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SECOND DIVISION

[G.R. No. 130547. October 3, 2000]

LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and minors LLOYD
and KRISTINE, all surnamed REYES, represented by their mother,
LEAH ALESNA REYES, petitioners, vs. SISTERS OF MERCY
HOSPITAL, SISTER ROSE PALACIO, DR. MARVIE BLANES, and DR.
MARLYN RICO,respondents.
DECISION
MENDOZA, J.:

This is a petition for review of the decision [1] of the Court of Appeals in CA-G.R. CV No.
36551 affirming the decision of the Regional Trial Court, Branch IX, Cebu City which
dismissed a complaint for damages filed by petitioners against respondents.
The facts are as follows:
Petitioner Leah Alesna Reyes is the wife of the late Jorge Reyes. The other petitioners,
namely, Rose Nahdja, Johnny, Lloyd, and Kristine, all surnamed Reyes, were their
children. Five days before his death on January 8, 1987, Jorge had been suffering from a
recurring fever with chills. After he failed to get relief from some home medication he was
taking, which consisted of analgesic, antipyretic, and antibiotics, he decided to see the doctor.
On January 8, 1987, he was taken to the Mercy Community Clinic by his wife. He was
attended to by respondent Dr. Marlyn Rico, resident physician and admitting physician on
duty, who gave Jorge a physical examination and took his medical history. She noted that at
the time of his admission, Jorge was conscious, ambulatory, oriented, coherent, and with
respiratory distress.[2] Typhoid fever was then prevalent in the locality, as the clinic had been
getting from 15 to 20 cases of typhoid per month. [3] Suspecting that Jorge could be suffering
from this disease, Dr. Rico ordered a Widal Test, a standard test for typhoid fever, 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 which Dr. Rico concluded that Jorge was positive for typhoid fever. As her shift was
only up to 5:00 p.m., Dr. Rico indorsed Jorge to respondent Dr. Marvie Blanes.
Dr. Marvie Blanes attended to Jorge at around six in the evening. She also took Jorges
history and gave him a physical examination. Like Dr. Rico, her impression was that Jorge
had typhoid fever. Antibiotics being the accepted treatment for 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 patient a dose of triglobe. As
she did not observe any adverse reaction by the patient to chloromycetin, Dr. Blanes ordered
the first five hundred milligrams of said antibiotic to be administered on Jorge at around 9:00
p.m. A second dose was administered on Jorge about three hours later just before midnight.
At around 1:00 a.m. of January 9, 1987, Dr. Blanes was called as Jorges temperature
rose to 41C. The patient also experienced chills and exhibited respiratory distress, nausea,
vomiting, and convulsions. Dr. Blanes put him under oxygen, used a suction machine, and
administered hydrocortisone, temporarily easing the patients convulsions. When he regained
consciousness, the patient was asked by Dr. Blanes whether he had a previous heart ailment
or had suffered from chest pains in the past. Jorge replied he did not.[5] After about 15
minutes, however, Jorge again started to vomit, showed restlessness, and his convulsions
returned. Dr. Blanes re-applied the emergency measures taken before and, in addition, valium
was administered. Jorge, however, did not respond to the treatment and slipped into
cyanosis, a bluish or purplish discoloration of the skin or mucous membrane due to deficient
oxygenation of the blood. At around 2:00 a.m., Jorge died. He was forty years old. The cause
of his death was Ventricular Arrythemia Secondary to Hyperpyrexia and typhoid fever.
On June 3, 1987, petitioners filed before the Regional Trial Court of Cebu City a
complaint[6]for damages against respondents Sisters of Mercy, Sister Rose Palacio, Dr.
Marvie Blanes, Dr. Marlyn Rico, and nurse Josephine Pagente. On September 24, 1987,
petitioners amended their complaint to implead respondent Mercy Community Clinic as
additional defendant and to drop the name of Josephine Pagente as defendant since she was
no longer connected with respondent hospital. Their principal contention 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
diligence, they would not have recommended and rushed the performance of the Widal Test,
hastily concluded that Jorge was suffering from typhoid fever, and administered chloromycetin
without first conducting sufficient tests on the patients compatibility with said drug. They
charged respondent clinic and its directress, Sister Rose Palacio, with negligence in failing to
provide adequate facilities and in hiring negligent doctors and nurses. [8]
Respondents denied the charges. During the pre-trial conference, the parties agreed to
limit the issues on the following: (1) whether the death of Jorge Reyes was due to or caused
by the negligence, carelessness, imprudence, and lack of skill or foresight on the part of
defendants; (2) whether respondent Mercy Community Clinic was negligent in the hiring of its
employees; and (3) whether either party was entitled to damages. The case was then heard
by the trial court during which, in addition to the testimonies of the parties, the testimonies of
doctors as expert witnesses were presented.
Petitioners offered the testimony of Dr. Apolinar Vacalares, Chief Pathologist at the
Northern Mindanao Training Hospital, Cagayan de Oro City. On January 9, 1987, Dr.
Vacalares performed an autopsy on Jorge Reyes to determine the cause of his
death. However, he did not open the skull to examine the brain. His findings[9] showed that
the gastro-intestinal tract was normal and without any ulceration or enlargement of the
nodules. Dr. Vacalares testified that Jorge did not die of typhoid fever. He also stated that he
had not seen a patient die of typhoid fever within five days from the onset of the disease.

For their part, respondents offered the testimonies of Dr. Peter Gotiong and Dr. Ibarra
Panopio. Dr. Gotiong is a diplomate in internal medicine whose expertise is microbiology and
infectious diseases. He is also a consultant at the Cebu City Medical Center and an associate
professor of medicine at the South Western University College of Medicine in Cebu City. He
had treated over a thousand cases of typhoid patients. According to Dr. Gotiong, the patients
history and positive Widal Test results ratio of 1:320 would make him suspect that the patient
had typhoid fever. As to Dr. Vacalares observation regarding the absence of ulceration in
Jorges gastro-intestinal tract, Dr. Gotiong said that such hyperplasia in the intestines of a
typhoid victim may be microscopic. He noted that since the toxic effect of typhoid fever may
lead to meningitis, Dr. Vacalares autopsy should have included an examination of the brain.
[10]

The other doctor presented was Dr. Ibarra Panopio, a member of the American Board of
Pathology, examiner of the Philippine Board of Pathology from 1978 to 1991, fellow of the
Philippine Society of Pathologist, associate professor of the Cebu Institute of Medicine, and
chief pathologist of the Andres Soriano Jr. Memorial Hospital in Toledo City. Dr. Panopio
stated that although he was partial to the use of the culture test for its greater reliability in the
diagnosis of typhoid fever, the Widal Test may also be used. Like Dr. Gotiong, he agreed that
the 1:320 ratio in Jorges case was already the maximum by which a conclusion of typhoid
fever may be made. No additional information may be deduced from a higher dilution. [11] He
said that Dr. Vacalares autopsy on Jorge was incomplete and thus inconclusive.
On September 12, 1991, the trial court rendered its decision absolving respondents from
the charges of negligence and dismissing petitioners action for damages. The trial court
likewise dismissed respondents counterclaim, holding that, in seeking damages from
respondents, petitioners were impelled by the honest belief that Jorges death was due to the
latters negligence.
Petitioners brought the matter to the Court of Appeals. On July 31, 1997, the Court of
Appeals affirmed the decision of the trial court.
Hence this petition.
Petitioners raise the following assignment of errors:
I. THE HONORABLE COURT OF APPEALS COMMITTED A REVERSIBLE ERROR WHEN
IT RULED THAT THE DOCTRINE OF RES IPSA LOQUITUR IS NOT APPLICABLE IN
THE INSTANT CASE.
II. THE HONORABLE COURT OF APPEALS COMMITTED REVERSIBLE ERROR WHEN IT
MADE AN UNFOUNDED ASSUMPTION THAT THE LEVEL OF MEDICAL PRACTICE IS
LOWER IN ILIGAN CITY.
III. THE HONORABLE COURT OF APPEALS GRAVELY ERRED WHEN IT RULED FOR A
LESSER STANDARD OF CARE AND DEGREE OF DILIGENCE FOR MEDICAL
PRACTICE IN ILIGAN CITY WHEN IT APPRECIATE[D] NO DOCTORS NEGLIGENCE IN
THE TREATMENT OF JORGE REYES.

Petitioners action is for medical malpractice. This is a particular form of negligence which

a patient must prove that the physician or surgeon either failed to do something which a reasonably prudent physician or surgeon would have done. Inasmuch as the causes of the injuries involved in malpractice actions are determinable only in the light of scientific knowledge. the court is permitted to find a physician negligent upon proper proof of injury to the patient. or that he or she did something that a reasonably prudent physician or surgeon would not have done. injury. under similar conditions. It is breach of this duty which constitutes actionable malpractice. it has been recognized that expert testimony is usually necessary to support the conclusion as to causation. testimony as to the statements and acts of physicians and surgeons. 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 and care. where the court from its fund of common knowledge can determine the proper standard of care. However. Court of Appeals:[16] Although generally. the determination of the reasonable level of care and the breach thereof. without the aid of expert testimony. Respondents were thus duty-bound to use at least the same level of care that any reasonably competent doctor would use to treat a condition under the same circumstances. which is . Ordinarily. and manifest conditions which are observable by any one may be given by non-expert witnesses. 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. namely: duty. and in like surrounding circumstances. and that the failure or action caused injury to the patient. an inference of negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur without medical evidence. [12] In order to successfully pursue such a claim. Where common knowledge and experience teach that a resulting injury would not have occurred to the patient if due care had been exercised. expert testimony is essential. breach. external appearances. [13] There are thus four elements involved in medical negligence cases. and not to matters that are within the common knowledge of mankind which may be testified to by anyone familiar with the facts. when the doctrine of res ipsa loquitor is availed by the plaintiff. The reason is that the general rule on the necessity of expert testimony applies only to such matters clearly within the domain of medical science. there is no doubt that a physician-patient relationship existed between respondent doctors and Jorge Reyes. in cases where the res ipsa loquitur is applicable. In the present case. and proximate causation.[15] Res Ipsa Loquitur There is a case when expert testimony may be dispensed with.consists in the failure of a physician or surgeon to apply to his practice of medicine that degree of care and skill which is ordinarily employed by the profession generally. As held in Ramos v.[14]As to this aspect of medical malpractice. and that is under the doctrine of res ipsa loquitur. Hence. the need for expert medical testimony is dispensed with because the injury itself provides the proof of negligence.

among others. [18] The contention is without merit. and ambulant when he went to the hospital. an anesthesiologist. removal of the wrong part of the body when another part was intended. and (3) the injury suffered must not have been due to any voluntary action or contribution of the person injured. Taking judicial notice that anesthesia procedures had become so common that even an ordinary person could tell if it was administered properly. In this case. he died after only ten hours from the time of his admission. Yet. or in the area. Noting that the patient was neurologically sound at the time of her operation. We agree with the ruling of the Court of Appeals. Resort to res ipsa loquitor is allowed because there is no other way. the question was whether a surgeon. while it is true that the patient died just a few hours after professional medical assistance was rendered. the patient was given anesthesia prior to her operation.[17] Petitioners asserted in the Court of Appeals that the doctrine 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. knocking out a tooth while a patients jaw was under anesthetic for the removal of his tonsils. Petitioners now contend that all requisites for the application of res ipsa loquitur were present. we allowed the testimony of a witness who was not an expert. and a hospital should be made liable for the comatose condition of a patient scheduled for cholecystectomy. during or following an operation for appendicitis. 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 anesthesiologist. the patient already had recurring fevers and chills for five days unrelieved by the analgesic. coherent. and loss of an eye while the patient was under the influence of anesthetic. by which the patient can obtain redress for injury suffered by him. Prior to his admission. This contention was rejected by the appellate court. 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. and antibiotics given him by his wife. 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. The question required expert opinion . under usual and ordinary conditions. injuries sustained on a healthy part of the body which was not under. Respondents alleged failure to observe due care was not immediately apparent to a layman so as to justify application of res ipsa loquitur. [19] In that case. This shows that he had been suffering from a serious illness and professional medical help came too late for him. namely: (1) the accident was of a kind which does not ordinarily occur unless someone is negligent. In the Ramos case. Thus.ordinarily required to show not only what occurred but how and why it occurred. of treatment. antipyretic. (2) the instrumentality or agency which caused the injury was under the exclusive control of the person in charge. When the doctrine is appropriate. there is really nothing unusual or extraordinary about his death.

. Chief Pathologist of the Northern Mindanao Training Hospital. Petitioners contend that: (1) Dr. It is also plain from his testimony that he has treated only about three cases of typhoid fever. as a matter of common knowledge and observation. As held in Ramos: . Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied.Furthermore. and immediately prescribed the administration of the antibiotic chloromycetin. It is generally restricted to situations in malpractice cases where a layman is able to say. based on his findings during the autopsy. diagnosed Jorges illness as typhoid fever. Furthermore. no presumption of negligence can be applied to Dr. that the consequences of professional care were not as such as would ordinarily have followed if due care had been exercised. Apolinar Vacalares as an expert witness. [21] and (2) Dr. Marlyn Rico hastily and erroneously relied upon the Widal test. Cagayan de Oro City. although he may have had extensive experience in performing autopsies. Apolinar Vacalares. We are not persuaded. Marvie Blanes erred in ordering the administration of the second dose of 500 milligrams of chloromycetin barely three hours after the first was given. depending upon the circumstances of each case. which could be due to allergic reaction or chloromycetin overdose. Thus. PASCUAL: Q Why? Have you not testified earlier that you have never seen a patient who died of typhoid fever? . [22] Petitioners presented the testimony of Dr. he admitted that he had yet to do one on the body of a typhoid victim at the time he conducted the postmortem on Jorge Reyes. A distinction must be made between the failure to secure results. First. or why any particular scientific treatment did not produce the desired result. he testified that: [23] ATTY. we do not find him to be so as he is not a specialist on infectious diseases like typhoid fever. . 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.on the alleged breach by respondents of the standard of care required by the circumstances. Vacalares testified that. It must be conceded that the doctrine of res ipsa loquitur can have no application in a suit against a physician or a surgeon which involves the merits of a diagnosis or of a scientific treatment. Jorge Reyes did not die of typhoid fever but of shock undetermined. While petitioners presented Dr. on the issue of the correctness of her diagnosis. Dr.[20] Specific Acts of Negligence We turn to the question whether petitioners have established specific acts of negligence allegedly committed by respondent doctors. Marlyn Rico. The physician or surgeon is not required at his peril to explain why any particular diagnosis was not correct. . who performed an autopsy on the body of Jorge Reyes.

the Widal test is normally used. Dr.A In autopsy. we rejected the opinion of the pulmonologist on the ground that he was not: (1) an anesthesiologist who could enlighten the court about anesthesia practice. when a case of typhoid fever is suspected. They vouched for the correctness of Dr. As the issue was whether the intubation was properly performed by an anesthesiologist.[25] and not due to faulty intubation by the anesthesiologist. a diplomate whose specialization is infectious diseases and microbiology and an associate professor at the Southwestern University College of Medicine and the Gullas College of Medicine. Q And you testified that you have never seen a patient who died of typhoid fever within five days? A I have not seen one. his impression would also be that the patient . the two doctors presented by respondents clearly were experts on the subject. that was when I was a resident physician yet. the defendants presented the testimony of a pulmonologist to prove that brain injury was due to oxygen deprivation after the patient had bronchospasms [24] triggered by her allergic response to a drug. Q How many typhoid fever cases had you seen while you were in the general practice of medicine? A In our case we had no widal test that time so we cannot consider that the typhoid fever is like this and like that. But. nor (3) a pharmacologist who could explain the pharmacologic and toxic effects of the drug allegedly responsible for the bronchospasms. Peter Gotiong. He is thus not qualified to prove that Dr. In Ramos. Marlyn Rico erred in her diagnosis. and their complications. testified that he has already treated over a thousand cases of typhoid fever. Q The question is: how many typhoid fever cases had you seen in your general practice regardless of the cases now you practice? A I had only seen three cases.[27]and if the 1:320 results of the Widal test on Jorge Reyes had been presented to him along with the patients history. which is really inadmissible. Q Clinically? A Way back before my training. procedure. Both lower courts were therefore correct in discarding his testimony. Q And that was way back in 1964? A Way back after my training in UP. Marlyn Ricos diagnosis. nor (2) an allergologist who could properly advance expert opinion on allergic mediated processes. Q But you have not performed an autopsy of a patient who died of typhoid fever? A I have not seen one. And the widal test does not specify the time of the typhoid fever. On the other hand.[26] According to him. Second.

Doctor. [28] As to the treatment of the disease. Q In such case. rise in temperature to 41 oC. . Q Even if the same patient who. Q Even that 40-year old married patient who received medication of chloromycetin of 500 milligrams intravenous. Q And in order to see those changes would it require opening the skull? . . what could possibly come to your mind? A Well. [29] He also explained that despite the measures taken by respondent doctors and the intravenous administration of two doses of chloromycetin. the finding would be more on the meninges or covering of the brain. the patient developed chills . whether you have suffered complications to think of -heart toxic myocardities. Q And presently what are the treatments commonly used? A Drug of choice of chloramphenical. and received a second dose of chloromycetin of 500 miligrams. Q And what will you consider on the complication of typhoid? A One must first understand that typhoid fever is toximia. Q Doctor. PASCUAL: Q If with that count with the test of positive for 1 is to 320. when it is change in the clinical finding. then you can consider a toxic meningitis and other complications and perforations and bleeding in the ilium. the patient associated with chills. what treatment if any would be given? A If those are the findings that would be presented to me. what finding if any could you expect on the post-mortem examination? A No. temperature . . became conscious and coherent about 20 minutes later. . he stated that chloromycetin was the drug of choice. His testimony is as follows:[30] ATTY. after the skin test. you have to think of complication. cardiac rate of 150 per minute who appeared to be coherent. the first thing I would consider would be typhoid fever. and death: what significance would you attach to this development? A We are probably dealing with typhoid to meningitis.was suffering from typhoid fever. The problem is complications are caused by toxins produced by the bacteria . and then about 40 minutes later the temperature rose to 100 oF. restless.41 oC. if given the same patient and after you have administered chloramphenical about 3 1/2 hours later. complications of the disease could not be discounted. which was toxic meningitis and probably a toxic meningitis because of the high cardiac rate. . . 3 hours later. after having given intramuscular valium. have seizure and cyanosis and rolling of eyeballs and vomitting . with seizures: what significance could you attach to these clinical changes? A I would then think of toxemia. nauseating.

Third. Panopio who is a member of the Philippine and American Board of Pathology. The burden of proving that Jorge Reyes was suffering from any other illness rested with the petitioners. while hyperplasia [31] in the payers patches or layers of the small intestines is present in typhoid fever. Rico was also justified in recommending the administration of the drug chloromycetin. Marlyn Rico did not depart from the reasonable standard recommended by the experts as she in fact observed the due care required under the circumstances. per instruction of Dr. but the reasonable average merit among the ordinarily good physicians. as well as liver and cerebral complications. Rico explained that.[34] As regards the 1:320 results of the Widal test on Jorge Reyes. Petitioners contend that respondent Dr. and chief pathologist at the MetroCebu Community Hospital. [37] Here. the same may not always be grossly visible and a microscope was needed to see the texture of the cells. As they failed to present expert opinion on this. Gotiongs testimony that the danger with typhoid fever is really the possible complications which could develop like perforation. Dr. who took over from Dr. write that chlorampenicol (which is the generic of chloromycetin) is the drug of choice for typhoid fever and that no drug has yet proven better in promoting a favorable clinical response. although he did not encourage its use because a single test would only give a presumption necessitating that the test be repeated. Gotiong that hyperplasia in the payers patches may be microscopic. an examiner of the Philippine Board of Pathology. in the present case. Wilson. Dr. it remains a standard diagnostic test for typhoid fever and. Panopio stated that no additional information could be obtained from a higher ratio. [35] He also agreed with Dr. the standard contemplated is not what is actually the average merit among all known practitioners from the best to the worst and from the most to the least experienced. Marlyn Rico. however: That chloromycetin was likewise a proper prescription is best established by medical authority. Petitioners claim that Jorge Reyes died of anaphylactic shock[38] or possibly from overdose as the second dose should have been administered five to six hours after the first. taken with the fact that typhoid fever was then prevalent as indicated by the fact that the clinic had been getting about 15 to 20 typhoid cases a month. al. was negligent in ordering the intravenous administration of two doses of 500 milligrams of chloromycetin at an interval of less than three hours. were sufficient to give upon any doctor of reasonable skill the impression that Jorge Reyes had typhoid fever. [32] Respondents also presented the testimony of Dr. Dr. greater accuracy through repeated testing was rendered unobtainable by the early death of the patient. as a clinical pathologist. hemorrhage. [36] Indeed. et. Marvie Blanes. preponderant evidence to support their contention is clearly absent. Perpetual Succor Hospital. Vacalares finding during the autopsy that the deceaseds gastro-intestinal tract was normal. and the Andres Soriano Jr.A Yes.. [33] He corroborated Dr. he recognized that the Widal test is used for typhoid patients. 12th ed. Rico. becoming more conclusive at the second and third weeks of the disease. The results of the Widal test and the patients history of fever with chills for five days. Dr. Memorial Medical Center. the drug of choice for typhoid fever. As regards Dr. Though the Widal test is not conclusive. in Harrisons Principle of Internal Medicine. As held by the Court of Appeals. . He stated that. Ibarra T.

ONick. this. rickettsial infections. 16-17) Once more. prescribed and administered medication with recklessness and exhibited an absence of the competence and skills expected of general practitioners similarly situated. The onus probandi was on the appellants to establish. (Decision. (PIMS Annual. p. 1996).. bacteriodes infections. pp. 1994. typhoid fever. it has been observed: Skin testing with haptenic drugs is generally not reliable.. Committee on Therapeutics and Toxicology. (Terr. producing a weal-and-flare reaction in normal individuals. Common carriers. from the nature of their business and for reasons of public policy. 211) The dosage likewise including the first administration of five hundred milligrams (500 mg. this Court rejects any claim of professional negligence in this regard. The law cannot require them to predict every possible reaction to all drugs administered. is affected with public interest. (Mansser. so a negative skin test to a univalent haptenic drug does not rule out anaphylactic sensitivity to that drug. .. before the trial court. are bound to observe extraordinary diligence in the vigilance over the goods and for the safety of the passengers transported by them. p.) at around nine oclock in the evening and the second dose at around 11:30 the same night was still within medically acceptable limits..[39] Fourth. 1st Ed. since the recommended dose of chloromycetin is one (1) gram every six (6) hours. Petitioners correctly observe that the medical profession is one which. As regards anaphylactic shock. Moreover. Certain drugs cause nonspecific histamine release. according to the circumstances of . the evidence introduced that it was Dra. of itself. Philippine Pediatric Society. The intravenous route is likewise correct. that the appellee-physicians ignored standard medical procedure. 349) What all this means legally is that even if the deceased suffered from an anaphylactic shock.Chlorampenicol (Chloromycetin) is specifically indicated for bacterial meningitis. 1733. Blanes who interpreted the results remain uncontroverted. is the skin test of which. [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. etc. The standard of extraordinary diligence is peculiar to common carriers. Pharmacology and Therapeutics) Even if the test was not administered by the physician-on-duty. Anaphylaxis and Urticaria in Basic and Clinical Immunology. the usual way of guarding against it prior to the administration of a drug. thereby reducing the standard of care and degree of diligence required from physicians and surgeons in Iligan City. however. (cf. 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.Pediatric Drug Handbook. [40] physicians and surgeons should have the same duty toward their patients. like the business of a common carrier. 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. The Civil Code provides: Art. Immunologic activation of mast cells requires a polyvalent allergen.

No.** Acting Chairperson. training. the practice of medicine is already conditioned upon the highest degree of diligence. there is no need to expressly require of doctors the observance of extraordinary diligence. EMMANUEL JARCIA. That is reasonable diligence for doctors or. Petitioners. the conduct of doctors is also strictly governed by the Hippocratic Oath. . In addition to state regulation.. as the Court of Appeals called it. . Given these safeguards.R.* J. . the reasonable skill and competence . . PERALTA. the instant petition is DENIED and the decision of the Court of Appeals is AFFIRMED. that a physician in the same or similar locality . The practice of medicine is a profession engaged in only by qualified individuals. G. .and DR. as we have already noted. the standard contemplated for doctors is simply the reasonable average merit among ordinarily good physicians. WHEREFORE. and by first obtaining a license from the state through professional board examinations. at any time and for cause. As it is now. It is a right earned through years of education. Republic of the Philippines Supreme Court Manila THIRD DIVISION DR. . .each case. an ancient code of discipline and ethical rules which doctors have imposed upon themselves in recognition and acceptance of their great responsibility to society. Present: CARPIO. 187926 JR. MARILOU BASTAN. Such license may. should apply. be revoked by the government. . SO ORDERED. And.

- versus -

ABAD,
PEREZ,*** and
MENDOZA, JJ.

Promulgated:
PEOPLE OF THEPHILIPPINES,
Respondent.

February 15, 2012

x --------------------------------------------------------------------------------------- x

DECISION
MENDOZA, J.:
Even early on, patients have consigned their lives to the skill of their
doctors. Time and again, it can be said that the most important goal of the
medical profession is the preservation of life and health of the people.
Corollarily, when a physician departs from his sacred duty and endangers
instead the life of his patient, he must be made liable for the resulting
injury. This Court, as this case would show, cannot and will not let the act
go unpunished.[1]
This is a petition for review under Rule 45 of the Rules of Court challenging the August
29, 2008 Decision[2] of the Court of Appeals (CA), and its May 19, 2009
Resolution[3] in CA-G.R. CR No. 29559, dismissing the appeal and affirming in toto the
June 14, 2005 Decision[4] of the Regional Trial Court, Branch 43, Manila (RTC), finding
the accused guilty beyond reasonable doubt of simple imprudence resulting to serious
physical injuries.

