LEGAL MEDICINE Petition for review under Rule 45 RIC: Allowed respondents to take oth and register CA: affirmed r fh oF ey passed the Physician Licensure ination conducted in February 1993 by the Board of Medicin PRC then released their names as successful examinees in the medical licensure examination. ‘The Boars observe that the\grades ofthe 79 successul examinees! fram Fatima Colege inthe two most dificult subject inthe medial licensure exam, ‘Blocheristry (Bio-Chem) and Obstetrics and Gecibey OP Biel Were Unusual vod: exceptional igh) 1 Fatima examines Scored 100% nSk-Chem and 10 g0 10% in Os-Gime, another 11 got 99% In i-Chem, and 21 unred 99% in Ose. he ord od ot el wo ped from Fatima got marks of or better in subjects, and no one Wp RI TRA OESD: compara ce porters of er SORE ort orca ioale nas ase, Toe nae ech thoes tein Neh answer on OMRERIMED twas 's reowsrastng hevcrneed toa Wife We Pies tare Barinetony ‘The Board issued a Resolution. The Board requested FRvBienVEhdO FS NEbIES Sj fon expert tmatheratian and authorty in statist, and later president ofthe ‘Ateneo de Mania University, to conduct a statistical analss ofthe reautsin io-Chem and Ob-Gyne othe sald examination Fr. Nebres reported that a comparison of the scores in Bio-Chem ‘and Ob-Gyne, of the Fatima College examinees with those of examinees from De La Sale Unversity and Perpetual Hep Colas of Medicine showed that the scores of Fatima College examinees were! ‘not only incredibly high but unusually clustered close to each other. He concluded that there must be some unusual reason creating the clustering of scores in the two subjects. It must be a cause strong ‘enough to eliminate the normal variations that one should expect from the examinees [of Fatima College] in terms of talent, effort, energy, etc. ‘NBI found that the questionable passing we re Respondents (Arlene V. De Guzman et of, fled a special civil action for mandamus, with prayer for preliminary mandatory injunction with ATC, Meanwhile, the Board issued 2 Resolution charging respondents ‘with immorality, dishonest conduct, fraud, and deceit in connection with the Bio: It recommended that the Elbe an oer rig he sinacion SOuEM ty te repontens toatl Rea the piscine onthfo lene V. De Gutman er and ee te panei ie Sorte Theypettionastien fed 3 ith cA, {0 set aside the mandatory injunctive wrt. This petition was ranted. RULING: Yes On The Existence of o Duty of the Board of Medicine To Issue ‘ertficates of Registration as Physicians under Rep. Act No. 2382. For mandamus to prosper, there must be a showing that the officer, board, or official concerned, has a clear legal duty, not involving, discretion. Moreover, there must be statutory authority for the performance of the act, and the performance of the duty has been Tefused. Thus, it must be pertinently asked now: Did petitioners have the duty to administer the Hippocratic Oath and register respondents as physicians under the Medical Act of 1959? ‘As found by CA, on which we agree on the basis ofthe records: Ie bears emphasing. herein. ca: (raommpappalaces aa inerenot appellee Rae fl conpleePURIPaT he SGN dT fequirements for admission into the licensure examinations for ‘physicians conducted and administered by the respondent- epelonts on February 12,18, 2 and 2,199. Ses, to, mus bbe made of the fact that all of them successfully passe eee A careful reading of that the law uses the word ith respect to the issuance of certificates of registration. TAds-the petitioners shall sign and issue certificates of registration to those who have satisfactorily complied with the requirements of the Board. In statutory construction the term shall is a word of command. {It is given imperative meaning. Thus, when an examinee satisfies the requirements for the grant of pvc hws vs cg one om ‘oath and register him as a physician, pursuant to Section 20 and pac. (hot section a ofthe Media act of 1959. However, the surrounding circumstances in this case cal for serious inquiry concerning the satisfactory compliance with the Board requirements by the cespondents. The unusually high scores in the two most difficult subjects was phenomenal, according to Fr. Nebres, the consultant of PRC on the matter, and raised grave doubts about the integrity, if not validity, of the tests. These doubts have to be appropriately resolved. Under the\second paragraph of Section’22;the Board is vested with the power to conduct administrative investigations and disapprove applications for examination or registration, pursuant to. the objectives of Rep. Act No, 2382 as outlined in Section 1 thereof Until the moral/and’ mental fitness of the’ respondents could faaee to petitioners, the Board has diser eg in abeyance the administration ofthe Hippocratic Oath and the, cates nda Sections of Reps Act Now 2382 prescrbes, among others, that 9 Person who aspires to practice medicine in the Philippines, must hhave satisfactorily passed the corresponding Board Examination. Section 22, in turn, provides that the oath may only be administered to physic Qualified in the examinations. The operative word here isGatisfactoril) defined as sufficient to meet a condition of obligation fe of dispelin ‘Or ignorance, Gleaned from m he licensing authority apparently did not find that the respondents satisfactorily passed the’ licensure examinations. The Board instead sought to'nulliy the examination results obtained by the respondents. @on te ian ofthe respondents To Be Regiered s Physiion ‘The function of mandamus an ca al remedy, and the writ of mandamus is a legal remedy for a legal right. There must be a well-defined, clear and certainLEGAL MEDICINE The aforementioned guidelines are provided for injReps/Act|No:y ‘amended, which prescribes thdequirements for admission to the practice of medicine®he qualifications of candidates for the board examinations, th€@icope and conduct of the examinations, Qe grounds for denying the issuance of a physicians license, or ‘@evoking a license that has been issued. Verily, to be granted the privilege to practice medicine, the applicant must show that he possesses all the qualifications and none of the disqualifications. Furthermore, it must appear that he has fully with all the conditions and requirements imposed by the law and the licensing authority. Should doubt taint or mar the compliance as being less than satisfactory, then the privilege will not issue, For said privilege is distinguishable from a matter of ght, “which may be demanded if denied. Thus, without a definite showing that” the aforesaid) requirements and conditions have been satisfactorily met, the courts may not grant the writ of mandamus to secure sald privilege without thwarting the legislative will 3.) On the Ripeness of the Petition for Mandamus Section 260f the Medical Act of 1959 provides for the administrative and judicial remedies that respondents herein can avail to question Resolution No. 26 of the Board of Medicine, ‘namely: (a) appeal the unfavorable judgment to the PRC; (b) should the PRC ruling still be unfavorable, to elevate the matter on appeal to the Office of the President; and (c) should they still be unsatisfied, to ask for a review of the case or to bring the case to court viaa special civil action of certiorari. Thus, aS_a_tule, ‘mandamus! will not fielwhen administrative remedies are still availables However, the doctrine of exhaustion of administrative remedies does not apply where, as in this case, a pure question of Jaws raised. On this issue, no reversible error may, thus, be laid at the door of the appellate court. ‘This Decisions binding only onthe remeining respondents, namely: Acene V de Guzmon, ClerinaS Novorro, Roe! |. Tolentino, Bernordite Sy, Glerio 7: Jularbl, Hubert. Nezareno, Nancy J. Chavez, Ernesto L. Cue, Herminio V. Fernandes, J, Morie Victoria IM. Leesomona and Mery O. Ste. Ain, os well, (0 the petitioners. 2. DECS vs. SAN DI claims that he took the NMAT three times and flunked it as many’ times; When he applied to take it again, the petitioner rejected his application. The petitioner contends he may not, under its rule that hh) A student shall be allowed only three (3) chances to take the NMAT. After three (3} successive failures, a student shall not be allowed to take the NMAT for the fourth time. ‘The private respondent insists he can, on constitutional grounds. He then went to RTC Valenzuela, to compel his admission to the test. In his original petition for mandamus, he first invoked his ‘constitutional rights to academic freedom and uality education| By ‘agreement of the parties, nged. the constitutionalty of the above-cited rule. ‘The additional grounds raised were due process and equal protection, |RTCjtigeldeciored the chalenad ordes valde It was held thatthe patitoner had been deprived of his fight to pursue a medial education through an arbitrary exercise of the police power, >) Whether 2 person who has thrice failed the National Admission Test (NMAT) is entitled to take it again. HELD: NO. We cannot sustain the respondent judge. Her decision must be reversed. In his Court Upheld the Constitutionality of the NMAT as a measure intended to limit the admission to medical schools only to those who have intially proved their competence, and preparation for a medical education. ‘The proper exercise of the police power requires the concurrence of a lawful subject and a lawful method. The subject ofthe challenged regulation.is certainly within the.ambit of the:police,power,Itis the right and indeed the responsibilty of the State to insure that the imedial_ profession ig not infltrated by incompetents to_whom) Patients may unwarlly entrust thelr lives and health. ‘The method employed by the challenged regulation is not irrelevant to the purpose of the law nor isi arbitrary or oppressive. The three: flunk ‘rule is intended’ to’ insulate the medical schools and ultimately the medical profession from the intrusion of those not qualified to be doctors. While every person is entitled to aspire to be a doctor, he'doesinot) hhaVe'a' constitutional right to be/a doctor! This is true of any other calling in which the public interest is involved; and the closer the link, the longer the bridge to one’s ambition. The State has the responsibilty to harness its human resources and to see to it that they are not dissipated or, no less worse, not used at all. These resources must be applied in a manner that will best promote the ‘common good while also giving the individual @ sense of satisfaction. ‘A person cannot insist on being a physician if he will be'a menace to his patients. f one who wants to be a lawyer may prove better ‘36 a plumber, he should be so advised and adviced. Of course, he may not be forced to be a plumber, but on the otfier hand he may not force his entry into the bar. By the same token, a student who hhas demonstrated promise as a pianist cannot be shunted aside to take a course in nursing, however appropriate this career may be for others. The to alt education voted by the private respondent There can be no question that a Substantial distinction "ests [between medical” studentsand other students) who are not subjected to the NMAT and the three-flunk rule. The medical profession directly affects the very lives of the people, unlike other careers which, for this reason, do not require more vigilant regulation. ‘The Court feels that itis not enough to simply invoke the right to uality education as a guarantee of the Constitution: one must show ‘that he is entitled to it because of his preparation and promise. The private respondent has failed the NMAT five times. While his ppersistence is noteworthy, to say the least, it is certainly misplaced, like a hopelesslove-K 11's 4AM ana this? No depreciation is intended or made against the private respondent. I is stressed that a person who does not qualify in the NMAT is not an absolute incompetent unfit for any work orLEGAL MEDICINE ‘occupation. The only-inference is that-he-is-a-probably-better,-not. for-the:medical. profession, but-for-another-caling that has-not excited his interest In the former, he may be a bungler or at least lackluster; in the latter, he is more likely to succeed and may even be outstanding. It Is for the appropriate calling that he is entitled to quality education for the full harnessing of his potentials and the sharpening of his Fatent talents toward what may even be a briliant future We cannot have a society of square pegs in round holes, of dentists who should never have left the farm and engineers who should have studied banking and teachers who could be better as merchants, Ie is time indeed that the State took decisive steps to regulate and enrich our system of education by directing the student to the course for which he is best suited as determined by intial tests and evaluations. Otherwise, Wet in who prescribed ‘medicines which she religiously took. Nevertheless, the abdominal pains and fever kept on recurring and bothered Mrs. Villegas to no : lof the exaanalion mpeled Kr agg tat Mr igs be aah rh hh! inte atl wien sh oe he atone o vee peed eee asicliacoera tones ofthe lett nd rah ovres which gave out pus eta pos being the urs ands pee of ube ateralson the ight seo the tts embered on] Uw oratan et 2 ches 6a size. This piece of rubber material described as a have been a torn section of a surgeon's 5 oF could have come from other sources. And this foreign ‘body was the cause of the infection of the ovaries and consequently ofall the discomfort suffered by Mrs, Villegas after her delivery. ‘There are now two different versions on the whereabouts of that offending "rubber" (1) that it was sent to the Pathologist in Cebu as testified to in Court by Dr. Kho and (2) that Or. Kho threw it away as told by her to Defencant. ISSUE: The appreciation of Or. Kho's testimony. RULING: While the petitioners claim that contradictions and falsties punctured Or. Kho's testimony, a reading of the said testimony reveals no such infirmity and establishes Dr. Kho as a credible witness. Dr. Kho was frank throughout her turn on the witness Considering that we have assessed Dr. Kho to be a credible witness, her positive testimony (that a piece of rubber was indeed found in private respondent Villegas’ abdomen] prevails over the negative testimony in favor of the petitioners. ‘As such, the rule of res ipsa loquitur comes to fore ebuttable presui lant was negligent, which arises upon proof that [the] instrumentality causing injury was in defendant's exclusive control, and that the accident was one which ordinary does not happen in absence of negligence. Res ipso Inthe insfant case, arse» entire proceedings of the cé 3n section were tunder the exclusive control of Or. Batiqun. In tis ligt, the private respondents were bereft of direct evidence as to the actual culprit or the exact cause of the foreign object finding its way into private respondent Vilegas' body, which, needless to es not occur unless through the intervention of negligencet ince aside from the cesarean section, private respondent Vilegas underwent no other operation which could have caused the offending piece of rubber to appear in her uterus, it stands to reason that such could only have been a by-product of the c Dr, Batiquin. The: CU Sometime in 1985, finda Ramos} was advised to undergo an operation for the removal of a stone in her gall bladder (cholecystectomy). She was referred to:DrsHosaka/a surgeon, who agreed to perform the operation on her.The operation was Scheduled for June 17, 1985 at 9:00 in the morni Erlinda was admitted to the DLSMC the day before the scheduled ‘operation. By 7:30 in the morning of the following day, petitioner Erlinda was already being prepared for operation. Upon the request ‘of petitioner Erlinda, her sister-in-law, /Herminda Cruz! who was then pe e was allowed to accompany her 5 morning, when Rogelio already wanted to pull out his wife from the operating room. He met: ‘who remarked that he was also tired of waiting for Or. Hosaka. DrLEGAL MEDICINE Hosaka ie E88 was then sil inside the operating room, heard about Dr. Hosakas arrival. While she held the hand oF Ena, Cri saw Oe Gutired tring to intubate the patent. Cruz heard Dr. Gutierrez Utter ong firap masintubate nto, mali yaa ang pogtokapasok. 