sponges or other foreign substances in the wound after the

incision has been closed is at least prima facienegligence by

G.R. No. 126297. January 31, 2007.
the operating surgeon. To put it simply, such act is
PROFESSIONAL
SERVICES,
INC.,
considered so inconsistent with due care as to raise an
petitioner, vs.NATIVIDAD and ENRIQUE AGANA,
inference of negligence. There are even legions of
respondents.
authorities to the effect that such act is negligence per se.
G.R. No. 126467. January 31, 2007.
Same; Same; Same; To the mind of the Court, what was
NATIVIDAD and ENRIQUE AGANA, respondents.
initially an act of negligence by Dr. Ampil has ripened into a
NATIVIDAD
(Substituted
by
her
children
deliberate wrongful act of deceiving his patient.Here, Dr.
MARCELINO AGANA III, ENRIQUE AGANA, JR.,
Ampil did not inform Natividad about the missing two
EMMA AGANA ANDAYA, JESUS AGANA, and
pieces of gauze.Worse, he even misled her that the pain she
RAYMUND AGANA) and ENRIQUE AGANA,
was experiencing was the ordinary consequence of her
petitioners, vs. JUAN FUENTES, respondent.
operation. Had he been more candid, Natividad could have
G.R. No. 127590. January 31, 2007.
taken the immediate and appropriate medical remedy to
MIGUEL AMPIL, petitioner, vs. NATIVIDAD AGANA
remove the gauzes from her body. To our mind, what was
and ENRIQUE AGANA, respondents.
initially an act of negligence by Dr. Ampil has ripened into
a deliberate wrongful act of deceiving his patient.
_______________
Same; Same; Same; Doctrine
of
Res
Ipsa
Loquitur; Requisites for the Applicability of the Doctrine.
FIRST DIVISION.
Literally, res ipsa loquiturmeans the thing speaks for
479
itself. It is the rule that the fact of the occurrence of an
VOL. 513, JANUARY 31, 2007
479
injury, taken with the surrounding circumstances, may
Professional Services, Inc. vs. Agana
permit an inference or raise a presumption of negligence, or
Civil
Law; Damages; Negligence; The
leaving
of
make out a plaintiffs prima facie case, and present a
sponges or other foreign substances in the wound after the
question of fact for defendant to meet with an explanation.
incision has been closed is at least prima facie negligence by
Stated differently, where the thing which caused the injury,
the operating surgeon. An operation requiring the placing
without the fault of the injured, is under the exclusive
of sponges in the incision is not complete until the sponges
control of the defendant and the injury is such that it
are properly removed, and it is settled that the leaving of
478

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana
*

should not have occurred if he, having such control used

proper care, it affords reasonable evidence, in the absence of
explanation that the injury arose from the defendants want
of care, and the burden of proof is shifted to him to establish
that he has observed due care and diligence. From the
foregoing statements of the rule, the requisites for the
applicability of the doctrine of res ipsa loquiturare: (1) the
occurrence of an injury; (2) the thing which caused the
injury was under the control and management of the
defendant;(3) the occurrence was such that in the ordinary
course of things, would
480

SUPREME COURT REPORTS ANNOTATED

80
Professional Services, Inc. vs. Agana
not have happened if those who had control or
management used proper care; and (4) the absence of
explanation by the defendant. Of the foregoing requisites,
the most instrumental is the control and management of
the thing which caused the injury.
Same; Same; Same; Same; Res ipsa loquitur is not a
rule of substantive law, hence, does not per se create or
constitute an independent or separate ground of liability,
being a mere evidentiary rule.In this jurisdiction, res ipsa
loquitur is not a rule of substantive law, hence, does not per
se create or constitute an independent or separate ground of
liability, being a mere evidentiary rule. In other words,
mere invocation and application of the doctrine does not

dispense with the requirement of proof of negligence. Here,

the negligence was proven to have been committed by Dr.
Ampil and not by Dr. Fuentes.
Same; Same; Same; Professionals
are
considered
personally liable for the fault or negligence they commit in
the discharge of their duties and their employer cannot be
held liable for such fault or negligence.A prominent
civilist commented that professionals engaged by an
employer, such as physicians, dentists, and pharmacists,
are not employees under this article because the manner
in which they perform their work is not within the control
of the latter (employer). In other words, professionals are
considered personally liable for the fault or negligence they
commit in the discharge of their duties, and their employer
cannot be held liable for such fault or negligence. In the
context of the present case, a hospital cannot be held liable
for the fault or negligence of a physician or surgeon in the
treatment or operation of patients.
Same; Same; Same; In this jurisdiction, the nature of
the relationship between the hospital and the physicians is
rendered inconsequential in view of the pronouncement in
Ramos vs. Court of Appeals, 321 SCRA 584 (1999), that for
purposes of apportioning responsibility in medical
negligence cases, an employer-employee relationship in effect
exists between hospitals and their attending and visiting
physicians.In our shores, the nature of the relationship
between the hospital and the physicians is rendered
inconsequential in view of our categorical pronouncement

in Ramos v. Court of Appeals, 321 SCRA 584 (1999), that

for purposes of apportioning responsibility in
481

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana
medical
negligence
cases, an employer-employee
relationship in effect exists between hospitals and their
attending and visiting physicians.
Same;Same; Same; PSIs liability is also anchored
upon the agency principle of apparent authority or agency by
estoppel and the doctrine of corporate negligence.But
the Ramospronouncement is not our only basis in
sustaining PSIs liability. 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 hospitals
liability for negligent acts of health professionals. The
present case serves as a perfect platform to test the
applicability of these doctrines, thus, enriching our
jurisprudence. Apparent authority, or what is sometimes
referred to as the holding out theory, or doctrine
of ostensible agency or agency by estoppel, has its origin
from the law of agency. It imposes liability, not as the result
of the reality of a contractual relationship, 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. 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
48 the agent to assume, or which he holds the agent out to the
1 public as possessing. 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,
conversant with business usages and the nature of the
particular business, is justified in presuming that such
agent has authority to perform the particular act in
question.
Same; Same; Same; In cases where it can be shown that
a hospital, by its actions, 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, then the hospital
will be liable for the physicians negligence.The
applicability of apparent authority in the field of hospital
liability was upheld long time ago in Irving v. Doctor
Hospital of Lake Worth, Inc., 415 So. 2d 55 (1982). There, 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. Thus, in cases
where it can be shown that a hospital, by its actions, has
held out a particular physician as its agent and/or employee
and
482