THE FACTS
Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of
Investigation (NBI) against the petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr.
Marilou Bastan (Dr. Bastan), for their alleged neglect of professional duty which caused
her son, Roy Alfonso Santiago (Roy Jr.), to suffer serious physical injuries. Upon
investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was rushed to the
Manila Doctors Hospital for an emergency medical treatment; that an X-ray of the
victims ankle was ordered; that the X-ray result showed no fracture as read by Dr.
Jarcia; that Dr. Bastan entered the emergency room (ER) and, after conducting her own
examination of the victim, informed Mrs. Santiago that since it was only the ankle that
was hit, there was no need to examine the upper leg; that eleven (11) days later, Roy Jr.
developed fever, swelling of the right leg and misalignment of the right foot; that Mrs.
Santiago brought him back to the hospital; and that the X-ray revealed a right mid-tibial
fracture and a linear hairline fracture in the shaft of the bone.
The NBI indorsed the matter to the Office of the City Prosecutor of Manila for
preliminary investigation. Probable cause was found and a criminal case for reckless
imprudence resulting to serious physical injuries, was filed against Dr. Jarcia, Dr. Bastan
and Dr. Pamittan,[5] before the RTC, docketed as Criminal Case No. 01-196646.
On June 14, 2005, the RTC found the petitioners guilty beyond reasonable doubt
of the crime of Simple Imprudence Resulting to Serious Physical Injuries. The decretal
portion of the RTC decision reads:
WHEREFORE, premises considered, the Court finds accused DR.
EMMANUEL JARCIA, JR. and DR. MARILOU BASTAN GUILTY beyond
reasonable doubt of the crime of SIMPLE IMPRUDENCE RESULTING TO
SERIOUS PHYSICAL INJURIES and are hereby sentenced to suffer the penalty
of ONE (1) MONTH and ONE (1) DAY to TWO (2) MONTHS and to indemnify
MRS. BELINDA SANTIAGO the amount of ₱3,850.00 representing medical
expenses without subsidiary imprisonment in case of insolvency and to pay the
costs.
It appearing that Dr. Pamittan has not been apprehended nor voluntarily
surrendered despite warrant issued for her arrest, let warrant be issued for her
arrest and the case against her be ARCHIVED, to be reinstated upon her

apprehension.
SO ORDERED.[6]

The RTC explained:
After a thorough and in depth evaluation of the evidence adduced by the
prosecution and the defense, this court finds that the evidence of the
prosecution is the more credible, concrete and sufficient to create that moral
certainty in the mind of the Court that accused herein [are] criminally
responsible. The Court believes that accused are negligent when both failed to
exercise the necessary and reasonable prudence in ascertaining the extent of
injury of Alfonso Santiago, Jr.
However, the negligence exhibited by the two doctors does not approximate
negligence of a reckless nature but merely amounts to simple
imprudence. Simple imprudence consists in the lack of precaution displayed in
those cases in which the damage impending to be caused is not the immediate
nor the danger clearly manifest. The elements of simple imprudence are as
follows.
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
of the danger is not clearly manifest.
Considering all the evidence on record, The Court finds the accused guilty for
simple imprudence resulting to physical injuries. Under Article 365 of the
Revised Penal Code, the penalty provided for is arresto mayor in its minimum
period.[7]

Dissatisfied, the petitioners appealed to the CA.
As earlier stated, the CA affirmed the RTC decision in toto. The August 29,
2008 Decision of the CA pertinently reads:
This Court holds concurrently and finds the foregoing circumstances sufficient
to sustain a judgment of conviction against the accused-appellants for the crime
of simple imprudence resulting in serious physical injuries. The elements of
imprudence 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 without malice; (4) that
material damage results from the imprudence; and (5) that there is inexcusable
lack of precaution on the part of the offender, taking into consideration his

and for a reasonable conclusion of negligence. the very nature of certain types of occurrences may justify an inference of negligence on the part of the person who controls the instrumentality causing the injury in the absence of some explanation by the accused-appellant who is charged with negligence. time and place. there must be proof of breach of duty on the part of the physician as well as a causal connection of such breach and the resulting injury of his patient. In the case of Leonila Garcia-Rueda v. We are not convinced. in natural and continuous sequence. bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science. physical condition. unbroken by intervening efficient causes. having the needed training and skill possessed by physicians and surgeons practicing in the same field. In the case at bench. Whether or not Dr. The proximate cause of an injury is that cause which. negligence may be . In litigations involving medical negligence. no matter in what it consists. cannot create a right of action unless it is the proximate cause of the injury complained of. The prosecution is however after the cause which prolonged the pain and suffering of Roy and not on the failure of the accused-appellants to correctly diagnose the extent of the injury sustained by Roy. the Supreme Court stated that. The doctrine of res ipsa loquitur is simply a recognition of the postulate that. the negligence must be the proximate cause of the injury. degree of intelligence. Negligence. Jarcia and Dr. we shall first consider the applicability of the doctrine of res ipsa loquitur to the instant case.employment or occupation. on the basis of such experience or common knowledge. in accepting a case. the plaintiff has the burden of establishing accused-appellants negligence. a doctor in effect represents that. produces the injury and without which the result would not have occurred. Res ipsa loquitur is a Latin phrase which literally means the thing or the transaction speaks for itself. 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. he will employ such training. and other circumstances regarding persons. unbroken by any efficient intervening cause. the accused-appellants questioned the imputation against them and argued that there is no causal connection between their failure to diagnose the fracture and the injury sustained by Roy. Bastan had committed an inexcusable lack of precaution in the treatment of their patient is to be determined according to the standard of care observed by other members of the profession in good standing under similar circumstances. as a matter of common knowledge and experience. It is grounded in the superior logic of ordinary human experience and. The connection between the negligence and the injury must be a direct and natural sequence of events. In other words. Pascasio. For a more logical presentation of the discussion. care and skill in the treatment of his patients.

The specific acts of negligence was narrated by Mrs. sir.deduced from the mere occurrence of the accident itself. Dra. Pamittan was inside the cubicle of the nurses and I asked her. xxxxxxxxx A: I just listened to them. res ipsa loquitur is applied in conjunction with the doctrine of common knowledge. They just lifted the pants of my son. Bastan. Jarcia or Dra. And I just asked if I will still return my son. sir. Q: And what did she tell you? A: According to Dra. Sir. Q: What did you [tell] her? A: I told her. he is an intern did you not consult the doctors. Pamittan to confirm whether you should go home or not? A: Dra. sir. Q: And what did she [tell] you? A: They told me they will call a resident doctor. there is no need to x-ray because it was the ankle part that was run over. Bastan arrived. Q: Did you tell her what you want on you to be done? A: Yes. Hence. xxxxxxxxx Q: Was there a resident doctor [who] came? A: Yes. She testified as follows: Fiscal Formoso: Q: Now. Q: What did you do or tell her? A: I told her. sir. are you not going to x-ray up to the knee because my son was complaining pain from his ankle up to the middle part of the right leg. Dr. you let us go home and you dont even clean the wounds of my son. sir. while she was cleaning the wounds of my son. Q: So you mean to say there was no treatment made at all? A: None. Santiago who accompanied her son during the latters ordeal at the hospital. sir. why is it that they did not examine[x] the whole leg. xxxxxxxxx .

Santiago was corroborated by a bone specialist Dr. must show a situation where it is applicable and must establish that the essential elements of the doctrine were present in a particular incident. And then. in addition to proving injury or damage. the following requisites must be satisfactorily shown: 1. before resort to the doctrine may be allowed. A boy of tender age whose leg was hit by a vehicle would engender a well-founded belief that his condition may worsen without proper medical attention. considering their year of . Such element of control must be shown to be within the dominion of the accused-appellants. Because they have presented the patient and the history. Santiago insisted on having another x-ray of her child on the upper part of his leg. sir. When Mrs. The mother would not have asked them if they had no exclusive control or prerogative to request an x-ray test. Still. This omission alone constitutes simple imprudence on their part. As junior residents who only practice general surgery and without specialization with the case consulted before them. nadaanan lang po ito.Q: And you were present when they were called? A: Yes. Tacata. the fundamental element is the control of the instrumentality which caused the damage. The testimony of Mrs. The possibility of contributing conduct which would make the plaintiff responsible is eliminated. as he examined himself the child Roy. sir. He testified as follows: Fiscal Macapagal: Q: And was that the correct respon[se] to the medical problem that was presented to Dr. Retoria? A: When they were there they admitted that they have mistakes. they refused to do so. At sabi nila. and 3. a plaintiff. yes. Bastan? A: I would say at that stage. The accident is of a kind which ordinarily does not occur in the absence of someones negligence. In the above requisites. Such is a fact because a radiologist would only conduct the x-ray test upon request of a physician. He further testified based on his personal knowledge. Q: And what was discussed then by Sis. and not as an expert. It is caused by an instrumentality within the exclusive control of the defendant or defendants. Jarcia and Dra. The early treatment of the leg of Roy would have lessen his suffering if not entirely relieve him from the fracture. they should have referred the matter to a specialist. 2. In order to have the benefit of the rule.

the supervisor there is a consultant that usually comes from a family medicine. testimony as to the statements and acts of physicians. its entirely different thing. without the aid of expert testimony. it is the decision. Santiago by applying the doctrine of res ipsa loquitur. In the case at bench. there would be more precise and accurate decision compare to a general surgery resident in so far as involved. I dont [know] why they dont. Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied. . we give credence to the testimony of Mrs. in cases where the res ipsa loquitur is applicable. and manifest conditions which are observable by any one may be given by non-expert witnesses.Because at that time. However. where the court from its fund of common knowledge can determine the proper standard of care. I think. It is generally restricted to situations in malpractice cases where a layman is able to say. 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 and care. They see where a certain patient have to go and then if they cannot manage it. an inference of negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur without medical evidence. WHEREFORE. at the Manila Doctors Hospital. Now at that time. Hence. The latter circumstance is the primordial issue that confronted this Court and we find application of the doctrine of res ipsa loquitur to be in order. Because if you are an orthopedic resident. that the consequences of professional care were not as such as would ordinarily have followed if due care had been exercised. the appeal in this case is hereby DISMISSED and the assailed decision of the trial court finding accusedappellants guilty beyond reasonable doubt of simple imprudence resulting in serious physical injuries is hereby AFFIRMED in toto. Where common knowledge and experience teach that a resulting injury would not have occurred to the patient if due care had been exercised. in view of the foregoing. external appearances. I am not trying to saybut if I were an orthopedic resident. and they are not also orthopedic residents but general surgery residents. depending upon the circumstances of each case. they refer it to the consultant on duty. Q: You mean to say there is no supervisor attending the emergency room? A: At the emergency room. which is ordinarily required to show not only what occurred but how and why it occurred. as a matter of common knowledge and observation. the court is permitted to find a physician negligent upon proper proof of injury to the patient. Ordinarily. Since the x-rays.residency they are still junior residents. 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.

TO IMMEDIATELY BRING THE PATIENT BACK TO THE HOSPITAL. AND PROXIMATE CAUSE OF THE PHYSICAL INJURY OF THE PATIENT (FRACTURE OF THE LEG BONE OR TIBIA). 4. THE COURT OF APPEALS ERRED IN HOLDING THAT THE FAILURE OF PETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY EXAMINATION PROLONGED THE PAIN AND SUFFERING OF THE PATIENT. WHICH REQUIRED MEDICAL ATTENDANCE FOR MORE THAN THIRTY (30) DAYS AND INCAPACITATED HIM FROM PERFORMING HIS CUSTOMARY DUTY DURING THE SAME PERIOD OF TIME. DR. THE EVIDENCE ON RECORD. THE COURT OF APPEALS ERRED IN NOT HOLDING THAT THE ACTUAL. AND EVEN CONTRARY TO. ASSUMING ARGUENDO THAT THE PATIENT EXPERIENCED PROLONGED PAIN AND SUFFERING. SIGNIFICANTLY. NOT THE FAILURE OF THE ACCUSED-PETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY EXAMINATION. THUS. DIRECT. THAT PETITIONERS WERE NOT GUILTY OF NEGLIGENCE OR IMPRUDENCE COMPLAINED OF. but it was denied by the CA in its May 19. IMMEDIATE. AFTER HE COMPLAINED OF SEVERE PAIN IN HIS RIGHT LEG WHEN HE REACHED HOME AFTER HE WAS SEEN BY PETITIONERS AT THE HOSPITAL. Hence.[8] The petitioners filed a motion for reconsideration. THE COURT OF APPEALS ERRED IN DISREGARDING ESTABLISHED FACTS CLEARLY NEGATING PETITIONERS ALLEGED NEGLIGENCE OR IMPRUDENCE. WAS THE VEHICULAR ACCIDENT WHERE THE PATIENTS RIGHT LEG WAS HIT BY A TAXI. AS ADVISED BY THE PETITIONERS. SUCH CONCLUSION BEING UNSUPPORTED BY. THE COURT OF APPEALS ERRED IN NOT HOLDING THAT THE ALLEGED PAIN AND SUFFERING WERE DUE TO THE UNJUSTIFIED FAILURE OF THE PATIENTS MOTHER. 2009 Resolution. THE PATIENTS . 3. this petition. THE COURT OF APPEALS UNJUSTIFIABLY DISREGARDED THE OPINION OF THE PROSECUTIONS EXPERT WITNESS.SO ORDERED. The petitioners pray for the reversal of the decision of both the RTC and the CA anchored on the following GROUNDS1. CIRILO TACATA. A NURSE HERSELF. IN AFFIRMING ACCUSED-PETITIONERS CONVICTION. 2.

Under this . 5. Res ipsa loquitur is a rule of evidence whereby negligence of the alleged wrongdoer may be inferred from the mere fact that the accident happened provided the character of the accident and circumstances attending it lead reasonably to belief that in the absence of negligence it would not have occurred and that thing which caused injury is shown to have been under the management and control of the alleged wrongdoer. however. and the accident is such as in the ordinary course of things does not happen if those who have the management use proper care. the Court is not convinced that the petitioners are guilty of criminal negligence complained of.[9] The foregoing can be synthesized into two basic issues: [1] whether or not the doctrine of res ipsa loquitur is applicable in this case. PETITIONERS NOT BEING THE LATTERS ATTENDING PHYSICIAN AS THEY WERE MERELY REQUESTED BY THE EMERGENCY ROOM (ER) NURSE TO SEE THE PATIENT WHILE THEY WERE PASSING BY THE ER FOR THEIR LUNCH. As to the Application of The Doctrine of Res Ipsa Loquitur This doctrine of res ipsa loquitur means "Where the thing which causes injury is shown to be under the management of the defendant. THE COURTS RULING The CA is correct in finding that there was negligence on the part of the petitioners. Rebuttable presumption or inference that defendant was negligent. After a perusal of the records. that the accident arose from want of care. Thus: The thing speaks for itself. and [2] whether or not the petitioners are liable for criminal negligence. JR. 6. which arises upon proof that the instrumentality causing injury was in defendant's exclusive control. in the absence of an explanation by the defendant.ALLEGED INJURY (PROLONGED PAIN AND SUFFERING) WAS DUE TO HIS OWN MOTHERS ACT OR OMISSION. and that the accident was one which ordinarily does not happen in absence of negligence. THE COURT OF APPEALS GRAVELY ERRED IN NOT ACQUITTING ACCUSED-PETITIONERS OF THE CRIME CHARGED. it affords reasonable evidence." The Black's Law Dictionary defines the said doctrine.. THE COURT OF APPEALS ERRED IN NOT HOLDING THAT NO PHYSICIAN-PATIENT RELATIONSHIP EXISTED BETWEEN PETITIONERS AND PATIENT ALFONSO SANTIAGO. The Court is also of the view that the CA erred in applying the doctrine of res ipsa loquitur in this particular case.

not through the scholarly assumptions of a layman like the patients mother. is not meant to and does not dispense with the requirement of proof of culpable negligence on the party charged. The doctrine can be invoked when and only when. [13] While it may be true that the circumstances pointed out by the courts below seem doubtless to constitute reckless imprudence on the part of the petitioners. is not a rule of substantive law. The doctrine. It merely determines and regulates what shall be prima facie evidence thereof and helps the plaintiff in proving a breach of the duty. this conclusion is still best achieved. Jr. but by the unquestionable knowledge of expert witness/es.doctrine. and that the occurrence was such that in the ordinary course of things would not happen if reasonable care had been used. when applicable to the facts and circumstances of a given case.s injury and the series of tests that were supposed to be undergone by him to determine the extent of the injury suffered were not under the exclusive control of Drs. but merely a mode of proof or a mere procedural convenience. the circumstances that caused patient Roy Jr. (2) the instrumentality or agency which caused the injury was under the exclusive control of the person in charge. It was established that they are mere residents of the Manila Doctors Hospital at that time who attended to the victim at the emergency room.[10] The doctrine of res ipsa loquitur as a rule of evidence is unusual to the law of negligence which recognizes that prima facie negligence may be established without direct proof and furnishes a substitute for specific proof of negligence. Jarcia and Bastan.[11] The requisites for the application of the doctrine of res ipsa loquitur are: (1) the accident was of a kind which does not ordinarily occur unless someone is negligent. the happening of an injury permits an inference of negligence where plaintiff produces substantial evidence that the injury was caused by an agency or instrumentality under the exclusive control and management of defendant. under the circumstances involved. however. As to whether the petitioners have exercised the requisite degree of skill and care in treating patient Roy. direct evidence is absent and not readily available.[12] In this case. . is generally a matter of expert opinion. and (3) the injury suffered must not have been due to any voluntary action or contribution of the person injured. The rule.

Bastan are criminally negligent in this case. Jarcia and Dr. a specialist in pediatric orthopedic. were indeed aggravated by the petitioners judgment call and their diagnosis or appreciation of the condition of the victim at the time they assessed him. Cirilo R. Jarcia and Dr. Negligence is defined as the failure to observe for the protection of the interests of another person that degree of care. 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. as physicians on duty. without malice.[16] In this case. Bastan. The testimony of Dr. whereby such other person suffers injury.[14] Reckless imprudence consists of voluntarily doing or failing to do. although pointing to some medical procedures that could have been done by Dr. The elements thereof were not proved by the prosecution beyond reasonable doubt. Bastans negligence The totality of the evidence on record clearly points to the negligence of the petitioners. Thus: Q: Will you please tell us. and vigilance which the circumstances justly demand. for the record. Tacata). doctor. was not clear as to whether the injuries suffered by patient Roy Jr.[15] The elements of simple negligence are: (1) that there is lack of precaution on the part of the offender. Jarcia and Dr. what is your specialization? A: At present I am the chairman department of orthopedic in UP-PGH and I had special training in pediatric orthopedic for two (2) years. is not satisfied that Dr. Tacata (Dr. the Court is not convinced with moral certainty that the petitioners are guilty of reckless imprudence or simple negligence. however. and (2) that the damage impending to be caused is not immediate or the danger is not clearly manifest. precaution. the Court. At the risk of being repetitious. .As to Dr.

Alfonso Santiago. Q: Who did you interview? A: The mother. we request for a detailed history. actually. how long was this fracture? A: When we say spiral. the involved leg then was swollen and the patient could not walk. what was your position and what was your specialization at that time? A: Since 1980. at that time as I have said. Q: And as far as you can recall. we request for the exact mechanism of injuries. doctor. the patient could not walk so I [began] to suspect that probably he sustained a fracture as a result of a vehicular accident. did you ask for the history of such injury? A: Yes. that was a routine part of our examination that once a patient comes in. If it is an accident. the bigger one is the tibial and the smaller one is the fibula. doctor. did you request to be examined? A: If we refer for an x-ray. doctor. the answers are not accurate. will you please point to us. then. The bigger one is the one that get fractured. so I requested for the x-ray of [the] lower leg. I dont know if it is a car. what was the history of that injury that was told to you? A: The patient was sideswiped. the length was about six (6) to eight (8) centimeters. it was the mother that I interviewed. usually. I examined the patient physically and. Jr.Q: In June 1998. Q: How about the child himself. middle or lebistal tinial.? A: Normally. Q: When Alfonso Santiago. at his age. Jr. we suspect a fracture whether in approximal. Q: And what was the result? A: Well. Q: And in the course of your examination of Alfonso Santiago. Jr. Q: What part of the leg. it is a sort of letter S. before we actually examine the patient. I have been specialist in pediatric orthopedic. doctor. it is the bigger bone of the leg. but it is a vehicular accident. Q: And when you say spiral. . was brought to you by his mother. usually. So I examined the patient at that time. there are two bones here. we usually x-ray the entire extremity. I can say that it was a spiral fracture of the mid-tibial. Q: Mid-tibial. what did you do by way of physicians as first step? A: As usual. we do not interview the child because. So. the involved leg. Doctor. I dont know if that is left or right. where the tibial is? (Witness pointing to his lower leg) A: The tibial is here.

xxxx Q: Doctor. if you know that the patient sustained a fracture on the ankle and on the foot and the history that was told to you is the region that was hit is the region of the foot. They see where a certain patient have to go and then if they cannot manage it. sir. Jr. Doctor. you would conduct first an examination? A: Yes. xxxx Q: But if initially. Q: Not the entire body but the entire leg? A: I think. I think. Jr.Q: And were you informed also of his early medication that was administered on Alfonso Santiago. that time who happened to be my residents who were [on] duty at the emergency room. Q: And do you think that with that examination that you would have conducted you would discover the necessity subjecting the entire foot for x-ray? A: It is also possible but according to them. Bastan are not even an orthopedic specialist. including neurology. which sometimes normally happens that the actual fractured bone do not get swollen. Alfonso Santiago. Now at that time. they see everything at the emergency room. Since the x-rays xxx Q: You also said. because it would still depend on my examination. we cannot subject the whole body for x-ray if we think that the damaged was only the leg. You have to man[x] the emergency room. orthopedic. general surgery. they refer it to the consultant on duty. Jarcia and Dra. that Dr. Jarcia and Dra.? A: No. if my examination requires it. I was informed that this patient was seen initially at the emergency room by the two (2) physicians that you just mentioned. the supervisor there is a consultant that usually comes from a family medicine. Jarcia and Dra. at the Manila Doctors Hospital. Dr. it is the decision. and his case was presented to you at the emergency room. Bastan is the same? A: I could not directly say yes. you would have subjected the entire foot to x-ray even if the history that was given to Dr. xxxx A: At the emergency room. the foot and the ankle were swollen and not the leg. will the doctor subject the entire leg for x-ray? . A: They are general surgeon residents. Q: So. Bastan. I would. not actually medication. I dont why they dont Because at that time.

that opinion. however. the extent and severity of the injury. the patient fell. been treated properly and given the extensive X-ray examination. Thats why the leg seems to be fractured. Bastan were expected to know the medical protocol in treating leg fractures and in attending to victims of car accidents. finds the petitioners civilly liable for their failure to sufficiently attend to Roy Jr. The petitioners. paikot yung bale nya. As residents on duty at the emergency room. It may be true that the actual. Taken into account also was the fact that there was no bad faith on their part. Any person may opine that had patient Roy Jr. you have to subject an x-ray of the leg. nevertheless. no precise evidence and scientific explanation pointing to the fact that the delay in the application of the cast to the patients fractured leg because of failure to immediately diagnose the specific injury of the patient. Although the Court sympathizes with the plight of the mother and the child in this case. There was. and it got twisted.A: I am an orthopedic surgeon. and could not. the Court is bound by the dictates of justice which hold inviolable the right of the accused to be presumed innocent until proven guilty beyond reasonable doubt. For example spiral. cannot simply invoke such fact alone to . But still. prolonged the pain of the child or aggravated his condition or even caused further complications. The Court. Jarcia and Dr.s medical needs when the latter was rushed to the ER. a reasonable doubt as to the petitioners guilt. so it was possible that the leg was run over. Bastan cannot pass on the liability to the taxi driver who hit the victim. spiral fracture of the mid-tibial part or the bigger bone of the leg. only a preponderance of evidence is required to establish civil liability. Tacata that a thorough examination was not performed on Roy Jr. could have been prevented. thus. immediate. Dr. Dr. could have been detected early on and the prolonged pain and suffering of Roy Jr. for while a criminal conviction requires proof beyond reasonable doubt. even how logical it may seem would not.[17] [Emphases supplied] It can be gleaned from the testimony of Dr. was the vehicular accident when he was hit by a taxi. however. direct. Jarcia and Dr. and proximate cause of the injury (fracture of the leg bone or tibia) of Roy Jr. be enough basis to hold one criminally liable. Because you have to consider the kind of fracture that the patient sustained would you say the exact mechanism of injury.

. doctors would have a ready defense should they fail to do their job in attending to victims of hit-and-run. If this would be so. for all intents and purposes.[19] Assuming again for the sake of argument that the petitioners may still raise this issue of no physicianpatient relationship. and skill in the treatment of the patient. In the case of Lucas v. Bastan were remiss of their duties as members of the medical profession. Dr. immediate. Tuao. maltreatment. The petitioners. and ordinarily will not be.[20] the Court wrote that [w]hen a patient engages the services of a physician. and proximate cause of the injury is indubitably the act of the perpetrator/s. issues and arguments not brought to the attention of the trial court need not be. Jarcia and Dr. basic considerations of due process dictate that theories. represents that he has the needed training and skill possessed by physicians and surgeons practicing in the same field. Thus. the Court finds and so holds that there was a physicianpatient relationship in this case. and that he will employ such training. In failing to perform an extensive medical examination to determine the extent of Roy Jr. justice and due process. this issue was never raised during the trial at the RTC or even before the CA. And in accepting a case. and other crimes of violence in which the actual. direct. To allow him to do so is unfair to the other party and offensive to the rules of fair play. It has been settled that issues raised for the first time on appeal cannot be considered because a party is not permitted to change his theory on appeal. They claim that they were merely requested by the ER nurse to see the patient while they were passing by the ER for their lunch. since they were not his attending physicians at that time. care. the physician. Firstly. Assuming for the sake of argument that they did not have the capacity to make such thorough evaluation at that stage. raise the want of doctor-patient relationship for the first time on appeal with this Court. a physician-patient relationship is generated. considered by a reviewing court.s injuries. they should have referred the patient to another doctor with sufficient training and experience instead of assuring him and his mother that everything was all right. in . This Court cannot also stamp its imprimatur on the petitioners contention that no physician-patient relationship existed between them and patient Roy Jr.excuse themselves from any liability. therefore.[18] Stated differently.

Notably. a physician-patient relationship exists between the petitioners and patient Roy Jr. to another doctor who could competently and thoroughly examine his injuries. violation of this rule on his part is discreditable and inexcusable. indeed. As the sole tribunal to adjudge the physicians failure to fulfill his obligation to his patients is. By doing so. and could have done. if these doctors knew from the start that they were not in the position to attend to Roy Jr. was to refer Roy Jr. Article II. with the degree of diligence and commitment expected of every doctor in a case like this. a vehicular accident victim. residents on duty at the ER). the petitioners were. Section 1 of the Code of Medical Ethics of the Medical Profession in the Philippines states: A physician should attend to his patients faithfully and conscientiously. Clearly.[21] They obliged and examined the victim. All told. Indubitably. in most cases. they should have not made a baseless assurance that everything was all right. Tacata that they were. the physician has the obligation to use at least the same level of care that any other reasonably competent physician would use to treat the condition under similar circumstances. To repeat for clarity and emphasis. his own conscience. He should secure for them all possible benefits that may depend upon his professional skill and care. The petitioners allegedly passed by and were requested to attend to the victim (contrary to the testimony of Dr. skill and diligence which physicians in the same general neighborhood and in the same general line of practice ordinarily possess and exercise in like cases. and not criminally.[22] . liable as the facts show.. What petitioners should have done. the latter and his mother went to the ER for an immediate medical attention. they deprived Roy Jr. a physician is under a duty to exercise that degree of care. a physician-patient relationship was established between the petitioners and the patient Roy Jr. Stated otherwise. and later assured the mother that everything was fine and that they could go home.treating his patient. at that time. negligent but only civilly. of adequate medical attention that placed him in a more dangerous situation than he was already in.

Established medical procedures and practices, though in constant instability, are
devised for the purpose of preventing complications. In this case, the petitioners failed to
observe the most prudent medical procedure under the circumstances to prevent the
complications suffered by a child of tender age.
As to the Award of
Damages
While no criminal negligence was found in the petitioners failure to administer the
necessary medical attention to Roy Jr., the Court holds them civilly liable for the
resulting damages to their patient. While it was the taxi driver who ran over the foot or
leg of Roy Jr., their negligence was doubtless contributory.
It appears undisputed that the amount of ₱3,850.00, as expenses incurred by patient Roy
Jr., was adequately supported by receipts. The Court, therefore, finds the petitioners
liable to pay this amount by way of actual damages.
The Court is aware that no amount of compassion can suffice to ease the sorrow felt by
the family of the child at that time. Certainly, the award of moral and exemplary
damages in favor of Roy Jr. in the amount of ₱100,000.00 and ₱50,000.00, respectively,
is proper in this case.
It is settled that moral damages are not punitive in nature, but are designed to
compensate and alleviate in some way the physical suffering, mental anguish, fright,
serious anxiety, besmirched reputation, wounded feelings, moral shock, social
humiliation, and similar injury unjustly inflicted on a person. Intended for 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. 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)
(2)
(3)
(4)

₱3,850.00 as actual damages;
₱100,000.00 as moral damages;
₱50,000.00 as exemplary damages; and

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.