0 [umole ong tion Cruz noticed a Bish dscoloraton of Erindas ralleds on er left hand. She then heard Dr. Hosaka instruct Someone to call Dr: Calderon, another anesthesoigist When he arrived, Dr. Caléeron attempted to intubate the patient. The railbeds ofthe patient remained bush, thus, she was placed ina A postion wiere the Mead ofthe patient is ,, "placed ina poston lowe than her fet. 3 WORD! ‘at almost 3:00 in the afternoon, she saw Ends bing Wheeled ta ihe fCUsThe decors explained to petitioner Rogelio that his wie had bronchospasm, Eins stayed in the ICU for @ month She was released from the hosital ony four non lter, Since he i-ated opeation, lind remained in comatose condition unt sh Pettoner filed with te RTCof Quezon City chi case for damages aoinst prvate respondents,RTCFendered judgment in favor off petioners:On appeal by private respondents, the “Tesdecsion! gkoncriospasm sudden consiricin of the muses in te nals of the bronchioles; ISSUE: abnormal contraction of smooth muscl€ oF the 1. WON Dr. GutbrretTaiesthesilogst is lable for neligence 2. WON Dr Hosaka (surgeon) abe For negligence ; and 2, WON DISMC sable for any act of negligence commited by thei Visiting consultant surgeon and anesthesiologist. RUSCULT~ fo listen (heart, ngs, Fie OE RR ts ilo GANAS noraibhpreonsrat evaluation-on Erlinda. As she herself admitted, she saw Erlinda for the fist time on the day ofthe operation itself, one hour before the scheduled operation. she GisculttaBthe patients heart and lungs and checked the laters blood pressure to determine if Eriinda was endelenburg pe indeed fit for operation. However, Shedd not proceed to examine taken by physicians er Sep ts Sa CEN tbe a ee ee ea ony aneRaUe before the scheduled operate procedure was °c, therefore, an act_of exceptional negligence and_ profesional o upholffresponsibility: ‘The measures cautioning prudence and vigilance In” Mal esi wih human lives lie a the core ofthe physicians centres- dards cleGippocratic ORT He flue to folow this medical procedure, therefore, @ clearindicia of her negligence. It was the faulty intubation on Erlinda that caused her comatose condition. There is ro question that Erlinda became comatose after Or. Gutierrez performed a medical procedure on her The€QRSRBLIsh coloration ofthe skin or mucous membranes caused rfock of nen or abnormal hemogoin nthe lod) ad enlargement of the stomach of Etnds indate that the tndovoceal tube was impronety igered ite the esophagus ata ofthe tacheo,Conseauert, xen Was Gelvared t the lungs bok fo tHe qasoinestnal tact Ths concson Is Supported by the fet that Enda wat leced in wrecelenburg postion. This ndeaes tat thee was a decease of blood spa 0 the patients brain. The brain was thus temporarily deprived of ‘oxygen supply causing Erlinda to go into coma.The BR.HOSAKA is tigble, ‘e. 2 Wes) Bre ves For ene pecana? Facil circumstances obtaining in this case justly the application of the|Captain-othe:ship GORI the fats on record it can be logically inferred that Dr. Hosaka exercised a certain degree of, at the Very least, supervision oer the procedure then being performed on Ernda (Gis) t was Dr. Hoska who recommended to pettioners the services of Dr. Gutierrez. In elfect, he represented to petitioners that Dr. Guieres possessed the necessary competence and ski. Whenever Dr. Hosaka performed a surgery, he would always engage the services of Or. Gutiere to administer the anesthesia on hie patient ond) Dr. Hosaka himself admitted that he was the attending Dilan of Elinda, Thus, when Erlinda showed signs ofeyanoss, it was r. Hosaka who gave instructions to call for another anesthesiologist and cardiologist to help resuscitate Erlinda. Chird) ors. Hosaka and Gutierrez worked as a team. Their duties Inleraect with each other br, Hosaka was keeping an eye on the intubation of the patient by br. Gutierrez, and while doing so, he observed that the patients rails had become dusky and had to call Dr. Gutierrezs attention thereto. They have a common responsiblity to treat the patient, which responsibility necessitates that they call each others attention to the condition of the patient while the other physician Is performing the necessary medical procedures. duty of attending to petitioner Erlinda promptly for he arrived more than 3 hours late for the scheduled operation. The unreasonable [delay In petitioner Erindas scheduled operation subjected her to, continued starvation and consequently, to the risk acidosis, or the Condition of decreased alkalinity of the blood and tissues, marked by sickly sweet breath, headache, nausea and vomiting, and visual Gisturbances, The long period that Dr. Hosaka made Erlinda wait for hhim certainly (aggravated the)anetyithat she must have been feeling at the time. It could be safely sid that her anxiety adversely affected the administration of anesthesia on her. It is equally important to point out that Or. Hosaka was remiss in his | brs Hosaka's responsible ‘conduct of arriving very late for the Scheduled operation of petitioner Erlinda is violative, not only of his, duty as a physician to serve the interest of his patients with the sreatest solcitude, giving them always his best talent and skil, but busMic, NOT HABLE. 3.NOs There is no emplayer-employée relationship between DISMC ‘and Ors. Cue SEER HSSEE WET WoUTE Ral OLSMC soliary liable for the injury suffered by petitioner Erlinda under/Article 2180) Further, no evidence was adduced to show that the injury suffered by petitioner Erlinda was due to a failure on the part of respondent DLSMC to provide for hospital facilities and staff necessary for her treatment. oe Ey BHLEGAL MEDICINE Facts: Pregnant with her ath child, Corazon Nogales, 37 years old, ‘was under the exclusive prenatal care of Dr. Oscar Estrada beginning ‘on her ath month of pregnancy or as early as December 1975. While Corazon was on her last trimester of pregnancy, Dr, Estrade noted fan increase in her blood pressure and development of leg edemaindicating preeclampsia,which is a dangerous complication of pregnancy. ‘Around midnight of 25 May 1976, Corazon started to experience ‘mild labor pains prompting Corazon and Rogelio Nogales to see Dr. Estrada at his home. After examining Corazon, Or. Estrada advised her immediate admission to the Capitol Medical Center (CMC). (On 26 May 1976, Corazon was admitted at 2:30 am. at the CMC after the staff nurse noted the written admission requestof Or. Estrada. Corazon was then brought to the labor room of the CMC. Dr. Rosa Uy, who was then a resident physician of CMC, conducted ‘an internal examination of Corazon. Dr. Uy then called up Or. estrada to—notify him = of-—her_‘findings. Based on the Doctor's Order Sheet, around 3:00 a.m., Dr. Estrada ordered for 10 mg. of valium to be administered immediately by ‘nteamuscular injection. Dr. Estrada later ordered the start of Intravenous administration of syntocinon admixed with dextrose, 5%, in lactated Ringers’ solution, at the rate of eight to ten micro- ‘drops per minute. Subsequently, when asked ifr. Estrada needed the services of an anesthesiologist, he refused. Despite Dr. Estrada’s refusal, Dr. Enriquez, an anethesiologist at CMEC, stayed to observe Corazon's condition. [At 6:22 am, Dr. Estrada, assisted by Or. Villaflor, applied low forceps to extract Corazon's baby. In the process, a 1.0 x 2.5 em. piece of cervical tissue was allegedly torn. The baby came out in an apnic, cyanotic, weak and injured condition. Consequently, the baby had to be intubated and resuscitated by Dr. Enriquez and Dr. Payumo. ‘At 6:27 a.m,, Corazon began to manifest moderate vaginal bleeding which rapidly became profuse. Corazon's blood pressure dropped from 130/80 to 60/40 within five minutes. There was continuous profuse vaginal bleeding. [At 9:15am, Corazon died and the cause of death was "hemorrhage, post partum.” Rogelio, the husband, filed complaint for damages ‘against CMC, Dr. Estrada and the other doctors who assisted during the delivery of Corazon. Issue: Whether CMC is vicariously liable for the negligence of Or. Estrada Ruling: YES. Or. Estrada is an independent contractor. Applying the control test, SC did not find evidence pointing to CMC's exercise of ‘control over Dr. Estrada's treatment and management of Corazon's condition, The patient was under the exclusive prenatal care of Or. Estrada, CMC merely allowed Dr. Estrada to use its facilties when Corazon was about to give birth, which CMC considered an emergency, But while SC held that Dr. Estrada is not CMC's employee, CMC is vicariously liable under the @ectrine of apparent authority General Rule: A hospital is not liable for the negligence of an independent contractor-physician, Except: When physician is the "ostensible" agent of the hospital (doctrine of apparent authority) (‘ete ieee (2) the hospital, or its agent, acted in a manner that would lead a feasonable person to conclude that the individual who was alleged to be negligent was an employee or agent of the hospital; (2) where the acts of the agent create the appearance of authority, the plaintiff must also prove that the hospital had knowledge of and ‘acquiesced in them; and {@) the plaintiff acted in reliance upon the conduct of the hospital or at with ordinary care and prudence. ther the hospital acted in a manner which would lead a reasonable person to conclude that the individual who was alleged to be negligent was an employee or agent of the hospital. ‘The hospital need not make express representations to the patient that the treating physician is an employee of the hospital; rather a representation may be general and implied. 2) An inquiry on whether the plaintiff acted in reliance upon the ‘conduct of the hospital or its agent, consistent with ordinary care and prudence. plication of these factors to this che: ‘a member of its medical staff. a) CMC granted staff privileges to Or. Estrada. CMC ‘extended its medical staff and facilities to Dr. Estrada. b) CMC made Rogelio sign consent forms printed on CMC letterhead. These forms did not indicate that he was an independent contractor- physician. No one from CMC Informed the Spouses, ¢) Dr. Estrada’s referral of Corazon's profuse vaginal bleeding to Dr. Espinola, who was then the Head of the Obstetrics and Gynecology Department of CMC, gave the impression that Dr. Estrada as a member of CMC's medical staff was collaborating with other CMC- employed specialists in treating Corazon. 