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Res Ipsa Loquitur; Medical Negligence Cases

Once again, the SC in Dr. Milagros Cantre v. Sps. Go, G.R. No. 160889, April 27, 2007, had the occasion
to say that the Hippocratic Oath mandates physicians to give primordial consideration to the well-being of
their patients. If a doctor fails to live up to this precept, he is accountable for his acts. This
notwithstanding, courts face a unique restraint in adjudicating medical negligence cases because
physicians are not guarantors of case and, they never set out to intentionally cause injury to their patients.
However, intent is immaterial in negligence cases because where negligence exists and is proven, it
automatically gives the injured a right to reparation for the damage caused. (Ramos v. CA, G.R. No.
124354, December 29, 1999, 321 SCRA 584).
In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere existence of an
injury to justify a presumption of negligence on the part of the person who controls the instrument causing
the injury, provided that the following requisites concur:
1. The accident is of a kind which ordinarily does not occur in the absence of someones negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or defendants; and
3. the possibility of contributing conduct would make the plaintiff responsible is eliminated.
In this case, a woman gave birth. Due to the operation, there was profuse bleeding inside her womb,
hence, the doctors performed various medical procedures. Her blood pressure was monitored with the
use of a sphygmomamometer. It was observed later on that there was a fresh gaping wound in the inner
portion of her left arm. The NBI-Medico Legal found out that it appeared to be a burn resulting in the
placing of a droplight near her skin. Despite surgical operation, there was an unsightly mark in her left
arm and the pain remained and her movements were restricted. A complaint was filed praying for
damages where the RTC rendered judgment holding the doctor liable. The CA affirmed, but modified the
judgment. On appeal to the SC it was contended that the wound was not caused by the droplight but by
the constant taking of her blood pressure.
The SC said that, that is immaterial. The medical practice is to deflate the blood pressure cuff immediately
after each use. Otherwise, the inflated band can cause injury to the patient similar to what could have
happened in this case. Thus, if the wound was caused by the blood pressure cuff, then the taking of the
blood pressure must have been done so negligently as to have inflicted a gaping wound on her arm, for
which the defendant cannot escape liability under the captain of the ship doctrine.
The argument that the failed plastic surgery was 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 defendant was negligent in the exercise of her profession
stands unrebutted. In this connection, the Civil Code provides:
ART. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done

ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious anxiety,
besmirched reputation, wounded feelings, moral shock, social humiliation, and similar injury.
Though incapable of pecuniary computation, moral damages may be recovered if they are the
proximate result of the defendants wrongful act or omission.
Clearly, under the law, the defendant is obliged to pay plaintiff for moral damages suffered by the latter as
a proximate result of her negligence.
On the presumption of negligence under the principle of res ipsa loquitur, the SC in applying the
requirements of the rule said:
As to the first requirement, the gaping wound the plaintiffs 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 unless negligence had set in somewhere.
Second, whether the injury was caused by the droplight or by the blood pressure cuff is of no moment.
Both instruments are deemed within the exclusive control of the physician in charge under the captain of
the ship doctrine. This doctrine holds the surgeon in charge of an operation liable for the negligence of
his assistants during the time when those assistants are under the surgeons control. (Black Law
Dictionary, 192 (5th ed., 1979). In this particular case, it can be logically inferred that defendant, the
senior consultant in charge during the delivery of the baby, exercised control over the assistants assigned
to both the use of the droplight and the taking of the plaintiffs blood pressure. Hence, the use of the
droplight and the blood pressure cuff is also within her exclusive control.
Third, the gaping wound on the plaintiffs left arm, by its very nature and considering her condition, could
only be caused by something external to her and outside her control as she was unconscious while in
hypovolemic shock. Hence, plaintiff could not, by any stretch of the imagination, have contributed to her
own injury.
The defense that the wound was caused not by the droplight but by the constant taking of her blood
pressure, even if the latter was necessary given her condition, does not absolve her from liability.