SUPREME COURT REPORTS ANNOTATED

82
Professional Services, Inc. vs. Agana
that a patient has accepted treatment from that
physician in the reasonable belief that it is being rendered
in behalf of the hospital, then the hospital will be liable for
the physicians negligence.
Same; Same; Same; By accrediting Dr. Ampil and Dr.
Fuentes and publicly advertising their qualifications, the
hospital created the impression that they were its agents,
authorized to perform medical or surgical services for its
patients.In this case, PSI publicly displays in the lobby of
the Medical City Hospital the names and specializations of
the physicians associated or accredited by it, including
those of Dr. Ampil and Dr. Fuentes. 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.
Indeed, PSIs act is tantamount to holding out to the public
that Medical City Hospital, through its accredited
physicians, offers quality health care services. By
accrediting Dr. Ampil and Dr. Fuentes and publicly
advertising their qualifications, the hospital created the
impression that they were its agents, authorized to perform
medical or surgical services for its patients. As expected,
these patients, Natividad being one of them, accepted the
services on the reasonable belief that such were being

rendered by the hospital or its employees, agents, or

servants.

PETITION for review on certiorari of the decisions of

the Court of Appeals.
The facts are stated in the opinion of the Court.
Bengzon, Narciso, Cudala, Pecson, Bengzon &
Jimenez for petitioner Professional Services, Inc.
Enrique Agana & Associates for petitioners
Natividad and Enrique Agana.
The Law Firm of Raymundo M. Armovit for
petitioner Miguel Ampil.
Agcaoili Law Offices collaborating counsel for
Heirs of Natividad Agana.
Benjamin M. Tongol for Juan Fuentes.
483

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana

483

SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankinds most
important and delicate endeavors, must assume the
grave responsibility of pursuing it with appropriate
care. The care and service dispensed through this high
trust, however technical, complex and esoteric its
character may be, must meet standards of
responsibility commensurate with the undertaking to
preserve and protect the health, and indeed, the very
lives of those placed in the hospitals keeping.
1

Assailed in these three consolidated petitions for

review on certiorari is the Court of Appeals
Decision dated September 6, 1996 in CA-G.R. CV No.
42062 and CA-G.R. SP No. 32198 affirming with
modification the Decision 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.
2

Professional Services, Inc. vs. Agana

On April 11, 1984, Dr. Ampil, assisted by the medical

staff of the Medical City Hospital, performed an
anterior resection surgery on Natividad. He found that
the malignancy in her sigmoid area had spread on her
left ovary, necessitating the removal of certain
portions of it. Thus, Dr. Ampil obtained the consent of
Natividads husband, Enrique Agana, to permit Dr.
Juan Fuentes, 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:
4

sponge count lacking 2

_______________

announced to surgeon searched (sic) done but to no avail

Beeck v. Tucson General Hospital, 500 P. 2d 1153 (1972), citingDarling v.

Charleston Community Memorial Hospital, 33 Ill. 2d 326, 211 N.E. 2d 253.

2

Penned by Associate Justice Cancio C. Garcia (now a member of the Supreme

Court) and concurred in by Associate Justices Eugenio S. Labitoria and Artemio

G. Tuquero (both retired), Rollo, G.R. No. 126297, pp. 36-51; 126467, pp. 27-42;
127590, pp. 23-38.
3

Penned by Judge Lucas P. Bersamin (now Justice of the Court of

Appeals), Rollo, G.R. No. 126647, pp. 69-83.

484

484

SUPREME COURT REPORTS ANNOTATED

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.

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
The medical staff was composed of physicians, both residents and interns, as
Hospital, Dr. Ampil, and Dr. Fuentes, docketed as
well as nurses.
Civil Case No. Q-43322. They alleged that the latter
485
are liable for negligence for leaving two pieces of gauze
VOL. 513, JANUARY 31, 2007
485
inside Natividads body and malpractice for concealing
Professional Services, Inc. vs. Agana
their acts of negligence.
On August 31, 1984, Natividad flew back to the
Meanwhile, Enrique Agana also filed with the
Philippines, still suffering from pains. Two weeks
Professional Regulation Commission (PRC) an
thereafter, her daughter found a piece of gauze
administrative complaint for gross negligence and
protruding from her vagina. Upon being informed
malpractice against Dr. Ampil and Dr. Fuentes,
about it, Dr. Ampil proceeded to her house where he
docketed as Administrative Case No. 1690. The PRC
managed to extract by hand a piece of gauze
Board of Medicine heard the case only with respect to
measuring 1.5 inches in width. He then assured her
Dr. Fuentes because it failed to acquire jurisdiction
that the pains would soon vanish.
over Dr. Ampil who was then in the United States.
Dr. Ampils assurance did not come true. Instead,
On February 16, 1986, pending the outcome of the
the pains intensified, prompting Natividad to seek
above cases, Natividad died and was duly substituted
treatment at the Polymedic General Hospital. While
by her abovenamed children (the Aganas).
confined there, Dr. Ramon Gutierrez detected the
486
presence of another foreign object in her vaginaa
4

486

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana

4. 5.Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove,

from date of filing of the complaint until full payment; and

On March 17, 1993, the RTC rendered its Decision in

favor of the Aganas, finding PSI, Dr. Ampil and Dr.
Fuentes liable for negligence and malpractice, the
decretal part of which reads:
WHEREFORE, judgment is hereby rendered for the plaintiffs ordering
the defendants PROFESSIONAL SERVICES, INC., DR. MIGUEL
AMPIL and DR. JUAN FUENTES to pay to the plaintiffs, jointly and
severally, except in respect of the award for exemplary damages and the
interest thereon which are the liabilities of defendants Dr. Ampil and Dr.
Fuentes only, as follows:

1. a.The equivalent in Philippine Currency of the total of

at

the

rate

of

P21.60-US$1.00,

as

reimbursement of actual expenses incurred in the United

States of America;
2. b.The sum of P4,800.00 as travel taxes of plaintiffs and their
physician daughter;
3. c.The total sum of P45,802.50, representing the cost of
hospitalization at Polymedic Hospital, medical fees, and cost of
the saline solution;
1. 2.As moral damages, the sum of P2,000,000.00;
2. 3.As exemplary damages, the sum of P300,000.00;
3. 4.As attorneys fees, the sum of P250,000.00;

SO ORDERED.

Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed

an appeal to the Court of Appeals, docketed as CAG.R. CV No. 42062.
Incidentally, on April 3, 1993, the Aganas filed with
the RTC a motion for a partial execution of its
Decision, which was granted in an Order dated May
11, 1993. Thereafter, the sheriff levied upon certain
properties of Dr. Ampil and sold
487

1. 1.As actual damages, the following amounts:

US$19,900.00

5. 6.Costs of suit.

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana

them for P451,275.00 and delivered the amount to the

Aganas.
Following their receipt of the money, the Aganas
entered into an agreement with PSI and Dr. Fuentes
to indefinitely suspend any further execution of the
RTC Decision. However, not long thereafter, the
Aganas again filed a motion for an alias writ of
execution against the properties of PSI and Dr.
Fuentes. On September 21, 1993, the RTC granted the
motion and issued the corresponding writ, prompting
Dr. Fuentes to file with the Court of Appeals a petition
for certiorari and prohibition, with prayer for

487

preliminary injunction, docketed as CA-G.R. SP No.

32198. During its pendency, the Court of Appeals
issued a Resolution dated October 29, 1993 granting
Dr. Fuentes prayer for injunctive relief.
On January 24, 1994, CA-G.R. SP No. 32198 was
consolidated with CA-G.R. CV No. 42062.
Meanwhile, on January 23, 1995, the PRC Board of
Medicine rendered its Decision in Administrative Case
No. 1690 dismissing the case against Dr. Fuentes. The
Board held that the prosecution failed to show that Dr.
Fuentes was the one who left the two pieces of gauze
inside Natividads body; and that he concealed such
fact from Natividad.
5

On September 6, 1996, the Court of Appeals rendered

its Decision jointly disposing of CA-G.R. CV No. 42062
and CA-G.R. SP No. 32198, thus:
WHEREFORE, except for the modification that the case against
defendant-appellant Dr. Juan Fuentes is hereby DISMISSED, and with
the pronouncement that defendant-appellant Dr. Miguel Ampil is liable
to

reimburse

defendant-appellant Professional

Services,

Inc.,

whatever amount the latter will pay or had paid to the plaintiffsappellees, the decision appealed from is herebyAFFIRMED and the
instant appeal DISMISSED.
Concomitant with the above, the petition for certiorari and
prohibition filed by herein defendant-appellant Dr. Juan Fuentes in CAG.R. SP No. 32198 is hereby GRANTED and the challenged order of the
respondent judge dated September 21, 1993, as well as the alias writ of

_______________

execution issued pursuant thereto are hereby NULLIFIED and SET

The dispositive portion reads:

WHEREFORE, let a writ of preliminary injunction be issued upon petitioners posting of

bond in the amount of P20,000.00, ENJOINING public respondents from implementing the
questioned order dated September 21, 1993 and from further taking any action in Civil Case
No. Q-43322 entitled Natividad G. Agana, et al., plaintiffs, versus Professional Services, Inc.,
et al., defendants pending resolution of the instant petition.
SO ORDERED. See Rollo, G.R. No. 126297, p. 42.
6

Rollo of G.R. No. 126467, pp. 84-89.

488

488

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana

ASIDE. The bond posted by the petitioner in connection with the writ of
preliminary injunction issued by this Court on November 29, 1993 is
hereby cancelled.
Costs

against

defendants-appellants Dr.

Miguel

Ampil andProfessional Services, Inc.

SO ORDERED.

Only Dr. Ampil filed a motion for reconsideration, but

it was denied in a Resolution dated December 19,
1996.
Hence, the instant consolidated petitions.
In G.R. No. 126297, PSI alleged in its petition that
the Court of Appeals erred in holding that: (1) it is
estopped from raising the defense that Dr. Ampil is not
7

its employee;(2) it is solidarily liable with Dr. Ampil;

and (3) it is not entitled to its counterclaim against the
Aganas. PSI contends that Dr. Ampil is not its
employee, but a mere consultant or independent
contractor. As such, he alone should answer for his
negligence.
_______________

Rollo of G.R. No. 127590, p. 40.

489

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana

In G.R. No. 126467, the Aganas maintain that the

Court of Appeals erred in finding that Dr. Fuentes is
not guilty of negligence or medical malpractice,
invoking the doctrine ofres ipsa loquitur. They contend
that the pieces of gauze areprima facie proofs that the
operating surgeons have been negligent.
Finally, in G.R. No. 127590, Dr. 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 Natividads vagina. He
pointed to other probable causes, such as: (1) it was
Dr. Fuentes who used gauzes in performing the
hysterectomy; (2) the attending nurses failure to
properly count the gauzes used during surgery;
and (3) the medical intervention of the American

doctors who examined Natividad in the United States

of America.
For our resolution are these three vital issues: first,
whether the Court of Appeals erred in holding Dr.
Ampil liable for negligence and malpractice; second,
whether the Court of Appeals erred in absolving Dr.
Fuentes of any liability; and third, whether PSI may
be held solidarily liable for the negligence of Dr. Ampil.
IG.R.
No.
127590
Whether the Court of Appeals Erred in Holding Dr. Ampil
Liable for Negligence and Malpractice.

489 Dr. Ampil, in an attempt to absolve himself, gears the

Courts attention to other possible causes of

Natividads detriment. He argues that the Court
should not discount either of the following
possibilities: first, Dr. Fuentes left the gauzes in
Natividads
body
after
performing
hysterectomy; second, the attending nurses erred in
counting the gauzes; and third, the American doctors
were the ones who placed the gauzes in Natividads
body.
Dr. Ampils arguments are purely conjectural and
without basis. Records show that he did not present
any evidence to prove that the American doctors were
the ones who put or left
490

490

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana

the gauzes in Natividads body. Neither did he submit

evidence to rebut the correctness of the record of
operation, particularly the number of gauzes used. As
to the alleged negligence of Dr. Fuentes, we are
mindful that Dr. Ampil examined his (Dr. Fuentes)
work and found it in order.
The glaring truth is that all the major
circumstances, taken together, as specified by the
Court of Appeals, directly point to Dr. Ampil as the
negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges to
control the bleeding of the patient during the surgical operation.
Second, immediately after the operation, the nurses who assisted in
the surgery noted in their report that the sponge count (was) lacking
2; that such anomaly was announced to surgeon and that a
search was done but to no avail prompting Dr. Ampil to
continue for closure x x x.
Third, after the operation, two (2) gauzes were extracted from the
same spot of the body of Mrs. Agana where the surgery was performed.