2) Rogelio testified that he and his wife specifically chose Or. Estrada to handle Corazon's delivery not only because of their friend's recommendation, but more importantly because of Dr. Estrada's connection with a reputable hospital, the CMC." In other words, Dr. Esteada's relationship with CMC played @ significant role in the Spouses Nogales’ decision in accepting Dr. Estrada’s services. “The element of "holding out" on the part of the hospital does not require an express representation by the hospital that the person alleged to be negligent is an employee. Rather, the element is satisfied if the hospital holds itself out as a provider of emergency room care without informing the patient that the care is provided by independent contractors. ‘The doctrine of apparent authority is a species of the doctrine of estoppel. Article 1431 of the Civil Code provides that "through estoppel, an admission or representation is rendered conclusive ‘upon the person making it, and cannot be denied or disproved 2s ‘against the person relying thereon.” Estoppel rests on "Whenever a party has, by his own declaration, act, or omission, intentionally and deliberately led another to believe a particular thing tru, and to act upon such belief, he cannot, in any litigation arising out of such declaration, act or omission, be permitted to falsity a” In the instant case, CMC impliedly held out Dr. Estrada as 2 member of its medical staf. Through CMC's acts, CMC clothed Dr. Estrada with apparent authority thereby leading the Spouses Nogales toLEGAL MEDICINE believe that Or. Estrada was an employee or agent of CMC. CMC cannot now repudiate such authority. ‘The Court finds respondent Capitol Medical Center vicariously liable for the negligence of Dr. Oscar Estrada. The amounts of P105,000 as actual damages and P700,000 as moral damages should each earn legal interest at the rate of six percent (6%) per annum computed from the date of the judgment of the trial court. GR Ponent Quisumbing FACTS: Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics ‘and Gynecology at the Dr. Jesus Delgado Memorial Hospital. She was the attending physician of respondent Nora S. Go, who was ‘admitted atthe said hospital on April 19, 1992. [At 1:30 a.m, of April 20, 1992, Nora gave birth to her fourth child, & aby boy. However, at around 3:30 am., Nora suffered profuse beading inside her womb due to some parts of the placenta which were not completely expelled from her womb after delivery. Consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood pressure to "40" over "0." Petitioner and the assisting resident physician performed various medical procedures to stop the bleeding and to restore Nora's blood pressure. Her blood pressure was frequently monitored with the use of a sphygmomanometer. While petitioner was massaging Nora's uterus for it to contract and stop bleeding, she ordered a droplight to warm "Nora and her baby. Nora remained unconscious until she recovered, While in the recovery room, her husband, respondent John David 2. Go noticed a fresh gaping wound two and a haf (2 %) by three and a half (3 %) inches in the inner portion of her left arm, close to the armpit. He asked the nurses what caused the injury. He was lnformed it was a burn Thereafter, on April 22, 1992, John David filed a request for investigation, and in response, Dr. Rainerio S. Abad, the medical director of the hospital, called petitioner and the assisting resident physician to explain what happened. Petitioner said the blood pressure cuff caused the injury. (On May 7, 1992, John David brought Nora to the National Bureau of Investigation for a physical examination, which was conducted by ‘medico-legal officer Or. Floresto Arizala, Jr. The medico-legal officer later testified that Nora's injury appeared to be a burn and that @ | premature. Citing Section 26 of Republic Act (R.A) No. 2382 or the ditha to undergo 2 Dilstation and Cucsttage Procedure (DECTOr | Medical Act of 1959, the CA held that the plain, speedy and Osea. adequate remedy under the ordinary course of law which petitioner < should have availed herself of was to appeal to the Office of the n July 30, 1994, petitioner performed the D&C procedure. Editha | President. wa chara rom ne hora he folowre dyLEGAL MEDICINE Petitioner claims that the law does not allow complainants to appeal to the PRC from the decision of the Board. She invokes Article 1V, Section 35 of the Rules and Regulations Governing the ‘Regulation and Practice of Professionals, which provides: Sec. 35. The respondent may appeal the decision of the Board within thirty days from receipt thereof to the Commission whose decision shall be final. Complainant, when allowed by law, may interpose an appeal from the Decision of the Board within the same period. (Emphasis supplied) Petitioner asserts that a careful reading of the above law indicates that while the respondent, as a matter of right, may appeal the Decision of the Board to the Commission, the complainant may interpose an appeal from the decision of the Board only when so allowed by law. Petitioner cited Section 26 of Renublic Act No, 2382.0r The Medical ‘Act of 1959, to wit Section 26, Appeal fcom judgment. The decision of the B887TGF ‘Medical Examiners (now Medical Boar) shall automatically become final thirty days after the date of its promulgation unless the respondent, during the same period, hasappealed: tow the’ wv Professional Regulations Commission) Philippiness if the final decision is not satisfactory, the respondent, may ask for Tein Niece ora le eet een ee may file in court a petition fo fh Petitioner posits that the reason why the. ‘only the respondent in-an administrative case to file an anneal with, the Commission while the complainant is not allowed to do so i joubTe jeopardy. Petitioner is of the belief that the revocation of Ticenseto practice a profession is penal in nature feld)The Court does not agree. For one, the Double Jeopardy attaches only: () upon a valid indictment; (2) before a ‘competent court; (3) after arreignment; (4) when a valid plea has been entered; and (5) when the defendant was acquitted or convicted, or the case was dismissed or otherwise terminated ‘without the express consent of the accused, These elements were: ‘ot present in the proceedings before the Board of Medicine, as the proceedings involved in the Instant case were administrative and ‘ot criminal in nature. The Court has already held that double Jeopardy does not le in administrative cases, Moreover, Sgction 35 of the Rules and Regulations Govesning the Regulation 2h cited by petitioner was Subsequently amended to read: Sec, 35. The complainant/respondent may appeal the order, the ‘resolution or the decision of the Board within thirty (30) days from receipt thereof to the Commission whose decision shall be final and executory. interlocutory order shall not be appealable to the Commission. (Amended by Res. 174, Series of 1990), Whatever doubt was created by the previous provision was settled with said amendment. Its axiomatic that the right to appeal is not a natural right or a part of due process, but a mere statutory privilege that may be exercised only in the manner prescribed by law. ‘Such conclusion is bolstered by the fact that in 2006, the PRC issued Resolution No. 06-342(A), or the New Rules of Procedure in ‘Administrative Investigations in the Professional Regulations Commission and the Professional Regulatory Boards, which provides for the method of appeal, to wit: Sec. 1. Appeal; Period NonExtendible.- The decision, order or ‘resolution of the Board shall be final and executory after the lapse of fifteen (15) days from receipt of the decision, order or resolution without an appeal being perfected or taken by either the respondent or the complainant. A party aggrieved by the decision, ‘order or resolution may file a notice of appeal from the decision, ‘order or resolution of the Board to the Commission within fifteen (25) days from receipt thereof, and serving upon the adverse party 3 notice of appeal together with the appellants brief or memorandum ‘on appeal, and paying the appeal and legal research foes. xxx ‘nent the substantive merits of the case, petitioner questions the PRC decision for being without an expert testimony to support its conclusion and to establish the cause of Edithas injury Clee riparia particular form of negigence whied ‘const MEYanure of a physician or surgeon to apply to his prortce of medicine that degre of cae and stl which ordinary tavcored ithe protein geval under nla Solis, ot in He surrounding ceumstances. in order to sucessfully pursua Bait There are EP Gryscian patient relations} wes created when Editha employed the Sear or Grier. As Ecithas physician, petitioner was 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 cumstances. The breach ofthese professional duties of Skil ond cote, or their improper performance by a_physicaq strgeon, whereby the ‘patient is injured in body or in health, Constitutes actionable. malp 0 th of mes In the present case, WITNESS Generally, to qualify as argéxpert witness, one must have acquired eee nie exmesneee ee or by practical experience. ‘Manald specializes in gynecology and obstetrics, authored and, co-authored Targus pubWations on the subject and Stihe Une mes, According to him, his lagnoss faiths case was Ectopic Pregnancy Intersil (also referred to as _Aeorwsal, Ruptured stating that the OBC procedure was nt the proximate couse ofthe rupture of Edthas uterus resuiting in her hysterectomy It is clear thatLEGAL MEDICINE to treat a condition under the same circumstances, and that there was nothing irregular in the way the petitioner dealt with Editha, Medical malpractice, in our jurisdiction, is often brought as a civil action for damages under -Aftic| the Givi he defenses in an action for damages, provided for under Article 2179 of the Civil Code a Aart. 2179. When the plaintiffs own negligence was the immediate and proximate cause of his injury, he cannot recover damages. But if his negligence was only contributory, the immediate and proximate cause of the injury being the defendants lack of due care, the plaintiff may recover damages, but the courts shall mitigate the damages to be awarded. ‘An injury or damage is proximately caused by an act or a failure to ‘act, whenever It appears from the evidence in the case that the act (or omission played a substantial part in bringing about or actually ‘causing the injury or damage; and that the injury or damage was either a direct result or a reasonably probable consequence of the ‘actor omission, which could have avoided the injury. The omission in not returning for a follow-up evaluation played a substantial part in bringing about Edithas own injury. Had Editha returned, petitioner could have conducted the proper ‘medical tests and procedure necessary to determine Edithas health condition and applied the corresponding treatment which could have prevented the rupture of Edithas uterus. T proper diligence required to avoid the injury. WHEREFORE, theg@iition is GRANTED The assailed Decision of the Court of Appeals dater in CA-GR SP No, 62206 is hereby REVERSED and SET ASIDE. The Decision of the Board of Medicine Gated March 4, 1999 exonerating petitioner is AFFIRMED. No pronouncement as t0 cost. FACTS: Petitioner Peter Paul Patrick Luca (Peter) con Gedmtimpecat Complaining of a Peter made use of his health core insurance issued by Philamcare Health ystems, Inc @iiameare) for a possible consult The Phlamcare Coordinator, Dr. Edwin Oca, MO.,referes respondent, Dr. Prospero Ma. C. Tuake, M.D. (Or acted Upon consuittion with Dr. Tuafo, Peter narrated that it had been ine (9 ays since the problem with his right eye began; and that he was address the problem in his eye. According to Dr. Tuafo, he performed "ocular routine examination’ fon Peter's eyes. On that particular consultation, Dr. Tugito diagnosed that Peter was suffering from conjunctvitisor Tuato then prescri for Peter ‘and told the latter to return Tor follow-up after one week. Peter ‘went back to Dr. Tuafio/ Upon examination, Or. Tuafo told Peter Address the new problem with Peter's right eye, (py. Tuafo dosage of six (6) drops per day. To recall, Peter hati already been Using Maxitcol prior to his consult with Dr. Tuafio. Peter would go back and forth to Tuano’s clinic to complain about the worsening condition of his right eye. In these instances, Tuano weds to counter the recurring EKC. On Ghserved by his wife, Fatime, who had juano ordered the Immediate discontinuation of ‘Maxiteol and prescribed other meds. eter had no vision in his right eye. Fatima observed that Peter's right eye appeared to be bloody ‘and swollen, Thus, spouses Peter and Fatima rushed to the clinic of Dr. Tuaflo: Peter reported to Or. Tuafio that he had been suffering from constant Peter went to 110 I), on 21 December 1988, who allegedi ‘onducted @ complete ophthalmological examination of Peter's eyes. Dr. Batungbacal's diagnosis wasGlaucoma))He recommended ser Te for Peter's right eye. Peter to Dr. Agul to who ‘concurred on Peter's condition and recommended the same ‘medication. Also, Peter was padded by his friends to seek a second ‘medical opinion. Thus hel He informed Peter that his opi eyes were relatively normal ex right eye, Petitioners claimed that Or. Aquino essentially told Peter that the latter's condition would require lifetime medication and foliow-ups. Thus, he underwent 2 procedures of the aser trabeculoplasty. * Claiming to have sterold- induced glaucoma and blaming Tuano fo, the same. , @s aera GI crac rtbbece of hs protrged vse of Mantra, Be suffered from steroid induced glaucoma as well as incurable impairment of vision which may lead to permanent blindness. They prayed that prayed that Tuafo be adjudged liable for compensation for his impaired vision, actual, moral and exemplary damages plus attorney's fees AIO In his defense, Tuano asserted that the dru temporary and curable and that Steroids are prescribed to treat induced glaucoma is ie Stressed that Peter's glaucoma can only be due to other causes not attributable to steroids long standing glaucoma; and that in factLEGAL MEDICINE steoits were in fact nated) asthey provoked the latest glaucoma to be revealed earl (CDYamissed she complaint fornsuifcent evidences The RTC ‘Oped that petitioners failed to prove by preponderance of evidence that Dr. Tuarlo was negligent in his treatment of Peter's condition. in particular, the record of the case was bereft of any evidence to establish that the steroid medication and its dosage, as prescribed by Dr. Tuafo, caused Peter's glaucoma. The tral court reasoned that the "recognized standards of the medical community has not been established in this case, much less has causation been established to render {Tuafo] lable. (@eIAMEDATCs DECISION upon appeal ISSUE: whether the Court of Appeals committed reversible error in affirming the judgment of the RTC that petitioners failed to prove, by preponderance of evidence, their claim for damages against Dr. Tuafo. ‘We are not convinced, The judgments of both the Court of Appeals and the RTC are in accord with the evidence on record, and we are accordingly bound by the findings of fact made therein. ‘The case at bar is a medical negligence case against a physician based on the later's professional negligence. 