jut out. MCM's Dr. Benito Chua re-sutured the
Unite and Dr. Aquino were not under the hospital’s payroll and wound.[16]
there were no evidence presented that Raymunda’s fate was
caused by defective hospital facilities. Not even the doctrine of Raymunda never regained consciousness, prompting her MCM
ostensible agency or doctrine of apparent authority would make doctors to advise Rodrigo to take her home since they could do no
Dr. Reyes liable since there was no evidence adduced to this more to improve her condition. MCM discharged her on
effect. November 30, 1990 and she died 15 days later on December 14,
1990.
GR No. 158461, Aug 22, 2012 ]
DR. EDUARDO AQUINO v. CALAYAG +
Rodrigo filed, together with his seven children, a complaint[17] that physicians have extraordinary technical skills that laymen do
for damages against Dr. Unite, Dr. Aquino, and Dr. Reyes before not have.[22]
the Regional Trial Court (RTC) of Malolos. Rodrigo claimed that
Dr. Unite and Dr. Aquino failed to exercise the diligence required To successfully mount a medical malpractice action, the plaintiff
for operating on Raymunda. As for Dr. Reyes, Rodrigo averred should establish four basic things: (1) duty; (2) breach; (3) injury;
that he was negligent in supervising the .work of Dr. Unite and and (4) proximate causation.[23] The evidence should show that
Dr. Aquino. the physician or surgeon, either failed to do something which a
reasonably prudent physician or surgeon would have done, or that
Defendant doctors uniformly denied the charge of negligence he or she did something that a reasonably prudent physician or
against them. They claimed that they exercised the diligence surgeon would not have done; and that the failure or action caused
required of them and that causes other than negligence brought injury to the patient.[24]
about Raymunda's condition.
Here, to prove Dr. Unite and Dr. Aquino's negligence, Rodrigo
On August 22, 1994, after hearing the parties on their evidence, presented Dr. Libarnes, Raymunda's attending neurologist, and
the RTC rendered a decision, finding the three doctors liable for Dr. Chua, the general surgeon who re-stitched her wound.
negligence. The proximate cause of Raymunda's cardiac arrest,
said the RTC, was an anesthetic accident, occasioned by injecting Dr. Libarnes- explained that it was cyanosis or lack of oxygen in
her with a high spinal anesthesia. The operating doctors failed to the brain that caused Raymunda's vegetative state. Her brain
correctly monitor her condition, resulting in a critical delay in began to starve for oxygen from the moment she suffered cardio-
resuscitating her after the cardiac arrest. The RTC ordered the respiratory arrest during caesarean section. That arrest, said Dr.
doctors to pay Raymunda's heirs P153,270.80 as actual damages, Libarnes, could in turn be traced to the anesthetic accident that
P300,000.00 as moral damages, and P80,000.00 as attorney's fees resulted when Dr. Aquino placed her under anesthesia.[25]
and cost of suit.
Dr. Libarnes also blamed the doctors who operated on Raymunda
On appeal,[18] the Court of Appeals entirely affirmed the findings for not properly keeping track of her vital signs during the
of the RTC.[19] Undaunted, Dr. Unite, Dr. Aquino, and Dr. Reyes caesarean procedure resulting in their failure to promptly address
filed separate petitions for review that the Court subsequently the cyanosis when it set in.[26] Dr. Chua, on the other hand,
consolidated. testified that Raymunda's surgical wound would not have split
open if it had been properly closed.[27]
In her petition, Dr. Unite washed her hands of any responsibility
in Raymunda's operation. She claimed that it was not her suturing For their defense, Dr. Unite and Dr. Aquino presented Dr. Reyes,
that caused the splitting open of the patient's surgical wound. their co-defendant, who practiced general surgery. Dr. Reyes
Further, although some negligence may have attende'd the testified that Raymunda's cardio-respiratory arrest could have
operation, this could be traced to the anesthesiologist, Dr. Aquino. been caused by factors other than high spinal anesthesia, like
sudden release of intra-abdominal pressure and amniotic fluid
Dr. Aquino claims, on the other hand, that the evidence was embolism.[28] Insofar as Raymunda's dehiscence or splitting
insufficient to support the conclusion that anesthetic accident open of wound was concerned, Dr. Reyes testified that
caused the cardio-respiratory arrest since, as testified, other Raymunda's poor nutrition as well as the medication contributed
factors may have caused the same. to the dehiscence.

Finally, Dr. Reyes claims that he cannot be held liable for While the Court cannot question the expertise of Dr. Reyes as a
Raymunda's death since Dr. Unite and Dr. Aquino were not his general surgeon, it cannot regard him as a neutral witness. Given
employees. Based on the control test, he did not exercise control that he himself was a defendant in the case, he had a natural bias
and supervision over their work. They merely used his hospital's for testifying to favor his co-defendants.[29] Further, since he had
facilities for the operation. no opportunity to actually examine Raymunda, Dr. Reyes could
only invoke textbook medical principles that he could not clearly
The Issues Presented and directly relate to the patient's specific condition.

The cases present two issues: In contrast, as a neurologist with expertise in the human nervous
system, including the brain, Dr. Libarnes was in a better position
1. Whether or not Dr. Unite (the surgeon) and Dr. Aquino (the to explain Raymunda's "vegetative" condition and its cause. In his
anesthesiologist) acted negligently in handling Raymunda's opinion, an anesthetic accident .during her caesarean section
operation, resulting in her death; and caused a cardio-respiratory arrest that deprived her brain of
oxygen, severely damaging it. That damage could have been
2. Whether or not Dr. Reyes is liable, as hospital owner, for the averted had the attending doctors promptly detected the situation
negligence of Dr. Unite and Dr. Aquino. and resuscitated her on time. Thus, Dr. Libarnes said:

The Court's Rulings Atty. Lazaro:

What could have been the probable cause of this cardio-
The cause of action against the doctors in these cases is respiratory arrest now Doctor?
commonly known as medical malpractice. It is a form of
negligence which consists in the physician or surgeon's failure to Dr. Libarnes:
apply to his practice that degree of care and skill that the Well, most common cause of intra-operative cardio-respiratory
profession generally and ordinarily employs under similar arrest is anesthesia, an anesthetic accident.
conditions and circumstances.[20] Q:
Will you kindly explain that in layman's language now Doctor?
For this reason, the Court always seeks guidance from expert A:
testimonies in determining whether or not the defendant in a The spinal anesthesia can re [suit] in depression of respiratory
medical malpractice case exercised the degree of care and function. Respiratory arrest if significantly prolonged] can lead to
diligence required of him.[21] The Court has to face up to the fact
cardiac arrest. Cardiac arrest of significant duration can res[ult] in Nor would the doctrine of ostensible agency or doctrine of
brain injury.[30] apparent authority make Dr. Reyes liable to Raymunda's heirs for
xxxx her death. Two factors must be present under this doctrine: 1) the
Q: hospital acted in a manner which would lead a reasonable person
Now, when you refer to anoxic injury Doctor, you are referring to to believe that the person claimed to be negligent was its agent or
the lack of supply of oxygen going to the brain that is what you employee; and 2) the patient relied on such belief.
mean?
A: Here, there is no evidence that the hospital acted in a way that
Yes. made Raymunda and her husband believe that the two doctors
Q: were in the hospital's employ. Indeed, the couple had been
And this is due to the weak pumping of the heart, that is correct consulting Dr. Unite at St. Michael's Clinic, which she owned and
Doctor? operated in Malolos, Bulacan. She convinced them that the
A: caesarean section had to be performed at the SHH because it had
Yes. the facilities that such operation required. If the Court were to
Q: allow damages against the hospital under this arrangement,
And. the weak pumping of the heart under the events indicated by independently licensed surgeons would be unreasonably denied
you could have been due to anesthesia accident, that is correct? access to properly-equipped operating rooms in big hospitals.
A:
Hypoxia meaning lobe of the lung not providing oxygen, the heart As to the award of damages, following precedents set in Flores v.
has been stressed under hypoxic condition eventually giving out. Pineda[37] respondent heirs of Raymunda are entitled to
Yes, that is correct.[31] P50,000.00 as death indemnity pursuant to Article 2206 of the
Civil Code.
Dr. Aquino administered to Raymunda a high spinal anesthesia
when he should have given her only a low or mid-spinal WHEREFORE, premises considered, this Court DENIES the
anesthesia.[32] petitions and AFFIRMS the decision of the Court of Appeals
dated November 28, 2002 and resolution dated May 27, 2003
Notably, Dr. Unite corroborated the fact that Raymunda suffered subject to MODIFICATION directing petitioners, Dr. Divinia
from cyanosis due to deprivation of oxygen. This was Dr. Unite's Unite and Dr. Eduardo Aquino to pay the heirs of Raymunda
explanation when Rodrigo, seeing his wife after the operation, Calayag, in addition to the damages that the Court of Appeals
asked why she had a bluish color. Moreover, Dr. Unite admitted awarded them, P50,000.00 as death indemnity.
in her petition, that the proximate cause of Raymunda's brain
injury was Dr. Aquino's acts as anesthesiologist.[33] SO ORDERED.

But Dr. Unite cannot exempt herself from liability. Dr. Aquino
was not feeling well on the day of the operation as he was in fact
on sick leave.[34] As surgeon in charge, Dr. Unite should not
have allowed Dr. Aquino to take part in the operation.

Besides, as the RTC found; the record of the operation contained

no notation just when Raymunda had a cardio-respiratory arrest
and ceased to take in oxygen. This notation played a critical role
since the surgeons had between 6 to 8 minutes from the time of
arrest, called the golden period of reversibility, within which to
save her from becoming a vegetable. The absence of the notation
on record, an important entry because the absence of which is
itself a ground for malpractice,[35] implies that the surgeons had
no inkling when the cardio-respiratory arrest occurred and how
much time they had left to revive their patient. Indeed, it took a
subsequent examination by an internist for them to realize that
Raymunda had suffered a cardio-respiratory arrest.

As for Dr. Reyes, the hospital owner, there appears no concrete

proof to show that Dr. Unite and Dr. Aquino were under the
hospital's payroll. Indeed, Dr. Aquino appeared to be a
government physician connected with the Integrated Provincial
Health Office of Bulacan.[36] Dr. Unite appeared to be a self-
employed doctor. The hospital allowed these doctors to operate on
their patients, using its operating room and assisting staffs for a
fee. No evidence has been presented that Raymunda suffered her
fate because of defective hospital facilities or poor staff support to
the surgeons.

That Dr. Reyes and his wife rushed to the operating room the
moment they heard that Raymunda's vital signs had ceased is not
an evidence that they exercised supervision over the conduct of
the operation. They evidently came to see what was happening
possibly to provide help if needed. Their showing up after the
operation is not a proof that they had control and supervision over
the work of the two doctors.
DR. PEDRO DENNIS CERENO, and DR. SANTOS ZAFE v. suffering from major blood loss requiring an immediate operation,
COURT OF APPEALS We find it reasonable that petitioners decided to wait for Dr.
Tatad to finish her surgery and not to call the standby
FACTS: anesthesiologist anymore. There is, after all, no evidence that
At about 9:15 in the evening of 16 September 1995, Raymond S. shows that a prudent surgeon faced with similar circumstances
Olavere (Raymond), a victim of a stabbing incident, was rushed to would decide otherwise.
the Bicol Regional Medical Center (BRMC). Dr. Realuyo, the
emergency room resident physician, recommended that Raymond In medical negligence cases, it is settled that the complainant has
should undergo blood transfusion. the burden of establishing breach of duty on the part of the
doctors or surgeons. It must be proven that such breach of duty
At 10:30 P.M., Raymond was brought inside the operating room. has a causal connection to the resulting death of the patient.
During that time, the hospital surgeons, Drs. Zafe and Cereno,
were busy operating on gunshot victim Charles Maluluy-on. Upon opening of his thoracic cavity, it was discovered that there
Assisting them in the said operation was Dr. Rosalina Tatad (Dr. was gross bleeding inside the body. Thus, the need for petitioners
Tatad), who was the only senior anesthesiologist on duty at to control first what was causing the bleeding.
BRMC that night. Just before the operation on Maluluy-on was GRANTED
finished, another emergency case involving Lilia Aguila, a
woman who was giving birth to triplets, was brought to the
operating room. DR. ENCARNACION LUMANTAS V. HANZ CALAPIZ

Drs. Zafe and Cereno, in the meantime, proceeded to examine

Raymond and they found that the latters blood pressure was FACTS:
normal and "nothing in him was significant." There being no
other available anesthesiologist to assist them, Drs. Zafe and In 1995, Spouses Hilario Calapiz, Jr. and Herlita Calapiz brought
Cereno decided to defer the operation on Raymond. their 8-year-old son, Hanz Calapiz (Hanz), to the Misamis
Occidental Provincial Hospital, Oroquieta City, for an emergency
At 11:15 P.M., the relatives of Raymond brought the bag of blood appendectomy. Hanz was attended to by the petitioner, who
to be used for blood transfusion. Drs. Cereno and Zafe suggested to the parents that Hanz also undergo circumcision at
immediately started their operation on Raymond at around 12:15 no added cost to spare him the pain. With the parents’ consent, the
A.M. of 17 September 1995. Upon opening of Raymonds thoracic petitioner performed the coronal type of circumcision on Hanz
cavity, they found that 3,200 cc of blood was stocked therein. Dr. after his appendectomy. On the following day, Hanz complained
Cereno did not immediately transfuse the blood since the bleeders of pain in his penis, which exhibited blisters. His testicles were
had to be controlled first. Blood was finally transfused on swollen. The parents noticed that the child urinated abnormally
Raymond at 1:40 A.M. However, during the operation, Raymond after the petitioner forcibly removed the catheter, but the
died due to massive loss of blood. petitioner dismissed the abnormality as normal. Hanz was
discharged from the hospital over his parents’ protestations, and
Claiming that there was negligence on the part of those who was directed to continue taking antibiotics. After a few days,
attended to their son, the parents of Raymond (herein Hanz was confined in a hospital because of the abscess formation
respondents) filed a complaint for damages against Drs. Zafe and between the base and the shaft of his penis. Presuming that the
Cereno. The RTC found Drs. Zafe and Cereno negligent for not ulceration was brought about by Hanz’s appendicitis, the
immediately conducting surgery on Raymond. On appeal, the CA petitioner referred him to Dr. Henry Go, an urologist, who
affirmed RTCs findings. diagnosed the boy to have a damaged urethra. Thus, Hanz
underwent cystostomy, and thereafter was operated on three times
ISSUE: to repair his damaged urethra.
Are Drs. Zafe and Cereno guilty of gross negligence in the
performance of their duties? When his damaged urethra could not be fully repaired and
reconstructed, Hanz’s parents brought a criminal charge against
HELD: the petitioner for reckless imprudence resulting to serious physical
The type of lawsuit which has been called medical malpractice or, injuries. In his defense, the petitioner denied the charge. He
more appropriately, medical negligence, is that type of claim contended that at the time of his examination of Hanz, he had
which a victim has available to him or her to redress a wrong found an accumulation of pus at the vicinity of the appendix two
committed by a medical professional which has caused bodily to three inches from the penis that had required immediate
harm. In order to successfully pursue such a claim, a patient must surgical operation; that after performing the appendectomy, he
prove that a health care provider, in most cases a physician, either had circumcised Hanz with his parents’ consent by using a congo
failed to do something which a reasonably prudent health care instrument, thereby debunking the parents’ claim that their child
provider would have done, or that he or she did something that a had been cauterized; that he had then cleared Hanz once his fever
reasonably prudent provider would not have done; and that the had subsided; that he had found no complications when Hanz
failure or action caused injury to the patient. returned for his follow up check-up; and that the abscess
formation between the base and the shaft of the penis had been
Given that Dr. Tatad was already engaged in another urgent brought about by Hanz’s burst appendicitis.
operation and that Raymond was not showing any symptom of
The RTC acquitted the petitioner of the crime charged for once that integrity has been violated. The assessment is but an
insufficiency of the evidence. It held that the Prosecution’s imperfect estimation of the true value of one’s body. The usual
evidence did not show the required standard of care to be practice is to award moral damages for the physical injuries
observed by other members of the medical profession under sustained. In Hanz’s case, the undesirable outcome of the
similar circumstances. Nonetheless, the RTC ruled that the circumcision performed by the petitioner forced the young child
petitioner was liable for moral damages because there was a to endure several other procedures on his penis in order to repair
preponderance of evidence showing that Hanz had received the his damaged urethra. Surely, his physical and moral sufferings
injurious trauma from his circumcision by the petitioner. The properly warranted the amount of P50,000.00 awarded as moral
Petitioner appealed his case to the CA contending that he could damages.
not be held civilly liable because there was no proof of his
negligence. The CA affirmed the RTC, sustaining the award of Many years have gone by since Hanz suffered the injury. Interest
moral damages. of 6% per annum should then be imposed on the award as a
sincere means of adjusting the value of the award to a level that is
ISSUE: not only reasonable but just and commensurate. Unless we make
the adjustment in the permissible manner by prescribing legal
Whether the CA erred in affirming the petitioner’s civil liability interest on the award, his sufferings would be unduly
despite his acquittal of the crime of reckless imprudence resulting compounded. For that purpose, the reckoning of interest should be
in serious physical injuries. from the filing of the criminal information on April 17, 1997, the
making of the judicial demand for the liability of the petitioner.
HELD:

NO. It is axiomatic that every person criminally liable for a felony SOLIDUM V. PEOPLE GR No. 192123 March 10, 2014
is also civilly liable. xxx Our law recognizes two kinds of
acquittal, with different effects on the civil liability of the
accused. First is an acquittal on the ground that the accused is not
FACTS:
the author of the act or omission complained of. This instance
Gerald Albert Gercayo was born on June 2, 1992 with an
closes the door to civil liability, for a person who has been found
imperforate anus. Two days after his birth, Gerald under went
to be not the perpetrator of any act or omission cannot and can
colostomy, a surgical procedure to bring one end of the large
never be held liable for such act or omission. There being no
intestine out through the abdominal walls, enabling him to excrete
delict, civil liability ex delicto is out of the question, and the civil
through a colostomy bag attached to the side of his body. On May
action, if any, which may be instituted must be based on grounds
17, 1995, Gerald was admitted at the Ospital ng Maynila for a
other than the delict complained of. This is the situation
pull-through operation. Dr. Leandro Resurreccionheaded the
contemplated in Rule 111 of the Rules of Court. The second
surgical team, and was assisted by Dr. Joselito Lucerio,
instance is an acquittal based on reasonable doubt on the guilt of
Dr.Donatella Valeria and Dr. Joseph Tibio. The anesthesiologist
the accused. In this case, even if the guilt of the accused has not
included Drs. Abella, Razon and Solidum. During the operation,
been satisfactorily established, he is not exempt from civil
Gerald experienced bradycardia and went into a coma. His coma
liability which may be proved by preponderance of evidence only.
lasted for two weeks , but he regained consciousness only after a
month. He could no longer see, hear, or move. A complaint for
reckless imprudence resulting in serious physical injuries were
The petitioner’s contention that he could not be held civilly liable
filed by Gerald’s parents against the team of doctors alleging that
because there was no proof of his negligence deserves scant
there was failure in monitoring the anesthesia administered to
consideration. The failure of the Prosecution to prove his criminal
Gerald.
negligence with moral certainty did not forbid a finding against
him that there was preponderant evidence of his negligence to
hold him civilly liable. With the RTC and the CA both finding ISSUES:
that Hanz had sustained the injurious trauma from the hands of 1. Whether or not petitioner is liable for medical
the petitioner on the occasion of or incidental to the circumcision, negligence.
and that the trauma could have been avoided, the Court must
concur with their uniform findings. In that regard, the Court need 2. Whether or not res ipsa liquitor can be resorted to in
not analyze and weigh again the evidence considered in the medical negligence cases.
proceedings a quo. The Court, by virtue of its not being a trier of
facts, should now accord the highest respect to the factual
findings of the trial court as affirmed by the CA in the absence of HELD:
a clear showing by the petitioner that such findings were tainted No. Negligence is defined as the failure to observe for the
with arbitrariness, capriciousness or palpable error. protection of the interests of another person that degree of care,
precaution, and vigilance that the circumstances justly demand,
Every person is entitled to the physical integrity of his body. whereby such other person suffers injury. Reckless imprudence,
Although we have long advocated the view that any physical on the other hand, consists of voluntarily doing or failing to do,
injury, like the loss or diminution of the use of any part of one’s without malice, an act from which material damage results by
body, is not equatable to a pecuniary loss, and is not susceptible reason of an inexcusable lack of precaution on the part of the
of exact monetary estimation, civil damages should be assessed person to perform or failing to perform such act.
showing is that the desired result of an operation or treatment was
The negligence must be the proximate cause of the injury. For, not accomplished. The real question, therefore, is whether or not
negligence no matter in what it consists, cannot create a right of in the process of the operation any extraordinary incident or
action unless it is the proximate cause of the injury complained of. unusual event outside the routine performance occurred which is
And the proximate cause of an injury is that cause, which, in beyond the regular scope of customary professional activity in
natural and continuous sequence and unbroken by any efficient such operations, which if unexplained would themselves
intervening cause, produces the injury, and without which the reasonably speak to the average man as the negligent case or
result would not have occurred. causes of the untoward consequence. If there was such extraneous
An action upon medical negligence – whether criminal, civil or intervention, the doctrine of res ipsa liquitor may be utilized and
administrative – calls for the plaintiff to prove by competent the dependent is called upon to explain the matter, by evidence of
evidence each of the following four elements namely: a.) the duty exculpation, if he could.
owed by the physician to the patient, as created by the physician-
patient relationship, to act in accordance with the specific norms
or standards established by his profession; b.) the breach of the CABUGAO V PEOPLE
duty by the physician’s failing to act in accordance with the
applicable standard of care; c.) the causation, is, there must be a
reasonably close and casual connection between the negligent act FACTS:
or omission and the resulting injury; and d.) the damages suffered
by the patient. An information was filed against Dr. Antonio P. Cabugao and Dr.
Clenio Ynzon of the crime of Reckless Imprudence Resulting to
In the medical profession, specific norms on standard of care to Homicide.
protect the patient against unreasonable risk, commonly referred
to as standards of care, set the duty of the physician in respect of
the patient. The standard of care is an objective standard which On June 14, 2000, at around 4 o'clock in the afternoon, ten (10)-
conduct of a physician sued for negligence or malpractice may be year old Rodolfo F. Palma, Jr. (JR) complained of abdominal pain
measured, and it does not depend therefore, on any individual’s to his mother, Rosario Palma. At 5 o’clock that same afternoon,
physician’s own knowledge either. In attempting to fix a standard Palma's mother and father, Atty. Rodolfo Palma Sr., brought JR to
by which a court may determine whether the physician has the clinic of accused Dr. Cabugao. Dr. Cabugao, a general
properly performed the requisite duty toward the patient, expert practitioner, specializing in family medicine gave medicines for
medical testimony from both plaintiff and defense experts is the pain and told Palma's parents to call him up if his stomach
required. pains continue. Due to persistent abdominal pains, at 4:30 in the
early morning of June 15, 2000, they returned to Dr. Cabugao,
The doctrine of res ipsa liquitor means that where the thing which who advised them to bring JR to the Nazareth General Hospital in
causes injury is shown to be under the management of the Dagupan City, for confinement. JR was admitted at the said
defendant, and the accident is such as in ordinary course of things hospital at 5:30 in the morning.
does not happen if those who have management use proper care, it
affords reasonable evidence, in the absence of an explanation by
defendant that the accident arose from want of care. Blood samples were taken from JR for laboratory testing. The
findings showed an inflammatory process wherein appendiceal or
Nevertheless, despite the fact that the scope of res ipsa liquitor has periappendiceal pathology cannot be excluded.
been measurably enlarged, it does not automatically apply to all
cases of medical negligence as to mechanically shift the burden of
proof to the defendant to show that he is not guilty of the ascribed Dr. Cabugao did a rectal examination. The initial impression was
negligence. Res ipsa liquitor is not a rigid or ordinary doctrine to Acute Appendicitis, and hence, he referred the case to his co-
be perfunctorily used but a rule to be cautiously applied, accused, Dr. Ynzon, a surgeon. In the later part of the morning of
depending upon the circumstances of each case. It is generally June 15, 2000, Dr. Ynzon went to the hospital and read the CBC
restricted to situations in malpractice cases where a layman is able and ultrasound results. The administration of massive antibiotics
to say, as a matter of common knowledge and observation, that and pain reliever to JRwere ordered. Thereafter, JR was placed on
the consequences of professional care were not as such as would observation for twenty-four (24) hours.
ordinarily have followed if due care had been exercised. A
distinction must be made between the failure to secure results, and
the occurrence of something more unusual and not ordinarily
In the morning of June 16, 2000, JR complained again of
found if the service or treatment rendered followed the usual
abdominal pain and his parents noticeda swelling in his scrotum.
procedure of those skilled in that particular practice. It must be
In the afternoon of the same day, JR vomitted out greenish stuff
conceded that the doctrine of res ipsa liquitor can have no
three times and had watery bowels also three times. The nurses
application in a suit against a physician or surgeon which involves
on-duty relayed JR's condition to Dr. Ynzon who merely gave
the merits of a diagnosis or of a scientific treatment. The
orders via telephone. Accused continued medications to alleviate
physician or surgeon is not required at his peril to explain why
JR's abdominal spasms and diarrhea. By midnight, JR again
any particular diagnosis was not correct, or why any particular
vomitted twice, had loose bowel movements and was unable to
scientific treatment did not produce the desired results. Thus, res
sleep. The following morning, JR's condition worsened, he had a
ipsa liquitor is not available in a malpractice suit if the only
running fever of 38°C. JR's fever remained uncontrolled and he suspected appendicitis.
became unconscious, he was given Aeknil (1 ampule) and Valium
(1 ampule). JR's condition continued to deteriorate that by 2 While this case is pending appeal, counsel for petitioner Dr.
o'clock in the afternoon, JR's temperature soared to 42°C, had Ynzon informed the Court that the latter died on December 23,
convulsions and finally died. RTC and CA found the accused 2011 due to "multiorgan failure" as evidenced by a copy of death
guilty certificate. Thus, the effect of death, pending appeal of his
conviction of petitioner Dr. Ynzon with regard to his criminal and
pecuniary liabilities should be in accordance to People v. Bayotas,
ISSUES: wherein the Court laid down the rules in case the accused dies
prior to final judgment:

1. WoN Dr. Ynzon is guilty = YES

2. 2. WoN Dr. Cabugao is guilty = NO 1. Death of the accused pending appeal of his conviction
extinguishes his criminal liability as well as the civil liability
based solely thereon. As opined by Justice Regalado, in this
regard, "the death of the accused prior to final judgment
terminates his criminal liability and only the civil liability directly
arising from and based solely on the offense committed, i.e.,civil
HELD:
liability ex delictoin senso strictiore."
2. Corollarily, the claim for civil liability survives
(1)Dr. Ynzon revealed want of reasonable skill and care in
notwithstanding the death of accused, if the same may also be
attending to the needs of JR by neglecting to monitor effectively
predicated on a source of obligation other than delict. Article
the developments and changes on JR's condition during the
1157 of the Civil Code enumerates these other sources of
observation period, and to act upon the situation after the 24-hour
obligation fromwhich the civil liability may arise as a result of the
period when his abdominal pain persisted and his condition
same act or omission:
worsened. He appeared to have visited JR briefly only during
regular rounds in the mornings. He was not there during the
crucial times on June 16, 2000 when JR's condition started to
deteriorate until JR's death. As the attending surgeon, he should a) Law
be primarily responsible in monitoring the condition of JR, as he b) Contracts
is in the best position considering his skills and experience to c) Quasi-contracts
know if the patient's condition had deteriorated. Upon the d) x x x x x x x x x
extinction ofthe criminal liability and the offended party desires to e) Quasi-delicts
recover damages from the same act or omission complained of, 3. Where the civil liability survives, as explained in Number 2
the party may file a separate civil action based on the other above, an action for recovery therefor may be pursued but only by
sources of obligation in accordance with Section 4, Rule 111. If way of filing a separate civil action and subject to Section 1, Rule
the same act or omission complained of arises from quasi-delict, 111 of the 1985 Rules on Criminal Procedure as amended. This
as in this case, a separate civil action must be filed against the separate civil action may be enforced either againstthe
executor or administrator of the estate of the accused, pursuant to executor/administrator or the estate of the accused, depending on
Section 1, Rule 87 of the Rules of Court. the source of obligation upon which the same is based as
explained above.
4. Finally, the private offended party need not fear a forfeiture of
his right to file this separate civil action by prescription, in cases
Conversely, if the offended party desires to recover damages from
where during the prosecution of the criminal action and prior to
the same act or omission complained of arising from contract, the
its extinction, the private-offended party instituted together
filing of a separate civil action must be filed against the estate,
therewith the civil action. In such case, the statute of limitationson
pursuant to Section 5, Rule 86 of the Rules of Court. It was
the civil liability is deemed interrupted during the pendency of the
sufficiently established that to prevent certain death, it was
criminal case, conformably with provisions of Article 1155 of the
necessary to perform surgery on JR immediately. Also, if JR’s
Civil Code, that should thereby avoid any apprehension on a
condition remained unchecked it would ultimately result in his
possible privation of right by prescription.
death, as what actually happened in the present case. Another
expert witness for the defense, Dr. Vivencio Villaflor, Jr. testified
on direct examination that he would perform a personal and It is clear that the death of the accused Dr. Ynzon pending appeal
thorough physical examination of the patient as frequent as every of his conviction extinguishes his criminal liability. However, the
4 to 6 hours. recovery of civil liability subsists as the same is not based on
delict but by contract and the reckless imprudence he was guilty
(2)Dr. Cabugao is not in any position to perform the required of under Article 365 of the Revised Penal Code. For this reason, a
appendectomy. He is not a surgeon,but a general practitioner separate civil action may be enforced either against the
specializing in family medicine; thus, even if he wanted to, he executor/administrator or the estate of the accused, depending on
cannot do an operation, much less an appendectomy on JR. It is the source of obligation upon which the same is based, and in
precisely for this reason why he referred JR to Dr. Ynzon after he accordance with Section 4, Rule 111 of the Rules on Criminal
Procedure. Whether or not respondents were liable for medical malpractice
that resulted to Carmen’s death.
Dr. Cabugao has shown to have exerted all efforts to monitor his
patient and under these circumstances he did not have any cause HELD:
to doubt Dr. Ynzon’s competence and diligence. No. Medical malpractice or, more appropriately, medical
negligence, is that type of claim which a victim has available to
In sum, upon the extinction of the criminal liability and the him or her to redress a wrong committed by a medical
offended party desires to recover damages from the same act or professional which has caused bodily harm. In order to
omission complained of, the party may file a separate civil action successfully pursue such a claim, a patient, or his or her family as
based on the other sources of obligation in accordance with in this case, must prove that healthcare provider, in most cases, a
Section 4, Rule 111. If the same act or omission complained of physician, either failed to do something which a reasonably
arises from quasi- delict, as in this case, a separate civil action prudent health care provider would have done, or that he or she
must be filed against the executor or administrator of the estate of did something that a reasonably prudent provider would not have
the accused, pursuant to Section 1, Rule 87 of the Rules of Court. done; and that failure or action caused injury to the patient.

Conversely, if the offended party desires to recover damages from Four essential elements must be established namely: 1.) duty; 2.)
the same act or omission complained of arising from contract, the breach; 3.) injury and 4.) proximate causation. All four elements
filing of a separate civil action must be filed against the estate, must be present in order to find the physician negligent and thus,
pursuant to Section 5, Rule 86 of the Rules of Court. The heirs of liable for damages.
JR must choose which of the available causes of action for For the trial court to give weight to Dr. Partilano’s report, it was
damages they will bring. necessary to show first Dr. Partilano’s specialization and
competence to testify on the degree of care, skill and diligence
needed for the treatment of Carmen’s case. Considering that it
DELA TORRE V, IMBUIDO was not duly established that Dr. Partilano practiced and was an
GR No. 192973 September 29, 2014 expert on the fields that involved Carmen’s condition, he could
not have accurately identified the said degree of care, skill and
FACTS: diligence and the medical procedure, that should have been
At around 3:00pm of February 3, 1992, Carmen was brought to applied.
Divine Spirit General Hospital’s operating room for her caesarian
section operation, which was to be performed by Dr. Nestor. By
5:30pm, of the same day, Pedrito was informed by his wife’s BONDOC V. MANTALA
delivery of a baby boy. In the early morning of February 4, 1992, GR No. 203080 November 12, 2014
Carmen experienced abdominal pains and difficulty in urinating.
She was diagnosed to be suffering from urinary tract infection FACTS:
(UTI), and was prescribed medication by Dr. Norma. On February Respondent was admitted at the Oriental Mindoro Provincial
10, 1992, Pedrito noticed that Carmen’s stomach was getting Hospital (OMPH) on April 3, 2009, at around 11:00am, with
bigger, but Dr. Norma dismissed the patient’s condition as mere referral from the Bansud Municipal Health Office. She was due to
fratulence. When Carmen’s stomach still grow bigger despite deliver her 5th child and was advised for a caesarian section
medications, Dr. Norma advised Pedrito of the possibility of a because her baby was big and there was excessive amniotic fluid
second operation on Carmen. Dr. Norma, however, provided no in her womb. She started to labor at 7:00am and was initially
details on its purpose and the doctor who would perform it. At brought to the Bongabon Health Center. However, said health
around 3:00pm on February 12, 1992 Carmen had her second center also told her to proceed directly to the hospital. In her
operation. Later in the evening, Dr. Norma informed Pedrito that complaint-affidavit, respondent alleged that inside the delivery
“everything was going on fine with his wife.” The condition of room of OMPH, she was attended to by petitioner who instructed
Carmen, however, did not improve. It instead worsened that on the midwife and two younger assistants to press down on
February 13, 1992, she vomited dark red blood. At 9:30pm of the respondent’s abdomen and even demonstrated to them how to
same day, Carmen died. Per her death certificate upon insert their fingers into her vagina. Thereafter, petitioner went out
information provided by the hospital, the immediate cause of of the delivery room and later, his assistants also left. After hours
Carmen’s death was cardio- respiratory arrest secondary to of being in labor, respondent pleaded for a caesarian section. The
cerebro vascular accident, hypertension and chronic nephritis midwife and the younger assistants pressed down on her abdomen
induced by pregnancy. An autopsy report prepared by Dr. causing excruciating pains on her ribs and made her very weak.
Partilano, medico-legal officer designate of Olongapo City, They repeatedly did this pressing until the bay and placenta came
however, provided that the cause of Carmen’s death was shock out. When she regained consciousness, she was already at the
due to peritonitis severe with multiple intestinal adhesions; status recovery room, she learned that an operation was performed on
post caesarian section and exploratory laparotomy. Pedrito her by petitioner to removed her ruptured uterus but what
claimed in his complaint that the respondents failed to exercise depressed her most was her stillborn baby and the loss of her
the degree of diligence required of them as members of the reproductive capacity. The respondent noticed that her vulva
medical profession, and were negligent for practicing surgery on swollen and there is an open wound which widened later on and
Carmen in the most unskilled, ignorant, and cruel manner. was re-stitched by petitioner. Petitioner was heard uttering words
unbecoming of his profession pertaining to the respondent’s states
ISSUE: while in labor. Respondent filed then a complaint for grave
misconduct against the petitioner before the ombudsman. The On April 22, 1988, at about 11:30 in the morning, Mrs. Cortejo
petitioner resigned as medical officer of OMPH, alleging that the brought her 11-year old son, Edmer, to the Emergency Room of
complaint against him is now moot and academic. the San Juan de Dios Hospital (SJDH) because of difficulty in
breathing, chest pain, stomach pain, and fever. Thereafter, she
ISSUE: was referred and assigned to Dr. Casumpang, a pediatrician. At
Whether or not petitioner’s conduct during the delivery of 5:30 in the afternoon of the same day, Dr. Casumpang, upon
respondent’s baby constitute grave misconduct. examination using only a stethoscope, confirmed the diagnosis of
Bronchopneumonia. Mrs. Cortejo immediately advised Dr.
HELD: Casumpang that Edmer had a high fever, and had no colds or
Yes. Misconduct is defined as a transgression of some established cough but Dr. Casumpang merely told her that her son's
and definite rule of action, more particularly unlawful behavior or bloodpressure is just being active and remarked that that's the
gross negligence by a public officer, a forbidden act, a dereliction usual bronchopneumonia, no colds, no phlegm.
of duty, willful in character, and implies wrongful intent and not
mere error in judgement. It generally means wrongful, improper Dr. Casumpang next visited the following day. Mrs. Cortejo again
or unlawful conduct motivated by a premeditated, obstinate or called Dr. Casumpang's attention and stated that Edmer had a
intentional purpose. The term, however does not necessarily fever, throat irritation, as well as chest and stomach pain. Mrs.
imply corruption or criminal intent. To constitute an Cortejo also alerted Dr. Casumpang about the traces of blood in
administrative offense, misconduct should relate to or be Edmer's sputum. Despite these pieces of information, however,
connected with the performance of the official functions and Dr. Casumpang simply nodded and reassured Mrs. Cortejo that
duties of a public officer. On the other hand, when the elements of Edmer's illness is bronchopneumonia.
corruption, clear intent to violate the law or flagrant disregard of
established rule are manifest, the public officer shall be liable for At around 11:30 in the morning of April 23, 1988, Edmer vomited
grave misconduct. phlegm with blood streak prompting the Edmer's father to request
In deliberately leaving the respondent to a midwife and two for a doctor. Later, Miranda, one of the resident physicians of
inexperienced assistants despite knowing that she was under SJDH, arrived. She claimed that although aware that Edmer had
prolonged painful labor and about to give birth to a macrosomic vomited phlegm with blood streak she failed to examine the blood
baby by vaginal delivery, petitioner clearly committed a specimen. She then advised the respondent to preserve the
dereliction of duty and a breach of his professional obligations. specimen for examination. Thereafter, Dr. Miranda conducted a
The gravity of respondent’s conditions is highlighted by the check-up on Edmer and found that Edmer had a low-grade fever
expected complications she suffered – her stillborn baby, a and rashes.
ruptured uterus that necessitated the immediate surgery and blood
transfusion and vulvar hematomas. At 3:00 in the afternoon, Edmer once again vomited blood. Dr.
Miranda then examined Edmer's sputum with blood and noted
Article II section 1 of the code of medical ethics of the medical that he was bleeding. Suspecting that he could be afflicted with
profession in the Philippines states: A physician, should attend to dengue, Dr. Miranda conducted a tourniquet test, which turned
his patients faithfully and conscientiously. He should secure fore out to be negative. Dr. Miranda then called up Dr. Casumpang at
them all possible benefits that may depend upon his professional his clinic and told him about Edmer's condition. Upon being
skill and care. As the sole tribunal to adjudge the physician’s informed, Dr. Casumpang ordered several procedures done. Dr.
failure to fulfill his obligation to his patient is, in most cases, his Miranda advised Edmer's parents that the blood test results
own conscience, violation of this rule on his part is discreditable showed that Edmer was suffering from Dengue Hemorrhagic
and inexcusable. Fever. Dr. Casumpang recommended Edmer’s transfer to the
ICU, but since the ICU was then full, the respondent, insisted on
A doctor’s duty to his patient is not required to be extraordinary. transferring his son to Makati Medical Center.
The standard contemplated for doctors is simply the reasonable At 12:00 midnight, Edmer, accompanied by his parents and by
coverage merit among ordinarily good physicians i.e. reasonable Dr. Casumpang, was transferred to Makati Medical Center. Upon
skill and competence. Even by this standard, petitioner fill short examination, the attending physician diagnosed Dengue Fever
when he routinely delegated an important task that requires his Stage IV that was already in its irreversible stage. Edmer died at
professional skill and competence to his subordinates who have 4:00 in the morning of April 24, 1988. His Death Certificate
no requisite training and capability to make crucial decisions in indicated the cause of death as Hypovolemic Shock/hemorrhagic
difficult child births. shock/Dengue Hemorrhagic Fever Stage IV.
Believing that Edmer's death was caused by the negligent and
A physician should be dedicated to provide competent medical erroneous diagnosis of his doctors, the respondent instituted an
care with full professional skill and accordance with the current action for damages against SJDH, and its attending physicians:
standards of care, compassion, independence, and respect for Dr. Casumpang and Dr. Miranda.
human dignity.
Dr. Casumpang contends that he gave his patient medical
treatment and care to the best of his abilities, and within the
CASUMPANG, ET AL V. CORTEJO proper standard of care required from physicians under similar
circumstances.

FACTS:
Dr. Miranda argued that the function of making the diagnosis and taken. We also believe that a finding of negligence should also
undertaking the medical treatment devolved upon Dr. depend on several competing factors. In this case, before Dr.
Casumpang, the doctor assigned to Edmer. Dr. Miranda also Miranda attended to Edmer, Dr. Casumpang had diagnosed
alleged that she exercised prudence in performing her duties as a Edmer with bronchopneumonia. There is also evidence supporting
physician, underscoring that it was her professional intervention Dr. Miranda's claim that she extended diligent care to Edmer. In
that led to the correct diagnosis of Dengue Hemorrhagic Fever. fact, when she suspected, during Edmer's second episode of
bleeding, that Edmer could be suffering from dengue, she wasted
SJDH, on the other hand, disclaims liability by asserting that Dr. no time in conducting the necessary tests, and promptly notified
Casumpang and Dr. Miranda are mere independent contractors Dr. Casumpang about the incident. Indubitably, her medical
and consultants (not employees) of the hospital; hence, Article assistance led to the finding of dengue fever. Dr. Miranda's error
2180 of the Civil Code does not apply. was merely an honest mistake of judgment; hence, she should not
be held liable for medical negligence.
ISSUES:
1. W/N Casumpang had committed inexcusable lack of precaution 3. Yes, causal connection between the petitioners' negligence and
in diagnosing and in treating the patient the patient's resulting death was established
2. W/N Miranda had committed inexcusable lack of precaution in
diagnosing and in treating the patient Casumpang failed to timely diagnose Edmer with dengue fever
3. W/N Whether or not the petitioner hospital is solidarity liable despite the presence of its characteristic symptoms; and as a
with the petitioner doctors consequence of the delayed diagnosis, he also failed to promptly
4. W/N or not there is a causal connection between the petitioners' manage Edmer's illness. Had he immediately conducted
negligent act/omission and the patient's resulting death confirmatory tests, and promptly administered the proper care and
management needed for dengue fever, the risk of complications or
HELD/RATIO: even death, could have been substantially reduced. That Edmer
1. YES, Casumpang was negligent. later died of Dengue Hemorrhagic Fever Stage IV, a severe and
Even assuming that Edmer's symptoms completely coincided fatal form of dengue fever, established the causal link between Dr.
with the diagnosis of bronchopneumonia, we still find Dr. Casumpang's negligence and the injury. The element of causation
Casumpang guilty of negligence. Wrong diagnosis is not by itself is successfully proven.
medical malpractice. Physicians are generally not liable for
damages resulting from a bona fide error of judgment and from 4. YES, SJDH is solidarily liable.
acting according to acceptable medical practice standards. As a rule, hospitals are not liable for the negligence of its
Nonetheless, when the physician's erroneous diagnosis was the independent contractors. However, it may be found liable if the
result of negligent conduct, it becomes an evidence of medical physician or independent contractor acts as an ostensible agent of
malpractice. the hospital. This exception is also known as the doctrine of
apparent authority.
In the present case, evidence on record established that in
confirming the diagnosis of bronchopneumonia, Dr. Casumpang SJDH impliedly held out and clothed Dr. Casumpang with
selectively appreciated some and not all of the symptoms apparent authority leading the respondent to believe that he is an
presented, and failed to promptly conduct the appropriate tests to employee or agent of the hospital. Based on the records, the
confirm his findings. In sum, Dr. Casumpang failed to timely respondent relied on SJDH rather than upon Dr. Casumpang, to
detect dengue fever, which failure, especially when reasonable care and treat his son Edmer. His testimony during trial showed
prudence would have shown that indications of dengue were that he and his wife did not know any doctors at SJDH; they also
evident and/or foreseeable, constitutes negligence. Apart from did not know that Dr. Casumpang was an independent contractor.
failing to promptly detect dengue fever, Dr. Casumpang also They brought their son to SJDH for diagnosis because of their
failed to promptly undertake the proper medical management family doctor's referral. The referral did not specifically point to
needed for this disease. Dr. Casumpang failed to measure up to Dr. Casumpang or even to Dr. Miranda, but to SJDH.
the acceptable medical standards in diagnosing and treating
dengue fever.
Mrs. Cortejo accepted Dr. Casumpang's services on the
reasonable belief that such were being provided by SJDH or its
Dr. Casumpang's claim that he exercised prudence and due employees, agents, or servants. By referring Dr. Casumpang to
diligence in handling Edmer's case, sside from being self-serving, care and treat for Edmer, SJDH impliedly held out Dr.
is not supported by competent evidence. He failed, as a medical Casumpang as a member of its medical staff. SJDH cannot now
professional, to observe the most prudent medical procedure disclaim liability since there is no showing that Mrs. Cortejo or
under the circumstances in diagnosing and treating Edmer. the respondent knew, or should have known, that Dr. Casumpang
is only an independent contractor of the hospital. In this case,
2. No, Dr. Miranda is not liable for negligence. estoppel has already set in.