An operation requiring the placing of sponges in the

incision is not complete until the sponges are properly
removed, and it is settled that the leaving of sponges
or other foreign substances in the wound after the
incision has been closed is at least prima
facie negligence by the operating surgeon. To put it
simply, such act is considered so inconsistent with due
care as to raise an inference of negligence. There are
8

even legions of authorities to the effect that such act

is negligence per se.
9

_______________

Rule v. Cheeseman, 317 P. 2d 472 (1957), citing Russel v. Newman, 116 Kan.

268 P. 752; Bernsden v. Johnson, 174 Kan. 230, 255 P. 2d 1033.

9

Smith v. Zeagler, 157 So. 328 Fla. (1934), citing Ruth v. Johnson, (C.C.A.)

172 F. 191; Reeves v. Lutz, 179 Mo. App. 61, 162 S.W. 280;Rayburn v. Day, 126 Or.
135, 68 P. 1002, 59 A.L.R. 1062; Wynne v. Harvey, 96 Wash. 379, 165 P. 67; Harris
v. Fall (C.C.A.), 177 F. 79,

491

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana

Of course, the Court is not blind to the reality that

there are times when danger to a patients life
precludes a surgeon from further searching missing
sponges or foreign objects left in the body. But this
does not leave him free from any obligation. Even if it
has been shown that a surgeon was required by the
urgent necessities of the case to leave a sponge in his
patients abdomen, because of the dangers attendant
upon delay, still, it is his legal duty to so inform his
patient within a reasonable time thereafter by advising
her of what he had been compelled to do. This is in
order that she might seek relief from the effects of the
foreign object left in her body as her condition might
permit. The ruling in Smith v. Zeagler is explicit,
thus:
10

491

Professional Services, Inc. vs. Agana

The removal of all sponges used is part of a surgical operation, and

when a physician or surgeon fails to remove a sponge he has placed in his
patients body that should be removed as part of the operation, he
thereby leaves his operation uncompleted andcreates a new condition
which imposes upon him the legal duty of calling the new
condition to his patients attention, and endeavoring with the
means he has at hand to minimize and avoid untoward results
likely to ensue therefrom.

Here, Dr. Ampil did not inform Natividad about the

missing two pieces of gauze. Worse, he even misled her
that the pain she was experiencing was the ordinary
consequence of her operation. Had he been more
candid, Natividad could have taken the immediate and
appropriate medical remedy to remove the gauzes from
her body. To our mind, what was initially an act of
negligence by Dr. Ampil has ripened into a deliberate
wrongful act of deceiving his patient.
This is a clear case of medical malpractice or more
appropriately, medical negligence. To successfully
pursue this kind of case, a patient must only prove
that a health care provider

either failed to do something which a reasonably

prudent health care provider would have done, or that
he did something that a reasonably prudent provider
would not have done; and that failure or action caused
injury to the patient. Simply put, the elements
are duty, breach, injury and proximate causation. Dr,
Ampil, as the lead surgeon, had the duty to remove all
foreign objects, such as gauzes, from Natividads body
before closure of the incision. When he failed to do so,
it was his duty to inform Natividad about it. Dr. Ampil
breached both duties. Such breach caused injury to
Natividad, necessitating her further examination by
American doctors and another surgery. That Dr.
Ampils negligence is the proximate cause of
Natividads injury could be traced from his act of
closing the incision despite the information given by the
attending nurses that two pieces of gauze were still
missing. That they were later on extracted from
Natividads vagina established the causal link between
Dr. Ampils negligence and the injury. And what
further aggravated such injury was
11

12

_______________
_______________
27 L.R.A. (N.S.) 1174; Moore v. Ivey, (Tex. Civ. App.) 264 S.W. 283; 21 R.C. L.
388.

11

10

157 So. 328 Fla. (1934)

492

492

SUPREME COURT REPORTS ANNOTATED

769.

Garcia-Rueda v. Pascasio, G.R. No. 118141, September 5, 1997, 278 SCRA

Literally, res ipsa loquitur means the thing speaks

for itself. It is the rule that the fact of the occurrence
Court laid down the following definition of proximate cause in this jurisdiction as
of an injury, taken with the surrounding
follows:
circumstances, may permit an inference or raise a
[T]hat cause, which, in natural and continuous sequence unbroken by any efficient
presumption of negligence, or make out a
intervening cause, produces the injury and without which the result would not have occurred.
plaintiffs prima facie case, and present a question of
And more comprehensively, the proximate cause is that acting first and producing the injury,
fact for defendant to meet with an explanation. Stated
either immediately or by setting other events in motion, all constituting a natural and
differently, where the thing which caused the injury,
continuous chain of events, each having a close causal connection with the immediate
without the fault of the injured, is under the exclusive
predecessor, the final event in the chain immediately effecting the injury as a natural and
control of the defendant and the injury is such that it
probable result of the cause which first acted, under which circumstances that the person
should not have occurred if he, having such control
responsible for the first event should, as an ordinarily prudent and intelligent person, have
used proper care, it affords reasonable evidence, in the
reasonable ground to expect at the moment of his act or default that an injury to some person
absence of explanation that the injury arose from the
might probably result therefrom.
defendants want of care, and the burden of proof is
493
VOL. 513, JANUARY 31, 2007
493 shifted to him to establish that he has observed due
Professional Services, Inc. vs. Agana
care and diligence.
From the foregoing statements of the rule, the
his deliberate concealment of the missing gauzes from
requisites for the applicability of the doctrine of res
the knowledge of Natividad and her family.
IIG.R.
No.
126467
ipsa loquitur are:(1) the occurrence of an injury; (2) the
Whether the Court of Appeals Erred in Absolving Dr.
thing which caused the injury was under the control
Fuentes of any Liability
and management of the defenThe Aganas assailed the dismissal by the trial court of
_______________
the case against Dr. Fuentes on the ground that it is
contrary to the doctrine of res ipsa loquitur. According
Ramos v. Court of Appeals, G.R. No. 124354, December 29, 1999, 321 SCRA
to them, the fact that the two pieces of gauze were left
584.
inside Natividads body is a prima facie evidence of Dr.
Africa v. Caltex (Phils.) Inc., 123 Phil. 280; 16 SCRA 448 (1966).
Fuentes negligence.
494
We are not convinced.
12