2 Gzae of sil care, ond learning possessed by other persons in he Same profession; and that as a proximate reul of such feiure, the patient or his heirs suffered damages. Such claim for damages is favs anchored on the alleged violation of Article 2376 of damages, 4@l&mhts Must be shown to co-exist: (1) duty (2) breach; (ery: od) prxiete custo, There tach of Bay cae Sl and gece, ofthe improper prformagsoF ch dy when the poet injured in Boy oF route reas the estimony af an expert ness thatthe estmencrse to th paint fed to mest the sonar lvl of cae, aki and igen whch pico lathe sare general Une of paca ondary possess ard err ne caves Prot of beth of dy ‘injury for which recovery is sought must consequence of the wrong done. In other words, negli be the proximate cause of the injury or that caust Saar ihe Saran canines sequences urbrolan By any efficent intervening cause, produces the injury, and without which the result would not have occurred. To establish the proximate cause, one ‘must similarly use expert testimony {0 present to the court 2 realistic assessment of the likelihood that the physician's alleged negligence caused the patient's injury. No question that a physician- patient relationship developed between Dr-Tualo and Peter, The ous probandi was on the patient to establish before the tial court that the physicians ign. lored standard medical procedure. failure on However, there wasabsolute to ‘he standard of care to be implemented by competent physicians 2 that,_in is treatment of Peter, Or, Tuafio failed in his _dut (Geercise sald standard of care that any other competent physician ‘would usp, 3) that the injury or his glaucoma was the result of his ‘seof Maxitrol as prescribed by Dr. Tuafo. Failure to prove the first “element alone is already fatal, Petitioners maintain that Or. Tuano falled to follow in Peter's case the required procedure for the rolonged use of Maxitro Beene ts THERE MUST BE pf STANDARD he Court has 10 ‘Jardstick upon which to evaluate or weigh the attendant facts to state with confidence that the acts complained of, indeed, constituted negligence. Critical and clinching factor in a medical negligence case is proof of the causal connection between the regligence which the evidence established and the plaintt's injures itis necessary to prove not only that he has been injured ‘and defendant has been at fault, but also that the defendant's fault ‘caused the injury. Causation must be proven within a reasonable medical probability based upon competent expert testimony - proof that Peter's glaucoma would not have occurred but for Dr. Tuano's supposed negligent conduct. ‘What constitutes proper medical treatment is 3 medical question that should have been presented to experts. Cnet PROFESSIONAL SERVICES, INC. vs. NATIVIDAD and ENRIQUE AGANA GR. No. 126467 BRUM net ee oan EN cw MNO G A cE! Ane ni ones Cianeerre) Pence ems EEL Geren ccUn) Teac ror evan Cay FACTS: On April 4, 1984, 1as rushed to the se ofCGificuity of Dr. Miguel Ampll diagr her to be suffering fror (On April 11, Dr. Amgil, assisted by the medical staff of the said hospital He found that the far Fe sro en tS on er oe pace ete she removal of cera potter e Ts OF Are obtained th@Lonsent of Natividad’s husband, Enrique Agana, to permit juan Fuentes, respondent ino perform bystesectomy.on Fiera couple of dvs, she complained Orexeriting ana FEBGRE she consulted both Or. Api and Dr Fuentes about i. They told her thatthe pain was the natural consequence of theLEGAL MEDICINE surgery. Or. Ampil then recommended that she consult an fogist to examine the cancerous nodes which were not Femoved during the operation. OnMay 9, 3884, Navidad, eecomparied by her husband ROAR er four neh of conatatos Pe Bboatoy examinations she wes tl she yas avid ew back the Pipies, stl iff mpl. upon being Ifomed that there was 3 ‘ompting her to seek treatment at she underwent another surgery to remedy the damage caused by a foreign object in her vagina (another @ oF November 12, 1984, Natividad and her husband filed with the Aeic)ot cueron Ciy + comple for damages agains the @Qréessional Services, Inc, (PSI), owner of the Medical City Hospital, br. Ampil, and Or. Fuentes They alleged thatthe later are lable for FeGiigengh for leaving two pleces of gauze inside Natividac's body Se gcealing their acts of negligence. Envigue gf filed with t fe ministrative complaint for gross negligence and maloractioe ainst Or. Ari and Or. Fuentes. The PRC Board of Medicine heard the case only wit respect to Dr Fuentes because it fale to acquire jurisdiction ove Or. Amp who was then inthe US. In 1986, pending the outcome of the above case, Nativided died fan appeal to the CA. Incidentally, the Aganas fled with the RTC @ motion for a partial execution of its decision where certain properties of Dr. Ampil were levied aad sold and the amount s 's was the one who left the two pieces of gauze inside Natividad’s body, and that he concealed such fact from her. ISSUES: 41) whether Or. Ampilis liable for negligence and malpractice 2} whether Dr. Fuentes is absolved of any lability 3) whether PSI may be held solidarly lable for the negligence of Or. Ampil auuns: Da. Amp 26 beable Go — SS a ReTTe e oretrel we pu pn Domistewrsnne ocd hatte cout choad or aur repaints tr Foe fe gees a Nati ea ea ve nae rear oe ie pier Radon omen acts ron te Suto Sartre ous nenoads boa Ar rumen pur contend wit ass All the major circumstances, taken together, as specified by the CA, directly point to Dr. Ampil as the negligent party. Surgeons used ‘gauzes as sponges to control the bleeding of the patient during the surgical operation. After the operation, the nurses noted in thelr report that 2 sponges were lacking and after search was done but to no avail, Dr. Ampil continued for closure. After the operation, 2 ‘gauzes were extracted from the same spot of the body of Mrs. ‘Agana where the surgery was performed. “An oration requiring the placing of sponges in the incision Is not complete until the sponges are properly removed, and itis settled that the leaving of sponges or other foreign substances in the ‘wound after the incision has been closed is at least prima facie geeligence by the operating surgeon. To put it simply, such act i Considered so inconsistent with due care as to raise an inference of negligence. There are even legions of authorities to the effect that Such aét is negligence per se. # ‘isle experiencing was the ordinary consequence of her operation. 1 what was intially an act of negligence by Dr. (mpl 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 2 reasonably prudent provider would not have done; and that failure or setion caused injury to the patient. Simply put, the elements are duty, breach, injury and proximate causation. Of, Ampil, as the lead surgeon, beached both duties to remove all foreign objects, suchas gauzes, from Natividad’s body before closure,of the incision and when he filed to do s0, to inform Natividad about it. What further agggavated such injury was his deliberate concealment of the ‘missing gauzes from the knowledge of Natividad and her family. aes Die Faantes it not Wabpeo. ‘The Court is not convinced with the arguments of the Aganas. They assdiléd’the dismissal by the tral court of the case against Dr. Fuentes on the ground that itis contrary to the doctrine of res ipse loguitur. According to them, the fact that the two pieces of gauze were left inside Natividad’s body is a prima facie evidence of Dr. Fuentes’ negligence. Lkerally, eis the rule that the fact of the occurrence of an injury, taken with the surrounding ciccumstances, may permit an inference or raise @ presumption of negligence, or make out a plaintiffs prima facie case, and present a question of fact for defendant to meet with an ‘explanation. Stated differently, where the thing which caused the injury, without the fault of the injured, is under the exclusive control of the defendant and the injury Is such that it should not have ‘occurred if he, having such control used proper. care, it affords reasonable evidence, in the absence of explanation that the injury ‘arose from the defendant's want of care, and the burden of proof is shifted to him to establish that he has observed due care and itigence. From the foregoing statements of the rule, the : (2) theio LEGAL MEDICINE defendant; (3) 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. In this case, he was the one who called Or. Fuentes to perform hysterectomy and examined his work and found It to be in order. He granted Or. Fuentes’ permission to leave. He ‘was about to finish the procedure when the attending nurses informed him that two pleces of gauze were missing, A “diligent search” was conducted fut the misplaced gauzes were not found, 7 Amplt then directed that the incision be closed. It was this act of lordering the closure of the incision notwithstanding the fact that two pieces of gauze remained unaccounted for that caused injury to NNatividad’s body. Clearly, the spbstantive law, hence. dass not per se create or constitute an, independent_or separate sround of ability. being a_mere, evidentiary rule. In other words, mere invocation and application af {Be doctrine does not dispense with the requirement of proof of Degligence. Here, the negligence was proven to have been ‘Committed by Dr. Ampil and not by Or. Fuentes. ged the injury was ‘there is no reason to exempt hospitals from the universal rule of frst place, hospitals exercise significant control in the hiring end firing of consultants and in the conduct of their work within the hospital premises. Accordingly, the Court ruled that for the purpose of allocating responsibility in medical negligence cases, an Syer-employee relationship in effect exists between hospitals ding and visiting physicians. * Tali ts perros nee pre FRED) Geos) agency by estoppel aed the socte of Sram ‘Apparent authority, or what is sometimes referred to as the Sievers ‘Out” theo’), or doctrine of ostensible agency or agency by ‘estoppel, Tas Ts origin from the law of agency. It imposes lability, not as the result of The concept is essentially one of estoppel. "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 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. Art. 1869 of the Civil Code recognizes the concept of an agency by Implication or estoppel ich states that agency may be express, or implied from the acts 3) Yes. Propessiewat~ penvi tea-tve~is- solidarity ‘of the principal, from his silence or lack of action, or his failure to In this jurisdiction, the statute govérning liability fornegligent acts is Aicles 2176 and 2180 of the Civil Code. A prominent civlist 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 ferform their work i not within the control of the employer. They re considered personaly lable for the fault oF negligence they commit in the discharge of their duties, and their employer cannot be held liabie for such fault or negligence. In the context of the present case, "a hospital cannot be held lable for the fault or negligence of a physician or surgeon in the teatment or operation EF patients." The Weemtoendo 5 (egards a physician, ever employed by a hospital as af independent contractor because of the skill he exercises and the lack of contol exerted over his work. Under this doctrine, hospitais are exempt from the application of the respondeat superior principle for fault or negligence committed by physicians in the discharge of ther 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. They regularly 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 repuciate the agency, knowing that another person is acting on his behalf without authority, 7 In this case, PSI publicly displays in the Jobby of the Medical City Hospital the names and specializations of the physicians associated fEntamount 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 impfession 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 bbeing rendered by the hospital or its employees, agents, or servants. PSI is also liable for breach of duty premised on corporate negligence. Its formulation proceeds from the judiciary’ ‘acknowledgment that in these modern times, the duty of providing quality medical service is no longer the ‘ole prerogative and responsibility of the physician. Hospitals now tend to organize a highly professional medical staff whose competence and performance need to be monitored by the hospitals commensurate with thelr inherent responsibilty to provide quality medical care. inLEGAL MEDICINE 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. PS failed in lis duty to exercise reasonable care to protect from patients admitted into its facility for medical treatment. ividad wit ssistance of the Medical City Hospitals staff, composed of resident doctors, nurses, and interns. 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 2 matter to which their authority extends. This means that the knowledge of any of the staff of ‘Medical ci Now, the failure Cf PSI, despite the attending nurses’ report, to investigate and inform Natividad regarding the missing gauzes amounts to callous negligence. Not only did PS! breach its duties to oversee or supervise all persons who practice medicine within its walls it also falled to take an active step in fixing the negligence committed. This renders PSI, not only vicariously liable for the negligence of Dr. Ampill under Article 2180 of the Civil Code, but also directly lable for its own negligence under Aticle 2176. It filed to adduce evidence showing that it exercised the diligence of a good father of a family in the accreditation and supervision ofthe 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 Or. Ampil. Moreover, PSI is also ditectiy liable to the Aganas. 