Liability Of Hospitals Under The Doctrine of


Apparent Authority and Doctrine of Corporate
Negligence
The case of Professional Services, Inc. v. Agana, G.R. No. 126297; Agana, et al. v. Fuentes, G.R. No.
126467; Ampil v. Agana, et al., G.R. No. 127590, January 31, 2007 set the precedent for the liability of
hospitals for the negligence of doctors employed by it, or even consultants. The SC said that courts in
holding a hospital liable for damages, having undertaken one of mankinds most important and delicate
endeavors, must assume the grave responsibility of pursuing it with appropriate care. The care and
service dispensed through this high trust, however technical, complex and esoteric its character may be,
must meet standards of responsibility commensurate with the undertaking to preserve and protect the
health, and indeed, the very lives of those placed in the hospitals keeping. (Beeck v. Tuzon General

Hospital, 500 P. 2d 1153 (1972), citing Darling v. Charleston Community Memorial Hospital, 33 Ill. 2d
326, 211 N.E. 2d 253).
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 sigmoid area had spread on her left ovary,
necessitating the removal of certain portions of it. Thus, Dr. Ampil obtained the consent of Natividads
husband, Enrique Agana, to permit Dr. Juan Fuentes, to perform hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and
closed the incision.
The operation appeared to be flawed, because the attending nurse entered these remarks:
sponge count lacking 2
announced to surgeon searched (sic) done but to no avail continue for closure.
Natividad was released from the hospital, but later on complained of excruciating pain in her anal region.
She consulted both doctors about it. They told her that the pain is the natural consequence of the surgery.
Dr. Ampil then recommended that she consult an oncologist to examine the cancerous nodes which were
not removed during the operation.
Accompanied by her husband she went to the United States to seek further treatment. After four months
of consultations and laboratory examinations, she was told she was free of cancer. Hence, she was
advised to return to the Philippines.
After her return to the Philippines, her daughter found a piece of gauze protruding from her vagina. Upon
being informed about it, Dr. Ampil proceeded to her house where he managed to extract by hand a piece
of gauze measuring 1.5 inches in width. He then assured her that the pains would soon vanish.
Dr. Ampils assurance did not come true. Instead, the pains intensified, prompting Natividad to seek
treatment at the Polymedic General Hospital. While confined there, Dr. Ramon Gutierrez detected the
presence of another foreign object in her vagina a foul-smelling gauze measuring 1.5 inches in width
badly infected her vaginal vault. A recto-vaginal fistula had formed in her reproductive organs which
forced stool to excrete through the vagina. Another surgical operation was needed to remedy the
damage. Thus, in October 1984, she underwent another surgery.
The spouses filed a complaint for damages alleging that the doctors are liable for negligence for leaving
two pieces of gauze inside Natividads body and malpractice for concealing their acts of negligence.
On February 16, 1986, pending the outcome of the above case, she died and was duly substituted by her
children.
The trial court rendered a judgment holding the doctors liable for negligence and malpractice.
On appeal, the CA dismissed the case against Dr. Fuentes but affirmed the judgment against Dr. Ampil
and the hospital.

On September 6, 1996, the Court of Appeals rendered its Decision jointly disposing of CA-GR CV No.
42062 and CA-GR SP No. 32198, dismissing the case against Dr. Fuentes and holding PSI and Dr. Ampil
solidarily liable.
Only Dr. Ampil filed a motion for reconsideration, but was denied.
PSI alleged in its petition that the Court of Appeals erred in holding that: (1) it is estopped from raising the
defense that Dr. Ampil is not its employee; (2) it is solidarily liable with Dr. Ampil; and (3) it is not entitled
to its counterclaim against the Aganas. PSI contended that Dr. Ampil is not its employee, but a mere
consultant or independent contractor. As such, he alone should answer for his negligence.
The Aganas maintained that the Court of Appeals erred in finding that Dr. Fuentes is not guilty of
negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. They contended that the
pieces of gauze are prima facie proofs that the operating surgeons have been negligent.
Dr. Ampil asserted that the Court of Appeals erred in finding him liable for negligence and malpractice
sans evidence that he left the two pieces of gauze in Natividads vagina. He pointed to other probable
cause, such as: (1) it was Dr. Fuentes who used gauzes in performing the hysterectomy; (2) the attending
nurses failure to properly count the gauzes used during surgery; and (3) the medical intervention of the
American doctors who examined Natividad in the United States of America.
The issues submitted to the court were: first, whether the Court of Appeals erred in holding Dr. Ampil
liable for negligence and malpractice; second, whether the Court of Appeals erred in absolving Dr.
Fuentes of any liability; and third, whether PSI may be held solidarily liable for the negligence of Dr.
Ampil.
Held: (1) Whether the Court of Appeals erred in holding Dr. Ampil liable for negligence and malpractice.
Dr. Ampil argued that the Court should not discount either of the following possibilities: first, Dr. Fuentes
left the gauzes in Natividads body after performing hysterectomy; second, the attending nurses erred in
counting the gauzes; and third, the American doctors were the ones who placed the gauzes in Natividads
body.
The arguments are purely conjectural and without basis. Records show that he did not present any
evidence to prove that the American doctors were the ones who put or left the gauzes in Natividads
body. Neither did he submit evidence to rebut the correctness of the record of operation, particularly the
number of gauzes used. As to the alleged negligence of Dr. Fuentes, Dr. Ampil examined his work and
found it in order.
The glaring truth is that all the major circumstances, taken together, as specified by the Court of Appeals,
directly point to Dr. Ampil as the negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges to control the bleeding of the patient
during the surgical operation.
Second, immediately after the operation, the nurses who assisted in the surgery noted in their support
that the sponge count (was) lacking 2; that such anomaly was announced to surgeon and that a search
was done but to no avail prompting Dr. Ampil to continue for closure x x x.