In the leading case of Vda. de Bataclan v. Medina, (102 Phil. 181[1957]), this

13

14

13

14

494

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana

dant; (3) the occurrence was such that in the ordinary

course of things, would not have happened if those who
had control or management used proper care;
and (4) the absence of explanation by the defendant.
Of the foregoing requisites, the most instrumental is
the control and management of the thing which
caused the injury.
We find the element of control and management of
the thing which caused the injury to be wanting.
Hence, the doctrine of res ipsa loquitur will not lie.
It was duly established that Dr. Ampil was the lead
surgeon during the operation of Natividad. He
requested the assistance of Dr. Fuentes only to
perform hysterectomy when he (Dr. Ampil) found that
the malignancy in her sigmoid area had spread to her
left ovary. Dr. Fuentes performed the surgery and
thereafter reported and showed his work to Dr.
Ampil. The latter examined it and finding everything to
be in order, allowed Dr. Fuentes to leave the operating
room. Dr. Ampil then resumed operating on Natividad.
He was about to finish the procedure when the
attending nurses informed him that two pieces of
gauze were missing. A diligent search was conducted,
but the misplaced gauzes were not found. Dr. Ampil
then directed that the incision be closed. During this
entire period, Dr. Fuentes was no longer in the
operating room and had, in fact, left the hospital.

Under the Captain of the Ship rule, the operating

surgeon is the person in complete charge of the
surgery room and all personnel connected with the
operation. Their duty is to obey his orders. As stated
before, Dr. Ampil was the lead surgeon. In other words,
he was the Captain of the Ship. That he discharged
such role is evident from his following
16

15

_______________

15

Ranos v. Court of Appeals, supra. In Ramos, the phrase used is control of

the instrumentality which caused the damage, citing St. Johns Hospital and
School of Nursing v. Chapman, 434 P2d 160 (1967).
16

Rural Educational Assn v. Bush, 42 Tenn. App. 34, 298 S.W. 2d 761 (1956).

495

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana

conduct: (1) calling Dr. Fuentes to perform a

hysterectomy;(2) examining the work of Dr. Fuentes
and finding it in order; (3) granting Dr. Fuentes
permission to leave; and (4)ordering the closure of the
incision. To our mind, it was this act of ordering the
closure of the incision notwithstanding that two pieces
of gauze remained unaccounted for, that caused injury
to Natividads body. Clearly, the control and
management of the thing which caused the injury was
in the hands of Dr. Ampil, not Dr. Fuentes.
In this jurisdiction, res ipsa loquitur is not a rule of
substantive law, hence, does not per se create or

495

constitute an independent or separate ground of

liability, being a mere evidentiary rule. In other
words, mere invocation and application of the doctrine
does not dispense with the requirement of proof of
negligence. Here, the negligence was proven to have
been committed by Dr. Ampil and not by Dr. Fuentes.
17

IIIG.R.
No.
126297
Whether PSI Is Liable for the Negligence of Dr. 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.
Until the mid-nineteenth century, hospitals were
generally charitable institutions, providing medical
services to the lowest classes of society, without regard
for a patients ability to pay. Those who could afford
medical treatment were usually treated at home by
their doctors. However, the days of house calls and
philanthropic health care are over. The modern health
care industry continues to distance itself from its
18

19

_______________

17

Ramos v. Court of Appeals, supra at footnote 13.

18

Levin, Hospital Vicarious Liability for Negligence by Independent Contractor

Physicians: A New Rule for New Times, October 17, 2005.

19

Id.

charitable past and has experienced a significant

conversion from a not-for-profit health care to forprofit hospital businesses. Consequently, significant
changes in health law have accompanied the businessrelated changes in the hospital industry. One
important legal change is an increase in hospital
liability for medical malpractice. Many courts now
allow claims for hospital vicarious liability under the
theories of respondeat superior, apparent authority,
ostensible authority, or agency by estoppel.
In this jurisdiction, the statute governing liability
for negligent acts is Article 2176 of the Civil Code,
which reads:
20

Art. 2176. Whoever by act or omission causes damage to another, there

being fault or negligence, is obliged to pay for the damage done. Such
fault or negligence, if there is no pre-existing contractual relation
between the parties, is called a quasi-delict and is governed by the
provisions of this Chapter.

A derivative of this provision is Article 2180, the rule

governing vicarious liability under the doctrine
ofrespondeat superior, thus:
ART. 2180. The obligation imposed by Article 2176 is demandable not
only for ones own acts or omissions, but also for those of persons for
whom one is responsible.
xxx

xxx

The owners and managers of an establishment or enterprise are

496

496

Professional Services, Inc. vs. Agana

SUPREME COURT REPORTS ANNOTATED

likewise responsible for damages caused by their employees in the

The
foregoing
view
is
grounded
on
the traditional notion that the professional status and
the very nature of the physicians calling preclude him
from being classed as an agent or employee of a
hospital, whenever he acts in a professional
capacity. It has been said that medical practice
strictly involves highly developed and specialized
knowledge, such that physicians are generally free to
exercise their own skill

service of the branches in which the latter are employed or on the

occasion of their functions.
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.
xxx

xxx

22

_______________

20

23

Id.

497

_______________

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana
The responsibility treated of in this article shall cease when the persons

497
21

Tolentino, The Civil Code of the Philippines, Volume V, 1992 Ed., p. 616.

22

Arkansas M.R. Co. v. Pearson, 98 Ark. 442, 153 SW 595 (1911);Runyan v.

herein mentioned prove that they observed all the diligence of a good

Goodrum, 147 Ark. 281, 228 SW 397, 13 ALR 1403 (1921);Rosane v. Senger, 112

father of a family to prevent damage.

