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LEGAL MEDICINE

It is also important to determine the position and distance of the


assailant.

Ben Dela Cruz, UST 2C

WITHIN 3 INCHES (FLAME) there is Singeing in the victim


Captain of the Ship Doctrine principle of medical malpractice
law holding a surgeon liable for the actions of assistants who are
under the surgeons control but who are employees of the hospital,
not the surgeon. The surgeon as the captain of the ship, is directly
responsible for an alleged error or negligence because he or she
controls and directs the actions of those in assistance.
INJURIES:
1.
2.
3.
4.

Stab wound by pointed and sharp edge object (Ex. Knife)


Puncture wound by pointed object (Ex. Icepick)
Hacked Wound by bladed object (Ex. Katana, Bolo, Axe)
Incised wound by sharp edge instrument, clear cut, hair
valves are cut, linear.
5. Lacerated wound by blunt instrument, hair valves not cut.
6. Avulsions by explosions
7. Hematoma elevation of the skin, accumulation of Blood
vessels. Bukol
8. Abraision scratch wounds gasgas
9. Contusion pasa
10. Gunshot wound by firearms.
Pasa + Bukol = Contusion hematoma
Entry wound generally round
Exit wound linear wound
Determining the exit wound is important to ascertain whether the
bullet is still inside the victim.
ODD-EVEN RULE
Even no bullet is left
Odd bullet is still inside the victim

WITHIN 6 INCHES (SMOKE) there is Sumdging


WITHIN 12 INCHES (UNBURNED POWDER) there is peppering on
the skin of the victim.

Medical Aspects of Death


Death is the termination of life, the complete cessation of vital
functions without possibility of resuscitation.
1.

2.

Clinical death death as pronounced by physician in the


hospital, no vital signs and the respiratory rate as well as
the blood pressure is zero.
Cellular death death of the individual cells
a. 3 HRS complete cellular death in which there is a
sudden decrease in temperature.

Changes in the body of the person:


ALGOR MORTIS Temperature drops/ cools down, before cells die.
(3 Hours)
Then there would be changes in the muscle of the deceased.

Muscle becomes flaccid (lantang gulay) 3 Hours from


temperature drop
Then Rigor Mortis, slow process, stiffness 12 Hours upon
death
Then the muscles become completely flaccid 12 Hours
from complete Rigor Mortis, 24-36 Hours from death.
Decomposition, there is foul odor, at least 24 hours dead.

POST MORTEM LIVIDITY blood goes down to the most dependent


parts of the body, 3 Hours from death.
It is important to determine the position of the body when the
victim died.

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Homicide or Suicide in Slit/cut throat:


Homicide below Adams apple.
Suicide above Adams apple and it is diagonal.
There is stiffening of muscles in case of suicide by shooting (the
trigger finger).
CADAVERIC SPASM only a group of muscles become rigid where
as in Rigor Mortis, all become rigid.
In Traumatic death, there is cadaveric spasm, it is due to tension,
adrenaline. It usually stiffens 3 Hours from temperature drop.
Kinds of laceration of hymen:
1.
2.
3.

Superficial Laceration
Complete Hymenal Laceration
Complex Laceration

Medical Examination is not needed in convicting rape cases.

CASES:
Nogales v. Capitol Medical Center
Facts:
Corazon Nogales, 37, was under exclusive prenatal care of Dr.
Oscar Estrada with her fourth child. An increase in her blood
pressure and development of leg edema indicating preeclampsia
was noted during her last trimester of pregnancy; a dangerous
complication of her pregnancy. On 26 May 1976, Corazon was
admitted to CMC after the staff nurse noted the written admission
request for Dr. Estrada. Rogelio executed and signed the Consent
Admission and Agreement and Admission Agreement. During
the operation, Dr. Estrada was assisted by doctors of CMC. The
baby came out in an apnic, cyanotic, weak and injured condition
and had to be incubated and resuscitated by Drs. Enriquez and
Payumo. Corazons blood pressure dropped, she had continuous
vaginal bleeding, was administered hemacel and undergone
immediate hysterectomy. Eventually, she died at 9:15 a.m. with
hemorrhage, post partum.

Hence, a complaint for damages was filed. For failure to


answer, trial ensued. CA upheld the trial courts ruling.
Issue: Whether or not CMC is vicariously liable for the negligence
of Dr. Estrada under Art. 2180 in relation to Art. 2176 of the Civil
Code.
Ruling: Under the control test, an employer-employee relationship
between hospitals and their attending and visiting physicians must
exist in allocating responsibility in medical negligence cases. The
Court finds no single evidence pointing to CMC's exercise of control
over Dr. Estrada's treatment and management of Corazon's
condition. It is undisputed that throughout Corazon's pregnancy,
she was under the exclusive prenatal care of Dr. Estrada. At the
time of Corazon's admission at CMC and during her delivery, it was
Dr. Estrada, assisted by Dr. Villaflor, who attended to Corazon.
There was no showing that CMC had a part in diagnosing Corazon's
condition. While Dr. Estrada enjoyed staff privileges at CMC, such
fact alone did not make him an employee of CMC. CMC merely
allowed Dr. Estrada to use its facilities when Corazon was about to
give birth, which CMC considered an emergency. Considering these
circumstances, Dr. Estrada is not an employee of CMC, but an
independent contractor.
In general, a hospital is not liable for the negligence of an
independent contractor-physician except under the doctrine of
apparent authority. In the instant case, CMC impliedly held out Dr.
Estrada as a member of its medical staff. Through CMCs acts, CMC
clothed Dr. Estrada with apparent authority thereby leading the
Spouses Nogales to believe that Dr. Estrada was an employee or
agent of CMC. CMC cannot now repudiate such authority.
CMC is liable for damages. Dr. Estrada did not appeal the findings
of CA, rendering him solely liable for damages.
[Note: * Doctrine of Apparent Authority: a hospital can be
held vicariously liable for the negligent acts of a physician
providing care at the hospital, regardless of whether the physician
is an 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:
"For a hospital to be liable under the doctrine of apparent
authority, a plaintiff must show that: (1) the hospital, or its agent,
acted in a manner that would lead a reasonable person to conclude