We find that Dr. Miranda was not independently negligent.

Although she was subject to the same standard of care applicable
to attending physicians, as a resident physician, she merely
operates as a subordinate who usually refer to the attending DR. CRUZ V. AGAS,JR. G.R. No. 204095 June 15, 2015
physician on the decision to be made and on the action to be
FACTS:
Dr. Jaime Cruz (Cruz) engaged the services of St. Luke’s Medical A medical negligence case can prosper if the patient can present
Center (SLMC) for a solid proof that the doctor, like in this case, either failed to do
medical check-up. He underwent stool, urine, bloody and other something which a reasonably prudent doctor would have done,
body fluid tests. He was then sent to the Gastro-Enterology or that he did something that a reasonably prudent doctor would
Department for a scheduled gastroscopy and colonoscopy. The not have done, and such failure
specialist assigned to him was absent, so he gave the colonoscopy or action caused injury to the patient.
results to the attending female anesthesiologist. Thereafter he
underwent the procedure, but when he woke up he felt something To successfully pursue this kind of case, a patient must only prove
was wrong. He felt dizzy, cold clammy perspiration and pain in that a health care provider either failed to do something which a
his abdomen, and when he tried to urinate he collapsed. He tried reasonably prudent health care provider would have done, or that
to consult the specialist who treated him, but was nowhere to be he did something that a reasonably prudent provider would not
found. He then found his cardiologist Dra. Agnes Del Rosario have done; and that failure or action caused injury to the patient.
(Rosario) who observed his condition and referred him to the Simply put, the elements are duty, breach, injury and proximate
surgical department which suspected that he had a hemorrhage. causation.

Dr. Cruz agreed, and upon waking up in the ICU, he found that 6- In this case, Dr. Cruz has the burden of showing the negligence or
8 inches of his colon was missing. It was found out that there was recklessness of Dr. Agas. Although there is no dispute that Dr.
a tear in the colonic wall which caused the bleeding. During his Cruz sustained internal hemorrhage due to a tear in the serosa of
recuperation, despite the painkillers, he was in under so much his sigmoid colon, he failed to show that it was caused by Dr.
pain. Agas’s negligent and reckless conduct of the colonoscopy
procedure. In other words, Dr. Cruz failed to show and explain
Dr. Cruz claimed that Dr. Felicismo Agas (Agas) admitted that he that particular negligent or reckless act or omission committed by
was the one who conducted the colonoscopy procedure, but Dr. Agas. Stated differently, Dr. Cruz did not demonstrate that
insisted that nothing was wrong. Dr. Cruz was discharged from there was "inexcusable lack of precaution" on the part of Dr.
SLMC, nevertheless he complained of having a hard time Agas.
digesting his food, he had to be fed every 2 hours because he
easily got full, and had fresh blood stools every time he moved his 2) NO. The requisites for the applicability of the doctrine of res
bowel, and had lost his appetite and had gastric acidity. He ipsa loquitur are:
claimed that he was in good condition prior to the surgery. (1) the occurrence of an injury;
(2) the thing which caused the injury was under the control and
Dr. Cruz filed a complaint for serious physical injuries, through management of the
reckless imprudence and medical malpractice against Dr. Agas defendant;
before office of the prosecutor. Dr. Agas had countered that Dr. (3) the occurrence was such that in the ordinary course of things,
Cruz failed to prove the basic elements of reckless impudence or would not have happened
medical negligence. Furthermore, the procedure was conducted if those who had control or management used proper care; and
properly considering there did not manifest any significant (4) the absence of explanation by the defendant. Of the foregoing
adverse reaction or body resistance during the procedures. Finally requisites, the most
he had added certifications and sworn statements by the: Assistant instrumental is the control and management of the thing which
Medical Directior for Professional Services, the Director of the caused the injury.
Institute of Digestive Diseases, the anesthesiologist, and the
gospital nurse that testitfied that the intraperonial bleeding was In this case, the Court agrees with Dr. Agas that his purported
immediately managed and cure. negligence in performing the colonoscopy on Dr. Cruz was not
immediately apparent to a layman to justify the application of res
The office of the prosecutor however dismissed the case, Dr. Cruz ipsa loquitur doctrine.
appealed of the DOJ which likewise dismissed the case. The case Dr. Agas was able to establish that the internal bleeding sustained
was then elevated to the CA which also dismissed the case, hence by Dr. Cruz was due to the abnormal condition and configuration
this petition. of his sigmoid colon which was beyond his control considering
that the said condition could not be detected before a
ISSUES: colonoscopic procedure. Dr. Agas adequately explained that no
1) Whether Dr. Agas is guilty of reckless imprudence and medical clinical findings, laboratory tests, or diagnostic imaging, such as
negligence x-rays, ultrasound or computed tomography (CT) scan of the
2) Whether the doctrine of Res Ipsa Loquitur is applicable in the abdomen, could have detected this condition prior to an
case at hand endoscopic procedure.

RULING: On the other hand, in the present case, the correlation between
1) NO. In the case at hand, Dr. Cruz failed to show that the DOJ petitioner’s injury, i.e., tear in the serosa of sigmoid colon, and the
gravely abused its discretion in finding that there was lack of colonoscopy conducted by respondent to the petitioner clearly
probable cause and dismissing the complaint against Dr. Agas for requires the presentation of an expert opinion considering that no
Serious Physical Injuries through Reckless Imprudence and perforation of the sigmoid colon was ever noted during the
Medical Malpractice. laparotomy. It cannot be overemphasized that the colonoscope
inserted by the respondent only passed through the inside of 2. The instrumentality or agency that caused the injury was under
petitioner’s sigmoid colon while the damaged tissue, i.e., serosa, the exclusive control of the person charged
which caused the bleeding, is located in the outermost layer of the 3. The injury suffered must not have been due to any voluntary
colon. It is therefore impossible for the colonoscope to touch, action or contribution of the person injured
scratch, or even tear the serosa since the said membrane is beyond
reach of the colonoscope in the absence of perforation on the In this case, the essential requisites for the application of the
colon. doctrine of res ipsa loquitur are present.

The first element was sufficiently established when Rosit proved

that one of the screws installed by Dr. Gestuvo struck his molar.
NILO B ROSIT vs DAVAO DOCTORS HOSPITAL and DR.
An average man of common intelligence would know that striking
ROLANDO GESTUVO GR No. 210445, December 7, 2015
a tooth with any foreign object much less a screw would cause
FACTS:
severe pain.
Rosit figured in a motorcycle accident where he fractured his jaw.
Anent the second element, it is sufficient that the operation which
He was referred to Dr. Gestuvo, a specialist in mandibular
resulted in the screw hitting Rosit’s molar was, indeed, performed
injuries, who operated on Rosit. As the operation required the
by Dr. Gestuvo.
smallest screws available, Dr. Gestuvo cut the screws on hand to
Lastly, the third element, it was not shown that Rosit’s lung
make them smaller. Dr. Gestuvo knew that there were smaller
disease could have contributed to the pain. What is clear is that he
titanium screws available in Manila, but did not so inform Rosit
suffered because one of the screws that Dr. Gestuvo installed hit
supposing that the latter would not be able to afford the same.
Rosit’s molar.
Clearly then, the res ipsa loquitur doctrine finds application in the
Following the procedure, Rosit could not properly open and close
instant case and no expert testimony is required to establish the
his mouth and was in pain. Xrays showed that his jaw was aligned
negligence of defendant Dr. Gestuvo.
by the screws used on him touched his molar. Dr. Gestuvo
referred Rosit to Dr. Pangan, a dentist who then opined that
another operation is necessary and that it is to be performed in
Cebu. Rosit went to Cebu and underwent the operation BORROMEO V. FAMILY CARE HOSPITAL (G.R. No.
successfully. 191018)

On his return to Davao, Rosit demanded the Dr. Gestuvo FACTS:

reimburse him for the cost of the operation and the expenses
incurred in Cebu amounting to P140,000. Dr. Gestuvo refused to On July 13, 1999, the Borromeo brought his wife to the Family
pay. Thus, Rosit filed a civil case for damages. RTC adjudged Dr. Care Hospital because she had been complaining of acute pain at
Gestuvo negligent holding that res ipsa loquitur principle applies, the lower stomach area and fever for two days. She was admitted
thus, expert medical testimony may be dispensed with because the at the hospital and placed under the care of Dr. Inso.
injury itself provides the proof of negligence. CA reversed the
decision. Hence, this appeal. Dr. Inso suspected that Lilian might be suffering from acute
appendicitis. However, there was insufficient data to rule out
ISSUE: other possible causes and to proceed with an appendectomy.
Whether or not CA correctly absolved Dr. Gestuvo from liability. Thus, he ordered Lilian’s confinement for testing and evaluation.
However, the tests were not conclusive enough to confirm that
RULING: she had appendicitis. Lilian abruptly developed an acute surgical
Petition granted. CA erred in absolving Dr. Gestuvo from abdomen.
liability. A medical negligence is a type of claim to redress a
wrong committed by a medical professional, that has caused
bodily harm to or the death of a patient. There are four elements
involved in a medical negligence case, namely: duty, breach, On July 15, 1999, Dr. Inso decided to conduct an exploratory
injury, and proximate causation. laparotomy on Lilian because of the findings on her abdomen and
his fear that she might have a ruptured appendix. During the
To establish medical negligence, the Court has held that an expert operation, Dr. Inso confirmed that Lilian was suffering from acute
testimony is generally required to define the standard of appendicitis. He proceeded to remove her appendix which was
behaviour by which the court may determine whether the already infected and congested with pus. The operation was
physician has properly performed the requisite duty toward the successful.
patient. But, although generally, expert medical testimony is
relied upon in malpractice suits to prove that a physician has done Six hours after Lilian was brought back to her room, Dr. Inso was
a negligent act or that he has deviated from the standard medical informed that her blood pressure was low. After assessing her
procedure, when the doctrine of res ipsa loquitur is availed by the condition, he ordered the infusion of more intravenous (IV) fluids
plaintiff, the need for expert medical testimony is dispensed with which somehow raised her blood pressure. Subsequently, a nurse
because the injury itself provides the proof of negligence. The informed him that Lilian was becoming restless. Dr. Inso
exception may be availed of if the following requisites concur: immediately went to Lilian and saw that she was quite pale. He
1. The accident was of a kind that does not ordinarily occur unless immediately requested a blood transfusion. Lilian did not respond
someone is negligent
to the blood transfusion even after receiving two 500 cc-units of The expert witness must be a similarly trained and experienced
blood. physician. Thus, a pulmonologist is not qualified to testify as to
the standard of care required of an anesthesiologist and an autopsy
Eventually, an endotracheal tube connected to an oxygen tank was expert is not qualified to testify as a specialist in infectious
inserted into Lilian to ensure her airway was clear and to diseases.
compensate for the lack of circulating oxygen in her body from
the loss of red blood cells. Nevertheless, her condition continued xxxx
to deteriorate. At this point, Dr. Inso suspected that Lilian had
Disseminated Intravascular Coagulation (DIC), a blood disorder Dr. Reyes is not an expert witness who could prove Dr. Inso’s
characterized by bleeding in many parts of her body caused by the alleged negligence. His testimony could not have established the
consumption or the loss of the clotting factors in the blood. standard of care that Dr. Inso was expected to observe nor
However, Dr. Inso did not have the luxury to conduct further tests assessed Dr. Inso’s failure to observe this standard. His testimony
because the immediate need was to resuscitate Lilian. Dr. Inso cannot be relied upon to determine if Dr. Inso committed errors
and the nurses performed CPR on Lilian. Dr. Inso also informed during the operation, the severity of these errors, their impact on
her family that there may be a need to re-operate on her, but she Lilian’s probability of survival, and the existence of other
would have to be put in an Intensive Care Unit (ICU). diseases/condition.
Unfortunately, Family Care did not have an ICU because it was
only a secondary hospital and was not required by the Department xxxx
of Health to have one. Dr. Inso then personally coordinated with
the Muntinlupa Medical Center (MMC) which had an available The petitioner cannot invoke the doctrine of res ipsa loquitur to
bed. Upon reaching the MMC, a medical team was on hand to shift the burden of evidence onto the respondent. Res ipsa
resuscitate. Unfortunately, Lilian passed away despite efforts to loquitur, literally, “the thing speaks for itself;” is a rule of
resuscitate her. evidence that presumes negligence from the very nature of the
accident itself using common human knowledge or experience.
According to the autopsy report, Dr. Reyes concluded that the
cause of Lilian’s death was haemorrhage due to bleeding The application of this rule requires: (1) that the accident was of a
petechial blood vessels: internal bleeding. He further concluded kind which does not ordinarily occur unless someone is negligent;
that the internal bleeding was caused by the 0.5 x 0.5 cm opening (2) that the instrumentality or agency which caused the injury was
in the repair site. He opined that the bleeding could have been under the exclusive control of the person charged with
avoided if the site was repaired with double suturing instead of negligence; and (3) that the injury suffered must not have been
the single continuous suture repair that he found. due to any voluntary action or contribution from the injured
person. The concurrence of these elements creates a presumption
Based on the autopsy, the petitioner filed a complaint for damages of negligence that, if unrebutted, overcomes the plaintiff’s burden
against Family Care and against Dr. Inso for medical negligence. of proof. xxxx

The rule is not applicable in cases such as the present one where
ISSUE: the defendant’s alleged failure to observe due care is not
immediately apparent to a layman. These instances require expert
Whether or not respondents are guilty of medical negligence (NO) opinion to establish the culpability of the defendant doctor. It is
also not applicable to cases where the actual cause of the injury
had been identified or established. While this Court sympathizes
with the petitioner’s loss, the petitioner failed to present sufficient
RULING: convincing evidence to establish: (1) the standard of care
expected of the respondent and (2) the fact that Dr. Inso fell short
A medical professional has the duty to observe the standard of of this expected standard. Considering further that the respondents
care and exercise the degree of skill, knowledge, and training established that the cause of Lilian’s uncontrollable bleeding (and,
ordinarily expected of other similarly trained medical ultimately, her death) was a medical disorder – Disseminated
professionals acting under the same circumstances. A breach of Intravascular Coagulation – we find no reversible errors in the
the accepted standard of care constitutes negligence or CA’s dismissal of the complaint on appeal.
malpractice and renders the defendant liable for the resulting
injury to his patient. OUR LADY OF LOURDES HOSPITAL, vs. SPOUSES
ROMEO AND REGINA CAPANZANA, G.R. No. 189218
The standard is based on the norm observed by other reasonably
competent members of the profession practicing the same field of
medicine. Because medical malpractice cases are often highly
technical, expert testimony is usually essential to establish: (1) the FACTS:
standard of care that the defendant was bound to observe under
the circumstances; (2) that the defendant’s conduct fell below the Regina Capanzana was pregnant with her third child. A week
acceptable standard; and (3) that the defendant’s failure to before her scheduled caesarean section (C-section), she went into
observe the industry standard caused injury to his patient. active labor and was brought to Our Lady of Lourdes Hospital for
an emergency C-section. She went into a pre-operative
examination done by Dr. Ramos and Dr. Santos. They proceeded The SC found that there was sufficient evidence to prove that the
with the operation after having found Regina fit for anesthesia. nurses were negligent. When Regina was gasping for breath and
The operation was successful and she gave birth to a baby boy. turning cyanotic, it was the duty of the nurses to intervene
immediately by informing the resident doctor. Had they done so,
Thirteen hours after her operation, Regina complained of a proper oxygenation could have been restored and other
headache, a chilly sensation, restlessness and shortness of breath. interventions performed without wasting valuable time.
She asked for oxygen and later became cyanotic. After
undergoing x-ray, she was found to be suffering from pulmonary According to the expert witness, the occurrence of “hypoxic
edema. Since her condition showed no improvement, she was encephalopathy” could have been avoided since lack or
transferred to the Cardinal Santos Hospital. The doctors in said inadequate supply of oxygen to the brain for 5 minutes will cause
hospital found that she was suffering from rheumatic heart disease damage to it. It was found that the nurses took 10- 15
mitral stenosis with mild pulmonary hypertension, which minutes to respond to the call of Regina’s niece before going to
contributed to the onset of Fluid in her lung tissue (pulmonary the room. Also, it took about 20 minutes before the oxygen
edema). This development resulted in cardio-pulmonary arrest arrived. Another instance of negligence was the delay in the
and, subsequently, brain damage. removal of Regina’s consumed dextrose which caused Regina
discomfort. The nurses only attended to her after being called
Regina lost the use of her speech, eyesight, hearing and limbs. twice.
Due to this, spouses Capanzana filed a complaint for damages
against Our Lady of Lourdes Hospital along with Dr. Ramos, Dr. In Ramos, the SC defined “Proximate cause” as that which, in
Santos and the nurses on duty stationed on the second floor. natural and continuous sequence, unbroken by any efficient
During the course of the proceedings, Regina died and was intervening cause, produces injury, and without which the result
substituted by her heirs. would not have occurred. An injury or damage is proximately
caused by an act or a failure to act, whenever it appears from the
The RTC found no negligence on the part of Dr. Ramos and Dr. evidence in the case, that the act or omission played a substantial
Santos as they were compliant of the standard practices in part in bringing about or actually causing the injury or damage;
attending to a patient during a C-Section. The court reasoned that and that the injury or damage was either a direct result or a
the primary cause of Regina’s vegetative state, amniotic fluid reasonably probable consequence of the act or omission. It is the
embolism, was not within the control of the doctor to anticipate. dominant, moving or producing cause.
The Court, however, found the nurses on duty liable for their
failure to immediately administer the oxygen. This failure having Applying the above definition to the facts in the present case, the
contributed to the onset of hypoxic encephalopathy. omission of the nurses — their failure to check on Regina and to
refer her to the resident doctor and, thereafter, to immediately
provide oxygen — was clearly the proximate cause that led to the
brain damage suffered by the patient. The liability of the hospital
The Court held that the Our Lady of Lourdes Hospital is free from The Our Lady of Lourdes hospital is liable under Article 2180 in
liability as it was able to discharge the burden of proof that it had relation to Article 2176 of the Civil Code. Under Article 2180, an
exercised the diligence of a good father of a family in the employer may be held liable for the negligence of its employees
selection and supervision of its employees. On appeal, the CA based on its responsibility under a relationship of patria potestas.
affirmed the ruling of the RTC except as to the liability of the The liability of the employer under this provision is “direct and
midwife (Ballano) and the Our Lady of Lourdes Hospital. It was immediate; it is not conditioned upon a prior recourse against the
found that while there was evidence to prove that petitioner negligent employee or a prior showing of the insolvency of that
hospital showed diligence in its selection and hiring processes, employee.” The employer may only be relieved of responsibility
there was no evidence to prove that it exercised the required upon a showing that it exercised the diligence of a good father of
diligence in the supervision of its nurses. a family in the selection and supervision of its employees. The SC
held that the hospital sufficiently proved due diligence in the
ISSUE: selection of the nurses. The nurses undergo a series of
examination, orientation, training, on the job observation and
Whether Our Lady of Lourdes Hospital is liable for damages due evaluation before they are hired as regular employees. However,
to its failure to exercise due diligence in the supervision of its it failed to prove due diligence in their supervision. The
nurses. formulation of a supervisory hierarchy, company rules and
regulations, and disciplinary measures upon employees in case of
RULING: breach, is indispensable. However, to prove due diligence in the
supervision of employees, it is not enough for an employer such
YES. The plaintiff must show the following elements by a as petitioner to emptily invoke the existence of such a
preponderance of evidence: duty of the health professional, formulation. What is more important is the actual implementation
breach of that duty, injury of the patient, and proximate causation and monitoring of consistent compliance with the rules. In this
between the breach and the injury. case, it was found that there is failure on the part of the hospital to
sanction the tardiness of the nurses which shows an utter lack of
The NeGligence of the Nurses actual implementation and monitoring of compliance with the
rules and ultimately of supervision over its nurses. Also, on the
nights subject of the present controversy, there is failure to show
who were the actual nurses on duty and who was supervising
these nurses due to the conflicting accounts on the documents of
the hospital. All these negate the due diligence on the part of the
nurses, their supervisors, and ultimately, the hospital. Thus,
petitioner was held liable for damages.
Republic of the Philippines At 11:15 P.M., Deogenes and Andrew Olavere returned to the
SUPREME COURT BRMC with a bag containing the requested 500 cc type "O"
Manila SECOND DIVISION blood. They handed over the bag of blood to Dr. Realuyo.
G.R. No. 167366 September 26, 2012 After Dr. Tatad finished her work with the Lilia Aguila operation,
DR. PEDRO DENNIS CERENO, and DR. SANTOS ZAFE, petitioners immediately started their operation on Raymond at
Petitioners, around 12:15 A.M. of 17 September 1995. Upon opening of
vs. Raymond’s thoracic cavity, they found that 3,200 cc of blood was
COURT OF APPEALS, SPOUSES DIOGENES S. stocked therein. The blood was evacuated and petitioners found a
OLAVERE and FE R. SERRANO, Respondents. puncture at the inferior pole of the left lung.
In his testimony, Dr. Cereno stated that considering the loss of
blood suffered by Raymond, he did not immediately transfuse
Before the Court is a Petition for Review on Certiorari 1 under blood because he had to control the bleeders first.4
Rule 45 of the Rules of Court seeking the annulment and setting Blood was finally transfused on Raymond at 1:40 A.M. At 1:45
aside of the 21 February 2005 decision2 of the Court of Appeals A.M., while the operation was on-going, Raymond suffered a
(CA) in CA-G.R. CV No. 65800. In the assailed decision, the CA cardiac arrest. The operation ended at 1:50 A.M. and Raymond
affirmed in toto the decision of the Regional Trial Court (R TC), was pronounced dead at 2:30 A.M.
Branch 22, Nag a City finding herein petitioners Dr. Pedro Dennis Raymond’s death certificate5 indicated that the immediate cause
Cereno (Dr. Cereno) and Dr. Santos Zafe (Dr. Zafe) liable for of death was "hypovolemic shock" or the cessation of the
damages. functions of the organs of the body due to loss of blood.6
Culled from the records are the following antecedent facts: Claiming that there was negligence on the part of those who
At about 9:15 in the evening of 16 September 1995, Raymond S. attended to their son, the parents of Raymond, on 25 October
Olavere (Raymond), a victim of a stabbing incident, was rushed to 1995, filed before the RTC, Branch 22, Naga City a complaint for
the emergency room of the Bicol Regional Medical Center damages7 against Nurse Balares, Dr. Realuyo and attending
(BRMC). There, Raymond was attended to by Nurse Arlene surgeons Dr. Cereno and Dr. Zafe.
Balares (Nurse Balares) and Dr. Ruel Levy Realuyo (Dr. During trial, the parents of Raymond testified on their own behalf.
Realuyo) — the emergency room resident physician. They also presented the testimonies of Andrew Olavere and one
Subsequently, the parents of Raymond—the spouses Deogenes Loira Oira, the aunt of Raymond. On the other hand, Dr. Cereno,
Olavere (Deogenes) and Fe R. Serrano—arrived at the BRMC. Dr. Realuyo, Nurse Balares and Security Guard Diego Reposo
They were accompanied by one Andrew Olavere, the uncle of testified for the defense. On rebuttal, the parents of Raymond
Raymond. presented Dr. Tatad, among others.
After extending initial medical treatment to Raymond, Dr.
Realuyo recommended that the patient undergo "emergency On 15 October 1999, the trial court rendered a decision8 the
exploratory laparotomy." Dr. Realuyo then requested the parents dispositive portion of which reads:
of Raymond to procure 500 cc of type "O" blood needed for the WHEREFORE, premises considered, this Court hereby renders
operation. Complying with the request, Deogenes and Andrew judgment:
Olavere went 1. Dismissing the case against Dr. Ruel Levy Realuyo and
to the Philippine National Red Cross to secure the required blood. Arlene Balares for lack of merit;
At 10:30 P.M., Raymond was wheeled inside the operating room. 2. Ordering defendants Dr. Santos Zafe and Dr. Dennis
During that time, the hospital surgeons, Drs. Zafe and Cereno, Cereno to pay the heirs of Raymond Olavere, jointly and
were busy operating on gunshot victim Charles Maluluy-on. severally the following amounts:
Assisting them in the said operation was Dr. Rosalina Tatad (Dr. 1. P 50,000.00 for the death of the victim; 2. P 150,000.00 as
Tatad), who was the only senior anesthesiologist on duty at moral damages;
BRMC that night. Dr. Tatad also happened to be the head of 3. P 100,000.00 as exemplary damages; 4. P 30,000.00 for
Anesthesiology Department of the BRMC. attorney’s fees; and
Just before the operation on Maluluy-on was finished, another 5. Cost of suit.9
emergency case involving Lilia Aguila, a woman who was giving x x x x.
birth to triplets, was brought to the operating room. The trial court found petitioners negligent in not immediately
At 10:59 P.M., the operation on Charles Maluluy-on was finished. conducting surgery on Raymond. It noted that petitioners have
By that time, however, Dr. Tatad was already working with the already finished operating on Charles Maluluy-on as early as
obstetricians who will perform surgery on Lilia Aguila. There 10:30 in the evening, and yet they only started the operation on
being no other available anesthesiologist to assist them, Drs. Zafe Raymond at around 12:15 early morning of the following day.
and The
Cereno decided to defer the operation on Raymond. trial court held that had the surgery been performed promptly,
Drs. Zafe and Cereno, in the meantime, proceeded to examine Raymond would not have lost so much blood and, therefore,
Raymond and they found that the latter’s blood pressure was could have been saved.10
normal and "nothing in him was significant."3 Dr. Cereno The trial court also held that the non-availability of Dr. Tatad after
reported that based on the xray result he interpreted, the fluid the operation on Maluluy-on was not a sufficient excuse for the
inside the thoracic cavity of Raymond was minimal at around petitioners to not immediately operate on Raymond. It called
200-300 cc.
attention to the testimony of Dr. Tatad herself, which disclosed
the possibility of calling a standby anesthesiologist in that
situation. The trial court opined that the petitioners could have The best way to prove these is through the opinions of expert
just requested for the standby anesthesiologist from Dr. Tatad, but witnesses belonging in the same neighborhood and in the same
they did not. general line of practice as defendant physician or surgeon. The
Lastly, the trial court faulted petitioners for the delay in the
transfusion of blood on Raymond. deference of courts to the expert opinion of qualified physicians
On appeal, the CA in a decision dated 21 February 2005 affirmed stems from the former’s realization that the latter possess unusual
in toto the judgment rendered by the RTC finding herein technical skills which laymen in most instances are incapable of
petitioners guilty of gross negligence in the performance of their intelligently evaluating, hence, the indispensability of expert
duties and awarding damages to private respondents. testimonies.14
Hence, this petition for review on certiorari under Rule 45 of the Guided by the foregoing standards, We dissect the issues at hand.
Rules of Court assailing the CA decision on the following Petitioners Not Negligent
grounds: The trial court first imputed negligence on the part of the
1. THAT THE CA ERRED IN RULING THAT PETITIONERS petitioners by their failure to perform the operation on Raymond
WERE GROSSLY NEGLIGENT IN THE PERFORMANCE OF immediately after finishing the Maluluy-on operation. It rejected
THEIR DUTIES; as an excuse the nonavailability of Dr. Tatad. The trial court
2. THAT THE CA ERRED IN NOT CONSIDERING THE relied on the testimony of Dr. Tatad about a "BRMC protocol"
BICOL REGIONAL MEDICAL CENTER AS AN that introduces the possibility that a standby anesthesiologist
INDISPENSABLE PARTY AND SUBSIDIARILY LIABLE could have been called upon. The pertinent portions of the
SHOULD PETITIONERS BE FOUND LIABLE FOR testimony of Dr. Tatad provides:
DAMAGES; and Q: Aside from you and Dr. Rebancos, who was the standby
3. THAT THE CA ERRED IN NOT FINDING THE AWARD anesthesiologist?
OF MORAL AND EXEMPLARY DAMAGES AS WELL AS A: We have a protocol at the Bicol Medical Center to have a
ATTORNEY’S FEES EXORBITANT OR EXCESSIVE. consultant who is on call.
We grant the petition Q: How many of them?
It is well-settled that under Rule 45 of the Rules of Court, only A: One.
questions of law may be raised. The reason behind this is that this Q: Who is she?
Court is not a trier of facts and will not re-examine and re- A: Dra. Flores.
evaluate the evidence on record.11Factual findings of the CA, Q: What is the first name? A: Rosalina Flores.
affirming that
Q: Is she residing in Naga City? A: In Camaligan.
of the trial court, are therefore generally final and conclusive on Q: She is on call anytime when there is an emergency case to be
this Court. This rule is subject to the following exceptions: (1) the attended to in the Bicol Medical Center?
conclusion is grounded on speculations, surmises or conjectures; A: Yes sir.15
(2) the inference is manifestly mistaken, absurd or impossible; (3) Dr. Tatad further testified:
there is grave abuse of discretion; (4) the judgment is based on a Q: Alright (sic), considering that you said you could not attend to
misapprehension of facts; (5) the findings of fact are conflicting; Raymond Olavere because another patient was coming in the
(6) there is no citation of specific evidence on which the factual person of Lilia Aguila, did you not suggest to Dr. Cereno to call
findings are based; (7) the findings of absence of fact are the standby anesthesiologist?
contradicted by the presence of evidence on record; (8) the A: They are not ones to do that. They have no right to call for the
findings of the CA are contrary to those of the trial court; (9) the standby anesthesiologist.
CA manifestly overlooked certain relevant and undisputed facts Q: Then, who should call for the standby anesthesiologist? A: It is
that, if properly considered, would justify a different conclusion; me if the surgeon requested.
(10) the findings of the CA are beyond the issues of the case; and Q: But in this case, the surgeon did not request you?
(11) such findings are contrary to the admissions of both A: No. It is their prerogative.
parties.12 In this case, We find exceptions (1) and (4) to be Q: I just want to know that in this case the surgeon did not request
applicable. you to call for the standby anesthesiologist?
The type of lawsuit which has been called medical malpractice or, A: No sir.16
more appropriately, medical negligence, is that type of claim From there, the trial court concluded that it was the duty of the
which a victim has available to him or her to redress a wrong petitioners to request Dr. Tatad to call on Dr. Rosalina Flores, the
committed by a medical professional which has caused bodily standby anesthesiologist. Since petitioners failed to do so, their
harm. In order to successfully pursue such a claim, a patient must inability to promptly perform the operation on Raymond becomes
prove that a health care provider, in most cases a physician, either negligence on their part.
failed to do something which a reasonably prudent health care
provider would have done, or that he or she did something that a This Court does not agree with the aforesaid conclusion.
reasonably prudent provider would not have done; and that the First. There is nothing in the testimony of Dr. Tatad, or in any
failure or action caused injury to the patient.13 Stated otherwise, evidence on the record for that matter, which shows that the
the complainant must prove: (1) that petitioners were aware of the "BRMC protocol" that the hospital
the health care provider, either by his act or omission, had been keeps a standby anesthesiologist available on call. Indeed, other
negligent, and (2) that such act or omission proximately caused than the testimony of Dr. Tatad, there is no evidence that proves
the injury complained of. that any such "BRMC protocol" is being practiced by the
hospital’s surgeons at all.
Evidence to the effect that petitioners knew of the "BRMC A: The blood arrived at 1:40 a.m. and that was the time when this
protocol" is essential, especially in view of the contrary assertion blood was hooked to the patient.
of the petitioners that the matter of assigning anesthesiologists xxxx
rests within the full discretion of the BRMC Anesthesiology Q: Prior to the arrival of the blood, you did not request for blood?
Department. Without any prior knowledge of the "BRMC A: I requested for blood.
protocol," We find that it is quite reasonable for the petitioners to Q: From whom?
assume that matters regarding the administration of anesthesia and A: From the attending physician, Dr. Realuyo.
the assignment of anesthesiologists are concerns of the Q: What time was that?
Anesthesiology Department, while matters pertaining to the xxxx
surgery itself fall under the concern of the surgeons. Certainly, A: 9:30.
We cannot hold petitioners accountable for not complying with xxxx
something that they, in the first place, do not know. Q: Had this blood been given to you before the operation you
Second. Even assuming ex gratia argumenti that there is such could have transfused the blood to the patient?
"BRMC protocol" and that petitioners knew about it, We find that A: Of course, yes.
their failure to request for the assistance of the standby Q: And the blood was transfused only after the operation?
anesthesiologist to be reasonable when taken in the proper A: Because that was the time when the blood was given to us.
context. There is simply no competent evidence to the contrary. xxxx
From the testimony of Dr. Tatad herself, it is clear that the matter Q: Have you monitored the condition of Raymond Olavere?
of requesting for a standby anaesthesiologist is not within the full
discretion of petitioners. The "BRMC protocol" described in the A: I monitored the condition during the time when I would
testimony requires the petitioners to course such request to Dr. administer anesthesia.
Tatad who, as head of the Department of Anesthesiology, has the Q: What time was that?
final say of calling the standby anesthesiologist. A: 11:45 already.
Q: What was the condition of the blood pressure at that time?
As revealed by the facts, however, after the Maluluy-on A: 60/40 initial.
operation, Dr. Tatad was already assisting in the Lilia Aguila Q: With that kind of blood pressure the patient must have been in
operation. Drs. Zafe and Cereno then proceeded to examine critical condition?
Raymond and they found that the latter’s blood pressure was A: At the time when the blood pressure was 60/40 I again told Dr.
normal and "nothing in him was significant."17 Dr. Cereno even Cereno that blood was already needed.
concluded that based on the x-ray result he interpreted, the fluid Q: With that condition, Doctor, that the patient had 60/40 blood
inside the thoracic cavity of Raymond was minimal at around pressure you did not decide on transfusing blood to him?
200-300 cc. Such findings of Drs. Cereno and Zafe were never A: I was asking for blood but there was no blood available.
challenged and were unrebutted. Q: From whom did you ask?
Given that Dr. Tatad was already engaged in another urgent A: From the surgeon. According to Dr. Zafe there was only 500
operation and that Raymond was not showing any symptom of cc but still for cross-matching.18
suffering from major blood loss requiring an immediate operation, From the aforesaid testimony, the trial court ruled that there was
We find it reasonable that petitioners decided to wait for Dr. negligence on the part of petitioners for their failure to have the
Tatad to finish her surgery and not to call the standby blood ready for transfusion. It was alleged that at 11:15 P.M., the
anesthesiologist anymore. There is, after all, no evidence that 500 cc of blood was given to Dr. Realuyo by Raymond’s parents.
shows that a prudent surgeon faced with similar circumstances At 11:45 P.M., when Dr. Tatad was asking for the blood, 30
would decide otherwise. minutes had passed. Yet, the blood was not ready for transfusion
Here, there were no expert witnesses presented to testify that the as it was still being cross-matched.19 It took another two hours
course of action taken by petitioners were not in accord with those before blood was finally transfused to Raymond at 1:40 A.M. of
adopted by other reasonable surgeons in similar situations. 17 September 1995.
Neither was there any testimony given, except that of Dr. Tatad’s, Again, such is a mistaken conclusion.
on which it may be inferred that petitioners failed to exercise the
standard of care, diligence, learning and skill expected from First, the alleged delay in the cross-matching of the blood, if
practitioners of their profession. Dr. Tatad, however, is an expert there was any, cannot be attributed as the fault of the petitioners.
neither in the field of surgery nor of surgical practices and The petitioners were never shown to be responsible for such
diagnoses. Her expertise is in the administration of anesthesia delay. It is highly unreasonable and the height of injustice if
and not in the determination of whether surgery ought or not petitioners were to be sanctioned for lapses in procedure that does
ought to be performed. not fall within their duties and beyond their control.
Another ground relied upon by the trial court in holding Second, Dr. Cereno, in his unchallenged testimony, aptly
petitioners negligent was their failure to immediately transfuse explained the apparent delay in the transfusion of blood on
blood on Raymond. Such failure allegedly led to the eventual Raymond before and during the operation.
death of Before the operation, Dr. Cereno explained that the reason why no
blood transfusion was made on Raymond was because they did
Raymond through "hypovolemic shock." The trial court relied on not then see the need to administer such transfusion, viz:
the following testimony of Dr. Tatad: Q: Now, you stated in your affidavit that prior to the operation
Q: In this case of Raymond Olavere was blood transfused to him you were informed that there was 500 cc of blood available and
while he was inside the operating room?
was still to be cross-matched. What time was that when you were considering that the name, reputation and career of petitioners are
informed that 500 cc of blood was due for crossmatching? at stake.
A: I am not sure of the time. The Court understands the parents’ grief over their son’s
Q: But certainly, you learned of that fact that there was 500 cc of death.1âwphi1 That notwithstanding, it cannot hold petitioners
blood, which was due for crossmatching immediately prior to the liable. It was noted that Raymond, who was a victim of a stabbing
operation? incident, had multiple wounds when brought to the hospital. Upon
A: Yes, sir. opening of his thoracic cavity, it was discovered that there was
Q: And the operation was done at 12:15 of September 17? A: gross bleeding inside the body. Thus, the need for petitioners to
Yes, sir. control first what was causing the bleeding. Despite the situation
Q: And that was the reason why you could not use the blood that evening i.e. numerous patients being brought to the hospital
because it was being crossmatched? for emergency treatment considering that it was the height of the
A: No, sir. That was done only for a few minutes. We did not Peñafrancia Fiesta, it was evident that petitioners exerted earnest
transfuse at that time because there was no need.There is a
efforts to save the life of Raymond. It was just unfortunate that
necessity to transfuse blood when we saw there is gross bleeding the loss of his life was not prevented.
inside the body. 20(Emphasis supplied) In the case of Dr. Cruz v. CA, it was held that "[d]octors are
During the operation, on the other hand, Dr. Cereno was already protected by a special law. They are not guarantors of care. They
able to discover that 3,200 cc of blood was stocked in the thoracic do not even warrant a good result. They are not insurers against
cavity of Raymond due to the puncture in the latter’s left lung. mishaps or unusual consequences. Furthermore, they are not
Even then, however, immediate blood transfusion was not feasible liable for honest mistake of judgment..."23
because: This Court affirms the ruling of the CA that the BRMC is not an
Q: Now considering the loss of blood suffered by Raymund indispensible party. The core issue as agreed upon by the parties
Olavere, why did you not immediately transfuse blood to the and stated in the pre-trial order is whether petitioners were
patient and you waited for 45 minutes to elapse before transfusing negligent in the performance of their duties. It pertains to
the blood? acts/omissions of petitioners for which they could be held liable.
A: I did not transfuse blood because I had to control the bleeders. The cause of action against petitioners may be prosecuted fully
If you will transfuse blood just the same the blood that you and the determination of their liability may be arrived at without
transfuse will be lost. After evacuation of blood and there is no impleading the hospital where they are employed. As such, the
more bleeding... BRMC cannot be considered an indispensible party without
Q: It took you 45 minutes to evacuate the blood? A: The whom no final determination can be had of an action.24
evacuation did not take 45 minutes. IN THE LIGHT OF THE FOREGOING, the instant Petition for
Q: So what was the cause of the delay why you only transfuse Review on Certiorari is hereby GRANTED. The Court of Appeals
blood after 45 minutes? decision dated 21 February 2005 in CA-G.R. CV No. 65800 is
A: We have to look for some other lesions. It does not mean that hereby REVERSED and SET ASIDE. No costs.
when you slice the chest you will see the lesions SO ORDERED.
already.21 (Emphasis supplied)
Again, the foregoing testimonies of Dr. Cereno went
unchallenged or unrebutted. The parents of Raymond were not
able to present any expert witness to dispute the course of action G.R. No. 163753 January 15, 2014
taken by the petitioners.
DR. ENCARNACION C. LUMANTAS, M.D., Petitioner,
Causation Not Proven vs.
In medical negligence cases, it is settled that the complainant has HANZ CALAPIZ, REPRESENTED BY HIS PARENTS,
the burden of establishing breach of duty on the part of the HILARIO CALAPIZ, JR. and HERLITA CALAPIZ,
doctors or surgeons. It must be proven that such breach of duty Respondent.
has a causal connection to the resulting death of the patient.22 A
verdict in malpractice action cannot be based on speculation or
conjecture. Causation must be proven within a reasonable medical The acquittal of the accused does not necessarily mean his
probability based upon competent expert testimony. absolution from civil liability.
The parents of Raymond failed in this respect. Aside from their
failure to prove negligence on the part of the petitioners, they also The Case
failed to prove that it was petitioners’ fault that caused the injury.
Their cause stands on the mere assumption that Raymond’s life In this appeal, an accused desires the reversal of the decision
would have been saved had petitioner surgeons immediately promulgated on February 20, 2003,1 whereby the Court of
operated on him; had the blood been cross-matched immediately Appeals (CA) affirmed the judgment rendered on August 6, 1999
and had the blood been transfused immediately. There was, by the Regional Trial Court (RTC), Branch 13, in Oroquieta City
however, no proof presented that Raymond’s life would have ordering him to pay moral damages despite his acquittal of the
been saved had those things been done. Those are mere crime of reckless imprudence resulting in serious physical injuries
assumptions and cannot guarantee their desired result. Such charged against him.2
cannot be made basis of a decision in this case, especially
Antecedents
evidence. It held that the Prosecution’s evidence did not show the
On January 16, 1995, Spouses Hilario Calapiz, Jr. and Herlita required standard of care to be observed by other members of the
Calapiz brought their 8-year-old son, Hanz Calapiz (Hanz), to the medical profession under similar circumstances. Nonetheless, the
Misamis Occidental Provincial Hospital, Oroquieta City, for an RTC ruled that the petitioner was liable for moral damages
emergency appendectomy. Hanz was attended to by the petitioner, because there was a preponderance of evidence showing that
who suggested to the parents that Hanz also undergo circumcision Hanz had received the injurious trauma from his circumcision by
at no added cost to spare him the pain. With the parents’ consent, the petitioner. The decision disposed as follows:
the petitioner performed the coronal type of circumcision on Hanz
after his appendectomy. On the following day, Hanz complained WHEREFORE, for insufficiency of evidence, this court renders
of pain in his penis, which exhibited blisters. His testicles were judgment acquitting the accused, Dr. Encarnacion Lumantas, of
swollen. The parents noticed that the child urinated abnormally reckless imprudence resulting in serious physical injuries, but
after the petitioner forcibly removed the catheter, but the ordering him to pay Hanz Calapiz ₱50,000.00 as moral damages.
petitioner dismissed the abnormality as normal. On January 30, No costs.
1995, Hanz was discharged from the hospital over his parents’
protestations, and was directed to continue taking antibiotics. SO ORDERED.