Republic of the Philippines
SUPREME COURT
Manila
FIRST DIVISION
G.R. No. 126297

January 31, 2007

PROFESSIONAL SERVICES, INC., Petitioner,
vs.
NATIVIDAD and ENRIQUE AGANA, Respondents.
x-----------------------x
G.R. No. 126467

January 31, 2007

NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE AGANA, JR., EMMA
AGANA ANDAYA, JESUS AGANA, and RAYMUND AGANA) and ENRIQUE AGANA, Petitioners,
vs.
JUAN FUENTES, Respondent.
x- - - - - - - - - - - - - - - - - - - -- - - - x
G.R. No. 127590

January 31, 2007

MIGUEL AMPIL, Petitioner,
vs.
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
DECISION

SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankind’s 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 hospital’s keeping.1
Assailed in these three consolidated petitions for review on certiorari is the Court of Appeals’
Decision2 dated September 6, 1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198 affirming with
modification the Decision3 dated March 17, 1993 of the Regional Trial Court (RTC), Branch 96, Quezon
City in Civil Case No. Q-43322 and nullifying its Order dated September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital (Medical City Hospital)
because of 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 the sigmoid."
On April 11, 1984, Dr. Ampil, assisted by the medical staff 4 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
Natividad’s husband, Enrique Agana, to permit Dr. Juan Fuentes, respondent in G.R. No. 126467, to
perform hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and
closed the incision.
However, the operation appeared to be flawed. In the corresponding Record of Operation dated April 11,
1984, the attending nurses entered these remarks:
"sponge count lacking 2
"announced to surgeon searched (sic) done but to no avail continue for closure."
On April 24, 1984, Natividad was released from the hospital. Her hospital and medical bills, including the
doctors’ fees, amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating pain in her anal region. She consulted both Dr.
Ampil and Dr. Fuentes about it. They told her that the pain was 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.
On May 9, 1984, Natividad, accompanied by her husband, went to the United States to seek further
treatment. After four months of consultations and laboratory examinations, Natividad was told she was free
of cancer. Hence, she was advised to return to the Philippines.
On August 31, 1984, Natividad flew back to the Philippines, still suffering from pains. Two weeks thereafter,
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. Ampil’s 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
which 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, Natividad underwent another surgery.
On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, Quezon City a
complaint for damages against 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 leaving two pieces of gauze inside Natividad’s body and malpractice for concealing their

Dr. Fuentes only. the Court of Appeals rendered its Decision jointly disposing of CA-G.acts of negligence. Fuentes liable for negligence and malpractice.000. 2. JUAN FUENTES to pay to the plaintiffs.R. The Board held that the prosecution failed to show that Dr.R. 32198. SO ORDERED. representing the cost of hospitalization at Polymedic Hospital. Incidentally. On September 21. The equivalent in Philippine Currency of the total of US$19. the sum of P300. On January 24.275. Ampil and Dr. as reimbursement of actual expenses incurred in the United States of America. 1993 granting Dr. on January 23. The sum of P4. Fuentes. from date of filing of the complaint until full payment. and 3 hereinabove. Ampil and Dr.00. Fuentes. which was granted in an Order dated May 11. 1993. 2. The total sum of P45.000. On February 16. with prayer for preliminary injunction.00 as travel taxes of plaintiffs and their physician daughter. Fuentes was the one who left the two pieces of gauze inside Natividad’s body.00. Fuentes and Dr. On March 17. 1993. the Court of Appeals issued a Resolution5 dated October 29. docketed as CA-G. The PRC Board of Medicine heard the case only with respect to Dr. However.00.50. and cost of the saline solution. 5. Enrique Agana also filed with the Professional Regulation Commission (PRC) an administrative complaint for gross negligence and malpractice against Dr. finding PSI. 1995. As moral damages.00 and delivered the amount to the Aganas.60US$1.800. SP No. Ampil and sold them for P451. 1993. Aggrieved. CV No. (b). pending the outcome of the above cases.000. Costs of suit. Dr.R. 1690. 4. Thereafter. 1993.00. 32198 was consolidated with CA-G. jointly and severally. and 6. 1986. the sheriff levied upon certain properties of Dr. SP No. the sum of P250. the PRC Board of Medicine rendered its Decision 6 in Administrative Case No. thus: . CA-G. medical fees. Following their receipt of the money. Meanwhile. Fuentes. the sum of P2. and that he concealed such fact from Natividad.. prompting Dr. Legal interest on items 1 (a). 3. 42062. As actual damages. Natividad died and was duly substituted by her above-named children (the Aganas).00 at the rate of P21. CV No.R. on April 3.000. Meanwhile. the RTC granted the motion and issued the corresponding writ. the Aganas filed with the RTC a motion for a partial execution of its Decision. the RTC rendered its Decision in favor of the Aganas. INC. Fuentes’ prayer for injunctive relief. the Aganas entered into an agreement with PSI and Dr. Fuentes to indefinitely suspend any further execution of the RTC Decision. MIGUEL AMPIL and DR. docketed as Administrative Case No.900. Fuentes because it failed to acquire jurisdiction over Dr. As attorney’s fees. 32198. 1690 dismissing the case against Dr. judgment is hereby rendered for the plaintiffs ordering the defendants PROFESSIONAL SERVICES. Ampil interposed an appeal to the Court of Appeals. the Aganas again filed a motion for an alias writ of execution against the properties of PSI and Dr. except in respect of the award for exemplary damages and the interest thereon which are the liabilities of defendants Dr. and (c). not long thereafter. docketed as CAG. Ampil and Dr. 1994.R. PSI. SP No. Fuentes to file with the Court of Appeals a petition for certiorari and prohibition. CV No. DR. the decretal part of which reads: WHEREFORE. Ampil who was then in the United States. On September 6. 1996. b. During its pendency.802. As exemplary damages. c. the following amounts: a.R. as follows: 1. 42062 and CA-G. 42062.

the attending nurses erred in counting the gauzes. as specified by the Court of Appeals. whether the Court of Appeals erred in holding Dr. Costs against defendants-appellants Dr. Ampil examined his (Dr. 127590. 32198 is hereby GRANTED and the challenged order of the respondent judge dated September 21. Neither did he submit evidence to rebut the correctness of the record of operation. particularly the number of gauzes used. Hence. For our resolution are these three vital issues: first. gears the Court’s attention to other possible causes of Natividad’s detriment. 1993. No. it is not disputed that the surgeons used gauzes as sponges to control the bleeding of the patient during the surgical operation. Ampil filed a motion for reconsideration. He pointed to other probable causes.WHEREFORE. and third. In G. Fuentes of any liability. 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 Natividad’s body. I . Ampil liable for negligence and malpractice. whether PSI may be held solidarily liable for the negligence of Dr.R. taken together. As such. Ampil. the petition for certiorari and prohibition filed by herein defendant-appellant Dr.G. Ampil. (2) it is solidarily liable with Dr.. Concomitant with the above. Fuentes. Dr. As to the alleged negligence of Dr. Miguel Ampil and Professional Services. as well as the alias writ of execution issued pursuant thereto are hereby NULLIFIED and SET ASIDE. but it was denied in a Resolution 7 dated December 19.R. and (3) the medical intervention of the American doctors who examined Natividad in the United States of America. and (3) it is not entitled to its counterclaim against the Aganas. second. such as: (1) it was Dr. In G.R. the instant consolidated petitions. Finally. PSI contends that Dr. Ampil. SO ORDERED. Dr. The bond posted by the petitioner in connection with the writ of preliminary injunction issued by this Court on November 29. except for the modification that the case against defendant-appellant Dr. he alone should answer for his negligence. the decision appealed from is hereby AFFIRMED and the instant appeal DISMISSED. Dr. whatever amount the latter will pay or had paid to the plaintiffs-appellees. we are mindful that Dr. No. 1993 is hereby cancelled. directly point to Dr. Fuentes who used gauzes in performing the hysterectomy. . Inc. invoking the doctrine of res ipsa loquitur. They contend that the pieces of gauze are prima facie proofs that the operating surgeons have been negligent. the American doctors were the ones who placed the gauzes in Natividad’s body. (2) the attending nurses’ failure to properly count the gauzes used during surgery. 126297. Ampil’s arguments are purely conjectural and without basis.R. SP No. in G. the Aganas maintain that the Court of Appeals erred in finding that Dr. Juan Fuentes is hereby DISMISSED. 1996. thus: First. Ampil is not its employee. Ampil Liable for Negligence and Malpractice. No. The glaring truth is that all the major circumstances.R. Fuentes’) work and found it in order. PSI alleged in its petition that the Court of Appeals erred in holding that: (1) it is estopped from raising the defense that Dr. Fuentes is not guilty of negligence or medical malpractice. second. Only Dr. Dr. Fuentes left the gauzes in Natividad’s body after performing hysterectomy. in an attempt to absolve himself. Juan Fuentes in CA-G. but a mere consultant or independent contractor. Miguel Ampil is liable to reimburse defendant-appellant Professional Services. and with the pronouncement that defendant-appellant Dr. whether the Court of Appeals erred in absolving Dr. No. He argues that the Court should not discount either of the following possibilities: first. and third. Ampil as the negligent party. 127590 Whether the Court of Appeals Erred in Holding Dr. Ampil is not its employee. Inc. Ampil asserts 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 Natividad’s vagina. 126467.

To our mind. the Court is not blind to the reality that there are times when danger to a patient’s life precludes a surgeon from further searching missing sponges or foreign objects left in the body. or that he did something that a reasonably prudent provider would not have done. According to them. When he failed to do so. And what further aggravated such injury was his deliberate concealment of the missing gauzes from the knowledge of Natividad and her family. Literally.G.11 Simply put. II . Fuentes on the ground that it is contrary to the doctrine of res ipsa loquitur. two (2) gauzes were extracted from the same spot of the body of Mrs. the fact that the two pieces of gauze were left inside Natividad’s body is a prima facie evidence of Dr. 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. No. thus: The removal of all sponges used is part of a surgical operation. it was his duty to inform Natividad about it. the nurses who assisted in the surgery noted in their report that the ‘sponge count (was) lacking 2’. such as gauzes. may permit an inference or raise a presumption of negligence. 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. such act is considered so inconsistent with due care as to raise an inference of negligence. Dr.Second." It is the rule that the fact of the occurrence of an injury. and when a physician or surgeon fails to remove a sponge he has placed in his patient’s body that should be removed as part of the operation. or make out a plaintiff’s prima facie case. and endeavoring with the means he has at hand to minimize and avoid untoward results likely to ensue therefrom. and that failure or action caused injury to the patient. Dr. 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. had the duty to remove all foreign objects. from Natividad’s body before closure of the incision. Here. This is a clear case of medical malpractice or more appropriately. Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Ampil. 8 To put it simply. as the lead surgeon. 9 Of course. That Dr. Even if it has been shown that a surgeon was required by the urgent necessities of the case to leave a sponge in his patient’s abdomen. medical negligence. 126467 Whether the Court of Appeals Erred in Absolving Dr. 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 patient’s attention. Such breach caused injury to Natividad. Agana where the surgery was performed. taken with the surrounding circumstances. 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. The ruling in Smith v. That they were later on extracted from Natividad’s vagina established the causal link between Dr. There are even legions of authorities to the effect that such act is negligence per se. Ampil’s negligence and the injury. immediately after the operation. res ipsa loquitur means "the thing speaks for itself.R. the elements are duty. Ampil’s negligence is the proximate cause 12 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. breach. Zeagler 10 is explicit. Had he been more candid. Ampil has ripened into a deliberate wrongful act of deceiving his patient. But this does not leave him free from any obligation. Worse. he even misled her that the pain she was experiencing was the ordinary consequence of her operation. An operation requiring the placing of sponges in the incision is not complete until the sponges are properly removed. necessitating her further examination by American doctors and another surgery. Fuentes’ negligence. Ampil to ‘continue for closure’ x x x. that such anomaly was ‘announced to surgeon’ and that a ‘search was done but to no avail’ prompting Dr. after the operation. We are not convinced. Fuentes of any Liability The Aganas assailed the dismissal by the trial court of the case against Dr. Ampil breached both duties. what was initially an act of negligence by Dr. Third. injury and proximate causation. To successfully pursue this kind of case. Natividad could have taken the immediate and appropriate medical remedy to remove the gauzes from her body. still. because of the dangers attendant upon delay. and present a question of fact for defendant to meet .

that caused injury to Natividad’s body. Fuentes. Consequently. mere invocation and application of the doctrine does not dispense with the requirement of proof of negligence. The modern health care industry continues to distance itself from its charitable past and has experienced a significant conversion from a not-for-profit health care to for-profit hospital businesses. not Dr. he was the "Captain of the Ship.13 Stated differently. 14 From the foregoing statements of the rule. 17 In other words. the requisites for the applicability of the doctrine of res ipsa loquitur are: (1) the occurrence of an injury. In this jurisdiction. One important legal change is an increase in hospital liability for medical malpractice. the negligence was proven to have been committed by Dr. Dr. allowed Dr. where the thing which caused the injury. Ampil. in fact. Ampil was the lead surgeon. but the misplaced gauzes were not found. Dr.R. 126297 Whether PSI Is Liable for the Negligence of Dr. Ampil and not by Dr. significant changes in health law have accompanied the businessrelated changes in the hospital industry. it affords reasonable evidence. apparent authority. Fuentes and finding it in order. and (4) the absence of explanation by the defendant. Many courts now allow claims for hospital vicarious liability under the theories of respondeat superior. without the fault of the injured. and the burden of proof is shifted to him to establish that he has observed due care and diligence. In other words. Here. 19 However. Ampil then resumed operating on Natividad. the most instrumental is the "control and management of the thing which caused the injury. III . hospitals were generally charitable institutions. He was about to finish the procedure when the attending nurses informed him that two pieces of gauze were missing. the control and management of the thing which caused the injury was in the hands of Dr. in the absence of explanation that the injury arose from the defendant’s want of care. Fuentes was no longer in the operating room and had. Dr. (3) granting Dr. No."15 We find the element of "control and management of the thing which caused the injury" to be wanting. Fuentes only to perform hysterectomy when he (Dr. Dr. Fuentes to leave the operating room. Ampil was the lead surgeon during the operation of Natividad. the days of house calls and philanthropic health care are over. providing medical services to the lowest classes of society. Fuentes performed the surgery and thereafter reported and showed his work to Dr.with an explanation. Under the "Captain of the Ship" rule." That he discharged such role is evident from his following conduct: (1) calling Dr. does not per se create or constitute an independent or separate ground of liability. hence.G. left the hospital. A "diligent search" was conducted. (2) examining the work of Dr. Fuentes to perform a hysterectomy. He requested the assistance of Dr. Until the mid-nineteenth century. Dr. being a mere evidentiary rule. and (4) ordering the closure of the incision. It was duly established that Dr. which reads: . 20 In this jurisdiction. Ampil. the doctrine of res ipsa loquitur will not lie. Ampil The third issue necessitates a glimpse at the historical development of hospitals and the resulting theories concerning their liability for the negligence of physicians. To our mind. Fuentes. (3) the occurrence was such that in the ordinary course of things. is under the exclusive control of the defendant and the injury is such that it should not have occurred if he. (2) the thing which caused the injury was under the control and management of the defendant. it was this act of ordering the closure of the incision notwithstanding that two pieces of gauze remained unaccounted for. 16 As stated before. the statute governing liability for negligent acts is Article 2176 of the Civil Code. Fuentes’ permission to leave. or agency by estoppel. without regard for a patient’s ability to pay. Clearly. Their duty is to obey his orders. res ipsa loquitur is not a rule of substantive law. would not have happened if those who had control or management used proper care. 18 Those who could afford medical treatment were usually treated at home by their doctors. Hence. having such control used proper care. Of the foregoing requisites. the operating surgeon is the person in complete charge of the surgery room and all personnel connected with the operation. During this entire period. Ampil) found that the malignancy in her sigmoid area had spread to her left ovary. The latter examined it and finding everything to be in order. ostensible authority. Ampil then directed that the incision be closed.

is obliged to pay for the damage done. In other words. administrative and manual workers.22 It has been said that medical practice strictly involves highly developed and specialized knowledge. In the context of the present case. 24 Hence. such as physicians. facilities for treatment and operation. even collecting for such services through legal action. The "Schloendorff doctrine" regards a physician. However. Thunig. dentists. 2176. They charge patients for medical care and treatment. noting that modern hospitals actually do far more than provide facilities for treatment." 21 The foregoing view is grounded on the traditional notion that the professional status and the very nature of the physician’s calling preclude him from being classed as an agent or employee of a hospital. 25 The case of Schloendorff v. x x x x x x The owners and managers of an establishment or enterprise are likewise responsible for damages caused by their employees in the service of the branches in which the latter are employed or on the occasion of their functions. but also for those of persons for whom one is responsible. on a salaried basis. and their employer cannot be held liable for such fault or negligence. In our shores. A derivative of this provision is Article 2180. hospitals are exempt from the application of the respondeat superior principle for fault or negligence committed by physicians in the discharge of their profession. the efficacy of the foregoing doctrine has weakened with the significant developments in medical care. thus: ART. are not "employees" under this article because the manner in which they perform their work is not within the control of the latter (employer). whenever he acts in a professional capacity. x x x x x x The responsibility treated of in this article shall cease when the persons herein mentioned prove that they observed all the diligence of a good father of a family to prevent damage. there being fault or negligence. the rule governing vicarious liability under the doctrine of respondeat superior. 2180. Employers shall be liable for the damages caused by their employees and household helpers acting within the scope of their assigned tasks even though the former are not engaged in any business or industry. the nature of the relationship between the hospital and the physicians is rendered inconsequential in view of our categorical pronouncement in Ramos v. This Court held: "We now discuss the responsibility of the hospital in this particular incident.Art. when a doctor practices medicine in a hospital setting. Society of New York Hospital 26 was then considered an authority for this view. No longer were a hospital’s functions limited to furnishing room. even if employed by a hospital. in Bing v. The obligation imposed by Article 2176 is demandable not only for one’s own acts or omissions. The court then concluded that there is no reason to exempt hospitals from the universal rule of respondeat superior. Such fault or negligence. interns. professionals are considered personally liable for the fault or negligence they commit in the discharge of their duties. and attendants for its patients. they regularly employ.23 such that physicians are generally free to exercise their own skill and judgment in rendering medical services sans interference. The unique practice (among . "a hospital cannot be held liable for the fault or negligence of a physician or surgeon in the treatment or operation of patients. as an independent contractor because of the skill he exercises and the lack of control exerted over his work. and pharmacists. Rather. Thus. A prominent civilist commented that professionals engaged by an employer. nurses. a large staff of physicians. food. Whoever by act or omission causes damage to another. Under this doctrine. the hospital and its employees are deemed to subserve him in his ministrations to the patient and his actions are of his own responsibility. Courts came to realize that modern hospitals are increasingly taking active role in supplying and regulating medical care to patients. is called a quasi-delict and is governed by the provisions of this Chapter. an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians. Court of Appeals 28 that for purposes of apportioning responsibility in medical negligence cases. 27 the New York Court of Appeals deviated from the Schloendorff doctrine. if necessary. if there is no pre-existing contractual relation between the parties.

private hospitals) of filling up specialist staff with attending and visiting "consultants. and the right to terminate consultants all fulfill the important hallmarks of an employer-employee relationship. Our jurisdiction recognizes the concept of an agency by implication or estoppel. or which he holds the agent out to the public as possessing. then the hospital will be liable for the physician’s negligence. Agency may be express. or his failure to repudiate the agency. private hospitals. or implied from the acts of the principal. In addition to these. the control exercised. Doctor Hospital of Lake Worth. These requirements are carefully scrutinized by members of the hospital administration or by a review committee set up by the hospital who either accept or reject the application. In assessing whether such a relationship in fact exists. enriching our jurisprudence. or a consultant who regularly falls short of the minimum standards acceptable to the hospital or its peer review committee. Article 1869 of the Civil Code reads: ART. In other words.30 The concept is essentially one of estoppel and has been explained in this manner: "The principal is bound by the acts of his agent with the apparent authority which he knowingly permits the agent to assume. conduct bedside rounds for clerks. It imposes liability. Apparent authority. but rather because of the actions of a principal or an employer in somehow misleading the public into believing that the relationship or the authority exists. x x x. the control test is determining. fire and exercise real control over their attending and visiting ‘consultant’ staff. are required to submit proof of completion of residency." Thus. The present case serves as a perfect platform to test the applicability of these doctrines. knowing that another person is acting on his behalf without authority. the hiring. After a physician is accepted. is justified in presuming that such agent has authority to perform the particular act in question. In the first place. conversant with business usages and the nature of the particular business. Accordingly. and feedback from patients. x x x. has held out a particular physician as its agent and/or employee and that a patient has accepted treatment from that physician in the reasonable belief that it is being rendered in behalf of the hospital. While ‘consultants’ are not. or what is sometimes referred to as the "holding out" theory. in cases where it can be shown that a hospital. interns and residents. it was explicitly stated that "there does not appear to be any rational basis for excluding the concept of apparent authority from the field of hospital liability. Doctors who apply for ‘consultant’ slots. thus. is normally politely terminated. A consultant remiss in his duties. Its liability is also anchored upon the agency principle of apparent authority or agency by estoppel and the doctrine of corporate negligence which have gained acceptance in the determination of a hospital’s liability for negligent acts of health professionals. not as the result of the reality of a contractual relationship. the difficulty is more apparent than real. on the basis of the foregoing. 29 has its origin from the law of agency. evidence of accreditation by the appropriate board (diplomate). their educational qualifications. hospitals exercise significant control in the hiring and firing of consultants and in the conduct of their work within the hospital premises. we rule that for the purpose of allocating responsibility in medical negligence cases. 31 The applicability of apparent authority in the field of hospital liability was upheld long time ago in Irving v. generally. or doctrine of ostensible agency or agency by estoppel. the physician’s performance as a specialist is generally evaluated by a peer review committee on the basis of mortality and morbidity statistics. an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians. The question in every case is whether the principal has by his voluntary act placed the agent in such a situation that a person of ordinary prudence. visiting or attending. Inc. However. . he is normally required to attend clinico-pathological conferences. for the privilege of being able to maintain a clinic in the hospital. moderate grand rounds and patient audits and perform other tasks and responsibilities. hire. 1869. presents problems in apportioning responsibility for negligence in medical malpractice cases. " But the Ramos pronouncement is not our only basis in sustaining PSI’s liability. either as a visiting or attending consultant. by its actions. nurses. evidence of fellowship in most cases.32 There. interns and residents. technically employees. and/or for the privilege of admitting patients into the hospital." who are allegedly not hospital employees. and references. with the exception of the payment of wages. from his silence or lack of action.

Its formulation proceeds from the judiciary’s acknowledgment that in these modern times. Hospitals now tend to organize a highly professional medical staff whose competence and performance need to be monitored by the hospitals commensurate with their inherent responsibility to provide quality medical care. failing to require a consultation with or examination by members of the hospital staff. 39 it was held that a hospital. Q-43332 for negligence and malpractice is that PSI as owner. the Supreme Court of Illinois held that "the jury could have found a hospital negligent. Corporate entities. inter alia. are capable of acting only through other individuals. more duties were expected from hospitals. 37 With the passage of time. in failing to have a sufficient number of trained nurses attending the patient. Natividad being one of them. Such duty includes the proper supervision of the members of its medical staff. regardless of whether he is independent or employed. v. Ampil and Fuentes in the performance of their duties as surgeons. Inc. Charleston Community Hospital. and failing to review the treatment rendered to the patient. such as physicians. The modern hospitals have changed structure. like PSI. Fuentes. Fuentes and publicly advertising their qualifications. We concur with the Court of Appeals’ conclusion that it "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. (2) the selection and retention of competent physicians. including those of Dr. accepted the services on the reasonable belief that such were being rendered by the hospital or its employees. where negligence mars the quality of its services. We now proceed to the doctrine of corporate negligence or corporate responsibility."34 Premised on the doctrine of corporate negligence. has the duty to see that it meets the standards of responsibilities for the care of patients. these patients. and medical interns who assisted Drs. offers quality health care services. PSI publicly displays in the lobby of the Medical City Hospital the names and specializations of the physicians associated or accredited by it. As expected. he ought not be burdened with the defense of absence of employer-employee relationship between the hospital and the independent physician whose name and competence are certainly certified to the general public by the hospital’s act of listing him and his specialty in its lobby directory. and (4) the formulation. Logically.In this case. Recent years have seen the doctrine of corporate negligence as the judicial answer to the problem of allocating hospital’s liability for the negligent acts of health practitioners. the hospital should not be allowed to escape liability for the acts of its ostensible agents. the duty of providing quality medical service is no longer the sole prerogative and responsibility of the physician. Ampil and Dr. as in the case herein. The high costs of today’s medical and health care should at least exact on the hospital greater. Misevich. 40 the court concluded that a patient who enters a hospital does so with the reasonable expectation that it will . Ampil and Dr. authorized to perform medical or surgical services for its patients." On the basis of Darling. or servants. through its accredited physicians."33 The wisdom of the foregoing ratiocination is easy to discern. following the doctrine of corporate responsibility. The trial court correctly pointed out: x x x regardless of the education and status in life of the patient. if not broader. in Tucson Medical Center. 38 Thus. By accrediting Dr. One allegation in the complaint in Civil Case No. And in Bost v. Riley. agents. among them: (1) the use of reasonable care in the maintenance of safe and adequate facilities and equipment. the trial court held that PSI is directly liable for such breach of duty. resident doctors. adoption and enforcement of adequate rules and policies that ensure quality care for its patients. "did not perform the necessary supervision nor exercise diligent efforts in the supervision of Drs. operator and manager of Medical City Hospital. 36 There. other jurisdictions held that a hospital’s corporate negligence extends to permitting a physician known to be incompetent to practice at the hospital. If these accredited physicians do their job well. legal responsibility for the conduct of treatment and surgery within its facility by its accredited physician or surgeon. PSI’s act is tantamount to holding out to the public that Medical City Hospital.35 The doctrine has its genesis in Darling v. We agree with the trial court. (3) the overseeing or supervision of all persons who practice medicine within its walls. absent facts to support the application of respondeat superior or apparent authority." Indeed. the hospital created the impression that they were its agents. the hospital succeeds in its mission of offering quality medical services and thus profits financially. Ampil and Fuentes and its nursing staff.

and their institutions like PSI’s hospital facility. however. it is reasonable to conclude that PSI. Ampil for damages. x x x. despite the attending nurses’ report. 18 Ariz. are sufficient to support the hospital’s liability based on the theory of negligent supervision. has actual or constructive knowledge of the procedures carried out.attempt to cure him. 2d 1153 (1972). Ampil under Article 2180 of the Civil Code. 23 (1977). Ethical considerations. Subsequent to the Purcell decision. The emerging trend is to hold the hospital responsible where the hospital has failed to monitor and review medical services being provided within its walls. In Purcell. See Kahn Hospital Malpractice Prevention. In Fridena v. and the court held that a hospital would be negligent where it had knowledge or reason to believe that a doctor using the facilities was employing a method of treatment or care which fell below the recognized standard of care. then in the interest of arriving at the truth. Accordingly. the Arizona Court of Appeals held that a hospital has certain inherent responsibilities regarding the quality of medical care furnished to patients within its walls and it must meet the standards of responsibility commensurate with this undertaking. the Supreme Court of Arizona held: x x x In recent years. through their members like defendant surgeons. the duty of care owed to the patient by the hospital has expanded. Tucson General Hospital. Now. Rev. the plaintiffs did plead that the operation was performed at the hospital with its knowledge. PSI failed to perform such duty. 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. 75. along with the evidence produced at the trial of this case. it also failed to take an active step in fixing the negligence committed. Unfortunately. App. The findings of the trial court are convincing. not only vicariously liable for the negligence of Dr.500 P. 165. composed of resident doctors. thus: x x x PSI’s liability is traceable to its failure to conduct an investigation of the matter reported in the nota bene of the count nurse. it was duly established that PSI operates the Medical City Hospital for the purpose and under the concept of providing comprehensive medical services to the public. the hospital argued that it could not be held liable for the malpractice of a medical practitioner because he was an independent contractor within the hospital. and that the negligence of the defendants was the proximate cause of the patient’s injuries. 18 Ariz. The Court of Appeals pointed out that the hospital had created a professional staff whose competence and performance was to be monitored and reviewed by the governing body of the hospital. Ampil and Dr. In Fridena. Such failure established PSI’s part in the dark conspiracy of silence and concealment about the gauzes. can callously turn their backs on and disregard even a mere probability of mistake or negligence by refusing or failing to investigate a report of such seriousness as the one in Natividad’s case. This means that the knowledge of any of the staff of Medical City Hospital constitutes knowledge of PSI. Beeck v. it has the duty to exercise reasonable care to protect from harm all patients admitted into its facility for medical treatment. Not only did PSI breach its duties to oversee or supervise all persons who practice medicine within its walls.41 it was held that a corporation is bound by the knowledge acquired by or notice given to its agents or officers within the scope of their authority and in reference to a matter to which their authority extends. Zimbelman. let it be emphasized . aid. 27 De Paul . App. and assistance. Fuentes operated on Natividad with the assistance of the Medical City Hospital’s staff. and interns. as the operator of the hospital. 2d 335 (1972). if not for the benefit of the patient to whom the duty is primarily owed. We find that such general allegations of negligence. As such. Among the cases indicative of the ‘emerging trend’ is Purcell v. The Court cannot accept that the medical and the healing professions. This renders PSI. x x x x x x In the amended complaint. the failure of PSI." Anent the corollary issue of whether PSI is solidarily liable with Dr. but also directly liable for its own negligence under Article 2176. dictated the holding of an immediate inquiry into the events. if not also legal. It is worthy to note that Dr. In the present case. 500 P. Evans. particularly the report of the attending nurses that the two pieces of gauze were missing. nurses. The hospital accordingly has the duty to make a reasonable effort to monitor and oversee the treatment prescribed and administered by the physicians practicing in its premises. to investigate and inform Natividad regarding the missing gauzes amounts to callous negligence.