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that the individual who was alleged to be negligent was an


employee or agent of the hospital; (2) where the acts of the agent
create the appearance of authority, the plaintiff must also prove
that the hospital had knowledge of and acquiesced in them; and
(3) the plaintiff acted in reliance upon the conduct of the hospital
or its agent, consistent with ordinary care and prudence."

consequence of the surgery. Dr. Ampil recommended that she

The element of "holding out" on the part of the hospital does not
require an express representation by the hospital that the person
alleged to be negligent is an employee. Rather, the element is
satisfied if the hospital holds itself out as a provider of emergency
room care without informing the patient that the care is provided
by independent contractors.

gauze (1.5 in) protruding from her vagina, so Dr. Ampil manually

The element of justifiable reliance on the part of the plaintiff is


satisfied if the plaintiff relies upon the hospital to provide complete
emergency room care, rather than upon a specific physician.

consult an oncologist to examine the cancerous nodes which were


not removed during the operation. After months of consultations
and examinations in the US, she was told that she was free of
cancer. Weeks after coming back, her daughter found a piece of
extracted this, assuring Natividad that the pains will go away.
However, the pain worsened, so she sought treatment at a
hospital, where another 1.5 in piece of gauze was found in her
vagina. She underwent another surgery.
Sps. Agana filed a complaint for damages against PSI
(owner of Medical City), Dr. Ampil, and Dr. Fuentes, alleging that
the latter are liable for negligence for leaving 2 pieces of gauze in
Natividad's body, and malpractice for concealing their acts of
negligence.

Enrique

Agana

also

filed

an administrative

complaint for gross negligence and malpractice against the two


doctors with the PRC (although only the case against Dr. Fuentes

PSI vs. Agana

was heard since Dr. Ampil was abroad). Pending the outcome of the
cases, Natividad died (now substituted by her children). RTC

FACTS

found PSI and the two doctors liable for negligence and

Natividad Agana was rushed to Medical City because of difficulty of

malpractice. PRC dismissed the case against Dr. Fuentes.

bowel movement and bloody anal discharge. Dr. Ampil diagnosed

CA dismissed only the case against Fuentes.

her to be suffering from cancer of the sigmoid. Dr. Ampil


performed an anterior resection surgery on her, and finding
that the malignancy spread on her left ovary, he obtained the
consent of her husband, Enrique, to permit Dr. Fuentes to
perform hysterectomy on her. After the hysterectomy, Dr. Fuentes

ISSUE AND HOLDING

showed his work to Dr. Ampil, who examined it and found it in

1.

order, so he allowed Dr. Fuentes to leave the operating room. Dr.

and malpractice. NO; DR. AMPIL IS GUILTY

Ampil was about to complete the procedure when the attending

2.

WON CA erred in absolving Dr. Fuentes of any liability. NO

3.

WON PSI may be held solidarily liable for Dr. Ampil's

nurses made some remarks on the Record of Operation: "sponge


count lacking 2; announced to surgeon search done but to
no avail continue for closure" (two pieces of gauze were
missing). A "diligent search" was conducted but they could not be
found. Dr. Ampil then directed that the incision be closed.
A couple of days after, she complained of pain in her anal
region, but the doctors told her that it was just a natural

WON CA erred in holding Dr. Ampil liable for negligence

negligence. YES
RATIO
DR. AMPIL IS LIABLE FOR NEGLIGENCE AND MALPRACTICE
His arguments are without basis [did not prove that the American
doctors were the ones who put / left the gauzes; did not submit
evidence to rebut the correctness of the operation record (re:

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number of gauzes used); re: Dr. Fuentes' alleged negligence, Dr.

1.

Occurrence of injury

Ampil examined his work and found it in order].

2.

Thing which caused injury was under the control and

Leaving

foreign

substances

in

the

wound

after

management of the defendant [DR. FUENTES] -- LACKING

incision has been closed is at least prima facie negligence

SINCE CTRL+MGT WAS WITH DR. AMPIL

by the operating surgeon. Even if it has been shown that a

3.

surgeon was required to leave a sponge in his patient's abdomen

would not have happened if those who had control or management

because of the dangers attendant upon delay, still, it is his legal

used proper care

duty to inform his patient within a reasonable time by advising her

4.

of what he had been compelled to do, so she can seek relief from

Absence of explanation by defendant

the effects of the foreign object left in her body as her condition

Under the Captain of the Ship rule, the operating surgeon is the

might permit. What's worse in this case is that he misled her by

person in complete charge of the surgery room and all personnel

saying that the pain was an ordinary consequence of her

connected with the operation. That Dr. Ampil discharged such role

operation.