On February 8, 1995, Hanz was confined in a hospital because of Ruling of the CA

the abscess formation between the base and the shaft of his penis.
Presuming that the ulceration was brought about by Hanz’s On appeal, the CA affirmed the RTC,7 sustaining the award of
appendicitis, the petitioner referred him to Dr. Henry Go, an moral damages. It opined that even if the petitioner had been
urologist, who diagnosed the boy to have a damaged urethra. acquitted of the crime charged, the acquittal did not necessarily
Thus, Hanz underwent cystostomy, and thereafter was operated mean that he had not incurred civil liability considering that the
on three times to repair his damaged urethra. Prosecution had preponderantly established the sufferings of Hanz
as the result of the circumcision.
When his damaged urethra could not be fully repaired and
reconstructed, Hanz’s parents brought a criminal charge against The petitioner moved for reconsideration, but the CA denied the
the petitioner for reckless imprudence resulting to serious physical motion on April 28, 2004.8
injuries. On April 17, 1997, the information3 was filed in the
Municipal Trial Court in Cities of Oroquieta City (MTCC), to Hence, this appeal.
which the latter pleaded not guilty on May 22, 1998.4 Under the
order of April 30, 1999, the case was transferred to the RTC Issue
pursuant to Supreme Court Circular No. 11-99.5
Whether the CA erred in affirming the petitioner’s civil liability
At the trial, the Prosecution presented several witnesses, including despite his acquittal of the crime of reckless imprudence resulting
Dr. Rufino Agudera as an expert witness and as the physician who in serious physical injuries.
had operated on Hanz twice to repair the damaged urethra. Dr.
Agudera testified that Hanz had been diagnosed to have urethral Ruling
stricture and cavernosal injury left secondary to trauma that had
necessitated the conduct of two operations to strengthen and to The petition for review lacks merit.
lengthen the urethra. Although satisfactorily explaining that the
injury to the urethra had been caused by trauma, Dr. Agudera It is axiomatic that every person criminally liable for a felony is
could not determine the kind of trauma that had caused the injury. also civilly liable.9 Nevertheless, the acquittal of an accused of
the crime charged does not necessarily extinguish his civil
In his defense, the petitioner denied the charge. He contended that liability. In Manantan v. Court of Appeals,10 the Court elucidates
at the time of his examination of Hanz on January 16, 1995, he on the two kinds of acquittal recognized by our law as well as on
had found an accumulation of pus at the vicinity of the appendix the different effects of acquittal on the civil liability of the
two to three inches from the penis that had required immediate accused, viz:
surgical operation; that after performing the appendectomy, he
had circumcised Hanz with his parents’ consent by using a congo Our law recognizes two kinds of acquittal, with different effects
instrument, thereby debunking the parents’ claim that their child on the civil liability of the accused.1âwphi1 First is an acquittal
had been cauterized; that he had then cleared Hanz on January 27, on the ground that the accused is not the author of the act or
1995 once his fever had subsided; that he had found no omission complained of. This instance closes the door to civil
complications when Hanz returned for his follow up check-up on liability, for a person who has been found to be not the perpetrator
February 2, 1995; and that the abscess formation between the base of any act or omission cannot and can never be held liable for
and the shaft of the penis had been brought about by Hanz’s burst such act or omission. There being no delict, civil liability ex
appendicitis. delicto is out of the question, and the civil action, if any, which
may be instituted must be based on grounds other than the delict
Ruling of the RTC complained of. This is the situation contemplated in Rule 111 of
the Rules of Court. The second instance is an acquittal based on
In its decision rendered on August 6, 1999,6 the RTC acquitted reasonable doubt on the guilt of the accused. In this case, even if
the petitioner of the crime charged for insufficiency of the the guilt of the accused has not been satisfactorily established, he
is not exempt from civil liability which may be proved by not only reasonable but just and commensurate. Unless we make
preponderance of evidence only. the adjustment in the permissible manner by prescribing legal
interest on the award, his sufferings would be unduly
The Rules of Court requires that in case of an acquittal, the compounded. For that purpose, the reckoning of interest should be
judgment shall state "whether the evidence of the prosecution from the filing of the criminal information on April 17, 1997, the
absolutely failed to prove the guilt of the accused or merely failed making of the judicial demand for the liability of the petitioner.
to prove his guilt beyond reasonable doubt. In either case, the
judgment shall determine if the act or omission from which the WHEREFORE, the Court AFFIRMS the decision promulgated on
civil liability might arise did not exist."11 February 20, 2003, with the modification that legal interest of 6%
per annum to start from April 17, 1997 is imposed on the award
Conformably with the foregoing, therefore, the acquittal of an of:₱50,000.00 as moral damages; and ORDERS the petitioner to
accused does not prevent a judgment from still being rendered pay the costs of suit.
against him on the civil aspect of the criminal case unless the
court finds and declares that the fact from which the civil liability SO ORDERED.
might arise did not exist.
DR. FERNANDO P. SOLIDUM, Petitioner,
Although it found the Prosecution’s evidence insufficient to
sustain a judgment of conviction against the petitioner for the vs.
crime charged, the RTC did not err in determining and adjudging
his civil liability for the same act complained of based on mere PEOPLE OF THE PHILIPPINES, Respondent.
preponderance of evidence.12 In this connection, the Court
reminds that the acquittal for insufficiency of the evidence did not
require that the complainant’s recovery of civil liability should be
through the institution of a separate civil action for that
purpose.13
This appeal is taken by a physician-anesthesiologist who has been
pronounced guilty of reckless imprudence resulting in serious
The petitioner’s contention that he could not be held civilly liable
physical injuries by the Regional Trial Court (RTC) and the Court
because there was no proof of his negligence deserves scant
of Appeals (CA). He had been part of the team of
consideration. The failure of the Prosecution to prove his criminal
anesthesiologists during the surgical pull-through operation
negligence with moral certainty did not forbid a finding against
conducted on a three-year old patient born with an imperforate
him that there was preponderant evidence of his negligence to
anus.1
hold him civilly liable.14 With the RTC and the CA both finding
that Hanz had sustained the injurious trauma from the hands of
the petitioner on the occasion of or incidental to the circumcision,
and that the trauma could have been avoided, the Court must
concur with their uniform findings. In that regard, the Court need The antecedents are as follows:
not analyze and weigh again the evidence considered in the
proceedings a quo. The Court, by virtue of its not being a trier of
facts, should now accord the highest respect to the factual
findings of the trial court as affirmed by the CA in the absence of Gerald Albert Gercayo (Gerald) was born on June 2, 19922 with
a clear showing by the petitioner that such findings were tainted an imperforate anus. Two days after his birth, Gerald underwent
with arbitrariness, capriciousness or palpable error. colostomy, a surgical procedure to bring one end of the large
intestine out through the abdominal wall,3 enabling him to excrete
Every person is entitled to the physical integrity of his through a colostomy bag attached to the side of his body.4
body.1âwphi1 Although we have long advocated the view that
any physical injury, like the loss or diminution of the use of any
part of one’s body, is not equatable to a pecuniary loss, and is not
susceptible of exact monetary estimation, civil damages should be On May 17, 1995, Gerald, then three years old, was admitted at
assessed once that integrity has been violated. The assessment is the Ospital ng Maynila for a pull-through operation.5 Dr. Leandro
but an imperfect estimation of the true value of one’s body. The Resurreccion headed the surgical team, and was assisted by Dr.
usual practice is to award moral damages for the physical injuries Joselito Luceño, Dr. Donatella Valeña and Dr. Joseph Tibio. The
sustained.15 In Hanz’s case, the undesirable outcome of the anesthesiologists included Dr. Marichu Abella, Dr. Arnel Razon
circumcision performed by the petitioner forced the young child and petitioner Dr. Fernando Solidum (Dr. Solidum).6 During the
to endure several other procedures on his penis in order to repair operation, Gerald experienced bradycardia,7 and went into a
his damaged urethra. Surely, his physical and moral sufferings coma.8 His coma lasted for two weeks,9 but he regained
properly warranted the amount of ₱50,000.00 awarded as moral consciousness only after a month.10 He could no longer see, hear
damages. or move.11

Many years have gone by since Hanz suffered the injury. Interest
of 6% per annum should then be imposed on the award as a
sincere means of adjusting the value of the award to a level that is
Agitated by her son’s helpless and unexpected condition, Ma. Luz ng Maynila, Dr. Anita So and Dr. Marichu Abella, private
Gercayo (Luz) lodged a complaint for reckless imprudence complainant Luz Gercayo, the amount of P500,000.00 as moral
resulting in serious physical injuries with the City Prosecutor’s damages and P100,000.00 as exemplary damages and to pay the
Office of Manila against the attending physicians.12 costs.

Upon a finding of probable cause, the City Prosecutor’s Office Accordingly, the bond posted by the accused for his provisional
filed an information solely against Dr. Solidum,13 alleging: – liberty is hereby CANCELLED. SO ORDERED.17

Upon motion of Dr. Anita So and Dr. Marichu Abella to

That on or about May 17, 1995, in the City of Manila, Philippines, reconsider their solidary liability,18 the RTC excluded them from
the said accused, being then an anesthesiologist at the Ospital ng solidary liability as to the damages, modifying its decision as
Maynila, Malate, this City, and as such was tasked to administer follows:
the anesthesia on three-year old baby boy GERALD ALBERT
GERCAYO, represented by his mother, MA. LUZ GERCAYO, WHEREFORE, premises considered, the Court finds accused Dr.
the former having been born with an imperforate anus [no anal Fernando Solidum, guilty beyond reasonable doubt as principal of
opening] and was to undergo an operation for anal opening [pull the crime charged and is hereby sentenced to suffer the
through operation], did then and there willfully, unlawfully and indeterminate penalty of two (2) months and one (1) day of
feloniously fail and neglect to use the care and diligence as the arresto mayor as minimum to one (1) year, one (1) month and ten
best of his judgment would dictate under said circumstance, by (10) days of prision correccional as maximum and to indemnify
failing to monitor and regulate properly the levels of anesthesia jointly and severally with Ospital ng Maynila, private
administered to said GERALD ALBERT GERCAYO and using complainant Luz Gercayo the amount of P500,000.00 as moral
100% halothane and other anesthetic medications, causing as a damages and P100,000 as exemplary damages and to pay the
consequence of his said carelessness and negligence, said costs.
GERALD ALBERT GERCAYO suffered a cardiac arrest and
consequently a defect called hypoxic encephalopathy meaning Accordingly, the bond posted by the accused for his provisional
insufficient oxygen supply in the brain, thereby rendering said liberty is hereby cancelled.19
GERALD ALBERT GERCAYO incapable of moving his body,
seeing, speaking or hearing, to his damage and prejudice. Decision of the CA

On January 20, 2010, the CA affirmed the conviction of Dr.

Solidum,20 pertinently stating and ruling:
Contrary to law.14

The case was initially filed in the Metropolitan Trial Court of

Manila, but was transferred to the RTC pursuant to Section 5 The case appears to be a textbook example of res ipsa loquitur.
xxxx

x x x [P]rior to the operation, the child was evaluated and found

of Republic Act No. 8369 (The Family Courts Act of 1997),15 fit to undergo a major operation. As noted by the OSG, the
where it was docketed as Criminal Case No. 01-190889. accused himself testified that pre-operation tests were conducted
Judgment of the RTC to ensure that the child could withstand the surgery. Except for his
imperforate anus, the child was healthy. The tests and other
procedures failed to reveal that he was suffering from any known
ailment or disability that could turn into a significant risk. There
was not a hint that the nature of the operation itself was a
On July 19, 2004, the RTC rendered its judgment finding Dr.
causative factor in the events that finally led to hypoxia.
Solidum guilty beyond reasonable doubt of reckless imprudence
resulting to serious physical injuries,16 decreeing:
In short, the lower court has been left with no reasonable
hypothesis except to attribute the accident to a failure in the
proper administration of anesthesia, the gravamen of the charge in
this case. The High Court elucidates in Ramos vs. Court of
WHEREFORE, premises considered, the Court finds accused DR. Appeals 321 SCRA 584 –
FERNANDO P. SOLIDUM GUILTY beyond reasonable doubt
as principal of the crime charged and is hereby sentenced to suffer In cases where the res ipsa loquitur is applicable, the court is
the indeterminate penalty of TWO (2) MONTHS and ONE (1) permitted to find a physician negligent upon proper proof of
DAY of arresto mayor as minimum to ONE (1) YEAR, ONE (1) injury to the patient, without the aid of expert testimony, where
MONTH and TEN (10) DAYS of prision correccional as the court from its fund of common knowledge can determine the
maximum and to indemnify, jointly and severally with the Ospital proper standard of care.
Where common knowledge and experience teach that a resulting CLEAR MISAPPREHENSION OF FACTS WHICH IF
injury would not have occurred to the patient if due care had been CORRECTED, WILL RESULT TO THE ACQUITTAL OF THE
exercised, an inference of negligence may be drawn giving rise to PETITIONER. FURTHER, THE HONORABLE COURT
an application of the doctrine of res ipsa loquitur without medical ERRED IN AFFIRMING THE SAID DECISION OF THE
evidence, which is ordinarily required to show not only what LOWER COURT, AS THIS BREACHES THE CRIMINAL
occurred but how and why it occurred. When the doctrine is LAW PRINCIPLE THAT THE PROSECUTION MUST PROVE
appropriate, all that the patient must do is prove a nexus between THE ALLEGATIONS OF THE INFORMATION BEYOND
the particular act or omission complained of and the injury REASONABLE DOUBT, AND NOT ON THE BASIS OF ITS
sustained while under the custody and management of the PRESUMPTIVE CONCLUSION.
defendant without need to produce expert medical testimony to
establish the standard of care. Resort to res ipsa loquitur is
allowed because there is no other way, under usual and ordinary
conditions, by which the patient can obtain redress for injury II.
suffered by him.

The lower court has found that such a nexus exists between the
act complained of and the injury sustained, and in line with the
THE HONORABLE COURT OF APPEALS ERRED IN
hornbook rules on evidence, we will afford the factual findings of
APPLYING THE PRINCIPLE OF RES IPSA LOQUITOR (sic)
a trial court the respect they deserve in the absence of a showing
WHEN THE DEFENSE WAS ABLE TO PROVE THAT
of arbitrariness or disregard of material facts that might affect the
THERE IS NO NEGLIGENCE ON THE PART OF THE
disposition of the case. People v. Paraiso 349 SCRA 335.
PETITIONER, AND NO OVERDOSING IN THE
APPLICATION OF THE ANESTHETIC AGENT BECAUSE
THERE WAS NO 100% HALOTHANE ADMINISTERED TO
The res ipsa loquitur test has been known to be applied in criminal THE CHILD, BUT ONLY ONE (1%) PERCENT AND THE
cases. Although it creates a presumption of negligence, it need not APPLICATION THEREOF, WAS REGULATED BY AN
offend due process, as long as the accused is afforded the ANESTHESIA MACHINE. THUS, THE APPLICATION OF
opportunity to go forward with his own evidence and prove that THE PRINCIPLE OF RES IPSA LOQUITOR (sic)
he has no criminal intent. It is in this light not inconsistent with CONTRADICTED THE ESTABLISHED FACTS AND THE
the constitutional presumption of innocence of an accused. LAW APPLICABLE IN THE CASE.

IN VIEW OF THE FOREGOING, the modified decision of the

lower court is affirmed.
III.

SO ORDERED.21

Dr. Solidum filed a motion for reconsideration, but the CA denied

his motion on May 7, 2010.22 Hence, this appeal. THE AWARD OF MORAL DAMAGES AND EXEMPLARY
DAMAGES IS NOT JUSTIFIED THERE BEING NO
NEGLIGENCE ON THE PART OF THE PETITIONER.
ASSUMING THAT THE CHILD IS ENTITLED TO
FINANCIAL CONSIDERATION, IT SHOULD BE ONLY AS A
FINANCIAL ASSISTANCE, BECAUSE THERE WAS NO
NEGLIGENCE, AND NO OVERDOSING OF ANESTHETIC
AGENT AND AS SUCH, THE AWARD IS SO EXCESSIVE,
AND NO FACTUAL AND LEGAL BASIS.23

Dr. Solidum avers that:

Issues To simplify, the following are the issues for resolution, namely:
(a) whether or not the doctrine of res ipsa loquitur was applicable
herein; and (b) whether or not Dr. Solidum was liable for criminal
negligence.
I.

THE HONORABLE COURT OF APPEALS ERRED IN ruling

AFFIRMING THE DECISION OF THE LOWER COURT IN
UPHOLDING THE PETITIONER’S CONVICTION FOR THE The appeal is meritorious.
CRIME CHARGED BASED ON THE TRIAL COURT’S
OPINION, AND NOT ON THE BASIS OF THE FACTS Applicability of the Doctrine of Res Ipsa Loquitur
ESTABLISHED DURING THE TRIAL. ALSO, THERE IS A
Res ipsa loquitur is literally translated as "the thing or the and care. However, testimony as to the statements and acts of
transaction speaks for itself." The doctrine res ipsa loquitur means physicians and surgeons, external appearances, and manifest
that "where the thing which causes injury is shown to be under the conditions which are observable by any one may be given by non-
management of the defendant, and the accident is such as in the expert witnesses. Hence, in cases where the res ipsa loquitur is
ordinary course of things does not happen if those who have the applicable, the court is permitted to find a physician negligent
management use proper care, it affords reasonable evidence, in upon proper proof of injury to the patient, without the aid of
the absence of an explanation by the defendant, that the accident expert testimony, where the court from its fund of common
arose from want of care."24 It is simply "a recognition of the knowledge can determine the proper standard of care. Where
postulate that, as a matter of common knowledge and experience, common knowledge and experience teach that a resulting injury
the very nature of certain types of occurrences may justify an would not have occurred to the patient if due care had been
inference of negligence on the part of the person who controls the exercised, an inference of negligence may be drawn giving rise to
instrumentality causing the injury in the absence of some an application of the doctrine of res ipsa loquitur without medical
explanation by the defendant who is charged with negligence. It is evidence, which is ordinarily required to show not only what
grounded in the superior logic of ordinary human experience and occurred but how and why it occurred. When the doctrine is
on the basis of such experience or common knowledge, appropriate, all that the patient must do is prove a nexus between
negligence may be deduced from the mere occurrence of the the particular act or omission complained of and the injury
accident itself. sustained while under the custody and management of the
defendant without need to produce expert medical testimony to
Hence, res ipsa loquitur is applied in conjunction with the establish the standard of care. Resort to res ipsa loquitur is
doctrine of common knowledge."25 allowed because there is no other way, under usual and ordinary
conditions, by which the patient can obtain redress for injury
suffered by him.
Jarcia, Jr. v. People26 has underscored that the doctrine is not a
rule of substantive law, but merely a mode of proof or a mere Thus, courts of other jurisdictions have applied the doctrine in the
procedural convenience. The doctrine, when applicable to the following situations: leaving of a foreign object in the body of the
facts and circumstances of a given case, is not meant to and does patient after an operation, injuries sustained on a healthy part of
not dispense with the requirement of proof of culpable negligence the body which was not under, or in the area, of treatment,
against the party charged. It merely determines and regulates what removal of the wrong part of the body when another part was
shall be prima facie evidence thereof, and helps the plaintiff in intended, knocking out a tooth while a patient’s jaw was under
proving a breach of the duty. The doctrine can be invoked when anesthetic for the removal of his tonsils, and loss of an eye while
and only when, under the circumstances involved, direct evidence the patient plaintiff was under the influence of anesthetic, during
is absent and not readily available.27 or following an operation for appendicitis, among others.

The applicability of the doctrine of res ipsa loquitur in medical

negligence cases was significantly and exhaustively explained in Nevertheless, despite the fact that the scope of res ipsa loquitur
Ramos v. Court of Appeals,28 where the Court said – has been measurably enlarged, it does not automatically apply to
all cases of medical negligence as to mechanically shift the
burden of proof to the defendant to show that he is not guilty of
Medical malpractice cases do not escape the application of this the ascribed negligence. Res ipsa loquitur is not a rigid or
doctrine. Thus, res ipsa loquitur has been applied when the ordinary doctrine to be perfunctorily used but a rule to be
circumstances attendant upon the harm are themselves of such a cautiously applied, depending upon the circumstances of each
character as to justify an inference of negligence as the cause of case. It is generally restricted to situations in malpractice cases
that harm. The application of res ipsa loquitur in medical where a layman is able to say, as a matter of common knowledge
negligence cases presents a question of law since it is a judicial and observation, that the consequences of professional care were
function to determine whether a certain set of circumstances does, not as such as would ordinarily have followed if due care had
as a matter of law, permit a given inference. been exercised. A distinction must be made between the failure to
secure results, and the occurrence of something more unusual and
not ordinarily found if the service or treatment rendered followed
Although generally, expert medical testimony is relied upon in the usual procedure of those skilled in that particular practice. It
malpractice suits to prove that a physician has done a negligent must be conceded that the doctrine of res ipsa loquitur can have
act or that he has deviated from the standard medical procedure, no application in a suit against a physician or surgeon which
when the doctrine of res ipsa loquitur is availed by the plaintiff, involves the merits of a diagnosis or of a scientific treatment. The
the need for expert medical testimony is dispensed with because physician or surgeon is not required at his peril to explain why
the injury itself provides the proof of negligence. The reason is any particular diagnosis was not correct, or why any particular
that the general rule on the necessity of expert testimony applies scientific treatment did not produce the desired result. Thus, res
only to such matters clearly within the domain of medical science, ipsa loquitur is not available in a malpractice suit if the only
and not to matters that are within the common knowledge of showing is that the desired result of an operation or treatment was
mankind which may be testified to by anyone familiar with the not accomplished. The real question, therefore, is whether or not
facts. Ordinarily, only physicians and surgeons of skill and in the process of the operation any extraordinary incident or
experience are competent to testify as to whether a patient has unusual event outside of the routine performance occurred which
been treated or operated upon with a reasonable degree of skill is beyond the regular scope of customary professional activity in
such operations, which, if unexplained would themselves responding. The doctor ordered that a medicine be administered,
reasonably speak to the average man as the negligent cause or and he departed for the hospital. When he arrived, the physician
causes of the untoward consequence. If there was such extraneous who had been on call at the hospital had begun attempts to revive
intervention, the doctrine of res ipsa loquitur may be utilized and the patient. Dr. Brigham joined him in the effort, but the patient
the defendant is called upon to explain the matter, by evidence of died.
exculpation, if he could.
The doctor who performed the autopsy concluded that the patient
died between 4:25 a.m. and 4:30 a.m. of asphyxia, as a result of a
sudden, acute closing of the air passage. He also found that the air
In order to allow resort to the doctrine, therefore, the following passage had been adequate to maintain life up to 2 or 3 minutes
essential requisites must first be satisfied, to wit: (1) the accident prior to death. He did not know what caused the air passage to
was of a kind that does not ordinarily occur unless someone is suddenly close.
negligent; (2) the instrumentality or agency that caused the injury
was under the exclusive control of the person charged; and (3) the
injury suffered must not have been due to any voluntary action or
contribution of the person injured.29 xxxx

The Court considers the application here of the doctrine of res It is a rare occurrence when someone admitted to a hospital for
ipsa loquitur inappropriate. Although it should be conceded the treatment of infectious mononucleosis dies of asphyxiation.
without difficulty that the second and third elements were present, But that is not sufficient to invoke res ipsa loquitur. The fact that
considering that the anesthetic agent and the instruments were the injury rarely occurs does not in itself prove that the injury was
exclusively within the control of Dr. Solidum, and that the patient, probably caused by someone's negligence. Mason v. Ellsworth, 3
being then unconscious during the operation, could not have been Wn. App. 298, 474 P.2d 909 (1970). Nor is a bad result by itself
guilty of contributory negligence, the first element was enough to warrant the application of the doctrine. Nelson v.
undeniably wanting. Luz delivered Gerald to the care, custody Murphy, 42 Wn.2d 737, 258 P.2d 472 (1953). See 2 S. Speiser,
and control of his physicians for a pull-through operation. Except The Negligence Case – Res Ipsa Loquitur § 24:10 (1972). The
for the imperforate anus, Gerald was then of sound body and mind evidence presented is insufficient to establish the first element
at the time of his submission to the physicians. Yet, he necessary for application of res ipsa loquitur doctrine. The acute
experienced bradycardia during the operation, causing loss of his closing of the patient’s air passage and his resultant asphyxiation
senses and rendering him immobile. Hypoxia, or the insufficiency took place over a very short period of time. Under these
of oxygen supply to the brain that caused the slowing of the heart circumstances it would not be reasonable to infer that the
rate, scientifically termed as bradycardia, would not ordinarily physician was negligent. There was no palpably negligent act.
occur in the process of a pull- through operation, or during the The common experience of mankind does not suggest that death
administration of anesthesia to the patient, but such fact alone did would not be expected without negligence. And there is no expert
not prove that the negligence of any of his attending physicians, medical testimony to create an inference that negligence caused
including the anesthesiologists, had caused the injury. In fact, the the injury.
anesthesiologists attending to him had sensed in the course of the
operation that the lack of oxygen could have been triggered by the Negligence of Dr. Solidum
vago-vagal reflex, prompting them to administer atropine to the
patient.30 In view of the inapplicability of the doctrine of res ipsa loquitur,
the Court next determines whether the CA correctly affirmed the
conviction of Dr. Solidum for criminal negligence.

This conclusion is not unprecedented. It was similarly reached in

Swanson v. Brigham,31 relevant portions of the decision therein Negligence is defined as the failure to observe for the protection
being as follows: of the interests of another person that degree of care, precaution,
and vigilance that the circumstances justly demand, whereby such
On January 7, 1973, Dr. Brigham admitted 15-year-old Randall other person suffers injury.32 Reckless imprudence, on the other
Swanson to a hospital for the treatment of infectious hand, consists of voluntarily doing or failing to do, without
mononucleosis. The patient's symptoms had included a swollen malice, an act from which material damage results by reason of an
throat and some breathing difficulty. Early in the morning of inexcusable lack of precaution on the part of the person
January 9 the patient was restless, and at 1:30 a.m. Dr. Brigham performing or failing to perform such act.33
examined the patient. His inspection of the patient's air passage
revealed that it was in satisfactory condition. At 4:15 a.m. Dr. Dr. Solidum’s conviction by the RTC was primarily based on his
Brigham received a telephone call from the hospital, advising him failure to monitor and properly regulate the level of anesthetic
that the patient was having respiratory difficulty. The doctor agent administered on Gerald by overdosing at 100% halothane.
ordered that oxygen be administered and he prepared to leave for In affirming the conviction, the CA observed:
the hospital. Ten minutes later, 4:25 a.m., the hospital called a
second time to advise the doctor that the patient was not
On the witness stand, Dr. Vertido made a significant turnaround. The implication of Dr. Vertido’s admission is that there was no
He affirmed the findings and conclusions in his report except for overdose of the anesthetic agent, and the accused Dr. Solidum
an observation which, to all intents and purposes, has become the stakes his liberty and reputation on this conclusion. He made the
storm center of this dispute. He wanted to correct one piece of assurance that he gave his patient the utmost medical care, never
information regarding the dosage of the anesthetic agent leaving the operating room except for a few minutes to answer the
administered to the child. He declared that he made a mistake in call of nature but leaving behind the other members of his team
reporting a 100% halothane and said that based on the records it Drs. Abella and Razon to monitor the operation. He insisted that
should have been 100% oxygen. he administered only a point 1% not 100% halothane, receiving
corroboration from Dr. Abella whose initial MA in the record
should be enough to show that she assisted in the operation and
The records he was relying on, as he explains, are the following: was therefore conversant of the things that happened. She
revealed that they were using a machine that closely monitored
the concentration of the agent during the operation.
(a) the anesthesia record – A portion of the chart in the record was
marked as Exhibit 1-A and 1-B to indicate the administration at
intervals of the anesthetic agent.
But most compelling is Dr. Solidum’s interpretation of the
(b) the clinical abstract – A portion of this record that reads as anesthesia record itself, as he takes the bull by the horns, so to
follows was marked Exhibit 3A. 3B – Approximately 1 hour and speak. In his affidavit, he says, reading from the record, that the
45 minutes through the operation, patient was noted to have quantity of halothane used in the operation is one percent (1%)
bradycardia (CR = 70) and ATSO4 0.2 mg was immediately delivered at time intervals of 15 minutes. He studiedly mentions –
administered. However, the bradycardia persisted, the inhalational the concentration of halothane as reflected in the anesthesia
agent was shut off, and the patient was ventilated with 100% record (Annex D of the complaint-affidavit) is only one percent
oxygen and another dose of ATSO4 0.2 mg was given. However, (1%) – The numbers indicated in 15 minute increments for
the patient did not respond until no cardiac rate can be auscultated halothane is an indication that only 1% halothane is being
and the surgeons were immediately told to stop the operation. The delivered to the patient Gerard Gercayo for his entire operation;
patient was put on a supine position and CPR was initiated. The amount of halothane delivered in this case which is only one
Patient was given 1 amp of epinephrine initially while percent cannot be summated because halothane is constantly
continuously doing cardiac massage – still with no cardiac rate being rapidly eliminated by the body during the entire operation.
appreciated; another ampule of epinephrine was given and after xxxx
45 secs, patient’s vital signs returned to normal. The entire
resuscitation lasted approximately 3-5 mins. The surgeons were In finding the accused guilty, despite these explanations, the RTC
then told to proceed to the closure and the child’s vital signs argued that the volte-face of Dr. Vertido on the question of the
throughout and until the end of surgery were: BP = 110/70; CR = dosage of the anesthetic used on the child would not really
116/min and RR = 20-22 cycles/min (on assisted ventilation). validate the non-guilt of the anesthesiologist. Led to agree that the
halothane used was not 100% as initially believed, he was
nonetheless unaware of the implications of the change in his
testimony. The court observed that Dr. Vertido had described the
Dr. Vertido points to the crucial passage in the clinical abstract condition of the child as hypoxia which is deprivation of oxygen,
that the patient was ventilated with 100% oxygen and another a diagnosis supported by the results of the CT Scan. All the
dose of ATSO4 when the bradycardia persisted, but for one symptoms attributed to a failing central nervous system such as
reason or another, he read it as 100% halothane. He was asked to stupor, loss of consciousness, decrease in heart rate, loss of usual
read the anesthesia record on the percentage of the dosage acuity and abnormal motor function, are manifestations of this
indicated, but he could only sheepishly note I can’t understand the condition or syndrome. But why would there be deprivation of
number. There are no clues in the clinical abstract on the quantity oxygen if 100% oxygen to 1% halothane was used? Ultimately, to
of the anesthetic agent used. It only contains the information that the court, whether oxygen or halothane was the object of mistake,
the anesthetic plan was to put the patient under general anesthesia the detrimental effects of the operation are incontestable, and they
using a nonrebreathing system with halothane as the sole can only be led to one conclusion – if the application of anesthesia
anesthetic agent and that 1 hour and 45 minutes after the was really closely monitored, the event could not have
operation began, bradycardia occurred after which the inhalational happened.34
agent was shut off and the patient administered with 100%
oxygen. It would be apparent that the 100% oxygen that Dr. The Prosecution did not prove the elements of reckless
Vertido said should be read in lieu of 100% halothane was the imprudence beyond reasonable doubt because the circumstances
pure oxygen introduced after something went amiss in the cited by the CA were insufficient to establish that Dr. Solidum
operation and the halothane itself was reduced or shut off. had been guilty of inexcusable lack of precaution in monitoring
the administration of the anesthetic agent to Gerald. The Court
aptly explained in Cruz v. Court of Appeals35 that:
The key question remains – what was the quantity of halothane
used before bradycardia set in? Whether or not a physician has committed an "inexcusable lack of
precaution" in the treatment of his patient is to be determined
according to the standard of care observed by other members of
the profession in good standing under similar circumstances particular physician in a particular case exists. Because most
bearing in mind the advanced state of the profession at the time of medical malpractice cases are highly technical, witnesses with
treatment or the present state of medical science. In the recent special medical qualifications must provide guidance by giving
case of Leonila Garcia-Rueda v. Wilfred L. Pacasio, et. al., this the knowledge necessary to render a fair and just verdict. As a
Court stated that in accepting a case, a doctor in effect represents result, the standard of medical care of a prudent physician must be
that, having the needed training and skill possessed by physicians determined from expert testimony in most cases; and in the case
and surgeons practicing in the same field, he will employ such of a specialist (like an anesthesiologist), the standard of care by
training, care and skill in the treatment of his patients. He which the specialist is judged is the care and skill commonly
therefore has a duty to use at least the same level of care that any possessed and exercised by similar specialists under similar
other reasonably competent doctor would use to treat a condition circumstances. The specialty standard of care may be higher than
under the same circumstances. It is in this aspect of medical that required of the general practitioner.37
malpractice that expert testimony is essential to establish not only
the standard of care of the profession but also that the physician's
conduct in the treatment and care falls below such standard. The standard of care is an objective standard by which the
Further, inasmuch as the causes of the injuries involved in conduct of a physician sued for negligence or malpractice may be
malpractice actions are determinable only in the light of scientific measured, and it does not depend, therefore, on any individual
knowledge, it has been recognized that expert testimony is usually physician’s own knowledge either. In attempting to fix a standard
necessary to support the conclusion as to causation. by which a court may determine whether the physician has
properly performed the requisite duty toward the patient, expert
medical testimony from both plaintiff and defense experts is
required. The judge, as the trier of fact, ultimately determines the
xxxx standard of care, after listening to the testimony of all medical
experts.38
In litigations involving medical negligence, the plaintiff has the
burden of establishing appellant's negligence and for a reasonable Here, the Prosecution presented no witnesses with special medical
conclusion of negligence, there must be proof of breach of duty qualifications in anesthesia to provide guidance to the trial court
on the part of the surgeon as well as a causal connection of such on what standard of care was applicable. It would consequently be
breach and the resulting death of his patient. In Chan Lugay v. St truly difficult, if not impossible, to determine whether the first
Luke's Hospital, Inc., where the attending physician was absolved three elements of a negligence and malpractice action were
of liability for the death of the complainant’s wife and newborn attendant.
baby, this Court held that:
Although the Prosecution presented Dr. Benigno Sulit, Jr., an
"In order that there may be a recovery for an injury, however, it anesthesiologist himself who served as the Chairman of the
must be shown that the ‘injury for which recovery is sought must Committee on Ethics and Malpractice of the Philippine Society of
be the legitimate consequence of the wrong done; the connection Anesthesiologists that investigated the complaint against Dr.
between the negligence and the injury must be a direct and natural Solidum, his testimony mainly focused on how his Committee
sequence of events, unbroken by intervening efficient causes.’ In had conducted the investigation.39 Even then, the report of his
other words, the negligence must be the proximate cause of the Committee was favorable to Dr. Solidum,40 to wit:
injury. For, ‘negligence, no matter in what it consists, cannot
create a right of action unless it is the proximate cause of the
injury complained of.’ And ‘the proximate cause of an injury is Presented for review by this committee is the case of a 3 year old
that cause, which, in natural and continuous sequence, unbroken male who underwent a pull-thru operation and was administered
by any efficient intervening cause, produces the injury, and general anesthesia by a team of anesthesia residents. The patient,
without which the result would not have occurred.’" at the time when the surgeons was manipulating the recto-sigmoid
and pulling it down in preparation for the anastomosis, had
An action upon medical negligence – whether criminal, civil or bradycardia. The anesthesiologists, sensing that the cause thereof
administrative – calls for the plaintiff to prove by competent was the triggering of the vago-vagal reflex, administered atropine
evidence each of the following four elements, namely: (a) the to block it but despite the administration of the drug in two doses,
duty owed by the physician to the patient, as created by the cardiac arrest ensued. As the records show, prompt resuscitative
physician-patient relationship, to act in accordance with the measures were administered and spontaneous cardiac function re-
specific norms or standards established by his profession; (b) the established in less than five (5) minutes and that oxygen was
breach of the duty by the physician’s failing to act in accordance continuously being administered throughout, unfortunately, as
with the applicable standard of care; (3) the causation, i.e., there later become manifest, patient suffered permanent irreversible
must be a reasonably close and causal connection between the brain damage.
negligent act or omission and the resulting injury; and (4) the
damages suffered by the patient.36 In view of the actuations of the anaesthesiologists and the
administration of anaesthesia, the committee find that the same
In the medical profession, specific norms or standards to protect were all in accordance with the universally accepted standards of
the patient against unreasonable risk, commonly referred to as medical care and there is no evidence of any fault or negligence
standards of care, set the duty of the physician to act in respect of on the part of the anaesthesiologists.
the patient. Unfortunately, no clear definition of the duty of a
Dr. Antonio Vertido, a Senior Medico-Legal Officer of the WITNESS Well, one of the more practical reason why there is
National Bureau of Investigation, was also presented as a slowing of the heart rate is when you do a vagal reflex in the neck
Prosecution witness, but his testimony concentrated on the results wherein the vagal receptors are located at the lateral part of the
of the physical examination he had conducted on Gerald, as borne neck, when you press that, you produce the slowing of the heart
out by the following portions of his direct examination, to wit: rate that produce bradycardia.
FISCAL CABARON Doctor, what do you mean by General
Anesthetic Agent?

Q I am pro[p]ounding to you another question doctor, what about

the deficiency in the supply of oxygen by the patient, would that
WITNESS General Anesthetic Agent is a substance used in the also cause the slowing of the heart rate?
conduction of Anesthesia and in this case, halothane was used as a
sole anesthetic agent.

A Well that is a possibility sir, I mean not as slowing of the heart

rate, if there is a hypoxia or there is a low oxygen level in the
xxxx blood, the normal thing for the heart is to pump or to do not a
bradycardia but a ... to counter act the Hypoxia that is being
experienced by the patient

Q Now under paragraph two of page 1 of your report you

mentioned that after one hour and 45 minutes after the operation,
the patient experienced a bradycardia or slowing of heart rate, (sic).
now as a doctor, would you be able to tell this Honorable Court as
to what cause of the slowing of heart rate as to Gerald Gercayo?

xxxx

WITNESS Well honestly sir, I cannot give you the reason why
there was a bradycardia of time because is some reason one way
or another that might caused bradycardia. Q Now, you made mention also doctor that the use of general
anesthesia using 100% halothane and other anesthetic medications
probably were contributory to the production of hypoxia.

FISCAL CABARON What could be the possible reason?

A Yes, sir in general sir.

A Well bradycardia can be caused by anesthetic agent itself and

that is a possibility, we’re talking about possibility here.
On cross-examination, Dr. Vertido expounded more specifically
on his interpretation of the anesthesia record and the factors that
could have caused Gerald to experience bradycardia, viz:
Q What other possibility do you have in mind, doctor?

ATTY. COMIA I noticed in, may I see your report Doctor, page
3, will you kindly read to this Honorable court your last paragraph
A Well, because it was an operation, anything can happen within and if you will affirm that as if it is correct?
that situation.

A "The use of General Anesthesia, that is using 100% Halothane

FISCAL CABARON Now, this representation would like to ask probably will be contributory to the production of Hypoxia and - -
you about the slowing of heart rate, now what is the immediate - -"
cause of the slowing of the heart rate of a person?
ATTY COMIA And do you affirm the figure you mentioned in
this Court Doctor? WITNESS Based on the records, I know the - -
- Q I remember doctor, according to you there are so many factors
that contributed to what you call hypoxia and according to you,
Q 100%? when this Gerald suffered hypoxia, there are other factors that
might lead to this Hypoxia at the time of this operation is that
A 100% based on the records. correct?

WITNESS The possibility is there, sir.

Q I will show you doctor a clinical record. I am a lawyer I am not

a doctor but will you kindly look at this and tell me where is
100%, the word "one hundred" or 1-0-0, will you kindly look at Q And according to you, it might also be the result of such other,
this Doctor, this Xerox copy if you can show to this Honorable some or it might be due to operations being conducted by the
Court and even to this representation the word "one hundred" or doctor at the time when the operation is being done might also
1-0-0 and then call me. contribute to that hypoxia is that correct?

xxxx A That is a possibility also.

ATTY. COMIA Doctor tell this Honorable Court where is that xxxx
100, 1-0-0 and if there is, you just call me and even the attention
of the Presiding Judge of this Court. Okay, you read one by one. ATTY. COMIA How will you classify now the operation
conducted to this Gerald, Doctor?

WITNESS Well, are you only asking 100%, sir?

WITNESS Well, that is a major operation sir.
ATTY. COMIA I’m asking you, just answer my question, did you
see there 100% and 100 figures, tell me, yes or no? WITNESS
I’m trying to look at the 100%, there is no 100% there sir.
Q In other words, when you say major operation conducted to this
Gerald, there is a possibility that this Gerald might [be] exposed
to some risk is that correct?
ATTY. COMIA Okay, that was good, so you Honor please, may
we request also temporarily, because this is just a xerox copy
presented by the fiscal, that the percentage here that the Halothane
administered by Dr. Solidum to the patient is 1% only so may we
A That is a possibility sir.
request that this portion, temporarily your Honor, we are marking
this anesthesia record as our Exhibit 1 and then this 1% Halothane
Q And which according to you that Gerald suffered hypoxia is
also be bracketed and the same be marked as our Exhibit "1-A".
that correct? A Yes, sir.

Q And that is one of the risk of that major operation is that

correct?
xxxx
A That is the risk sir.42

ATTY. COMIA Doctor, my attention was called also when you

said that there are so many factors that contributed to Hypoxia is At the continuation of his cross-examination, Dr. Vertido
that correct? maintained that Gerald’s operation for his imperforate anus,
considered a major operation, had exposed him to the risk of
suffering the same condition.43 He then corrected his earlier
finding that 100% halothane had been administered on Gerald by
WITNESS Yes, sir. saying that it should be 100% oxygen.44
Although the result now reached has resolved the issue of civil
liability, we have to address the unusual decree of the RTC, as
Dr. Solidum was criminally charged for "failing to monitor and affirmed by the CA, of expressly holding Ospital ng Maynila
regulate properly the levels of anesthesia administered to said civilly liable jointly and severally with Dr. Solidum. The decree
Gerald Albert Gercayo and using 100% halothane and other was flawed in logic and in law.
anesthetic medications."45 However, the foregoing
circumstances, taken together, did not prove beyond reasonable
doubt that Dr. Solidum had been recklessly imprudent in
administering the anesthetic agent to Gerald. Indeed, Dr. In criminal prosecutions, the civil action for the recovery of civil
Vertido’s findings did not preclude the probability that other liability that is deemed instituted with the criminal action refers
factors related to Gerald’s major operation, which could or could only to that arising from the offense charged.48 It is puzzling,
not necessarily be attributed to the administration of the therefore, how the RTC and the CA could have adjudged Ospital
anesthesia, had caused the hypoxia and had then led Gerald to ng Maynila jointly and severally liable with Dr. Solidum for the
experience bradycardia. Dr. Vertido revealingly concluded in his damages despite the obvious fact that Ospital ng Maynila, being
report, instead, that "although the anesthesiologist followed the an artificial entity, had not been charged along with Dr. Solidum.
normal routine and precautionary procedures, still hypoxia and its The lower courts thereby acted capriciously and whimsically,
corresponding side effects did occur."46 which rendered their judgment against Ospital ng Maynila void as
the product of grave abuse of discretion amounting to lack of
jurisdiction.