Does the instant case warrant a departure from the foregoing general rule? When a . this Court has consistently held that courts will not interfere with the discretion of the fiscal or the Ombudsman to determine the specificity and adequacy of the averments of the offense charged. Once a physician undertakes the treatment and care of a patient. SO ORDERED. he must possess that reasonable degree of learning. PORFIRIO MACARAEG. WHEREFORE. One final word. At the same time. Ampil. or he may proceed with the investigation of the complaint if.R. PSI is also directly liable to the Aganas. DECISION ROMERO. PASCASIO. CV No. ABELARDO L. petitioner. APORTADERA JR. all of the Office of the Ombudsman. SP No. VASQUEZ.that PSI. and exert his best judgment. must be adjudged solidarily liable with Dr. Moreover. In neglecting to offer such proof. PSI failed to discharge its burden under the last paragraph of Article 2180 cited earlier. failed to adduce evidence showing that it exercised the diligence of a good father of a family in the accreditation and supervision of the latter. No. and GREGORIO A. respondents. ARNAU. and. Miguel Ampil. Honorable CONDRADO M. skill and experience required by his profession. apart from a general denial of its responsibility.R. Ombudsman [1] which states: In the exercise of its investigative power. as we have discussed. therefore. WILFREDO L. RAUL R. 32198. JESUS F. 42062 and CA-G. He may dismiss the complaint forthwith if he finds it to be insufficient in form and substance or if he otherwise finds no ground to continue with the inquiry. September 5. it is in due and proper form. Costs against petitioners PSI and Dr. in his view. we DENY all the petitions and AFFIRM the challenged Decision of the Court of Appeals in CA-G. vs. he must apply reasonable care and diligence in the exercise of his skill and the application of his knowledge. 118141. SECOND DIVISION [G. the law imposes on him certain obligations.. In order to escape liability. ARIZALA. all of the Office of the City Prosecutor. Manila.: May this Court review the findings of the Office of the Ombudsman? The general rule has been enunciated in Ocampo v. J. GUERRERO. 1997] LEONILA GARCIA-RUEDA.R.

Pursuant to its findings. who issued a resolution recommending that only Dr. a series of nine prosecutors toss the responsibility of conducting a preliminary investigation to each other with contradictory recommendations. who recommended that Dr. Leono who was. recommended that the case be re-raffled on the ground that Prosecutor Carisma was partial to the petitioner. the investigative pingpong continued when the case was again assigned to another prosecutor. Eudoxia T. the NBI ruled that Florencios death was due to lack of care by the attending physician in administering anaesthesia. Petitioner filed a motion for reconsideration. As a result. During the preliminary investigation. where a volte face occurred again with the endorsement that the complaint against Dr. petitioner requested the National Bureau of Investigation (NBI) to conduct an autopsy on her husbands body. Domingo Antonio and Dr. while Dr. Israel. the case was transferred to Prosecutor Leoncia R. Much as we sympathize with the bereaved widow. Thus. Pending the resolution of petitioners motion for reconsideration regarding Prosecutor Dimagibas resolution. underwent surgical operation at the UST hospital for the removal of a stone blocking his ureter. ping-pong style. Jr. Reyes be . Florencio V. Antonio be dismissed. a corresponding information be filed against Dr. however.patient dies soon after surgery under circumstances which indicate that the attending surgeon and anaesthesiologist may have been guilty of negligence but upon their being charged. who was the surgeon. disqualified on motion of the petitioner since he disregarded prevailing laws and jurisprudence regarding preliminary investigation. Erlinda Balatbat-Reyes was the anaesthesiologist. Erlinda Balatbat-Reyes be charged for Homicide through Reckless Imprudence before the Office of the City Prosecutor. Dimagiba. the case was re-raffled to Prosecutor Norberto G. questioning the findings of Prosecutor Dimagiba. Domingo Antonio. The case took another perplexing turn when Assistant City Prosecutor Josefina Santos Sioson. He was attended by Dr. perhaps the distraught widow is not to be blamed if she finally decides to accuse the City Prosecutors at the end of the line for partiality under the Anti-Graft and Corrupt Practices Act. who had to inhibit himself because he was related to the counsel of one of the doctors. Reyes be dismissed and instead. in the interest of justice and peace of mind of the parties. the NBI recommended that Dr. what transpired was a confounding series of events which we shall try to disentangle. [2] Not satisfied with the findings of the hospital. Reyes be held criminally liable and that the complaint against Dr. the respondent Ombudsman did not commit grave abuse of discretion in deciding against filing the necessary information against public respondents of the Office of the City Prosecutor. however. Nor 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 ground of lack of evidence. In other words. The case was then referred to Prosecutor Ramon O. husband of petitioner Leonila Garcia-Rueda. Rueda. however. Antonio. The following facts are borne out by the records. Six hours after the surgery. Gualberto. Florencio died of complications of unknown cause. according to officials of the UST Hospital. Consequently. Carisma. The case was initially assigned to Prosecutor Antonio M. this Court is of the opinion that the general rule still finds application in instant case.

however. authority to inquire and obtain information. Reyes from any wrongdoing. on July 11. the case was transferred to Senior State Prosecutor Gregorio A. Macaraeg. institute and implement preventive measures. Article VIII of the 1987 Constitution. the Ombudsman should have been more vigilant and assiduous in determining the reasons behind the buckpassing to ensure that no irregularity took place.included in the criminal information of Homicide through Reckless Imprudence.A. Preliminarily. Macaraeg and City Prosecutor Jesus F. Arizala. One would have expected the Ombudsman. prosecutory power. No. public assistance function. 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. and Arizala for manifest partiality in favor of Dr. Petitioner faults the Ombudsman for. While the recommendation of Prosecutor Gualberto was pending. the Ombudsman issued the assailed resolution dismissing the complaint for lack of evidence. improper or inefficient. Guerrero. Whether such transfers were due to any outside pressure or ulterior motive is a matter of evidence. 3019 [3] against Prosecutors Guerrero. [6] In this regard. However. allegedly in grave abuse of discretion. nonfeasance and malfeasance of public officials. Reyes before the Office of the Ombudsman. the powers and functions of the Ombudsman have generally been categorized into the following: investigatory powers. and function to adopt. In fine. function and duty to act promptly on complaints filed in any form or manner against public officials and to investigate any act or omission of any public official when such act or omission appears to be illegal. in which case Rule 65 of the Rules of Court may exceptionally be invoked pursuant to Section I. or in contemplation of law. this Court is not precluded from reviewing the Ombudsmans action when there is an abuse of discretion. [5] While the Ombudsman has the full discretion to determine whether or not a criminal case should be filed. who resolved to exonerate Dr. unjust. [7] From a procedural standpoint. 3019. grave abuse of discretion has been defined as where a power is exercised in an arbitrary or despotic manner by reason of passion or personal hostility so patent and gross as to amount to evasion of positive duty or virtual refusal to perform a duty enjoined by. Being the proper investigating authority with respect to misfeasance. petitioner filed graft charges specifically for violation of Section 3(e) of Republic Act No. Aggrieved. to inquire into what could hardly qualify as standard operating procedure. it is certainly odd why the successive transfers from one prosecutor to another were not sufficiently explained in the Resolution of the Ombudsman. given the surrounding circumstances of the . 1994. [4] As protector of the people. the Office of the Ombudsman has the power. a resolution which was approved by both City Prosecutor Porfirio G. refusing to find that there exists probable cause to hold public respondent City Prosecutors liable for violation of Section 3(e) of R.

especially when there are conflicting evidence and findings. breach. a physician-patient relationship was created.[10] In the instant case. medical negligence. in most cases a physician. Antonio and Dr. acting on the facts within the knowledge of the prosecution. a patient must prove that a health care provider. such a state of facts in the mind of the prosecutor as would lead a person of ordinary caution and prudence to believe. injury and proximate causation. A word on medical malpractice or negligence cases. that the person charged was guilty of the crime for which he was prosecuted. or that he or she did something that a reasonably prudent provider would not have done. Dr. Evidently. Reyes in effect represented that.case. Clearly. more appropriately. that a thing is so. in a reasonable mind. Thus. and that that failure or action caused injury to the patient. the City Prosecutors are not in a competent position to pass judgment on such a technical matter. [8] Probable cause has been defined as the existence of such fact and circumstances as would excite the belief. While it is true that a preliminary investigation is essentially inquisitorial. Reyes. there is a trial for the reception of evidence of the prosecution in support of the charge. when the victim employed the services of Dr. there are four elements involved in medical negligence cases: duty.[9] Probable cause is a reasonable ground of presumption that a matter is. Antonio and Dr. either failed to do something which a reasonably prudent health care provider would have done. the veracity of which can best be passed upon after a full-blown trial for it is virtually impossible to ascertain the merits of a medical negligence case without extensive investigation. It is merely based on opinion and reasonable belief. The bases of a partys accusation and defenses are better ventilated at the trial proper than at the preliminary investigation. 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. Precisely. In order to successfully pursue such a claim. 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. evaluation and consultations with medical experts. and is often the only means to discover who may be charged with a crime. The term does not mean actual and positive cause nor does it import absolute certainty. [11] The fact of want of competence or diligence is evidentiary in nature. In its simplest terms. the type of lawsuit which has been called medical malpractice or. or may be. It is enough that it is believed that the act or omission complained of constitutes the offense charged. its function is merely to determine the existence of probable cause. In accepting the case.[12] Hence. having the needed training and skill possessed by physicians and . well founded. or entertain an honest or strong suspicion. research. a finding of probable cause does not require an inquiry into whether there is sufficient evidence to procure a conviction.

it requires two-pronged evidence: evidence as to the recognized standards of the medical community in the particular kind of case. 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 malignant hyperthermia. they will employ such training. or their improper performance. elect to charge respondents under the above law? . Moreover.[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 condition under the same circumstances. Also.surgeons practicing in the same field. evident bad faith or gross. The public officer committed the prohibited act during the performance of his official duty or in relation to his public position. in the event that any injury results to the patient from want of due care or skill during the operation. the NBI deduced that the attending surgeons did not conduct the necessary interview of the patient prior to the operation. The breach of these professional duties of skill and care. petitioner in instant case. the surgeons may be held answerable in damages for negligence. advantage or preference to such parties. [18] Indeed here. The City Prosecutors were charged with violating Section 3(e) of the Anti-Graft and Corrupt Practices Act which requires the following facts: 1. 3. The accused is a public officer discharging administrative or official functions or private persons charged in conspiracy with them. [19] Why these precautionary measures were disregarded must be sufficiently explained. the necessity of expert testimony and the availability of the charge of res ipsa loquitur to the plaintiff. by a physician surgeon whereby the patient is injured in body or in health. and a showing that the physician in question negligently departed from this standard in his treatment. [20] Why did the complainant. constitutes actionable malpractice. and 4. have been applied in actions against anaesthesiologists to hold the defendant liable for the death or injury of a patient under excessive or improper anaesthesia. we cannot ignore the fact that an antidote was readily available to counteract whatever deleterious effect the anaesthesia might produce. [17] Another element in medical negligence cases is causation which is divided into two inquiries: whether the doctors actions in fact caused the harm to the patient and whether these were the proximate cause of the patients injury. care and skill in the treatment of their patients. The public officer acted with manifest partiality. [14] Consequently. the allegation of negligence is not entirely baseless. or gave any party any unwarranted benefit. [15] Moreover. in malpractice or negligence cases involving the administration of anaesthesia. if confirmed. To be sure. a causal connection is discernible from the occurrence of the victims death after the negligent act of the anaesthesiologist in administering the anesthesia. [16] Essentially. inexcusable negligence. should warrant the filing of the appropriate criminal case. a fact which. 2. His action caused undue injury to the Government or any private party.

While a party who feels himself aggrieved is at liberty to choose the appropriate weapon from the armory. ..Only resolutions of the Chief State Prosecutor/Regional State Prosecutor/Provincial or City Prosecutor dismissing a criminal complaint may be the subject of an appeal to the Secretary of Justice except as otherwise provided in Section 4 hereof. ROMMEL RAMOS. DELOS SANTOS MEDICAL CENTER. 223. and Torres. [21] otherwise known as the 1993 Revised Rules on Appeals From Resolutions In Preliminary Investigations/Reinvestigations. On the other hand. Republic of the Philippines SUPREME COURT Manila FIRST DIVISION G. RAMOS and ERLINDA RAMOS. respondents. affirm or modify the appealed resolution. What May Be Appealed. the instant petition is DISMISSED. COURT OF APPEALS. No. without prejudice to the filing of an appeal by the petitioner with the Secretary of Justice assailing the dismissal of her criminal complaint by the respondent City Prosecutors.. Mendoza. (Chairman). petitioners. SO ORDERED. ROY RODERICK RAMOS and RON RAYMOND RAMOS. What action may the Secretary of Justice take on the appeal? Section 9 of Order No. WHEREFORE. PERFECTA GUTIERREZ. in view of the foregoing. ORLINO HOSAKA and DRA. 223 states: The Secretary of Justice may reverse. Section 1 of which provides: Section 1. To our mind. Puno. dismiss outright the appeal on specified grounds. 1999 ROGELIO E. as amended by Department Order No. the better and more logical remedy under the circumstances would have been to appeal the resolution of the City Prosecutors dismissing the criminal complaint to the Secretary of Justice under the Department of Justices Order No. in their own behalf and as natural guardians of the minors. . 359. 124354 December 29. the Ombudsman acted within his power and authority in dismissing the complaint against the Prosecutors and this Court will not interfere with the same. it is with no little surprise that this Court views the choice made by the complainant widow. vs. DR. No costs. concur. He may motu proprio or on motion of the appellee. Jr. Regalado. [22] In exercising his discretion under the circumstances.R. JJ.

which overturned the decision 4 of the Regional Trial Court. "A") robust woman (TSN. At around 7:30 A. dated 29 May 1995.: The Hippocratic Oath mandates physicians to give primordial consideration to the health and welfare of their patients. finding private respondents liable for damages arising from negligence in the performance of their professional duties towards petitioner Erlinda Ramos resulting in her comatose condition. Ramos. p. Rogelio E..000. Although not a member of the hospital staff. After praying. to them. she was as normal as any other woman. Dr. on June 10. Hosaka charged a fee of P16. FEU Hospital and DLSMC) presented to him. 5-6). 1989. At around 9:30 A. Her husband. October 19. see TSN. 1988. January 13. 1985. Herminda introduced herself as Dean of the College of Nursing at the Capitol Medical Center who was to provide moral support to the patient. October 19. She reiterated her previous request for Herminda to be with her even during the operation. 22-23. Dr. 1985 and while still in her room. an anesthesiologist and a hospital should be made liable for the unfortunate comatose condition of a patient scheduled for cholecystectomy. would be on June 17. of June 17.. Dr. 1989. p. may spell the difference between life and death. A mistake. "A" and "C") which indicated she was fit for surgery. Married to Rogelio E. until the afternoon of June 17. she and her husband Rogelio met for the first time Dr. 1990. 1989. who was to administer anesthesia. located along E. Quezon City (TSN. 1988. the other defendant. 3). she sought professional advice. Except for occasional complaints of discomfort due to pains allegedly caused by the presence of a stone in her gall bladder (TSN. November 9. January 13. 1985. Dr. 3-4. Hosaka who was . in turn. Orlino Hozaka (should be Hosaka. January 13. p. 1990. 1 In the case at bar. who was the Dean of the College of Nursing at the Capitol Medical Center. assured Rogelio that he will get a good anesthesiologist. 10. pp.00. 13. The antecedent facts as summarized by the trial court are reproduced hereunder: Plaintiff Erlinda Ramos was. and TSN. At the operating room. Herminda was allowed to stay inside the operating room. 18). 1988. she has three children whose names are Rommel Ramos. 11).KAPUNAN.M. In this sense. asked Dr. through gross negligence or incompetence or plain human error. 10). Roy Roderick Ramos and Ron Raymond Ramos (TSN. Because the discomforts somehow interfered with her normal ways. Hosaka. the Court is called upon to rule whether a surgeon. pp. a 47-year old (Exh. 14-15. Herminda Cruz. 1985 at 9:00 A. one of the defendants in this case. Hosaka to look for a good anesthesiologist. 5). she was prepared for the operation by the hospital staff. dated 30 January 1992. an executive of Philippine Long Distance Telephone Company. 7). 17). If a doctor fails to live up to this precept. p. Gutierrez reached a nearby phone to look for Dr.M. She underwent a series of examinations which included blood and urine tests (Exhs. Ramos.M. which was to include the anesthesiologist's fee and which was to be paid after the operation (TSN. 31-33. Herminda saw about two or three nurses and Dr. 1989. 4-5). Her sister-in-law. pp. TSN. Perfecta Gutierrez. Dr. 9-11). They agreed that their date at the operating table at the DLSMC (another defendant). pp. Hosaka decided that she should undergo a "cholecystectomy" operation after examining the documents (findings from the Capitol Medical Center. p. January 13. p. 2 Petitioners seek the reversal of the decision 3 of the Court of Appeals. A day before the scheduled date of operation. February 20. 1989.1989. Rodriguez Avenue. she was admitted at one of the rooms of the DLSMC. p. was also with her (TSN. October 19. Her hands were held by Herminda as they went down from her room to the operating room (TSN. Buenviaje (TSN. Through the intercession of a mutual friend. the doctor plays God on his patient's fate. October 19. was also there for moral support. Rogelio. pp. She was advised to undergo an operation for the removal of a stone in her gall bladder (TSN. she was given injections. he is made accountable for his acts. October 19. however. J. February 27. 1988.

and she told Rogelio E. October 19... inip na inip na ako. p. Gutierrez. The latter informed the former that something went wrong during the intubation.). Gutierrez thereafter informed Herminda Cruz about the prospect of a delay in the arrival of Dr. Rogelio. 1988. 16. p. who was inside the operating room with the patient. she focused her attention on what Dr. Rogelio reminded the doctor that the condition of his wife would not have happened. Meanwhile. Garcia) was also tired of waiting for Dr. Doctors Gutierrez and Hosaka were also asked by the hospital to explain what happened to the patient.M. The patient's nailbed became bluish and the patient was placed in a trendelenburg position — a position where the head of the patient is placed in a position lower than her feet which is an indication that there is a decrease of blood supply to the patient's brain (Id. "Mindy.. another anesthesiologist (id. 19-20). darating na iyon" (Ibid. mali yata ang pagkakapasok. 19). Calderon arrived at the operating room... Hosaka is already here. doing this and that. 1988. p. happening" (Ibid. Calderon. 1990. he went down to the lobby and waited for the operation to be completed (id.M." Upon hearing those words. Because of the remarks of Dra. He also saw several doctors rushing towards the operating room. she saw this anesthesiologist trying to intubate the patient. she returned to the operating room. The doctors explained that the patient had bronchospasm (TSN. She thereafter heard Dr.. "Huwag kang mag-alaala. that the doctor was not yet around (id. Dr. She thereafter noticed bluish discoloration of the nailbeds of the left hand of the hapless Erlinda even as Dr. At almost 12:00 noon. Hosaka. and saw that the patient was still in trendelenburg position (TSN. While talking to Dr. She then heard Dr. 1989. wala pa ba ang Doctor"? The former replied. dumating na raw. "Nandiyan na si Dr. who was inside the operating room waiting for the doctor to arrive (ibid. Thereafter. About four months thereafter or on November . October 19. Dr. 1991.M. After Dr. About two days thereafter.. 29-30). Herminda Cruz. Ramos was able to talk to Dr. Garcia who remarked that he (Dr. 31). ikuha mo ako ng ibang Doctor. 21).).. p. "ang hirap ma-intubate nito. pp. 1988. July 25. When she returned to the operating room. Hosaka. Gutierrez was doing. October 19. saw a respiratory machine being rushed towards the door of the operating room. 1989. Herminda then went back to the patient who asked. Hosaka) looked for a good anesthesiologist (TSN. 26-27). 20). pp. Erlinda Ramos stayed at the ICU for a month.). 15). Ramos "that something wrong was . 1989. Rogelio E. 19-20). January 13. Garcia at around 12:10 P. 9). 11-12). At around 10:00 A. Herminda went out of the operating room and informed the patient's husband. had he (Dr. At about 12:15 P. 16). Gutierrez say. p. At almost 3:00 P. who was outside the operating room. [and] preparing the patient for the operation" (TSN. 17).. p. the patient told her. Calderon was then able to intubate the patient (TSN. . Hosaka to arrive (id. pp. pp. January 13. When informed by Herminda Cruz that something wrong was happening. Hosaka. Hosaka approached her. 13). she went out of the operating room. November 15. Gutierrez intubating the hapless patient. pp. O lumalaki ang tiyan" (id. . January 13. Ramos was "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 wife from the operating room (TSN. Reacting to what was told to him. pp. "Mindy." So.M. he met Dr. Rogelio. he told her (Herminda) to be back with the patient inside the operating room (TSN. Rogelio E. p. heard somebody say that "Dr. she went out again and told Rogelio about what the patient said (id. he came to know that Dr. Hosaka issue an order for someone to call Dr." She then saw people inside the operating room "moving. Thereafter. of that fateful day. p. He also thought of the feeling of his wife. she then saw Dr. As she held the hand of Erlinda Ramos. 25-28). Herminda Cruz immediately rushed back. she saw the patient taken to the Intensive Care Unit (ICU). p.not yet in (TSN.. Immediately thereafter. Hosaka arrived as a nurse remarked.

Mariano Gavino to prove that the sustained by Erlinda was due to lack of oxygen in her brain caused by the faulty management of her airway by private respondents during the anesthesia phase. On the part of DLSMC (the hospital). Eduardo Jamora.000. She cannot do anything. see also TSN. a pulmonologist. 5 Thus. this Court rejects the defense raised by defendants that they have acted with due care and prudence in rendering medical services to plaintiff-patient. During the whole period of her confinement. After being discharged from the hospital. this Court finds that it is liable for the acts of negligence of the doctors in their "practice of medicine" in the operating room. Perfecta Gutierrez whom he had chosen to administer anesthesia on the patient as part of his obligation to provide the patient a good anesthesiologist'. August 20. private respondents primarily relied on the expert testimony of Dr. She cannot see or hear. this Court finds and so holds that defendants are liable to plaintiffs for damages. negligence in the performance of their duty to plaintiff-patient Erlinda Ramos. and applying the aforecited provisions of law and jurisprudence to the case at bar. On the part of Dr. "G". she has been staying in their residence. . 1989. thereafter. caused the patient to become comatose. to wit: After evaluating the evidence as shown in the finding of facts set forth earlier. she has been in a comatose condition. still needing constant medical attention. with her husband Rogelio incurring a monthly expense ranging from P8. the hospital is liable for failing through its responsible officials. pp. if defendants acted with due care and prudence as the patient's case was an elective. at the very least. both parties presented evidence as to the possible cause of Erlinda's injury. was placed in trendelenburg position. 5-10). this Court finds that he is liable for the acts of Dr.25 which is the subject of a promissory note and affidavit of undertaking executed by Rogelio E. the defendants should have rescheduled the operation to a later date. For after she committed a mistake in intubating [the] patient. October 19. pp. Ramos in favor of DLSMC. She cannot move any part of her body. She was also diagnosed to be suffering from "diffuse cerebral parenchymal damage" (Exh. petitioners filed a civil case 6 for damages with the Regional Trial Court of Quezon City against herein private respondents alleging negligence in the management and care of Erlinda Ramos. After considering the evidence from both sides. In having held thus. Moreover. without due regard to the fact that the patient was inside the operating room for almost three (3) hours.15. The defendants were guilty of. the patient was released from the hospital. During the trial. 21-22). p. On the other hand.000. Orlino Hosaka. She suffered brain damage as a result of the absence of oxygen in her brain for four to five minutes (TSN. belie their claim. 1989. She is living on mechanical means.00 to P10. For if the patient was properly intubated as claimed by them. the patient would not have become comatose. On the part of Dr. Furthermore. the Regional Trial Court rendered judgment in favor of petitioners. December 21. Thiopental Sodium (Pentothal). 1991. 1985. Plaintiff presented the testimonies of Dean Herminda Cruz and Dr. 6). on 8 January 1986. to the effect that the cause of brain damage was Erlinda's allergic reaction to the anesthetic agent. they should have done. Hosaka inexcusably failed to arrive on time. Since that fateful afternoon of June 17. because of the decrease of blood supply to the patient's brain.00 (TSN. November 9. This. 1985. this Court finds that she omitted to exercise reasonable care in not only intubating the patient. 1989. The evidence further shows that the hapless patient suffered brain damage because of the absence of oxygen in her (patient's) brain for approximately four to five minutes which. but also in not repeating the administration of atropine (TSN. the fact that another anesthesiologist was called to try to intubate the patient after her (the patient's) nailbed turned bluish. pp. the patient's nailbed became bluish and the patient.542. 32-34). she incurred hospital bills amounting to P93. in turn. and for arriving for the scheduled operation almost three (3) hours late. And. Perfecta Gutierrez. to cancel the scheduled operation after Dr.

the latter are ordered to pay. Sillano filed on 7 August 1995 a motion to admit the motion for reconsideration contending that the period to file the appropriate pleading on the assailed decision had not yet commenced to run as the Division Clerk of Court of the Court of Appeals had not yet served a copy thereof to the counsel on record. It is. and in view of the foregoing. petitioners engaged the services of another counsel. the Motion for Extension (Rollo. then counsel on record of petitioners. judgment is rendered in favor of the plaintiffs and against the defendants. for the foregoing premises the appealed decision is hereby REVERSED.542.000. 8 The decision of the Court of Appeals was received on 9 June 1995 by petitioner Rogelio Ramos who was mistakenly addressed as "Atty. Sillano. to replace Atty. Ligsay. Atty. Sillano on 11 April 1996. 1995. The next day. plus legal interest for justice must be tempered with mercy. Ligsay. However. the appellate court still denied the motion to admit the motion for reconsideration of petitioners in its Resolution. for lack of merit. the former the following sums of money.00 as of April 15. 12) was denied. 4) the costs of the suit. SO ORDERED. Atty. 10 A copy of the above resolution was received by Atty. 1985 or in the total sum of P632. the appellate court denied the motion for extension of time in its Resolution dated 25 July 1995. is hereby DENIED. Atty. only on 20 June 1995. Despite this explanation. The motion for reconsideration was submitted on 4 July 1995. On the same day. the period to file a Motion for Reconsideration expired on June 24. Rogelio referred the decision of the appellate court to a new lawyer. Ligsay. The decretal portion of the decision of the appellate court reads: WHEREFORE. in turn. and. dated 29 May 1995. dated 29 March 1996. 7 Private respondents seasonably interposed an appeal to the Court of Appeals. admitted in the latter Motion that plaintiffs/appellees received a copy of the decision as early as June 9. The Motion for Reconsideration. the former. 3) the sum of P800. necessarily. the 15-day period already passed. Even assuming admissibility of the Motion for the Reconsideration. was received by the Court of Appeals already on July 4. was sent nor received by the Coronel Law Office. SO ORDERED. SO ORDERED. Computation wise. that the filing of a Motion for Reconsideration cannot be extended. xxx xxx xxx WHEREFORE.00 by way of moral damages and the further sum of P200. Rogelio Ramos. or on 12 April 1996. For that alone. to wit: We said in our Resolution on July 25. 2) the sum of P100.000.00 as actual monthly expenses for the plaintiff Erlinda Ramos reckoned from November 15. and the complaint below against the appellants is hereby ordered DISMISSED. the latter should be denied. but after considering the Comment/Opposition. p. 1992. precisely. jointly and severally. 1995.not an emergency case. on the other hand. The appellate court rendered a Decision. reversing the findings of the trial court.00 by way of exemplary damages. however. filed with the appellate court a motion for extension of time to file a motion for reconsideration." No copy of the decision. The counterclaim of appellant De Los Santos Medical Center is GRANTED but only insofar as appellees are hereby ordered to pay the unpaid hospital bills amounting to P93. Atty. subject to its being updated.000. Atty. primarily on the ground that the fifteen-day (15) period for filing a motion for reconsideration had already expired. Sillano filed before this Court a motion for extension of time to file the present petition . or four (4) days before the expiration of the reglementary period for filing a motion for reconsideration.000. to wit: 1) the sum of P8.00 as reasonable attorney's fees. Accordingly.25. 9Meanwhile.000.

as a matter of common . Rogelio Ramos. and denied the motion for reconsideration of petitioner. III IN NOT APPLYING THE DOCTRINE OF RES IPSA LOQUITUR. The petition was filed on 9 May 1996. which superseded the earlier resolution issued on 25 July 1995. The due date fell on 27 May 1996. and present a question of fact for defendant to meet with an explanation.for certiorari under Rule 45. 12 private respondents contend that the petition should not be given due course since the motion for reconsideration of the petitioners on the decision of the Court of Appeals was validly dismissed by the appellate court for having been filed beyond the reglementary period. For a more logical presentation of the discussion we shall first consider the issue on the applicability of the doctrine of res ipsa loquitur to the instant case. DRA. the Coronel Law Office. since a copy of the decision of the appellate court was not sent to the counsel on record of petitioner. We do not agree. Based on this. 11 Before we discuss the merits of the case. Moreover. we believed that the receipt of the former should be considered in determining the timeliness of the filing of the present petition. dated 29 March 1996. With a few exceptions." The phrase "res ipsa loquitur'' is a maxim for the rule that the fact of the occurrence of an injury. Based on the other communications received by petitioner Rogelio Ramos. Hence. Res ipsa loquitur is a Latin phrase which literally means "the thing or the transaction speaks for itself. may permit an inference or raise a presumption of negligence. the petition before us was submitted on time. it affords reasonable evidence. GUTIERREZ. Petitioner. A careful review of the records reveals that the reason behind the delay in filing the motion for reconsideration is attributable to the fact that the decision of the Court of Appeals was not sent to then counsel on record of petitioners. the delay in the filing of the motion for reconsideration cannot be taken against petitioner. After resolving the foregoing procedural issue. 13 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 such as in ordinary course of things does not happen if those who have its management or control use proper care. since the Court of Appeals already issued a second Resolution. Petitioners assail the decision of the Court of Appeals on the following grounds: I IN PUTTING MUCH RELIANCE ON THE TESTIMONIES OF RESPONDENTS DRA. taken with the surrounding circumstances. or make out a plaintiff's prima faciecase. a copy of the decision of the appellate court was instead sent to and received by petitioner Rogelio Ramos on 9 June 1995 wherein he was mistakenly addressed as Atty. there can be no sufficient notice to speak of. no copy of the decision of the counsel on record. that the accident arose from or was caused by the defendant's want of care. we shall first dispose of the procedural issue on the timeliness of the petition in relation to the motion for reconsideration filed by petitioners with the Court of Appeals. in the absence of explanation by the defendant. In their Comment. well within the extended period given by the Court. not being a lawyer and unaware of the prescriptive period for filing a motion for reconsideration. we shall now look into the merits of the case. the first two assigned errors shall be tackled in relation to the res ipsa loquitur doctrine. notice to a litigant without notice to his counsel on record is no notice at all. CALDERON AND DR. Thus. II IN FINDING THAT THE NEGLIGENCE OF THE RESPONDENTS DID NOT CAUSE THE UNFORTUNATE COMATOSE CONDITION OF PETITIONER ERLINDA RAMOS. Thereafter. It is elementary that when a party is represented by counsel. referred the same to a legal counsel only on 20 June 1995. The Court granted the motion for extension of time and gave petitioners additional 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. all notices should be sent to the party's lawyer at his given address. In fact. the appellate court apparently mistook him for the counsel on record. JAMORA. In the present case. 14 The doctrine of res ipsa loquitur is simply a recognition of the postulate that.