Occurrence was such that in the ordinary course of things,

is evident from the following:


He called Dr. Fuentes to perform a hysterectomy

Medical negligence; standard of diligence

He examined Dr. Fuentes' work and found it in order

To successfully pursue this case of medical negligence, a patient

He granted Dr. Fuentes permission to leave

must only prove that a health care provider either failed to do

He ordered the closure of the incision

something [or did something] which a reasonably prudent health

HOSPITAL OWNER PSI SOLIDARILY LIABLE WITH DR. AMPIL

care provider would have done [or wouldn't have done], and that

[NCC 2180], AND DIRECTLY LIABLE TO SPS. AGANAS [NCC

the failure or action caused injury to the patient.


Duty - to remove all foreign objects from the body before
closure of the incision; if he fails to do so, it was his duty to inform
the patient about it

2176]
Previously, employers cannot be held liable for the fault or
negligence of

its

professionals.

However,

this

doctrine has

Breach - failed to remove foreign objects; failed to inform

weakened since courts came to realize that modern hospitals are

patient

taking a more active role in supplying and regulating medical care

Injury - suffered pain that necessitated examination and


another surgery

to its patients, by employing staff of physicians, among others.

Proximate Causation - breach caused this injury; could be


traced from his act of closing the incision despite information given
by the attendant nurses that 2 pieces of gauze were still missing;
what established causal link: gauze pieces later extracted from
patient's vagina

rule of respondeat superior. Here are the Court's bases for

DR. FUENTES NOT LIABLE


The res ipsa loquitur [thing speaks for itself] argument of the
Aganas' does not convince the court. Mere invocation and

Hence, there is no reason to exempt hospitals from the universal

sustaining PSI's liability:


Ramos v. CA doctrine on E-E relationship
For purposes of apportioning responsibility in medical negligence
cases, an employer-employee relationship in effect exists between
hospitals and their attending and visiting physicians. [LABOR
LESSON: power to hire, fire, power of control]
Agency principle of apparent authority / agency by estoppel

application of this doctrine does not dispense with the requirement


of proof of negligence.
Requisites for the applicability of res ipsa loquitur

Imposes liability because of the actions of a principal or employer


in somehow misleading the public into believing that the
relationship or the authority exists [see NCC 1869]

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PSI publicly displays in the Medical City lobby the names and
specializations of their physicians. Hence, PSI is now estopped from
passing all the blame to the physicians whose names it proudly
paraded in the public directory, leading the public to believe that it
vouched for their skill and competence.

If doctors do well, hospital profits financially, so when negligence


mars the quality of its services, the hospital should not be allowed
to escape liability for its agents' acts.
Doctrine of corporate negligence / corporate responsibility

This is the judicial answer to the problem of allocating hospital's


liability for the negligent acts of health practitioners, absent facts
to support the application of respondeat superior.
This provides for the duties expected [from hospitals]. In this case,
PSI failed to perform the duty of exercising reasonable care to
protect from harm all patients admitted into its facility for medical
treatment. PSI failed to conduct an investigation of the
matter reported in the note of the count nurse, and this
established PSI's part in the dark conspiracy of silence and
concealment about the gauzes.
PSI has actual / constructive knowledge of the matter, through the
report of the attending nurses + the fact that the operation was
carried on with the assistance of various hospital staff
It also breached its duties to oversee or supervise all persons who
practice medicine within its walls and take an active step in fixing
the negligence committed
PSI also liable under NCC 2180

It failed to adduce evidence to show that it exercised the diligence


of a good father of the family in the accreditation and supervision
of Dr. Ampil

Ramos v. CA
Facts:
Erlinda Ramos, a 47-year old robust woman, was normal except for
her experiencing occasional pain due to the presence of stone in
her gall bladder. She was advised to undergo an operation for its

removal. The results in the examinations she underwent indicate


that she was fit for the operation. She and her husband Rogelio
met Dr. Hosaka, one of the defendants, who advised that she
should undergo cholecystectomy. Dr. Hosaka assured them that he
will get a good anaesthesiologist. At 7:30 a.m. on the day of the
operation at Delos Santos Medical Center, Herminda Cruz, Erlindas
sister-in-law and the dean of the College of Nursing in Capitol
Medical Center, was there to provide moral support. Dr. Perfecta
Gutierrez was to administer the anaesthesia. Dr. Hosaka arrived
only at 12:15 p. m. Herminda saw Dr. Gutierrez intubating the
patient, and heard the latter say Ang hirap ma-intubate nito, mali
yata ang pagkakapasok. O, lumalaki ang tiyan. Herminda saw
bluish discoloration of the nailbeds of the patient. She heard Dr.
Hosaka issue an order for someone to call Dr. Calderon. The doctor
arrived and placed the patient in trendelenburg position, wherein
the head of the patient is positioned lower than the feet, which
indicates a decrease of blood supply in the brain. Herminda knew
and told Rogelio that something wrong was happening. Dr.
Calderon was able to intubate the patient. Erlinda was taken to the
ICU and became comatose.
Rogelio filed a civil case for damages. The trial court ruled in his
favor, finding Dr. Gutierrez, Dr. Hosaka, and the hospital, guilty of
negligence, but the Court of Appeals reversed the decision. Hence,
petitioner filed a Motion for Reconsideration, which the Court of
Appeals denied for having been filed beyond the reglementary
period. However, it was found that the notice of the decision was
never sent to the petitioners counsel. Rather, it was sent to the
petitioner, addressing him as Atty. Rogelio Ramos, as if he was the
legal counsel. The petitioner filed the instant petition for certiorari.
On the procedural issue, the Supreme Court rules that since the
notice did not reach the petitioners then legal counsel, the motion
was filed on time.
Issue:
Whether a surgeon, an anaesthesiologist, and a hospital, should be
made liable for the unfortunate comatose condition of a patient
scheduled for cholecystectomy
Held:
Res Ipsa Loquitor
Res ipsa loquitur is a Latin phrase which literally means "the thing
or the transaction speaks for itself." The phrase "res ipsa loquitur''
is a maxim for 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
plaintiff's prima facie case, and present a question of fact for
defendant to meet with an explanation. Where the thing which
caused the injury complained of is shown to be under the
management of the defendant or his servants and the accident is