4 SENT FACTS: Raymond S. Olavere (Raymond), af Gees ese ot ec eee ae a Z sd a to bf Raymond's parents (Deogenes Olavere and Fe Serrano) artived at the BRMC, accompanied by one Andrew Olavere (Raymond's uncle). After extending intial medical treatment to Raymond, Olavere went to the required blood, ‘n6G30>.m., Raymond was wheeled inside the operating room. X(%:18)PM. Raymond's parents returned wth the bag of blood witty h - a ant to secure the Barents to ‘cS of pe “0 Gs ene for the operation. Comping with the request, Deogenes and Andew Deere ererenen ter ate (Maluhy-On ard Agua) bere stig on israel bees popeioat ar (cae! aerator? rcpalar ail ce tr slecr Rrc e tod a tle" preter teal ed ating him ns eaten or Keres Reason rete terre, the RB de the hoa ent of two other 2 Upon opening of Raymond's thoracic cavity, howeve, Drs. ate and Cereno found that 3,200 cc of ‘The blood was evacuated and patitioners found a puncture at the inferior pole of the left lung. In his testimony, Dr. Cereno stated that considering the loss of blood suffered by Raymond, he did not, ately transfuse blood because he had to control the bleeders Becsnn Gnt 250 Amro doh coat dhetolnsof bond Raymond's parents, claiming that there was negligence on the part of the doctors who attended to their son, fled before the \gainst Nurse Balares, Dr. Realuyo and attending surgeons Or. Cereno and Or. Zafe. a Th in not immediately conducting surgery on Raymond. It noted that petitioners have already finished operating on one of the two other patients in the Of as early as 10:30 in the evening, and yet they only started the operation on Raymond at around 12:15 early morning of the following day. The RTC held that had the surgery been performed promptly, Raymond would not have lost so much blood and, therefore, could have been saved. ‘The tral court also held that the non-availability of Or. ‘Tatad after the operation on the first patient was not a sufficient ‘excuse for the petitioners to not immediately operate on Raymond. It called attention to the testimony of Dr. Tatad herself, which disclosed the possibilty of calling a standby anesthesiologist in that situation. The trial court opined that the petitioners could have jus requested for the standby anesthesiologist from Dr. Tat ‘against Or. Ruel Lewy and Arlene Balares for lack of merit, but ordered for the death of Raymond, as well as moral and exemplary dama; Storney’s Tees, and costs of suit. Qo appeal, the CA affirmed in toto the judgment rendered by the RTC Paging herein petitioners guilty of gross negligence in the performance Otxheir duties and awarding damages to private respondents. Pabee (are) ISSUE: WON the CA erred in ruling that petitioners were grossly ‘negligent in the performance of their duties. ana pe Cf lawsuit which has been nse ical ‘malpractice or, more appropriately, medical negligence, is that type Of claim which a victim has available to him or her to redress 2 wrong committed by a medical professional which has caused bodily, harm. In order to successfully pursue such a claim, a patient must prove that a health care provider, in most cases a physician, either failed to do something which a reasonably prudent health care Provider would hay meth provider would have dane, or that he ar she did something that a Feasonably prudent provider would not have done; and that the Talure or action caused injury to the patient. Stated otherwise, theLEGAL MEDICINE st way to prove these is through the opinions of longing in the same neighborhood and in the cipert witnesses ‘same general line of practice as defendant physician or surgeon. The deference of courts to the expert opinion of qualified physicians stems from the former's realization that the latter possess unusual technical skils which laymen in most instances are incapable of Inteligently evaluating, hence, the indispensabllity of expert testimonies. ==) The tral court first imputed negligence on the part of the petitioners by their failure to perform the operation on Raymond immeciately after finishing the other patient's operation. It rejected {as an excuse the non-availability of Dr. Tatad. The trial court relied fon the testimony of Or. Tatad about 2 "BRMC protocol” that introduces the possibility that a standby anesthesiologist could have ‘been called upon. From there, the trial court concluded that it was the duty of the petitioners to request Or. Tatad to call on Dr. Rosalina Flores, the standby anesthesiologist. Since petitioners failed to do so, their inability to promptly perform the operation on Raymond becomes negligence on their part. ‘This Court does not agree with the aforesaid conclusion. First. There is nothing in the testimony of Or, Tatad, or in any evidence on the re titioners were aware of vghat the hospital 5 2 standby anes Indeed, other than the testimony of Dr. Tatad, there is no evidence that proves that any such "BRMC protocol” is being practiced by the hospita’s surgeons ata aa Evidence to the effect that petitioners knew of the "BMC protocol” is essential, especially in view of the contrary assertion of the petitioners that the matter of assigning anesthesiologists rests within the full discretion of the BRMC Anesthesiology Department, Without any prior knowledge of the "BRMC protocol,” We find that it is quite reasonable for the petitioners to assume that matters regarding the administration of anesthesia and the assignment of anesthesiologists are concerns of the Anesthesiology Department, ‘while matters pertaining to the surgery itself fall under the concern of the surgeons. Certainly, We cannot hold petitioners accountable {ornot complying with something that they, in the first place. do not drow, Second. Even assuming ex gratia argumenti that there is such "BRMC protocol” and that petitioners knew about it, We find ‘that their failure to request for the assistance of the standby ‘anesthesiologist to be reasonable when taken in the proper context. ‘There is simply no competent evidence to the contrary. From the testimony of Or. Tatad herself, iis clear that the matter of requesting for a standby anaesthesiologist is not within the full discretion of petitioners. The "BRM protocol” described in the testimony requires the petitioners to course such request to Dr. TTatad who, as head of the Department of Anesthesiology, has the final say of calling the standby anesthesiologist ‘As revealed by the facts, however, after the Maluluy-on Operation, Or. Tatad was already assisting in the Lilia Aguila ‘operation. Ors. Zafe and Cereno then proceeded to examine the life of Raymore Raymond and they found that the latter's blood pressure was normal and “nothing in him was significant." Dr. Cereno even concluded that based on the x-ray result he interpreted, the fluid inside the thoracic cavity of Raymond was minimal at around 200- 300 cc. Such findings of Ors. Cereno and Zafe were never challenged and were unrebutted Tatad was alre Given that Or ‘that @ prudent surgeon faced with similar circumstances would decide otherwise. ee tere wae thane course of acon kn by peitoner Was notin accord wth those adopted by ther enone surges Insist Nether was there any testimony gen, excep ht of Or. Tatas, on which may be inferred that pettiones fled to exec the andad of cae, digence, leanne, a sil expected om brttnes of th pote SEED nether in the fi Causation Not Proven tn medal epasnce case, ft sled that he compliant has the burden of easing reach of ety ote papel the dtr or suger tut be proven tat sux(@ae) Gait cma sonar Bef: n maroc scion cnn be bed on secon carer. Guton ms be proven hn xsl med pobbiy Seetiporconpetencenertesinen Tne pret of Raya aed nts spec te om thei 0 alone, they do cased the iu TH case anon he mee SUTTON hat Rome's fe woud tv Den saved had peter surgeons needy peated on hi od the ood been ess nthe needy and tad the od been tanssed nmedaey Thee way, however no 0 rested that Raymore fe wel ave een sovednedtove things bre one, Tose ae ere sumptions sa Cannot pares he desired sik, Such eanot be mace as ot 2 ecson in ths cae, especialy consermg tht the rae, ceuaon nd cae of atone ee at ata ‘The Court understands the parents’ grief over their son’s death. That notwithstanding, it cannot hold petitioners liable. It was ‘noted that Raymond, who was a victim of a stabbing incident, had ‘Multiple wounds when brought to the hospital. Upon opening of his thoracic cavity, it was discovered that there was gross bleeding Inside the body. Thus, the need for petitioners to control first what was causing the bleeding. Despite the situation that evening, i. humerous patients being brought to the hospital for emergency treatment considering that it was the height of the Pefafrancia Fiesta, it was evident that petitioners exerted earnest efforts to save Je was st unfortunate that the loss of his life"LEGAL MEDICINE ‘was not prevented. Doctors are protected by a special law. They are rot guarantors of care. They do not even warrant a good result ‘They are not insurers against mishaps or unusual consequences. Furthermore, they are not lable fs bagest mistake of judgment Petition for Review on Certiorar Grate Pa ruling REVERSED and SET ASIDE Next m Of 26 Fea Natal fury af Inestzaton agit thy peor, [DE Get af goferSoral GA hh eed her sn, Roy Afonso Sarangi avy Hse Seslerion te: R0l fed oat pn e) Goren bees rset the Mania Doctors Hoel Tr Tate toca ade tht eo th es eso tng cr sk aed ia e Ja Bastan entered the emergency room and, af ‘Conducting her own examination of the victim, informed Ms Sn it was only the ankle that was hit, there w: need to examine the upper leg. despite Mrs. Santiago's protest the Zoctors did not examine the upper portion of the leg of Roy. that even (3) ete fy. eed ee leg and esalignmens bf the rant foo; thST Ws Saigo brought him back tothe Fospal; and tat the Xray revealed a cght id- tibial fracture anda linea hairline facture inthe hat ofthe bond ‘ter tial and applying the doctrine of ces ipsa oguitor o> found petitioners to be gyiK of simple negligence. he decision Was affirmed in toto by the CA. (2) Whether of not the petitioner physicians are negligent, hence liable for damages. 1s to the first issue: This doctrine of res ipsa loquitur here the thing which causes injury is shown to be under the management of the defendant, and the accident is such as in the ordinary course of things does not happen if those who have the ‘management use proper care, it affords reasonable evidence, in the ‘absence of an explanation by the defendant, thatthe accident arose from want of care." 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; (2) the instrumentality or agency which caused the injury was under the exclusive control ofthe person in charge: and (a) the injury suffered must not have been due to any voluntary ‘action of contribution of the person injures. However, the doctrine of res ipsa loquitur as 2 rule of evidence is ‘unusual to the law of negligence which recognizes that prima facie negligence may be established without aaa tai substitute for spacific proof of negligence. Stcemmenem Relative to the case, It was established that they are mere resie nts of the Manila Doctors Hospital at that time who attended, to th victim at the emergency room. While it may be true that the sireu astances pointed out by the courts below seem doubtless to constitute reckless imprudence on the part of the petitioners, this conclusion is still best achieved, not through the scholarly assumptions of a layman like the patient’s mother, but by the unquestionable knowledge of expert witness/es. AS ro whether the petitioners have exercised the requisite degree of skill and care in treating patient Roy, Jr. is generally a matter of expert opinion. "oe eae i se i: (a) that there Is lack of precaution on TRE BaP ofthe offender, and (2) tat the damage impending to be caused is not Immediate or the danger is not clearly manifest. br. Jareia and Or. Bastan, explained the court, cannot pass on the liability to the taxi driver who hit the victim. It may be tre thatthe actual, direct, immediate, and proximate cause of the injury (fracture of the leg bone oF tibia) of Roy Jr. was the vehicular accident when he was hit by 2 tax. The petitioners, however, ‘cannot simply invoke such fact alone to stiarstestion a 9M iabinty ff this would be so, doctors would have a ready defense ‘Should they fail to do their job in attending to victims of hit-and-run, maltreatment, and other crimes of violence in which the actual Tiree, immediate, and f the injury i indubitably the at of the perpetrators In falling to perform an extensive medical examination 10 determine the extent of Roy Jr injuries, Dr. Jarcia and Dr. Bastan were remiss of their duties as members of the medical profession. ‘Assuming for the sake of argument that they did not have the capacity to make such thorough evaluation at that stage, they should have referred the patient to another doctor with sufficient training and experience instead of assuring him and his mother that everything was allright. ‘Moreover, the contention of petitioners that they cannot be Rel Physician-patient relationship exists when a patient engages the services of a physician, a physician-patient relationship is generated. ‘And in accepting a case, the physician, forall intents and purposes, represents that he has the needed training and skil possessed by physicians and surgeons practicing in the same field; and that he will employ such training, care, and skill in the treatment of the patient. ‘Thus, in treating his patlent, a physician is under a duty to exerciseLEGAL MEDICINE Stated otherwise, 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.” ‘There is 2 physician-patient relationship in this case since the pelraoner oblged Temselves and examiied the victiny and later aSsured the mother that everything was fine and that they could go home. Theicassurance that everything is fine deprived the victim of seeking, medical hel FERN OEIC ald) was born on June 2, 1992 with an Two days after his birth, Gerald underwent ical procedure to bring one end of the large InTERUTRE out through the abdominal wall, enabling him to excrete through a colostomy bag attached to the side of his body. On May 17, 1995, Gerald, then three years old, was admitted at the Qspital_ng Maynila fora pullthrough operation. Dr. Leandro SEE ase GAS aaa oar Sal ico oe ae ees Peeloeuss debe atcha hai ctl ha od ee a ee eee ae crs) Cent Sib tcadl bd ard und wert ess eae Ys-comt lasted Tor iwo weeks, but he regained consciousness only after a month He coulaoionger bx ear oF movy Agitated by her son’s helpless and unexpected condition, Ma. Luz Gercayo (Luz) lodged a complaint for reckless imprudence resulting Jn serious physical injuries with the City Prosecutor's Office of ‘Wanila against the attending physicians. The¢RTEYound Or, skin BS beyond reasonable doubt of reckBssTmprudence resulting To-Physical injuries. Th the conviction stating that the case isa textbook example