The existence of the probability about other factors causing the Not surprisingly, the flawed decree raises other material concerns
hypoxia has engendered in the mind of the Court a reasonable that the RTC and the CA overlooked. We deem it important, then,
doubt as to Dr. Solidum’s guilt, and moves us to acquit him of the to express the following observations for the instruction of the
crime of reckless imprudence resulting to serious physical Bench and Bar.
injuries. "A reasonable doubt of guilt," according to United States
v. Youthsey:47

For one, Ospital ng Maynila was not at all a party in the

proceedings. Hence, its fundamental right to be heard was not
x x x is a doubt growing reasonably out of evidence or the lack of respected from the outset. The R TC and the CA should have been
it. It is not a captious doubt; not a doubt engendered merely by alert to this fundamental defect. Verily, no person can be
sympathy for the unfortunate position of the defendant, or a prejudiced by a ruling rendered in an action or proceeding in
dislike to accept the responsibility of convicting a fellow man. If, which he was not made a party. Such a rule would enforce the
having weighed the evidence on both sides, you reach the constitutional guarantee of due process of law.
conclusion that the defendant is guilty, to that degree of certainty
as would lead you to act on the faith of it in the most important
and crucial affairs of your life, you may properly convict him.
Proof beyond reasonable doubt is not proof to a mathematical Moreover, Ospital ng Maynila could be held civilly liable only
demonstration. It is not proof beyond the possibility of mistake. when subsidiary liability would be properly enforceable pursuant
to Article 103 of the Revised Penal Code. But the subsidiary
liability seems far-fetched here. The conditions for subsidiary
We have to clarify that the acquittal of Dr. Solidum would not liability to attach to Ospital ng Maynila should first be complied
immediately exempt him from civil liability.1âwphi1 But we with. Firstly, pursuant to Article 103 of the Revised Penal Code,
cannot now find and declare him civilly liable because the Ospital ng Maynila must be shown to be a corporation "engaged
circumstances that have been established here do not present the in any kind of industry." The term industry means any department
factual and legal bases for validly doing so. His acquittal did not or branch of art, occupation or business, especially one that
derive only from reasonable doubt. There was really no firm and employs labor and capital, and is engaged in industry.49
competent showing how the injury to Gerard had been caused. However, Ospital ng Maynila, being a public hospital, was not
That meant that the manner of administration of the anesthesia by engaged in industry conducted for profit but purely in charitable
Dr. Solidum was not necessarily the cause of the hypoxia that and humanitarian work.50 Secondly, assuming that Ospital ng
caused the bradycardia experienced by Gerard. Consequently, to Maynila was engaged in industry for profit, Dr. Solidum must be
adjudge Dr. Solidum civilly liable would be to speculate on the shown to be an employee of Ospital ng Maynila acting in the
cause of the hypoxia. We are not allowed to do so, for civil discharge of his duties during the operation on Gerald. Yet, he
liability must not rest on speculation but on competent evidence. definitely was not such employee but a consultant of the hospital.
And, thirdly, assuming that civil liability was adjudged against
Dr. Solidum as an employee (which did not happen here), the
execution against him was unsatisfied due to his being insolvent.
Liability of Ospital ng Maynila
WHEREFORE, the Court GRANTS the petition for review on
certiorari; REVERSES AND SETS ASIDE the decision
promulgated on January 20, 2010; ACQUITS Dr. Fernando P.
Solidum of the crime of reckless imprudence resulting to serious On June 14, 2000, at around 4 o'clock in the afternoon, ten (10)-
physical injuries; and MAKES no pronouncement on costs of suit. year old Rodolfo F. Palma, Jr. (JR) complained of abdominal pain
to his mother, Rosario Palma. At 5 o’clock that sameafternoon,
Palma's mother and father, Atty. Rodolfo Palma Sr., brought JR to
the clinic of accused Dr. Cabugao. Dr. Cabugao, a general
DR. ANTONIO P. CABUGAO, Petitioner, practitioner, specializing in familymedicine gave medicines for
the pain and told Palma's parents to call him up if his stomach
vs. pains continue. Due to persistent abdominal pains, at 4:30 in the
early morning of June 15, 2000, they returnedto Dr. Cabugao,
PEOPLE OF THE PHILIPPINES and SPOUSES RODOLFO who advised them to bring JR to the Nazareth General Hospital in
M. PALMA and ROSARIO F. PALMA, Respondents. Dagupan City, for confinement. JR was admitted at the said
hospital at 5:30 in the morning.5

Before this Court are appeals via Rule 45 from the Decision1 Blood samples were taken from JR for laboratory testing. The
dated June 4, 2004 of the Court of Appeals in CA G.R. CR No. complete blood count conveyed the following result: wbc – 27.80
27293, affirming the Decision2 dated February 28,2003 of the x 10 9/L; lymphocytes – 0.10 and neutrophils – 0.90. Diagnostic
Regional Trial Court (RTC), convicting appellant Dr. Antonio P. ultrasound was likewise conducted on the patient's lower
Cabugao (Dr. Cabugao) and Dr. Clenio Ynzon (Dr. Ynzon) of the abdomen by radiologist, Dr. Ricky V. Querubin, with the
crime of Reckless Imprudence Resulting to Homicide. following findings:

Normal liver, bile ducts, gallbladder, pancreas, spleen, kidneys

and urinary bladder.
The Information3 alleged –
There is no free peritoneal fluid.
That on or about June 17, 2000in the City of Dagupan,
Philippines, and within the jurisdiction of this Honorable Court, There is localized tenderness in the paraumbilical region, more so
the abovenamed accused, DR. ANTONIO P.CABUGAO and DR. in the supra and right paraumbilical areas.
CLENIO YNZON, being then the attending physicians of one
RODOLFO PALMA, JR., a minor 10 years old, confederating There is a vague elongated hypoechoic focus in the right
and acting jointly with one another, did, then and there, willfully, periumbilical region roughly about 47 x 18 mm surrounded by
unlawfully and feloniously fail through negligence, carelessness undistended gasfilled bowels. This is suggestive of an
and imprudence to perform immediate operation upon their inflammatory process wherein appendiceal or periappendiceal
patient, RODOLFO PALMA, JR. of acute appendicitis, when pathology cannot be excluded. Clinical correlation is essential."6
they, the said physicians, should have been done so considering
that examinations conducted upon their patient Rodolfo Palma, Jr.
seriously manifest todo so, causing by such negligence,
carelessness, and imprudence the victim, RODOLFO PALMA Dr. Cabugao did a rectal examination noting the following:
JR., to die due to: "rectal: good sphincter, negative tenderness, negative mass." The
initial impression was Acute Appendicitis,7 and hence, he
"CARDIORESPIRATORY ARREST, METABOLIC referred the case to his coaccused, Dr. Ynzon, a surgeon.8 In the
ENCEPHALOPATHY, SEPTICEMIA (ACUTE later part of the morning of June 15, 2000, Dr. Ynzon went to the
APPENDICITIS), CEREBRAL ANEURYSM RUPTURED (?)" hospital and readthe CBC and ultrasound results. The
administration of massive antibiotics and pain reliever to JRwere
As per Certificate of Death issued by accused Dr. Antonio P. ordered. Thereafter, JR was placed on observation for twentyfour
Cabugao, to the damage and prejudice of the legal heirs of said (24) hours.
deceased RODOLFO PALMA, JR. and other consequential
damages relative thereto. In the morning of June 16, 2000, JR complained again of
abdominal pain and his parents noticeda swelling in his scrotum.
In the afternoon of the same day, JR vomitted out greenish stuff
three (3) times and had watery bowels also three (3) times. The
nurses onduty relayed JR's condition to Dr. Ynzon who merely
CONTRARY to Article 365, 1st par. of the Revised Penal Code.
gaveorders via telephone.9 Accused continued medications to
Dagupan City, Philippines, January 29, 2001.
alleviate JR's abdominal spasms and diarrhea. By midnight, JR
again vomitted twice, had loose bowel movements and was
unable to sleep. The following morning, June 17,2000, JR's
condition worsened, he had a running fever of 38°C. JR's fever
Arising from the same events, the Court resolved to consolidate remained uncontrolled and he became unconscious, he was given
these cases.4 The facts, as culled from the records, are as follows: Aeknil (1 ampule) and Valium (1 ampule). JR's condition
continued to deteriorate that by 2 o'clock in the afternoon, JR's
temperature soared to 42°C, had convulsions and finally died.
The Death Certificate10 dated June 19, 2000 prepared by Dr. which necessitated personal, not delegated, attention of attending
Cabugao indicated the following causes of death: Immediate physicians, namely JR and the accused in this case.
cause: CARDIORESPIRATORY ARREST
Throughout the course of the hospitalization and treatment of JR,
Antecedent cause: METABOLIC ENCEPHALOPATHY the accused failed to address the acute appendicitis which was the
Underlying cause: SEPTICEMIA (ACUTE APPENDICITIS) initial diagnosis. They did not take steps to find out if indeed
acute appendicitis was what was causing the massive infection
that was ongoing inside the body of JR even when the
inflammatory process was located at the paraumbilical region
Other significant conditionscontributing to death: where the appendix can be located. x x x

CEREBRAL ANEURYSM RUPTURED (?) There may have been other diseases but the records do not show
that the accused took steps to find outwhat disease exactly was
plaguing JR. It was their duty to find out the disease causing the
health problem of JR, but they did not perform any process of
No postmortem examination was conducted on JR. On February elimination. Appendicitis, according to expert testimonies, could
1, 2001, an Information was filed against accused for reckless be eliminated only by surgery but no surgery was done by the
imprudence resulting to homicide. At their arraignment, both accused. But the accused could not have found out the real disease
accused, duly assisted by counsel, pleaded not guilty to the of JR because they were treating merely and exclusively the
charge. symptoms by means of the different medications to arrest the
manifested symptoms. In fact, by treating the symptoms alone, the
accused were recklessly and wantonly ignoring the same as signs
of the graver health problem of JR. This gross negligence on the
On February 28, 2003, in convicting both the accused, the trial part of the accused allowed the infection to spread inside the body
court found the following circumstances as sufficient basis to of JR unabated. The infection obviously spread so fastand was so
conclude that accused were indeed negligent in the performance massive that within a period of only two and a half (2 1⁄2) days
of their duties: from the day of admission to the hospital on June 15, 2000, JR
who was otherwise healthy died [of] Septicemia (Acute
Appendicitis) on June 17, 2000.11

It is unquestionable that JR was under the medical care of the

accused from the time of his admission for confinement at the
Nazareth General Hospital until his death. Upon his admission, On June 4, 2004, in affirming the accused' conviction, the Court
the initial working diagnosis was to consider acute appendicitis. of Appeals gave similar observations, to wit:
To assist the accused in the consideration of acute appendicitis,
Dr. Cabugao requested for a complete blood count (CBC) and a
diagnostic ultrasound on JR. The findings of the CBC and
ultrasound showed that an inflammatory process or infection was The foregoing expert testimony clearly revealed such want of
going on inside the body of JR. Said inflammatory process was reasonable skill and care on the part of JR's attending physicians,
happening in the periumbilical region where the appendix could appellants Dr. Cabugao and Dr. Ynzon in neglecting to monitor
be located. The initial diagnosis of acute appendicitis appears to effectively and sufficiently the developments/changes during the
be a distinct possibility. x x x. observation period and act upon the situation after said 24hour
period when his abdominal pain subsisted, his condition even
worsened with the appearance of more serious symptoms of
nausea, vomiting and diarrhea. Considering the brief visit only
Dr. Ynzon ordered medications to treat the symptoms being made on regular rounds, the records clearly show such gross
manifested by JR. Thereafter, he ordered that JR be observed for negligence in failing to take appropriate steps to determine the
24 hours. However, the accused, as the attending physicians, did real cause of JR's abdominal pain so that the crucial decision to
not personally monitor JR in order to check on subtle changes that perform surgery (appendectomy) had even been ruled out
may occur. Rather, they left the monitoring and actual observation precisely because of the inexcusable neglect to undertake
to resident physicians who are just on residency training and in suchefficient diagnosis by process of elimination, as correctly
doing so, they substituted their own expertise, skill and pointed out by the trial court. As has been succinctly emphasized
competence with those of physicians who are merely new doctors by Dr. Mateo, acute appendicitis was the working diagnosis, and
still on training. Not having personally observed JR during this with the emergence of symptoms after the 24hour observation
24hour critical period of observation, the accused relinquished (high fever, vomiting, diarrhea) still, appellants ruled out surgery,
their duty and thereby were unable to give the proper and correct not even considering exploratory laparoscopy. Dr. Mateo also
evaluation as to the real condition of JR. In situations where expressed the opinion that the decision to operate could have been
massive infection is going on as shown by the aggressive made after the result of the ultrasound test, considering that acute
medication of antibiotics, the condition of the patient is serious
appendicitis was the initial diagnosis by Dr. Cabugao after he had WHETHER THE SUBJECT INFORMATION APPEARS TO
conducted a rectal examination. HAVE ACCUSED BOTH ACCUSED DOCTORS OF
CONSPIRACY AND THE APPEALED DECISION SEEMS TO
HAVE TREATED BOTH ACCUSED DOCTORS TO BE IN
CONSPIRACY;
Medical records buttress the trial court's finding that in treating
JR, appellants have demonstrated indifference and neglect of the
patient's condition as a serious case. Indeed, appendicitis remains
a clinical emergencyand a surgical disease, as correctly III
underscored by Dr. Mateo, a practicing surgeon who has already
performed over a thousand appendectomy. In fact, appendectomy
is the only rational therapy for acute appendicitis; it avoids
clinical deterioration and may avoid chronic or recurrent WHETHER PETITIONER DR. CABUGAO IS A GENERAL
appendicitis. Although difficult, prompt recognition and PRACTITIONER (NOT A SURGEON) AND HAVE
immediate treatment of the disease prevent complications. Under EXCLUDED SURGERY FROM THE LIMITS OFHIS
the factual circumstances, the inaction, neglect and indifference of PRACTICE, AND IT WAS NOT AND NEVER HIS DUTY TO
appellants who, after the day of admission and after being OPERATE THE PATIENT RODOLFO PALMA JR., THAT
apprised of the ongoing infection from the CBC and initial WAS WHY HE REFERRED SUBJECT PATIENT TO A
diagnosis as acute appendicitis from rectal examination and SURGEON, DR. CLENIO YNZON;
ultrasound testand only briefly visited JR once during regular
rounds and gave medication orders by telephone – constitutes
gross negligenceleading to the continued deterioration of the
patient, his infection having spread in sofast a pace that he died
IV
within just two and a half (2 1⁄2) days’ stay inthe hospital.
Authorities state that if the clinical picture is unclear a short
period of 4 to 6 hours of watchful waiting and a CT scan may
improve diagnostic accuracy and help to hasten diagnosis.Even
assuming that JR's case had an atypical presentation in view of the WHETHER THE DEFENSE NEVER STATED THAT THERE
location of his appendix, laboratory tests could have helped to IS GUARANTEE THAT DOING SURGERY WOULD HAVE
confirm diagnosis, as Dr. Mateo opined thatthe possibility of JR SAVED THE PATIENT;
having a retrocecal appendicitis should have been a strong
consideration. Lamentably, however, as found by the trial court,
appellants had not taken steps towards correct diagnosis and
demonstrated laxity even when JR was already running a high V
fever in the morning of June 17, 2000 and continued vomiting
with diarrhea, his abdominal pain becoming more intense. This is
the reason why private complainants were not even apprised of
the progress of appellants' diagnosis – appellants have nothing to WHETHER THE WITNESSES FOR THE PROSECUTION
report because they did nothing towards the end and merely gave INCLUDING PROSECUTION'S EXPERT WITNESSES EVER
medications to address the symptoms.12 DECLARED/TESTIFIED THAT PETITIONER DR. CABUGAO
HAD THE DUTY TO PERFORM IMMEDIATE OPERATION
ON RODOLFO PALMA, JR., AND THEY FAILED TO
STATE/SHOW THAT THE PROXIMATE CAUSE OF DEATH
Thus, these appeals brought beforethis Court raising the following OF JR WAS ACUTE APPENDICITIS;
arguments: I

VI
WHETHER THE CAUSE OF ACCUSATION AS CONTAINED
IN THE INFORMATION IS "FAILURE TO PERFORM
IMMEDIATE OPERATION UPON THE PATIENT ROFOLFO
PALMA JR. OF ACUTE APPENDICITIS; WHETHER THE EXPERT WITNESSES PRESENTED BY
THE PROSECUTION EVER QUESTIONED THE
MANAGEMENT AND CARE APPLIED BY PETITIONER DR.
CABUGAO;
II

VII
person performing or failing to perform such act.13 The elements
of reckless imprudence are: (1) that the offender does or fails to
WHETHER THE EXPERT WITNESSES PRESENTED BY do an act; (2) that the doing or the failure to do that act is
THE DEFENSE ARE UNANIMOUS IN APPROVING THE voluntary; (3) that it bewithout malice; (4) that material damage
METHOD OF TREATMENT APPLIED BY BOTH ACCUSED results from the reckless imprudence; and (5) that there is
DOCTORS ON SUBJECT PATIENT, AND THEY inexcusable lack of precaution on the part of the offender, taking
DECLARED/AFFIRMED THAT THEY WOULD FIRST into consideration his employment or occupation, degree of
PLACE SUBJECT THE PATIENT UNDER OBSERVATION, intelligence, physical condition, and other circumstances
AND WOULD NOT PERFORM IMMEDIATE OPERATION; regarding persons, time and place.14

VIII With respect to Dr. Ynzon, all the requisites of the offense have
been clearly established by the evidence on record. The court a
quoand the appellate court were one in concluding that Dr. Ynzon
failed to observe the required standard of care expected from
doctors.
WHETHER THE CONVICTION OF PETITIONER DR.
YNZON WAS ESTABLISHED WITH THE REQUIRED
In the instant case, it was sufficiently established that to prevent
QUANTUM OF PROOF BEYOND REASONABLE DOUBT
certain death, it was necessary to perform surgery on JR
THAT THE PATIENT WAS SPECIFICALLY SUFFERING
immediately. Even the prosecution’s own expert witness, Dr.
FROM AND DIED OF ACUTE APPENDICITIS; and
Antonio Mateo,15 testified during crossexamination that he would
perform surgery on JR:

IX

ATTY. CASTRO:

WHETHER THE FAILURE TO CONDUCT THE SPECIFIC

SURGICAL OPERATION KNOWN AS APPENDECTOMY
Q. Given these data soft nontender abdomen, ambulatory, watery
CONSTITUTED CRIMINAL NEGLIGENCE.
diarrhea, Exhibit C which is the ultrasound result, with that
laboratory would you operate the patient?

In a nutshell, the petition brought before this Court raises the issue
of whether or not petitioners' conviction of the crime of reckless
A Yes, I would do surgery.
imprudence resulting in homicide, arising from analleged medical
malpractice, is supported by the evidence on record.

Q And you should have done surgery with this particular case?"
Worth noting is that the assigned errors are actually factual in
nature, which as a general rule, findings of factof the trial court
and the Court of Appeals are binding and conclusiveupon this
Court, and we will not normally disturb such factual findings A Yes, sir.16
unless the findings of the court are palpably unsupported by the
evidence on record or unless the judgment itself is based on
misapprehension of facts. Inthe instant case, we find the need to
make certain exception. xxxx

AS TO DR. YNZON'S LIABILITY: COURT:

Reckless imprudence consists of voluntarily doing or failing to Q You stated a while ago doctor thatyou are going to [do] surgery
do, without malice, an act from which material damage results by to the patient, why doctor, if you are notgoing to do surgery, what
reason of an inexcusable lack of precautionon the part of the will happen?
Q. So, are you saying more than 24 hours when there are
changes?
A If this would be appendicitis, the usual progress would be that it
would be ruptured and generalized peritonitis and eventually
septicemia, sir.
A. If there are changes in the patient pointing towards
appendicitis then you have to decide right there and then, sir.

Q What do you mean by that doctor?

Q. So if there are changes in the patient pointing to appendicitis?

A That means that infection would spread throughout the body, A. It depends now on what you are trying to wait for in the
sir. observation period, sir.

Q If unchecked doctor, what will happen? Q. So precisely if the change is a condition which bring you in
doubt that there is something else other than appendicitis, would
you extend over a period of 24 hours?

A It will result to death.17

A. It depends on the emergent development, sir.

xxxx

Q. That is the point, if you are the attending physician and there is
a change not pointing to appendicitis, would you extend over a
period of 24 hours?
Q And what would have you doneif you entertain other
considerations from the time the patient was admitted?

A. In 24 hours you have to decide, sir. xxxx

A From the time the patient was admitted until the report of the
sonologist, I would have made a decision by then.

Q. And that is based on the assessment of the attending physician?

A. Yes, sir.18
Q And when to decide the surgery would it be a particular exact
Dr. Mateo further testified on crossexamination:
time, would it be the same for all surgeons?

ATTY. CASTRO:

A If you are asking acute appendicitis, it would be about 24 hours

because acute appendicitis is a 24hour disease, sir.
Q: So you will know yourself, as far as the record is concerned,
because if you will agree with me, you did not even touch the
patient?

Q. And would it be correct to say that it depends on the changes

on the condition of the patient?

A. Yes, I based my opinion on what is put on record, sir. The

records show that after the observation period, the abdominal pain
is still there plus there are already other signs and symptoms
A. Yes, sir.
which are not seen or noted.
Q. But insofar as you yourself not having touched the abdomen of
the patient, would you give a comment on that?
A. Yes, now that I have seen the records of the patient, it says
here, impression and T/C means to consider the appendicitis.

A. Yes, based on the record, after 24 hours of observation, the

pain apparently was still there and there was more vomiting and
there was diarrhea. In my personal opinion, I think the condition Q. Isn't it that it is worth then to say that the initial working
of the patient was deteriorating. diagnosis on Rodolfo Palma, Jr., otherwise known as JR, to whom
I shall now refer to as JR, the primary consideration then is acute
appendicitis, is that correct to say Doctor?

Q. Even though you have not touched the patient?

A. I think so, that is the impression.

A. I based on what was on the record, sir.19

Q. x x x Now if it is to be considered as the primary consideration

in the initial working diagnosis, isn't it a fact that it has tobe ruled
From the foregoing, it is clear that if JR’s condition remained out in order to consider it as not the disease of JR?
unchecked it would ultimately result in his death, as what actually
happened in the present case. Another expert witness for the
defense, Dr. Vivencio Villaflor, Jr. testified on direct examination
that he would perform a personal and thorough physical A. Yes. Sir.
examination of the patient as frequent as every 4 to 6 hours, to
wit:

Q. Isn't it a fact thatto rule out acute appendicitis as not the

disease of JR, surgery or operation must be done, isn't it Doctor?
ATTY. CASTRO:

A. You have to correlate all the findings. Q. Is it yes or no,

Q. As an expert doctor, if you were faced with a history of Doctor?
abdominal pain with nausea, vomiting, fever, anurecia (sic),
elevated white blood cell count, physical examination of a A. Yes
positive psoas sign, observation of the sonologist of abdominal
tenderness and the ultrasound findings of the probability of
appendiceal (sic) pathology, what will you do if you have faced
these problems, Doctor?

Q. So, you are saying then that in order to rule out acute
appendicitis there must be an operation, that is right Doctor?
A. I will examine the patient thoroughly and it will depend on my
physical examination and that isprobably every 4 to 6 hours,
sir.20
A. No, sir. If your diagnosis is toreally determine if it is an acute
appendicitis, you have to operate.21

On crossexamination, Dr. Villaflor affirmed: Cross Exam. By

Atty. Marteja:
xxxx

Q. x x x However, there are corrections and admissions made at

that time, your Honor, do I understand thatT/C does not mean
Q. Now Doctor, considering the infection, considering that there
ruled out but rather to consider the matter?
was a [symptom] that causes pain, considering that JR likewise
was feverish and that he was vomiting, does that not show a Among the elements constitutive of reckless imprudence, what
disease of acute appendicitis Doctor? perhaps is most central to a finding of guilt is the conclusive
determination that the accused has exhibited, by his voluntary act
without malice, an inexcusable lack of precaution. It is that which
supplies the criminal intent so indispensable as tobring an act of
A. Its possible. mere negligence and imprudence under the operation of the penal
law. This is because a conscious indifference to the consequences
of the conduct is all that is required from the standpoint of the
frame of mind of the accused.24 Quasioffenses penalize the
mental attitudeor condition behind the act, the dangerous
Q. So that if that is possible, are we getting the impression then
recklessness, the lack of care or foresight, the "imprudencia
Doctor what you have earlier mentioned that the only way to rule
punible," unlike willful offenses which punish the intentional
out the suspect which is acute appendicitis is by surgery, you have
criminal act.25 This is precisely where this Court found Dr.
said that earlier Doctor, I just want any confirmation of it?
Ynzon to be guilty of his seemingly indifference to the
deteriorating condition of JR that he as a consequence, failed to
exercise lack of precaution which eventually led to JR's death.

A. Yes, sir.22

To be sure, whether or not a physician has committed an

"inexcusable lack of precaution" in the treatment of his patient is
Verily, whether a physician or surgeon has exercised the requisite to be determined according to the standard of care observed by
degree of skill and care in the treatment of his patient is, in the other members of the profession in good standing under similar
generality of cases, a matter of expert opinion. The deference of circumstances bearing in mind the advanced state of the
courts to the expert opinions of qualified physicians stems from profession at the time of treatment or the present state of medical
its realization that the latter possess unusual technical skills which science. In accepting a case, a doctor in effect represents that,
laymen in most instances are incapable of intelligently having the needed training and skill possessed by physicians and
evaluating.23 From the testimonies of the expert witnesses surgeons practicing in the same field, he will employ such
presented, it was irrefutably proven that Dr. Ynzon failed to training, care and skill in the treatment of his patients. He,
practice that degree of skill and care required in the treatment of therefore, has a duty to use at least the same level of care that any
his patient. other reasonably competent doctor would use to treat a condition
under the same circumstances.26 Sadly, Dr. Ynzon did not
display that degree of care and precaution demanded by the
circumstances.
As correctly observed by the appellate court, Dr. Ynzon revealed
want of reasonable skill and care in attending to the needs of JR
by neglecting to monitor effectively the developmentsand changes
on JR's condition during the observation period, and to act upon AS TO DR. CABUGAO'S LIABILITY:
the situation after the 24hour period when his abdominal pain
persisted and his condition worsened. Lamentable, Dr. Ynzon
appeared to have visited JRbriefly only during regular rounds in
the mornings. He was not there during the crucial times on June
Every criminal conviction requires of the prosecution to prove
16, 2000 when JR's condition started to deteriorate until JR's
two things — the fact of the crime, i.e., the presence of all the
death. As the attending surgeon, he should be primarily
elements of the crime for which the accused stands charged, and
responsible in monitoring the condition of JR, as he is in the best
the fact that the accused is the perpetrator of the crime. Based on
position considering his skills and experience to know if the
the above disquisitions, however, the prosecution failed to prove
patient's condition had deteriorated. While the residentdoctors-
these two things. The Court is not convinced with moral certainty
onduty could likewise monitor the patient’scondition, he is the
that Dr. Cabugao isguilty of reckless imprudence as the elements
one directly responsible for the patient as the attending surgeon.
thereof were not proven by the prosecution beyond a reasonable
Indeed, it is reckless and gross negligence of duty to relegate his
doubt.
personal responsibility to observe the condition of the patient.
Again, acute appendicitis was the working diagnosis, and with the
emergence of graver symptoms after the 24hour observation, Dr.
Ynzon ruled out surgery for no apparent reason. We, likewise,
note that the records are devoid of showing of any reasonable Both the trial court and the appellate court bewail the failure to
cause which would lead Dr. Ynzon tooverrule appendectomy perform appendectomy on JR, or the failure to determine the
despite the initial diagnosis of appendicitis. Neitherwas there any source of infection which caused the deterioration of JR's
showing that he was entertaining another diagnosis nor he took condition. However, a review of the records fail to show that Dr.
appropriate steps towards another diagnosis. Cabugao is in any position to perform the required appendectomy.
Immediately apparent from a review of the records of this case is circumstances he did not have any cause to doubt Dr. Ynzon’s
the fact that Dr. Cabugao is not a surgeon,but a general competence and diligence. Expert testimonies have been offered
practitioner specializing in family medicine;27 thus, even if he to prove the circumstances surrounding the case of JR and the
wanted to, he cannot do an operation, much less an appendectomy need to perform an operation. Defense witness, Dr. Villaflor, on
on JR. It is precisely for this reason why he referred JR to Dr. cross examination testified, to wit:
Ynzon after he suspected appendicitis. Dr. Mateo, the
prosecution’s expert witness, emphasized the role of the surgeon
during direct examination, to wit:
Q. Isn't it a fact that torule out acute appendicitis as notthe disease
of JR, surgery or operation mustbe done, isn't it Doctor?

ATTY. MARTEJA:

A. You have to [correlate] all the findings.

Q. You had mentioned that under this circumstances and

condition, you have mentioned that surgery is the solution, would
you have allowed then a 24 hour observation? Q. Is it yes or no, Doctor?

A. If there is a lingering doubt, inshort period of observation of A. Yes.

1824 hours can be allowed provided that there would be close
monitoring of the patient, sir.

Q. So, you are saying then that in order to rule out acute
appendicitis there must be an operation, that is right Doctor?
Q. Would you please tell us who would be doing the monitoring
doctor? A. The best person should be the first examiner, the best
surgeon, sir.
A. No, sir. If your diagnosis is to really determine if it is an acute
appendicitis, you have to operate.29

Q. So that would you say that it is incumbent on the surgeon

attending to the case to have been the one to observe within the
period of observation?
xxxx

A. Yes, because he will be in the best position to observe the

Q. Now Doctor, considering the infection, considering that there
sudden changes in the condition of the patient, sir.
was a [symptom] that causes pain, considering that JR likewise
was feverish and that he was vomitting, does that not show a
disease of acute appendicitis Doctor?

Q. And how often would in your experience doctor, how often

would the surgeon reassist (sic) the condition of the patient during
the period of observation?
A. It’s possible.

A. Most foreign authors would recommend every four (4) hours,

Q. So that if that is possible, are we getting the impression then
some centers will recommend hourly or every two hours but here
Doctor what you have earlier mentioned that the only way to rule
in the Philippines, would recommend for 4 to 6 hours, sir.28
out the suspect which is acute appendicitis is by surgery, you have
said that earlier Doctor, I just want any confirmation of it?

Dr. Cabugao’s supervision does not cease upon his endorsement

of his patient to the surgeon. Here, Dr. Cabugao has shown to
A. Yes, sir.30
have exerted all efforts to monitor his patient and under these
based solely thereon. As opined by Justice Regalado, in this
regard, "the death of the accused prior to final judgment
Neither do we find evidence that Dr. Cabugao has been negligent terminates his criminal liability and only the civil liability directly
or lacked the necessary precaution in his performance of his duty arising from and based solely on the offense committed, i.e.,civil
as a family doctor. On the contrary, a perusal ofthe medical liability ex delictoin senso strictiore."
records would show that during the 24hour monitoring on JR, it
was Dr. Cabugao who frequently made orders on the
administration of antibiotics and pain relievers. There was also
repetitive instructions from Dr. Cabugao to refer JR to Dr. Ynzon 2. Corollarily, the claim for civil liability survives
as it appeared that he is suspecting appendicitis. The referral of JR notwithstanding the death of accused, if the same may also be
to Dr. Ynzon, a surgeon, is actually an exercise of precaution as predicated on a source of obligation other than delict. Article
he knew that appendicitis is not within his scope of expertise. This 1157 of the Civil Code enumerates these other sources of
clearly showed that he employed the best of his knowledge and obligation fromwhich the civil liability may arise as a result of the
skill in attending to JR's condition, even after the referral of JR to same act or omission:
Dr. Ynzon. To be sure, the calculated assessment of Dr. Cabugao
to refer JRto a surgeon who has sufficient training and experience
to handle JR’s case belies the finding that he displayed
inexcusable lack of precaution in handling his patient.31
a) Law

b) Contracts

We likewise note that Dr. Cabugao was out of town when JR's c) Quasicontracts d) x x x x x x x x x e) Quasidelicts
condition began to deteriorate. Even so, before he left, he made
endorsement and notified the residentdoctor and nursesonduty
that he will be on leave.
3. Where the civil liability survives, as explained in Number 2
above, an action for recovery therefor may be pursued but only by
way of filing a separate civil action and subject to Section 1, Rule
Moreover, while both appeared to be the attending physicians of 111 of the 1985 Rules on Criminal Procedure as amended. This
JR during his hospital confinement, it cannot be said that the separate civil action may be enforced either againstthe
finding of guilt on Dr. Ynzon necessitates the same finding on the executor/administrator or the estate of the accused, depending on
coaccused Dr. Cabugao. Conspiracy is inconsistent with the idea the source of obligation upon which the same is based as
of a felony committed by means of culpa.32 Thus, the accused- explained above.
doctors to be found guilty of reckless imprudence resulting in
homicide, it must be shown that both accuseddoctors
demonstratedan act executed without malice or criminal intent –
but with lack of foresight, carelessness, or negligence.
4. Finally, the private offended party need not fear a forfeiture of
Noteworthy, the evidence on record clearly points to the reckless
his right to file this separate civil action by prescription, in cases
imprudence of Dr. Ynzon; however, the same cannot be said in
where during the prosecution of the criminal action and prior to
Dr. Cabugao's case.
its extinction, the privateoffended party instituted together
therewith the civil action. In such case, the statute of limitationson
the civil liability is deemed interrupted during the pendency of the
criminal case, conformably with provisions of Article 1155 of the
AS TO CIVIL LIABILITY Civil Code, that should thereby avoid any apprehension on a
possible privation of right by prescription.35

While this case is pending appeal, counsel for petitioner Dr.

Ynzon informed the Court that the latter died on December 23, In view of the foregoing, it is clear that the death of the accused
2011 due to "multiorgan failure" as evidenced by a copy of death Dr. Ynzon pending appeal of his conviction extinguishes his
certificate.33 Thus, the effect of death, pending appeal of his criminal liability. However, the recovery of civil liability subsists
conviction of petitioner Dr. Ynzon with regard to his criminal and as the same is not based on delictbut by contract and the reckless
pecuniary liabilities should be in accordance to People v. imprudence he was guilty of under Article 365 of the Revised
Bayotas,34 wherein the Court laid down the rules in case the Penal Code.1 â w p h i1 For this reason, a separate civil action
accused dies prior to final judgment: may be enforced either against the executor/administrator or the
estate of the accused, depending on the source of obligation upon
which the same is based,36 and in accordance with Section 4,
Rule 111 of the Rules on Criminal Procedure, we quote:
1. Death of the accused pending appeal of his conviction
extinguishes his criminal liability as well as the civil liability
Sec. 4. Effect of death on civil actions. – The death of the accused Section 5. Claims which must be filed under the notice. If not
after arraignment and during the pendency of the criminal action filed, barred; exceptions. — All claims for money against the
shall extinguish the civil liability arising from the delict. decent, arising from contract, express or implied, whether the
However, the independent civil action instituted under section 3 same be due, not due, or contingent, all claims for funeral
of this Rule or which thereafter is instituted to enforce liability expenses and expense for the last sickness of the decedent, and
arising from other sources of obligation may be continued against judgment for money against the decent, must be filed within the
the estate or legal representative of the accused after proper time limited in the notice; otherwise they are barred forever,
substitution or against said estate, as the case may be. The heirs of except that they may be set forth as counterclaims in any action
the accused may besubstituted for the deceased without requiring that the executor or administrator may bring against the claimants.
the appointment of an executor or administrator and the court may Where an executor or administrator commencesan action, or
appoint a guardian ad litem for the minor heirs. prosecutes an action already commenced by the deceased in his
lifetime, the debtor may set forth by answer the claims he has
against the decedent, instead of presenting them independently to
the court as herein provided, and mutual claims may be set off
The court shall forthwith order said legal representative or against each other in such action; and if final judgment is
representatives to appear and be substituted within a period of rendered in favor of the defendant, the amount so determined
thirty (30) days from notice. shall be considered the true balance against the estate, as though
the claim had been presented directly beforethe court in the
administration proceedings. Claims not yet due, or contingent,
may be approved at their present value.
A final judgment entered in favor of the offended party shall be
enforced in the manner especially provided in these rules for
prosecuting claims against the estate of the deceased.
As a final note, we reiterate thatthe policy against double recovery
requires that only one action be maintained for the same act or
omission whether the action is brought against the executor or
administrator, or the estate.39 The heirs of JR must choose which
If the accused dies before arraignment, the case shall be dismissed
of the available causes of action for damages they will bring.
without prejudice to any civil action the offended party may file
against the estate of the deceased. (Emphases ours)

WHEREFORE, premises considered, petitioner DR. ANTONIO

P. CABUGAO is hereby ACQUITTEDof the crime of reckless
In sum, upon the extinction of the criminal liability and the
imprudence resulting to homicide.
offended party desires to recover damages from the same act or
omission complained of, the party may file a separate civil action
based on the other sources of obligation in accordance with
Section 4, Rule 111.37 If the same act or omission complained of
arises from quasi delict,as in this case, a separate civil action must Due to the death of accused Dr. Clenio Ynzon prior to the
be filed against the executor or administrator of the estate of the disposition of this case, his criminal liability is extinguished;
accused, pursuant to Section 1, Rule 87 of the Rules of Court:38 however, his civil liability subsists. A separate civil action may be
filed either against the executor/administrator, or the estateof Dr.
Ynzon, depending on the source of obligation upon which the
same are based.
Section 1. Actions which may and which may not be brought
against executor or administrator. — No action upon a claim for
the recovery of money or debtor interest thereon shall be
commenced against the executor or administrator; but to recover PEDRITO DELA TORRE, PETITIONER, VS. DR.
real or personal property, or an interest therein, from the estate, or ARTURO IMBUIDO, DRA. NORMA IMBUIDO in their
to enforce a lien thereon, and actions to recover damages for an capacity as owners and operators of DIVINE SPIRIT
injury to person or property, real or personal, may be commenced GENERAL HOSPITAL AND/OR DR. NESTOR PASAMBA,
against him. (Emphases ours) RESPONDENTS.

This resolves the petition for review on certiorari1 filed by

Conversely, if the offended party desires to recover damages from
petitioner Pedrito Dela Torre (Pedrito) assailing the Decision2
the same act or omission complained of arising from contract, the
dated December 15, 2009 and Resolution3 dated July 27, 2010 of
filing of a separate civil action must be filed against the estate,
the Court of Appeals (CA) in CA-G.R. CV No. 78534.
pursuant to Section 5, Rule 86 of the Rules of Court, to wit:
The case stemmed from a complaint4 for damages filed by
Pedrito against herein respondents Dr. Arturo Imbuido and Dr.
Norma Imbuido (Dr. Norma), in their capacity as the owners and
operators of the Divine Spirit General Hospital in Olongapo City,
and Dr. Nestor Pasamba (Dr. Nestor) (respondents). Pedrito
alleged in his complaint that he was married to one Carmen
Castillo Dela Torre (Carmen), who died while admitted at the
In their answer12 to the complaint, the respondents argued that
Divine Spirit General Hospital on February 13, 1992. Carmen was
they “observed the required standard of medical care in attending
due to give birth on February 2, 1992 and was brought at around
to the needs of Carmen.”13 The respondents explained that
11:30 p.m. on that day by Pedrito to the Divine Spirit General
Carmen was admitted in Divine Spirit General Hospital for
Hospital. When Carmen still had not delivered her baby at the
“pregnancy in labor and pre-eclampsia.” Her condition was
expected time, Dr. Norma discussed with Pedrito the possibility
closely monitored during her confinement. A caesarian section
of a caesarean section operation.5
operation became necessary, as she manifested no significant
progress for the spontaneous delivery of her baby.14 No unusual
events were observed during the course of Carmen’s caesarian
section operation. The second surgery, however, became
At around 3:00 p.m. on February 3, 1992, Carmen was brought to necessary due to suspected intestinal obstruction and adhesions.
the hospital’s operating room for her caesarian section operation, This procedure was fully explained to Carmen and Pedrito prior to
which was to be performed by Dr. Nestor. By 5:30 p.m. of the its conduct. During the second operation, the diagnosis of
same day, Pedrito was informed of his wife’s delivery of a baby intestinal obstruction and adhesion was confirmed but resolved by
boy. In the early morning of February 4, 1992, Carmen her doctors. Despite the observance of due care by the doctors,
experienced abdominal pain and difficulty in urinating. She was however, Carmen died on February 13, 1992.15
diagnosed to be suffering from urinary tract infection (UTI), and
was prescribed medications by Dr. Norma. On February 10, 1992,
Pedrito noticed that Carmen’s stomach was getting bigger, but Dr.
Norma dismissed the patient’s condition as mere flatulence
The respondents included in their answer a counterclaim for
(kabag).6
P48,515.58 as unpaid hospital charges, professional fees and
medicines, P3,000,000.00 for moral damages, P1,500,000.00 for
exemplary damages, and attorney’s fees.16

When Carmen’s stomach still grew bigger despite medications,

Dr. Norma advised Pedrito of the possibility of a second operation
on Carmen. Dr. Norma, however, provided no details on its
After the pre-trial conference, trial proper ensued. To support his
purpose and the doctor who would perform it. At around 3:00
claim, Pedrito presented the testimony of Dr. Patilano, the
p.m. on February 12, 1992, Carmen had her second operation.
medicolegal officer who conducted an autopsy on the body of
Later in the evening, Dr. Norma informed Pedrito that
Carmen upon a telephone request made by the City Health Officer
“everything was going on fine with [his] wife.”7
of Olongapo City, Dr. Generoso Espinosa. Among Dr. Patilano’s
observations, as narrated in the lower court’s decision, were as
follows:

The condition of Carmen, however, did not improve. It instead

worsened that on February 13, 1992, she vomited dark red blood.
At 9:30 p.m. on the same day, Carmen died.8 Per her certificate of
In the intestines, [Dr. Patilano] found out that it was more reddish
death upon information provided by the hospital, the immediate
than the normal condition which is supposed to be pinkish. There
cause of Carmen’s death was “cardio-respiratory arrest secondary
was presence of adhesions, meaning, it sticks to each other and
to cerebro vascular accident, hypertension and chronic nephritis
these areas were dilated. There were constricted areas. He
induced by pregnancy.”9 An autopsy report10 prepared by Dr.
concluded that there might have been foreign organic matters in
Richard Patilano (Dr. Patilano), Medico-Legal Officer-Designate
the intestines. He did not see any swelling but assuming that there
of Olongapo City, however, provided that the cause of Carmen’s
was, it would be concomitant to the enlargement. x x x He came
death was “shock due to peritonitis, severe, with multiple
to the conclusion that the cause of death was peritonitis, with the
intestinal adhesions; Status post C[a]esarian Section and
multiple adhesions status in the post caesarian section. In
Exploratory Laparotomy.”
connection with peritonitis, this is the inflammation of the
abdomen. This peritonitis in the abdominal cavity may be caused
by several conditions which are supposed to be infections,
entrance of foreign bodies in the intestines in connection with
Pedrito claimed in his complaint that the respondents “failed to ruptured peptic ulcer or [may be] somewhere in the spleen. The
exercise the degree of diligence required of them” as members of entrance of foreign object in the abdominal cavities may cause
the medical profession, and were “negligent for practicing surgery severe infections of the intra-abdominal cavities resulting [in]
on [Carmen] in the most unskilled, ignorant and cruel manner, x x multiple adhesions of the intestines. In cases of surgical operation,
x[.]”11 it [may be] due to the conditions of the instruments used, the
materials used in the operating room being not aseptic and the 2.) the sum of Fifty Thousand (Php 50,000.00) Pesos as indemnity
ladies assisting the operation were not in uniform. x x x.17 for the death of Carmen dela Torre;

3.) the sum of Fifty Thousand (Php 50,000.00) Pesos as moral

damages and the further sum of Twenty Thousand (Php
Dr. Patilano claimed that peritonitis could have been prevented 20,000.00) Pesos as exemplary damages;
through proper medical procedures and medicines. He also stated
that if the cause of Carmen’s death was actually cerebro-vascular
accident, there would have been ruptured blood vessels and blood
clot in her head; but there were none in Carmen’s case.18 4.) the sum of Twenty Thousand (Php 20,000.00) Pesos as
attorney’s fees; and 5.) the costs of [suit].

Among those who testified to refute Pedrito’s claim was Dr.

Nestor. He claimed that when Carmen was referred to him on SO ORDERED.25
February 3, 1992, she was in full term uterine pregnancy, with
pre-eclampsia, fetal distress and active labor pains. A caesarian
section operation became necessary to terminate the pregnancy
for her safety. Carmen was ready to go home four days after Dissatisfied with the RTC ruling, the respondents appealed to the
giving birth, but was advised by the doctors to stay more because CA. On December 15, 2009, the CA rendered its Decision
of her persistent hypertension.19 reversing and setting aside the decision of the RTC. For the
appellate court, it was not established that the respondents failed
to exercise the degree of diligence required of them by their
profession as doctors. The CA also granted the respondents’
The second surgery performed on Carmen was necessary after she counterclaim for the amount of P48,515.58, as it held:
showed symptoms of intestinal obstruction, which happens as the
intestines get twisted due to adhesions and the normal flow of
intestinal contents are obstructed. For Dr. Nestor, this occurrence
was not preventable since any interference of the abdominal WHEREFORE, the Decision of the Regional Trial Court of
cavity would irritate the serosa of the intestines, inviting Olongapo City dated January 28, 2003 in Civil Case No. 165-0-92
adhesions that could cause obstruction. Surgery could remedy the is hereby REVERSED AND SET ASIDE.
adhesions and obstruction.20 Both Carmen and Pedrito gave their
written consent to this second procedure.21

Dr. Bienvenido G. Torres (Dr. Torres), Chief of the Medico-Legal

Plaintiff-appellee is directed to pay the unpaid balance for
Division of the Philippine National Police (PNP) Crime
hospital bills, professional fees and other expenses in the amount
Laboratory Service,22 also testified for the respondents. He
of [P]48,515.58.
claimed that based on Dr. Patilano’s report, vital internal organs
of Carmen, such as her brain, lungs, kidneys, liver and adrenal
SO ORDERED.26
glands, were not examined during the autopsy.23

Hence, this petition for review on certiorari in which Pedrito

On January 28, 2003, the Regional Trial Court (RTC) of
insists that the respondents should be held liable for the death of
Olongapo City, Branch 75, rendered its Decision24 in favor of
Carmen.
Pedrito. The trial court gave greater weight to the testimony of Dr.
Patilano and thus disposed of the case as follows:

The petition is denied.

WHEREFORE, premises considered, judgment is hereby

rendered in favor of the plaintiff and against the defendants,
ordering the latter to pay jointly and severally, the former, the
following sums of money, to wit: “[M]edical malpractice or, more appropriately, medical
negligence, is that type of claim which a victim has available to
him or her to redress a wrong committed by a medical
professional which has caused bodily harm.” In order to
successfully pursue such a claim, a patient, or his or her family as
1.) the sum of Php 28,759.46 as actual damages;
in this case, “must prove that a health care provider, in most cases
a physician, either failed to do something which a reasonably
prudent health care provider would have done, or that he or she
did something that a reasonably prudent provider would not have her then unborn child. For lack of sufficient information on
done; and that failure or action caused injury to the The Court Carmen’s health condition while still alive, Dr. Patilano could not
emphasized in Lucas, et al. v. Tuaño28 that in medical negligence have fully evaluated the suitability of the respondents’ decisions
cases, there is a physician-patient relationship between the doctor in handling Carmen’s medical condition as it turned critical.
and the victim, but just like in any other proceeding for damages,
four essential elements must be established by the plaintiff,
namely: (1) duty; (2) breach; (3) injury; and (4) proximate
causation. All four elements must be present in order to find the On the other hand, the CA pointed out that Dr. Nestor, a surgeon,
physician negligent and, thus, liable for damages.29 possessed the reasonable degree of learning, skill and experience
required by his profession for the treatment of Carmen. The
respondents also emphasized in their pleadings before the RTC
that Dr. Nestor had his training and experience in surgery and
It is settled that a physician’s duty to his patient relates to his obstetrics since 1970. Without sufficient proof from the claimant
exercise of the degree of care, skill and diligence which on a different degree of care, skill and diligence that should be
physicians in the same general neighborhood, and in the same expected from the respondents, it could not be said with certainty
general line of practice, ordinarily possess and exercise in like that a breach was actually committed.
cases. There is breach of this duty when the patient is injured in
body or in health. Proof of this breach rests upon the testimony of
an expert witness that the treatment accorded to the patient failed
to meet the standard level of care, skill and diligence. To justify Moreover, while Dr. Patilano opined that Carmen died of
an award of damages, the negligence of the doctor must be peritonitis which could be due to the poor state of the hospital
established to be the proximate cause of the injury.30 equipment and medical supplies used during her operation, there
was no sufficient proof that any such fault actually attended the
surgery of Carmen, caused her illness and resulted in her death. It
is also significant that the Chief of the Medico-Legal Division of
Through the instant petition, Pedrito seeks the reinstatement of the the PNP Crime Laboratory Service, Dr. Torres, testified before
decision of the RTC whose finding of the respondents’ medical the trial court that based on the autopsy report issued by Dr.
negligence depended mainly on the testimony of Dr. Patilano. Patilano, the latter did not comply with the basic autopsy
Upon review, however, the Court agrees with the CA that the procedure when he examined the cadaver of Carmen. Dr. Patilano
report and testimony of Dr. Patilano failed to justify Pedrito’s did not appear to have thoroughly examined Carmen’s vital
entitlement to the damages awarded by the RTC. organs such as her heart, lungs, uterus and brain during the
autopsy. His findings were then inconclusive on the issue of the
actual cause of Carmen’s death, and the claim of negligence
allegedly committed by the respondents.
For the trial court to give weight to Dr. Patilano’s report, it was
necessary to show first Dr. Patilano’s specialization and
competence to testify on the degree of care, skill and diligence
needed for the treatment of Carmen’s case. Considering that it As the Court held in Spouses Flores v. Spouses Pineda, et al.,31
was not duly established that Dr. Patilano practiced and was an the critical and clinching factor in a medical negligence case is
expert in the fields that involved Carmen’s condition, he could not proof of the causal connection between the negligence and the
have accurately identified the said degree of care, skill, diligence injuries. The claimant must prove not only the injury but also the
and the medical procedures that should have been applied by her defendant’s fault, and that such fault caused the injury. A verdict
attending physicians. in a malpractice action cannot be based on speculation or
conjecture. Causation must be proven within a reasonable medical
probability based upon competent expert testimony,32 which the
Court finds absent in the case at bar.
Similarly, such duty, degree of care, skill and diligence were not
sufficiently established in this case because the testimony of Dr.
Patilano was based solely on the results of his autopsy on the
cadaver of Carmen. His study and assessment were restricted by As regards the respondents’ counterclaim, the CA’s award of
limitations that denied his full evaluation of Carmen’s case. He P48,515.58 is sustained, considering that among the parties’
could have only deduced from the injuries apparent in Carmen’s stipulations during the pre-trial indicated:
body, and in the condition when the body was examined. Judging
from his testimony, Dr. Patilano did not even take full
consideration of the medical history of Carmen, her actual health
condition at the time of hospital admission, and her condition as it 5. That at the time of the death of the patient Carmen C. dela
progressed while she was being monitored and treated by the Torre[,] there was an unpaid balance for hospital bills,
respondents. There was also no reference to the respondents’ professional fees and other expenses in the amount of P48,515.58,
defense that the emergency caesarian section operation had to be incurred by plaintiff when the patient was confined at said
performed in order to protect the lives and safety of Carmen and hospital from February 3 to 13, 1992.33
DR. IDOL L. BONDOC, Petitioner,
WHEREFORE, the petition is DENIED. The Decision dated
December 15, 2009 and Resolution dated July 27, 2010 of the vs.
Court of Appeals in CA-G.R. CV No. 78534 are AFFIRMED.
MARILOU R. MANTALA, Respondent.