26 Although generally. 17 Instead.knowledge and experience. and relieves a plaintiff of. 25 The application of res ipsa loquitur in medical negligence cases presents a question of law since it is a judicial function to determine whether a certain set of circumstances does. However. 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. under usual and ordinary conditions. and must establish that the essential elements of the doctrine were present in a particular incident. the following requisites must be satisfactorily shown: 1. 30 Where common knowledge and experience teach that a resulting injury would not have occurred to the patient if due care had been exercised. and manifest conditions which are observable by any one may be given by non-expert witnesses. in cases where the res ipsa loquitur is applicable. 27 The reason is that the general rule on the necessity of expert testimony applies only to such matters clearly within the domain of medical science. 29 Hence. Thus. or a mere procedural of convenience since it furnishes a substitute for. where the court from its fund of common knowledge can determine the proper standard of care. 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. the court is permitted to find a physician negligent upon proper proof of injury to the patient. testimony as to the statements and acts of physicians and surgeons. 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. 20 Still. and 3. Thus. before resort to the doctrine may be allowed. it is considered as merely evidentiary or in the nature of a procedural rule. in addition to proving injury or damage. and not to matters that are within the common knowledge of mankind which may be testified to by anyone familiar with the facts. permitting the plaintiff to present along with the proof of the accident. Resort to res ipsa loquitur is allowed because there is no other way. 2. the burden of producing specific proof of negligence. the very nature of certain types of occurrences may justify an inference of negligence on the part of the person who controls the instrumentality causing the injury in the absence of some explanation by the defendant who is charged with negligence. creating an inference or presumption of negligence. 23 Medical malpractice 24 cases do not escape the application of this doctrine. the fundamental element is the "control of instrumentality" which caused the damage. It is simply a step in the process of such proof. 19 In other words. 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 and care. 28 Ordinarily. The possibility of contributing conduct which would make the plaintiff responsible is eliminated. as a matter of law. much has been said that res ipsa loquitur is not a rule of substantive law and. must show a situation where it is applicable. mere invocation and application of the doctrine does not dispense with the requirement of proof of negligence. 31 When the doctrine is appropriate. external appearances. 15 It is grounded in the superior logic of ordinary human experience and on the basis of such experience or common knowledge. does not create or constitute an independent or separate ground of liability. when the doctrine of res ipsa loquitur is availed by the plaintiff. by which the patient can obtain redress for injury suffered by him. permit a given inference. 16 Hence. a plaintiff. res ipsa loquitur is applied in conjunction with the doctrine of common knowledge. 18 It is regarded as a mode of proof. courts of other jurisdictions have applied the doctrine in the following situations: leaving of a foreign . enough of the attending circumstances to invoke the doctrine. However. The accident is of a kind which ordinarily does not occur in the absence of someone's negligence. In order to have the benefit of the rule. an inference of negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur without medical evidence. and to thereby place on the defendant the burden of going forward with the proof. which is ordinarily required to show not only what occurred but how and why it occurred. as such. 22Such element of control must be shown to be within the dominion of the defendant. without the aid of expert testimony. negligence may be deduced from the mere occurrence of the accident itself. It is caused by an instrumentality within the exclusive control of the defendant or defendants. the need for expert medical testimony is dispensed with because the injury itself provides the proof of negligence. 21 In the above requisites.

res ipsa loquitur is not available in a malpractice suit if the only showing is that the desired result of an operation or treatment was not accomplished. At the time of submission he was neurologically sound and physically fit in mind and body. 41 If there was such extraneous interventions. as a matter of common knowledge and observation. 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. custody and control of his physician who had complete and exclusive control over him. that the consequences of professional care were not as such as would ordinarily have followed if due care had been exercised. the doctrine of res ipsa loquitur may be utilized and the defendant is called upon to explain the matter. On that fateful day she delivered her person over to the care. A case strikingly similar to the one before us is Voss vs. The injury was one which does not ordinarily occur in the process of a mastoid operation or in the absence of negligence in the administration of an anesthetic. In the present case. of treatment. conditions and circumstances alleged in Count II it is held that a cause of action is stated under the doctrine of res ipsa loquitur. if unexplained would themselves reasonably speak to the average man as the negligent cause or causes of the untoward consequence. 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 negligence. Ordinarily a person being put under anesthesia is not rendered decerebrate as a consequence of administering such anesthesia in the absence of negligence. custody and control of private respondents who exercised complete and exclusive control over her. depending upon the circumstances of each case. that the consequences of professional treatment were not as such as would ordinarily have followed if due care had been exercised. and the circumstances are such that the true explanation of event is more accessible to the defendants than to the plaintiff for they had the exclusive control of the instrumentalities of anesthesia. as a matter of common knowledge and observation. the principles enunciated in the aforequoted case apply with equal force here. Here the plaintiff could not have been guilty of contributory negligence because he was under the influence of anesthetics and unconscious. 36 among others. by evidence of exculpation. . therefore. It is generally restricted to situations in malpractice cases where a layman is able to say. 44 Indeed. 33 removal of the wrong part of the body when another part was intended. Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied. but the operation was never performed. As will hereinafter be explained. and in the use and employment of an endoctracheal tube. or why any particular scientific treatment did not produce the desired result. At the time of submission. Upon these facts and under these circumstances a layman would be able to say. Bridwell. 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. 34 knocking out a tooth while a patient's jaw was under anesthetic for the removal of his tonsils. during or following an operation for appendicitis. which. or in the area. Erlinda submitted herself for cholecystectomy and expected a routine general surgery to be performed on her gall bladder. 35 and loss of an eye while the patient plaintiff was under the influence of anesthetic. 42 We find the doctrine of res ipsa loquitur appropriate in the case at bar. but he suffered irreparable damage and injury rendering him decerebrate and totally incapacitated.object in the body of the patient after an operation. Upon all the facts. despite the fact that the scope of res ipsa loquitur has been measurably enlarged. 38 The physician or surgeon is not required at his peril to explain why any particular diagnosis was not correct. if he could. 39 Thus. 32 injuries sustained on a healthy part of the body which was not under. 37 A distinction must be made between the failure to secure results. 40 The real question. 43 where the Kansas Supreme Court in applying the res ipsa loquitur stated: The plaintiff herein submitted himself for a mastoid operation and delivered his person over to the care. Nevertheless. It must be conceded that the doctrine of res ipsa loquitur can have no application in a suit against a physician or surgeon which involves the merits of a diagnosis or of a scientific treatment. the damage sustained by Erlinda in her brain prior to a scheduled gall bladder operation presents a case for the application of res ipsa loquitur.

Corollary thereto. Considering that a sound and unaffected member of the body (the brain) is injured or destroyed while the patient is unconscious and under the immediate and exclusive control of the physicians. Thus. Gutierrez. We disagree with the findings of the Court of Appeals. as a matter of common knowledge and observation. Furthermore. the appellate court returned a verdict in favor of respondents physicians and hospital and absolved them of any liability towards Erlinda and her family. In fact. including the endotracheal tube. Having in mind the applicability of the res ipsa loquitur doctrine and the presumption of negligence allowed therein. In so holding. As borne by the records. Gutierrez. In the instant case. as testified on by their expert witness. was likewise physically fit in mind and body. being a nurse. the liability of the physicians and the hospital in this case is not predicated upon an alleged failure to secure the desired results of an operation nor on an alleged lack of skill in the diagnosis or treatment as in fact no operation or treatment was ever performed on Erlinda. brain damage. As will be shown hereinafter. the Court of Appeals relied on the testimonies of Dra. In giving weight to the testimony of Dra. were all under the exclusive control of private respondents. Obviously. the Court of Appeals rationalized that she was candid enough to admit that she experienced some difficulty in the endotracheal intubation 45 of the patient and thus. the appellate court rejected the testimony of Dean Herminda Cruz offered in favor of petitioners that the cause of the brain injury was traceable to the wrongful insertion of the tube since the latter. if in the affirmative. Each case must be viewed in its own light and scrutinized in order to be within the res ipsa loquitur coverage. petitioner Erlinda could not have been guilty of contributory negligence because she was under the influence of anesthetics which rendered her unconscious. Jamora. However. was allegedly not knowledgeable in the process of intubation. whether the alleged negligence was the proximate cause of Erlinda's comatose condition. Gutierrez. Jamora. Moreover. 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. the instruments used in the administration of anesthesia. we find her negligent in the care of Erlinda during the anesthesia phase. private respondents' own testimonies which are reflected in the transcript of stenographic notes are replete of signposts indicative of their negligence in the care and management of Erlinda. Dr. a person being put under anesthesia is not rendered decerebrate as a consequence of administering such anesthesia if the proper procedure was followed. who are the physicians-in-charge. Thus. except for a few minor discomforts. we shall also determine if the Court of Appeals erred in relying on the testimonies of the witnesses for the private respondents. Normally. is an injury which does not normally occur in the process of a gall bladder operation. The appellate court likewise opined that private respondents were able to show that the brain damage sustained by Erlinda was not caused by the alleged faulty intubation but was due to the allergic reaction of the patient to the drug Thiopental Sodium (Pentothal). during the administration of anesthesia and prior to the performance of cholecystectomy she suffered irreparable damage to her brain. respondent Dra. upon all these initial determination a case is made out for the application of the doctrine of res ipsa loquitur. Nonetheless. the Court now comes to the issue of whether the Court of Appeals erred in finding that private respondents were not negligent in the care of Erlinda during the anesthesia phase of the operation and.Erlinda was neurologically sound and. We hold that private respondents were unable to disprove the presumption of negligence on their part in the care of Erlinda and their negligence was the proximate cause of her piteous condition. or to any and all anesthesia cases. Upon these facts and under these circumstances the Court would be able to say. she went out of the operating room already decerebrate and totally incapacitated. Likewise. cannot be said to be covering her negligence with falsehood. in holding that res ipsa loquitur is available to the present case we are not saying that the doctrine is applicable in any and all cases where injury occurs to a patient while under anesthesia. On the other hand. without undergoing surgery. we hold that a practical administration of justice dictates the application of res ipsa loquitur. Gutierrez failed to properly intubate the patient. if negligence attended the management and care of the patient. which Erlinda sustained. the records are helpful in furnishing not only the logical scientific evidence of the pathogenesis of the injury but also in providing the Court the legal nexus upon which liability is based. a short-acting barbiturate. In sustaining the position of private respondents. Dra. Calderon and Dr. With regard to Dra. This fact was .

Perfecta Gutierrez. Q: Where was Dr. xxx xxx xxx Q: After hearing the phrase "lumalaki ang tiyan. She was saying "Ang hirap ma-intubate nito. Calderon. I was with the patient. xxx xxx xxx Q: Do you know the reason why the patient was placed in that trendelenburg position? . who was in the operating room right beside the patient when the tragic event occurred. after a while the patient's nailbed became bluish and I saw the patient was placed in trendelenburg position. ALCERA: She will be incompetent Your Honor. Gutierrez? ATTY. O lumalaki ang tiyan. I could see that she was intubating the patient. what did Dra. PAJARES: Q: From whom did you hear those words "lumalaki ang tiyan"? A: From Dra. Perfecta Gutierrez herself. Q: What happened to the patient? A: When Dr. PAJARES: Q: In particular. Q: Did Dr. what did he do. Q: Do you know what happened to that intubation process administered by Dra. A: As have said." what did you notice on the person of the patient? A: I notice (sic) some bluish discoloration on the nailbeds of the left hand where I was at. Calderon try (sic) to intubate the patient. Witness Cruz testified to this effect: ATTY. COURT: Witness may answer if she knows. Herminda Cruz. arrive inside the operating room? A: Yes sir. Q: When he approached the patient. Q: What did [s]he do. Orlino Ho[s]aka then at that particular time? A: I saw him approaching the patient during that time. upon being called. xxx xxx xxx ATTY. mali yata ang pagkakapasok. Dean of the Capitol Medical Center School of Nursing and petitioner's sister-in-law. Perfecta Gutierrez do. if any? A: He made an order to call on the anesthesiologist in the person of Dr. I was beside the stretcher holding the left hand of the patient and all of a sudden heard some remarks coming from Dra. if any? A: [S]he tried to intubate the patient. Calderon. if any on the patient? A: In particular.attested to by Prof.

A: As far as I know. July 25. and considered a layman in the process of intubation. Doctora. an experienced clinical nurse whose long experience and scholarship led to her appointment as Dean of the Capitol Medical Center School at Nursing. 47 In other words. witness Cruz's categorical statements that appellant Dra. At any rate. Although witness Cruz is not an anesthesiologist. This kind of observation. witness Herminda Cruz. More importantly. 46 xxx xxx xxx The appellate court. while you were intubating at your first attempt (sic). she can very well testify upon matters on which she is capable of observing such as. however. With her clinical background as a nurse. and to determine the condition of the heart. was fully capable of determining whether or not the intubation was a success. with the kind of detail. and cannot. you did not immediately see the trachea? DRA. (TSN. Gutierrez who admitted that she experienced difficulty in inserting the tube into Erlinda's trachea. disbelieved Dean Cruz's testimony in the trial court by declaring that: A perusal of the standard nursing curriculum in our country will show that intubation is not taught as part of nursing procedures and techniques. admittedly. 49 We take judicial notice of the fact that anesthesia procedures have become so common. 1991. Q: Did you or did you not? A: I did not pull the tube. we take judicial notice of the fact that nurses do not. there is a decrease of blood supply to the brain. LIGSAY: Q: In this particular case. GUTIERREZ: A: Yes sir. intubate. Thus. petitioner's witness. lungs. Illinois. her testimony was affirmed by no less than respondent Dra. there is no evidence that she ever auscultated the patient or that she conducted any type of examination to check if the endotracheal tube was in its proper place. it would not be too difficult to tell if the tube was properly inserted. Most of all. . Even on the assumption that she is fully capable of determining whether or not a patient is properly intubated. As such. 48 This is precisely allowed under the doctrine of res ipsa loquitur where the testimony of expert witnesses is not required. and manifest conditions which are observable by any one. and then Dean of the Capitol Medical Center School of Nursing. we believe. consistency and spontaneity which would have been difficult to fabricate. 13). We do not agree with the above reasoning of the appellate court. or where the lack of skill or want of care is so obvious as to render expert testimony unnecessary. Calderon who succeeded in doing so clearly suffer from lack of sufficient factual bases. to wit: ATTY. 50Reviewing witness Cruz' statements. witness Cruz is not competent to testify on whether or not the intubation was a success. Dean of the Laguna College of Nursing in San Pablo City. without doubt. external appearances. what the Court of Appeals is trying to impress is that being a nurse. It is the accepted rule that expert testimony is not necessary for the proof of negligence in non-technical matters or those of which an ordinary person may be expected to have knowledge. Gutierrez failed to intubate the appellee Erlinda Ramos and that it was Dra. . clarity. the Court is satisfied that she was able to demonstrate through her testimony what truly transpired on that fateful day. staff nurse and clinical instructor in a teaching hospital. we find that the same were delivered in a straightforward manner. the FEU-NRMF. does not require a medical degree to be acceptable. Indeed. when a patient is in that position. p. and other organs. the statements and acts of the physician and surgeon. She had extensive clinical experience starting as a staff nurse in Chicago. that even an ordinary person can tell if it was administered properly. . did not peep into the throat of the patient. Q: Did you pull away the tube immediately? A: You do not pull the .

58 However. Gutierrez. prominent central incisors. She was likewise not properly informed of the possible difficulties she would face during the administration of anesthesia to Erlinda. review of current drug therapy. if at all. cardiovascular system. The argument does not convince us. Elective procedures. ability to visualize uvula and the thyromental distance. or pre-operative evaluation of Erlinda was done by her. Gutierrez' act of seeing her patient for the first time only an hour before the scheduled operative procedure was. 55 A thorough analysis of the patient's airway normally involves investigating the following: cervical spine mobility. GUTIERREZ: A: As I said in my previous statement.Q: When you said "mahirap yata ito. Her failure to follow this medical procedure is. Respondent Dra. 51 Curiously in the case at bar. Q: So. as a means of defense. 57 Where the need arises. that it is good medical practice to see the patient a day before so you can introduce yourself to establish good doctorpatient relationship and gain the trust and confidence of the patient? DRA. In her testimony she asserted: ATTY. Pre-operative evaluation and preparation for anesthesia begins when the anesthesiologist reviews the patient's medical records and visits with the patient. physical characteristics of the patient's upper airway that could make tracheal intubation difficult should be studied. an act of exceptional negligence and professional irresponsibility. lungs and upper airway. Until the day of the operation. it appears that the observation was made only as an afterthought. a clear indicia of her negligence. you found some difficulty in inserting the tube? A: Yes. physical examination and interpretation of laboratory data. attempts to gloss over this omission by playing around with the trial court's ignorance of clinical procedure. it depends on the operative procedure of the anesthesiologist and in my case. as when initial assessment indicates possible problems (such as the alleged short neck and protruding teeth of Erlinda) a thorough examination of the patient's airway would go a long way towards decreasing patient morbidity and mortality. there is hardly enough time available for the fastidious demands of pre-operative procedure so that an anesthesiologist is able to see the patient only a few minutes before surgery. private respondents adduced no evidence demonstrating that they proceeded to make a thorough assessment of Erlinda's airway. therefore. on 17 June 1985. I usually don't do it except on emergency and on cases that have an abnormalities (sic). are operative . on the other hand. no prior consultations with. because of (sic) my first attempt. with elective cases and normal cardio-pulmonary clearance like that. In an emergency procedure. Gutierrez was unaware of the physiological make-up and needs of Erlinda. even if this would mean postponing the procedure. respondent Dra. respondent Dra." what were you referring to? A: "Mahirap yata itong i-intubate. 54 The physical examination performed by the anesthesiologist is directed primarily toward the central nervous system. prior to the induction of anesthesia. Gutierrez made the haphazard defense that she encountered hardship in the insertion of the tube in the trachea of Erlinda because it was positioned more anteriorly (slightly deviated from the normal anatomy of a person) 52 making it harder to locate and. LIGSAY: Q: Would you agree. however. Gutierrez admitted that she saw Erlinda for the first time on the day of the operation itself. I did not see right away. hoping that she could get away with it. the day before elective surgery. Respondent Dra." that was the patient. Doctor. Respondent Dra. The measures cautioning prudence and vigilance in dealing with human lives lie at the core of the physician's centuries-old Hippocratic Oath. diseased or artificial teeth. since Erlinda is obese and has a short neck and protruding teeth. 53 It includes taking the patient's medical history. traditionally. 56 Thus. the exact opposite is true. therefore. Before this date. The pre-operative evaluation of a patient prior to the administration of anesthesia is universally observed to lessen the possibility of anesthetic accidents. temporomandibular mobility. it made intubation even more difficult. From their testimonies. If this was indeed observed. Gutierrez tried to muddle the difference between an elective surgery and an emergency surgery just so her failure to perform the required pre-operative evaluation would escape unnoticed. In the case at bar. respondent Dra.

LIGSAY: Q: In your line of expertise on pulmonology. she had all the time to make a thorough evaluation of Erlinda's case prior to the operation and prepare her for anesthesia. the drugs to be used. did you have any occasion to use pentothal as a method of management? DR. we now determine if the faulty intubation is truly the proximate cause of Erlinda's comatose condition. and their possible hazards for purposes of informed consent. Since Dr. She herself admitted that she had seen petitioner only in the operating room. Gutierrez failed to perform pre-operative evaluation of the patient which. Q: But not in particular when you practice pulmonology? A: No. Moreover. We find the theory of private respondents unacceptable. I went into bronchospasm during my appendectomy.procedures that can wait for days. As such. could not have been capable. She negligently failed to take advantage of this important opportunity. Jamora is likewise not an allergologist and could not therefore properly advance expert opinion on allergic-mediated processes. in turn. in these cases. the pre-operative assessment is conducted at least one day before the intended surgery. he could not have been capable of properly enlightening the court about anesthesia practice and procedure and their complications. introduced into her system. Towards this end. Q: How many times have you used pentothal? A: They used it on me. he is not a pharmacologist and. to wit: ATTY. Hence. she never saw the patient at the bedside. a Fellow of the Philippine College of Physicians and Diplomate of the Philippine Specialty Board of Internal Medicine. they presented Dr. resulted to a wrongful intubation. as such. 60 was due to an unpredictable drug reaction to the short-acting barbiturate. Dr. Jamora. the anesthesiologist possesses the luxury of time to be at the patient's beside to do a proper interview and clinical evaluation. who advanced private respondents' theory that the oxygen deprivation which led to anoxic encephalopathy. Thus. as an expert would. First of all. your knowledge about pentothal is based only on what you have read from books and not by your own personal application of the medicine pentothal? A: Based on my personal experience also on pentothal. weeks or even months. There is ample time to explain the method of anesthesia. The inappropriateness and absurdity of accepting Dr. Usually. Erlinda's case was elective and this was known to respondent Dra. but only from reading certain references. Thiopental Sodium (Pentothal). Jamora cannot be considered an authority in the field of anesthesiology simply because he is not an anesthesiologist. Jamora is a pulmonologist. Jamora's testimony as an expert witness in the anesthetic practice of Pentothal administration is further supported by his own 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. Thiopental Sodium. JAMORA: A: We do it in conjunction with the anesthesiologist when they have to intubate our patient. Q: In other words. However. Q: And because they have used it on you and on account of your own personal experience you feel that you can testify on pentothal here with medical authority? . of explaining to the court the pharmacologic and toxic effects of the supposed culprit. when the patient is relaxed and cooperative. Having established that respondent Dra. her attempt to exculpate herself must fail. Private respondents repeatedly hammered the view that the cerebral anoxia which led to Erlinda's coma was due to bronchospasm 59 mediated by her allergic response to the drug. Gutierrez. and only on the actual date of the cholecystectomy. Dr.

internal medicine-allergy. private respondents' intentionally avoided providing testimony by competent and independent experts in the proper areas. private respondents themselves admit that Thiopental induced. unbroken by any efficient intervening cause. has no support in evidence. Jamora does not qualify as an expert witness based on the above standard since he lacks the necessary knowledge. The provision in the rules of evidence 62 regarding expert witnesses states: Sec. If courts were to accept private respondents' hypothesis without supporting medical proof. Evidently. many bronchospastic-mediated pulmonary diseases are within the expertise of pulmonary medicine. the anesthetic drug-induced. Private respondents themselves admitted in their testimony that the first intubation was a failure. may be received in evidence. allergic-mediated bronchospasm happens only very rarely. In view of the evidence at hand. together with respiratory embarrassment indicates that the endotracheal tube entered the esophagus instead of the respiratory tree. witness Cruz noticed abdominal distention on the body of Erlinda. experience or training which he is shown to possess. 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. and without which the result would not have occurred. The resulting anoxic encephalopathy belongs to the field of neurology. the Thiopental-allergy theory vigorously asserted by private respondents was a mere afterthought. and that the injury or damage was either a direct result or a reasonably probable consequence of the act or omission. in which the pulmonologist himself admitted that he could not testify about the drug with medical authority. While admittedly. During intubation. 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 . Such an explanation was advanced in order to advanced in order to absolve them of any and all responsibility for the patient's condition. Jamora's testimony as an expert in the administration of Thiopental Sodium. ultimately. 49. moving or producing cause. In other words. and clinical pharmacology. 64 An injury or damage is proximately caused by an act or a failure to act. Proximate cause has been defined as that which.A: No. Jamora's field. then every anesthetic accident would be an act of God. one must have acquired special knowledge of the subject matter about which he or she is to testify. skin reactions. her comatosed condition. to qualify as an expert witness. it is clear that the appellate court erred in giving weight to Dr. apart from submitting testimony from a specialist in the wrong field. Oddly." Thereafter. skill. whenever it appears from the evidence in the case. and training in the field of anesthesiology. That is why I used references to support my claims. produces injury. instead of the intended endotracheal intubation what actually took place was an esophageal intubation. allergic mediated bronchospasm alleged in this case is within the disciplines of anesthesiology. Opinion of expert witness. such distention indicates that air has entered the gastrointestinal tract through the esophagus instead of the lungs through the trachea. and against the weight of available evidence. Generally. Gutierrez remarked.63 Clearly. This fact was likewise observed by witness Cruz when she heard respondent Dra. Dr. mali yata ang pagkakapasok. 61 An anesthetic accident caused by a rare drug-induced bronchospasm properly falls within the fields of anesthesia. skill. private respondents' theory. O lumalaki ang tiyan. 65 It is the dominant. The development of abdominal distention. faulty intubation is undeniably the proximate cause which triggered the chain of events leading to Erlinda's brain damage and. On the basis of the foregoing transcript. In any case. Applying the above definition in relation to the evidence at hand. that the act or omission played a substantial part in bringing about or actually causing the injury or damage. that Thiopental Sodium may have produced Erlinda's coma by triggering an allergic mediated response. — The opinion of a witness on a matter requiring special knowledge. in natural and continuous sequence. allergology and pharmacology. "Ang hirap ma-intubate nito. either by the study of recognized authorities on the subject or by practical experience. No laboratory data were ever presented to the court. we are inclined to believe petitioners' stand that it was the faulty intubation which was the proximate cause of Erlinda's comatose condition. No evidence of stridor. Dr. Moreover. or wheezing — some of the more common accompanying signs of an allergic reaction — appears on record.