of ses ipsa. loquitur. According to the CA, the child except for his imperforate ‘Snus, was healthy. The tests and other procedures failed to reveal that he was suffering from any known ailment or disability that could turn into a significant risk. There was not 2 hint that the nature of the operation itself was 2 causative factor in the ev ‘Tot finaly led to hypoxia, In short, the lower court has been left Sith no reasonable hypothesis except to attribute the accident to a failure in the proper administration of anesthesia, the gravamen of the charge in this ease, Dr. Solidum appealed to the Supreme Court. Issues: 1. Whether of not the doctrine of res ipsa loquitur was applicable herein 2, Whether or not Dr. Solidum was lable for criminal negligence RULING: 1(%9)Res ipsa loquitur is literally translated as “the th transaction speaks for itsell,” The doctrine res ipsa Toquitur means That “where the thing which causes injury is shown to be under the management of the defendant, and the accident is such as in the ordinary course of things does not happen if those who have the ‘management use proper care, it affords reasonable evidence, in the ‘absence of an explanation by the defendant, that the accident arose from want of care.” In order to allow resort to the doctrine, therefore, the following essential requisites must first be satisfied, to wit: (1) the accident ‘Was of @ kind that does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency that caused the injury was under the exclusive control of the person charged; and (3) the injury suffered must not have been due to any voluntary action or contribution ofthe person injured. ‘Goons alent det patra fnappropriaie, Although it should be conceded without Gificulty that the second and third elements were present, considering that the anesthetic agent and the instruments were ‘exclisively within the control of Dr. Solidum, and thatthe patient, being then unconscious during the operation, could not have been guilty of contributory negligence, the first element was undeniably wanting. Luz delivered Gerald to tW@ care, custody and control of his “Physicians for a pull-through operation. Except for the imperforate anus, Gerald was then of sound body and mind at the time of hs submission to the physicians. Yet, he experienced bradycardia during the operation, causing loss of his senses and rendering him immobile. Hyporia, or the insufficiency of oxygen supply to the brain that caused the slowing ofthe heart rate, scientifically termed as bradycardia, would not ordinarily occur inthe process ofa pull through operation, or during the administration of anesthesia to the patient, but such fact alone did not prove thatthe negligence of any of his attending physicians, including the anesthesiologists, had caused the injury In fact, the anesthesiologist attending to him had sensed in the course of the operation that the lack of oxygen could have been triggered by the vago-agal reflex, prompting them to administer atropine to the patient. —— net pmb ercae a aan er fallre to monitor and properly regulate the level of anesthetic agent administered on Gerald by overdosing at 100% halothane. In affirming the conviction, the CA observed: ‘On the witness stand, Or, Vertido made a significant turnaround. He affirmed the findings and conclusions in his report except for an observation which, to all intents and purposes, has become the storm center of this dispute. He wanted to correct one piece of information regarding the dosage of the anesthetic agent ‘administered to the child. He declared that he made a mistake in reporting a 100% halothane and said that based on the records it should have been 100% oxygen. The implication of Dr. Vertido’s admission is that there was no overdose of the anesthetic agent, and the accused Dr. Solidum stakes his liberty and reputation on this conclusion. He made the assurance that he gave his patient the utmost medical care, never leaving the operating room except for a few minutes to answer the call of nature but leaving behind the other members of his team Ors. ‘Abella and Razon to monitor the operation. He insisted that he administered only a point 1% not 100% halothane, receivingLEGAL MEDICINE corroboration from Or. Abella whose initial MA in the record should bbe enough to show that she assisted in the operation and was therefore conversant of the things that happened. She revealed that they were using a machine that closely monitored the concentration of the agent during the operation. ‘The Prosecution did not prove the elements of reckless imprudence beyond reasonable doubt because the circumstances cited by the ‘cAwere insufficient to establish that Or. Solidum had been guilty of iiexcusable lack of precaution in monitoring the administration of the anesthetic agent to Gerald. [An action upon medical negligence - whether criminal, chil or ‘administrative - calls for the plaintiff to prove by competent evidence each of the following four elements, namely: (1) the duty ‘owed by the physician to the patient, as created by the physician- patient relationship, to act in accordance with the specific norms or standards established by his profession; (2) the breach of the duty by the physician’s falling to act in accordance with the applicable standard of care; (3) the causation, ie, there must be a reasonably close and causal connection between the negligent act or omission ‘and the resulting injury; and (4) the damages suffered by the patient. Here, the Prosecution presented no witnesses with special medical qualfications in anesthesia to provide guidance to the trial court on what standard of care was applicable. It would consequently be ttuly dificult, f not impossible, to determine whether the first three elements of a negligence and malpractice action were attendant. Dr, Solidum was criminally charged for “failing to monitor and regulate properly the levels of anesthesia administered to said Gerald Albert Gercayo and using 100% halothane and other anesthetic medications.” However, the foregoing circumstances, taken together, did not prove beyond reasonable doubt that Or. Solidum had been recklessly imprudent in administering the anesthetic agent to Gerald. indeed, Dr. Vertido's findings did not preclude the probability that other factors related to Gerald's major ‘operation, which could or could not necessarily be attributed to the ‘administration of the anesthesia, had caused the hypoxia and had then Jed Gerald to experience bradycardia. Or. Vertido revealingly concluded in his report, instead, that “although the anesthesiologist followed the normal routine and precautionary procedures, still hypoxia and its corresponding side effects did occur.” ‘The existence of the probability about other factors causing the hypoxia has engendered in the mind of the Court 3 reasonable doubt as to Dr. Solidum’s guilt, and,moves us to acquit him of the crime of reckless imprudence resulting to serious physical injuries. H Ie OO FACTS: Pedrito was married to one Carmen Castillo Dela Torre(Carmen). She was due to give birth on February 2,1992 and ‘was brought at around 11:30 p.m. on that day. At around 3:00 p.m. ‘on February 3, Carmen was brought to the hospital's operating. room for her caesarian section operation, which was to be performed by Dr. Nestor. By 5:30 p.m. of the same day, Pedrito was informed of his wife's delivery of a baby boy. Inthe early morning of February 4, Carmen experienced abdominal pain and difficulty in urinating. On February 10, Pedrito noticed that Carmen's stomach ‘was getting bigger, but Dr. Norma dismissed the patient's condition as mer flatulence (kabag). (On February 12, Carmen had her second operation. The condition of Carmen, did not improve. it instead worsened that on February 13, she vomited dark red blood. At 9:30 p.m. on the same day, Carmen died. Per her certificate of death upon information provides by the hospitalthe immediate cause of Carmen's death was “cardio- respiratory arrest secondary to cerebro vascular accident, hypertension and chronic nephritis induced by pregnancy.” An autopsy Report prepared by Dr. Richard Patilano(Or. Patileno), Medico-Legal Officer-Designate of Olongapo City, however, provided that the cause of Carmen’s death was "shock due to peritonitis, severe, with multiple intestinal adhesions; Status post Clalesarian Section and Exploratory Laparotomy.” Pedrito filed a complaint for damages against herein respondents. In their answer to the complaint, they explained that there was no ‘unusual events that were observed during the course of Carmen’s caesarian section operation. The second surgery, however, became necessary due to suspected intestinal obstruction and adhesions. This procedure was fully explained to Carmen and Pedrito prior to its conduct, During the second operation, the diagnosis of intestinal obstruction and adhesion was confirmed but resolved by her doctors, Despite the observance of due care by the doctors, however, Carmen died on February 13, 1992. TC of Olongapo City, Branch 75, rendered its Decision in favor of Pedrito, The tral court gave greater weight to the testimony of Dr. Patilano. CA rendered its Decision reversing and setting aside the decision of the RTC. For the appellate court, it was not established that the respondents failed to exercisethe degree of diligence required of them by their profession as doctors. The CA also granted the respondents’ counterclaim for the amount of P48,$15.58. ISSUE: Should respondents be held liable forthe death of Carmen? RULING: No. "[Mledical malpractice or, more appropriately, ‘medical negligence, is that type of claim which a victim has available to him or her to redress @ wrong committed by a medical professional which has causéd bodily harm.” In order to successfully pursue such a claim, a patient, or his or her family as in this case, "must prove that a health care provider, in most cases a physician, either failed to do something which a reasonably prudent health ‘care provider would have done, or that he or she did something that 2 reasonably prudent provider would not have done; and that failure or action caused injury to the patient.” ‘The Court emphasized in Lucas, et al. v. Tuatlo that in medical negligence cases, there is @ physician-patient relationship between the doctor and the victim, but just lke In any other proceeding for damages, four essential elements must be established by the plaintiff, namely: (2) duty; (2) breach; (3) injury: and (4) proximate causation. All four elements must be present in order to find the physician negligent and, thus, able for damages. It is settled that a physician’s duty to his patient relates t0 his ‘exercise of the degree of care, 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. There is breach of this duty when the patient is injured in body or in heath. Proof of this breach rests upon the testimony of an expert witnessLEGAL MEDICINE that the treatment accorded to the patient failed to meet the standard level of care, skill and diligence. To justify an award of damages, the negligence of the doctor must be established to be the proximate cause of the injury. Upon review, the Court agrees with the CA that the report and testimony of Or. Patilano failed to justify Pedrito's entitlement to ‘the damages awarded by the RTC. Considering that it was not duly established that Or. Patilano practiced and was an expert in the fields that involied Carmen's condition, he could not have accurately identified the said degree of care, skil, diligence and the ‘medical procedures that should have been applied by her attending physicians. Similariy, such duty, degree of care, skill and diligence were not sufficiently established in this case because the testimony of Or. Patilano was based solely on the results of his autopsy on the cadaver of Carmen. His study and assessment were restricted by limitations that denied his full evaluation of Carmen's case. He could have only deduced from the injuries apparent in Carmen's body, {and in the condition when the body was examined. Judging from his testimony, Dr. Patilano did not even take full consideration of the ‘medical history of Carmen, her actual health condition at the time (of hospital admission, and her condition as it progressed while she was being monitored and treated by the respondents. There was also no reference to the respondents’ defense that the emergency ‘caesarian section operation had to be performed in order to protect the lives and safety of Carmen and her then unborn child. For lack of sufficient information on Carmen's health condition while stil alive, Dr, Patilano could not have fully evaluated the suitability of the respondents’ decisions in handling Carmen's medical condition as it turned critical Itis also significant that the Chief of the Medico-Legal Division of the PNP Crime Laboratory Service, Dr. Torres, testified before the trial court that based on the autopsy report issued by Dr. Patilano, the latter did not comply with the basic autopsy procedure when he examined the cadaver of Carmen, Dr. Patilano did not appear to have thoroughly examined Carmen's vital organs such as her heart, lungs, uterus and brain during the autopsy. His findings were then inconclusive on the issue of the actual cause of Carmen’s death, and the claim of negligence allegedly committed by the respondents. [As the Court held in Spouses Flores v. Spouses Pineda, et al,, the critical and clinching factor in a medical negligence case Is proof of the causal connection between the negligence and the injuries. The Claimant must prove not only the injury but also the defendant's fault, and that such fault caused the injury. A verdict in 2 ‘malpractice action cannot be based on speculation or conjecture. Causation must be proven within a reasonable medical probability based upon competent expert testimony, which the Court finds absent in the case at bar Petition is DENIED. 