Before us is a petition for review on certiorari assailing the

Decision1 dated May 24, 2012 and Resolution2 dated August 14,
2012 of the Court of Appeals (CA) in CA-G.R. SP No. 120563.
The CA affirmed the Decision3 dated August 12, 2010 and
Order4 dated February 28, 2011 of the Office of the Deputy
Ombudsman for Luzon in OMB-L-A-09-0681-K.

The Facts

On November 6, 2009, Marilou R. Mantala (respondent) filed a

complaint for grave misconduct against Dr. Idol L. Bondoc
(petitioner), Medical Officer III at the Oriental Mindoro
Provincial Hospital (OMPH).

Respondent was admitted at the OMPH on April 3, 2009, at

around 11 :00 in the morning, with referral5 from the Bansud
Municipal Health Office (BMHO). She was due to deliver her
fifth child and was advised by the BMHO for a cesarean section
because her baby was big and there was excessive amniotic fluid
in her womb. She started to labor at 7:00 in the morning and was
initially brought tothe Bongabon Health Center. However, said
health center also told her to proceed directly to the hospital.

In her complaint-affidavit,6 respondent alleged that inside the

delivery room of OMPH, she was attended toby petitioner who
instructed the midwife and two younger assistants topress down
on respondent’s abdomen and even demonstrated to them how to
insert their fingers into her vagina. Thereafter, petitioner went out
of the delivery room and later, his assistants also left. As she
labored in pain, she felt the movement of her baby inside her
womb and the intermittent stiffening of her abdomen.

At about 4:00 in the afternoon, petitioner returned to the delivery

room and asked her, "Hindi ka pa nanganganak?" Since she could
no longer bear the pain, she requested petitioner to perform a
cesarean section but this was not done. The midwife arrived and
berated her for not yet sleeping and holding on to the steelbar.
The midwife and the younger assistants again pressed down on
her abdomen causing excruciating pain on her ribs and made her
very weak. They repeatedly did this pressing until the baby and
placenta came out. When she regained consciousness, she was
already at the recovery room. She learned that an operation was
performed on her by petitioner to removeher ruptured uterus but
what depressed her most was her stillborn baby and the loss of her
reproductive capacity. The next day, she was transferred to a
ward. She noticedher very swollen vulva and her surgical wound
open with liquid squirting from

it. Her wound was regularly cleaned by a nurse. On April 9, 2009,

she was discharged notwithstanding that the suture on her wound
needs to be fixed and she still has a cough. At home, she took the
antibiotics, cough medicine and multivitamins prescribed by her uterus probably ruptured in the process of childbirth. "Pinilit
petitioner. no’ng tatlong ungas, ayon lumusot pero patay ang bata, tapos ito,
mukhang pumutok," petitioner said.
After two days, the opening in her wound widened.Her husband
brought her to the Bongabon Community Hospital but they were Dr. Fabon immediately prepared respondent for General
advised to have her wound re-stitched by the samesurgeon Anesthesia; respondent was inducted at 8:35 p.m. while surgery
(petitioner) who operated on her. Thus, on April 14, 2009, began at 8:45 p.m. He continued to narrate what transpired next
theywent back to OMPH. She was attended to by a certain Dr. and his observations, as follows:
Gonzales who cleaned her wound which now has a lot of pus, and
the said doctor commented that "problema ito ni Bondoc." On That right after induction – when patient was asleep already and
April 18, 2009, after she was given blood transfusion, petitioner don’t feel any pain at all – her blood pressure suddenly dropped to
re-stitched her wound. Thereafter, it was Dr. Gonzales who 70/40 mmHg;
regularly checked on her condition.
That after opening the abdomen, I saw massive hemoperitonium
On April 27, 2009, petitioner removed the sutures but still left and the ruptured uterus with bleeding from various directions. I
open three of them. She wondered then why petitioner suddenly immediately requested for additional blood to be used intra-
showed kindness towards her. In the evening of April 28, 2009, operatively while at the same time I established another
petitioner talked to her and said in a threatening tone "Ikaw ang intravenous lineso as to cope with on-going surgical blood loss. I
sadyang ayaw magpa-cs" and also told her that he just came from had now three big-bore fast-dripping IV lines.
Pinamalayan and Bansud and already talked to Dr. Atienza and
Dr. Sales. Petitioner then told the nurse on duty, "Papirmahin mo That in spite of this measure,blood pressure dropped to 50/30
si Mantala, pauuwiin ko na ‘yan bukas. Tanggalin mo na rin ang mmHg. There was an instance wherein I cannot even appreciate
tahi." He further said, "huwag sana akong idemanda ni Mantala the blood pressure of the patient, her pulse hardly noticeable on
kasi kaya ko siyang baligtarin." The following day, she was palpation and she was very pale that necessitates turning the
discharged after the nurse had removed the remaining sutures. At anesthetic gas off so as to keep her alive. She was given a dose of
home, it was her sister who cleaned the still open wound. Joel F. Atropine after patientdid not respond to two 10mg doses of
Mantala, respondent’s husband, Ephedrine. I prescribed Dobutamine and Dopamine drips to help
improve her blood pressure and maintain adequate urine output.
and her sisters Mylen R. Amistad and Lucia Rala, executed their Unfortunately, only Dopamine was available. I had to use 100%
respective affidavits7 to corroborate her story. In addition, Oxygen at 3L/minute without mixture ofvolatile gas for several
respondent submitted the affidavit of Dr. Rosinico F. Fabon, the minutes. She was maintained using musclerelaxants alone on
anesthesiologist on duty during the operation performed by controlled ventilation.
petitioner on April 3, 2009.
That Dr. Bondoc operated on the patient all by himself without
Joel Mantala claimed that at the OMPH at around 2:30 in the the help of a consultant or an assistant surgeon. Nowhere in the
afternoon when her wife was still laboring, petitioner talked to patient chart will show that he referred this case tohis consultant;
him and told her that the baby is too big and if it comes out alive one thing that I was wondering why he was doing the surgery
it will probably be abnormal so that it would be better ifthe baby alone. He utilized the scrub nurse to assist him making a delicate
is stillborn. He further averred that despite the pleas of her wife and bloody surgery more bloody and difficult.
for a cesarean operation, petitioner insisted on a normal delivery
during which she almost died.8 That after Dr. Bondoc had removed the ruptured uterus and the
bleeding was controlled, he made intra-operative referral to Dr.
On the other hand, Dr. Fabon narrated that in the afternoon of Ariel
April 3, 2009, he was attending to a patient being operated on by
petitioner when he heard the latter saying that "meron pa nga Tria, a resident surgeon, to check on the urinary bladder and the
kami sa DR macrosomia, polyhydramnios pa, pero paanakin na ureters.
lang ‘yon, abnormal din naman ang bata kahit mabuhay, kawawa
lang siya." After the operation, petitioner went out of the That the operation performed was Subtotal Hysterectomy with
Operating Room (OR)and proceeded towards the direction of the Unilateral Salpingooophorectomy. I noticed that the operation
OB ward. At 5:35 in the afternoon, a Request for Surgery9 was technique was different from that which Dr. Bondoc had written
forwarded to the OR for Emergency Pelvic Laparotomy of in the Surgical Memo and that the patient did nottolerate the
respondent with a diagnosis of T/C Ruptured Uterus. procedure well.

When respondent was brought to the OR at 8:15 p.m., Dr. Fabon That the patient was very pale after the procedure with low blood
found her conscious but very weak and pale, with abdominal pain pressure due to massive blood loss. That her blood pressure
and started to improve at the Recovery Room but the pulse rate
remained considerably high for several hours. Her urine
tenderness on very slight palpation. He then heard from petitioner outputwas inadequate and that it had to be maintained using
himself that it was the same patient he was referring to earlier Dopamine.
with a diagnosis of macrosomia, polyhydramnios. Petitioner
volunteered that respondent had just delivered her baby but that
That when Leo Reyes, the Recovery Room nurse, referred the Petitioner blamed respondent for risking her own life in not
patient to me and I checked the urinary catheter, I noticed her seeking immediately a higher level of medical care and instead
vagina to be massively swollen with hematomas all over. preferring a TBA who is prohibited under a 2006 provincial
circular tohandle deliveries at home. He emphasized that upon
That the patient had to be referred to Internal Medicine for admission the fetal heart tone is no longer appreciated and
comanagement[.] maintained that diligent care was extended to respondent during
her stay at OMPH. As to the complications like cough and wound
dehiscence, he explained that these were the effects of anesthesia
and surgery (loss of blood, massive bloodtransfusion and
That Marilou Mantala stayed in the Recovery Room for almost intravenous fluid infusion), and also poor compliance
eleven (11) hours. She was transferred to Gyne Ward at 9:20 AM withprescribed medication. He further asserted that he had
the following day.10 referred the patient to other co-doctors on duty like Dr. Romy
Lomio (Internal Medicine) for co-management.
In his counter-affidavit,11 petitioner averred thatwhen respondent
was brought to OMPH with referral form from BMHO, she had On April 23, 2010, petitioner submitted a manifestation that he
been in labor for more than twelve (12) hours at home. He had resigned as Medical Officer of OMPH effective March 5,
submitted his admitting diagnosis of the patient, "Gravida 5 Parity 2010. He thus posited that the administrative case isnow rendered
4 (4004) Pregnancy Uterine 38 to 39 Weeks Age of Gestation by moot and academic.
Last Menstrual Period Cephalic in Labor; Macrosomia; Fetal
Death in Utero." On August 12, 2010, the Office of the Deputy Ombudsman for
Luzon rendered a Decision finding the petitioner administratively
Petitioner alleged that during his interview with respondent, the liable. It held that by fully entrusting to his subordinates the task
latter admitted to him that she doesn’t want tobe confined at any of handling respondent’s complicated delivery, petitioner
hospital because she was afraid to be handled by medical doctors. exhibited an improper or wrongful conduct and dereliction of duty
Instead, she went to a traditional birth attendant (TBA) or "hilot" as medical practitioner. Being the most competent person who
which she voluntarily named as Apolonia Salcedo, residing at should have rendered the appropriate medical service to
Dalapian, Labasan, Bongabon, Oriental Mindoro. Respondent respondent, petitioner should have personally attended to the
clearly defied the advice of Drs. Theresa Atienza and Mario Sales latter. Such action or inaction of his part amounts tointentional or
not to give birth at home. As to her swollen vulvar hematoma willful neglect in discharging his sworn duty as a government
which was noticed by Dr. Fabon, it was the result of prolonged physician which is also
labor.
equivalent to misconduct in office. The administrative case filed
As to the charge that he abandoned the respondent to his against the respondent is also not rendered moot by his
assistants, petitioner claimed that between 12 noonand 2:00 subsequent resignation in office.
o’clock in the afternoon, he was busy checking on pregnant
patients at the out-patient department (OPD) of OMPH until he The Decision of the OMB thus decreed:
was called for his first cesarean section (CS). Later at 4:00
o’clock, without resting and having lunch, he visited respondent WHEREFORE, judgment is hereby rendered finding respondent
and other admitted patients atthe Medical Officer Idol L. Bondoc of Oriental Mindoro Provincial
Hospital (OMPH), Barangay Ilaya, Calapan City, Oriental
delivery room. Together with the nurse on duty, Mrs. Evelyn D. Mindoro, guilty of Grave Misconduct.
Morales, petitioner said he explained to respondent her and her
baby’s condition based on the referral from BMHO Respondent Idol L. Bondocis hereby meted the penalty of
(polyhydramnios)and initial findings that her abdomen and baby DISMISSALin the Government Service pursuant to Section 10,
were big and the baby’s heartbeat is not appreciated. He presented Rule III, Administrative Order No. 07, as amended by
the respondent with two options: have a normal delivery or Administrative Order No. 17, in relation to Section 25 of Republic
undergo cesarean section, and the consequences of each choice. Act No. 6770. The penalty of dismissal shall carry with it that of
Respondent chose the former believing that she can handle this cancellation of eligibility, forfeiture of the retirement benefits, and
childbirth at home, and petitioner respected her decision. the perpetual disqualification for reemployment in the
government service pursuant to Section 58, Rule IV of the
After seeing other patients at the delivery room, petitioner was Uniform Rules on Administrative Cases in the Civil Service.
called for his second CS that day. Thus, he was obliged to proceed
to the OR and left the respondent under the care of three The Honorable Governor of the Province of Oriental Mindoro, is
assistants, one of whom is an experienced midwife. That he was hereby directed to implement this DECISION immediately upon
not the one who attended to the respondent during her delivery is receipt thereof pursuant to Section 7, Rule III of Administrative
confirmed by the statements of respondent herself, Dr. Fabon and Order No. 7, as amended by Administrative Order No. 17
Mrs. Morales. Further, petitioner claimed it has been a long-time (Ombudsman Rules of
practice at OMPH that whenever the doctor is at the OR, the
experienced midwives will take over the delivery of laboring
patients.
Procedure) in relation to Memorandum Circular No. 1, series of development aswell. However, increased levels of the fluid can
2006 dated 11 April 2006 and to promptly inform this Office of cause various complications during different stages of pregnancy
the action taken hereon. and childbirth.16Intra-amniotic pressureis markedly elevated in
most patients with severe hydramnios. The incidence of cesarean
SO DECIDED.12 section is also increased as a result of unstable lie and placental
abruption, which may occur with the rapid decrease in intrauterine
The foregoing ruling was affirmedby the CA and petitioner’s pressure that accompanies membrane rupture.17 One of the
motion for reconsideration was denied. known causes and risk factors of polyhydramniosis fetal
macrosomia (having a baby too large for the gestational age).18
The CA concurred that petitioner should have chosen to stay in
the delivery room and personally attend to the patient as he is the According to medical authorities,a macrosomic infant poses a
most competent person to render medical service in view of different set of complications. The incidences of shoulder
respondent’s critical condition. It likewise faulted the petitioner dystocia,19 birth injuries, perinatal death, and low Apgar scores
for deliberately leaving the laboring and unstable respondent tothe are increased in macrosomic infants.20 In these cases, careful
care of his inexperienced subordinates at the time she was about attention to the patient,
to give birth. As to petitioner’s excuse that he had to attend to an
equally important cesarean operation, the CA said there was no potential risk factors, clinical progress, and fetal size should
sufficient showing of the latter’s urgency and assuming it to be allow obstetricians to reduce the occurrence of maternaland
true, still, petitioner should have exerted efforts to refer neonatal morbidity.21 Vaginal delivery of the macrosomic infant
respondent’s case to another competent doctor or one of his is associated with anincreased incidence of birth trauma. The
consultants. question whether to perform cesarean section thus arises.22

Petitioner is now before this Court arguing that the CA erred in If the estimated fetal weight is 4000 to 4500 g by ultrasonography
affirming the Ombudsman’s ruling that he is guilty of grave and the patient has a clinically adequate pelvis, labor may be
misconduct and imposing on him the penalty of dismissal from allowed. If labor is protracted or the second stage is prolonged, a
the service. He reiterates that his failure to attend to respondent cesarean section would avoid the possible trauma of a difficult
was not without vaginal delivery. Because of the greater morbidity associated with
infants who weigh more than 4500 g, elective cesarean section is
justification and that in the seven years he had been a medical warranted.23
officer of OMPH, he has dutifully observed the sworn duties of
the medical profession and would not neglect his responsibilities On the other hand, prolonged labormay culminate in obstructed
nor commit misconductat the risk of his medical career which he labor, and is associated with maternal infection, uterine rupture
had nurtured through the years. and postpartum hemorrhage.24

The petition has no merit. As per the admitting diagnosis25 submitted by petitioner, the
latter was aware of macrosomia and the fetal heartbeat
Misconduct is defined as a transgression of some established and notappreciated. He also maintains that respondent’s baby was
definite rule of action, more particularly, unlawful behavior or already dead due to prolonged labor but she had insisted on
gross negligence by a public officer,13 a forbidden act, a having a normal delivery. However, this claim is belied by the
dereliction of duty, willful in character, and implies wrongful sworn statements of respondent, her husband and her sisters, all of
intent and not mere error in judgment.14 It generally means whom averred that they requested for a cesarean section as per the
wrongful, improper or unlawful conduct motivated by a advice given by Dr. Atienza who examined her in March 2009,
premeditated, obstinate or intentional purpose. The term, and as confirmed at the
however, does not necessarily imply corruption or criminal intent.
To constitute an administrative offense,misconduct should relate
to or be connected with the performance of the official functions
and duties of a public officer. On the other hand, whenthe Bansud Health Center where she was told that it would be risky
elements of corruption, clear intent to violate the law or flagrant for her to have a normal delivery.Moreover, Joel Mantala asserted
disregard of established rule are manifest, the public officer shall that what petitioner said to him was that the baby was too big and
be liable for grave misconduct.15 if born alive it would probably have abnormalities so it would be
better that the baby is stillborn.
In this case, both the Ombudsman and CA found the petitioner
guilty of grave misconduct in failing to attend to respondent when The Court is more inclined to believe respondent’s version which
she was having prolonged difficult labor and vaginal delivery was duly corroborated by Dr. Fabon who heard petitioner saying
after being diagnosed with macrosamiaand polyhydramnios. that: "Meron pa nga kami sa DR macrosomnia, polyhydramnios
pa, pero paanakin na lang ‘yon. Abnormal din namanang bata
Polyhydramniosis an abnormal condition occurring in pregnancy, kahit mabuhay." This puts into doubt petitioner’s supposed
characterized by excessive amniotic fluid (the fluid surrounding finding that the baby was already dead upon respondent’s
the baby in the uterus). Apart from protecting the baby from any admission at OMPH and thatit was respondent who insisted on a
external impact by providing a cushioning effect, the clear or normal delivery. Even assuming that petitioner had actually
slightly yellowish fluid plays a vital role in proper fetal confirmed intrauterine fetal death, this only aggravates the
patient’s condition and it was incumbent upon petitioner as the Not only did petitioner routinely delegate his responsibility to his
obstetrician on duty to personally attend to her and render subordinates, he casually instructedthem to press down repeatedly
appropriate management or treatment. on respondent’s abdomen, unmindful of her critical condition as
borne out by his very own findings. Worse, petitioner haughtily
In deliberately leaving the respondent to a midwife and two and callously spoke of respondent’s case to the other doctors and
inexperienced assistants despite knowing that she was under medical staff while performing a CS after he had briefly attended
prolonged painful labor and about to give birth to a macrosomic to her at the delivery room "...paanakin na lang ‘yon, abnormal
baby by vaginal delivery, petitioner clearly committed a din naman ang bata kahit mabuhay, kawawa lang siya." Such
dereliction of duty and a breach of his professional obligations. insensitive and derisive language was again heard from the
The gravity of respondent’s condition is highlighted by the petitioner when he referred for the second time to respondent’s
expected complications she suffered – her stillborn baby, a traumatic delivery, saying that: "Pinilit no’ng tatlong ungas,ayon
ruptured uterus that necessitated immediate surgery and blood lumusot pero patay ang bata, tapos ito, mukhang pumutok." As a
transfusion, and vulvar hematomas. government physician, petitioner’s demeanor is unbecoming and
bespeaks of his indifference to the well-being of his patients.
Article II, Section 1 of the Code of Medical Ethics of the Medical
Profession in the Philippines states: Petitioner thus not only committed a dereliction of duty, but also
transgressed the ethical norms of his profession when he failed to
A physician should attend to his patients faithfully and render competent medical care with compassion and respect for
conscientiously. He should secure for them all possible benefits his patient’s dignity.
that may depend upon his professional skill and care. As the sole
tribunal to adjudge the physician’s failure to fulfill his obligation A physician should be dedicated to provide competent medical
to his patients is, in most cases, his own conscience, violation of care with full professional skill in accordance with the current
this rule on his part is discreditable and inexcusable.26 standards of care, compassion, independence and respect for
human dignity.28 (Italics supplied.)
A doctor’s duty to his patient is not required to be extraordinary.
The standard contemplated for doctors issimply the reasonable
average merit among ordinarily good physicians, i.e.reasonable
skill and competence.27 Even by this standard, petitioner fell Finally, we find no merit in petitioner's argument that the CA
short when he routinely delegated an important task that requires should have at least considered as mitigating circumstances his
his professional skill and competence to his subordinates who being a first offender,29 his 16 years in government service, and
have no requisite training and capability to make crucial decisions that he had not acted in bad faith and with clear intent to violate
in difficult childbirths. the law and established rules. Jurisprudence is replete with cases
declaring that a grave offense cannot be mitigated by the fact that
Petitioner’s proffered excuse that it was the practice in OMPH to the accused is a first time offender or by the length of service of
allow midwives to administer to patients during deliveries, is the accused.30 While in most cases, length of service is
unacceptable. No proof of such alleged hospital practice such as considered in favor of the respondent, it is not considered where
an official written directive was presented. Besides, it is doubtful the offense committed is found to be serious or grave.31 In
whether hospital administrators would remedy personnel shortage Medina v. Commission on Audit,32 the Court stressed that
by permitting inexperienced staff, by themselves, to handle dishonesty and grave misconduct have always been and should
laboring patients with high-risk pregnancies and maternal/fetal remain anathema in the civil service. They inevitably reflect on
complications. the fitness of a civil servant to continue in office. When an officer
or employee is disciplined, the object sought is not the
As to the two other scheduled CS performed by petitioner on the punishment of such officer or employee but the improvement of
same day, this will not exculpate him from administrative the public service and the preservation of the public's faith and
liability.1âwphi1 As correctly pointed out by the CA, there was confidence in the government. WHEREFORE, the petition is
no showing of similar urgency in the said operations, and DENIED for lack of merit. The Decision dated May 24, 2012 and
petitioner could have referred respondent to another competent Resolution dated August 14, 2012 of the Court of Appeals in CA-
physician. He could have likewise arranged for adjustment in the G.R. SP No. 120563 are AFFIRMED and UPHELD.
operation schedules considering that his personal attention and
management is urgently needed in respondent’s difficult and With costs against the petitioner.
complicated delivery. But there is no indication in the records that
petitioner duly informed or referred the matter to the other doctors
or the administrators of OMPH.

We therefore hold that the CA correctly affirmed the Ombudsman

in finding the petitioner guilty of grave misconduct. His violation
NOEL CASUMPANG, RUBY SANGA-MIRANDA
of the sworn duty to attend to his patients faithfully and
AND SAN JUAN DE DIOS
conscientiously is inexcusable. Such flagrant disregard of
established rule and improper conduct were proven by substantial
HOSPITAL, Petitioners, v.NELSON CORTEJO, Respondent.
evidence.
[G.R. No. 171217]
DRA. RUBY SANGA-MIRANDA, Petitioner, v. NELSON room. Using only a stethoscope, he confirmed the initial diagnosis
CORTEJO, Respondent. [G.R. No. 171228] of "Bronchopneumonia."9

SAN JUAN DE DIOS HOSPITAL, Petitioner, v. NELSON At that moment, Mrs. Cortejo recalled entertaining doubts on the
CORTEJO, Respondent. doctor's diagnosis. She immediately advised Dr. Casumpang that
Edmer had a high fever, and had no colds or cough10 but Dr.
D E CI SI ON Casumpang merely told her that her son's "bloodpressure is just
being active,"11 and remarked that "that's the usual
BRION, J.: bronchopneumonia, no colds, no phlegm."12

We resolve the three (3) consolidated petitions for review on Dr. Casumpang next visited and examined Edmer at 9:00 in the
certiorari1 involving medical negligence, commonly assailing the morning the following day.13 Still suspicious about his son's
October 29, 2004 decision2 and the January 12, 2006 resolution3 illness, Mrs. Cortejo again called Dr. Casumpang's attention and
of the Court of Appeals (CA) in CA-G.R. CV No. 56400. This stated that Edmer had a fever, throat irritation, as well as chest
CA decision affirmed en toto the ruling of the Regional Trial and stomach pain. Mrs. Cortejo also alerted Dr. Casumpang about
Court (RTC), Branch 134, Makati City. the traces of blood in Edmer's sputum. Despite these pieces of

The RTC awarded Nelson Cortejo (respondent) damages in the information, however, Dr. Casumpang simply nodded, inquired if
total amount of P595,000.00, for the wrongful death of his son Edmer has an asthma, and reassured Mrs. Cortejo that Edmer's
allegedly due to the medical negligence of the petitioning doctors illness is bronchopneumonia.14
and the hospital.
At around 11:30 in the morning of April 23, 1988, Edmer vomited
Factual Antecedents "phlegm with blood streak"15prompting the respondent (Edmer's
father) to request for a doctor at the nurses' station.16
The common factual antecedents are briefly summarized below.
Forty-five minutes later, Dr. Ruby Sanga-Miranda (Dr. Miranda),
On April 22, 1988, at about 11:30 in the morning, Mrs. Jesusa one of the resident physicians of SJDH, arrived. She claimed that
Cortejo brought her 11-year old son, Edmer Cortejo (Edmer), to although aware that Edmer had vomited "phlegm with blood
the Emergency Room of the San Juan de Dios Hospital (SJDH) streak," she failed to examine the blood specimen because the
because of difficulty in breathing, chest pain, stomach pain, and respondent washed it away. She then advised the respondent to
fever.4 preserve the specimen for examination.

Dr. Ramoncito Livelo (Dr. Livelo) initially attended to and Thereafter, Dr. Miranda conducted a physical check-up covering
examined Edmer. In her testimony, Mrs. Cortejo narrated that in Edmer's head, eyes, nose, throat, lungs, skin and abdomen; and
the morning of April 20, 1988, Edmer had developed a slight found that Edmer had a low-grade non-continuing fever, and
fever that lasted for one day; a few hours upon discovery, she rashes that were not typical of dengue fever.17 Her medical
brought Edmer to their family doctor; and two hours after findings state:
administering medications, Edmer's fever had subsided.5
the patient's rapid breathing and then the lung showed sibilant and
After taking Edmer's medical history, Dr. Livelo took his vital the patient's nose is flaring which is a sign that the patient is in
signs, body temperature, and blood pressure.6 Based on these respiratory distress; the abdomen has negative finding; the
initial examinations and the chest x-ray test that followed, Dr.
Livelo diagnosed Edmer with "bronchopneumonia."7 Edmer's patient has low grade fever and not continuing; and the rashes in
blood was also taken for testing, typing, and for purposes of the patient's skin were not "Herman's Rash" and not typical of
administering antibiotics. Afterwards, Dr. Livelo gave Edmer an dengue fever.18
antibiotic medication to lessen his fever and to loosen his phlegm.
At 3:00 in the afternoon, Edmer once again vomited blood. Upon
Mrs. Cortejo did not know any doctor at SJDH. She used her seeing Dr. Miranda, the respondent showed her Edmer's blood
Fortune Care card and was referred to an accredited Fortune Care specimen, and reported that Edmer had complained of severe
coordinator, who was then out of town. She was thereafter stomach pain and difficulty in moving his right leg.19
assigned to
Dr. Miranda then examined Edmer's "sputum with blood" and
noted that he was bleeding. Suspecting that he could be afflicted
with dengue, she inserted a plastic tube in his nose, drained the
Dr. Noel Casumpang (Dr. Casumpang), a pediatrician also liquid from his stomach with ice cold normal saline solution, and
accredited with Fortune Care.8 gave an instruction not to pull out the tube, or give the patient any
oral medication.
At 5:30 in the afternoon of the same day, Dr. Casumpang for the
first time examined Edmer in his Dr. Miranda thereafter conducted a tourniquet test, which turned
out to be negative.20 She likewise ordered the monitoring of the
patient's blood pressure and some blood tests. Edmer's blood In ruling that the petitioning doctors were negligent, the RTC
pressure was later found to be normal.21 found untenable the petitioning doctors' contention that Edmer's
initial symptoms did not indicate dengue fever. It faulted them for
At 4:40 in the afternoon, Dr. Miranda called up Dr. Casumpang at heavily relying on the chest x-ray result and for not considering
his clinic and told him about Edmer's condition.22 Upon being the other manifestations that Edmer's parents had relayed. It held
informed, Dr. Casumpang ordered several procedures done that in diagnosing and treating an illness, the physician's conduct
including: hematocrit, hemoglobin, blood typing, blood should be judged not only by what he/she saw and knew, but also
transfusion and tourniquet tests. by what he/she could have reasonably seen and known. It also
observed that based on Edmer's signs and symptoms, his medical
The blood test results came at about 6:00 in the evening. history and physical examination, and also the information that
the petitioning doctors
Dr. Miranda advised Edmer's parents that the blood test results
showed that Edmer was suffering from "Dengue Hemorrhagic gathered from his family members, dengue fever was a
Fever." reasonably foreseeable illness; yet, the petitioning doctors failed
to take a second look, much less, consider these indicators of
One hour later, Dr. Casumpang arrived at Edmer's room and he dengue.
recommended his transfer to the Intensive Care Unit (ICU), to
which the respondent consented. Since the ICU was then full, Dr. The trial court also found that aside from their self-serving
Casumpang suggested to the respondent that they hire a private testimonies, the petitioning doctors did not present other evidence
nurse. The respondent, however, insisted on transferring his son to to prove that they exercised the proper medical attention in
Makati Medical Center. diagnosing and treating the patient, leading it to conclude that
they were guilty of negligence.
After the respondent had signed the waiver, Dr. Casumpang, for
the last time, checked Edmer's condition, found that his blood The RTC also held SJDH solidarity liable with the petitioning
pressure was stable, and noted that he was "comfortable." The doctors for damages based on the following findings of facts:
respondent requested for an ambulance but he was informed that first, Dr. Casumpang, as consultant, is an ostensible agent of
the driver was nowhere to be
SJDH because before the hospital engaged his medical services, it
found. This prompted him to hire a private ambulance that cost scrutinized and determined his fitness, qualifications, and
him P600.00.23 competence as a medical practitioner; and second, Dr. Miranda, as
resident physician, is an employee of SJDH because like Dr.
At 12:00 midnight, Edmer, accompanied by his parents and by Casumpang, the hospital, through its screening committee,
Dr. Casumpang, was transferred to Makati Medical Center. scrutinized and determined her qualifications, fitness, and
competence before engaging her services; the hospital also
Dr. Casumpang immediately gave the attending physician the exercised control over her work.
patient's clinical history and laboratory exam results. Upon
examination, the attending physician diagnosed "Dengue Fever The dispositive portion of the decision reads:
Stage IV" that was already in its irreversible stage.
WHEREFORE, judgment is hereby rendered in favor of the
Edmer died at 4:00 in the morning of April 24, 1988.24 His Death plaintiff and against the defendants, ordering the latter to pay
Certificate indicated the cause of death as "Hypovolemic solidarity and severally plaintiff the following:
Shock/hemorrhagic shock;" "Dengue Hemorrhagic Fever Stage
IV." (1) Moral damages in the amount of P500,000.00;

Believing that Edmer's death was caused by the negligent and (2) Costs of burial and funeral in the amount of P45,000.00; (3)
erroneous diagnosis of his doctors, Attorney's fees of P50,000.00; and

(4) Cost of this suit.

the respondent instituted an action for damages against SJDH, SO ORDERED.

and its attending physicians: Dr. Casumpang and Dr. Miranda
(collectively referred to as the "petitioners") before the RTC of The petitioners appealed the decision to the CA.
Makati City.
The Ruling of the Court of Appeals
The Ruling of the Regional Trial Court
In its decision dated October 29, 2004, the CA affirmed en toto
In a decision25 dated May 30, 1997, the RTC ruled in favor of the the RTC's ruling, finding that SJDH and its attending physicians
respondent, and awarded actual and moral damages, plus failed to exercise the minimum medical care, attention, and
attorney's fees and costs. treatment expected of an ordinary doctor under like
circumstances.
The CA found the petitioning doctors' failure to read even the function of making the diagnosis and undertaking the medical
most basic signs of "dengue fever" expected of an ordinary doctor treatment devolved upon Dr. Casumpang, the doctor assigned to
as medical negligence. The CA also considered the petitioning Edmer, and who confirmed "bronchopneumonia."
doctors' testimonies as self-serving, noting that they presented no
other evidence to prove that they exercised due diligence in Dr. Miranda also alleged that she exercised prudence in
diagnosing Edmer's illness. performing her duties as a physician, underscoring that it was her
professional intervention that led to the correct diagnosis of
The CA likewise found Dr. Rodolfo Jaudian's (Dr. Jaudian) "Dengue Hemorrhagic Fever." Furthermore, Edmer's Complete
testimony admissible. It gave credence to his opinion26 that: (1) Blood Count (CBC) showed leukopenia and an increase in
given the exhibited symptoms of the patient, dengue fever should balance as shown by the differential count, demonstrating that
definitely be considered, and bronchopneumonia could be Edmer's infection, more or less, is of bacterial and not viral in
reasonably ruled out; and (2) dengue fever could have been nature.
detected earlier than 7:30 in the evening of April 23, 1988
because the symptoms were already evident; and agreed with the Dr. Miranda as well argued that there is no causal relation
RTC that the petitioning doctors should not have solely relied between the alleged erroneous diagnosis and medication for
"Bronchopneumonia," and Edmer's death due to "Dengue
Hemorrhagic Fever."

on the chest-x-ray result, as it was not conclusive. Lastly, she claimed that Dr. Jaudian is not a qualified expert
witness since he never presented any evidence of formal
On SJDH's solidary liability, the CA ruled that the hospital's residency training and fellowship status in Pediatrics.
liability is based on Article 2180 of the Civil Code. The CA
opined that the control which the hospital exercises over its III. SJDH's Position (G.R. No. 171228)
consultants, the hospital's power to hire and terminate their
services, all fulfill the employer-employee relationship SJDH, on the other hand, disclaims liability by asserting that Dr.
requirement under Article 2180. Casumpang and Dr. Miranda are mere independent contractors
and "consultants" (not employees) of the hospital. SJDH alleges
Lastly, the CA held that SJDH failed to adduce evidence showing that since it did not exercise control or supervision over the
that it exercised the diligence of a good father of a family in the consultants' exercise of medical profession, there is no employer-
hiring and the supervision of its physicians. employee relationship between them, and consequently, Article
2180 of the Civil Code does not apply.
The petitioners separately moved to reconsider the CA decision,
but the CA denied their motion in its resolution of January 12, SJDH likewise anchored the absence of, employer-employee
2006; hence, the present consolidated petitions pursuant to Rule relationship on the following circumstances: (1) SJDH does not
45 of the Rules of Court. hire consultants; it only grants them privileges to admit patients in
the hospital through accreditation; (2) SJDH does not pay the
The Petitions consultants wages similar to an ordinary employee; (3) the
consultants earn their own professional fees directly from their
I. Dr. Casumpang's Position (G.R. No. 171127) patients; SJDH does not fire or terminate their services; and (4)
SJDH does not control or interfere with the
Dr. Casumpang contends that he gave his patient medical
treatment and care to the best of his abilities, and within the
proper standard of care required from physicians under similar
circumstances. He claims that his initial diagnosis of manner and the means the consultants use in the treatment of
bronchopneumonia was supported by the chest x-ray result. their patients. It merely provides them with adequate space in
exchange for rental payment.
Dr. Casumpang also contends that dengue fever occurs only after
several days of confinement. He alleged that when he had Furthermore, SJDH claims that the CA erroneously applied the
suspected that Edmer might be suffering from dengue fever, he control test when it treated the hospital's practice of accrediting
immediately attended and treated him. consultants as an exercise of control. It explained that the control
contemplated by law is that which the employer exercises over
Dr. Casumpang likewise raised serious doubjs on Dr. Jaudian's the: (i) end result; and the (ii) manner and means to be used to
credibility, arguing that the CA erred in appreciating his reach this end, and not any kind of control, however significant, in
testimony as an expert witness since he lacked the necessary accrediting the consultants.
training, skills, and experience as a specialist in dengue fever
cases. SJDH moreover contends that even if the petitioning doctors are
considered employees and not merely consultants of the hospital,
II. Dr. Miranda's Position (G.R. No. 171217) SJDH cannot still be held solidarity liable under Article 2180 of
the Civil Code because it observed the diligence of a good father
In her petition, Dr. Miranda faults the CA for holding her of a family in their selection and supervision as shown by the
responsible for Edmer's wrong diagnosis, stressing that the following: (1) the adequate measures that the hospital undertakes
to ascertain the petitioning doctors' qualifications and medical 2. Whether or not the petitioner hospital is solidarity liable with
competence; and (2) the documentary evidence that the the petitioning doctors;
petitioning doctors presented to prove their competence in the
field of pediatrics.27 3. Whether or not there is a causal connection between the
petitioners' negligent act/omission and the patient's resulting
SJDH likewise faults the CA for ruling that the petitioning death; and
doctors are its agents, claiming that this theory, aside from being
inconsistent with the CA's finding of employment relationship, is
unfounded because: first, the petitioning doctors are independent
contractors, not agents of SJDH; and second, as a medical 4. Whether or not the lower courts erred in considering Dr.
institution, SJDH cannot practice medicine, much more, extend its Rodolfo Tabangcora Jaudian as an expert witness.
personality to physicians to practice medicine on its behalf.
Our Ruling We find the petition partly meritorious.
Lastly, SJDH maintains that the petitioning doctors arrived at an
intelligently deduced and correct diagnosis. It claimed that based A Petition for Review on Certiorari under Rule 45 of the Rules of
on Edmer's signs and symptoms at the time of admission (i.e., one Court is Limited to Questions of Law.
day fever,28bacterial infection,29 and lack of hemorrhagic
manifestations30), there was no reasonable indication yet that he The settled rule is that the Court's jurisdiction in a petition for
was suffering from dengue fever, and accordingly, their failure to review on certiorari under Rule 45 of the Rules of Court is limited
diagnose dengue fever, does not constitute negligence on their only to the review of pure questions of law. It is not the Court's
part. function to inquire on the veracity of the appellate court's factual
findings and conclusions; this Court is not a trier of facts.31
The Case for the Respondent
A question of law arises when there is doubt as to what the law is
In his comment, the respondent submits that the issues the on a certain state of facts, while
petitioners raised are mainly factual in nature, which a petition for
review on certiorari under Rule 45 of the Rules of Court does not there is a question of fact when the doubt arises as to the truth or
allow. falsity of the alleged facts.32

In any case, he contends that the petitioning doctors were These consolidated petitions before us involve mixed questions of
negligent in conducting their medical examination and diagnosis fact and law. As a rule, we do not resolve questions of fact.
based on the following: (1) the petitioning doctors failed to timely However, in determining the legal question of whether the
diagnose Edmer's correct illness due to their non-observance of respondent is entitled to claim damages under Article 2176 of the
the proper and acceptable standard of medical examination; (2) Civil Code for the petitioners' alleged medical malpractice, the
the petitioning doctors' medical examination was not determination of the factual issues - i.e., whether the petitioning
comprehensive, as they were always in a rush; and (3) the doctors were grossly negligent in diagnosing the patient's illness,
petitioning doctors employed a guessing game in diagnosing whether there is causal relation between the petitioners'
bronchopneumonia. act/omission and the patient's resulting death, and whether Dr.
Jaudian is qualified as an expert witness - must necessarily be
The respondent also alleges that there is a causal connection resolved. We resolve these factual questions solely for the
between the petitioning doctors' negligence and Edmer's untimely purpose of determining the legal issues raised.
death, warranting the claim for damages.
Medical Malpractice Suit as a Specialized Area of Tort Law
The respondent, too, asserted that SJDH is also negligent because
it was not equipped with proper paging system, has no The claim for damages is based on the petitioning doctors'
bronchoscope, and its doctors are not proportionate to the number negligence in diagnosing and treating the deceased Edmer, the
of its patients. He also pointed out that out of the seven resident child of the respondent. It is a medical malpractice suit, an action
physicians in the hospital, only two available to victims to redress a wrong committed by medical
professionals who caused bodily harm to, or the death of, a
resident physicians were doing rounds at the time of his son's patient.33 As the term is used, the suit is brought whenever a
confinement. medical practitioner or health care provider fails to meet the
standards demanded by his profession, or deviates from this
The Issues standard, and causes injury to the patient.

The case presents to us the following issues: To successfully pursue a medical malpractice suit, the plaintiff (in
this case, the deceased patient's heir) must prove that the doctor
1. Whether or not the petitioning doctors had committed either failed to do what a reasonably prudent doctor would have
"inexcusable lack of precaution" in diagnosing and in treating the done, or did what a reasonably prudent doctor would not have
patient; done; and the act or omission had caused injury to the patient.34
The patient's heir/s bears the burden of proving his/her cause of
action.
The Elements of a Medical Malpractice Suit a. The Relationship Between Dr. Casumpang and Edmer

The elements of medical negligence are: (1) duty; (2) breach; (3) In the present case, the physician-patient relationship between Dr.
injury; and (4) proximate causation. Casumpang and Edmer was created when the latter's parents
sought the medical services of Dr. Casumpang, and the latter
Duty refers to the standard of behavior that imposes restrictions knowingly accepted Edmer as a patient. Dr. Casumpang's
on one's conduct.35 It requires acceptance is implied from his affirmative examination, diagnosis
and treatment of Edmer. On the other hand, Edmer's parents, on
proof of professional relationship between the physician and the their son's behalf, manifested their consent by availing of the
patient. Without the professional relationship, a physician owes benefits of their health care plan, and by accepting the hospital's
no duty to the patient, and cannot therefore incur any liability. assigned doctor without objections.

A physician-patient relationship is created when a patient engages b. The Relationship Between Dr. Miranda and Edmer
the services of a physician,36 and the latter accepts or agrees to
provide care to the patient.37 The establishment of this With respect to Dr. Miranda, her professional relationship with
relationship is consensual,38 and the acceptance by the physician Edmer arose when she assumed the obligation to provide resident
essential. The mere fact that an individual approaches a physician supervision over the latter. As second year resident doctor tasked
and seeks diagnosis, advice or treatment does not create the duty to do rounds and assist other physicians, Dr. Miranda is deemed
of care unless the physician agrees.39 to have agreed to the creation of physician-patient relationship
with the hospital's patients when she participated in the diagnosis
The consent needed to create the relationship does not always and prescribed a course of treatment for Edmer.
need to be express.40 In the absence of an express agreement, a
physician-patient relationship may be implied from the The undisputed evidence shows that Dr. Miranda examined
physician's affirmative action to diagnose and/or treat a patient, or Edmer twice (at around 12:00 and 3:30 in the afternoon of April
in his participation in such diagnosis and/or treatment.41 The 23, 1988), and in both instances, she prescribed treatment and
usual illustration would be the case of a patient who goes to a participated in the diagnosis of Edmer's medical condition. Her
hospital or a clinic, and is examined and treated by the doctor. In affirmative acts amounted to her acceptance of the physician-
this case, we can infer, based on the established and patient relationship, and incidentally, the legal duty of care that
went with it.