hospitals exercise significant control in the hiring and firing of consultants and in the conduct of their work within the hospital premises. Even granting that the tube was successfully inserted during the second attempt. visiting or attending. We now discuss the responsibility of the hospital in this particular incident. As the so-called "captain of the ship. would have had little difficulty going around the short neck and protruding teeth. Erlinda already suffered brain damage as a result of the inadequate oxygenation of her brain for about four to five minutes. Thus. is normally politely terminated. that the second intubation was accomplished. A consultant remiss in his duties. private respondents contend that a second intubation was executed on Erlinda and this one was successfully done. 72 Having failed to observe common medical standards in preoperative management and intubation. evidence of fellowship in most cases. the lack of oxygen became apparent only after he noticed that the nailbeds of Erlinda were already blue. defects which would have been easily overcome by a prior knowledge of those variations together with a change in technique. and references. the difficulty is only more apparent than real. However. Hosaka's negligence can be found in his failure to exercise the proper authority (as the "captain" of the operative team) in not determining if his anesthesiologist observed proper anesthesia protocols. Scientific studies point out that intubation problems are responsible for one-third (1/3) of deaths and serious injuries associated with anesthesia. or a consultant who regularly falls short of the minimum standards acceptable to the hospital or its peer review committee. Hosaka had scheduled another procedure in a different hospital at the same time as Erlinda's cholecystectomy. We now determine the responsibility of respondent Dr. We do not think so. an experienced anesthesiologist. and/or for the privilege of admitting patients into the hospital. 67 However. are required to submit proof of completion of residency. Proceeding from this event (cyanosis). as private respondents insist. ninety-eight percent (98%) or the vast majority of difficult intubations may be anticipated by performing a thorough evaluation of the patient's airway prior to the operation. for the privilege of being able to maintain a clinic in the hospital. either as a visiting or attending consultant. These requirements are carefully scrutinized by members of the hospital administration or by a review committee set up by the hospital who either accept or reject the application. and feedback from patients. In the first place. interns and residents. cyanosis was again observed immediately after the second intubation. generally. interns and residents. Orlino Hosaka as the head of the surgical team. Respondent Dr. 69 Nevertheless. conduct bedside rounds for clerks. As aptly explained by the trial court. Hosaka verified if respondent Dra. their educational qualifications. 75 This is particularly true with respondent hospital. no evidence on record exists to show that respondent Dr." 73 it is the surgeon's responsibility to see to it that those under him perform their task in the proper manner. respondent physician could have been much more prepared to meet the contingency brought about by the perceived anatomic variations in the patient's neck and oral area. Gutierrez' negligence resulted in cerebral anoxia and eventual coma of Erlinda. In fact. respondent Dra. it does not escape us that respondent Dr. No evidence exists on record. presents problems in apportioning responsibility for negligence in medical malpractice cases. Because of this. The unique practice (among private hospitals) of filling up specialist staff with attending and visiting "consultants. Hosaka. This indicates that he was remiss in his professional duties towards his patient. 70 As stated beforehand. Assuming that the endotracheal tube finally found its way into the proper orifice of the trachea. After a physician is accepted. it could not be claimed. Gutierrez failed to observe the proper pre-operative protocol which could have prevented this unfortunate incident. the physician's performance as a specialist is generally evaluated by a peer review committee on the basis of mortality and morbidity statistics. he had little or no time to confer with his anesthesiologist regarding the anesthesia delivery. In addition to these. ." 74 who are allegedly not hospital employees.withdrawn for the second attempt) was fairly significant. Gutierrez properly intubated the patient. evidence of accreditation by the appropriate board (diplomate). moderate grand rounds and patient audits and perform other tasks and responsibilities. In fact. 71 In other words. Had appropriate diligence and reasonable care been used in the pre-operative evaluation. the hallmark of a successful intubation. which supports the contention that the second intubation was successful. 66 As stated in the testimony of Dr. and was in fact over three hours late for the latter's operation. Due to the delay in the delivery of oxygen in her lungs Erlinda showed signs of cyanosis. it was obviously too late. Doctors who apply for "consultant" slots. the same gave no guarantee of oxygen delivery. he is normally required to attend clinico-pathological conferences. nurses. beyond private respondents' bare claims. he shares equal responsibility for the events which resulted in Erlinda's condition. Furthermore. respondent Dra. 68 The above conclusion is not without basis. adequately alerted by a thorough pre-operative evaluation.

and by a pulmonary therapist to prevent the accumulation of secretions which can lead to respiratory complications. Erlinda has to be constantly turned from side to side to prevent bedsores and hypostatic pneumonia.In other words. The trial court awarded a total of P632. 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. It failed to adduce evidence with regard to the degree of supervision which it exercised over its physicians.00. Given these considerations. 78 In other words. we rule that for the purpose of allocating responsibility in medical negligence cases. the control test is determining. not the cost of the care the family is usually compelled to undertake at home to avoid bankruptcy. — Except as provided by law or by stipulation. fire and exercise real control over their attending and visiting "consultant" staff. At current levels. 77 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. we hold that the Court of Appeals erred in accepting and relying on the testimonies of the witnesses for the private respondents. respondent hospital is consequently solidarily responsible with its physicians for Erlinda's condition. the question now arises as to whether or not respondent hospital is solidarily liable with respondent doctors for petitioner's condition. private respondents were unable to rebut the presumption of negligence. 76 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. apart from a general denial of its responsibility over respondent physicians. the hiring. respondent hospital thereby failed to discharge its burden under the last paragraph of Article 2180. Based on the foregoing. the burden shifts to the respondents (parent. Upon these disquisitions we hold that private respondents are solidarily liable for damages under Article 2176 79 of the Civil Code. as shown by the above discussions.000. private hospitals. one is entitled to an adequate . the amount of actual damages recoverable in suits arising from negligence should at least reflect the correct minimum cost of proper care. "subject to its being updated" covering the period from 15 November 1985 up to 15 April 1992. with the exception of the payment of wages. while the burden of proving negligence rests on the plaintiffs. 2199. Indeed. This being the case. 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. In the instant case for instance. Accordingly.000. Feeding is done by nasogastric tube. Having failed to do this. 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. 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. Furthermore. Well-settled is the rule that actual damages which may be claimed by the plaintiff are those suffered by him as he has duly proved. guardian. on the basis of the foregoing. However. the provisions of the Civil Code on actual or compensatory damages present us with some difficulties. an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians.000. respondent hospital. she has to be seen on a regular basis by a physical therapist to avoid muscle atrophy. In assessing whether such a relationship in fact exists.00) in compensatory damages to the plaintiff. technically employees. the control exercised. In neglecting to offer such proof. The calculated amount was not even arrived at by looking at the actual cost of proper hospice care for the patient. based on monthly expenses for the care of the patient estimated at P8.00 pesos (should be P616. Food preparation should be normally made by a dietitian to provide her with the correct daily caloric requirements and vitamin supplements. We now come to the amount of damages due petitioners. teacher or employer) who should prove that they observed the diligence of a good father of a family to prevent damage. The Civil Code provides: Art. a point which respondent hospital asserts in denying all responsibility for the patient's condition. hire. and the right to terminate consultants all fulfill the important hallmarks of an employer-employee relationship. While "consultants" are not. once negligence is shown. And yet ideally. In the instant case. or proof of a similar nature.

Such compensation is referred to as actual or compensatory damages. are difficult to predict.500. the prosthetic devise will have to be replaced and readjusted to changes in the size of her lower limb effected by the biological changes of middle-age.000. All of these adjustments. be made with certainty.000. The replacements. while certain to occur. 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. Valenzuela will forever be deprived of the full ambulatory functions of her left extremity.compensation only for such pecuniary loss suffered by him as he has duly proved. Assuming she reaches menopause. prosthetic replacements and months of physical and occupational rehabilitation and therapy. Under the circumstances. they were likely to arise only in the future. the damage done to her would not only be permanent and lasting. Having premised our award for compensatory damages on the amount provided by petitioners at the onset of litigation. xxx xxx xxx A prosthetic devise. The amount given as temperate damages. the prosthetic will have to be adjusted to respond to the changes in bone resulting from a precipitate decrease in calcium levels observed in the bones of all post-menopausal women. for example. it has been documented. the amount of damages which should be awarded. Describing the nature of the injury. where the resulting injury might be continuing and possible future complications directly arising from the injury. Lourdes Valenzuela underwent a traumatic amputation of her left lower extremity at the distal left thigh just above the knee. it would also be permanently changing and adjusting to the physiologic changes which her body would normally undergo through the years. 80 In other words. an award of P1. And because of the unique nature of such cases. even with the use of state of the art prosthetic technology. They should not be compelled by dire circumstances to provide substandard care at home without the aid of professionals. These adjustments entail costs. 81 In Valenzuela vs. and adjustments will require corresponding adjustive physical and occupational therapy. In the instant case. The reason is that these damages cover two distinct phases. up to the time of trial. as in this case.000. will only allow a reasonable amount . she will be required to undergo adjustments in her prosthetic devise due to the shrinkage of the stump from the process of healing. menopause and aging. and were certain to be incurred by the plaintiff. the injury suffered as a consequence of an act of negligence has been completed and that the cost can be liquidated. In other words. and one which would meet pecuniary loss certain to be suffered but which could not. Our rules on actual or compensatory damages generally assume that at the time of litigation. changes. however technologically advanced. the Court therein stated: As a result of the accident. should take into account the cost of proper care.00 in moral damages in that case. 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. During the lifetime. for anything less would be grossly inadequate. though to a certain extent speculative. these provisions neglect to take into account those situations. from the nature of the case. However. In these cases. should be one which compensates for pecuniary loss incurred and proved. are painful. Well beyond the period of hospitalization (which was paid for by Li). Ma. Court of Appeals. 82 this Court was confronted with a situation where the injury suffered by the plaintiff would have led to expenses which were difficult to estimate because while they would have been a direct result of the injury (amputation). temperate damages can and should be awarded on top of actual or compensatory damages in instances where the injury is chronic and continuing. if they are to adequately and correctly respond to the injury caused.00 in temperate damages would therefore be reasonable. petitioners were able to provide only home-based nursing care for a comatose patient who has remained in that condition for over a decade. no incompatibility arises when both actual and temperate damages are provided for. Because of this. We awarded P1.

the physician would necessarily be called to account for it. when failure to follow established procedure results in the evil precisely sought to be averted by observance of the procedure and a nexus is made between the deviation and the injury or damage. the actual physical. SO ORDERED. However. Established medical procedures and practices.000. and. They have fashioned their daily lives around the nursing care of petitioner. not the respondents. However. The family's moral injury and suffering in this case is clearly a real one. We recognized.00 as moral damages. A physician's experience with his patients would sometimes tempt him to deviate from established community practices. Jr. by way of example. They.83 The injury suffered by Erlinda as a consequence of private respondents' negligence is certainly much more serious than the amputation in the Valenzuela case. She has been in a comatose state for over fourteen years now. are charged with the moral responsibility of the care of the victim. and solidarily against private respondents the following: 1) P1.352. WHEREFORE.00 are hereby awarded. Finally. all petitioners in this case. though in constant flux are devised for the purpose of preventing complications.000.J.00 as temperate damages.00 in moral damages would be appropriate. Puno. 4) P100.00 are likewise proper. JJ. psychological damage and injury suffered by the victim or those actually affected by the victim's condition. intent is immaterial in negligence cases because where negligence exists and is proven.00 each as exemplary damages and attorney's fees. who.000. exemplary damages in the amount of P100. 2) P2. The burden of care has so far been heroically shouldered by her husband and children.000.. 84The husband and the children. will have to live with the day to day uncertainty of the patient's illness. an award of P2. 5) the costs of the suit. Pardo and Ynares-Santiago. The sensory functions are forever lost. the failure to observe pre-operative assessment protocol which would have influenced the intubation in a salutary way was fatal to private respondents' case. Considering the length and nature of the instant suit we are of the opinion that attorney's fees valued at P100. Petitioner Erlinda Ramos was in her mid-forties when the incident occurred. mental and physical pain are inestimable. and he may end a distinguished career using unorthodox methods without incident. Our courts face unique difficulty in adjudicating medical negligence cases because physicians are not insurers of life and. Meanwhile. the decision and resolution of the appellate court appealed from are hereby modified so as to award in favor of petitioners.00 as actual damages computed as of the date of promulgation of this decision plus a monthly payment of P8. Davide.of functional restoration of the motor functions of the lower limb. altering their long term goals to take into account their life with a comatose patient. sleeplessness.500.000.000. The resultant anxiety.000. psychological injury. 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 the amount of emotional and moral pain. 3) P1.000. knowing any hope of recovery is close to nil. C.000. concur. Even the temperate damages herein awarded would be inadequate if petitioner's condition remains unchanged for the next ten years. emotional and financial cost of the care of petitioner would be virtually impossible to quantify. For the foregoing reasons. in the intervening years have been deprived of the love of a wife and a mother.00 up to the time that petitioner Erlinda Ramos expires or miraculously survives. they rarely set out to intentionally cause injury or death to their patients... In the case at bar. . the same automatically gives the injured a right to reparation for the damage caused.000.

which affirmed with modification the Decision[2] of the Regional Trial Court (RTC) of Nueva Ecija. No. all surnamed PINEDA. INC. The dispositive portion of the assailed CA decision states: WHEREFORE. and BRION. JJ.SECOND DIVISION SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA FLORES. - versus - G.. MARTA. CARPIO MORALES. BALTAZAR and November 14. JR..: This petition involves a medical negligence case that was elevated to this Court through an appeal by certiorari under Rule 45 of the Rules of Court. PINEDA. Promulgated: CANDIDA. x -------------------------------------------------------------------------------------------x DECISION BRION. Respondents. J. Branch37 in Civil Case No. 2008 LUCENA. SD-1233. and UNITED DOCTORS MEDICAL CENTER. SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO.R. J. as heirs of the deceased TERESITA S. VELASCO. 63234. Chairperson. CV No. TINGA. Petitioners.. and FLORENCIO. premises considered. GODOFREDO.R. The petition assails the Decision[1] of the Court of Appeals (CA) in CA G. the assailed Decision of the Regional Trial Court . 158996 Present: QUISUMBING.

1987.00 by way of exemplary damages. Sto. As for her other symptoms. While this case essentially involves questions of facts. Inc. SO ORDERED. She complained of general body weakness. Flores at his UDMC clinic on April 28. all surnamed Pineda. Baltazar and Lucena.000. she went to further consult Dr. to jointly and severally pay the plaintiff-appellees heirs of Teresita Pineda. Lucena later testified that her sister was then so weak that she had to lie down on the couch of the clinic while they .of Baloc. Godofredo. However. Candida. Marta. namely.000. regarding her medical condition. frequent urination and thirst.000. and Dra. Spouses Dominador Pineda and Virginia Saclolo and Florencio. and on the importance of this type of ruling on medical practice. travelling for at least two hours from Nueva Ecija to Quezon City with her sister.00 by way of moral damages. 2) Ordering the above-named defendant-appellants to jointly and severally pay the above-named plaintiff-appellees the sum of P100. Fredelicto initially interviewed the patient and asked for the history of her monthly period to analyze the probable cause of the vaginal bleeding. Flores and the United Doctors Medical Center.m. Dr. the sum of P400. They arrived at UDMC at around 11:15 a. he suspected that Teresita might be suffering from diabetes and told her to continue her medications.00 by way of actual and compensatory damages. we opted for the requested review in light of questions we have on the findings of negligence below. 3) Ordering the above-named defendant-appellants to jointly and severally pay the above-named plaintiff-appellees the sum of P36. when her condition persisted. and on-and-off vaginal bleeding. Nueva Ecija.. Domingo. on the awarded damages and costs. and 4) Deleting the award of attorneys fees and costs of suit.[3] BACKGROUND FACTS Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto. She consulted on April 17. He advised her to return the following week or to go to the United Doctors Medical Center (UDMC) in Quezon City for a general check-up.[4] Teresita did not return the next week as advised. Fredelicto Flores. Lucena Pineda. 1987 her townmate. Dr. Fredelicto A. Domingo. loss of appetite. Nueva Ecija. Branch 37 is hereby AFFIRMED but with modifications as follows: 1) Ordering defendant-appellants Dr.

he did a routine check-up and ordered Teresitas admission to the hospital. Felicisima thereafter called up the laboratory for the results of the tests. Further tests confirmed that she was suffering from Diabetes Mellitus Type II. Teresita was brought to her hospital room at around 12 noon. while the resident physician and the medical intern gave Dr. When Dr. Felicisima and Dr. Teresita opted for hospital confinement. She also interviewed and conducted an internal vaginal examination of the patient which lasted for about 15 minutes. Due to complications induced by diabetes. Teresitas condition had worsened. Fredelicto arrived. By April 30. Felicisima Flores (Dr. Fredelicto. Amado Jorge. Teresita died in the morning of May 6.m. Teresitas complete laboratory examination results came only on that day (April 29. an obstetrician and gynecologist. Fredelicto administering the general anesthesia.m. advised Teresita that she could spend her recovery period at home.[11] . She was then placed under the care of Dr. She experienced difficulty in breathing and was rushed to the intensive care unit. Teresita was subjected to an ultrasound examination as a confirmatory procedure. 1987). Teresitas BS count was 10.[10] Insulin was administered on the patient. of that same day. The D&C operation lasted for about 10 to 15 minutes. only the results for the blood sugar (BS). It was only then that she met Dr. Dr. At that time. Still feeling weak. an internist. Fredelicto ordered. and complete blood count (CBC) were available. however. Dr. 1987. In the admission slip. 1987).waited for the doctor.[8] Based on these preparations. The two doctors Dr. At 2:40 p. Felicisima). Felicisima their own briefings. The results showed that she had an enlarged uterus and myoma uteri. Teresitas urinalysis showed a three plus sign (+++) indicating that the sugar in her urine was very high.[9] Dr. By 3:40 p.. Teresita was taken to the operating room. uric acid determination. Felicisima. conferred on the patients medical condition. he directed the hospital staff to prepare the patient for an on call D&C[5] operation to be performed by his wife. Felicisima. the hospital staff forthwith took her blood and urine samples for the laboratory tests[6]which Dr. cholesterol determination. Dr. Felicisima proceeded with the D&C operation with Dr. Teresita was wheeled back to her room. 1987.67mmol/l[7] and her CBC was 109g/l. A day after the operation (or on April 29. but the medication might have arrived too late.

but modified the amount of damages awarded and deleted the award for attorneys fees and costs of suit. Fredelicto Flores and Dr.[12] The CA affirmed the judgment. her family (respondents) instituted an action for damages against Dr. In addition. the petitioner spouses Dr. amounted to negligence. Felicisima Flores (collectively referred to as the petitioner spouses) before the RTC of Nueva Ecija. On the other hand. Felicisima Flores allege that the RTC and CA committed a reversible error in finding them liable through negligence for the death of Teresita Pineda. They had attended to the patient to the best of their abilities and undertook the management of her case based on her complaint of an on-and-off vaginal bleeding. The RTC ruled in favor of Teresitas family and awarded actual. and exemplary damages. plus attorneys fees and costs. ASSIGNMENT OF ERRORS The petitioner spouses contend that they exercised due care and prudence in the performance of their duties as medical professionals. they 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.Believing that Teresitas death resulted from the negligent handling of her medical needs.[13] Through this petition for review on certiorari. The respondents claim for damages is predicated on their allegation that the decision of the petitioner spouses to proceed with the D&C operation. notwithstanding Teresitas condition and the laboratory test results. Fredelicto (now deceased) and Dr. moral. the petitioner spouses contend that a D&C operation is the proper and accepted procedure to . THE COURTS RULING We do not find the petition meritorious.

injury. Salvador Nieto (Dr.[14] Duty refers to the standard of behavior which imposes restrictions on ones conduct. [15] The standard in turn refers to the amount of competence associated with the proper discharge of the profession. Elements of a Medical Negligence Case A medical negligence case is a type of claim to redress a wrong committed by a medical professional.[17] To successfully pursue a claim. and two. the plaintiff must prove by preponderance of evidence that.[19] Standard of Care and Breach of Duty D&C is the classic gynecologic procedure for the evaluation and possible therapeutic treatment for abnormal vaginal bleeding. the core issue is whether the decision to proceed with the D&C operation was an honest mistake of judgment or one amounting to negligence. NIETO: [W]hat I know among obstetricians. breach. or that he did something that a reasonably prudent provider would not have done. they perform what we call D&C for diagnostic purposes.[20] That this is the recognized procedure is confirmed by Drs. If injury results to the patient as a result of this breach. A physician is expected to use at least the same level of care that any other reasonably competent doctor would use under the same circumstances.[16] As in any civil action. xxx xxx xxx . Mercado). the physician is answerable for negligence. if there is bleeding. one. the failure or action caused injury to the patient. the burden to prove the existence of the necessary elements rests with the plaintiff. the physician either failed to do something which a reasonably prudent health care provider would have done. Nieto) and Joselito Mercado (Dr. There are four elements involved in a medical negligence case.[18] Expert testimony is therefore essential since the factual issue of whether a physician or surgeon has exercised the requisite degree of skill and care in the treatment of his patient is generally a matter of expert opinion.address vaginal bleeding the medical problem presented to them. namely: duty. Given that the patient died after the D&C. the expert witnesses presented by the respondents: DR. and proximate causation.Breach of duty occurs when the physician fails to comply with these professional standards. that has caused bodily harm to or the death of a patient.

Mercado.Q: So are you trying to tell the Court that D&C can be a diagnostic treatment? A: Yes.[21] Dr. her diabetic condition should have been . objected with respect to the time the D&C operation should have been conducted in Teresitas case. He opined that given the blood sugar level of Teresita. however. sir. Any doctor knows this.

that it is inappropriate? A: The timing of [when] the D&C [was] done.[27] When a patient exhibits symptoms typical of a particular disease. frequent urination. and thirst all of which are classic symptoms of diabetes. 1987 when the laboratory result revealed Teresitas increased blood sugar level. the petitioner spouses were duly advised that the patient was experiencing general body weakness. and blood sugar was 10. as early as April 17. the petitioner spouses did not wait for the full medical laboratory results before proceeding with the D&C. these symptoms should. alert the physician of the possibility that the patient may be afflicted with the suspected disease: [Expert testimony for the plaintiff showed that] tests should have been ordered . your opinion.[22] The petitioner spouses countered that.[24] Furthermore. loss of appetite. [there is] spillage in the urine. based on the record. Teresita was already suspected to be suffering from diabetes.[23] there were other factors that might have caused Teresitas blood sugar to rise such as the taking of blood samples during lunchtime and while patient was being given intra-venous dextrose. at the very least. in my personal opinion.67. The petitioner spouses contentions. [25]This suspicion again arose right before the D&C operation on April 28. at the time of the operation. they claim that their principal concern was to determine the cause of and to stop the vaginal bleeding.67mmol/l did not necessarily mean that she was a diabetic considering that this was random blood sugar. a fact that was never considered in the courts below. in our view. that D&C should be postponed a day or two. xxx xxx xxx COURT: In other words. Q: Does it indicate sickness? A: 80 to 95% it means diabetes mellitus.addressed first: Q: Why do you consider the time of performance of the D&C not appropriate? A: Because I have read the record and I have seen the urinalysis. there was nothing to indicate that Teresita was afflicted with diabetes: a blood sugar level of 10. The blood sugar was 10. miss several points.[26] Unfortunately.67 Q: What is the significance of the spillage in the urine? A: It is a sign that the blood sugar is very high. 1987. Second. the operation conducted on the patient. First.

an obstetrician and gynecologist. Mendoza opined that the attending physician should have postponed the 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. during.[34] He went on to state that he scheduled the D&C operation without conducting any physical examination on the patient. Delfin Tan (Dr. we choose not to rely on the assertions of the petitioner spouses that there was profuse bleeding. not only because the statements were self-serving. This was corroborated by Dr. and that failure to recognize the existence of diabetes constitutes negligence. Taking into account Teresitas high blood sugar.[33] but later on said that he did not see it and relied only on Teresitas statement that she was bleeding. Fredelicto testified earlier that on April 28. that disability must be taken into account so long as it is or should have been known to the physician. The likely story is that although Teresita experienced vaginal bleeding on April 28. Tan). the petitioner spouses cannot claim that their principal concern was the vaginal bleeding and should not therefore be held accountable for complications coming from other sources. he personally saw the bleeding. This is a very narrow and self-serving view that even reflects on their competence.immediately on admission to the hospital in view of the symptoms presented.[30] Dr. Taken together. If a patient suffers from some disability that increases the magnitude of risk to him.[32] Indeed.[28] Third.[29] And when the patient is exposed to an increased risk. the expert witnesses 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. we find that reasonable prudence would have shown that diabetes and its complications were foreseeable harm that should have been taken into consideration by the petitioner spouses. In this case. but also because the petitioner spouses were inconsistent in their testimonies. it is incumbent upon the physician to take commensurate and adequate precautions. and after the operation. Dr. it . who stated that the patients diabetes should have been managed by an internist prior to. vaginal bleeding is only rarely so heavy and life-threatening that urgent first-aid measures are required.[31] Apart from bleeding as a complication of pregnancy.

The claim that there was profuse vaginal bleeding although this was not reflected in the medical records strikes us as odd since the main complaint is vaginal bleeding. In this process. and up-to-date. the physician must conduct a thorough preoperative evaluation of the patient in order to adequately prepare her for the operation and minimize possible risks and complications. but rather to identify and quantify comorbidity that may impact on the operative outcome. not an emergency case. Optimal record-keeping includes all patient inter-actions.[37] Thus. The records should always be clear.[38] The aim of pre-operative evaluation is not to screen broadly for undiagnosed disease.] Significantly. communication between the surgeons and the consultants is essential to define realistic goals for this optimization process and to expedite surgical management. This evaluation is driven by findings on history and physical examination suggestive of organ system dysfunctionThe goal is to uncover problem areas that may require further investigation or be amenable to preoperative optimization. Tan[35] and Dr. The internist is responsible for generating a comprehensive evaluation of all medical problems during the pre-operative evaluation. In an elective procedure. Because the D&C was merely an elective procedure. That the D&C operation was conducted principally to diagnose the cause of the vaginal bleeding further leads us to conclude that it was merely an elective procedure. consultation with an internist or medical specialist may be required to facilitate the work-up and direct management. [39] [Emphasis supplied. the evidence strongly suggests that the pre-operative evaluation was less than complete as the laboratory results were fully reported only on the day following the D&C operation. Felicisima only secured a telephone report of the preliminary laboratory result prior to the D&C. Dr. its maintenance is considered a priority in hospital practice. objective. a medical record that does not indicate profuse medical bleeding speaks loudly and clearly of what it does not contain. Mendoza[36] both testified that the medical records of Teresita failed to indicate that there was profuse vaginal bleeding.Dr. The . This preliminary report did not include the 3+ status of sugar in the patients urine[40] a result highly confirmatory of diabetes. the patients uncontrolled hyperglycemia presented a far greater risk than her on-and-off vaginal bleeding. A medical record is the only document that maintains a long-term transcription of patient care and as such.was not sufficiently profuse to necessitate an immediate emergency D&C operation. If the preoperative evaluation uncovers significant comorbidity or evidence of poor control of an underlying disease process.

Tan testified. As Dr. The net effect is to lower blood glucose levels. Mercado. In this case. Insulin was only administered two days after the operation. the petitioner spouses still did not recognize any post-operative concern that would require the monitoring of Teresitas condition in the hospital. Injury and Causation . but also immediately after.[44] The prudent move is to address the patients hyperglycemic state immediately and promptly before any other procedure is undertaken. as the petitioner spouses expressly admitted. Interestingly. she was advised that she could be discharged a day after the operation and that her recovery could take place at home.[42] According to Dr. the possibility was casually ignored even in the post-operative evaluation of the patient.[41]Elective surgery in people with uncontrolled diabetes should preferably be scheduled after acceptable glycemic control has been achieved. Whether this breach of duty was the proximate cause of Teresitas death is a matter we shall next determine. was limited to the complaint of vaginal bleeding. This advice implied that a day after the operation and even after the complete laboratory results were submitted. while the ultrasound test confirmed that Teresita had a myoma in her uterus. this is done by administering insulin on the patient. Despite the possibility that Teresita was afflicted with diabetes.[43] The management approach in this kind of patients always includes insulin therapy in combination with dextrose and potassium infusion. the patients hyperglycemic condition should have been managed not only before and during the operation. to comply with their duty to observe the standard of care to be given to hyperglycemic/diabetic patients undergoing surgery. as medical professionals. point only to one conclusion that the petitioner spouses failed.presence of hyperglycemia in a surgical patient is associated with poor clinical outcomes. the concern. Insulin xxx promotes glucose uptake by the muscle and fat cells while decreasing glucose production by the liver xxx. The above facts. there was no evidence that insulin was administered on Teresita prior to or during the D&C operation. and aggressive glycemic control positively impacts on morbidity and mortality.

and the result is high levels of waste products (called ketones) in the blood and urine (called diabetic ketoacidiosis. When this happens over several days. Dr.As previously mentioned. Thus.[49] This was apparently what happened in Teresitas case. could lead to death. is a factor that can aggravate diabetes.0mmol/l. A verdict in a malpractice action cannot be based on speculation or conjecture. reacts by secreting hormones which are counter-regulatory. the body uses its own fat to produce energy. between the D&C and death was the diabetic complication that could have been prevented with the observance of standard medical precautions. Jorge. after she had been referred to the internist Dr. [48] Medical literature further explains that if the blood sugar has become very high.[45] the plaintiff must plead and prove not only that he had been injured and defendant has been at fault. especially the autonomic system. if unchecked. The D&C operation and Teresitas death due to aggravated diabetic condition is therefore sufficiently established. ketoacidocis Underlying cause: Diabetes Mellitus II Other significant conditions contributing to death: Renal Failure Acute[47] Stress. the patient becomes comatose (diabetic coma).[46] The respondents contend that unnecessarily subjecting Teresita to a D&C operation without adequately preparing her. Mendoza explained how surgical stress can aggravate the patients hyperglycemia: when stress occurs. The trial court and the appellate court pinned the liability for Teresitas death on both the . a medical emergency with a significant mortality). laboratory test showed that her blood sugar level shot up to 14. she can have prolonged hyperglycemia which. way above the normal blood sugar range. but also that the defendants fault caused the injury. whether physical or emotional. The death certificate of Teresita lists down the following causes of death: Immediate cause: Cardiorespiratory arrest Antecedent cause: Septicemic shock. in fact. aggravated her hyperglycemic state and caused her untimely demise. a D&C operation is a form of physical stress. the critical and clinching factor in a medical negligence case is proof of the causal connection between the negligence which the evidence established and the plaintiffs injuries. the diabetics body. Causation must be proven within a reasonable medical probability based upon competent expert testimony.