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such as in ordinary course of things does not happen if those who


have its management or control use proper care, it affords
reasonable evidence, in the absence of explanation by the
defendant, that the accident arose from or was caused by the
defendant's want of care. It is grounded in the superior logic of
ordinary human experience and on the basis of such experience or
common knowledge, negligence may be deduced from the mere
occurrence of the accident itself. However, much has been said
that res ipsa loquitur is not a rule of substantive law and, as such,
does not create or constitute an independent or separate ground of
liability. Mere invocation and application of the doctrine does not
dispense with the requirement of proof of negligence. It is simply a
step in the process of such proof, 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 to thereby place on the defendant
the burden of going forward with the proof. Still, before resort to
the doctrine may be allowed, the following requisites must be
satisfactorily shown.
(1) The accident is of a kind which ordinarily does not occur in the
absence of someone's negligence;
(2) It is caused by an instrumentality within the exclusive control of
the defendant or defendants; and
(3) The possibility of contributing conduct which would make the
plaintiff responsible is eliminated.
Medical malpractice cases do not escape the application of this
doctrine. Thus, res ipsa loquitur has been applied when the
circumstances attendant upon the harm are themselves of such a
character as to justify an inference of negligence as the cause of
that harm. Although generally, expert medical testimony is relied
upon in malpractice suits to prove that a physician has done a
negligent act or that he has deviated from the standard medical
procedure, when the doctrine of res ipsa loquitur is availed by the
plaintiff, the need for expert medical testimony is dispensed with
because the injury itself provides the proof of negligence. Hence, in
cases where the res ipsa loquitur is applicable, the court is
permitted to find a physician negligent upon proper proof of injury
to the patient, without the aid of expert testimony, where the court
from its fund of common knowledge can determine the proper
standard of care. When the doctrine is appropriate, all that the
patient must do is prove a nexus between the particular act or
omission complained of and the injury sustained while under the
custody and management of the 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 suffered by him.

Res ipsa loquitur is not a rigid or ordinary doctrine to be


perfunctorily used but a rule to be cautiously applied, depending
upon the circumstances of each case. 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 the usual procedure of those skilled in
that particular practice. The real question, therefore, is whether or
not in the process of the operation any extraordinary incident or
unusual event outside of the routine performance occurred which is
beyond the regular scope of customary professional activity in such
operations, which, if unexplained would themselves reasonably
speak to the average man as the negligent cause or causes of the
untoward consequence.
We find the doctrine of res ipsa loquitur appropriate in the case at
bar. Erlinda submitted herself for cholecystectomy and expected a
routine general surgery to be performed on her gall bladder. On
that fateful day she delivered her person over to the care, custody
and control of private respondents who exercised complete and
exclusive control over her. At the time of submission, Erlinda was
neurologically sound and, except for a few minor discomforts, was
likewise physically fit in mind and body. However, during the
administration of anesthesia and prior to the performance of
cholecystectomy she suffered irreparable damage to her brain.
Thus, without undergoing surgery, she went out of the operating
room already decerebrate and totally incapacitated. Obviously,
brain damage, which Erlinda sustained, is an injury which does not
normally occur in the process of a gall bladder operation. In fact,
this kind of situation does not in the absence of negligence of
someone in the administration of anesthesia and in the use of
endotracheal tube. 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-in-charge. Likewise, petitioner Erlinda could not
have been guilty of contributory negligence because she was
under the influence of anesthetics which rendered her
unconscious.
Negligence of the Anaesthesiologist
The pre-operative evaluation of a patient prior to the
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
scheduled operative procedure was, therefore, an act of
exceptional negligence and professional irresponsibility. Her failure
to follow this medical procedure is, therefore, a clear indicia of her
negligence. Erlinda's case was elective and this was known to
respondent Dra. Gutierrez. Thus, she had all the time to make a
thorough evaluation of Erlinda's case prior to the operation and
prepare her for anesthesia. However, she never saw the patient at