In Jarcia, Jr. v. People of the Philippines,46 the Court found the

customary practice in the medical community that a patient- doctors who merely passed by and were requested to attend to the
physician relationship exists. patient, liable for medical malpractice. It held that a physician-
patient relationship was established when they examined the
Once a physician-patient relationship is established, the legal duty patient, and later assured the mother that everything was fine.
of care follows. The doctor accordingly becomes duty-bound to
use at least the same standard of care that a reasonably competent In the US case of Mead v. Legacy Health System,47 the Court
doctor would use to treat a medical condition under similar also considered the rendering of an
circumstances.
opinion in the course of the patient's care as the doctor's assent to
Breach of duty occurs when the doctor fails to comply with, or the physician-patient relationship. It ruled that the relationship
improperly performs his duties under professional standards. This was formed because of the doctor's affirmative action.
determination is both factual and legal, and is specific to each
individual case.42 Likewise, in Wax v. Johnson,48 the court found that a physician-
patient relationship was formed between a physician who
If the patient, as a result of the breach of duty, is injured in body "contracts, agrees, undertakes, or otherwise assumes" the
or in health, actionable malpractice is committed, entitling the obligation to provide resident supervision at a teaching hospital,
patient to damages.43 and the patient with whom the doctor had no direct or indirect
contract.
To successfully claim damages, the patient must lastly prove the
causal relation between the negligence and the injury. This Standard of Care and Breach of Duty
connection must be direct, natural, and should be unbroken by any
intervening efficient causes. In other words, the negligence must A determination of whether or not the petitioning doctors met the
be the proximate cause of required standard of care involves a question of mixed fact and
law; it is factual as medical negligence cases are highly technical
the injury.44 The injury or damage is proximately caused by the in nature, requiring the presentation of expert witnesses to provide
physician's negligence when it appears, based on the evidence and guidance to the court on matters
the expert testimony, that the negligence played an integral part in
causing the injury or damage, and that the injury or damage was
either a direct result, or a reasonably probable consequence of the
physician's negligence.45
clearly falling within the domain of medical science, and legal, basketball.56 He based his diagnosis of bronchopneumonia on the
insofar as the Court, after evaluating the expert testimonies, and following observations: "difficulty in breathing, clearing run
guided by medical literature, learned treatises, and its fund of nostril, harsh breath sound, tight air, and sivilant sound."57
common knowledge, ultimately determines whether breach of
duty took place. It will be recalled that during Dr. Casumpang's first and second
visits to Edmer, he already had knowledge of Edmer's laboratory
Whether or not Dr. Casumpang and Dr. Miranda committed a test result (CBC), medical history, and symptoms (i.e., fever,
breach of duty is to be measured by the yardstick of professional rashes, rapid breathing, chest and stomach pain, throat irritation,
standards observed by the other members of the medical difficulty in breathing, and traces of blood in the sputum).
profession in good standing under similar circumstances.49 It is in However, these information did not lead Dr. Casumpang to the
this aspect of medical malpractice that expert testimony is possibility that Edmer could be suffering from either dengue
essential to establish not only the professional standards observed fever, or dengue hemorrhagic fever, as he clung to his diagnosis
in the medical community, but also that the physician's conduct in of broncho pneumonia. This means that given the symptoms
the treatment of care falls below such standard.50 exhibited, Dr. Casumpang already ruled out the possibility of
other diseases like dengue.
In the present case, expert testimony is crucial in determining
first, the standard medical examinations, tests, and procedures that In other words, it was lost on Dr. Casumpang that the
the attending physicians should have undertaken in the diagnosis characteristic symptoms of dengue (as Dr. Jaudian testified) are:
and treatment of dengue fever; and second, the dengue fever signs patient's rapid breathing; chest and stomach pain; fever; and the
and symptoms that the attending physicians should have noticed presence of blood in his saliva. All these manifestations were
and considered. present and known to Dr. Casumpang at the time of his first and
second visits to Edmer. While he noted some of these symptoms
Both the RTC and the CA relied largely on Dr. Jaudian's expert in confirming
testimony on dengue diagnosis and management to support their
finding that the petitioning doctors were guilty of breach of duty
of care.
bronchopneumonia, he did not seem to have considered the
Dr. Jaudian testified that Edmer's rapid breathing, chest and patient's other manifestations in ruling out dengue fever or dengue
stomach pain, fever, and the presence of blood in his saliva are hemorrhagic fever.58 To our mind, Dr. Casumpang selectively
classic symptoms of dengue fever. According to him, if the appreciated some, and not all of the symptoms; worse, he casually
patient was admitted for chest pain, abdominal pain, and difficulty ignored the pieces of information that could have been material in
in breathing coupled with fever, dengue fever should definitely be detecting dengue fever. This is evident from the testimony of Mrs.
considered;51 if the patient spits coffee ground with the presence Cortejo:
of blood, and the patient's platelet count drops to 47,000, it
becomes a clear case of dengue fever, and bronchopneumonia can TSN, Mrs. Cortejo, November 27, 1990
be reasonably ruled out.52
Q: Now, when Dr. Casumpang visited your son for the first time
Furthermore, the standard of care according to Dr. Jaudian is to at 5:30 p.m., what did he do, if any?
administer oxygen inhalation, analgesic, and fluid infusion or
dextrose.53 If the patient had twice vomited fresh blood and A: He examined my son by using stethoscope and after that, he
thrombocytopenia has already occurred, the doctor should order confirmed to me that my son was suffering from broncho
blood transfusion, monitoring of the patient every 30 minutes, pneumonia.
hemostatic to stop bleeding, and oxygen if there is difficulty in
breathing.54 Q: After he confirmed that your son was suffering broncho
pneumonia, what did you say if any?
We find that Dr. Casumpang, as Edmer's attending physician, did
not act according to these standards and, hence, was guilty of A: Again, I told Dr. Casumpang, how come it was broncho
breach of duty. We do not find Dr. Miranda liable for the reasons pneumonia when my son has no cough or colds.
discussed below.
Q: What was the answer of Dr. Casumpang to your statement?
Dr. Casumpang's Negligence
xxxx
a. Negligence in the Diagnosis
A: And then, Dr. Casumpang answered "THAT'S THE USUAL
At the trial, Dr. Casumpang declared that a doctor's impression BRONCHO PNEUMONIA, NO COLDS, NO PHLEGM."
regarding a patient's illness is 90% based on the physical
examination, the information given by the patient or the latter's Q: How long did Dr. Casumpang stay in your son's room? A: He
parents, and the patient's medical history.55 He testified that he stayed for a minute or 2.
did not consider either dengue fever or dengue hemorrhagic fever
because the patient's history showed that Edmer had low breath xxxx
and voluntary submission, and that he was up and about playing
Q: Q: When Dr. Casumpang arrived at 9:00 o'clock a.m. on April Dr. Jaudian likewise opined that Dr. Casumpang's medical
23, what did you examination was not comprehensive

tell him, if any?

xxxx enough to reasonably lead to a correct diagnosis.60 Dr.

Casumpang only used a stethoscope in coming up with the
A: I told Dr. Casumpang... After examining my son using diagnosis that Edmer was suffering from bronchopneumonia; he
stethoscope and nothing more, I told Dr. Casumpang about the never confirmed this finding with the use of a bronchoscope.
traces of blood in my son's sputum and I told him what is all Furthermore, Dr. Casumpang based his diagnosis largely on the
about and he has throat irritation. chest x-ray result that is generally inconclusive.61

Q: What did he tell you? Significantly, it was only at around 5:00 in the afternoon of April
23, 1988 (after Edmer's third episode of bleeding) that Dr.
A: He just nodded his head but he did not take the initiative of Casumpang ordered the conduct of hematocrit, hemoglobin, blood
looking at the throat of my son. typing, blood transfusion and tourniquet tests. These tests came
too late, as proven by: (1) the blood test results that came at about
Q: So what happened after that? 6:00 in the evening, confirming that Edmer's illness had
developed to "Dengue Hemorrhagic Fever" and (2) Dr. Jaudian's
A: I also told Dr. Casumpang about his chest pain and also testimony that "dengue fever could have been detected earlier
stomach pain. Q: So what did Dr. Casumpang do after you have than 7:30 in the evening of April 23, 1988 because the symptoms
narrated all these were already evident."62

complaints of your son? In Spouses Flores v. Spouses Pineda,63 a case involving a

medical malpractice suit, the Court ruled that the petitioner
A: Nothing. He also noticed the rapid breathing of my son and my doctors were negligent because they failed to immediately order
son was tests to confirm the patient's illness. Despite the doctors' suspicion
that the patient could be suffering from diabetes,
almost moving because of rapid breathing and he is swaying in
the bed. Q: Do you know what action was taken by Dr. the former still proceeded to the D&C operation. In that case,
Casumpang when you told expert testimony showed that tests should have been ordered
immediately on admission to the hospital in view of the symptoms
him that your son is experiencing a rapid breathing? presented. The Court held:

A: No action. He just asked me if my son has an asthma but I said When a patient exhibits symptoms typical of a particular disease,
none. these symptoms should, at the very least, alert the physician of the
possibility that the patient may be afflicted with the suspected
Q: So how long did Dr. Casumpang stay and attended your son on disease.
April 23? A: More or less two (2) minutes then I followed him up
to the door and I The Court also ruled that reasonable prudence would have shown
that diabetes and its complications were foreseeable harm.
repeated about the fever of my son. However, the petitioner doctors failed to take this into
consideration and proceeded with the D&C operation. Thus, the
Q: What did he tell you, if any, regarding that information you Court ruled that they failed to comply with their duty to observe
gave him the standard of care to be given to hyperglycemic/diabetic
patients.
that your son had a fever?
Similarly, in Jarcia,64 involving the negligence of the doctors in
A: He said, that is broncho pneumonia, It's only being active now. failing to exercise reasonable prudence in ascertaining the extent
of the patient's injuries, this Court declared that:
[Emphasis supplied]
In failing to perform an extensive medical examination to
We also find it strange why Dr. Casumpang did not even bother determine the extent of Roy Jr.'s injuries, Dr. Jarcia and Dr.
to check Edmer's throat despite knowing that as early as 9:00 in Bastan were remiss of their duties as members of the medical
the morning of April 23, 1988, Edmer had blood streaks in his profession. Assuming for the sake of argument that they did not
sputum. Neither did Dr. Casumpang order confirmatory tests to have the capacity to make such thorough evaluation at that stage,
confirm the source of bleeding. The Physician's Progress Notes59 they should have referred the patient to another doctor with
stated: "Blood streaks on phlegm can be due to bronchial irritation sufficient training and experience instead of assuring him and his
or congestion" which clearly showed that Dr. Casumpang merely mother that everything was all right. [Emphasis supplied]
assumed, without confirmatory physical examination, that
bronchopneumonia caused the bleeding.
Even assuming that Edmer's symptoms completely coincided with reflected in the records) did not include antibiotic therapy and
the diagnosis of bronchopneumonia (so that this diagnosis could complete physical examination. Dr. Casumpang's testimony
not be considered "wrong"), we still find Dr. Casumpang guilty of states:
negligence.
Q: Now, after entertaining - After considering that the patient
First, we emphasize that we do not decide the correctness of a Edmer Cortero was already suffering from dengue hemorrhagic
doctor's diagnosis, or the accuracy of the medical findings and fever, what did you do, if any?
treatment. Our duty in medical malpractice cases is to decide -
based on the evidence adduced and expert opinion presented - A: We ordered close monitoring of the blood pressure, the cardiac
whether a breach of duty took place. rate and respiratory rate of the patient.

Second, we clarify that a wrong diagnosis is not by itself medical Q: Now, was your instructions carried on?
malpractice.65 Physicians are generally not liable for damages
resulting from a bona fide error of judgment. Nonetheless, when A: Yes, sir.
the physician's erroneous diagnosis was the result of negligent
conduct (e.g., neglect of medical history, failure to order the Q: What was the blood pressure of the patient?
appropriate tests, failure to recognize symptoms), it becomes
A: During those times, the blood pressure of the patient was even
an evidence of medical malpractice. normal during

Third, we also note that medicine is not an exact science;66 and those times.
doctors, or even specialists, are not expected to give a 100%
accurate diagnosis in treating patients who come to their clinic for Q: How about the respiratory rate?
consultations. Error is possible as the exercise of judgment is
called for in considering and reading the exhibited symptoms, the A: The respiratory rate was fast because the patient in the
results of tests, and in arriving at definitive conclusions. But in beginning since
doing all these, the doctor must have acted according to
acceptable medical practice standards. admission had difficulty in breathing.

In the present case, evidence on record established that in Q: Then, after that, what did you do with the patient? Doctor?
confirming the diagnosis of bronchopneumonia, Dr. Casumpang
selectively appreciated some and not all of the symptoms A: We transfused platelet concentrate and at the same time, we
presented, and failed to promptly conduct the appropriate tests to monitor
confirm his findings. In sum, Dr. Casumpang failed to timely
detect dengue fever, which failure, especially when reasonable [sic] the patient.
prudence would have shown that indications of dengue were
evident and/or foreseeable, constitutes Q: Then, who monitor [sic] the patient?

A: The pediatric resident on duty at that time.

negligence. Q: Now, what happened after that?

a. Negligence in the Treatment and Management of Dengue Q: While monitoring the patient, all his vital signs were
________; his blood
Apart from failing to promptly detect dengue fever, Dr.
Casumpang also failed to promptly undertake the proper medical pressure was normal so we continued with the supportive
management needed for this disease. management at that

As Dr. Jaudian opined, the standard medical procedure once the time.
patient had exhibited the classic symptoms of dengue fever should
have been: oxygen inhalation, use of analgesic, and infusion of Q: Now, after that?
fluids or dextrose;67 and once the patient had twice vomited fresh
blood, the doctor should have ordered: blood transfusion, A: In the evening of April 23, 1988,1 stayed in the hospital and I
monitoring of the patient every 30 minutes, hemostatic to stop was informed by
bleeding, and oxygen if there is difficulty in breathing.68
the pediatric resident on duty at around 11:15 in the evening that
Dr. Casumpang failed to measure up to these standards. The the blood
evidence strongly suggests that he ordered a transfusion of
platelet concentrate instead of blood transfusion. The tourniquet pressure of the patient went down to .60 palpatory.
test was only conducted after Edmer's second episode of bleeding,
and the medical management (as Q: What did you do upon receipt of that information?
A: I immediately went up to the room of the patient and we The attending physician, on the other hand, is primarily
changed the IV responsible for managing the resident's exercise of duties. While
attending and resident physicians share the collective
fluid from the present fluid which was D5 0.3 sodium chloride to responsibility to deliver safe and appropriate care to the
patients,74 it is the attending physician who assumes the principal
lactated ringers solution. responsibility of patient care.75 Because he/she exercises a
supervisory role over the resident, and is ultimately responsible
Q: You mean to say you increased the dengue [sic] of the for the diagnosis and treatment of the patient, the standards
intervenus [sic] applicable to and the liability of the resident for medical
malpractice is theoretically less than that of the attending
fluid? physician. These relative burdens and distinctions, however, do
not translate to immunity from the legal duty of care for
A: We changed the IV fluid because lactated ringers was residents,76 or from the responsibility arising from their own
necessary to negligent act.

resume the volume and to bring back the blood pressure, to In Jenkins v. Clark,77 the Ohio Court of Appeals held that the
increase the blood pressure. [Emphasis supplied] applicable standard of care in medical malpractice cases involving
first-year residents was that of a reasonably prudent physician and
Although Dr. Casumpang presented the testimonies of Dr. not that of interns. According to Jenkins:
Rodolfo Jagonap and Dr. Ellewelyn Pasion (Dr. Pasion),
Personnel Officer and Medical Director of SJDH, respectively as It is clear that the standard of care required of physicians is not an
well as the testimonies of Dr. Livelo and Dr. Reyes (the individualized one but of physicians in general in the community.
radiologist who read Edmer's chest x-ray result), these witnesses In order to establish medical malpractice, it must be shown by a
preponderance of the evidence that a physician did some
particular thing or things that a physician or surgeon of ordinary
skill, care and diligence would not have done under like or similar
failed to dispute the standard of action that Dr. Jaudian conditions or circumstances, or that he failed or omitted to do
established in his expert opinion. We cannot consider them expert some particular thing or things that a physician or surgeon of
witnesses either for the sole reason that they did not testify on the ordinary skill, care and diligence would have done under like or
standard of care in dengue cases.69 similar conditions or circumstances, and that the inquiry
complained of was the direct result of such doing or failing to do
On the whole, after examining the totality of the adduced such thing or things.
evidence, we find that the lower courts correctly did not rely on
Dr. Casumpang's claim that he exercised prudence and due We note that the standard of instruction given by the court was
diligence in handling Edmer's case. Aside from being self- indeed a proper one. It clearly informed the jury that the medical
serving, his claim is not supported by competent evidence. As the care required is that of reasonably careful physicians
lower courts did, we rely on the uncontroverted fact that he failed,
as a medical professional, to observe the most prudent medical or hospital emergency room operators, not of interns or residents.
procedure under the circumstances in diagnosing and treating [Emphasis supplied]
Edmer.
A decade later, Centman v. Cobb,78 affirmed the Jenkins ruling
Dr. Miranda is Not Liable for Negligence and held that interns and first-year residents are "practitioners of
medicine required to exercise the same standard of care applicable
In considering the case of Dr. Miranda, the junior resident to physicians with unlimited licenses to practice." The Indiana
physician who was on-duty at the time of Edmer's confinement, Court held that although a first-year resident practices under a
we see the need to draw distinctions between the responsibilities temporary medical permit, he/she impliedly contracts that he/she
and corresponding liability of Dr. Casumpang, as the attending has the reasonable and ordinary qualifications of her profession
physician, and that of Dr. Miranda. and that he/she will exercise reasonable skill, diligence, and care
in treating the patient.
In his testimony, Dr. Pasion declared that resident applicants are
generally doctors of medicine licensed to practice in the We find that Dr. Miranda was not independently negligent.
Philippines and who would like to pursue a particular specialty.70 Although she had greater patient exposure, and was' subject to the
They are usually the front line doctors responsible for the first same standard of care applicable to attending physicians, we
contact with the patient. During the scope of the residency believe that a finding of negligence should also depend on several
program,71 resident physicians (or "residents")72 function under competing factors, among
the supervision of attending physicians73or of the hospital's
teaching staff. Under this arrangement, residents operate merely them, her authority to make her own diagnosis, the degree of
as subordinates who usually defer to the attending physician on supervision of the attending physician over her, and the shared
the decision to be made and on the action to be taken. responsibility between her and the attending physicians.
In this case, before Dr. Miranda attended to Edmer, both Dr. Q: So what examination did you specifically conduct to see that
Livelo and Dr. Casumpang had diagnosed Edmer with there was no
bronchopneumonia. In her testimony, Dr. Miranda admitted that
she had been briefed about Edmer's condition, his medical history, internal bleeding?
and initial diagnosis;79 and based on these pieces of information,
she confirmed the, finding of bronchopneumonia. A: At that time I did not do anything to determine the cause of
coughing of the blood because I presumed that it was a mucous
Dr. Miranda likewise duly reported to Dr. Casumpang, who (sic) produced by broncho pneumonia, And besides the patient did
admitted receiving updates regarding Edmer's condition.80 There not even show any signs of any other illness at that time.[83
is also evidence supporting Dr. Miranda's claim that she extended
diligent care to Edmer. In fact, when she suspected - during Based on her statements we find that Dr. Miranda was not
Edmer's second episode of bleeding - that Edmer could be entirely faultless. Nevertheless, her failure to discern the import of
suffering from dengue fever, she wasted no time in conducting the Edmer's second bleeding does not necessarily amount to
necessary tests, and promptly notified Dr. Casumpang about the
incident. Indubitably, her medical assistance led to the finding of negligence as the respondent himself admitted that Dr. Miranda
dengue fever. failed to examine the blood specimen because he washed it away.
In addition, considering the diagnosis previously made by two
We note however, that during Edmer's second episode of doctors, and the uncontroverted fact that the burden of final
bleeding,81 Dr. Miranda failed to immediately examine and note diagnosis pertains to the attending physician (in this case, Dr.
the cause of the blood specimen. Like Dr. Casumpang, she merely Casumpang), we believe that Dr. Miranda's error was merely an
assumed that the blood in Edmer's phlegm was caused by honest mistake of judgment influenced in no small measure by her
bronchopneumonia. Her testimony status in the hospital hierarchy; hence, she should not be held
liable for medical negligence.
states:
Dr. Jaudian 's Professional Competence and Credibility
TSN, June 8, 1993:
One of the critical issues the petitioners raised in the proceedings
Q: Let us get this clear, you said that the father told you the before the lower court and before this Court was Dr. Jaudian's
patient cocked [sic] out phlegm. competence and credibility as an expert witness. The petitioners
tried to discredit his expert testimony on the ground that he lacked
A: With blood streak. the proper training and fellowship status in pediatrics.

Q: Now, you stated specimen, were you not able to examine the
specimen? A: No, sir, I did not because according to the father he
wash [sic] his Criteria in Qualifying as an Expert Witness

hands. The competence of an expert witness is a matter for the trial court
to decide upon in the exercise of its discretion. The test of
xxxx qualification is necessarily a relative one, depending upon the
subject matter of the investigation, and the fitness of the expert
Q: Now, from you knowledge, what does that indicate if the witness.84 In our jurisdiction, the criterion remains to be the
patient expels a phlegm expert witness' special knowledge experience and practical
training that qualify him/her to explain highly technical medical
and blood streak? matters to the Court.

A: If a patient cocked [sic] out phlegm then the specimen could In Ramos v. Court of Appeals,85 the Court found the expert
have come from witness, who is a pulmonologist, not qualified to testify on the
field of anesthesiology. Similarly, in Cereno v. Court of
the lung alone.82 [Emphasis supplied] xxxx Appeals,86 a 2012 case involving medical negligence, the Court
excluded the testimony of an expert witness whose specialty was
TSN, June 17, 1993: anesthesiology, and concluded that an anesthesiologist cannot be
considered an expert in the field of surgery or even in surgical
Q: Now, in the first meeting you had, when that was relayed to practices and diagnosis.
you by the father that Edmer Cortejo had coughed out blood, what
medical action did you take? Interestingly in this case, Dr. Jaudian, the expert witness was
admittedly not a pediatrician but a practicing physician who
A: I examined the patient and I thought that, that coughed out specializes in pathology.87 He likewise does not possess any
phlegm was a product of broncho pneumonia. formal

xxxx residency training in pediatrics. Nonetheless, both the lower

courts found his knowledge acquired through study and practical
experience sufficient to advance an expert opinion on dengue-
related cases.
To qualify a witness as a medical expert, it must be shown that
We agree with the lower courts. the witness (1) has the required professional knowledge, learning
and skill of the subject under inquiry sufficient to qualify him to
A close scrutiny of Ramos and Cereno reveals that the Court speak with authority on the subject; and (2) is familiar with the
primarily based the witnesses' disqualification to testify as an standard required of a physician under similar circumstances;
expert on their incapacity to shed light on the standard of care that where a witness has disclosed sufficient knowledge of the subject
must be observed by the defendant-physicians. That the expert to entitle his opinion to go to the jury, the question of the degree
witnesses' specialties do not match the physicians' practice area of his knowledge goes more to the weight of the evidence than to
only constituted, at most, one of the considerations that should not its admissibility.
be taken out of context. After all, the sole function of a medical
expert witness, regardless of his/her specialty, is to afford xxxx
assistance to the courts on medical matters, and to explain the
medical facts in issue. Nor is it critical whether a medical expert is a general practitioner
or a specialist so long as he exhibits knowledge of the subject.
Furthermore, there was no reasonable indication in Ramos and Where a duly licensed and practicing physician has gained
Cereno that the expert witnesses possess a sufficient familiarity knowledge of the standard of care applicable to a specialty in
with the standard of care applicable to the physicians' specialties. which he is not directly engaged but as to which he has an opinion
based on education, experience, observation, or association wit
US jurisprudence on medical malpractice demonstrated the trial that specialty, his opinion is competent. (Emphasis supplied)
courts' wide latitude of discretion in allowing a specialist from Finally, Brown v. Mladineo92 adhered to the principle that the
another field to testify against a defendant specialist. witness' familiarity, and not the classification by title or specialty,
which should control issues regarding the expert witness'
In Brown v. Sims,88 a neurosurgeon was found competent to give
expert testimony regarding a gynecologist's standard of pre- qualifications:
surgical care. In that case, the court held that since negligence was
not predicated on the gynecologist's negligent performance of the The general rule as to expert testimony in medical malpractice
operation, but primarily on the claim that the pre-operative actions is that "a specialist in a particular branch within a
histories and physicals were inadequate, the neurosurgeon was profession will not be required." Most courts allow a doctor to
competent to testify as an expert. testify if they are satisfied of his familiarity with the standards of
a specialty, though he may not practice the specialty himself. One
Frost v. Mayo Clinic89 also allowed an orthopedic surgeon to court explained that "it is the scope of the witness' knowledge and
testify against a neurologist in a medical malpractice action. The not the artificial classification by title that should govern the
court considered that the orthopedic surgeon's opinion on the threshold question of admissibility. (Citations omitted)
"immediate need for decompression" need not come from a
specialist in neurosurgery. The court held that: Application to the Present Case

It is well established that "the testimony of a qualified medical In the case and the facts before us, we find that Dr. Jaudian is
doctor cannot be excluded simply because he is not a specialist x competent to testify on the standard of care in dengue fever cases.
x x." The matter of "x x x training and specialization of the
witness Although he specializes in pathology, it was established during
trial that he had attended not less than 30 seminars held by the
goes to the weight rather than admissibility x x x." xxxx Pediatric Society, had exposure in pediatrics, had been practicing
medicine for 16 years, and had handled not less than 50 dengue
It did not appear to the court that a medical doctor had to be a related cases.
specialist in neurosurgery to express the opinions permitted to be
expressed by plaintiffs' doctors, e.g., the immediate need for a As a licensed medical practitioner specializing in pathology, who
decompression in the light of certain neurological deficits in a had practical and relevant exposure in pediatrics and dengue
post-laminectomy patient. As stated above, there was no issue as related cases, we are convinced that Dr. Jaudian demonstrated
to the proper execution of the neurosurgery. The medical sufficient familiarity with the standard of care to be applied in
testimony supported plaintiffs' theory of negligence and dengue fever cases. Furthermore, we agree that he possesses
causation. (Citations omitted) knowledge and experience sufficient to qualify him to speak with
authority on the subject.
In another case,90 the court declared that it is the specialist's
knowledge of the requisite subject matter, rather than his/her The Causation Between Dr. Casumpang's Negligent
specialty that determines his/her qualification to testify. Act/Omission, and the Patient's Resulting Death was Adequately
Proven
Also in Evans v. Ohanesian,91 the court set a guideline in
qualifying an expert witness: Dr. Jaudian's testimony strongly suggests that due to Dr.
Casumpang's failure to timely diagnose Edmer with dengue, the
latter was not immediately given the proper treatment. In fact, provide him with portable oxygen;
even after Dr. Casumpang had discovered Edmer's real illness, he
still failed to promptly perform the standard medical procedure. (e) when Edmer was about to be transferred to another hospital,
We agree with these findings. SJDH's was not

As the respondent had pointed out, dengue fever, if left untreated, ready and had no driver; and
could be a life threatening disease. As in any fatal diseases, it
requires immediate medical attention.93 With the correct and (f) despite Edmer's critical condition, there was no doctor
timely diagnosis, coupled with the proper medical management, attending to him from
dengue fever is not a life-
5:30 p.m. of April 22, to 9:00 a.m. of April 23, 1988.
threatening disease and could easily be cured.94
SJDH on the other hand disclaims liability by claiming that the
Furthermore, as Dr. Jaudian testified, with adequate intensive petitioning doctors are not its employees but are mere consultants
care, the mortality rate of dengue fever should fall to less than and independent contractors.
2%. Hence, the survival of the patient is directly related to early
and proper management of the illness.95 We affirm the hospital's liability not on the basis of Article 2180
of the Civil Code, but on the basis of the doctrine of apparent
To reiterate, Dr. Casumpang failed to timely diagnose Edmer with authority or agency by estoppel.
dengue fever despite the presence of its characteristic symptoms;
and as a consequence of the delayed diagnosis, he also failed to There is No Employer-Employee Relationship Between SJDH
promptly manage Edmer's illness. Had he immediately conducted and the Petitioning Doctors
confirmatory tests, (i.e., tourniquet tests and series of blood tests)
and promptly administered the proper care and management In determining whether an employer-employee relationship exists
needed for dengue fever, the risk of complications or even death, between the parties, the following elements must be present: (1)
could have been substantially reduced. selection and engagement of services; (2) payment of wages; (3)
the power to hire and fire; and (4) the power to control not only
the end to be achieved, but the means to be used in reaching such
an end.97
Furthermore, medical literature on dengue shows that early
diagnosis and management of dengue is critical in reducing the Control, which is the most crucial among the elements, is not
risk of complications and avoiding further spread of the virus.96 present in this case.
That Edmer later died of "Hypovolemic Shock/hemorrhagic
shock," "Dengue Hemorrhagic Fever Stage IV," a severe and fatal Based on the records, no evidence exists showing that SJDH
form of dengue fever, established the causal link between Dr. exercised any degree of control over the means, methods of
Casumpang's negligence and the injury. procedure and manner by which the petitioning doctors conducted
and performed their medical profession. SJDH did not control
Based on these considerations, we rule that the respondent their diagnosis and treatment. Likewise, no evidence was
successfully proved the element of causation. presented to show that SJDH monitored, supervised, or directed
the petitioning doctors in the treatment and management of
Liability of SJDH Edmer's case. In these lights, the petitioning doctors were not
employees of SJDH, but were mere independent contractors.
We now discuss the liability of the hospital.
SJDH is Solidarity Liable Based on The Principle of Agency or
The respondent submits that SJDH should not only be held Doctrine of Apparent Authority
vicariously liable for the petitioning doctors' negligence but also
for its own negligence. He claims that SJDH fell short of its duty Despite the absence of employer-employee relationship between
of providing its patients with the necessary facilities and SJDH and the petitioning doctors, SJDH is not free from
equipment as shown by the following liability.98

circumstances: As a rule, hospitals are not liable for the negligence of its
independent contractors. However, it may be found liable if the
(a) SJDH was not equipped with proper paging system; physician or independent contractor acts as an ostensible agent of
the hospital. This exception is also known as the "doctrine of
(b) the number of its doctors is not proportionate to the number of apparent authority."99
patients;
The US case of Gilbert v. Sycamore Municipal Hospital100
(c) SJDH was not equipped with a bronchoscope; abrogated the hospitals' immunity to vicarious liability of
independent contractor physicians. In that case, the Illinois
(d) when Edmer's oxygen was removed, the medical staff did not Supreme Court held
immediately
independent contractor is an employee of the hospital;
representation may be general and implied.102
that under the doctrine of apparent authority, hospitals could be
found vicariously liable for the negligence of an independent In Pamperin v. Trinity Memorial Hospital,103 questions were
contractor: raised on "what acts by the hospital or its agent are sufficient to
lead a reasonable person to conclude that the individual was an
Therefore, we hold that, under the doctrine of apparent authority, agent of the hospital." In ruling that the hospital's manifestations
a hospital can be held vicariously liable for the negligent acts of a can be proven without the express representation by the hospital,
physician providing care at the hospital, regardless of whether the the court relied on several cases from other jurisdictions, and held
physician is an independent contractor, unless the patient knows, that:
or should have known, that the physician is an independent
contractor. The elements of the action have been set out as (1) the hospital, by providing emergency room care and by failing
follows: to advise patients that they were being treated by the hospital's
agent and not its employee, has created the appearance of agency;
For a hospital to be liable under the doctrine of apparent authority, and
a plaintiff must show that: (1) the hospital, or its agent, acted in a
manner that would lead a reasonable person to conclude that the (2) patients entering the hospital through the emergency room,
individual who was alleged to be negligent was an employee or could properly assume that the treating doctors and staff of the
agent of the hospital; (2) where the acts of the agent create the hospital were acting on its behalf.
appearance of authority, the plaintiff must also prove that the
hospital had knowledge of and acquiesced in them; and (3) the In this case, the court considered the act of the hospital of holding
plaintiff acted in reliance upon the conduct of the hospital or its itself out as provider of complete medical care, and considered the
agent, consistent with ordinary care and prudence. (Emphasis hospital to have impliedly created the appearance of authority.
supplied)
b. Patient's reliance
The doctrine was applied in Nogales v. Capitol Medical
Center101 where this Court, through It involves an inquiry on whether the plaintiff acted in reliance on
the conduct of the hospital or its agent, consistent with ordinary
the ponenciaof Associate Justice Antonio T. Carpio, discussed the care and prudence.104
two factors in determining hospital liability as follows:
In Pamperin, the court held that the important consideration in
The first factor focuses on the hospital's manifestations and is determining the patient's reliance is: whether the plaintiff is
sometimes described as an inquiry whether the hospital acted in a seeking care from the hospital itself or whether the plaintiff is
manner which would lead a reasonable person to conclude that the looking to the hospital merely as a place for his/her personal
individual who was alleged to be negligent was an employee or physician to provide medical care.105
agent of the hospital. In this regard, the hospital need not make
express representations to the patient that the treating physician is
an employee of the hospital; rather a representation may be
general and implied. Thus, this requirement is deemed satisfied if the plaintiff can
prove that he/she relied upon the hospital to provide care and
xxxx treatment, rather than upon a specific physician. In this case, we
shall limit the determination of the hospital's apparent authority to
The second factor focuses on the patient's reliance. It is Dr. Casumpang, in view of our finding that Dr. Miranda is not
sometimes characterized as an inquiry on whether the plaintiff liable for negligence.
acted in reliance upon the conduct of the hospital or its agent,
consistent with ordinary care and prudence. (Citation omitted) SJDH Clothed Dr. Casumpang With Apparent Authority

In sum, a hospital can be held vicariously liable for the negligent SJDH impliedly held out and clothed Dr. Casumpang with
acts of a physician (or an independent contractor) providing care apparent authority leading the respondent to believe that he is an
at the hospital if the plaintiff can prove these two employee or agent of the hospital.

factors: first, the hospital's manifestations; and second, the Based on the records, the respondent relied on SJDH rather than
patient's reliance. upon Dr. Casumpang, to care and treat his son Edmer. His
testimony during trial showed that he and his wife did not know
a. Hospital's manifestations any doctors at SJDH; they also did not know that Dr. Casumpang
was an independent contractor. They brought their son to SJDH
It involves an inquiry on whether the hospital acted in a manner for diagnosis because of their family doctor's referral. The referral
that would lead a reasonable person to conclude that the did not specifically point to Dr. Casumpang or even to Dr.
individual alleged to be negligent was an employee or agent of the Miranda, but to SJDH.
hospital. As pointed out in Nogales, the hospital need not make
express representations to the patient that the physician or
Significantly, the respondent had relied on SJDH's representation The Antecedents
of Dr. Casumpang's authority. To recall, when Mrs. Cortejo
presented her Fortune Care card, she was initially referred to the
Fortune Care coordinator, who was then out of town. She was
thereafter referred to Dr. Casumpang, who is also accredited with In his Complaint-Affidavit5 for Serious Physical Injuries through
Fortune Care. In both instances, SJDH through its agent failed to Reckless Imprudence and Medical Malpractice against Dr. Agas,
advise Mrs. Cortejo that Dr. Casumpang is an independent Dr. Cruz alleged, among others, that sometime in May 2003, he
contractor. engaged the services of St. Luke's Medical Center (SLMC) for a
medical check-up; that after being admitted in SLMC on May 28,
Mrs. Cortejo accepted Dr. Casumpang's services on the 2003, he underwent stool, urine, blood, and other body fluid tests
reasonable belief that such were being provided by SJDH or its conducted by the employees and doctors of the said hospital; that
employees, agents, or servants. By referring Dr. Casumpang to on May 29, 2003, he was sent to the Gastro-Enterology
care and treat for Edmer, SJDH impliedly held out Dr. Department for a scheduled gastroscopy and colonoscopy; that
Casumpang, not only as an accredited member of Fortune Care, because the specialist assigned to perform the procedure was
but also as a member of its medical staff. SJDH cannot now nowhere to be found, he gave the colonoscopy results to the
disclaim liability since there is no showing that Mrs. Cortejo or attending female anesthesiologist for the information and
the respondent knew, or should have known, that Dr. Casumpang consideration of the assigned specialist; that, thereafter, he was
is only an independent contractor of the hospital. In this case, sedated and the endoscopic examination was carried out; that
estoppel has already set in. when he regained consciousness, he felt that something went
wrong during the procedure because he felt dizzy, had cold
We also stress that Mrs. Cortejo's use of health care plan (Fortune clammy perspiration and experienced breathing difficulty; that he
Care) did not affect SJDH's liability. The only effect of the could not stand or sit upright because he felt so exhausted and so
availment of her Fortune Care card benefits is that her choice of much pain in his abdomen; that when he was about to urinate in
physician is limited only to physicians who are accredited with the comfort room, he collapsed; that he tried to consult the
Fortune Care. Thus, her use of health care plan in this case only specialist who performed the colonoscopy but he was nowhere to
limited the choice of doctors (or coverage of services, amount be found; and that his cardiologist, Dra. Agnes Del Rosario, was
etc.) and not the liability of doctors or the hospital. able to observe his critical condition and immediately referred
him to the surgical department which suspected that he had
WHEREFORE, premises considered, this Court PARTLY hemorrhage in his abdomen and advised him to undergo an
GRANTS the consolidated petitions. The Court finds Dr. Noel emergency surgical operation.
Casumpang and San Juan de Dios Hospital solidarity liable for
negligent medical practice. We SET ASIDE the finding of
liability as to Dr. Ruby Sanga-Miranda. The amounts of
P45,000.00 as actual damages and P500,000.00 as moral damages Dr. Cruz further averred that he agreed to the operation and upon
should each earn legal interest at the rate of six percent (6%) per waking up at the ICU on May 30, 2003, he found out that the
annum computed from the date of the judgment of the trial court. doctors did an exploratory laparatomy because of the internal
The Court AFFIRMSthe rest of the Decision dated October 29, bleeding; that he learned that the doctors cut a portion of the left
2004 and the Resolution dated January 12, 2006 in CA-G.R. CV side of his colon measuring 6-8 inches because it had a partial tear
No. 56400. of the colonic wall which caused the internal bleeding; that
despite the painkillers, he was under tremendous pain in the
SO ORDERED. incision area during his recovery period in the ICU and had fever;
and that he had intravenous tubes attached to his arms, subclavian
artery on the left part of his chest and a nasogastric tube through
his nose.
DR. JAIME T. CRUZ, Petitioner, v. FELICISIMO V. AGAS,
JR., Respondent.

Dr. Cruz claimed that Dr. Agas admitted that he was the one who
performed the colonoscopy procedure but the latter insisted that
This petition for review on certiorari under Rule 45 of the Rules nothing went wrong. On June 7, 2003, he was discharged from
of Court assails the May 22, 2012 Decision1 and October 18, SLMC. Nevertheless, he complained that he had a hard time
2012 Resolution2 of the Court of Appeals (CA), in CA-G.R. SP digesting his food; that he was frequently fed every two hours
No. 111910, which affirmed the March 2, 20073 and September because he easily got full; that he had fresh blood stools every
23, 20094 Resolutions of the Secretary of Justice. The said time he moved his bowel; that he had lost his appetite and had
resolutions let stand the February 16, 2004 Resolution of the gastric acidity; that he slept most of the day; and that he was in
Office of the Prosecutor of Quezon City, dismissing the complaint good physical condition before the colonoscopy procedure. He
of petitioner Dr. Jaime T. Cruz (Dr. Cruz) for Serious Physical asserted that at the time of the filing of the complaint, he was still
Injuries through Reckless Imprudence and Medical Malpractice weak, tired and in pain.
against respondent, Dr. Felicisimo V. Agas, Jr. (Dr. Agas).
Defense of Dr. Agas such executive determination was tainted with manifest error or
grave abuse of discretion. It stated that the public prosecutor's
finding of lack of probable cause against Dr. Agas was in
accordance with law and that his alleged negligence was not
Dr. Agas, on the other hand, countered that Dr. Cruz failed to adequately established by Dr. Cruz.
prove the basic elements of reckless imprudence or negligence.
He averred that Dr. Cruz unfairly made it appear that he did not
know that he would perform the procedure. He explained that
before the start of the colonoscopy procedure, he was able to The CA also declared that Dr. Cruz failed to state in his
confer with Dr. Cruz and review his medical history which was Complaint-Affidavit the specific procedures that Dr. Agas failed
taken earlier by a fellow gastrointestinal physician. He claimed to do which a reasonable prudent doctor would have done, or
that the gastroscopy and colonoscopy procedures conducted on specific norms he failed to observe which a reasonably prudent
Dr. Cruz were completely successful considering that the latter doctor would have complied with. The CA pointed out that Dr.
did not manifest any significant adverse reaction or body Agas was able to satisfactorily explain in his Counter-Affidavit
resistance during the procedures and that his vital signs were that the complications suffered by Dr. Cruz was not caused by his
normal throughout the procedure.6chanrobleslaw negligence or was the result of medical malpractice. Dr. Agas
explained as follows:chanRoblesvirtualLawlibrary

That the complication was due to the abnormal condition and

Dr. Agas added that certifications and sworn statements were configuration of the digestive system, colon in particular, of the
submitted by the Assistant Medical Director for Professional complainant and not from any negligent act in connection with the
Services, the Director of the Institute of Digestive Diseases, the conduct of colonoscopy. The surgical findings (xxx) revealed
anesthesiologist, and the hospital nurse attesting to the fact that marked adhesions in the sigmoid colon which is not and never
the intraperitonial bleeding which developed after the within my control. That the tear in the serosa (the outermost layer
colonoscopy procedure, was immediately recognized, evaluated, of the colonic wall which has 4 layers) happened likely because of
carefully managed, and corrected; that he provided an adequate the marked interloop adhesions and tortuousity of the sigmoid
and reasonable standard of care to Dr. Cruz; that the endoscopist segment of the colon. These adhesions that connect the serosa to
followed all precautionary measures; that the colonoscopy the peritoneal lining of each loop detached from the serosa during
procedure was done properly; that he was not negligent or the procedure. It is not possible to detect the presence of marked
reckless in conducting the colonoscopy procedure; that he did not adhesions prior to the endoscopic procedure because no clinical
deviate from any standard medical norm, practice or procedure; findings, laboratory tests or diagnostic imaging such as x-ray,
and that he exercised competence and diligence in rendering ultrasound or computed tomography (CT scan) of the abdomen
medical services to Dr. Cruz.7chanrobleslaw can diagnose these conditions. This can only be detected by
surgically opening up the abdomen. Moreover, marked adhesions
and serosal tear, in particular, cannot likewise be detected by
colonoscopy because they are in the outer wall of the colon and
Antecedents at the Prosecution Level only the inner lining of the colon is within the view of the
colonoscope (camera).9

The CA further wrote that the counter-affidavit of Dr. Agas was

On February 16, 2004, the Office of the City Prosecutor (OCP) supported by the sworn affidavit of Dr. Jennifel S. Bustos, an
issued a resolution dismissing the complaint for Serious Physical anesthesiologist at the SLMC and the affidavit of Evelyn E.
Injuries through Reckless Imprudence and Medical Malpractice. Daulat, a nurse at SLMC, both swearing under oath that Dr. Agas
Aggrieved, Dr. Cruz filed a petition for review with the was not negligent in conducting a gastroscopy and colonoscopy
Department of Justice (DOJ) but the same was dismissed in its procedure on Dr. Cruz and the certification issued by the Hospital
March 2, 2007 Resolution. Dr. Cruz filed a motion for Ethics Committee which stated that Dr. Cruz was given an
reconsideration but it was denied by the DOJ in its September 23, adequate and reasonable standard of care; that Dr. Agas followed
2009 Resolution.8chanrobleslaw all precautionary measures in safeguarding Dr. Cruz from any
possible complications; and that the colonoscopy was done
properly.

At the Court of Appeals

Hence, this petition.

Not satisfied, Dr. Cruz filed a petition for certiorari before the CA ISSUE
questioning the unfavorable DOJ resolutions. On May 22, 2012,
the CA rendered a decision affirming the said DOJ resolutions.
The CA explained that, as a matter of sound judicial policy, courts
would not interfere with the public prosecutor's wide discretion of WHETHER OR NOT THE CA WAS CORRECT IN
determining probable cause in a preliminary investigation unless AFFIRMING THE DECISION OF THE DOJ THAT NO
PROBABLE CAUSE EXISTS FOR FILING AN there was "inexcusable lack of precaution" on the part of Dr.
INFORMATION AGAINST THE RESPONDENT, THAT THE Agas.
RESPONDENT WAS NOT NEGLIGENT AND THAT THERE
WAS NO DENIAL OF DUE PROCESS.

Non-interference with Executive Determination of Probable Res Ipsa Loquitur Doctrine

Cause in Preliminary Investigations
Not Applicable Against Respondent

Under the doctrine of separation of powers, courts have no right

to directly decide on matters over which full discretionary Literally, res ipsa loquitur means the thing speaks for itself. It is
authority has been delegated to the Executive Branch of the the rule that the fact of the occurrence of an injury, taken with the
Government, or to substitute their own judgment for that of the surrounding circumstances, may permit an inference or raise a
Executive Branch, represented in this case by the Department of presumption of negligence, or make out a plaintiff's prima facie
Justice. The settled policy is that the courts will not interfere with case, and present a question of fact for defendant to meet with an
the executive determination of probable cause for the purpose of explanation.11chanrobleslaw
filing an Information, in the absence of grave abuse of discretion.
That abuse of discretion must be so patent and gross as to amount
to an evasion of a positive duty or a virtual refusal to perform a
duty enjoined by law or to act at all in contemplation of law, such The requisites for the applicability of the doctrine of res ipsa
as where the power is exercised in an arbitrary and despotic loquitur are: (1) the occurrence of an injury; (2) the thing which
manner by reason of passion or hostility. caused the injury was under the control and management of the
defendant; (3) the occurrence was such that in the ordinary course
of things, would not have happened if those who had control or
management used proper care; and (4) the absence of explanation
Medical Negligence and Malpractice Not Established by the defendant. Of the foregoing requisites, the most
instrumental is the control and management of the thing which
caused the injury.12chanrobleslaw

In the case at bench, Dr. Cruz failed to show that the DOJ gravely
abused its discretion in finding that there was lack of probable
cause and dismissing the complaint against Dr. Agas for Serious In this case, the Court agrees with Dr. Agas that his purported
Physical Injuries through Reckless Imprudence and Medical negligence in performing the colonoscopy on Dr. Cruz was not
Malpractice. immediately apparent to a layman to justify the application of res
ipsa loquitur doctrine.