Colo. 363, 149 P. 2d 372 (superseded by statute on other grounds); Moon v. Mercy

A prominent civilist commented that professionals

engaged by an employer, such as physicians, dentists,
and pharmacists, are not employees under this
article because the manner in which they perform
their work is not within the control of the latter
(employer). In
other
words,
professionals
are
considered personally liable for the fault or negligence
they commit in the discharge of their duties, and their
employer cannot be held liable for such fault or
negligence. In the context of the present case, a
hospital cannot be held liable for the fault or
negligence of a physician or surgeon in the treatment
or operation of patients.
21

Hosp., 150 Col. 430, 373 P. 2d 944 (1962);Austin v. Litvak, 682 P. 2d 41, 50 ALR
4th 225 (1984); Western Ins. Co. v. Brochner, 682 P. 2d 1213 (1983); Rodriguez v.
Denver, 702 P. 2d 1349 (1984).
23

Arkansas M.R. Co. v. Pearson, Id.; Nieto v. State, 952 P. 2d 834 (1997). But

see Beeck v. Tucson General Hosp., 18 Ariz. App. 165, 500 P. 2d 1153
(1972); Paintsville Hosp. Co., 683 SW 2d 255 (1985); Kelley v. Rossi, 395 Mass.
659, 481 NE 2d 1340 (1985) which held that a physicians professional status does
not prevent him or her from being a servant or agent of the hospital.

498

498

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana

and judgment in rendering medical services sans

interference. Hence, when a doctor practices medicine
24

in a hospital setting, the hospital and its employees

are deemed to subserve him in his ministrations to the
patient and his actions are of his own responsibility.
The case of Schloendorff v. Society of New York
Hospital was then considered an authority for this
view. The Schloendorff doctrine regards a physician,
even if employed by a hospital, as an independent
contractorbecause of the skill he exercises and the lack
of control exerted over his work. Under this doctrine,
hospitals are exempt from the application of
the respondeat superiorprinciple for fault or negligence
committed by physicians in the discharge of their
profession.
However, the efficacy of the foregoing doctrine has
weakened with the significant developments in
medical care. Courts came to realize that modern
hospitals are increasingly taking active role in
supplying and regulating medical care to patients. No
longer were a hospitals functions limited to furnishing
room, food, facilities for treatment and operation, and
attendants for its patients. Thus, in Bing v.
Thunig, the New York Court of Appeals deviated from
the Schloendorff doctrine,
noting
that
modern
hospitals actually do far more than provide facilities
for treatment. Rather, they regularly
25

26

27

25

Kitto v. Gilbert, 39 Colo App 374, 570 P. 2d 544 (1977).

26

211 N.Y. 125, 105 N.E. 92, 52 L.R.A., N.S., 505 (1914). The court

inSchloendorff opined that a hospital does not act through physicians but merely
procures them to act on their own initiative and responsibility. For subsequent
application of the doctrine, see for instance, Hendrickson v. Hodkin, 250 App. Div
649, 294 NYS 982, revd on other grounds, 276 NY 252, 11 NE 2d 899
(1937); Necolayff v. Genesee Hosp., 270 App. Div. 648, 61 NYS 2d 832, affd 296 NY
936, 73 NE2d 117 (1946); Davie v. Lenox Hill Hosp., Inc., 81 NYS 2d 583
(1948); Roth v. Beth El Hosp., Inc., 279 App. Div 917, 110 NYS 2d 583
(1952); Rufino v. US, 126 F. Supp. 132 (1954);Mrachek v. Sunshine Biscuit, Inc.,
308 NY 116, 123 N.E. 2d 801 (1954).
27

2 NY 2d 656, 163 NYS 2d 3, 143 N.E. 2d 3 (1957).

499

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana

499

employ, on a salaried basis, a large staff of physicians,

interns, nurses, administrative and manual workers.
They charge patients for medical care and treatment,
even collecting for such services through legal action, if
necessary. The court then concluded that there is no
reason to exempt hospitals from the universal rule
of respondeat superior.
In our shores, the nature of the relationship
between the hospital and the physicians is rendered
inconsequential
in
view
of
our
categorical
pronouncement in Ramos v. Court of Appeals that for
purposes of apportioning responsibility in medical
negligence cases, an employer-employee relationship in
28

_______________

24

Fridena v. Evans, 127 Ariz. 516, 522 P. 2d 463 (1980).

effect exists between hospitals and their attending and

visiting physicians. This Court held:

privilege of being able to maintain a clinic in the hospital, and/or

We now discuss the responsibility of the hospital in this particular

for the privilege of admitting patients into the hospital. In

incident. The unique practice (among private hospitals) of filling up

addition to these, the physicians performance as a specialist is generally

specialist staff with attending and visiting consultants, who are

evaluated by a peer review committee on the basis of mortality and

allegedly not hospital employees, presents problems in apportioning

morbidity statistics, and feedback from patients, nurses, interns and

responsibility for negligence in medical malpractice cases. However, the

residents. A consultant remiss in his duties, or a consultant who

difficulty is more apparent than real.

regularly falls short of the minimum standards acceptable to the

In the first place, hospitals exercise significant control in the

hiring and firing of consultants and in the conduct of their work

Professional Services, Inc. vs. Agana

hospital or its peer review committee, is normally politely

terminated.

within the hospital premises. Doctors who apply for consultant

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

slots, visiting or attending, are required to submit proof of

control over their attending and visiting consultant staff. While

completion

qualifications,

consultants are not, technically employees, x x x, the control

generally, evidence of accreditation by the appropriate board

exercised, the hiring, and the right to terminate consultants all

(diplomate), evidence of fellowship in most cases, and references.

fulfill

These requirements are carefully scrutinized by members of the

relationship, with the exception of the payment of wages. In

hospital administration or by a review committee set up by the

assessing whether such a relationship in fact exists, the control test is

hospital who either accept or reject the application. x x x.

determining. Accordingly, on the basis of the foregoing, we rule that for

of

residency,

their

educational

the

important

hallmarks

of

an

employer-employee

After a physician is accepted, either as a visiting or attending

the purpose of allocating responsibility in medical negligence

consultant, he is normally required to attend clinicopathological

cases, an employeremployee relationship in effect exists between

conferences, conduct bedside rounds for clerks, interns and

hospitals and their attending and visiting physicians.

residents, moderate grand rounds and patient audits and

But the Ramos pronouncement is not our only basis in

sustaining PSIs liability. 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 hospitals liability for negligent acts
of health professionals. The present case serves as a

perform other tasks and responsibilities, for the

_______________

28

Supra at footnote 13.