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the bedside. She herself admitted that she had seen petitioner only
in the operating room, and only on the actual date of the
cholecystectomy. She negligently failed to take advantage of this
important opportunity. As such, her attempt to exculpate herself
must fail.
Opinion of Expert Witness
An anesthetic accident caused by a rare drug-induced
bronchospasm properly falls within the fields of anesthesia, internal
medicine-allergy, and clinical pharmacology. The resulting anoxic
encephalopathy belongs to the field of neurology. While admittedly,
many bronchospastic-mediated pulmonary diseases are within the
expertise of pulmonary medicine, Dr. Jamora's field, the anesthetic
drug-induced, allergic mediated bronchospasm alleged in this case
is within the disciplines of anesthesiology, allergology and
pharmacology. On the basis of the foregoing transcript, in which
the pulmonologist himself admitted that he could not testify about
the drug with medical authority, it is clear that the appellate court
erred in giving weight to Dr. Jamora's testimony as an expert in the
administration of Thiopental Sodium. Generally, to qualify as an
expert witness, one must have acquired special knowledge of the
subject matter about which he or she is to testify, either by the
study of recognized authorities on the subject or by practical
experience. Clearly, Dr. Jamora does not qualify as an expert
witness based on the above standard since he lacks the necessary
knowledge, skill, and training in the field of anesthesiology. Oddly,
apart from submitting testimony from a specialist in the wrong
field, private respondents' intentionally avoided providing
testimony by competent and independent experts in the proper
areas.
Proximate Cause
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 act or a
failure to act, whenever it appears from the evidence in the case,
that the act or omission played a substantial part in 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. Instead of the intended
endotracheal intubation what actually took place 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
esophagus would certainly cause some delay in oxygen delivery
into the lungs as the tube which carries oxygen is in the wrong
place. That abdominal distention had been observed during the
first intubation suggests that the length of time utilized in inserting
the endotracheal tube (up to the time the tube was withdrawn for

the second attempt) was fairly significant. Due to the delay in the
delivery of oxygen in her lungs Erlinda showed signs of cyanosis.
Responsibility of the Surgeon
As the so-called "captain of the ship," it is the surgeon's
responsibility to see to it that those under him perform their task in
the proper manner. Respondent Dr. Hosaka's negligence can be
found in his failure to exercise the proper authority in not
determining if his anesthesiologist observed proper anesthesia
protocols. In fact, no evidence on record exists to show that
respondent Dr. Hosaka verified if respondent Dra. Gutierrez
properly intubated the patient. Furthermore, it does not escape us
that respondent Dr. Hosaka had scheduled another procedure in a
different hospital at the same time as Erlinda's cholecystectomy,
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
anesthesiologist regarding the anesthesia delivery. This indicates
that he was remiss in his professional duties towards his patient.
Thus, he shares equal responsibility for the events which resulted
in Erlinda's condition.
Responsibility of the Hospital
Hospitals hire, fire and exercise real control over their attending
and visiting "consultant" staff. While "consultants" are not,
technically employees, a point which respondent hospital asserts in
denying all responsibility for the patient's condition, 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.
The basis for holding an employer solidarily responsible for the
negligence of its employee is found in Article 2180 of the Civil
Code which considers a person accountable not only for his own
acts but also for those of others based on the former's
responsibility under a relationship of patria potestas. Such
responsibility ceases when the persons or entity concerned prove
that they have observed the diligence of a good father of the
family to prevent damage. In the instant case, respondent hospital,
apart from a general denial of its responsibility over respondent
physicians, failed to adduce evidence showing that it exercised the
diligence of a good father of a family in the hiring and supervision
of the latter. It failed to adduce evidence with regard to the degree
of supervision which it exercised over its physicians. In neglecting
to offer such proof, or proof of a similar nature, respondent hospital

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thereby failed to discharge its burden under the last paragraph of


Article 2180. Having failed to do this, respondent hospital is
consequently solidarily responsible with its physicians for Erlinda's
condition.
Damages
At current levels, the P8000/monthly amount established by the
trial court at the time of its decision would be grossly inadequate
to cover the actual costs of home-based care for a comatose
individual. The calculated amount was not even arrived at by
looking at the actual cost of proper hospice care for the patient.
What it reflected were the actual expenses incurred and proved by
the petitioners after they were forced to bring home the patient to
avoid mounting hospital bills. And yet ideally, a comatose patient
should remain in a hospital or be transferred to a hospice
specializing in the care of the chronically ill for the purpose of
providing a proper milieu adequate to meet minimum standards of
care. Given these considerations, the amount of actual damages
recoverable in suits arising from negligence should at least reflect
the correct minimum cost of proper care, not the cost of the care
the family is usually compelled to undertake at home to avoid
bankruptcy.
Our rules on actual or compensatory damages generally assume
that at the time of litigation, the injury suffered as a consequence
of an act of negligence has been completed and that the cost can
be liquidated. However, these provisions neglect to take into
account those situations, as in this case, where the resulting injury
might be continuing and possible future complications directly
arising from the injury, while certain to occur, are difficult to
predict. Temperate damages can and should be awarded on top 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.
Petitioner Erlinda Ramos was in her mid-forties when the incident
occurred. She has been in a comatose state for over fourteen years
now. The burden of care has so far been heroically shouldered by
her husband and children, who, in the intervening years have been
deprived of the love of a wife and a mother. Meanwhile, the actual
physical, emotional and financial cost of the care of petitioner
would be virtually impossible to quantify. Even the temperate
damages herein awarded would be inadequate if petitioner's
condition remains unchanged for the next ten years. The husband
and the children, all petitioners in this case, will have to live with
the day to day uncertainty of the patient's illness, knowing any
hope of recovery is close to nil. They have fashioned their daily
lives around the nursing care of petitioner, altering their long term
goals to take into account their life with a comatose patient. They,
not the respondents, are charged with the moral responsibility of
the care of the victim. The family's moral injury and suffering in
this case is clearly a real one. For the 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
P100,000.00 are hereby awarded. Considering the length and
nature of the instant suit we are of the opinion that attorney's fees
valued at P100,000.00 are likewise proper.
WHEREFORE, the decision and resolution of the appellate court
appealed from are hereby modified so as to award in favor of
petitioners, and solidarily against private respondents the
following: 1) P1,352,000.00 as actual damages computed as of the
date of promulgation of this decision plus a monthly payment of
P8,000.00 up to the time that petitioner Erlinda Ramos expires or
miraculously survives; 2) P2,000,000.00 as moral damages, 3)
P1,500,000.00 as temperate damages; 4) P100,000.00 each as
exemplary damages and attorney's fees; and, 5) the costs of the
suit.