Q: So it was you and your wife who made the evaluation when it was phoned in? A: Yes. anyway. sir. despite the patients complaints and his own suspicions.[51] he should have likewise refrained from making a decision to proceed with the D&C operation since he was niether an obstetrician nor a gynecologist. The latter point comes out clearly from the following exchange during the trial: Q: On what aspect did you and your wife consult [with] each other? A: We discussed on the finding of the laboratory [results] because the hemoglobin was below normal. Rather. that diabetes was a risk factor that should be guarded against. sir. [Emphasis supplied.petitioner spouses and this Court finds no reason to rule otherwise. the blood sugar was elevated. and his participation in the imprudent decision to proceed with the D&C operation despite his early suspicion and the confirmatory early laboratory results. Jorge). However. so that we have to evaluate these laboratory results what it means. These findings lead us to the conclusion that the decision to proceed with the D&C operation. it was his failure from the very start to identify and confirm. not being an internist or a diabetologist (for which reason he referred Teresita to Dr. Fredelictos negligence is not solely the act of ordering an on call D&C operation when he was mainly an anaesthesiologist who had made a very cursory examination of the patients vaginal bleeding complaint. we clarify that Dr. before performing D&C ask your opinion whether or not she can proceed? A: Yes. Fredelicto believed himself to be incompetent to treat the diabetes. she asked me whether we can do D&C based on my experience.] [50] If Dr. was contrary to the standards observed by the medical . Q: And your answer was in the positive notwithstanding the elevation of blood sugar? A: Yes. notwithstanding Teresitas hyperglycemia and without adequately preparing her for the procedure. it was both our disposition to do the D&C. Q: Did your wife.

which decision the CA affirmed. This is a question of law that the CA missed in its decision and which we now decide in the respondents favor. The RTC found the hospital jointly and severally liable with the petitioner spouses. stands.000. Deviation from this standard amounted to a breach of duty which resulted in the patients death. the respondent heirs of Teresita are likewise entitled to P50. In a Resolution dated August 28. Since UDMCs appeal has been denied and they are not parties to this case. liability must attach to the petitioner spouses. Thus. Liability of the Hospital In the proceedings below. Due to this negligent conduct.000. The same article allows the recovery of moral damages in case of death caused by a quasi-delict and enumerates the spouse. Award of Damages Both the trial and the appellate court awarded actual damages as compensation for the pecuniary loss the respondents suffered. legitimate or illegitimate ascendants or . the RTCs decision.00 representing the hospital expenses the patient incurred.profession. UDMC was the spouses Flores co-defendant. 2006. Consequently. as affirmed by the CA. The loss was presented in terms of the hospital bills and expenses the respondents incurred on account of Teresitas confinement and death.[53] even though there may have been mitigating circumstances xxx. The settled rule is that a plaintiff is entitled to be compensated for proven pecuniary loss. which states that the amount of damages for death caused by a xxx quasi-delict shall be at least three thousand pesos. this Court however denied UDMCs petition for review on certiorari.[52] This proof the respondents successfully presented. we affirm the award of actual damages of P36. In addition to the award for actual damages. we find it unnecessary to delve on the matter.00 as death indemnity pursuant to Article 2206 of the Civil Code.

the grant of attorneys fees is legally in order. [56] We therefore reverse the CA decision deleting these awards. moral damages of P400.000.00 as death indemnity and by reversing the deletion of the award of attorneys fees and costs and restoring the award of P100. the following awards shall be paid to the family of the late Teresita . With the award of exemplary damages.00 by way ofmoral damages to the respondents.00. and exemplary damages of P100.00 as attorneys fees taking into consideration the legal route this case has taken. that is.000. WHEREFORE.R. we AFFIRM the Decision of the CA dated June 20. We similarly affirm the grant of exemplary damages. and grant the respondents the amount of P100.descendants as the persons entitled thereto.000. We likewise AFFIRM the awards of actual and compensatory damages of P36. CV No. wounded feelings which the respondents herein must have surely felt with the unexpected loss of their daughter.000.[55] We therefore affirm the CAs award as an example to the medical profession and to stress that the public good requires stricter measures to avoid the repetition of the type of medical malpractice that happened in this case.[54] Because of the petitioner spouses negligence in subjecting Teresita to an operation without first recognizing and addressing her diabetic condition. Costs of litigation are adjudged against petitioner spouses. for the mental anguish.000.00 as attorneys fees. 2003 in CA G. Moral damages are designed to compensate the claimant for the injury suffered. Exemplary damages are imposed by way of example or correction for the public good.00.000. We affirm the appellate courts award of P400. We MODIFY the CA Decision by additionally granting an award of P50.000. Public policy requires such imposition to suppress the wanton acts of an offender.000. the appellate court awarded exemplary damages to the respondents in the amount of P100.00. serious anxiety.00. To summarize. 63234 finding petitioner spouses liable for negligent medical practice.

C.000. VELASCO. RUBI LI. NACHURA. . CARPIO MORALES. PEREZ.. The sum of P100. JR.000.000.. The sum of P50. MENDOZA.000. SPOUSES REYNALDO and LINAPromulgated: SOLIMAN. The sum of P36.00 by way of actual and compensatory damages. Petitioner. CARPIO. EN BANC DR.. The sum of P100.versus - G. 5. .00 by way of attorneys fees. and SERENO.00 by way of moral damages. The sum of P400. VILLARAMA. 165279 Present: CORONA. SO ORDERED. PERALTA.000. No.Pineda: 1.R. 2. 3.00 by way of death indemnity. BRION. 4. Respondents.00 by way of exemplary damages. DEL CASTILLO. and 6.J. LEONARDO-DE CASTRO.* ABAD. 2011 deceased Angelica Soliman. JR. Costs. BERSAMIN. JJ. as parents/heirs of June 7.

.. Tamayo referred Angelica to another doctor at SLMC.. a medical oncologist.... 2004 as well as the Resolution[2] dated September 1. 2004 of the Court of Appeals (CA) in CA-G. Tamayo. Lukes Medical Center (SLMC).[5] . Rubi Li. The factual antecedents: On July 7. Dr.. herein petitioner Dr.. respondents 11-year old daughter.. respondents brought the cadaver of Angelica to the Philippine National Police (PNP) Crime Laboratory at Camp Crame for post-mortem examination. and hence minimize the chances of recurrence and prevent the disease from spreading to other parts of the patients body (metastasis). Jaime Tamayo in order to remove the tumor. 8904. CV No.....Results showed that Angelica was suffering from osteosarcoma...[4] a high-grade (highly malignant) cancer of the bone which usually afflicts teenage children... However.... Angelica was admitted to SLMC.. underwent a biopsy of the mass located in her lower extremity at the St.. As adjuvant treatment to eliminate any remaining cancer cells. just eleven (11) days after the (intravenous) administration of the first cycle of the chemotherapy regimen....-x DECISION VILLARAMA. Angelicas right leg was amputated by Dr. JR.. she died on September 1. Branch 8 in Civil Case No..... The Medico-Legal Report issued by said institution indicated the cause of death as Hypovolemic shock secondary to multiple organ hemorrhages and Disseminated Intravascular Coagulation...Following this diagnosis and as primary intervention. osteoblastic type.: Challenged in this petition for review on certiorari is the Decision[1] dated June 15. chemotherapy was suggested by Dr..... 1993... Because SLMC refused to release a death certificate without full payment of their hospital bill. J.... 1993..... 1997 of the Regional Trial Court of Legazpi City.. On August 18..x...R. 1993.. 58013 which modified the Decision[3] dated September 5. Angelica Soliman.

She claimed that what happened to Angelica can be attributed to malignant tumor cells possibly left behind after surgery. In her answer. petitioner mentioned only slight vomiting. 1994. hair loss and weakness (Magsusuka ng kaunti. health and welfare by their careless administration of the chemotherapy drugs. the Certificate of Death[6] issued by SLMC stated the cause of death as follows: Immediate cause : a. Osteosarcoma. Such infection becomes uncontrollable and triggers a chain of events (sepsis or septicemia) that may lead to bleeding in the form of Disseminated Intravascular Coagulation (DIC). Further. Dr. Few as they may be. Leo Marbella. Status Post AKA Antecedent cause : b. Manghihina). (above knee amputation) Underlying cause : c. Respondents thus claimed that they would not have given their consent to chemotherapy had petitioner not falsely assured them of its side effects. Malulugas ang buhok. Respondents charged them with negligence and disregard of Angelicas safety. Status Post Chemotherapy On February 21. Arriete and SLMC. . Mr.[8] petitioner denied having been negligent in administering the chemotherapy drugs to Angelica and asserted that she had fully explained to respondents how the chemotherapy will affect not only the cancer cells but also the patients normal body parts. 95% ang healing) and when asked regarding the side effects.On the other hand. including the lowering of white and red blood cells and platelets. these have the capacity to compete for nutrients such that the body becomes so weak structurally (cachexia) and functionally in the form of lower resistance of the body to combat infection. a certain Dr. it was specifically averred that petitioner assured the respondents that Angelica would recover in view of 95% chance of healing with chemotherapy (Magiging normal na ang anak nyo basta ma-chemo. Jose Ledesma. respondents filed a damage suit[7] against petitioner. as what the autopsy report showed in the case of Angelica. which bleeding led to hypovolemic shock that caused Angelicas untimely demise. their failure to observe the essential precautions in detecting early the symptoms of fatal blood platelet decrease and stopping early on the chemotherapy.

00 a year from his jewelry and watch repairing business. (6) damage to the heart and kidneys. twice at her clinic and the fourth time when Angelicas mother called her through long distance.[10] This was disputed by respondents who countered that petitioner gave them assurance that there is 95% chance of healing for Angelica if she undergoes chemotherapy and that the only side effects were nausea. and that adjuvant chemotherapy is needed to clean out the small lesions in order to lessen the chance of the cancer to recur. (5) possible sterility due to the effects on Angelicas ovary. however. On August 18. Respondents were apprehensive due to financial constraints as Reynaldo earns only from P70. red blood cells [RBC] and platelets. 1993. vomiting and hair loss.000. (4) low count of white blood cells [WBC].Since the medical records of Angelica were not produced in court. The following chronology of events was gathered: On July 23. (3) loss of appetite. She actually talked with respondents four times. Petitioner claimed that she explained to respondents that even when a tumor is removed. principally the declarations of petitioner and respondents themselves. SLMC discharged Angelica. respondents brought Angelica to SLMC for chemotherapy.[11] Those were the only side-effects of chemotherapy treatment mentioned by petitioner. the trial and appellate courts had to rely on testimonial evidence. petitioner saw the respondents at the hospital after Angelicas surgery and discussed with them Angelicas condition. Petitioner told respondents that Angelica should be given two to three weeks to recover from the operation before starting chemotherapy. once at the hospital after the surgery. She did not give the respondents any assurance that chemotherapy will cure Angelicas cancer. 1993. During these consultations with respondents. (2) nausea and vomiting. she explained the following side effects of chemotherapy treatment to respondents: (1) falling hair. and (7) darkening of the skin especially when exposed to sunlight.000.[9] Petitioner. with instruction from petitioner that she be readmitted after two or three weeks for the chemotherapy.[12] On July 27. 1993. .00 to P150. assured them not to worry about her professional fee and told them to just save up for the medicines to be used. there are still small lesions undetectable to the naked eye.

Okay.[23] On the third day of chemotherapy.[26] Petitioner countered that there was no record of blackening of stools but only an episode of loose bowel movement (LBM). Petitioner supposedly replied: Dapat 15 Cosmegen pa iyan. but she merely quipped. not convulsion or epileptic attack. Victoria Abesamis on the matter. Epekto ng gamot. but petitioner dismissed it again as merely the effect of medicines. petitioner began administering three chemotherapy drugs Cisplatin. respondents asked petitioners permission to bring their child home. August 19. Angelica had difficulty breathing and was thus provided with oxygen inhalation apparatus. at around ten oclock in the morning. lets observe.Wala yan. Grace Arriete. Later in the evening. [13] Petitioner proceeded with the chemotherapy by first administering hydration fluids to Angelica. August 21. she entertained the possibility that Angelica also had systemic lupus and consulted Dr. Petitioner was supposedly assisted by her trainees Dr. August 20. Marbella denied having any participation in administering the said chemotherapy drugs. nor did she notice any difficulty in the childs breathing. upon seeing that their child could not anymore bear the pain.[15] Doxorubicin[16] and Cosmegen[17] intravenously. respondents noticed reddish discoloration on Angelicas face. bigyan uli ng chemo.bringing with them the results of the laboratory tests requested by petitioner: Angelicas chest x-ray. Dr.[21] They asked petitioner about it. She claimed that Angelica merely complained of nausea and was given ice chips.[20] On the second day of chemotherapy. . Leo Marbella[18] and Dr. ultrasound of the liver. the reddish discoloration on Angelicas face had extended to her neck. This time.[19] In his testimony.[14] The following day. creatinine and complete liver function tests. 1993. respondents pleaded with petitioner to stop the chemotherapy.[25] On August 22.[24] Petitioner testified that she did not see any discoloration on Angelicas face. If pwede na. At that moment. At this point. Petitioner also testified that what Angelica complained of was carpo-pedal spasm. Angelica passed black stool and reddish urine.[22] Petitioner recalled noticing the skin rashes on the nose and cheek area of Angelica.

Petitioner prescribed Solucortef. respondents claimed that Angelica still suffered from convulsions. consisting of packed red blood cells.[33] By August 26. They also noticed that she had a fever and had difficulty breathing. About four to eight bags of blood. Bagsak ang platelets ng anak mo. Angelica developed difficulty in breathing and had fever. Angelica was bleeding through the mouth. August 24.[32] to combat any infection on the childs body. and infused calcium gluconate on the patient at a stat dose. She then requested for an electrocardiogram analysis. She verified that at around 4:50 that afternoon. not convulsions. her convulsions returned and she also had LBM.[28] However. fresh . Four units of platelet concentrates were then transfused to Angelica.[29] The next day. She further ordered that Angelica be given Bactrim.Takehome medicines were also prescribed for Angelica. Considering that Angelicas fever was high and her white blood cell count was low.[27] The following day. August 23.[31] a synthetic antibacterial combination drug. petitioner prescribed Leucomax. the spasm and numbness subsided. but respondents can see her anytime if any immediate problem arises. Angelica was given oxygen and administration of calcium continued. petitioner requested for a repeat serum calcium determination and explained to respondents that the chemotherapy will be temporarily stopped while she observes Angelicas muscle twitching and serum calcium level. petitioner yielded to respondents request to take Angelica home. with instructions to respondents that the serum calcium test will have to be repeated after seven days. Petitioner told respondents that she will see Angelica again after two weeks. Angelica remained in confinement because while still in the premises of SLMC. [30]Petitioner insisted it was carpo-pedal spasm. petitioner replied. When Angelica was given calcium gluconate. Respondents also saw blood on her anus and urine. When Lina asked petitioner what was happening to her daughter.as respondents call it (petitioner described it in the vernacular as naninigas ang kamay at paa). She then requested for a serum calcium determination and stopped the chemotherapy. But prior to discharging Angelica.

respondents claimed that Angelica became hysterical.whole blood. Angelica continued bleeding. were transfused to Angelica. The next day. the attending physician was Dr. Abesamis who also told him to pray for his daughter. Petitioner also denied that there were gadgets attached to Angelica at that time. there were tears in her eyes and she kept turning her head.[36] At this time. Marbella who was shaking his head saying that Angelicas platelets were down and respondents should pray for their daughter. Lina asked for a doctor but the latter could not answer her anymore. Reynaldo claimed that he was introduced to a pediatrician who took over his daughters case. Angelica requested for an electric fan as she was in pain. which petitioner likewise denied.[35] She was also transferred to the intensive care unit to avoid infection. saying Ayaw ko na. Reynaldo claimed that Angelica already experienced difficulty in urinating and her bowel consisted of blood-like fluid. For two days (August 27 to 28). Angelica was given more platelet concentrate and fresh whole blood. Angelica developed ulcers in her mouth. Hospital staff attempted to take blood samples from Angelica but were . vomited blood and her body turned black. Respondents claimed that Angelica passed about half a liter of blood through her anus at around seven oclock that evening. On August 30. Part of Angelicas skin was also noted to be shredding by just rubbing cotton on it. Thereafter. Dr.Petitioner told Angelica not to remove the endotracheal tube because this may induce further bleeding.Observing her daughter to be at the point of death. Angelica was so restless she removed those gadgets attached to her.[34] On August 29. A nurse was posted inside Angelicas room to assist her breathing and at one point they had to revive Angelica by pumping her chest. or platelet concentrate. Angelica continued to have difficulty in her breathing and blood was being suctioned from her stomach. which petitioner said were blood clots that should not be removed. An aspiration of the nasogastric tube inserted to Angelica also revealed a bloody content. which petitioner claimed improved her condition. Angelica continued bleeding. but petitioner claimed it was lesser in amount and in frequency. She was restless as endotracheal and nasogastric tubes were inserted into her weakened body.

due to accumulation of fluids.[37] By petitioners own account. At three oclock in the morning of September 1. a priest came and they prayed before Angelica expired. (5) kidneys showed appearance of facial shock on account of hemorrhages. was septicemia. Jesusa Nieves-Vergara. Petitioner noted though that Angelicas skin was indeed sloughing off.unsuccessful because they could not even locate her vein. Angelica asked for a fruit but when it was given to her. which is not normal. Melinda Vergara Balmaceda who is a Medical Specialist employed at the Department of Health (DOH) Operations and Management Services. the esophagus. Dr. At this time. and Dr. Reynaldo claimed that petitioner acted arrogantly and called him names. Angelica died. [42] While he was seeking the release of Angelicas cadaver from SLMC. Testifying on the findings stated in her medico-legal report.[41] Petitioner attributed this to the patients poor defense mechanism brought about by the cancer itself. (4) lungs were heavy with bleeding at the back and lower portion. Reynaldo claimed he could not find either petitioner or Dr. That night.[43] Respondents also presented as witnesses Dr. Angelica became hysterical and started removing those gadgets attached to her.[39] On September 1. Angelica was merely irritable that day (August 31). which caused Angelicas other organs to fail. she only smelled it. and was due to hemorrhagic shock secondary to bleeding.[40]The cause of death. He was asked to sign a promissory note as he did not have cash to pay the hospital bill. exactly two weeks after being admitted at SLMC for chemotherapy. Medico-Legal Officer of the PNP-Crime Laboratory who conducted the autopsy on Angelicas cadaver. according to petitioner. Petitioner finally came back and supposedly told respondents that there was malfunction or bogged-down machine. Vergara noted the following: (1) there were fluids recovered from the abdominal cavity. or overwhelming infection. and (6) . (4) yellowish discoloration of the liver. (3) bleeding at the upper portion of and areas adjacent to.[38] She stressed that at 9:30 in the evening. (2) there was hemorrhage at the left side of the heart. Marbella. Angelica pulled out her endotracheal tube.

Balmaceda stressed that the patient or relatives must be informed of all known side effects based on studies and observations. Thus. Usually. The mortality rate of osteosarcoma at the time of modern chemotherapy and early diagnosis still remains at 80% to 90%. or spread of the cancer to other vital organs like the liver.[45] Dr. Jaime Tamayo. The modes of therapy available are the removal of the primary source of the cancerous growth and then the residual cancer cells or metastasis should be treated with chemotherapy. Dr. Dr. He explained that in case of malignant tumors. Dr. causing systemic complications. the orthopaedic surgeon who operated on Angelicas lower extremity. The physician thus bases his assurance to the patient on his personal assessment of the patients condition and his knowledge of the general effects of the agents or procedure that will be allowed on the patient. the hospital staff could have detected it. even if such will aggravate the patients condition. This oncologist supposedly said that if the victim already had DIC prior to the chemotherapy. there is no guarantee that the ablation or removal of the amputated part will completely cure the cancer.[44] On her part. The witness conceded that the victim will also die of osteosarcoma even with amputation or chemotherapy. before securing the consent of the patient or his relatives to such procedure or therapy. surgery is not enough. which caused platelet reduction resulting to bleeding sufficient to cause the victims death. The time lapse for the production of DIC in the case of Angelica (from the time of diagnosis of sarcoma) was too short. deaths occur from metastasis. Vergara admitted that she is not a pathologist but her statements were based on the opinion of an oncologist whom she had interviewed. All these were the end result of hypovolemic shock secondary to multiple organ hemorrhages and disseminated intravascular coagulation.reddishness on external surface of the spleen. Dr. considering the survival rate of about 3 years. Tamayo further explained that patients with osteosarcoma have poor defense mechanism due to the cancer cells in the blood . but in this case Angelicas death was not caused by osteosarcoma. Vergara opined that this can be attributed to the chemical agents in the drugs given to the victim. Dr. testified for the defendants. Balmaceda declared that it is the physicians duty to inform and explain to the patient or his relatives every known side effect of the procedure or therapeutic agents to be administered.

Cancer cells in the blood cannot be seen by the naked eye nor detected through bone scan. The appellate court stressed that since the respondents have been told of only three side effects of chemotherapy. Tamayo who testified that he considered petitioner one of the most proficient in the treatment of cancer and that the patient in this case was afflicted with a very aggressive type of cancer necessitating chemotherapy as adjuvant treatment. It cited the testimony of Dr. the patient developed sepsis which caused her death).[46] In dismissing the complaint. bleeding. infections and .[47] the trial court declared that petitioner has taken the necessary precaution against the adverse effect of chemotherapy on the patient. Dr.43. they readily consented thereto. sepsis. Tamayo stated that of the more than 50 child patients who had osteogenic sarcoma he had handled. it will cause the demise of the patient should there be no early intervention (in this case. the trial court held that petitioner was not liable for damages as she observed the best known procedures and employed her highest skill and knowledge in the administration of chemotherapy drugs on Angelica but despite all efforts said patient died. found that petitioner as her attending physician failed to fully explain to the respondents all the known side effects of chemotherapy. adding that a wrong decision is not by itself negligence. Respondents were ordered to pay their unpaid hospital bill in the amount of P139.064. Smith.such as carpopedal spasm. he had previously explained to her parents that after the surgical procedure. he thought that probably all of them died within six months from amputation because he did not see them anymore after follow-up. Had petitioner made known to respondents those other side effects which gravely affected their child -. Considering that this type of cancer is very aggressive and will metastasize early. On cross-examination. decrease in the blood platelet count. He referred the patient to petitioner because he felt that petitioner is a competent oncologist.[48] Respondents appealed to the CA which. Using the standard of negligence laid down in Picart v. chemotherapy is imperative so that metastasis of these cancer cells will hopefully be addressed. while concurring with the trial courts finding that there was no negligence committed by the petitioner in the administration of chemotherapy treatment to Angelica.stream. it is either they died or had seen another doctor. In the case of Angelica.

000. Rubi Li negligent which would entitle plaintiffs-appellants to their claim for damages. 2. 3.eventual death -.respondents could have decided differently or adopted a different course of action which could have delayed or prevented the early death of their child. Rubi Li that there were only three possible side-effects of the treatment. Petitioner assails the CA in finding her guilty of negligence in not explaining to the respondents all the possible side effects of the chemotherapy on their child.) Petitioner filed a motion for partial reconsideration which the appellate court denied. 4. Surely.828. Rubi Li is ordered to pay the plaintiffs-appellants the following amounts: 1. Accordingly. this petition. Attorneys fee of P30.43. those unexpected side-effects culminating in the loss of a love[d] one caused the appellants so much trouble. Actual damages of P139. the assailed decision is hereby modified to the extent that defendant-appellee Dr. Moral damages of P200. However.[49] (Emphasis supplied. Rubi Li. the instant appeal is hereby GRANTED. and in . On this point therefore.00 for funeral expenses. Rubi Lis representation that the deceased would have a strong chance of survival after chemotherapy and also because of the representation of appellee Dr. The appellants were clearly and totally unaware of these other side-effects which manifested only during the chemotherapy treatment. Hence. plus P9. The attending physician recommended that she undergo chemotherapy treatment after surgery in order to increase her chances of survival.064.00. xxxx WHEREFORE. This was shown by the fact that every time a problem would take place regarding Angelicas condition (like an unexpected side-effect manifesting itself). they would immediately seek explanation from Dr.00. SO ORDERED.000. Exemplary damages of P50. pain and suffering.00. [w]e find defendant-appellee Dr.000. Appellants consented to the chemotherapy treatment because they believed in Dr. all sorts of painful side-effects resulted from the treatment including the premature death of Angelica. The CA thus declared: Plaintiffs-appellants child was suffering from a malignant disease.

the patient might have died the next day because of massive infection. These are obviously dependent on too many known. general health and body constitution would respond to the treatment. constantly and closely monitored during the treatment. moral and exemplary damages and attorneys fees. or into her kidneys that she would have to undergo dialysis. Petitioner emphasized that she was not negligent in the pre-chemotherapy procedures and in the administration of chemotherapy treatment to Angelica. other medicines and supportive treatment. Petitioner then points to some probable consequences if Angelica had not undergone chemotherapy. thus requiring that Angelica be.While the theoretical side effects of chemotherapy were explained by her to the respondents. as these should be known to a competent doctor. Petitioner asserts that she did everything within her professional competence to attend to the medical needs of Angelica. Department of Medicine of SLMC. respondents could have spent as much because of these complications. Citing numerous trainings. distinctions and achievements in her field and her current position as co-director for clinical affairs of the Medical Oncology. unknown and immeasurable variables. including death. petitioner cannot possibly predict how a particular patients genetic make-up. She explains that the response rate to chemotherapy of patients with osteosarcoma is high. Indeed. The patient would have been deprived of the chance to survive the . or the cancer cells might have spread to the brain and brought the patient into a coma. Thus. As to the cause of death. or into the lungs that the patient could have been hooked to a respirator. without chemotherapy. so much so that survival rate is favorable to the patient. petitioner insists that Angelica did not die of platelet depletion but of sepsis which is a complication of the cancer itself.holding her liable for actual. she cannot be charged with negligence in not informing the respondents all the side effects of chemotherapy or in the pre-treatment procedures done on Angelica. petitioner argues that it was foolhardy to imagine her to be allknowing/omnipotent. state of mind. as she was. Sepsis itself leads to bleeding and death. petitioner contends that in the absence of any clear showing or proof. On her supposed non-disclosure of all possible side effects of chemotherapy.