15. DR. ANTONIO P. CABUGAO V PEOPLE; DR. CLENIO YNZON V Booman) (Sorry kung mahaba, | included the ruling of TC and CA; also there ‘are two decisions, one for each doctor) FACTS: On June 14, 2000 at 4pm, 10-yr old Rodolfo Palma Jr, (JR) complained of abdominal pain to his mother Rosario. At Spm, together with her husband, Atty. Rodolfo Palma Sr., they brought JR to the clinic of Dr who racttioner specializing in family medicine. Or. Cabugao gave them medicine for the pain and told them to call him if the pains continue. Due to persistent abdominal pains, the following morning, they returned to Dr. Cabugao who advised them to bring JR to Nazereth Gen. Hospital in Dagupan for confinement. JR was admitted at 5:30am. Blood samples were taken for testing and ultrasound was also conducted. After Or. Cabugao’s rectal examination, the initial impression was Acute Appendicitis, hence he coferrad the case to De Ynson, a surgeon, Late that morning, Or. Ynzon went to the hospital and read the lab results and ordered the administration of ‘massive antibiotics and pain relievers and put JR on observation for 24 hes, ln the mocning of lune 16, 18 complained of abdominal pains and 3 swelling in the scrotum. That afternoon, JR vomited out several times and had watery bowels. The nurses on-duty relayed JR's condition to Or. Yazon who merely gave orders via telephone. He advised them to continue the medications to alleviate the abdominal spasms and diarrhea. By midnight, JR vomited, had watery bowels and could not sleep. On June 17, JR had a fever of 38 dlegress C. He was glven one ampule Aeknil and 1 ampule Valium ‘out by 2pm that day/his temperature soared to 42 degreesC. He had convulsions and died, (On the death certificate prepared by Or. Cabugao, the Immediate cause of death was Cardiorespiratory arrest. The Antecedent cause was Metabolic Encephalopathy. The underlying cause was Speticemia (Acute Appendicitis). [An information was filed against the doctors for reckless imprudence resulting to homicide. At the arraignment, both doctors pleaded not guilty. The trial court convicted both accused. According to the trial court, JR was under the medical care of the accused from the time of admission to the hospital until his death, The initial working, diagnosis was acute appendicitis. However, the accused, as the attending physicians, did not personally monitor JR in order to check fon subtle changes thet may occur. Rather, they left the monitoring ‘and_actual_ob " cians wi 4 res aining and in doing so, they substituted their own xpertise, skill and comy with 3f physicians who a merely new doctors still on training. Throughout the course of the hospitalization and treatment of JR, the accused failed to address the acute appendicitis which was the initial diagnosis. They did not take steps to find out if indeed acute appendicitis was what was ‘causing the massive infection. Appendicitis, according to exert done by the accused, ‘On appeal, the CA affirmed the conviction: Expert testimony clearly revealed such want of reasonable skill and care on the part of JR's attending physicians, appellants Dr. Cabugao and Dr. Ynzon in neglecting to monitor effectively and sufficiently the developments/changes during the observation period and act upon the situation after said 24-hour period when his condition worsened. Considering the brief visit only made on regular rounds, records clearly show such gross negliger aleLEGAL MEDICINE roprate st ter seal cause of JR's abdominal nso that the crucial decision to perform sur endecto had even been ruled out because of the inexcus neglect to undertake such efficient diagnosis by process of elimination, as correctly pointed out by the trial court. In treating JR, appellants have demonstrated indifference and neglect of the patient's condition as a serious case. Appendectomy is the only rational therapy for acute appendicitis, Although difficult, prompt recognition and immediate treatment of the disease prevent complications. Under the factual circumstances, the inaction, neglect anc indifference of appellants who, after the day ‘of admission and after being apprised of the ongoing infection from ‘the CBC and initial diagnosis as acute appendicitis from rectal examination and ultrasound test and only briefly visited JR a1 during regular round lon or telephon constitutes g70ss negligence leading to the continued deterioration of the patient, his infection having spread in so fast a pace that he died within just two and a hal (2%) days’ stay inthe hospital ISSUE: Whether or not petitioners’ conviction of the crime of reckless imprudence resulting in homicide, arising from an alleged ‘medical malpractice, s supported by the evidence on record DECISION: ‘As to Dr. Ynzon’s Liability Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act from which material damage results by reason of an inexcusable lack of precaution on the part of the person performing o falling to perform such act. The elements of reckless 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 reckless imprudence; and (5) that there is inexcusable lack of precaution on the part of the offender, taking into consideration his employment or occupation, degree of intelligence, physical condition, and other circumstances regarding persons, time and place. with respect to Dr. Ynzon, all the requisites of the offense have been clearly established by the evidence. It wos sufficiently established that to prevent certain death, it was necessary to perform surgery on JR immediately. Even the prosecution's own expert witness, Dr. Antonio Mateo, testified during cross-examination that he would perform surgery on JR. Dr. (Mateo testified that if surgery was not performed, the appendix would rupture and infection would spread throughout the body. If unchecked, this will result to death. He testified that the surgeon rust decide within the 24 hour period whether or not to perform surgery, depending upon the changes in the body of the patient. It is clear that if JR's condition remained unchecked it would Ultimately result in his death, 2s what actually happened in the present case. Another expert witness for the defense, Or. Vivencio Vilalor, I. testified on direct exsmination that he would perform @ personal and thorough physical examination of the patient as frequent as every 4 to 6 hours. He also testified that the only way to rule out the initial diagnosis of acute appendicitis was to perform surgery. Whether a physi has exercised the requisite d cate in the treatment is, in the generality ‘of cases, a matter of expert opinion. From the testimonies of the expert witnesses presented, it was irefutably proven that Or. Ynzon failed to practice that degree of skill and care required in the treatment of his patient. ‘As correctly observed by the appellate court, Dr. Ynzon revealed "want of reasonable skill and care in attending to the needs of JR by neglecting to monitor effectively the developments and changes on JR's condition during the observation period, and to act upon the When the patient worsened. He was not there during the crucial times on June 16, 2000 when JR's condition started to deteriorate until JR's death. As the attending surgeon, he should be primarily responsible in monitoring the condition of JR, as he is in the best position considering his skills and experience to know ifthe patient's condition had deteriorated, While the resident-doctors-on_duty kewise monitor the patient's condition, he is the one direct ible for the patient as the attendin reckless and gross negligence of duty to relegate his personal responsibility to observe the condition of the patient. Again, acute appendicitis was the working diagnosis, and with the emergence of _raver symptoms after the 24-hour observation, Dr. Yazon ruled 0. Indeed, itis ‘out surgery for no apparent reason. ‘Among the elements constitutive of reckless imprudence, what perhaps is most central to a finding of guilt is the conclusive determination that the accused has exhibited, by his voluntary act without malice, an inexcusable lack of precaution. Quasi-ffenses penalize the mental attitude or condition behind the act, the dangerous recklessness, the lack of care or foresight, the imprudencia punible,” unlike willful offenses which punish the Intentional criminal act. To be sure, whether or not a physician has committed an “inexcusable lack of precaution" in the treatment of his patient is to be determined according to the standard of care observed by ‘other members of the profession in good standing under similar circumstances bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science. In accepting 2 case, a doctor in effect represents that, having the needed training and skill possessed by physicians and surgeons practicing in the same field, he will employ such training, care and skill in the treatment of his patients. He, therefore, has a ‘duty to use at least the same level of care that any other reasonably ‘competent doctor would use to treat a condition under the same circumstances, Sadly, Dr. Ynzon did not display that degree of care and precaution demanded by the circumstances, Decision as to Dr. Ynzon affirmed. ‘As to Dr. Cobugao’s Liability Every criminal conviction requires of the prosecution to prove two things — the fact of the crime, ie, the presence of all the elements of the crime for which the accused stands charged, and the fact that the accused is the perpetrator of the crime. Based on the above disquisitions, however, the prosecution failed to prove these two things. The Court is nat convinced with moral certainty that Or. Cabugao is guilty of reckless imprudence as the elements thereof were not proven by the prosecution beyond a reasonable doubt.LEGAL MEDICINE The TC and CA held that the failure to perform the appendectomy ‘on JR was the primary cause of his death, However, a review of the ‘ecords show that Dr. Cabugao was not in the position to perform the required surgery. Dr. Cabugao is not a surgeon but a general practitioner specializing in family medicine. Even if he wanted to, he cannot do an operation like an appendectomy. It is precisely for this reason that he referred JR's case to Dr. Ynzon after he suspected appendicitis. As testified by Or. Mateo, one of the expert witnesses, it is the surgeon who was in the best position to ‘observe the sudden changes in the condition of the patient. br. Cabugao’s supervision does not cease upon his endorsement of his patient to the surgeon. Here, Dr. Cabugao has shown to have exerted all efforts to monitor his patient and under these circumstances he did not have any cause to doubt Dr. Ynzon's ‘competence and diligence. Neither do we find evidence that Dr. Cabugao has been negligent or lacked the necessary precaution in his performance of his duty as a family doctor. On the contrary, a perusal of the medical records would show that during the 26-hour monitoring on JR, it was Or. CCabugao who frequently made orders on the administration of Antibiotics and pain relievers. There was also repetitive instructions from Or. Cabuga0 to refer JR to Dr. Ynzon as it appeared that he is suspecting appencicitis. The referral of JR to Dr. Ynzon, a surgeon, is actually an exercise of precaution as he knew that appendicitis is not within his scope of expertise. This clearly showed that he employed the best of his knowledge and skill in attending to JR's condition, even after the referral of JR to Or. Ynzon. To be sure, the calculated assessment of Or. Cabugao to refer JR to a surgeon who hhas sufficient taining and experience to handle JR's case belies the finding that he displayed inexcusable lack of precaution in handling, his patient. Dr. Cabuago was acquitted. Asto Civil Liability while pending on appeal, counsel for Dr. Yazon informed the Court that the latter died in 2011 due to multiorgan failure. In view of the foregoing, its clear that the death of the accused Dr. ‘Yoon pending appeal of his conviction extinguishes his criminal liability, However, the recovery of civil ability subsists as the same is not based on delictbut by contract and the reckless imprudence he was guilty of under Article 365 of the Revised Penal Code.For this reason, @ separate cwvil action may be enforced elther against the ‘executor/administrator or the estate of the accused, depending on ‘the source of obligation upon which the same is based, and in accordance with Section 4, Rule 111 of the Rules on Criminal Procedure. OUTLET Patents) rae TT Ee ‘March 11, 2015, Pesan Facts: ‘This cate is a result of three consolidated petitions for review on certiorari. This stemmed from the first case was filed by Nelson Cortejo for the wrongful death of his son allegedly due to the medical negligence of the petitioning doctors and the hospital ee nm oy rf ene oo on Sac enon eminent oer een enna or ee noe ene ae st ee aa, Somes ehenerern see i eee ere et aera aan ce ett Sr er meee ena eee aera means Ss ete ee ie orga iirc ba oceans ean er oh oa ee oe oreo one mere ets me eee Sete tng tn eet we homer eee ce ne rene eee ce eae en es Mie na Ge a oie eee ee Sierra oe a i oe Se css Roe een ee Some ene ioe eee sear or Sa it laggy ree Seo bene ap sce ia ieccre em sen nl cece ee aot Soper cee ea eee pio oer eee nore cee ne menen eee aoee oe oan es from “Dengue Hemorrhagic Fever.” One hous later, Dr. Casumpang arrived at Edmer’s room and he recommended his transfer to the ICU, to which the respondent consented, Since the ICU was then full, the respondent insisted on transferring his son to Makati Medical Center. At 12:00 midnight, Eder, accompanied by his parents and by Or. Casumpang, was transferred to Makati Medical Center. Or. Casumpang immediately gave the attending physician the patient’s clinical history andLEGAL MEDICINE laboratory exam results, Upon examination, the attending physician diagnosed “Dengue Fever Stage IV" that was already in its irreversible stage. Edmer died at 4:00 in the morning of April 24, 1988. His Death Certificate indicated the cause of death as “Hypovolemic Shock/hemorshagic shock;* “Dengue Hemorrhagic Fever stage IV.” Believing that Edmer’s death was caused by the negligent and erroneous diagnosis of his doctors, the respondent instituted an action for damages against San Juan De Dios, and its attending physicians: Dr. Casumpang and Dr, Sanga before the RTC of Makati City ‘The RTC ruled in favor of Cortejo. The trial court faulted them for heavily relying on the chest xray result and for not considering the other manifestations that Edmer’s parents had relayed. It held that in diagnosing and treating an illness, the physician's conduct should be judged not only by what he/she saw and knew, but also by what he/she could have reasonably seen and known. It also observed that based on Eémer’s signs and symptoms, his medical history and physical examination, and also. the information that the petitioning doctors gathered from his family members, dengue fever was a reasonably foreseeable illness; yet, the petitioning doctors falled to take a second look, much less, Consider these Indicators of dengue. Such decision was affirmed by a. ISSUES: 1. Whether or not the petitioning doctors had committed “inexcusable lack of precaution” in diagnosing and in treating the patient. 