Dr. Cereno & Dr. Zafe vs. Court of Appeals,


Sps. Olavere and Serrano
Facts:

8 | Page

9:15pm. Raymond Olavere, a victim of a stabbing incident, was


rushed to the ER of Bicol Regional Medical Center. He was attended
by a nurse and Dr. Realuyo (resident physician).

Dr. Tatad was engaged under another operation. Since Raymond


was not suffering from a major blood loss, it is reasonable for Dr.
Zafe and Dr. Cereno to wait for Dr. Tatad to finish his 1 st operation.

10:30pm. Raymond was brought to the operating room, during


that time, the Hospital surgeons were busy operating a gunshot
victim. (Dr. Zafe, Dr. Cereno)

The petitioners are not responsible for the alleged delay in blood
cross-matching. It is unreasonable if the petitioners were to be
sanctioned for lapses in procedure that does not fall within their
duties.

Dr. Zafe and Dr. Cereno examined Raymond and they found that
the latters blood pressure was normal.
At 12:15am, they started operating Raymond and they found
3,200cc of blood that was stocked in.
1:40am blood was transfused on Raymond, he suffered a cardiac
arrest.
1:50am the operation ended.
2:40am Raymond died.

In medical negligence cases, the complainant has the burden of


proof to establish a breach of duty on the part of the doctor and
such accusation must be proved.
The petition is granted, CAs decision was reversed.

Dr. Jarcia & Dr. Bestan vs. People of the


Philippines

The parents of Raymond filed this case against Dr. Zafe and Dr.
Cereno for damages.

Facts:

The Trial court dismissed the case against the Resident physician
and the nurse and rendered a decision making Dr. Zafe and Dr.
Cereno liable.

Roy Santiago was hit by a taxicab and he was immediately rushed


to the Manila Doctors Hospital for an emergency treatment. Dr.
Jarcia made an X-ray of Roys ankle and the result showed no
fracture.

The CA affirmed the TCs decision.


ISSUE: WON the petitioners were negligent.
HELD: The SC laid down requisites to prove medical negligence:
1.
2.

The doctor, either by his act/omission had been negligent.


Such act/omission proximately caused the injury/death of
the patient.

The SC found out that the petitioners were not negligent.


They found that Raymonds BP was normal and the fluid inside his
body was around 200-300 cc.

Dr. Bestan also conducted her own examination and told Mrs.
Santiago that there is no need to examine the upper leg of Roy.
11 days later, Roy developed a fever and there was a swelling on
his right foot. He was brought back to the hospital and a new x-ray
was conducted. They found out that there is a right mid-tibial
fracture and a linear hair line fracture on the shaft of the bone of
Roy.
Mrs. Santiago went to the NBI in which the latter endorsed the
matter to the Office of the prosecutor and found such probable
cause. The prosecutor filed a criminal case for reckless imprudence
resulting to serious physical injuries.
RTC found out that Dr. Jarcia and Dr. Bestan guilty of simple
imprudence resulting to SPI.

9 | Page

CA affirmed the decision of RTC.


The petitioners defense is that NO cause in connection with such
injury and the taxicab driver was the one liable.

Dr. Rubi Li vs. Sps. Reynaldo and Lina


Soliman
Legal Issue: How is medical malpractice proven?

ISSUE: WON the petitioners are liable.


HELD: YES, they are liable.
Res Ipso Liquitor the thing speaks for itself
Where the thing which causes injury is under the management of
the defendant and the accident is such as in the ordinary course of
things does not happen if those who have the management used
proper care, it affords reasonable evidence.

Legal Facts:
Respondents 11-year old daughter, Angelica Soliman,
underwent a biopsy of the mass located in her lower extremity at
the St. Lukes Medical Center (SLMC) on July 7, 1993 and results
showed

that

Angelica

was

suffering

from

osteosarcoma,

osteoblastic type, (highly malignant) cancer of the bone because of


that a necessity of amputation was conducted by Dr, Tamayo on
Angelicas right leg in order to remove the tumor and to prevent

Under this doctrine, the happening of an injury permits an


inference of negligence on the part of the plaintiffs and produces
substantial evidence that such injury would not have occurred if
reasonable care was exercised.

the metastasis that chemotherapy was suggested by Dr. Tamayo,

Requisites:

administration of chemotherapy first cycle. Respondents brought

1.

Laboratory at Camp Crame for post-mortem examination after the

2.
3.

The accident was of a kind, which does not ordinarily occur


unless someone is negligent.
The instrumentality/agency which caused the injury was
under the exclusive control of the person charged.
Injury suffered must not have been due to any voluntary
action of the person injured.