[51] This Court has recognized that medical negligence cases are best proved by opinions of expert witnesses belonging in the same general neighborhood and in the same general line of practice as defendant physician or surgeon. despite the absence of finding that petitioner was negligent in administering the said treatment. In order to successfully pursue such a claim. hence the indispensability of expert testimonies.[52] In this case. in most cases a physician. knowledge and professional competence in failing to observe the standard of care in her line of practice was the proximate cause of the patients . a patient must prove that a health care provider.[50] The issue to be resolved is whether the petitioner can be held liable for failure to fully disclose serious side effects to the parents of the child patient who died while undergoing chemotherapy.ailment. not being oncologists or cancer specialists. of any hope for life and her quality of life surely compromised. The petition is meritorious. The type of lawsuit which has been called medical malpractice or. Since she had not been shown to be at fault. were not qualified to give expert opinion as to whether petitioners lack of skill. more appropriately. The deference of courts to the expert opinion of qualified physicians stems from the formers realization that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating. Vergara and Balmaceda. both the trial and appellate courts concurred in finding that the alleged negligence of petitioner in the administration of chemotherapy drugs to respondents child was not proven considering that Drs. and that that failure or action caused injury to the patient. petitioner maintains that the CA erred in holding her liable for the damages suffered by the respondents. 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. or that he or she did something that a reasonably prudent provider would not have done. medical negligence. either failed to do something which a reasonably prudent health care provider would have done.

may intelligently exercise his judgment by reasonably balancing the probable risks against the probable benefits. doctors were charged with the tort of battery (i. exercising ordinary care for his own welfare.e. so that a patient.[57] The scope of disclosure is premised on the fact that patients ordinarily are persons unlearned in the medical sciences. Justice Benjamin Cardozos oft-quoted opinion upheld the basic right of a patient to give consent to any medical procedure or treatment: Every human being of adult years and sound mind has a right to determine what shall be done with his own body. commits an assault. the CA found petitioner liable for her failure to inform the respondents on all possible side effects of chemotherapy before securing their consent to the said treatment. As early as 1767. In the United States. an unauthorized physical contact with a patient) if they had not gained the consent of their patients prior to performing a surgery or procedure. respect for the patients right of self-determination on particular therapy demands a standard set by law for physicians rather than one which physicians may or may not impose upon themselves. Proficiency in diagnosis and therapy is not the full measure of a physicians responsibility. respondents case was not at all helped by the non-production of medical records by the hospital (only the biopsy result and medical bills were submitted to the court). Spence[56] the court observed that the duty to disclose should not be limited to medical usage as to arrogate the decision on revelation to the physician alone. Nevertheless. in Canterbury v. It is also his . the seminal case was Schoendorff v. The doctrine of informed consent within the context of physician-patient relationships goes far back into English common law.[54] From a purely ethical norm. for which he is liable in damages. and faced with a choice of undergoing the proposed treatment. Thus. or alternative treatment. and a surgeon who performs an operation without his patients consent. Society of New York Hospital[53] which involved unwanted treatment performed by a doctor.[55] Subsequently.death. or none at all. Furthermore. informed consent evolved into a general principle of law that a physician has a duty to disclose 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..

the goals expectably to be achieved. there must be a causal relationship between the physicians failure to divulge and damage to the patient. expectable effect of risk disclosure on the decision. and that need is whatever information is material to the decision. the patients reliance upon the physician is a trust of the kind which traditionally has exacted obligations beyond those associated with armslength transactions. is without legal consequence. However. Cited as exceptions to the rule that the patient should not be denied the opportunity to weigh the risks of surgery or treatment are emergency cases where it is evident he cannot evaluate data.And. the therapy alternatives open to him. Cobbs v. Grant[61] deemed it as integral part of physicians overall obligation to patient. for otherwise the omission. as in malpractice actions generally. or to the reasonably.[59] As to the issue of demonstrating what risks are considered material necessitating disclosure. The test therefore for determining whether a potential peril must be divulged is its materiality to the patients decision. the disclosure rule only requires of him a reasonable explanation.[58] The physician is not expected to give the patient a short medical education. which means generally informing the patient in nontechnical terms as to what is at stake. Such unrevealed risk that should have been made known must further materialize. the physician is not obliged to discuss relatively minor risks inherent in common procedures when it is common knowledge that such risks inherent in procedure of very low incidence. the duty of reasonable disclosure of available choices with respect to proposed therapy and of dangers inherently and potentially involved in each. then must be measured by the patients need.duty to warn of the dangers lurking in the proposed treatment and to impart information which the patient has every right to expect. Indeed.[63] . The scope of the physicians communications to the patient. and the risks that may ensue from particular treatment or no treatment.[60] Reiterating the foregoing considerations.[62] The court thus concluded that the patients right of selfdecision can only be effectively exercised if the patient possesses adequate information to enable him in making an intelligent choice. it was held that experts are unnecessary to a showing of the materiality of a risk to a patients decision on treatment. however unpardonable. and where the patient is a child or incompetent.

immediately or sometime after the administration of chemotherapy drugs. as with most other major medical procedures. The gravamen in an informed consent case requires the plaintiff to point to significant undisclosed information relating to the treatment which would have altered her decision to undergo it. (3) as a direct and proximate result of the failure to disclose. That death can possibly result from complications of the treatment or the underlying cancer itself. . consent to treatment would not have been given. there must be causal relationship between physicians failure to inform and the injury to patient and such connection arises only if it is established that. (2) he failed to disclose or inadequately disclosed those risks. Respondents could not have been unaware in the course of initial treatment and amputation of Angelicas lower extremity. the patient consented to treatment she otherwise would not have consented to. we hold that there was adequate disclosure of material risks inherent in the chemotherapy procedure performed with the consent of Angelicas parents. Grant further reiterated the pronouncement in Canterbury v. In other words. possible kidney or heart damage and skin darkening. had revelation been made. each patients reaction to the chemical agents even with pre-treatment laboratory tests cannot be precisely determined by the physician.[64] Examining the evidence on record. that her immune system was already weak on account of the malignant tumor in her knee. there is reasonable expectation on the part of the doctor that the respondents understood very well that the severity of these side effects will not be the same for all patients undergoing the procedure.Cobbs v. Spence that for liability of the physician for failure to inform patient. is a risk that cannot be ruled out. by the nature of the disease itself. but such conclusion can be reasonably drawn from the general side effects of chemotherapy already disclosed. and (4) plaintiff was injured by the proposed treatment. decrease in blood platelets. 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. When petitioner informed the respondents beforehand of the side effects of chemotherapy which includes lowered counts of white and red blood cells.

This change in perspective is especially important as medical breakthroughs move practitioners to the cutting edge of technology. informed consent laws in other countries generally require only a reasonable explanation of potential harms. the testimony of Dr. so specific disclosures such as statistical data. the Court feels hesitant in defining the scope of mandatory disclosure in cases of malpractice based on lack of informed consent. as it was unlikely for doctors like petitioner who were dealing with grave conditions such as cancer to have falsely assured patients of chemotherapys success rate. Balmaceda who is not an oncologist but a Medical Specialist of the DOHs Operational and Management Services charged with receiving complaints against hospitals.[65] The element of ethical duty to disclose material risks in the proposed medical treatment cannot thus be reduced to one simplistic formula applicable in all instances.As a physician. in a medical malpractice action based on lack of informed consent. As society has grappled with the juxtaposition between personal autonomy and the medical profession's intrinsic impetus to cure. even in foreign jurisdictions. much less set a standard of disclosure that. it is difficult to give credence to respondents claim that petitioner told them of 95% chance of recovery for their daughter. ever encountering new and heretofore unimagined treatments for currently incurable diseases or ailments. expanding and contracting with the ebb and flow of societal . In the absence of expert testimony in this regard. has been noted to be an evolving one. may not be legally necessary. the law defining adequate disclosure has undergone a dynamic evolution. the plaintiff must prove both the duty and the breach of that duty through expert testimony. Besides. Reasonableness analyses permeate our legal system for the very reason that they are determined by social norms. does not qualify as expert testimony to establish the standard of care in obtaining consent for chemotherapy treatment.[67] In this case. An adaptable standard is needed to account for this constant progression.[66] Such expert testimony must show the customary standard of care of physicians in the same practice as that of the defendant doctor. On the other hand. A standard once guided solely by the ruminations of physicians is now dependent on what a reasonable person in the patients position regards as significant. petitioner can reasonably expect the respondents to have considered the variables in the recommended treatment for their daughter afflicted with a lifethreatening illness. Further.

J. all surnamed Promulgated: . we now realize that the legal standard of disclosure is not subject to construction as a categorical imperative. Nevertheless. 58013 are SET ASIDE.PERALTA.R. 1997 of the Regional Trial Court of Legazpi City. 2004 and the Resolution dated September 1. As we progress toward the twenty-first century. JJ. JR. JENNIFER ADRIANE and JOHN ANDRE. and PERLAS-BERNABE. No costs. The Decision dated September 5.) WHEREFORE. ABAD. SO ORDERED.[68] (Emphasis supplied. CV No.. Chairperson. .. Whatever formulae or processes we adopt are only useful as a foundational starting point. The Decision dated June 15. Branch 8. No. 8904 is REINSTATED and UPHELD. Present: VELASCO. THIRD DIVISION MARITER MENDOZA.versus . in Civil Case No. juries that ultimately determine whether a physician properly informed a patient are inevitably guided by what they perceive as the common expectation of the medical consumera reasonable person in the patients position when deciding to accept or reject a recommended medical procedure.R. 2004 of the Court of Appeals in CA-G.evolution. the petition for review on certiorari is GRANTED. 197987 Petitioner. the particular quality or quantity of disclosure will remain inextricably bound by the facts of each case. ADRIANO CASUMPANG. MENDOZA. G.

the Court of Appeals (CA) rendered a decision on March 18. March 19. She tried calling Dr. substituted by her respondent husband Adriano and their children Jennifer Adriane and John Andre. Because Josephine died before trial could end. Josephine experienced recurring fever.x DECISION ABAD. Mendoza performed on her at the Iloilo Doctors Hospital. 2005. Mendoza guilty of neglect that caused Josephines illness and eventual death and ordering her to pay plaintiffs heirs actual damages of P50. finding Dr. On March 7. Mariter Mendoza in 1993 before the Regional Trial Court (RTC) of Iloilo City. The CA denied her motion for reconsideration on July 18. 2011. 2005 the RTC rendered judgment. On appeal. Mendoza to report it but the latter was unavailable. 2012 x --------------------------------------------------------------------------------------. nausea. 2011. The CA held that Dr. Mendoza before the RTC of Iloilo City. After her operation. Three months after the operation. Respondents.00. Dr. On February 13. filed an action for damages against petitioner Dr. She was a housewife and 40 years old when she died. partially expelled rolled gauze from her cervix. and attorneys fees of P20. moral damages of P200. her husband and their children substituted her in the case.000. Josephine instead went to see another physician. she noticed while taking a bath something protruding from her genital.CASUMPANG. however. 1993 Josephine underwent hysterectomy and myomectomy that Dr. [1] reinstating the RTCs original decision. and vomiting.000. Petitioner claims that no gauze or surgical material was left in Josephines body after her surgery as evidenced by the surgical sponge count in the hospital record. J. Edna Jamandre-Gumban. who extracted a foul smelling. the RTC reversed itself and dismissed the complaint in an order dated June 23. prompting her to file the present petition.000.: Josephine Casumpang.00. The discovery of the gauze and the illness she went through prompted Josephine to file a damage suit against Dr. On motion for reconsideration.00 plus costs of suit. Mendoza committed a breach of her duty as a physician when a gauze remained in her patients body after surgery. .

000. however. the factual findings of the latter court are generally binding. Further.[4] A surgical operation is the responsibility of the surgeon performing it.00.00 as attorneys fees and civil indemnity arising from death in the amount of P50. There are even legions of authorities to the effect that such act is negligence per se. additional P30. With few exceptions. Exemplary damages may also be awarded in cases of gross negligence. 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. The Court notes. And it would be much unlikely for her or for any woman to inject a roll of gauze into her cervix. an additional P50. Josephine did not undergo any other surgical operation. . The amount of P50. WHEREFORE.00 as exemplary damages.00 is fixed by prevailing jurisprudence for this kind. the award of exemplary damages in this case is in order.But she raises at this Courts level a question of fact when parties may raise only questions of law before it in petitions for review on certiorari from the CA. To put it simply.000.000. Inc. None of those exceptions applies to this case. To provide an example to the medical profession and to stress the need for constant vigilance in attending to a patients health. SO ORDERED. all surnamed Casumpang. Mendoza when. 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.00. under Article 2229 of the Civil Code. 2011 with the MODIFICATION ordering petitioner Mariter Mendoza to pay respondents Adriano.00 to P50.000. civil indemnity under Article 2206[5] of the Civil Code should be given to respondents as heirs. As the Court held in Professional Services.[2] As the RTC pointed out. that neither the CA nor the RTC awarded exemplary damages against Dr. the Court entirely AFFIRMS the decision of the Court of Appeals dated March 18. exemplary damages are imposed by way of example or correction for the public good.000.000. such act is considered so inconsistent with due care as to raise an inference of negligence. in view of Josephines death resulting from petitioners negligence. v. Jennifer Adriane and John Andre. Agana:[3] An operation requiring the placing of sponges in the incision is not complete until the sponges are properly removed. in addition to moral damages.[6] The Court also deems it just and equitable under Article 2208 of the Civil Code to increase the award of attorneys fees from P20.

Transplant Coordinator. Enrique T. DECISION PERALTA. [Logmao] was transferred to NKI at 10:10 in the morning. Cabrera. the name Angelito [Logmao] was recorded as Angelito Lugmoso. Dr. Dr. Respondent. whose area of jurisdiction includes Boni Avenue. so that should Lugmoso expire despite the necessary medical care and management and he would be found to be a suitable organ donor and his family would consent to organ donation. The CA's narration of facts is accurate. Mandaluyong. that the condition of [Logmao] progressively deteriorated and he was intubated and ambu-bagging support was provided. but there was no vacancy at the ICU and all the ventilator units were being used by other patients. was brought to the East Avenue Medical Center (EAMC) in Quezon City by two sidewalk vendors. Mandaluyong. ZENAIDA MAGUD-LOGMAO. observed that the severity of the brain injury of Lugmoso manifested symptoms of brain death. 5. Jennifer B. Mandaluyong. 1988. As Lugmoso had no relatives around. Certifications were . Defendant-appellant Dr. 1988. 2014 DR. be reversed and set aside. the organs thus donated could be detached and transplanted promptly to any compatible beneficiary. who was confined at NKI for severe head injury after allegedly falling from the Cubao overpass. FILOTEO A. March 2. Lugmoso was immediately attended to and given the necessary medical treatment. and the Resolution2dated November 22. Chairman of the Department of Surgery. who allegedly saw the former fall from the overpass near the Farmers’ Market in Cubao. No. J. Misa. with address at Boni Avenue. Petitioner. upon her request.R. that at around 4:00 o’clock in the morning of March 2. The patient’s data sheet identified the patient as Angelito Lugmoso of Boni Avenue. from EAMC the identity of Lugmoso and. she was furnished by EAMC a copy of the patient’s date sheet which bears the name Angelito Lugmoso. vs. to wit: Plaintiff-appellee Zenaida Magud-Logmao is the mother of deceased Arnelito Logmao. for assistance in locating the relatives of Angelito Lugmoso. was asked to locate his family by enlisting police and media assistance. Quezon City. Paterno F. denying petitioner's motion for reconsideration thereof. Ona. Mandaluyong. Eastern Police District. that the skull x-ray showed no fracture. 175540 April 7. that admission to the Intensive Care Unit (ICU) and mechanical ventilator support became necessary. dated March 31. the clinical abstract prepared by Dr. was conscious and coherent. that a resident physician of NKI.: This deals with the Petition for Review on Certiorari under Rule 45 of the Rules of Court praying that the Decision1of the Court of Appeals (CA). 1988. Filoteo Alano is the Executive Director of the National Kidney Institute (NKI). She then contacted several radio and television stations to request for air time for the purpose of locating the family of Angelito Lugmoso of Boni Avenue. [Logmao] developed generalized seizures and was managed by the neuro-surgery resident on-duty. At around 9:50 in the evening of March 1. the surgical resident on-duty at the Emergency Room of EAMC. Cabrera reported that [Logmao] was drowsy with alcoholic breath. 2006. 2006. who was rotating at EAMC. suggested that [Logmao] be transferred to NKI. Jennifer Misa verified on the same day. then eighteen (18) years old. However. and that after arrangements were made.Republic of the Philippines SUPREME COURT Baguio City THIRD DIVISION G. as well as Police Station No. He requested the Laboratory Section to conduct a tissue typing and tissue cross-matching examination. At the NKI. stated that the patient is Angelito [Logmao]. ALANO. adjudging petitioner liable for damages. Arnelito Logmao.

Mandaluyong attesting to the fact that on March 2. on the assumption that the incident which lead to the brain injury and death of Lugmoso was a medico legal case. Ona likewise instructed Dr. 1988 was issued by Dr. Dr. as principal surgeon. made arrangements with La Funeraria Oro for the embalmment of the cadaver of Lugmoso good for a period of fifteen (15) days to afford NKI more time to continue searching for the relatives of the latter. and by Dr. 1988. Drs. Ona requested Dr. regarding the case of Lugmoso. 856. Rose Marie Rosete-Liquete. . to authorize the removal of specific organs from the body of Lugmoso for transplantation purposes. 1988. Eastern Police District. Ona inquired from Jennifer Misa whether the relatives of Lugmoso had been located so that the necessary consent for organ donation could be obtained. Roberto Ortega. Aurea Ambrosio.issued by Channel 4. On March 4. Dr. Antonio R. The transplant operation was completed at around 11:00 o’clock in the evening of March 3. Liquete on March 3. removed the heart. stating that he received a telephone call from Dr. Ludivino de Guzman. Liquete sought from him a second opinion for organ retrieval for donation purposes even in the absence of consent from the family of the deceased. Mandaluyong was accommodated. Medico-Legal Officer of the NBI. permission and/or authority is hereby given to the Department of Surgery to retrieve and remove the kidneys. Jennifer Misa requested for assistance to immediately locate the family and relatives of Angelito Lugmoso and that she followed up her request until March 9. Jr. and that he verbally agreed to organ retrieval. 1988. at about 6:00 p. Jaime Velasquez. As shown by the medical records. Dr. Antonio Rafael. Dr. On March 3. If all the above has been complied with. Enrique Ona. 5. thereby confirming that Lugmoso was brain dead. liver and spleen of Lugmoso. 349 as amended and P. 1988. Head of the Cadaver Organ Retrieval Effort (CORE) program of NKI. a neurologist. Alano issued to Dr. ABS-CBN and GMA attesting that the request made by the NKI on March 2. Ona was informed that Lugmoso had been pronounced brain dead by Dr. Paraiso.m. which reads as follows: This is in connection with the use of the human organs or any portion or portions of the human body of the deceased patient. composed of Dr. the said patient died on March 3. 1988. 1988 from the East Avenue Medical Center. Please make certain that your Department has exerted all reasonable efforts to locate the relatives or next of kin of the said deceased patient such as appeal through the radios and television as well as through police and other government agencies and that the NBI [Medico-Legal] Section has been notified and is aware of the case. 1988. Dr. Manuel Chua-Chiaco. The medical team then transplanted a kidney and the pancreas of Lugmoso to Lee Tan Hoc and the other kidney of Lugmoso to Alexis Ambustan.D. Alano. and that a repeat electroencephalogram (EEG) was in progress to confirm the diagnosis of brain death. A Certification was likewise issued by Police Station No. liver and heart of the said deceased patient and to transplant the said organs to any compatible patient who maybe in need of said organs to live and survive.. Dr. Ona a Memorandum. and Myrna Mendoza. Funeral Consultant of La Funeraria Oro. Ona was informed that the EEG recording exhibited a flat tracing. Executive Director of NKI. On the same day. at about 7:00 o’clock in the morning. Maximo Reyes. no one responded. that Dr.. At 3:45 in the afternoon of March 3. Aquino. Ricardo Fernando. in accordance with the provisions of Republic Act No. A Certification dated March 10. On March 3. Upon learning that Lugmoso was a suitable organ donor and that some NKI patients awaiting organ donation had blood and tissue types compatible with Lugmoso. identified as a certain Mr. 1988 at 9:10 in the morning due to craniocerebral injury. 1988. 1988 at 9:15 a. a neurosurgeon and attending physician of Lugmoso. Abdias V. who was declared brain dead. kidneys. Rose Marie Rosete-Liquete to secure permission for the planned organ retrieval and transplantation from the Medico-Legal Office of the National Bureau of Investigation (NBI). pancreas. The Autopsy Report and Certification of Post-Mortem Examination issued by the NBI stated that the cause of death of Lugmoso was intracranial hemorrhage secondary to skull fracture. Two hours later. that despite efforts to locate the latter’s relatives. a medical team. Filoteo A. Angelito Lugmoso who was brought to the National Kidney Institute on March 2. Dr. pancreas. As the extensive search for the relatives of Lugmoso yielded no positive result and time being of the essence in the success of organ transplantation. Mary Litonjua.m. sent a request for autopsy to the NBI. 1988 to air its appeal to locate the family and relatives of Angelito Lugmoso of Boni Avenue.

and that the relatives of Arnelito were likewise informed that the latter was missing. 1988. Dr. the NKI issued a press release announcing its successful double organ transplantation. As the name of the donor sounded like Arnelito Logmao. SO ORDERED. Jr. German E. La Funeraria Oro. plaintiff filed with the court a quo a complaint for damages against Dr. WHETHER THE COURT OF APPEALS GRAVELY ERRED IN REFUSING AND/OR FAILING TO DECLARE THAT PETITIONER DR. 5.000. Jaime Velasquez. Plaintiff alleged that defendants conspired to remove the organs of Arnelito while the latter was still alive and that they concealed his true identity.00. Aida informed plaintiff of the news report. Enrique T. where the following issues are presented for resolution: A. represented by its Director. Dr. Ambrosio. On April 29. plaintiff and her other children went to La Funeraria Oro. Rosete-Liquete. heard the news aired on television that the donor was an eighteen (18) year old boy whose remains were at La Funeraria Oro in Quezon City. Inc.00 as attorney's fees. 2006. a cousin of plaintiff. 2000. Jennifer Misa. John Doe.00 as moral damages. WHETHER THE COURT OF APPEALS DISREGARDED EXISTING JURISPRUDENCE PRONOUNCED BY THIS HONORABLE SUPREME COURT IN HOLDING PETITIONER DR. Lee Tan Koc. Mary Litonjua. with MODIFICATION by DELETING the award ofP188.5 The first two issues boil down to the question of whether respondent's sufferings were brought about by . Ricardo Fernando. Ona. Dr.00. Jr. the CA issued its Decision. where they saw Arnelito inside a cheap casket. Manuel Chua-Chiaco. Dr. Alano. Dr.000. 1988. Cueva. On March 31. It appears that on March 3.00 and the award of attorney's fees to P100. P300. the court a quo rendered judgment finding only Dr.90 as actual damages. Antonio R. Dr.000. Peter Doe. FILOTEO ALANO LIABLE FOR MORAL AND EXEMPLARY DAMAGES AND ATTORNEY'S FEES DESPITE THE FACT THAT THE ACT OF THE PETITIONER IS NOT THE PROXIMATE CAUSE NOR IS THERE ANY FINDING THAT THE ACT OF THE PETITIONER WAS THE PROXIMATE CAUSE OF THE INJURY OR DAMAGE ALLEGEDLY SUSTAINED BY RESPONDENT ZENAIDA MAGUD-LOGMAO. C.On March 11. Myrna Mendoza.90 as actual damages and REDUCING the award of moral damages to P250.. Dr. Aurea Z. Arlen Logmao. Taurean Protectors Agency.740. Dr. Rose Marie O. Dr. Aida Doromal. National Kidney Institute. Dr. Upon receiving the news from Aida. Paraiso. Filoteo A. On January 17. represented by its President. and costs of suit. Petitioner appealed to the CA. 3 After finding petitioner liable for a quasi-delict. the award of exemplary damages to P200. Dr. Dr.740. 1988. the Regional Trial Court of Quezon City (RTC) ordered petitioner to pay respondent P188.. Alexis Ambustan. a brother of Arnelito. as evidenced by a Certification issued by said Station. Quezon City. Dr. Filoteo Alano liable for damages to plaintiff and dismissing the complaint against the other defendants for lack of legal basis.000. P500. the Decision appealed from is AFFIRMED. Ludivino de Guzman. Eastern Police District. represented by its Proprietor. WHETHER THE COURT OF APPEALS GRAVELY ERRED IN AWARDING RESPONDENT ZENAIDA MAGUD-LOGMAO MORAL AND EXEMPLARY DAMAGES AND ATTORNEY'S FEES THAT ARE NOT IN ACCORDANCE WITH AND ARE CONTRARY TO ESTABLISHED JURISPRUDENCE.. ALANO ACTED IN GOOD FAITH AND PURSUANT TO LAW WHEN HE ISSUED THE AUTHORIZATION TO REMOVE AND RETRIEVE THE ORGANS OF ANGELITO LUGMOSO (LATER IDENTIFIED TO BE IN FACT ARNELITO LOGMAO) CONSIDERING THAT NO NEGLIGENCE CAN BE ATTRIBUTED OR IMPUTED ON HIM IN HIS PERFORMANCE OF AN ACT MANDATED BY LAW. Roberto Ortega alias Bobby Ortega.000. P500. Ortega. B. Mariano B.4 Petitioner then elevated the matter to this Court via a petition for review on certiorari.00 as exemplary damages. Celso Santiago. reported to Police Station No.000. who was then a resident of 17-C San Pedro Street. the dispositive portion of which reads as follows: WHEREFORE. Mandaluyong that the latter did not return home after seeing a movie in Cubao. and Alex Doe in connection with the death of her son Arnelito. Mandaluyong. Emmanuel Lenon. Maximo Reyes.

It also clearly stated that permission or authorization to retrieve and remove the internal organs of the deceased was being given ONLY IF the provisions of the applicable law had been complied with. who had the opportunity to ascertain the name of the deceased. Thus. the doctors concerned also the sought the opinion and approval of the Medico-Legal Officer of the NBI. i. the said patient died on March 3.D. 1988 issued by petitioner. as well as through police and other government agencies and that the NBI [Medico-Legal] Section has been notified and is aware of the case. stated thus: As shown by the medical records. 349. pancreas.A. because as found by the lower courts.) 856. 6 The Memorandum dated March 3. The only question that remains pertains to the sufficiency of time allowed for notices to reach the relatives of the deceased. If all the above has been complied with. fault cannot be laid at petitioner's door. obeying all his directives. However. giving his subordinates instructions to exert all reasonable efforts to locate the relatives or next of kin of respondent's son. such as appeal through the radios and television. when affirmed by the appellate court. and the NBI MedicoLegal Section was notified. as found by the lower courts from the records of the case. there can be no cavil that petitioner employed reasonable means to disseminate notifications intended to reach the relatives of the deceased. the doctors and personnel of NKI disseminated notices of the death of respondent's son to the media and sought the assistance of the appropriate police authorities as early as March 2. If respondent failed to immediately receive notice of her son's death because the notices did not properly state the name or identity of the deceased. announcements were made through radio and television. Such instructions reveal that petitioner acted prudently by directing his subordinates to exhaust all reasonable means of locating the relatives of the deceased. as amended by Presidential Decree (P. 856.) No. 1988. Please make certain that your Department has exerted all reasonable efforts to locate the relatives or next-of-kin of the said deceased patient. even before petitioner issued the Memorandum. 349 as amended and P. he did so in accordance with the letter of the law. Petitioner maintains that when he gave authorization for the removal of some of the internal organs to be transplanted to other patients. 7 A careful reading of the above shows that petitioner instructed his subordinates to "make certain" that "all reasonable efforts" are exerted to locate the patient's next of kin.petitioner's alleged negligence in granting authorization for the removal or retrieval of the internal organs of respondent's son who had been declared brain dead. He could not have made his directives any clearer. the deceased was . permission and/or authority is hereby given to the Department of Surgery to retrieve and remove the kidneys. in accordance with the provisions of Republic Act No. a close examination of the records of this case would reveal that this case falls under one of the exceptions to the general rule that factual findings of the trial court. There are some important circumstances that the lower courts failed to consider in ascertaining whether it was the actions of petitioner that brought about the sufferings of respondent.e. liver and heart of the said deceased patient and to transplant the said organs to any compatible patient who maybe in need of said organs to live and survive. The trial and appellate courts found that it was the EAMC. He even specifically mentioned that permission is only being granted IF the Department of Surgery has complied with all the requirements of the law. The appellate court affirmed the trial court's finding that there was negligence on petitioner's part when he failed to ensure that reasonable time had elapsed to locate the relatives of the deceased before giving the authorization to remove said deceased's internal organs for transplant purposes. petitioner could not have been faulted for having full confidence in the ability of the doctors in the Department of Surgery to comprehend the instructions. are binding on this Court. Furthermore. and acting only in accordance with the requirements of the law.D. Verily. The NKI could not have obtained the information about his name from the patient. the assistance of police authorities was sought. 1988 at 9:10 in the morning due to craniocerebral injury. Prior to performing the procedure for retrieval of the deceased's internal organs. even enumerating ways in which to ensure that notices of the death of the patient would reach said relatives. who recorded the wrong information regarding the deceased's identity to NKI. Republic Act (R. In fact.. petitioner insists that he should not be held responsible for any damage allegedly suffered by respondent due to the death of her son and the removal of her son’s internal organs for transplant purposes. Thus.

1âwphi1 Verily. agree with the lower court. Ultimately. it is a basic rule that the party making allegations has the burden of proving them by a preponderance of evidence.8 "[i]n civil cases. WHEREFORE. the period of around 24 hours from the time notices were disseminated.already unconscious by the time he was brought to the NKI. As stated in Otero v. The Decision of the Court of Appeals. . dated March 31. 2006. it is respondent's failure to adduce adequate evidence that doomed this case. there is to proof that. the petition is GRANTED. Finding petitioner liable for damages is improper. They failed to present any expert witness to prove that given the medical technology and knowledge at that time in the 1980's. indeed. is REVERSED and SET ASIDE. cannot be considered as reasonable under the circumstances. the Court cannot. The parties must rely on the strength of their own evidence and not upon the weakness of the defense offered by their opponent. Tan. the doctors could or should have waited longer before harvesting the internal organs for transplantation. 1." 9 Here. thus. The complaint against petitioner is hereby DISMISSED. It should be emphasized that the internal organs of the deceased were removed only after he had been declared brain dead. Neither can the Court find evidence on record to show that respondent's emotional suffering at the sight of the pitiful state in which she found her son's lifeless body be categorically attributed to petitioner's conduct. SO ORDERED. in conscience. the emotional pain suffered by respondent due to the death of her son cannot in any way be attributed to petitioner.