Third, after the operation, two (2) gauzes were extracted from the same spot of the body of Mrs. Agana
where the surgery was performed.
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. (Rule v.
Cheeseman, 317 P. 2d 472 (1957), citing Russel v. Newman, 116 Kan. 268 P. 752; Bernsden v. Johnson,
174 Kan. 230, 255 P. 2d 1033). To put simply, such act is considered so inconsistent with due care as to
raise an inference of negligence. There are even legions of authorities to the effect that such act is
negligence per se.
The SC further ruled that it is not blind to the reality that there are times when danger to a patients life
precludes a surgeon from further searching missing sponges or foreign objects left in the body. But this
does not leave him free from any obligation. Even if it has been shown that a surgeon was required by the
urgent necessities of the case to leave a sponge in his patients abdomen, because of the dangers
attendant upon delay, still, it is his legal duty to so 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 might seek relief from the
effects of the foreign object left in her body as her condition might permit. In Smith v. Zeagler, it was
ruled, thus:
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 placed in his patients 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 calling the new condition to his patients attention, and endeavoring with the means he has at
hand to minimize and avoid untoward results likely to ensue therefrom. (157 So. 328 Pla. (1934)).
Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even misled her that
the pain she was experiencing was the ordinary consequence of her operation. Had he been more
candid, Natividad could have taken the immediate and appropriate medical remedy to remove the gauzes
from her body. What was initially an act of negligence by Dr. Ampil has ripened into a deliberate wrongful
act of deceiving his patient.
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. (Garcia-Rueda v. Pascasio, G.R. No. 118141, September 5, 1997, 278 SCRA 769).
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 Natividads 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. Ampils negligence is the proximate cause of Natividads 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 Natividads vagina
established the causal link between Dr. Ampils 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.

(2) Whether the Court of Appeals erred in absolving Dr. Fuentes of any liability.
The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes on the ground that it
is contrary to the doctrine of res ipsa loquitur. According to them, the fact that the two pieces of gauze
were left inside Natividads body is a prima facie evidence of Dr. Fuentes negligence.
Held: The SC ruled otherwise.
Literally, res ipsa loquitur means the thing speaks for itself. It is the rule that the fact of the occurrence of
an injury, taken with the surrounding circumstances, may permit an inference or raise a presumption of
negligence, or make out a plaintiffs prima facie case, and present a question of fact for defendant to meet
with an explanation. (Ramos v. CA, G.R. No. 124354, December 29, 1999, 321 SCRA 584). Stated
differently, where the thing which caused the injury, without the fault of the injured, is under the exclusive
control of the defendant and the injury is such that it should not have occurred if he, having such control
used proper care, it affords reasonable evidence, in the absence of explanation that the injury arose from
the defendants want of care, and the burden of proof is shifted to him to establish that he has observed
due care and diligence. (Africa v. Caltex (Phils.) Inc., 123 Phil. 280).
From the foregoing statements of the rule, the requisites for the applicability of the doctrine of res ipsa
loquitur are: (1) the occurrence of an injury; (2) the thing which 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 by the defendant. Of the foregoing requisites, the most instrumental is the control
and management of the thing which cause the injury.
The element of control and management of the thing which caused the injury are wanting in the case.
Hence, the doctrine of res ipsa loquitur will not lie.