500

500

SUPREME COURT REPORTS ANNOTATED

perfect platform to test the applicability of these

doctrines, thus, enriching our jurisprudence.
Apparent authority, or what is sometimes referred
to as the holding out theory, or doctrine of ostensible
agency or agency by estoppel, has its origin from the
law of agency. It

business usages and the nature of the particular business, is justified in

_______________

_______________

presuming that such agent has authority to perform the particular act in
question.

31

The applicability of apparent authority in the field of

hospital liability was upheld long time ago in Irving v.
Doctor Hos-

29

Blacks Law Dictionary (6th Ed. 1990) 1100. The terms ostensible agency,

579 P2d 970 (1978). Agency by estoppel is defined as one created by operation

agency by estoppel, apparent authority, and holding out tend to be used

of law and established by proof of such acts of the principal as reasonably lead

interchangeably by the courts to refer to this theory of liability. See for

third persons to the conclusion of its existence. Arises where principal by

instance, Baker v. Werner, 654 P2d 263 (1982) andAdamski v. Tacoma Gen. Hosp.,

negligence in failing to supervise agents affairs, allows agent to exercise powers

20 Wash App. 98,

not granted to him, thus justifying others in believing the agent possesses

29

501

requisite authority. Blacks, supra, p. 62. An ostensible agency is an implied or

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana

imposes liability, not as the result of the reality of a

contractual relationship, 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. The concept is
essentially one of estoppel and has been explained in
this manner:
30

The principal is bound by the acts of his agent with the apparent
authority which he knowingly permits the agent to assume, or which he
holds the agent out to the public as possessing. 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, conversant with

501

presumptive agency which exists where one, either intentionally or from want of
ordinary care, induces another to believe that a third person is his agent, though
he never in fact, employed him. It is, strictly speaking, no agency at all, but is in
reality based entirely upon estoppel. Apparent authority refers to the power to
affect the legal relations of another person by transactions with third persons,
professedly as agent for the other, arising from and in accordance with the others
manifestations to such third persons. Supra, p. 96.
30

Irving v. Doctors Hospital of Lake Worth, Inc., 415 So. 2d 55 (1982),

quoting Arthur v. St. Peters Hospital, 169 N.J. 575, 405 A. 2d 443 (1979).
31

Id., citing Hudson v. C., Loan Assn., Inc. v. Horowytz, 116 N.J.L. 605, 608,

186 A 437 (Sup. Ct. 1936).

502

502

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana

pital of Lake Worth, Inc. There, 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. Thus, in cases
where it can be shown that a hospital, by its actions,
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, then the
hospital will be liable for the physicians negligence.
Our jurisdiction recognizes the concept of an agency
by implication or estoppel. Article 1869 of the Civil
Code reads:
32

ART. 1869. Agency may be express, or implied from the acts of the

quality health care services. By accrediting Dr. Ampil

and Dr. Fuentes and publicly advertising their
qualifications, the hospital created the impression that
they were its agents, authorized to perform medical or
surgical services for its patients. As expected, these
patients, Natividad being one of them, accepted the
services on the reasonable belief that such were being
rendered by the hospital or its employees, agents, or
servants. The trial court correctly pointed out:
_______________

32

Supra.

503

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana

principal, from his silence or lack of action, or his failure to repudiate the
agency, knowing that another person is acting on his behalf without
authority.

In this case, PSI publicly displays in the lobby of the

Medical City Hospital the names and specializations of
the physicians associated or accredited by it, including
those of Dr. Ampil and Dr. Fuentes. 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. Indeed, PSIs act is tantamount
to holding out to the public that Medical City
Hospital, through its accredited physicians, offers

503

x x x regardless of the education and status in life of the patient,

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 hospitals act of

listing him and his specialty in its lobby directory, as in the case
herein. The high costs of todays medical and health care should
at least exact on the hospital greater, if not broader, legal
responsibility for the conduct of treatment and surgery within
its facility by its accredited physician or surgeon, regardless of
whether he is independent or employed.

33

The wisdom of the foregoing ratiocination is easy to

discern. Corporate entities, like PSI, are capable of

acting only through other individuals, such as

physicians. If these accredited physicians do their job
well, the hospital succeeds in its mission of offering
quality medical services and thus profits financially.
Logically, where negligence mars the quality of its
services, the hospital should not be allowed to escape
liability for the acts of its ostensible agents.
We now proceed to the doctrine of corporate
negligence or corporate responsibility.
One allegation in the complaint in Civil Case No. Q43332 for negligence and malpractice is that PSI as
owner, operator and manager of Medical City Hospital,
did not perform the necessary supervision nor exercise
diligent efforts in the supervision of Drs. Ampil and
Fuentes and its nursing staff, resident doctors, and
medical interns who assisted Drs. Ampil and Fuentes
in
the
performance
of
their
duties
as
surgeons. Premised on the doctrine of corporate
negligence, the trial court held that PSI is directly
liable for such breach of duty.
We agree with the trial court.
34

_______________

33

RTC Decision, p. 9, Rollo of G.R. No. 126467, p. 127.

34

RTC Decision, p. 2, Rollo of G.R. No. 126467, p. 120.

504

504

Recent years have seen the doctrine of corporate

negligence as the judicial answer to the problem of
allocating hospitals liability for the negligent acts of
health practitioners, absent facts to support the
application
ofrespondeat
superior or
apparent
authority. Its formulation proceeds from the judiciarys
acknowledgment that in these modern times, the duty
of providing quality medical service is no longer the
sole prerogative and responsibility of the physician.
The modern hospitals have changed structure.
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.
The doctrine has its genesis in Darling v.
Charleston Community Hospital. There, the Supreme
Court of Illinois held that the jury could have found a
hospital negligent, inter alia, in failing to have a
sufficient number of trained nurses attending the
patient; failing to require a consultation with or
examination by members of the hospital staff; and
failing to review the treatment rendered to the patient.
On the basis of Darling, other jurisdictions held that a
hospitals corporate negligence extends to permitting a
physician known to be incompetent to practice at the
hospital. With the passage of time, more duties were
expected from hospitals, among them: (1) the use of
35

36

37

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana

reasonable care in the maintenance of safe and

adequate facilities and equipment; (2) the selection and
retention of competent physicians; (3) the overseeing or
supervision of all persons who practice medicine within
its walls; and (4) the formulation, adoption and
enforcement of adequate rules

and administered by the physicians practicing in its

premises.
In the present case, 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. Accordingly, it has the duty to
exercise reasonable care to protect from harm all
patients admitted into its facility for medical
treatment.Unfortunately, PSI failed to perform such
duty. The findings of the trial court are convincing,
thus:

_______________

35

Purcell v. Zimbelman, 18 Ariz. App. 75, 500 P2d 335 (1972).