A medical negligence case can prosper if the patient can present

solid proof that the doctor, like in this case, either failed to do Dr. Agas was able to establish that the internal bleeding sustained
something which a reasonably prudent doctor would have done, by Dr. Cruz was due to the abnormal condition and configuration
or that he did something that a reasonably prudent doctor would of his sigmoid colon which was beyond his control considering
not have done, and such failure or action caused injury to the that the said condition could not be detected before a
patient. colonoscopic procedure. Dr. Agas adequately explained that no
clinical findings, laboratory tests, or diagnostic imaging, such as
To successfully pursue this kind of case, a patient must only prove x-rays, ultrasound or computed tomography (CT) scan of the
that a health care provider either failed to do something which a abdomen, could have detected this condition prior to an
reasonably prudent health care provider would have done, or that endoscopic procedure. Specifically, Dr. Agas
he did something that a reasonably prudent provider would not wrote:chanRoblesvirtualLawlibrary
have done; and that failure or action caused injury to the patient.
Simply put, the elements are duty, breach, injury and proximate On the other hand, in the present case, the correlation between
causation.10 petitioner's injury, i.e., tear in the serosa of sigmoid colon, and the
colonoscopy conducted by respondent to the petitioner clearly
In this case, Dr. Cruz has the burden of showing the negligence or requires the presentation of an expert opinion considering that no
recklessness of Dr. Agas. Although there is no dispute that Dr. perforation of the sigmoid colon was ever noted during the
Cruz sustained internal hemorrhage due to a tear in the serosa of laparotomy. It cannot be overemphasized that the colonoscope
his sigmoid colon, he failed to show that it was caused by Dr. inserted by the respondent only passed through the inside of
Agas's negligent and reckless conduct of the colonoscopy petitioner's sigmoid colon while the damaged tissue, i.e., serosa,
procedure. In other words, Dr. Cruz failed to show and explain which caused the bleeding, is located in the outermost layer of the
that particular negligent or reckless act or omission committed by colon. It is therefore impossible for the colonoscope to touch,
Dr. Agas. Stated differently, Dr. Cruz did not demonstrate that scratch, or even tear the serosa since the said membrane is beyond
reach of the colonoscope in the absence of perforation on the Alleging that the dentist told him that the operation conducted on
colon.13 his mandible was improperly done, Rosit went back to Dr.
Gestuvo to demand a loan to defray the cost of the additional
Dr. Cruz failed to rebut this. operation as well as the expenses of the trip to Cebu. Dr. Gestuvo
gave Rosit P4,500.

WHEREFORE, the petition is DENIED.

Rosit went to Cebu on February 19, 1999, still suffering from pain
and could hardly open his mouth.

NILO B. ROSIT, Petitioner, v. DAVAO DOCTORS

HOSPITAL AND DR. ROLANDO G. GESTUVO,
Respondent. In Cebu, Dr. Pangan removed the plate and screws thus installed
by Dr. Gestuvo and replaced them with smaller titanium plate and
screws. Dr. Pangan also extracted Rosit's molar that was hit with a
screw and some bone fragments. Three days after the operation,
This is a petition filed under Rule 45 of the Rules of Court Rosit was able to eat and speak well and could open and close his
assailing the Decision and Resolution dated January 22, 20131 mouth normally.7
and November 7, 2013,2 respectively, of the Court of Appeals,
Cagayan De Oro City (CA), in CA-G.R. CV No. 00911-MIN. The
CA Decision reversed the Decision dated September 14, 20043 of
the Regional Trial Court, Branch 33 in Davao City-(RTC) in Civil On his return to Davao, Rosit demanded that Dr. Gestuvo
Case No. 27,354-99, a suit for damages thereat which Nilo B. reimburse him for the cost of the operation and the expenses he
Rosit (Rosit) commenced against Dr. Rolando Gestuvo (Dr. incurred in Cebu amounting to P140,000, as well as for the
Gestuvo). P50,000 that Rosit would have to spend for the removal of the
plate and screws that Dr. Pangan installed. Dr. Gestuvo refused to
pay.8

Factual Antecedents

Thus, Rosit filed a civil case for damages and attorney's fees with
the RTC against Dr. Gestuvo and DDH, the suit docketed as Civil
On January 15, 1999, Rosit figured in a motorcycle accident. The Case No. 27,354-99.
X-ray soon taken the next day at the Davao Doctors Hospital
(DDH) showed that he fractured his jaw. Rosit was then referred
to Dr. Gestuvo, a specialist in mandibular injuries,4 who, on
January 19, 1999, operated on Rosit. The Ruling of the Regional Trial Court

During the operation, Dr. Gestuvo used a metal plate fastened to The RTC freed DDH from liability on the ground that it exercised
the jaw with metal screws to immobilize the mandible. As the the proper diligence in the selection and supervision of Dr.
operation required the smallest screws available, Dr. Gestuvo cut Gestuvo, but adjudged Dr. Gestuvo negligent and ruled, thus:
the screws on hand to make them smaller. Dr. Gestuvo knew that
there were smaller titanium screws available in Manila, but did FOR ALL THE FOREGOING, finding the plaintiff Nilo B. Rosit
not so inform Rosit supposing that the latter would not be able to to have preponderantly established his cause of action in the
afford the same.5 complaint against defendant Dr. Rolando G. Gestuvo only,
judgment is hereby rendered for the plaintiff and against said
defendant, ordering the defendant DR. ROLANDO G.
GESTUVO to pay unto plaintiff NILO B. ROSIT the
Following the procedure, Rosit could not properly open and close following:chanRoblesvirtualLawlibrary
his mouth and was in pain. X-rays done on Rosit two (2) days
after the operation showed that the fracture in his jaw was aligned
but the screws used on him touched his molar. Given the X-ray
results, Dr. Gestuvo referred Rosit to a dentist. The dentist who a)
checked Rosit, Dr. Pangan, opined that another operation is
necessary and that it is to be performed in Cebu.6 the sum of ONE HUNDRED FORTY THOUSAND ONE
HUNDRED NINETY NINE PESOS and 13/100 (P140,199.13)
representing reimbursement of actual expenses incurred by
plaintiff in the operation and re-operation of his mandible;
b) hereby MODIFIED. The monetary awards adjudged in favor of
Nilo B. Rosit are hereby DELETED for lack of basis.
the sum of TWENTY NINE THOUSAND AND SIXTY EIGHT
PESOS (P29,068.00) representing reimbursement of the filing
fees and appearance fees;
SO ORDERED.
c)
Unlike the RTC, the CA ruled that the res ipsa loquitur principle
the sum of ONE HUNDRED FIFTY THOUSAND PESOS is not applicable and that the testimony of an expert witness is
(P150,000.00) as and for attorney's fees; necessary for a finding of negligence. The appellate court also
gave credence to Dr. Pangan's letter stating the opinion that Dr.
d) Gestuvo did not commit gross negligence in his emergency
management of Rosit's fractured mandible.
the amount of FIFTY THOUSAND PESOS (P50,000.00) as
moral damages;

e) Rosit's motion for reconsideration was denied in the CA's

November 7, 2013 Resolution.
the amount of TEN THOUSAND PESOS (P10,000.00) as
exemplary damages; and

f) Hence, the instant appeal.

the costs of the suit.

The Issue

For lack of merit, the complaint against defendant DAVAO

DOCTORS HOSPITAL and the defendants' counterclaims are
hereby ordered DISMISSED. The ultimate issue for our resolution is whether the appellate court
correctly absolved Dr. Gestuvo from liability.

Cost against Dr. Rolando G. Gestuvo.

The Court's Ruling

SO ORDERED.
The petition is impressed with merit.
In so ruling, the trial court applied the res ipsa loquitur principle
holding that "the need for expert, medical testimony may be
dispensed with because the injury itself provides the proof of
negligence." In Flores v. Pineda,9 the Court explained the concept of a medical
negligence case and the elements required for its prosecution,
viz:chanRoblesvirtualLawlibrary

Therefrom, both parties appealed to the CA.

A medical negligence case is a type of claim to redress a wrong

committed by a medical professional, that has caused bodily harm
The Ruling of the Court of Appeals to or the death of a patient. There are four elements involved in a
medical negligence case, namely: duty, breach, injury, and
proximate causation.

In its January 22, 2013 Decision, the CA modified the appealed

judgment by deleting the awards made by the trial court,
disposing as follows: Duty refers to the standard of behavior which imposes restrictions
on one's conduct. The standard in turn refers to the amount of
WHEREFORE, the appeal filed by Gestuvo is GRANTED. The competence associated with the proper discharge of the
Decision dated September 14, 2004 of the Regional Trial Court, profession. A physician is expected to use at least the same level
Branch 33, Davao City, rendered in Civil Case No. 27,354-99 is of care that any other reasonably competent doctor would use
under the same circumstances. Breach of duty occurs when the
physician fails to comply with these professional standards. If
injury results to the patient as a result of this breach, the physician In its assailed Decision, the CA refused to acknowledge the
is answerable for negligence. (Emphasis supplied) application of the res ipsa loquitur doctrine on the ground that the
foregoing elements are absent. In particular, the appellate court is
of the position that post-operative pain is not unusual after surgery
and that there is no proof that the molar Dr. Pangan removed is
the same molar that was hit by the screw installed by Dr. Gestuvo
in Rosit's mandible. Further, a second operation was conducted
An expert witness is not necessary as the res ipsa loquitur doctrine within the 5-week usual healing period of the mandibular fracture
is applicable so that the second element cannot be considered present. Lastly,
the CA pointed out that the X-ray examination conducted on Rosit
prior to his first surgery suggests that he had "chronic
inflammatory lung disease compatible," implying that the injury
To establish medical negligence, this Court has held that an expert may have been due to Rosit's peculiar condition, thus effectively
testimony is generally required to define the standard of behavior negating the presence of the third element.13
by which the court may determine whether the physician has
properly performed the requisite duty toward the patient. This is
so considering that the requisite degree of skill and care in the
treatment of a patient is usually a matter of expert opinion.10 After careful consideration, this Court cannot accede to the CA's
findings as it is at once apparent from the records that the
essential requisites for the application of the doctrine of res ipsa
loquitur are present.
Solidum v. People of the Philippines11 provides an exception.
There, the Court explained that where the application of the
principle of res ipsa loquitur is warranted, an expert testimony
may be dispensed with in medical negligence cases: The first element was sufficiently established when Rosit proved
that one of the screws installed by Dr. Gestuvo struck his molar. It
Although generally, expert medical testimony is relied upon in was for this issue that Dr. Gestuvo himself referred Rosit to Dr.
malpractice suits to prove that a physician has done a negligent Pangan. In fact, the affidavit of Dr. Pangan presented by Dr.
act or that he has deviated from the standard medical procedure, Gestuvo himself before the trial court narrated that the same
when the doctrine of res ipsa loquitur is availed by the plaintiff, molar struck with the screw installed by Dr. Gestuvo was
the need for expert medical testimony is dispensed with because examined and eventually operated on by Dr. Pangan. Dr. Gestuvo
the injury itself provides the proof of negligence. The reason is cannot now go back and say that Dr. Pangan treated a molar
that the general rule on the necessity of expert testimony applies different from that which was affected by the first operation.
only to such matters clearly within the domain of medical science,
and not to matters that are within the common knowledge of
mankind which may be testified to by anyone familiar with the
facts. x x x Clearly, had Dr. Gestuvo used the proper size and length of
screws and placed the same in the proper locations, these would
not have struck Rosit's teeth causing him pain and requiring him
to undergo a corrective surgery.
Thus, courts of other jurisdictions have applied the doctrine in the
following situations: leaving of a foreign object in the body of the
patient after an operation, injuries sustained on a healthy part of
the body which was not under, or in the area, of treatment, Dr. Gestuvo knew that the screws he used on Rosit were too large
removal of the wrong part of the body when another part was as, in fact, he cut the same with a saw.14 He also stated during
intended, knocking out a tooth while a patient's jaw was under trial that common sense dictated that the smallest screws available
anesthetic for the removal of his tonsils, and loss of an eye while should be used. More importantly, he also knew that these screws
the patient plaintiff was under the influence of anesthetic, during were available locally at the time of the operation.15 Yet, he did
or following an operation for appendicitis, among others. not avail of such items and went ahead with the larger screws and
merely sawed them off. Even assuming that the screws were
We have further held that resort to the doctrine of res ipsa loquitur already at the proper length after Dr. Gestuvo cut the same, it is
as an exception to the requirement of an expert testimony in apparent that he negligently placed one of the screws in the wrong
medical negligence cases may be availed of if the following area thereby striking one of Rosit's teeth.
essential requisites are satisfied: (1) the accident was of a kind
that does not ordinarily occur unless someone is negligent; (2) the
instrumentality or agency that caused the injury was under the
exclusive control of the person charged; and (3) the injury In any event, whether the screw hit Rosit's molar because it was
suffered must not have been due to any voluntary action or too long or improperly placed, both facts are the product of Dr.
contribution of the person injured.12 Gestuvo's negligence. An average man of common intelligence
would know that striking a tooth with any foreign object much Witness
less a screw would cause severe pain. Thus, the first essential
requisite is present in this case. No, your Honor.

xxxx

Anent the second element for the res ipsa loquitur doctrine Witness
application, it is sufficient that the operation which resulted in the
screw hitting Rosit's molar was, indeed, performed by Dr. The reason I did not inform him anymore Judge because what I
Gestuvo. No other doctor caused such fact. thought he was already hard up with the down payment. And if I
will further introduce him this screws, the more he will not be
able to afford the operation.

The CA finds that Rosit is guilty of contributory negligence in xxxx

having Dr. Pangan operate on him during the healing period of his
fractured mandible. What the CA overlooked is that it was Dr. Court
Gestuvo himself who referred Rosit to Dr. Pangan. Nevertheless,
Dr. Pangan's participation could not have contributed to the This titanium screws and plates were available then it is up to
reality that the screw that Dr. Gestuvo installed hit Rosit's molar. Rosit to decide whether to use it or not because after all the
material you are using is paid by the patient himscll, is it not?

Witness
Lastly, the third element that the injury suffered must not have
been due to any voluntary action or contribution of the person Yes, that is true.
injured was satisfied in this case. It was not shown that Rosit's
lung disease could have contributed to the pain. What is clear is Li v. Soliman17 made the following disquisition on the relevant
that he suffered because one of the screws that Dr. Gestuvo Doctrine of Informed Consent in relation to medical negligence
installed hit Rosit's molar. cases, to wit:

The doctrine of informed consent within the context of physician-

patient relationships goes far back into English common law. x x
Clearly then, the res ipsa loquitur doctrine finds application in the x From a purely ethical norm, informed consent evolved into a
instant case and no expert testimony is required to establish the general principle of law that a physician has a duty to disclose
negligence of defendant Dr. Gestuvo. what a reasonably prudent physician in the medical community in
the exercise of reasonable care would disclose to his patient as to
whatever grave risks of injury might be incurred from a proposed
course of treatment, so that a patient, exercising ordinary care for
Petitioner was deprived of the opportunity to make an "informed his own welfare, and faced with a choice of undergoing the
consent" proposed treatment, or alternative treatment, or none at all, may
intelligently exercise his judgment by reasonably balancing the
probable risks against the probable benefits.

What is more damning for Dr. Gestuvo is his failure to inform

Rosit that such smaller screws were available in Manila, albeit at
a higher price.16 As testified to by Dr. Gestuvo himself: xxxx

Court Alright.

This titanium materials according to you were already available in There are four essential elements a plaintiff must prove in a
the Philippines since the time of Rosit's accident? malpractice action based upon the doctrine of informed consent:
"(1) the physician had a duty to disclose material risks; (2) he
Witness failed to disclose or inadequately disclosed those risks; (3) as a
direct and proximate result of the failure to disclose, the patient
Yes, your Honor. consented to treatment she otherwise would not have consented
to; and (4) plaintiff was injured by the proposed treatment." The
xxxx gravamen in an informed consent case requires the plaintiff to
"point to significant undisclosed information relating to the
Court treatment which would have altered her decision to undergo it."
(Emphasis supplied)
Did you inform Rosit about the existence of titanium screws and
plates which according to you is the screws and plates of choice? The four adverted essential elements above are present here.
weight. The CA, therefore, erred when it considered the affidavit
of Dr. Pangan, mpreso for considering the same as expert
First, Dr. Gestuvo clearly had the duty of disclosing to Rosit the testimony.
risks of using the larger screws for the operation. This was his
obligation as the physician undertaking the operation.

Moreover, even if such affidavit is considered as admissible and

the testimony of an expert witness, the Court is not bound by such
Second, Dr. Gestuvo failed to disclose these risks to Rosit, testimony. As ruled in Ilao-Quianay v. Mapile:20
deciding by himself that Rosit could not afford to get the more
expensive titanium screws. Indeed, courts are not bound by expert testimonies. They may
place whatever weight they choose upon such testimonies in
accordance with the facts of the case. The relative weight and
sufficiency of expert testimony is peculiarly within the province
Third, had Rosit been informed that there was a risk that the of the trial court to decide, considering the ability and character of
larger screws are not appropriate for the operation and that an the witness, his actions upon the witness stand, the weight and
additional operation replacing the screws might be required to process of the reasoning by which he has supported his opinion,
replace the same, as what happened in this case, Rosit would not his possible bias in favor of the side for whom he testifies, and
have agreed to the operation. It bears pointing out that Rosit was, any other matters which serve to illuminate his statements. The
in fact, able to afford the use of the smaller titanium screws that opinion of an expert should be considered by the court in view of
were later used by Dr. Pangan to replace the screws that were all the facts and circumstances of the case. The problem of the
used by Dr. Gestuvo. evaluation of expert testimony is left to the discretion of the trial
court whose ruling thereupon is not revicwable in the absence of
an abuse of that discretion.

Fourth, as a result of using the larger screws, Rosit experienced Thus, the belief of Dr. Pangan whether Dr. Gestuvo is guilty of
pain and could not heal properly because one of the screws hit his negligence or not will not bind the Court. The Court must weigh
molar. This was evident from the fact that just three (3) days after and examine such testimony and decide for itself the merits
Dr. Pangan repeated the operation conducted by Dr. Gestuvo, thereof.
Rosit was pain-free and could already speak. This is compared to
the one (1) month that Rosit suffered pain and could not use his
mouth after the operation conducted by Dr. Gestuvo until the
operation of Dr. Pangan. As discussed above, Dr. Gestuvo's negligence is clearly
demonstrable by the doctrines of res ipsa loquitur and informed
consent.

Without a doubt, Dr. Gestuvo is guilty of withholding material

information which would have been vital in the decision of Rosit
in going through with the operation with the materials at hand. Damages
Thus, Dr. Gestuvo is also guilty of negligence on this ground.

For the foregoing, the trial court properly awarded Rosit actual
Dr. Pangan's Affidavit is not admissible damages after he was able to prove the actual expenses that he
incurred due to the negligence of Dr. Gestuvo. In Mendoza v.
Spouses Gomez,21 the Court explained that a claimant is entitled
to actual damages when the damage he sustained is the natural
The appellate court's Decision absolving Dr. Gestuvo of and probable consequences of the negligent act and he adequately
negligence was also anchored on a letter signed by Dr. Pangan proved the amount of such damage.
who stated the opinion that Dr. Gestuvo did not commit gross
negligence in his emergency management of Mr. Rosit's fractured
mandible.18 Clearly, the appellate court overlooked the
elementary principle against hearsay evidence. Rosit is also entitled to moral damages as provided under Article
2217 of the Civil Code,22 given the unnecessary physical
suffering he endured as a consequence of defendant's negligence.

In Dantis v. Maghinang, Jr.,19 the Court reiterated the oft-

repeated rule that "an affidavit is merely hearsay evidence where
its affiant/maker did not take the witness stand." Here, Dr. Pangan To recall, from the time he was negligently operated upon by Dr.
never took the witness stand to affirm the contents of his affidavit. Gestuvo until three (3) days from the corrective surgery
Thus, the affidavit is inadmissible and cannot be given any
performed by Dr. Pangan, or for a period of one (1) month, Rosit
suffered pain and could not properly use his jaw to speak or eat.
Carlos Borromeo lost his wife Lillian when she died after
undergoing a routine appendectomy. The hospital and the
attending surgeon submit that Lillian bled to death due to a rare,
The trial court also properly awarded attorney's fees and costs of life-threatening condition that prevented her blood from clotting
suit under Article 2208 of the Civil Code,23 since Rosit was normally. Carlos believes, however, that the hospital and the
compelled to litigate due to Dr. Gestuvo's refusal to pay for surgeon were simply negligent in the care of his late wife.
Rosit's damages.

On January 22, 2010, the Court of Appeals (CA) in CA-G.R CV

As to the award of exemplary damages, the same too has to be No. 890961 dismissed Carlos' complaint and thus reversed the
affirmed. In Mendoza,24 the Court enumerated the requisites for April 10, 2007 decision of the Regional Trial Court (RTC) in
the award of exemplary damages: Civil Case No. 2000-603-MK2 which found the respondents
liable for medical negligence.
Our jurisprudence sets certain conditions when exemplary
damages may be awarded: First, they may be imposed by way of
example or correction only in addition, among others, to
compensatory damages, and cannot be recovered as a matter of The present petition for review on certiorari seeks to reverse the
right, their determination depending upon the amount of CA’s January 22, 2010 decision.
compensatory damages that may be awarded to the claimant.
Second, the claimant must first establish his right to moral,
temperate, liquidated or compensatory damages. Third, the
wrongful act must be accompanied by bad faith, and the award ANTECEDENTS
would be allowed only if the guilty party acted in a wanton,
fraudulent, reckless, oppressive or malevolent manner.

The three (3) requisites are met. Dr. Gestuvo's actions are clearly The petitioner, Carlos Borromeo, was the husband of the late
negligent. Likewise, Dr. Gestuvo acted in bad faith or in a Lilian V. Borromeo (Lilian). Lilian was a patient of the
wanton, fraudulent, reckless, oppressive manner when he was in respondent Family Care Hospital, Inc. (Family Care) under the
breach of the doctrine of informed consent. Dr. Gestuvo had the care of respondent Dr. Ramon Inso (Dr. Inso).
duty to fully explain to Rosit the risks of using large screws for
the operation. More importantly, he concealed the correct medical
procedure of using the smaller titanium screws mainly because of
his erroneous belief that Rosit cannot afford to buy the expensive On July 13, 1999, the petitioner brought his wife to the Family
titanium screws. Such concealment is clearly a valid basis for an Care Hospital because she had been complaining of acute pain at
award of exemplary damages. the lower stomach area and fever for two days. She was admitted
at the hospital and placed under the care of Dr. Inso.

WHEREFORE, the instant petition is GRANTED. The CA

Decision dated January 22, 2013 and Resolution dated November Dr. Inso suspected that Lilian might be suffering from acute
7, 2013 in CA-G.R. CV No. 00911-MIN are hereby REVERSED appendicitis. However, there was insufficient data to rule out
and SET ASIDE. Further, the Decision dated September 14, 2004 other possible causes and to proceed with an appendectomy.
of the Regional Trial Court, Branch 33 in Davao City in Civil Thus, he ordered Lilian’s confinement for testing and evaluation.
Case No. 27,345-99 is hereby REINSTATED and AFFIRMED.

Over the next 48 hours, Lilian underwent multiple tests such as

SO ORDERED. complete blood count, urinalysis, stool exam, pelvic ultrasound,
and a pregnancy test. However, the tests were not conclusive
enough to confirm that she had appendicitis.

CARLOS BORROMEO, Petitioner,

vs. Meanwhile, Lilian’s condition did not improve. She suffered from
spiking fever and her abdominal pain worsened. The increasing
FAMILY CARE HOSPITAL, INC. and RAMON S. INSO, tenderness of her stomach, which was previously confined to her
M.D., Respondents. lower right side, had also extended to her lower left side. Lilian
abruptly developed an acute surgical abdomen.
Inso suspected that Lilian had Disseminated Intravascular
Coagulation (DIC), a blood disorder characterized by bleeding in
On July 15, 1999, Dr. Inso decided to conduct an exploratory many parts of her body caused by the consumption or the loss of
laparotomy on Lilian because of the findings on her abdomen and the clotting factors in the blood. However, Dr. Inso did not have
his fear that she might have a ruptured appendix. Exploratory the luxury to conduct further tests because the immediate need
laparotomy is a surgical procedure involving a large incision on was to resuscitate Lilian.
the abdominal wall that would enable Dr. Inso to examine the
abdominal cavity and identify the cause of Lilian’s symptoms.
After explaining the situation, Dr. Inso obtained the patient’s
consent to the laparotomy. Dr. Inso and the nurses performed cardiopulmonary resuscitation
(CPR) on Lilian. Dr. Inso also informed her family that there may
be a need to re-operate on her, but she would have to be put in an
Intensive Care Unit (ICU). Unfortunately, Family Care did not
At around 3:45 P.M., Lilian was brought to the operating room have an ICU because it was only a secondary hospital and was not
where Dr. Inso conducted the surgery. During the operation, Dr. required by the Department of Health to have one. Dr. Inso
Inso confirmed that Lilian was suffering from acute appendicitis. informed the petitioner that Lilian would have to be transferred to
He proceeded to remove her appendix which was already infected another hospital.
and congested with pus.

At around 3:30 A.M., Dr. Inso personally called the Perpetual

The operation was successful. Lilian’s appearance and vital signs Help Medical Center to arrange Lilian’s transfer, but the latter had
improved. At around 7:30 P.M., Lilian was brought back to her no available bed in its ICU. Dr. Inso then personally coordinated
private room from the recovery room. with the Muntinlupa Medical Center (MMC) which had an
available bed.

At around 1:30 A.M. on July 16, 1999, roughly six hours after
Lilian was brought back to her room, Dr. Inso was informed that At around 4:00 A.M., Lilian was taken to the MMC by ambulance
her blood pressure was low. After assessing her condition, he accompanied by the resident doctor on duty and a nurse. Dr. Inso
ordered the infusion of more intravenous (IV) fluids which followed closely behind in his own vehicle.
somehow raised her blood pressure.

Upon reaching the MMC, a medical team was on hand to

Despite the late hour, Dr. Inso remained in the hospital to monitor resuscitate Lilian. A nasogastric tube (NGT) was inserted and IV
Lilian’s condition. Subsequently, a nurse informed him that Lilian fluids were immediately administered to her. Dr. Inso asked for a
was becoming restless. Dr. Inso immediately went to Lilian and plasma expander. Unfortunately, at around 10:00 A.M., Lilian
saw that she was quite pale. He immediately requested a blood passed away despite efforts to resuscitate her.
transfusion.

At the request of the petitioner, Lilian’s body was autopsied at the

Lilian did not respond to the blood transfusion even after Philippine National Police (PNP) Camp Crame Crime Laboratory.
receiving two 500 cc-units of blood. Various drugs, such as Dr. Emmanuel Reyes (Dr. Reyes), the medico-legal assigned to
adrenaline or epinephrine, were administered. the laboratory, conducted the autopsy. Dr. Reyes summarized his
notable findings as:

Eventually, an endotracheal tube connected to an oxygen tank was

inserted into Lilian to ensure her airway was clear and to x x x I opened up the body and inside the abdominal cavity which
compensate for the lack of circulating oxygen in her body from you call peritoneal cavity there were 3,000 ml of clot and unclot
the loss of red blood cells. Nevertheless, her condition continued blood accumulated thereat. The peritoneal cavity was also free
to deteriorate. from any adhesion. Then, I opened up the head and the brain
revealed paper white in color and the heart revealed abundant
petechial hemorrhages from the surface and it was normal. The
valvular leaflets were soft and pliable, and of course, the normal
Dr. Inso observed that Lilian was developing petechiae in various color is reddish brown as noted. And the coronary arteries which
parts of her body. Petechiae are small bruises caused by bleeding supply the heart were normal and unremarkable. Next, the lungs
under the skin whose presence indicates a blood-coagulation appears [sic] hemorrhagic. That was the right lung while the left
problem – a defect in the ability of blood to clot. At this point, Dr. lung was collapsed and paled. For the intestines, I noted
throughout the entire lengths of the small and large intestine were Dr. Ramos is a practicing pathologist with over 20 years of
hemorrhagic areas. Noted absent is the appendix at the ileo-colic experience. He is an associate professor at the Department of
area but there were continuous suture repair done thereat. Surgery of the Fatima Medical Center, the Manila Central
However, there was a 0.5 x 0.5 cm opening or left unrepaired at University, and the Perpetual Help Medical Center. He is a Fellow
that time. There was an opening on that repair site. Meaning it of the Philippine College of Surgeons, a Diplomate of the
was not repaired. There were also at that time clot and unclot Philippine Board of Surgery, and a Fellow of the Philippine
blood found adherent thereon. The liver and the rest of the Society of General Surgeons.
visceral organs were noted exhibit [sic] some degree of pallor but
were otherwise normal. The stomach contains one glassful about
400 to 500 ml.3
Dr. Ramos discredited Dr. Reyes’ theory that the 0.5 x 0.5 cm
opening at the repair site caused Lilian’s internal bleeding.
According to Dr. Ramos, appendical vessels measure only 0.1 to
Dr. Reyes concluded that the cause of Lilian’s death was 0.15 cm, a claim that was not refuted by the petitioner. If the 0.5 x
hemorrhage due to bleeding petechial blood vessels: internal 0.5 cm opening had caused Lilian’s hemorrhage, she would not
bleeding. He further concluded that the internal bleeding was have survived for over 16 hours; she would have died
caused by the 0.5 x 0.5 cm opening in the repair site. He opined immediately, within 20 to 30 minutes, after surgery.
that the bleeding could have been avoided if the site was repaired
with double suturing instead of the single continuous suture repair
that he found.
Dr. Ramos submitted that the cause of Lilian’s death was
hemorrhage due to DIC, a blood disorder that leads to the failure
of the blood to coagulate. Dr. Ramos considered the abundant
Based on the autopsy, the petitioner filed a complaint for damages petechial hemorrhage in the myocardic sections and the
against Family Care and against Dr. Inso for medical negligence. hemorrhagic right lung; the multiple bleeding points indicate that
Lilian was afflicted with DIC.

During the trial, the petitioner presented Dr. Reyes as his expert
witness. Dr. Reyes testified as to his findings during the autopsy Meanwhile, Dr. Hernandez is a general surgeon and a hospital
and his opinion that Lilian’s death could have been avoided if Dr. administrator who had been practicing surgery for twenty years as
Inso had repaired the site with double suture rather than a single of the date of his testimony.
suture.

Dr. Hernandez testified that Lilian’s death could not be attributed

However, Dr. Reyes admitted that he had very little experience in to the alleged wrong suturing. He submitted that the presence of
the field of pathology and his only experience was an on-the-job blood in the lungs, in the stomach, and in the entire length of the
training at the V. Luna Hospital where he was only on observer bowels cannot be reconciled with Dr. Reyes’ theory that the
status. He further admitted that he had no experience in hemorrhage resulted from a single-sutured appendix.
appendicitis or appendectomy and that Lilian’s case was his first
autopsy involving a death from appendectomy.

Dr. Hernandez testified that Lilian had uncontrollable bleeding in

the microcirculation as a result of DIC. In DIC, blood oozes from
Moreover, Dr. Reyes admitted that he was not intelligently guided very small blood vessels because of a problem in the clotting
during the autopsy because he was not furnished with clinical, factors of the blood vessels. The microcirculation is too small to
physical, gross, histopath, and laboratory information that were be seen by the naked eye; the red cell is even smaller than the tip
important for an accurate conclusion. Dr. Reyes also admitted that of a needle. Therefore, the alleged wrong suturing could not have
an appendical stump is initially swollen when sutured and that the caused the amount of hemorrhaging that caused Lilian’s death.
stitches may loosen during the healing process when the initial
swelling subside.

Dr. Hernandez further testified that the procedure that Dr. Inso
performed was consistent with the usual surgical procedure and
In their defense, Dr. Inso and Family Care presented Dr. Inso, and he would not have done anything differently.4
expert witnesses Dr. Celso Ramos (Dr. Ramos) and Dr. Herminio
Hernandez (Dr. Hernandez).

The petitioner presented Dr. Rudyard Avila III (Dr. Avila) as a

rebuttal witness. Dr. Avila, also a lawyer, was presented as an
expert in medical jurisprudence. Dr. Avila testified that between THE PETITION
Dr. Reyes who autopsied the patient and Dr. Ramos whose
findings were based on medical records, greater weight should be
given to Dr. Reyes’ testimony.
The petitioner argues: (1) that Dr. Inso and Family Care were
negligent in caring for Lilian before, during, and after her
appendectomy and were responsible for her death; and (2) that the
On April 10, 2007, the RTC rendered its decision awarding the doctrine of res ipsa loquitur is applicable to this case.
petitioner P88,077.50 as compensatory damages; P50,000.00 as
death indemnity; P3,607,910.30 as loss of earnings; P50,000.00 as
moral damages; P30,000.00 as exemplary damages; P50,000.00
as attorney’s fees, and the costs of the suit. In their Comment, the respondents counter: (1) that the issues
raised by the petitioner are not pure questions of law; (2) that they
exercised utmost care and diligence in the treatment of Lilian; (3)
that Dr. Inso did not deviate from the standard of care observed
The RTC relied on Dr. Avila’s opinion and gave more weight to under similar circumstances by other members of the profession
Dr. Reyes’ findings regarding the cause of Lilian’s death. It held in good standing; (4) that res ipsa loquitur is not applicable
that Dr. Inso was negligent in using a single suture on the repair because direct evidence as to the cause of Lilian’s death and the
site causing Lilian’s death by internal hemorrhage. It applied the presence/absence of negligence is available; and (5) that doctors
doctrine of res ipsa loquitur, holding that a patient’s death does are not guarantors of care and cannot be held liable for the death
not ordinarily occur during an appendectomy. of their patients when they exercised diligence and did everything
to save the patient.

The respondents elevated the case to the CA and the appeal was
docketed as CA-G.R. CV No. 89096. OUR RULING

On January 22, 2010, the CA reversed the RTC’s decision and The petition involves factual questions.
dismissed the complaint. The CA gave greater weight to the
testimonies of Dr. Hernandez and Dr. Ramos over the findings of
Dr. Reyes because the latter was not an expert in pathology,
appendectomy, nor in surgery. It disregarded Dr. Avila’s opinion Under Section 1 of Rule 45, a petition for review on certiorari
because the basic premise of his testimony was that the doctor shall only raise questions of law. The Supreme Court is not a trier
who conducted the autopsy is a pathologist of equal or of greater of facts and it is not our function to analyze and weigh evidence
expertise than Dr. Ramos or Dr. Hernandez. that the lower courts had already passed upon.

The CA held that there was no causal connection between the The factual findings of the Court of Appeals are, as a general rule,
alleged omission of Dr. Inso to use a double suture and the cause conclusive upon this Court. However, jurisprudence has also
of Lilian’s death. It also found that Dr. Inso did, in fact, use a carved out recognized exceptions 5 to this rule, to wit: (1) when
double suture ligation with a third silk reinforcement ligation on the findings are grounded entirely on speculation, surmises, or
the repair site which, as Dr. Reyes admitted on cross-examination, conjectures;6 (2) when the inference made is manifestly mistaken,
loosened up after the initial swelling of the stump subsided. absurd, or impossible;7 (3) when there is grave abuse of
discretion;8 (4) when the judgment is based on a misapprehension
of facts;9 (5) when the findings of facts are conflicting;10 (6)
when in making its findings the Court of Appeals went beyond
The CA denied the applicability of the doctrine of res ipsa the issues of the case, or its findings are contrary to the
loquitur because the element of causation between the admissions of both the appellant and the appellee;11 (7) when the
instrumentality under the control and management of Dr. Inso and findings are contrary to those of the trial court’s;12 (8) when the
the injury that caused Lilian’s death was absent; the respondents findings are conclusions without citation of specific evidence on
sufficiently established that the cause of Lilian’s death was DIC. which they are based;13 (9) when the facts set forth in the petition
as well as in the petitioner’s main and reply briefs are not disputed
by the respondent;14 (10) when the findings of fact are premised
on the supposed absence of evidence and contradicted by the
On March 18, 2010, the petitioner filed the present petition for evidence on record;15 and (11) when the Court of Appeals
review on certiorari. manifestly overlooked certain relevant facts not disputed by the
parties, which, if properly considered, would justify a different
conclusion.16
Ramos and Dr. Hernandez. On the other hand, the CA did not
consider Dr. Reyes or Dr. Avila as expert witnesses and
Considering that the CA’s findings with respect to the cause of disregarded their testimonies in favor of Dr. Ramos and Dr.
Lilian’s death contradict those of the RTC, this case falls under Hernandez. The basic issue, therefore, is whose testimonies
one of the exceptions. The Court will thus give due course to the should carry greater weight?
petition to dispel any perception that we denied the petitioner
justice.

We join and affirm the ruling of the CA.

The requisites of establishing medical malpractice

Other than their conclusion on the culpability of the respondents,

the CA and the RTC have similar factual findings. The RTC ruled
Whoever alleges a fact has the burden of proving it. This is a against the respondents based primarily on the following
basic legal principle that equally applies to civil and criminal testimony of Dr. Reyes.
cases. In a medical malpractice case, the plaintiff has the duty of
proving its elements, namely: (1) a duty of the defendant to his
patient; (2) the defendant’s breach of this duty; (3) injury to the
patient; and (4) proximate causation between the breach and the Witness: Well, if I remember right during my residency in my
injury suffered.17 In civil cases, the plaintiff must prove these extensive training, during the operation of the appendix, your
elements by a preponderance of evidence. Honor, it should really be sutured twice which we call double.

A medical professional has the duty to observe the standard of Court: What would be the result if there is only single?
care and exercise the degree of skill, knowledge, and training
ordinarily expected of other similarly trained medical
professionals acting under the same circumstances.18 A breach of
the accepted standard of care constitutes negligence or Witness: We cannot guarranty [sic] the bleeding of the sutured
malpractice and renders the defendant liable for the resulting blood vessels, your Honor.
injury to his patient.19

Court: So, the bleeding of the patient was caused by the single
The standard is based on the norm observed by other reasonably suture?
competent members of the profession practicing the same field of
medicine.20 Because medical malpractice cases are often highly
technical, expert testimony is usually essential to establish: (1) the
standard of care that the defendant was bound to observe under Witness: It is possible.24
the circumstances; (2) that the defendant’s conduct fell below the
acceptable standard; and (3) that the defendant’s failure to
observe the industry standard caused injury to his patient.21
Dr. Reyes testified that he graduated from the Manila Central
University (MCU) College of Medicine and passed the medical
board exams in 1994.25 He established his personal practice at his
The expert witness must be a similarly trained and experienced house clinic before being accepted as an on-the-job trainee in the
physician. Thus, a pulmonologist is not qualified to testify as to Department of Pathology at the V. Luna Hospital in 1994. In
the standard of care required of an anesthesiologist22 and an January 1996, he joined the PNP Medico-Legal Division and was
autopsy expert is not qualified to testify as a specialist in assigned to the Crime Laboratory in Camp Crame. He currently
infectious diseases.23 heads the Southern Police District Medico-Legal division.26 His
primary duties are to examine victims of violent crimes and to
conduct traumatic autopsies to determine the cause of death.

The petitioner failed to present an expert witness.

After having conducted over a thousand traumatic autopsies, Dr.

Reyes can be considered an expert in traumatic autopsies or
In ruling against the respondents, the RTC relied on the findings autopsies involving violent deaths. However, his expertise in
of Dr. Reyes in the light of Dr. Avila’s opinion that the former’s traumatic autopsies does not necessarily make him an expert in
testimony should be given greater weight than the findings of Dr. clinical and pathological autopsies or in surgery.
Witness: Before I took the board examination in the year 1984,
sir.
Moreover, Dr. Reyes’ cross-examination reveals that he was less
than candid about his qualifications during his initial testimony:

Atty. Castro: That was where?

Atty. Castro: Dr. Reyes, you mentioned during your direct

testimony last March 5, 2002 that you graduated in March of
1994, is that correct? Witness: MCU Hospital, sir.

Witness: Yes, sir. Atty. Castro: After the post graduate internship that was the time
you took the board examination?

Atty. Castro: You were asked by Atty. Fajardo, the counsel for the
plaintiff, when did you finish your medical works, and you Witness: Yes, sir.
answered the following year of your graduation which was in
1994?

Atty. Castro: And I supposed that you did it for the first take?

Witness: Not in 1994, it was in 1984, sir.

Witness: Yes, sir.

Atty. Castro: And after you graduated Mr. Witness, were there
further study that you undergo after graduation? [sic]
Atty. Castro: Are you sure of that?

Witness: It was during my service only at the police organization

that I was given the chance to attend the training, one year course. Witness: Yes, sir.

Atty. Castro: Did you call that what you call a post graduate Atty. Castro: After you took the board examination, did you
internship? pursue any study?

Witness: Residency. Witness: During that time, no sir.

Atty. Castro: Since you call that a post graduate, you were not Atty. Castro: You also testified during the last hearing that "page
undergo post graduate? [sic] 6 of March 5, 2002, answer of the witness: then I was accepted as
on the job training at the V. Luna Hospital at the Department of
Pathologist in 1994", could you explain briefly all of this Mr.
witness?
Witness: I did.

Witness: I was given an order that I could attend the training only
Atty. Castro: Where did you undergo a post graduate internship? as a civilian not as a member of the AFP because at that time they
were already in the process of discharging civilian from
undergoing training.
Atty. Castro: So in the Department of Pathology, what were you Atty. Castro: And you also mentioned during the last hearing
assigned to? shown by page 8 of the same transcript of the stenographic notes,
dated March 5, 2002 and I quote "and that is your residence
assignment?", and you answered "yes, sir." What was the meaning
of your answer? What do you mean when you say yes, sir?
Witness: Only as an observer status.

xxxx
Atty. Castro: So you only observed.

Witness: Okay, I stayed at the barracks of the Southern Police

Witness: Yes, sir. District Fort Bonifacio.

Atty. Castro: And on the same date during your direct testimony Atty. Castro: So this is not referring to any kind of training?
on March 5, 2002, part of which reads "well if I remember right
during my residency in my extensive training during the operation
of the appendix," what do you mean by that Mr. witness?
Witness: No, sir.

Witness: I was referring to my internship, sir.

Atty. Castro: This is not in anyway related to appendicitis?

Atty. Castro: So this is not a residency training?

Witness: No, sir.27

Witness: No, sir.

Atty. Reyes appears to have inflated his qualifications during his
direct testimony. First, his "extensive training during [his]
residency" was neither extensive actual training, nor part of
Atty. Castro: This is not a specialty training? medical residency. His assignment to the V. Luna Hospital was
not as an on-the-job trainee but as a mere observer. This
assignment was also before he was actually licensed as a doctor.
Dr. Reyes also loosely used the terms "residence" and "residency"
Witness: No, sir. – terms that carry a technical meaning with respect to medical
practice –during his initial testimony28 to refer to (1) his physical
place of dwelling and (2) his internship before taking the medical
board exams. This misled the trial court into believing that he was
Atty. Castro: This was the time the year before you took the board more qualified to give his opinion on the matter than he actually
examination? was.

Witness: That’s right, sir. Yes, sir. Perhaps nothing is more telling about Dr. Reyes’ lack of expertise
in the subject matter than the petitioner’s counsel’s own
admission during Dr. Reyes’ cross examination.

Atty. Castro: You were not then a license[d] doctor?

Atty. Castro: How long were you assigned to observe with the
Department of Pathology?
Witness: No, sir.

Witness: Only 6 months, sir.

Atty. Castro: During your studies in the medical school, Mr. On the other hand, the respondents presented testimonies from Dr.
Witness, do you recall attending or having participated or [sic] Inso himself and from two expert witnesses in pathology and
what you call motivity mortality complex? surgery.

Atty. Fajardo: Your honor, what is the materiality? Dr. Ramos graduated from the Far Eastern University, Nicanor
Reyes Medical Foundation, in 1975. He took up his post-graduate
internship at the Quezon Memorial Hospital in Lucena City,
before taking the board exams. After obtaining his professional
Atty. Castro: That is according to his background, your honor. license, he underwent residency training in pathology at the Jose
This is a procedure which could more or less measure his R. Reyes Memorial Center from 1977 to 1980. He passed the
knowledge in autopsy proceedings when he was in medical school examination in Anatomic, Clinical, and Physical Pathology in
and compared to what he is actually doing now. 1980 and was inducted in 1981. He also took the examination in
anatomic pathology in 1981 and was inducted in 1982.31

Atty. Fajardo: The witness is not an expert witness, your honor.