Petitioners were negligent, however, they are not criminally


negligent.
The elements of Reckless imprudence resulting to SPI were not
proved.
The testimony of Dr. Tacata Bone specialist
Thorough examination was not performed on Roy and the
petitioners, as resident physicians, are expected to know the
medical protocol. They should have referred the patient to another
doctor with sufficient training.

which he referred to petitioner Dr. Rubi Li, a medical oncologist.


The respondent was admitted to SLMC on August 18, 1993;
however, she died eleven (11) days after the (intravenous)
their daughters body to the Philippine National Police (PNP) Crime
refusal of the hospital to release the death certificate without full
payment of bills. The Medico-Legal Report showed that the cause
of death as "Hypovolemic shock secondary to multiple organ
hemorrhages and Disseminated Intravascular Coagulation. The
respondents filed charges against the SLMC and physicians involve
for negligence and failure to observe the essential precautions in to
prevent Angelicas untimely death. Petitioner denied the allegation
for damages as she observed best known procedures, highest skill
and knowledge in the administration of chemotherapy drugs
despite all efforts the patient died. The trial court was in favor of
the petitioner and ordered to pay their unpaid hospital bill in the
amount of P139, 064.43, but the Court of Appeals reversed the
decision supporting the respondents pray.
Holding:

They are acquitted of the criminal charge but held civilly liable.

10 | P a g e

In this case medical malpractice is proven because the four


essential elements of such action are present based upon the
doctrine of informed consent.

Rubi vs. Soliman : An Application of the Common-Law Doctrine of


Informed Consent in a Medical Malpractice (Medical Negligence)
Case under Article 2176 of the Civil Code

Reasoning:

In Dr.

There are four essential elements a plaintiff must prove in


a malpractice action based upon the doctrine of informed consent:
"(1) the physician had a duty to disclose material risks; (2) he
failed to disclose or inadequately disclosed those risks; (3) as a
direct and proximate result of the failure to disclose, the patient

Rubi

Li

vs.

Spouses

Reynaldo

and

Lina

Soliman, G.R. No.165279 promulgated last June 7, 2011, the


Supreme Court of the Philippines resolved an issue on the
application of the common-law doctrine of informed consent in
a medical malpractice (medical negligence) casesbased on

consented to treatment she otherwise would not have consented

Article 2176 of the Civil Code. As Justice Brion noted in his

to; and (4) plaintiff was injured by the proposed treatment."

Separate Opinion, this case is of first impression in the Philippine

Informed consent case requires the plaintiff to "point to significant

jurisdiction, especially so since informed consent litigation is

undisclosed information relating to the treatment that would alter

not an ordinary medical negligence case.

her decision to undergo. The physician is not expected to give the


patient a short medical education, the disclosure rule only requires
of him a reasonable general explanation in nontechnical terms.

The ponencia enumerated the four essential elements


that a plaintiff must prove in a medical malpractice action based
on the doctrine of informed consent, paraphrased as follows: (1)

Policy Formation:

the physicians

duty

to

disclosematerial

risks;

(2)

In all sorts of medical procedures either invasive or not,

the physicians failure to disclose, or inadequate disclosure, of

medical institution must have a certificate of competency in

those risks; (3) the patients consent to the treatment she

rendering standards of care to delicate medical procedures before

otherwise would not have consented to, which is a direct and

initiating a general protocol that would establish a guideline

proximate result of the physicians failure to disclose; and

principle in a form of proper disclosure of such procedure and

(4) plaintiffs injury as a consequence the proposed treatment.

presenting a consent or waiver to their patients so that possible

The gravamen in an informed consent case requires the plaintiff to

future

medico-legal

suits

will

be

prevented.

Synthesis:

point

to

significant

undisclosed

information

relating

to

the

treatment which would have altered her decision to undergo it.

In Dr. Rubi Li, vs. Spouses Reynaldo and Lina Soliman, as

Applying the foregoing to this case, it was held that

parents/heirs of deceased Angelica Soliman, Respondents, G.R. No.

petitioner Dr. Rubi Li, an oncologist who performed chemotherapy

165279, promulgated on June 7, 2011, the Court ruled that medical

on respondents daughter, who was sick with malignant bone

malpractice is proved base on lack/impaired informed consent, and

cancer, adequately disclosed material risks inherent in the

reasonable expert testimony subject a breach of duty causing

chemotherapy procedure performed with respondents consent.

gross injury to its patient.

When petitioner informed the respondents beforehand of the side


effects of chemotherapy, which includes lowered counts of white
and red blood cells, decrease in blood platelets, possible kidney or

11 | P a g e

heart damage and skin darkening, there is reasonable expectation


on the part of the doctor that the parents of the child understood

FACTS:

very well that the severity of these side effects will not be the

Nora Go gave birth to her 4th child. Two hours later, she suffered

same for all patients undergoing the procedure.

profuse bleeding inside her womb due to some placenta parts


which were not completely expelled after delivery. She then

As a physician, Dr. Li can reasonably expect the childs


parents to have considered the variables in the recommended

suffered hypovolemic shock, so her BP dropped to 40/0. Dr.