36

Supra at footnote 1.

37

Corleto v. Hospital, 138 N.J. Super. 302, 350 A. 2d 534 (Super. Ct. Law

x x x PSIs liability is traceable to its failure to conduct an

Div.1975); Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972); Hospital

investigation of the matter reported in the nota bene of the count

Authority v. Joiner, 229 Ga. 140,189 S.E. 2d 412 (1972).

nurse. Such failure established PSIs part in the dark conspiracy

505

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana

and policies that ensure quality care for its

patients. Thus, in Tucson Medical Center, Inc. v.
Misevich, it was held that a hospital, following the
doctrine of corporate responsibility, has the duty to see
that it meets the standards of responsibilities for the
care of patients. Such duty includes the proper
supervision of the members of its medical staff. And
in Bost v. Riley, the court concluded that a patient
who enters a hospital does so with the reasonable
expectation that it will attempt to cure him. The
hospital accordingly has the duty to make a reasonable
effort to monitor and oversee the treatment prescribed
38

39

505

of

silence

and

concealment

about

the

gauzes. Ethical

considerations, if not also legal, dictated the holding of an immediate

inquiry into the events, if not for the benefit of the patient to whom the
duty is primarily owed, then in the interest of arriving at the truth. The
Court cannot accept that the medical and the healing professions,
through their members like defendant surgeons, and their institutions
like PSIs hospital facility, 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
Natividads case.

40

_______________

38

Welsh v. Bulger, 548 Pa. 504, 698 A.2d 581 (1997).

39

115 Ariz. 34, 545 P2d 958 (1976).

40

262 S.E. 2d 391, cert denied 300 NC 194, 269 S.E. 2d 621 (1980).

506

506

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana

It is worthy to note that Dr. Ampil and Dr. Fuentes

operated on Natividad with the assistance of the
Medical City Hospitals staff, composed of resident
doctors, nurses, and interns. As such, it is reasonable
to conclude that PSI, as the operator of the hospital,
has actual or constructiveknowledge of the procedures
carried out, particularly the report of the attending
nurses that the two pieces of gauze were missing.
In Fridena v. Evans, 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. This means that the knowledge of
any of the staff of Medical City Hospital constitutes
knowledge of PSI. Now, the failure of PSI, despite the
attending nurses report, to investigate and inform
Natividad regarding the missing gauzes amounts to
callous negligence. Not only did PSI breach its duties
to oversee or supervise all persons who practice
medicine within its walls, it also failed to take an
active step in fixing the negligence committed. This
renders PSI, not only vicariously liable for the
negligence of Dr. Ampil under Article 2180 of the Civil
Code, but alsodirectly liable for its own negligence
41

under Article 2176. In Fridena, the Supreme Court of

Arizona held:
x x x In recent years, however, the duty of care owed to the patient by
the hospital has expanded. 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. See Kahn
Hospital Malpractice Prevention, 27 De Paul Rev. 23 (1977).
Among the cases indicative of the emerging trend is Purcell v.
Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972). In Purcell, the
hospital argued that it could not be held liable for the malpractice of a
medical practitioner because he was an independent contractor within
the hospital. The Court of Appeals pointed out that the hospital
had created a professional staff whose competence
_______________

41

127 Ariz. 516, 622 P. 2d 463 (1980).

507

VOL. 513, JANUARY 31, 2007

Professional Services, Inc. vs. Agana
and performance was to be monitored and reviewed by the
governing body of the hospital, 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.
Subsequent to the Purcell decision, the Arizona Court of
Appeals held that a hospital has certain inherent responsibilities
regarding the quality of medical care furnished to patients

507

within its walls and it must meet the standards of responsibility

commensurate with this undertaking. Beeck v. Tucson General

must possess that reasonable degree of learning, skill

and experience required by
508

Hospital, 18 Ariz. App. 165, 500 P. 2d 1153 (1972). This court has
confirmed the rulings of the Court of Appeals that a hospital has the duty

508

of supervising the competence of the doctors on its staff. x x x.

xxx

xxx

In the amended complaint, the plaintiffs did plead that the operation
was performed at the hospital with its knowledge, aid, and assistance,
and that the negligence of the defendants was the proximate cause of the
patients injuries. We

find

that

such

general

allegations

of

negligence, along with the evidence produced at the trial of this

case, are sufficient to support the hospitals liability based on the
theory of negligent supervision.

Anent the corollary issue of whether PSI is solidarily

liable with Dr. Ampil for damages, let it be emphasized
that PSI, apart from a general denial of its
responsibility, 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. In
neglecting to offer such proof, PSI failed to discharge
its burden under the last paragraph of Article 2180
cited earlier, and, therefore, must be adjudged
solidarily liable with Dr. Ampil. Moreover, as we have
discussed, PSI is also directly liable to the Aganas.
One final word. Once a physician undertakes the
treatment and care of a patient, the law imposes on
him certain obligations. In order to escape liability, he

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana

his profession. At the same time, he must apply

reasonable care and diligence in the exercise of his
skill and the application of his knowledge, and exert
his best judgment.
WHEREFORE, we DENY all the petitions and
AFFIRM the challenged Decision of the Court of
Appeals in CA-G.R. CV No. 42062 and CA-G.R. SP No.
32198.
Costs against petitioners PSI and Dr. Miguel Ampil.
SO ORDERED.
Puno (C.J., Chairperson), Corona and Azcuna,
JJ., concur.
Garcia, J., No part.
Petitions denied, challenged CA decision in CA-G.R.
No. CV No. 42062 and CA-G.R. SP No. 32198 affirmed.
Note.Under the Captain-of-the-Ship Doctrine, a
surgeon is likened to a captain of the ship in that it is
his duty to control everything going on in the
operating room. (Ramos vs. Court of Appeals, 380
SCRA 467 [2002])
o0o