At the time of his testimony, Dr. Ramos was an associate
professor in pathology at the Perpetual Help Medical School in
Biñan, Laguna, and at the De La Salle University in Dasmariñas,
Atty. Castro: He is being presented as an expert witness, your Cavite. He was the head of the Batangas General Hospital
honor.29 Teaching and Training Hospital where he also headed the
Pathology Department. He also headed the Perpetual Help
General Hospital Pathology department.32

When Atty. Castro attempted to probe Dr. Reyes about his

knowledge on the subject of medical or pathological autopsies,
Dr. Fajardo objected on the ground that Dr. Reyes was not an Meanwhile, Dr. Hernandez at that time was a General Surgeon
expert in the field. His testimony was offered to prove that Dr. with 27 years of experience as a General Practitioner and 20 years
Inso was negligent during the surgery without necessarily offering of experience as a General Surgeon.1âwphi1 He obtained his
him as an expert witness. medical degree from the University of Santo Tomas before
undergoing five years of residency training as a surgeon at the
Veterans Memorial Center hospital. He was certified as a surgeon
in 1985. He also holds a master’s degree in Hospital
Atty. Fajardo: x x x The purpose of this witness is to establish that Administration from the Ateneo de Manila University.33
there was negligence on the surgical operation of the appendix or
in the conduct of the appendectomy by the defendant doctor on
the deceased Lilian Villaran Borromeo.30
He was a practicing surgeon at the: St. Luke’s Medical Center,
Fatima Medical Center, Unciano Medical Center in Antipolo,
Manila East Medical Center of Taytay, and Perpetual Help
Dr. Reyes is not an expert witness who could prove Dr. Inso’s Medical Center in Biñan.34 He was also an associate professor at
alleged negligence. His testimony could not have established the the Department of Surgery at the Fatima Medical Center, the
standard of care that Dr. Inso was expected to observe nor Manila Central University, and the Perpetual Help Medical
assessed Dr. Inso’s failure to observe this standard. His testimony Center. He also chaired the Department of Surgery at the Fatima
cannot be relied upon to determine if Dr. Inso committed errors Medical Center.35
during the operation, the severity of these errors, their impact on
Lilian’s probability of survival, and the existence of other
diseases/conditions that might or might not have caused or
contributed to Lilian’s death. Dr. Hernandez is a Fellow of the American College of Surgeons,
the Philippine College of Surgeons, and the Philippine Society of
General Surgeons. He is a Diplomate of the Philippine Board of
Surgery and a member of the Philippine Medical Association and
The testimony of Dr. Avila also has no probative value in the Antipolo City Medical Society.36
determining whether Dr. Inso was at fault. Dr. Avila testified in
his capacity as an expert in medical jurisprudence, not as an
expert in medicine, surgery, or pathology. His testimony fails to
shed any light on the actual cause of Lilian’s death.
Dr. Hernandez affirmed that Dr. Inso did not deviate from the
usual surgical procedure.37 Both experts agreed that Lilian could
not have died from bleeding of the appendical vessel. They d. Where an operating surgeon left a foreign object (i.e., rubber
identified Lilian’s cause of death as massive blood loss resulting gloves) inside the body of the patient.41
from DIC.

The rule is not applicable in cases such as the present one where
To our mind, the testimonies of expert witnesses Dr. Hernandez the defendant’s alleged failure to observe due care is not
and Dr. Ramos carry far greater weight than that of Dr. Reyes. immediately apparent to a layman.42 These instances require
The petitioner’s failure to present expert witnesses resulted in his expert opinion to establish the culpability of the defendant doctor.
failure to prove the respondents’ negligence. The preponderance It is also not applicable to cases where the actual cause of the
of evidence clearly tilts in favor of the respondents. injury had been identified or established.43

Res ipsa loquitur is not applicable when the failure to observe due While this Court sympathizes with the petitioner’s loss, the
care is not immediately apparent to the layman. petitioner failed to present sufficient convincing evidence to
establish: (1) the standard of care expected of the respondent and
(2) the fact that Dr. Inso fell short of this expected standard.
Considering further that the respondents established that the cause
The petitioner cannot invoke the doctrine of res ipsa loquitur to of Lilian’s uncontrollable bleeding (and, ultimately, her death)
shift the burden of evidence onto the respondent. Res ipsa was a medical disorder – Disseminated Intravascular Coagulation
loquitur, literally, "the thing speaks for itself;" is a rule of – we find no reversible errors in the CA’s dismissal of the
evidence that presumes negligence from the very nature of the complaint on appeal.
accident itself using common human knowledge or experience.

WHEREFORE, we hereby DENY the petition for lack of merit.

The application of this rule requires: (1) that the accident was of a No costs.
kind which does not ordinarily occur unless someone is negligent;
(2) that the instrumentality or agency which caused the injury was
under the exclusive control of the person charged with
negligence; and (3) that the injury suffered must not have been OUR LADY OF LOURDES HOSPITAL, Petitioner
due to any voluntary action or contribution from the injured
person.38 The concurrence of these elements creates a vs
presumption of negligence that, if unrebutted, overcomes the
plaintiff’s burden of proof. SPOUSES ROMEO AND REGINA CAPANZANA,
Respondents

This doctrine is used in conjunction with the doctrine of common

knowledge. We have applied this doctrine in the following cases We resolve the instant Petition for Review on Certiorari1
involving medical practitioners: assailing the Decision2 and Resolution3 rendered by the Court of
Appeals (CA), Second Division, in CA-G.R. CV No. 89030.

a. Where a patient who was scheduled for a cholecystectomy

(removal of gall stones) but was otherwise healthy suffered THE ANTECEDENT FACTS
irreparable brain damage after being administered anesthesia prior
to the operation.39

Regina Capanzana (Regina), a 40-year-old nurse and clinical

instructor pregnant with her third child, was scheduled for her
b. Where after giving birth, a woman woke up with a gaping burn third caesarean section (C-section) on 2 January 1998. However, a
wound close to her left armpit;40 week earlier, on 26 December 1997, she went into active labor
and was brought to petitioner hospital for an emergency C-
section. She first underwent a preoperative physical examination
by Dr. Miriam Ramos4 (Dr. Ramos) and Dr. Milagros Joyce
c. The removal of the wrong body part during the operation; and Santos,5 (Dr. Santos) the same attending physicians in her prior
childbirths. She was found fit for anesthesia after she responded
negatively to questions about tuberculosis, rheumatic fever, and Petitioner hospital, defendants Dr. Ramos and Dr. Santos filed
cardiac diseases. On that same day, she gave birth to a baby boy. their respective Answers.13 On the other hand, the service of
When her condition stabilized, she was discharged from the summons on the nurses was unsuccessful, as they were no longer
recovery room and transferred to a regular hospital room.6 connected with the hospital. Thus, only defendant Fiorita Ballano
(Ballano), who was later proven to be a midwife and not a nurse,
filed her Answer.14

At 2:30 a.m. the following day, or 13 hours after her operation,

Regina who was then under watch by her niece, Katherine L.
Balad (Balad), complained of a headache, a chilly sensation, Petitioner hospital and defendant Ballano claimed that there was
restlessness, and shortness of breath. She asked for oxygen and no instruction to the hospital or the staff to place Regina in a room
later became cyanotic. After undergoing an x-ray, she was found with a standby oxygen tank. They also claimed that the nurses on
to be suffering from pulmonary edema. She was eventually duty had promptly attended to her needs. They prayed that the
transferred to the Intensive Care Unit, where she was hooked to a complaint be dismissed and respondent3 ordered to pay unpaid
mechanical ventilator. The impression then was that she was medical bills.15
showing signs of amniotic fluid embolism.7

Meanwhile, defendant Dr. Ramos claimed that in all of the

On 2 January 1998, when her condition still showed no consultations and prenatal check-ups of Regina in the latter's three
improvement, Regina was transferred to the Cardinal Santos pregnancies, she never complained nor informed the doctor of any
Hospital. The doctors thereat found that she was suffering from symptom or sign of a heart problem. Before the last C-section of
rheumatic heart disease mitral stenosis with mild pulmonary Regina, Dr. Ramos examined her and found no abnormal cardiac
hypertension, which contributed to the onset of fluid in her lung sound, murmur or sign of rheumatic heart ailment. The doctor
tissue (pulmonary edema). This development resulted in further claimed that since the operation was an emergency, she
cardiopulmonary arrest and, subsequently, brain damage. Regina had no time or chance to have Regina undergo any cardiac
lost the use of her speech, eyesight, hearing and limbs. She was examination and secure a cardiac clearance. Moreover, Dr. Ramos
discharged, still in a vegetative state, on 19January 1998.8 claimed that the cardio-pulmonary arrest took place 14 hours after
the operation, long after she had performed the operation. She
prayed that judgment be rendered ordering spouses Capanzana to
pay her moral damages amounting to ₱500,000; exemplary
Respondent spouses Capanzana filed a complaint for damages9 damages, ₱200,000; and attorney's fees, ₱l00,000.16
against petitioner hospital, along with co-defendants: Dr. Miriam
Ramos, an obstetrician/gynecologist; Dr. Milagros Joyce Santos,
an anesthesiologist; and Jane Does, the nurses on duty stationed
on the second floor of petitioner hospital on 26-27 December On the other hand, defendant Dr. Santos claimed that she was the
1997.10 anesthesiologist in Regina's first and second childbirths via C-
section. The doctor further stated that prior to the third emergency
C-section, she conducted a pre-operative evaluation, and Regina
showed no sign or symptom of any heart problem or abnormality
Respondents imputed negligence to Ors. Ramos and Santos for in the latter's cardiovascular, respiratory, or central nervous
the latter's failure to detect the heart disease of Regina, resulting systems. She then administered the anesthesia to Regina. She also
in failure not only to refer her to a cardiologist for cardiac stated that Regina's condition before, during, and after the
clearance, but also to provide the appropriate medical operation was stable. Dr. Santos prayed that the complaint against
management before, during, and after the operation. They further her be dismissed.17
stated that the nurses were negligent for not having promptly
given oxygen, and that the hospital was equally negligent for not
making available and accessible the oxygen unit on that same
hospital floor at the time.11 Trial ensued. Plaintiffs presented Dr. Erwin Dizon, a cardiologist;
Dr. Godfrey Robeniol, a neurologist; Mrs. Elizabeth Tayag; Dr.
Eleonor Lopez, a cardiologist; Kathleen Lucero Balad; Romeo
Capanzana; and Dr. Asuncion Ranezes, a physician.18
They prayed for actual damages amounting to ₱514,645.80;
compensatory damages, ₱3,4 l6,278.40; moral damages,
₱5,000,000; exemplary damages, ₱2,000,000; attorney's fees,
₱500,000 as well as ₱5,000 per hearing and the costs of suit. They After the plaintiffs rested their case, an amended complaint was
likewise prayed for other just and equitable reliefs.12 filed, this time identifying and impleading as defendants the
nurses on duty who included Czarina Ocampo, H.R. Bolatete,
Evelyn S. David, and Angelica Concepcion.19 After conducting a
deposition of the person in charge of the nurses' schedule, spouses
Capanzana further amended their complaint to implead nurses
Rochelle Padolina and Fiorita Ballano, while dropping defendants RTC therefore found the nurses liable for contributory
Czarina Ocampo, H.R. Bolatete, and Angelica Concepcion.20 negligence.25

The trial continued with the presentation of defense evidence. The On the issue of whether petitioner hospital could be held liable for
defense presented Dr. Santos; Dr. Ramos; Atty. Nicolas Lutero the negligence of its nurses, the RTC ruled that the hospital was
III, director of the Bureau of Licensing and Facilities of the able to discharge the burden of proof that it had exercised the
Department of Health; Lourdes H. Nicolas, the assistant nursing diligence of a good father of a family in the selection and
service director; Dr. Grace de los Angeles; Ma. Selerina Cuvin, supervision of its employees. The trial court arrived at this finding
the account receivable clerk; and Milagros de Vera, the on the basis of the testimony of the assistant nursing director,
administrative supervisor of the hospital.21 Lourdes Nicolas. She stated that the selection and hiring of their
nurses was a rigorous process, whereby the applicants underwent
a series of procedures - examination, orientation, training, on-the-
job observation, and evaluation - before they were hired as regular
On 11 May 2005, and pending the resolution of the case before employees. The nurses were supervised by their head nurses and
the trial court, Regina died and was substituted by her heirs the charge nurse. The nurses were also inspected by their clinical
represented by Romeo Capanzana.22 supervisor and nursing director. Consequently, only the nurses
were held liable to pay damages. However, since the trial court
acquired jurisdiction only over Ballano among those on duty on
that day, she was the only one held liable.26 The dispositive
THE RULING OF THE RTC portion of the RTC decision states:

On 29 December 2006, the RTC rendered judgment, finding no WHEREFORE, all foregoing considered, judgment is rendered as
negligence on the part of Dr. Ramos or Dr. Santos. It found that follows:
the medical community's recognized standard practices in
attending to a patient in connection with a C-section had been
duly observed by the doctors.23
A. Ordering the defendant FLORIT A BALLANO to pay the
plaintiff Romeo R. Capanzana and the children of the spouses
Capanzana, namely: Roxanne, Rizelle, and Reginald (all minors)
The RTC also found that the primary cause of Regina's vegetative who are represented by plaintiff Romeo R. Capanzana in respect
state was amniotic fluid embolism, an unfortunate condition that to the children's right to the interest of their deceased mother
was not within the control of any doctor to anticipate or prevent. Regina in this case:
This condition was the root cause of the pulmonary edema that
led to hypoxic encephalopathy, brain damage and, ultimately,
Regina's vegetative state. On the other hand, the trial court noted
that hypoxic encephalopathy was manageable. It could have been 1. The amount of Pesos: Two Hundred Ninety Nine Thousand
prevented, or at least minimized, had there been a timely One Hundred Two and 041100 (₱299,102.04), as and by way of
administration of oxygen.24 actual damages;

On the strength of the testimony of Balad, the RTC found that 2. The amount of Pesos: One Hundred Thousand (₱l00,000.00),
negligence on the part of the nurses contributed to the injury of as and by way of moral damages;
Regina. It found that they failed to respond immediately when
Regina was experiencing shortness of breath. It took the nurses
more or less 10 minutes after being informed of the condition of
Regina before they checked on her, called for the resident doctor, 3. The amount of Pesos: One Million Nine Hundred Fifty
and requested oxygen. While the trial court acknowledged that the Thousand Two Hundred Sixty Nine and 80/100 (₱l,950,269.80),
immediate administration of oxygen was not a guarantee that as and by way of compensatory damages;
Regina's condition would improve, it gave credence to the
testimony of the expert witness. The latter opined that the delay
contributed to the onset of hypoxic encephalopathy or diffuse
brain damage due to lack of oxygen in Regina's brain. The expert 4. The amount of Pesos: One Hundred Thousand (₱l00,000.00),
witness also said that had there been a timely administration of as and by way of attorney's fees;
oxygen the risk of brain damage would have been lessened, if not
avoided, and the onset of hypoxic encephalopathy reduced. The
5. The cost of suit. from rheumatic heart mitral valve stenosis, it was not established
that Dr. Ramos ignored standard medical procedure and exhibited
an absence of the competence and skill expected of practitioners
similarly situated.33
B. Ordering the DISMISSAL of the case as against defendants
Our Lady of Lourdes Hospital, Inc., Dr. Mirriam Ramos and Dr.
Milagros Joyce (Jocelyn) Santos; and
The CA especially took note of the fact that when Regina was
operated on for the third time, albeit in an emergency situation,
she had the benefit of her complete medical history. Also, even
C. DISMISSING the counterclaims of the defendants. the expert witness presented by the plaintiffs, Dr. Dizon, testified
that most patients suffering from mild mitral valve stenosis are
asymptomatic, so the disease cannot be detected on physical
examination. He further testified that a request for cardio-
SO ORDERED.27 pulmonary clearance is discretionary, and that a referral to a
pulmonologist can be done away with if the attending physician
finds the patient's heart normal. Thus, the appellate court upheld
the ruling of the trial court absolving Dr. Ramos.34
Respondents Capanzana filed their appeal28 before the CA,
arguing that the RTC committed error in holding that amniotic
fluid embolism, which could not have been foreseen or prevented
by the exercise of any degree of diligence and care by defendants, On the issue of the liability of Dr. Santos, the CA discredited the
caused the cardio-pulmonary arrest, brain damage, and death of theory of Dr. Dizon that the normal post-operation dosage of 3
the patient (instead of rheumatic heart mitral valve stenosis which liters of intravenous fluid for 24 hours, or 1 liter every 8 hours,
could have been detected and managed). Respondents further could be fatal to a patient with a heart problem. It ruled that Dr.
argued that it was error for the trial court to hold that defendants Dizon was presented as an expert witness on cardiology, and not
Dr. Ramos and Dr. Santos and petitioner hospital exercised due on anesthesiology. Upholding the RTC, the appellate court gave
diligence and to absolve them from liability for the untimely death more credence to the testimony of Dr. Santos, who was accepted
of Regina.29 as an expert witness in the fields of anesthesiology and obstetric
anesthesiology. She had testified that even if the dosage was
beyond the recommended amount, no harmful effect would have
ensued if the patient's kidney were functioning properly. She
Petitioner hospital also filed its notice of appeal.30 It imputed examined Regina before the operation and found no edema - an
error to the trial court for holding that the nurses had not exercised indication that the latter's kidney was functioning well. The
due diligence in attending to the needs of Regina, particularly testimony of Dr. Santos remained uncontroverted. The CA also
because (1) respondent spouses failed to prove any breach of duty upheld the ruling that respondents similarly failed to prove that
on the part of the nurses, particularly Ballano; (2) there was no Dr. Santos had ignored standard medical procedure and exhibited
delay in the delivery of oxygen to Regina; and (3) Regina was an absence of the competence and skill expected of practitioners
afflicted with amniotic fluid embolism, a condition that could not similarly situated. Consequently, the appellate court also upheld
have been foreseen or prevented by any degree of care by the ruling of the trial court absolving Dr. Santos.35
defendants.31 Also, petitioner hospital decried the dismissal of its
counterclaims and the exclusion of the material testimony of one
of the hospital nurses.32
Meanwhile, the CA absolved Ballano. Like the RTC, the appellate
court found evidence that the nurses were negligent. But contrary
to the trial court, the CA held that there was no showing whether
THE RULING OF THE CA Ballano, who was later identified as a midwife, was negligent in
attending to the needs of Regina. Further, it was not shown
whether Ballano was even one of the nurses on duty who had
attended to Regina. The appellate court also noted that the
The CA rendered the assailed decision affirming the RTC ruling execution of health care procedures and essential primary health
with modification. The appellate court upheld the finding of the care is a nurse's (not a midwife's) duty.36
trial court that the proximate cause of Regina's condition was
hypoxic encelopathy, a diffuse brain damage secondary to lack of
oxygen in the brain. Specifically, the cause was hypoxic
encelopathy secondary to pulmonary cardiac arrest on the Finally, the CA ruled that petitioner hospital should be held liable
background of pulmonary edema. The CA decreed that the failure based on the doctrine of corporate responsibility. It was found that
of Dr. Ramos to diagnose the rheumatic heart disease of Regina while there was evidence to prove that petitioner hospital showed
was not the proximate cause that brought about the latter's diligence in its selection and hiring processes, there was no
vegetative condition as a probable or natural effect thereof. Even evidence to prove that it exercised the required diligence in the
if the appellate court were to concede that Regina indeed suffered supervision of its nurses. Also, the appellate court ruled that the
non-availability of an oxygen unit on the hospital floor, a fact that
was admitted, constituted gross negligence on the part of
petitioner hospital. The CA stressed that, as borne out by the Petitioner filed its Reply.46 It vehemently protests the idea that
records, there was only one tank in the ward section of 27 beds. It Regina died at its hands. It reiterates that respondents failed to
said that petitioner hospital should have devised an effective way prove that its purported negligent act caused the injury she
for the staff to properly and timely respond to a need for an sustained, and that the administration of oxygen would have
oxygen tank in a situation of acute distress.37 prevented the brain damage she later suffered. Petitioner also
disputes the ruling that the nurses were negligent in attending to
her needs. It bewails the exclusion of the testimony of one of the
defendant nurses who could have debunked the testimony of
Accordingly, the CA awarded to respondents exactly the same Balad. It restates its prayer that the present petition be granted and
amounts decreed by the RTC. This time, however, instead of the assailed rulings of the CA reversed and set aside. Further, it
Ballano, petitioner hospital was deemed directly liable to pay for prays that the second amended complaint be dismissed and its
those amounts.38 counterclaims granted. Additionally, albeit belatedly, it asks that
the case be remanded to the trial court for the reception of the
testimony of defendant nurse David.

Only petitioner hospital filed a Motion for Reconsideration,39

which the CA denied. The denial came after a finding that the
errors raised in support of the motion were substantially a mere OUR RULING
reiteration of those already passed upon and considered in the
assailed decision.40

We find the petition partially meritorious.

Hence, this petition.

We reiterate the elementary rule that only questions of law are

entertained in a Rule 45 petition.47 Findings of fact of the lower
Petitioner hospital is now before this Court assailing the rulings. courts are generally conclusive and binding on this Court whose
First, it argues that the CA ruled contrary to law and evidence, function is not to analyze or weigh the evidence all over again.
because there was no proof of any breach of duty on the part of While there are exceptional cases in which this Court may review
the nurses. Petitioner argues that even if there was a failure to findings of fact of the CA, none of these exceptions is present in
provide oxygen, it did not cause the injury sustained by Regina. It the case at bar.48 We see no compelling reason to deviate from
emphasizes that she suffered from amniotic fluid embolism, a this general rule now. We therefore defer to the pertinent factual
condition that could not be detected or prevented by any degree of findings of the lower courts, especially because these are well-
care on the part of the hospital or its nurses. Second, it argues that supported by the records. It is in this light that we affirm the
it was an error for the CA to hold the former liable on the basis of findings of both the trial and the appellate courts which found
the doctrine of corporate responsibility. Third, it alleges that the negligence on the part of the nurses.
appellate court erroneously neglected to find respondents liable
for the unpaid hospital bill. Fourth, it claims that the CA
supposedly erred in upholding the exclusion of the testimony of
defendant David.41 Petitioner ultimately prays that the present In order to successfully pursue a claim in a medical negligence
petition be granted, the assailed rulings of the CA reversed and set case, the plaintiff must prove that a health professional either
aside, the second amended complaint dismissed, and petitioner's failed to do something which a reasonably prudent health
counterclaims granted.42 professional would have or have not done; and that the action or
omission caused injury to the patient. Proceeding from this
guideline, the plaintiff must show the following elements by a
preponderance of evidence: duty of the health professional,
Respondents filed their Comment,43 saying that the CA breach of that duty, injury of the patient, and proximate causation
committed no error in finding petitioner liable for the negligence between the breach and the injury.49 Meanwhile, in fixing a
of the nurses to timely administer oxygen to Regina. Neither did standard by which a court may determine whether the physician
the appellate court, they claim, err in applying the doctrine of res properly performed the requisite duty toward the patient, expert
ipsa loquitur or in decreeing that petitioner hospital had failed to medical testimonies from both plaintiff and defense are resorted
exercise due diligence in the selection and supervision of the to.50
latter's nurses. They further claim that the CA was correct in
holding petitioner liable under the doctrines of vicarious liability
and corporate negligence. Respondents also insist that Regina did
not die of amniotic fluid embolism.44 Hence, they pray that the In this case, the expert testimony of witness for the respondent Dr.
instant petition be denied and that the assailed ruling of the CA, Godfrey Robeniol, a neurosurgeon, provided that the best time to
which affirmed that of the RTC, be upheld.45 treat hypoxic encephalopathy is at the time of its occurrence; i.e.,
when the patient is experiencing difficulty in breathing and arrived and followed by the hospital aide with the oxygen tank. It
showing signs of cardiac arrest.51 was clear that the oxygen tank came late because the request for it
from the nurses also came late. Had the nurses exercised certain
degree of promptness and diligence in responding to the
patient[']s call for help[,] the occurrence of "hypoxic
To recall, the records, including petitioner's Nurses' Notes, encephalopathy" could have been avoided since lack or
indisputably show that Regina complained of difficulty in inadequate supply of oxygen to the brain for 5 minutes will cause
breathing before eventually showing signs of cyanosis.52 We damage to it. (Underscoring supplied)56
agree with the courts below in their finding that when she was
gasping for breath and turning cyanotic, it was the duty of the
nurses to intervene immediately by informing the resident doctor.
Had they done so, proper oxygenation could have been restored The CA agreed with the trial court's factual finding of delay in the
and other interventions performed without wasting valuable time. administration of oxygen as competently testified to by Balad.
That such high degree of care and responsiveness was needed Her testimony, which is uncontroverted in the records, proceeded
cannot be overemphasized - considering that according to expert as follows:
medical evidence in the records, it takes only five minutes of
oxygen deprivation for irreversible brain damage to set in.53
Indeed, the Court has emphasized that a higher degree of caution
and an exacting standard of diligence in patient management and Q [Atty. Diokno]: During this time from about 1:30 in the
health care are required of a hospital's staff, as they deal with the morning up to approximately 2:00 in the morning, did any nurse
lives of patients who seek urgent medical assistance.54 It is enter the room that you were in?
incumbent upon nurses to take precautions or undertake steps to
safeguard patients under their care from any possible injury that
may arise in the course of the latter's treatment and care.55
A [Balad]: None, sir.

The Court further notes that the immediate response of the nurses
was especially imperative, since Regina herself had asked for Q: After that conversation between your aunt when she's asking
oxygen. They should have been prompted to respond immediately you to [turn] off the aircon and turning on [sic] again and then
when Regina herself expressed her needs, especially in that turned it off, do you have any occasion to talk with her?
emergency situation when it was not easy to determine with
certainty the cause of her breathing difficulty. Indeed, even if the
patient had not asked for oxygen, the mere fact that her breathing
was labored to an abnormal degree should have impelled the A: None, sir.
nurses to immediately call the doctor and to administer oxygen.

Q: How did you describe her physical appearance when she was
In this regard, both courts found that there was a delay in the telling you that "hinihika yata ako"?
administration of oxygen to the patient, caused by the delayed
response of the nurses of petitioner hospital. They committed a
breach of their duty to respond immediately to the needs of
Regina, considering her precarious situation and her physical A: She feels [sic] very cold even if several blankets were placed
manifestations of oxygen deprivation. We quote below the crucial in [sic] her body and she is [sic] coughing at the same time.
finding of the trial court:

Q: What about during the time that you dropped some pillows at
[W]hen Kathleen [Balad] went to the nurse station to inform the her back?
nurses thereat that her aunt was experiencing shortness of
breathing and needed oxygen nobody rushed to answer her urgent
call. It took more or less 10 minutes for these nurses to go inside
the room to attend and to check the condition of their patient. A: She was running her breath sir, "at inaalala niya ang operasyon
When the nurse came in she saw the patient was having chilly niya."
sensation with difficulty in breathing [and was] at the same time
asking for oxygen. The nurse learned from Kathleen that the
patient was having an asthma attack. The nurse immediately
called resident physician Dr. De Los Angeles to proceed to room Q: Seeing her condition like that what did you do if anything to
328 and the hospital aide to bring in the oxygen tank in the said get any help for her?
room. Thereafter, resident doctors Gonzalez and de Los Angeles
A: I buzzered, sir. xxxx

Q: About how many time[ s] did you buzz for help? Q: Going back to the time when the nurse came in and asked you
if your family has an [sic] history of asthma. After that and after
touching the hands of Regina, what did the nurse do?

A: Several times, sir, because I saw Tita Regie [Regina] as if she

doesn't [sic] take it anymore, sir.
A: She went out because Tita Regie was asking for an oxygen, sir.

Q: How long did it take before any nurse come [sic] to the room?
Q: Did the nurse say anything or give any instruction before
leaving the room?

A: Ten (10) to fifteen (15 minutes) because they were not in the
nurse's station, sir.
A: I cannot recall, sir, because I was already afraid of the color
[cyanosis] of Tita Regie, sir.

xxxx

Q: How long did it take before any oxygen arrived if ever?

Q: What did the nurse do when she entered the room?

A: About 20 minutes, sir.57 (Emphases supplied)

A: She asked me if we have an [sic] history of asthma, sir, in the

family.
The appellate court also correctly noted that even the witness for
petitioner, resident physician Dr. Grace de los Angeles, noticed
that it took some time before the oxygen arrived as shown in her
Q: What was your answer. testimony:

A: We have, sir, then she hold [sic] the hand of Tita Regie. Q [Atty. Tanada]: But do you know how much time elapsed from
the time oxygen was first requested since you were not yet there?

Q: What, if anything, did Tita Regie saying [sic] at that time when
the nurse was inside the room? xxxx

A: She was running her breath and she was mentioning "oxygen, A [Dr. Delos Angeles]: The one who first orders not considering
oxygen," sir. the nurse's order, it was me who first ordered for the oxygen.

Q: What happened after that? Q: A nurse made an earlier order also?

A: The nurse went out, sir, I was holding Tita Regie at the same A: Yes, sir.
time I called up Tito Romy, sir.
Q [Atty. Diokno]: Would you try to recall what were the words
that were used by your aunt in telling you about the dextrose?
xxxx

A [Balad]: According to her you call [the] nurse at the nurse

Q: Do you recall having heard a statement made by any doctor to station for her to remove the dextrose from my hand, sir.
the effect why did the oxygen tank just arrive[ d] at that moment?

xxxx
xxxx

Q: When you saw that [sic] two (2) nurses there at the nurse
A: When the nurse, said 'nagpakuha na ng oxygen,' I could not station, what were they doing?
recall if it is [sic] me or Dra. Gonzales, we asked her 'Bakit wala
pa?'

A: The other one is sitting eating pansit, sir, and the other one is
standing holding a bottle, sir.
Q: So your answer is there was somebody who made that
comment?

Q: What did you tell them, if anything, when you arrived at the
nurse station?
A: Yes, Your Honor.58 (Underscoring supplied)

A: I told them that the dextrose at Room 238 was already

The CA also found that there was negligent delay in referring finished, sir.
Regina to the physicians.59 In fact, a member of the medical staff
chided the nurses for not immediately referring the patient's
condition to the physicians as the following excerpt shows:
xxxx

Q [Atty. Diokno]: Without mentioning anymore whom you

believed to be the speaker. Could you just relay what were the Q: How long did it take before any nurse arrived inside Room
things that you heard, said at that time. 238?

xxxx A: I went back to the nurse station because no one responded

from [sic] my call, sir.

A [Balad]: "Why is it that the dextrose is only now, why did you
not ask for assistance immediately," sir.60 (Underscoring Q: About how many minutes had elapsed from the time you went
supplied) to the nurse station for the first time and from the time you went
for the second time?

The records also show another instance of negligence, such as the

delay in the removal of Regina's consumed dextrose, a condition A: About three (3) to five (5) minutes, sir. "Yung pangalawang
that was already causing her discomfort. In fact, Balad had to tawag ko na sa kanya ay nakasunod na siya sa akin," sir.
inform the nurses and the patient had to instruct one of them, on
what to do as can be seen in this part of Balad's testimony:
Q: The second time when the nurse was already following you
back to the room. What happened there when you go [sic] inside
the room? Proximate cause has been defined as that which, in natural and
continuous sequence, unbroken by any efficient intervening
cause, produces injury, and without which the result would not
have occurred. An injury or damage is proximately caused by an
A: The nurse approached my Tita Regie and according to my Tita act or a failure to act, whenever it appears from the evidence in
Regie, "Nurse, please remove it because my hand was already the case, that the act or omission played a substantial part in
bulging," sir. bringing about or actually causing the injury or damage; and that
the injury or damage was either a direct result or a reasonably
probable consequence of the act or omission. It is the dominant,
moving or producing cause. (Underscoring supplied; citations
Q: What is the response of the nurse to that comment of your omitted).63
auntie?

Thus, a failure to act may be the proximate cause if it plays a

A: She was following the instruction of my Tita Regie and then substantial part in bringing about an injury. Note also that the
she told me to get a towel, sir, to be placed on her hand, "namaga omission to perform a duty may also constitute the proximate
na", sir.61 (Underscoring supplied) cause of an injury, but only where the omission would have
prevented the injury.64 The Court also emphasizes that the injury
need only be a reasonably probable consequence of the failure to
act. In other words, there is no need for absolute certainty that the
Taken together, the above instances of delay convinced the courts injury is a consequence of the omission.65
below, as well as this Court, that there was a breach of duty on the
part of the hospital's nurses. The CA therefore correctly affirmed
the finding of the trial court that the nurses responded late, and
that Regina was already cyanotic when she was referred to the Applying the above definition to the facts in the present case, the
resident doctor. omission of the nurses - their failure to check on Regina and to
refer her to the resident doctor and, thereafter, to immediately
provide oxygen - was clearly the proximate cause that led to the
brain damage suffered by the patient. As the trial court and the
Regina suffered from brain damage, particularly hypoxic CA both held, had the nurses promptly responded, oxygen would
encephalopathy, which is caused by lack of oxygen in the brain. have been immediately administered to her and the risk of brain
The testimonies of Dr. Dizon and Dr. Robeniol proved this fact. damage lessened, if not avoided.
And the proximate cause of the brain damage was the delay in
responding to Regina's call for help and for oxygen. The trial
court said:
For the negligence of its nurses, petitioner is thus liable under
Article 218066 in relation to Article 217667 of the Civil Code.
Under Article 2180, an employer like petitioner hospital may be
Had the nurses exercised certain degree of promptness and held liable for the negligence of its employees based on its
diligence in responding to the patient[']s call for help[,] the responsibility under a relationship of patria potestas.68 The
occurrence of "hypoxic encephalopathy" could have been avoided liability of the employer under this provision is "direct and
since lack or inadequate supply of oxygen to the brain for 5 immediate; it is not conditioned upon a prior recourse against the
minutes will cause damage to it.62 negligent employee or a prior showing of the insolvency of that
employee."69 The employer may only be relieved of
responsibility upon a showing that it exercised the diligence of a
good father of a family in the selection and supervision of its
The CA affirmed the above ruling of the RTC, that whatever the employees. The rule is that once negligence of the employee is
cause of the oxygen deprivation was, its timely and efficient shown, the burden is on the employer to overcome the
management would have stopped the chain of events that led to presumption of negligence on the latter's part by proving
Regina's condition. observance of the required diligence.70

We affirm the findings of the courts below that the negligent In the instant case, there is no dispute that petitioner was the
delay on the part of the nurses was the proximate cause of the employer of the nurses who have been found to be negligent in
brain damage suffered by Regina. In Ramos, the Court defines the performance of their duties. This fact has never been in issue.
proximate cause as follows: Hence, petitioner had the burden of showing that it exercised the
diligence of a good father of a family not only in the selection of
the negligent nurses, but also in their supervision.
Indeed, the formulation of a supervisory hierarchy, company rules
and regulations, and disciplinary measures upon employees in
case of breach, is indispensable. However, to prove due diligence
On this point, the rulings of the RTC and the CA diverge. While in the supervision of employees, it is not enough for an employer
the trial court found due diligence in both the selection and the such as petitioner to emptily invoke the existence of such a
supervision of the nurses, the appellate court found that petitioner formulation. What is more important is the actual implementation
proved due diligence only in the selection, but not in the and monitoring of consistent compliance with the rules.
supervision, of the nurses. Understandably, this actual implementation and monitoring
should be the constant concern of the employer, acting through
dependable supervisors who should regularly report on their
supervisory functions. Thus, there must be proof of diligence in
After a careful review of the records, we find that the the actual supervision of the employees' work.75
preponderance of evidence supports the finding of the CA that the
hospital failed to discharge its burden of proving due diligence in
the supervision of its nurses and is therefore liable for their
negligence. It must be emphasized that even though it proved due In the present case, there is no proof of actual supervision of the
diligence in the selection of its nurses, the hospital was able to employees' work or actual implementation and monitoring of
dispose of only half the burden it must overcome.71 consistent compliance with the rules. The testimony of petitioner's
Assistant Nursing Service Director, Lourdes H. Nicolas is belied
by the actual records76 of petitioner. These show that Nurses
David and Padolina had been observed to be latecomers and
We therefore note with approval this finding of the CA: absentees; yet they were never sanctioned by those supposedly
supervising them. While the question of diligent supervision
depends on the circumstances of employment,77 we find that by
the very nature of a hospital, the proper supervision of the
While Lourdes Hospital adduced evidence in the selection and attendance of its nurses, who are its frontline health professionals,
hiring processes of its employees, it failed to adduce evidence is crucial considering that patients' conditions can change
showing the degree of supervision it exercised over its nurses. In drastically in a matter of minutes. Petitioner's Employee
neglecting to offer such proof, or proof of similar nature, Handbook78 recognized exactly this as it decreed the proper
respondent [herein petitioner] hospital failed to discharge its procedure in availing of unavoidable absences and the
burden under the last paragraph of Article 2180. Consequently, it commensurate penalties of verbal reprimand, written warning,
should be held liable for the negligence of its nurses which caused suspension from work, and dismissal in instances of unexcused
damage to Regina.72 absence or tardiness.79 Petitioner's failure to sanction the
tardiness of the defendant nurses shows an utter lack of actual
implementation and monitoring of compliance with the rules and
ultimately of supervision over its nurses.
Indeed, whether or not the diligence of a good father of a family
has been exercised by petitioner is a matter of proof,73 which
under the circumstances in the case at bar has not been clearly
established. The Court finds that there is not enough evidence on More important, on that fatal night, it was not shown who were
record that would overturn the presumption of negligence. In the actual nurses on duty and who was supervising these nurses.
explaining its basis for saying that petitioner proved due diligence Although Lourdes H. Nicolas explained in her testimony that two
in the supervision of the nurses, the trial court merely said: nurses are assigned at the nurses' station for each shift and that
they are supervised by the head nurses or the charge nurses, the
documents of petitioner show conflicting accounts of what
happened on the fateful days of 26 and 27 of December 1997.
As testified to by Ms. Lourdes Nicolas, the assistant nursing
director, the process of selection and hiring of their nurses was a
rigorous process whereby the applicants undergo series of
examination, orientation, training, on the job observation and The schedule of nurses initially submitted by the director of the
evaluation before they are hired as regular employees. The nurses nursing service of petitioner hospital, Sister Estrella Crisologo,
are supervised by their head nurses and the charge nurse and indicated that David was on duty from 2 p.m. to 11 p.m. on 26
inspected by their clinical supervisor and nursing director. Based December 1997 and that Padolina and Ballano were on duty from
from this evidence the court believes that defendant hospital had 10 p.m. of 26 December 1997 to 6 a.m. of 27 December 1997.
exercised prudence and diligence required of it. The nurses it Ballano, however, was employed as a midwife and not a nurse.80
employed were equipped with sufficient knowledge and Also, the oral deposition of Sister Estrella Crisologo indicated that
instructions and are able to perform their work and familiar with a certain Molina, a nurse, did not report for work from 10 p.m. of
the duties and responsibilities assigned to them.74 26 December 1997 to 6 a.m. of 27 December 1997 leaving only
Padolina as the nurse on duty during the said period while Evelyn
David was on duty only from 2 p.m. to 11 p.m. on 26 December by the opposing party, that caused the delay in the court
1997.81 However, in a Manifestation82 dated 15 July 1999, proceedings. In this case, however, there is reason to suspect that
petitioner submitted a revised and more accurate schedule of the request was indeed meant to delay because the intended
nurses prepared by the nurse supervisor, Charina G. Ocampo, deposition in 2004 was meant to be an additional sur-rebuttal
which curiously contained erasures on the portion pertaining to evidence to Balad's testimony which, we characteristically take
Evelyn David in that David was now shown to be on duty from 10 note, was given in 1999, a long five years before. Moreover, the
p.m. on 26 December 1997 to 6 a.m. on 27 December 1997.83 trial court reasoned that the case had been tried for many years
and was about to be decided:

Another piece of documentary evidence, the Nurses' Notes, was

also not without inconsistencies. In a Manifestation and Motion84 The timeliness of the motion for leave of court to take deposition
dated 3 June 2003, petitioner admitted to having inadvertently through written interrogatories cast doubt whether or not it was
failed to include an entry or page in the Nurses' Notes initially intended to further delay the proceedings of this case. The instant
submitted to the trial court.85 That entry was the Nurse's case has obtained considerable length in its adjudication and to
Observation and Report on Capanzana from 8 p.m. of 26 allow movant-defendants to take deposition of Ms. David [the
December 1997 to 3:20 a.m. of 27 December 1997 signed by witness-deponent] would only further delay its disposition and
David.86 Moreover, in the testimony of witness for petitioner, would certainly defeat the purpose of a disposition which is to
Milagros de Vera, the administrative supervisor of the hospital, it expedite proceedings.89
was revealed that entries in the Nurses' Notes were made in
different colors of ink depending on the shift of the nurse: blue
ink for the morning shift, black for afternoon, and red for night.
Interestingly, as manifested by the counsel for respondents, the Second, in Hyatt, the trial court arbitrarily cancelled the taking of
entries made from 2:45 to 2:50 a.m. of 27 December 1997 were in depositions, which had been scheduled previously. In other
both blue and red.87 words, everything had been set, and the deponents were available
for deposition. Delay, if any, would have been minimal. In the
present case, no deposition was ever scheduled, and the
availability of the supposed deponent was not even ascertained. In
All these negate the due diligence on the part of the nurses, their fact, the uncertainty in the taking of the deposition was one of the
supervisors, and ultimately, the hospital. reasons cited by the trial court when it denied the Motion for
Leave.90

We therefore affirm the appellate court in finding petitioner

directly liable for the negligence of its nurses under Article 2180 Third, the RTC in this case noted that petitioner had agreed to a
in relation to Article 2176 of the Civil Code. self-imposed deadline for the submission of its sur-rebuttal
evidence. When the scheduled hearing came, petitioner's counsel
failed to attend purportedly because he was indisposed. But as
curiously observed by the trial court, the reception of sur-rebuttal
We are left with two minor issues that need to be addressed in evidence on that date could not have proceeded anyway since
order to completely resolve the petition. To recall, petitioner petitioner had no witnesses.91 The trial court likewise noted that
questioned before the CA not only the trial court's denial of petitioner failed to state any solid ground to justify the grant of the
petitioner's Motion for Leave to take the deposition of a witness taking of that deposition, except for the latter's naked assertion
but also the denial of its counterclaims. In the assailed Decision that the witness to be deposed was out of the country.92 The
and Resolution, the appellate court failed to make a Court finds that these considerations, taken together, provided one
pronouncement expressly addressing the issues. Petitioner now of the reasons for the RTC to properly deny the Motion for Leave
prays that we remand the case to the trial court for the reception to take the deposition of a witness. In Hyatt, the movant was
of the testimony of its witness and that we grant its counterclaims. completely faultless; in the present case, petitioner failed not only
to be present at the scheduled hearing for the submission of its
sur-rebuttal evidence, but also to show good faith in its request.

In support of the first issue, petitioner invokes our

pronouncements in Hyatt Manufacturing Corp. v. Ley
Construction Development Corp.,88 in which this Court affirmed Fourth, the movant in Hyatt was clearly prejudiced by the denial
the appellate court's ruling to remand the case to the trial court of its request, which it had promptly made before pretrial. The
and to order the deposition-taking to proceed. To bring this issue same cannot be said in the present case because petitioner filed
to a close, we see the need to present a nuanced parsing of the the motion to take deposition six years after trial had started. In
difference between the circumstances in Hyatt and in the present fact, petitioner was confident enough to agree to a deadline for the
petition. First, in the cited case, the party opposing the deposition submission of its sur-rebuttal evidence, a deadline that had long
made unwarranted claims of delay. This Comi found that it was passed when it filed a Motion for Leave. Petitioner is, therefore,
not the request for deposition, but the voluminous pleadings filed estopped from claiming that it was ever prejudiced.
All in all, petitioner's argument regarding the trial court's denial of
petitioner's Motion for Leave to take the deposition fails to
impress us.1âwphi1

This notwithstanding, we find merit in another argument

successively raised by petitioner before the Court of Appeals and
before this Court with respect to the unpaid hospital bill of
respondents - an issue not addressed again by the CA in the
assailed ruling. The unpaid hospital bill at petitioner hospital
amounted to ₱20,141.60 as of 30 October 1998.93 This fact was
uncontroverted by respondents. Since the amount for actual
damages as listed by respondents in their complaint was already
inclusive of the hospital bills incurred at petitioner hospital and at
Cardinal Santos Hospital, we deem it proper to deduct the unpaid
hospital bill from the actual damages decreed by the lower court
and affirmed by the appellate court. However, we additionally
impose the payment of interest on the resulting amount to
conform with prevailing jurisprudence.94

WHEREFORE, premises considered, we AFFIRM WITH

MODIFICATION the Decision and Resolution rendered by the
Court of Appeals in CA-G.R. CV No. 89030 in that petitioner is
hereby declared liable for the payment to respondents of the total
amount of ₱299,l 02.04 as actual damages minus ₱20, 141.60
representing the unpaid hospital bill as of 30 October 1998;
₱l,950,269.80 as compensatory damages; ₱l00,000.00 as moral
damages; ₱l00,000.00 as and by way of attorney's fees; and the
costs of suit, as well as interest at the rate of six percent (6%) per
annum on the resulting amount from the finality of this judgment
until full payment.

SO ORDERED.