Milagros Cantre, an Ob-Gyne specialist and Nora's attending
physician, together with an assisting resident physician, performed

treatment for their daughter afflicted with a life-threatening

various medical procedures to stop the bleeding and to restore

illness. On the other hand, it is difficult to give credence to the

Nora's BP. While Dr. Cantre was massaging Nora's uterus for it to

parents claim that petitioner Dr. Li told them of 95% chance of

contract and stop bleeding, she ordered a droplight to warm Nora

recovery for their daughter, as it was unlikely for doctors like

and her baby. At that time, she was unconscious.

petitioner who were dealing with grave conditions such as cancer

While in the recovery room, Nora's husband John David noticed

to have falsely assured patients of chemotherapys success

a fresh gaping wound (2 1/2 x 3 1/2 in) in the inner portion of her

rate. Besides, informed consent laws in other countries generally


require only a reasonable explanation of potential harms, so
specific disclosures such as statistical data, may not be legally
necessary.

left arm near the armpit. When he asked the nurses about the
cause of the injury, he was informed that it was due to a burn. John
David filed a request for investigation. Dr. Cantre said that what
caused the injury was the blood pressure cuff. John David brought
Nora to the NBI for a physical examination. The medico-legal said
that the injury appeared to be a burn and that a droplight when

Quite incongruously, however, the ponencia went on to

placed near the skin for about 10 minutes could cause such burn.

declare that in the absence of expert testimony on the standard

He dismissed the likelihood that the wound was caused by a blood

of

chemotherapy

pressure cuff since the scar was not around the arm, but just on

treatment [since the witness for the respondents-parents was not

one side of the arm. Nora's injury was referred to a plastic surgeon

an expert, not being an oncologist but a mere Medical Specialist of

for skin grafting. However, her arm would never be the same--the

care

in

obtaining

consent

in

the Department of Health charged with receiving complaints


against hospitals], the Court felt hesitant in defining the scope of
mandatory disclosure in cases of malpractice based on lack of
informed consent such as this case involving chemotherapy
treatment.

surgery left an unsightly scar, her movements are restricted, and


the injured arm aches at the slightest touch.
Sps. Go filed a complaint for damages against Dr. Cantre, the
medical director, and the hospital. In the RTC, parties have rested
their respective cases, but the court admitted additional exhibits
[consist mostly of medical records produced by the hospital during
trial pursuant to a subpoena duces tecum] offered by Sps. Go,

Petitioner Dr. Li was found NOT liable to pay damages to


the suing parents.

which were not testified to by any witness. RTC ruled in favor of the
spouses. CA affirmed RTC with modification (complaint dismissed
with respect to the medical director and the hospital; only moral

Dr. Milagros Cantre v. Sps. John David and


Nora Go

damages awarded).

12 | P a g e


ISSUES AND HOLDING:
1.

WON the questioned additional exhibits are admissible in

2.

evidence. YES
2.

Wound not an ordinary occurrence in the act of


delivering a baby; could not have happened unless
negligence set in somewhere
Caused

by

an instrumentality

exclusive control

WON Dr. Cantre is liable for the injury suffered by Nora

Go. YES
RATIO
Preliminary discussion
Dr. Cantre's counsel admitted the existence of the additional
exhibits when they were formally offered for admission by the RTC.

It doesn't matter WON the injury was caused by


the droplight or by the blood pressure cuff, since both are
within the exclusive control of the physician in charge [Dr.
Cantre] under the captain of the ship doctrine [surgeon in
charge of an operation is held liable for his assistants'
negligence during the time when they are under the
surgeon's control].

In any case, given the circumstances of this case, a ruling on Dr.

3.

Cantre's

plaintiff responsible is eliminated

negligence

may

be

made

based

on

the res

ipsa

loquitur doctrine even in the absence of the additional exhibits.


Backgrounder

live up to this precept, he is accountable for his acts. This


face

unique

restraint

in

adjudicating medical negligence cases because physicians


are not guarantors of care, and they never set out to
intentionally

cause

patients. HOWEVER, intent


because where

injury
is

negligence

to

immaterial in

exists

and

is

their

these

it

automatically gives the injured a right to reparation for the

The argument that the failed plastic surgery was a


measure to prevent complication (and not intended as a cosmetic
procedure) does not negate negligence on Dr. Cantre's part.

Dr. Cantre has been Nora's ob-gyne for her past 3


deliveries, and this is the first time that Dr. Cantre is being held
liable for damages due to negligence in the practice of her
profession. She promptly took care of the wound before infection
set in. Since Nora was in a critical condition at that time, saving her
life became Dr. Cantre's elemental concern. Still, her good
intentions characteristics do not justify negligence.

damage caused.
Res ipsa loquitur x Medical negligence cases
In medical

negligence

cases,

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.

Accident is of a kind which ordinarily does not occur

absent someone's negligence

saving grace
BP cuff defense does not afford her an escape. The
medical practice is to deflate the cuff immediately after use, or
else, it could cause an injury similar to what happened to Nora. If
the wound was caused by the constant taking of BP, it must have
been done so negligently as to inflict a gaping wound.

cases

proven,

Wound could only be caused by something external


to and outside the control of Nora since she was
unconscious while in hypervolemic shock.

On Dr. Cantre's other arguments + what would have been her

The Hippocratic Oath mandates physicians to give primordial

notwithstanding, courts

Possibility of contributing conduct which would make

consideration to their patients' well-being, and if a doctor fails to

within defendant's

NCC provisions applied


NCC 2176. Whoever by act or omission causes damage to
another, there being fault or negligence, is obliged to pay for the
damage done. [...]
NCC 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

13 | P a g e

defendant's wrongful act or omission. [200k moral damages


awarded]

14 | P a g e