2, Whether or not there is a causal connection between the petitioners’ negligent act/omission and the patient’s resulting death. DISCUSSION ON MEDICAL MALPRACTICE SUIT: ‘A medical malpractice suit isan action available to victims to redress ‘a wrong committed by medical professionals who caused bodily hharm to, or the death of, a patient. As the term is used, the sult is brought whenever a medical practitioner or health care provider fails to meet the standards demanded by his profession, or deviates from this standard, and causes injury to the patient, To successfully pursue a medical malpractice suit, the plaintiff must prove that the doctor either failed to do what 2 reasonably prudent doctor would have done, or did what a reasonably prudent doctor would not have done; and the act or omission had caused injury to the patient. The patient's heir/s bears the burden of proving his/her cause of action. ‘The elements of medical negligence are: 1. DUTY refers to the standard of behavior that imposes restrictions fon one's conduet. it requires proof of professional relationship ‘between the physician and the patient. Without the professional relationship, a physician owes no duty to the patient, and cannot therefore incur any lisbilty. A physician-patient relationship is ‘created when a patient engages the services of a physician and the latter accepts or agrees to provide care to the patient. The establishment of this relationship is consensual and the acceptance bby the physician essential. The mere fact that an individual approaches @ physician and seeks diagnosis, advice or treatment does not create the duty of care unless the physician agrees. The consent needed to create the relationship does not always need to be express. In the absence of an express agreement, a physician: patient relationship may be implied from the physician's affirmative action to diagnose and/or treat a patient, or in his participation in such diagnosis and/or treatment, The usual illustration would be the case of a patient who goes to a hospital or a clinic, and is examined and teated by the doctor. In this case, we can infer, based on the established and customary practice in the medical community that a patient-physician relationship exists. Once a physician-patient relationship is established, the legal duty of care follows. The doctor accordingly becomes duty-bound to use at least the same standard ‘of care that 2 reasonably competent doctor would use to treat a ‘medical condition under similar circumstances. 2. BREACH, 3. INJURY - Breach of duty occurs when the doctor fails to comply with, or improperly performs his duties under professional standards. This determination is both factual and legal, and is specific to each individual case. if the patient, as a result of the breach of duty, is injured in body or in health, actionable malpractice is committed, entitling the patient to damages. 4. PROXIMATE CAUSATION - To successfully claim damages, the patient must lastly prove the causal relation between the negligence and the Injury. This connection must be direct, natural, and should be unbroken by any intervening efficient causes. In other words, the negligence must be the proximate cause of the Injury. The injury oF damage Is proximately caused by the physician’s negligence when it appears, based on the evidence and the expert testimony, that the negligence played an integral part in causing the Injury or damage, and that the injury or damage was either a direct result, oF a reasonably probable consequence of the physician's negligence. a.ourTY 2. The Relationship Between Or. Casumpang and Edmer In the present case, the physician-patient relationship between Dr. Casumpang and Eémer was created when the latter's parents sought the medical services of Or. Casumpang, and the latter knowingly accepted Edmer as 2 patient. Dr. Casumpang’s ‘acceptance is implied from his affirmative examination, diagnosis ‘and treatment of Edmer. On the other hand, Edmer’s parents, on their son’s behalf, manifested their consent by availing of the benefits of their health care plan, and by accepting the hospita’s assigned doctor without objections. », The Relationship Between Dr. Sanga and Edmer ‘With respect to Dr. Sanga, her professional relationship with Edmer arose when she assumed the obligation to provide resident supervision over the latter. As second year resident doctor tasked to do rounds and assist other physicians, Dr. Sanga is deemed to have agreed to the creation of physician-patient relationship with the hhospital’s patients when she participated in the diagnosis and prescribed a course of treatment for Edmer. Her affirmative acts ‘amounted to her acceptance of the physiclan-patient relationship, ‘and incidentally, the legal duty of care that went with it. 2. Standard of Care and Breach of Duty. Based on Dr. Jaudian’s expert testimony on dengue diagnosis and ‘management, ifthe patient was admitted for chest pain, abdominal pain, and difficulty in breathing coupled with fever, dengue fever should definitely be considered; if the patient spits coffee ground ‘with the presence of blood, and the patient's platelet count drops to 47,000, it becomes a clear case of dengue fever, and bbronchopneumonia can be reasonably ruled out. Furthermore, the standard of care according to Dr. Jaudian ik to ‘administer oxygen inhalation, analgesic, and fiuid infusion or dextrose. If the patient had twice vomited fresh blood and thrombocytopenia has already occurred, the doctor should orderLEGAL MEDICINE blood transfusion, monitoring of the patient every 30 minutes, hemostatic to stop bleeding, and oxygen if there is difficulty in breathing. Therefore, we find that Or. Casumpang, as Edmer’s attending physician, did not act according to these standards and, hence, was guilty of breach of duty. In tis case, the Court ruled that Dr. Casumpang is negligent, while. Dr. Sanga is not liable. The Court ‘algo ruled that the hospital is solidarity abe. Dr, Casumpang'’s Negligence Ie will be recalled that during Dr. Casumpang's first and second visits to Edmer, he already had knowledge of Edmers laboratory test result, medical history, and symptoms. However, these information did not lead Dr. Casumpang to the possibilty that Edmer could be suffering from either dengue fever, or dengue hemorrhagic fever, as hhe clung to his diagnosis of broncho pneumonia. It was lost on Dr. Casumpang that the characteristic symptoms of dengue. All these manifestations were present and known to Or. Casumpang at the time of his first and second visits to Edmer. While he noted some of these symptoms in confirming bronchopneumonia, he did not seem to have considered the patient’s other manifestations in ruling out dengue fever or dengue hemorrhagic fever. To our mind, Dr. Casumpang selectively appreciated some, and not all of the symptoms; worse, he casually ignored the pieces of information that could have been material in detecting dengue fever. By the time that Edmer had blood streaks in his sputum, neither did Dr. Casumpang order confirmatory tests to confirm the source of bleeding. Dr. Casumpang only used a stethoscope in coming up with the diagnosis that Eémer was suffering from bronchopneumonia; he ever confirmed this finding with the use of a bronchoscope. Significantly, itis only after Edmer's third episode of bleeding that br. Casumpang ordered the conduct of hematocrit, hemoglobin, blood typing, blood transfusion and tourniquet tests, such tests ‘came too late. Even assuming that Edmer’s symptoms completely coincided with the diagnosis of bronchopneumonia, we stil find Dr. Casumpang guilty of negligence. In the present case, evidence on record established that in confirming the diagnosis of bronchopneumonia, Dr. Casumpang selectively appreciated some and not all of the symptoms presented, and failed to promptly conduct the appropriate tests to confirm his findings. In sum, Dr. Casumpang failed to timely detect dengue fever, which failure, especially when reasonable prudence would have shown that indications of dengue ‘were evident and/or foreseeable, constitutes negligence. ‘Dr. Sanga is Not Liable for Negligence (SHE WAS A JUNIOR RESIDENT poctoa) \We find that Dr. Sanga was not independently negligent. Although she had greater patient exposure, and was subject to the same standard of care applicable to attending physicians, we believe that 2 finding of negligence should also depend on several competing factors, among them, her authority to make her own diagnosis, the degree of supervision of the attending physician over her, and the shared responsibilty between her and the attending physicians. in this case, before Dr. Sanga attended to Edmer, both Or. Livelo and ‘Dr. Casumpang had diagnosed Edmer with bronchopneumonia, There is also evidence supporting Dr. Sanga’s claim that she ‘extended diligent care to Edmer. In fact, when she suspected that Edmer could be suffering from dengue fever, she wasted no time In conducting the necessary tests, and promptly notified Or. Casumpang about the incident. Indubitably, her medical assistance led to the finding of dengue fever. We note however, that during Edmer’s second episode of bleeding, Dr. Sanga failed to immediately ‘examine and note the cause of the blood specimen. Like Or. CCasumpang, she merely assumed that the blood in Edmer’s phlegm was caused by bronchopneumor Based on her statements we find that Or. Sanga was not entirely faultess, Nevertheless, her fallure to discern the import of Edmer's second bleeding does not necessarily amount to negligence as the ‘espondent himself admitted that Dr. Sanga failed to examine the blood specimen because he washed it away. We believe that Or. ‘Sanga’s error was merely an honest mistake of judgment influenced in no small measure by her status in the hospital hierarchy; hence, she should not be held liable for medical negligence. 3 and 4. Injury and the Causation Between Dr, Casumpang’s ‘Negligent Act/Omission, and the Patient’s Resulting Death br. Casumpang’s failure to timely diagnose Edmer with dengue, the latter was not immediately given the proper treatment. In fact, even after Dr. Casumpang had discovered Edmer’s real illness, he still failed to promptly perform the standard medical procedure. Dengue fever, if left untreated, could be a life threatening disease. As in any fatal diseases, It requires immediate medical attention, With the correct and timely diagnosis, coupled with the proper medical management, dengue fever is not a life threatening disease and could easily be cured. To reiterate, Dr. Casumpang failed to timely diagnose Edmer with dengue fever despite the presence of its characteristic symptoms; and as @ consequence of the delayed diagnosis, he also failed to promptly manage Edmer's illness. Had he immediately conducted confirmatory tests and promptly administered the proper care and management needed for dengue fever, the risk of complications or even death, could have been substantially reduced. Edmer died of “Htypovolemic Shock/hemorchagic shock,” “Dengue Hemorrhagic Fever Stage IV,” a severe and fatal form of dengue fever, established the causal link between Dr. Casumpang’s negligence and the injury. Luabilty of San Juan De Dios Hospital We affirm the hospital's liability on the basis of the doctrine of apparent authority or agency by estoppel. On one hand, there is no Employer-Employee relationship between SIDH and the Doctors. The power of control is not present in this case. Based on the records, no evidence exists showing that SIDH exercised any degree of control over the means, methods of procedure and ‘manner by which the petitioning doctors conducted and performed their medical profession. In these lights, the doctors were not employees of SIDH, but were mere independent contractors. (On the other hand, SIDH is solidarily liable based on the principle of ‘agency or doctrine of apparent authority. As a rule, hospitals are not liable for the negligence of its independent contractors. However, ‘may be found liable if the physician or independent contractor acts as an ostensible agent of the hospital. This exception is also known 23s the “doctrine of apparent authority In this case at bar, SIDH clothed Or. Casumpang with ‘apparent authority. Based on the records, the respondent relied on SIOH rather than upon Dr. Casumpang, to care and treat his son Edmer. The spouses Cornejo brought their son to SIDH for diagnosis because of their family doctor's referral. The referral did not specifically point to Dr. Casumpang or even to Dr. Sanga, but to SIDH. Significantly, the cespendent had relied on SIOM's representation of Dr. Casumpang's authority. ‘Mrs. Cortejo accepted Dr. Casumpang's services on the reasonable belief that such were being provided by SIDH or its employees,LEGAL MEDICINE agents, or servants. By referring Dr. Casumpang to care and treat for Edmer, SJOH impliedly held out Or. Casumpang, not only as an accredited member of Fortune Care, but also as a member of its medical staff. SIDH cannot now disclaim liability since there is no showing that Mrs. Cortejo or the respondent knew, or should have known, that Dr. Casumpang is only an independent contractor of the hospital. In this case, estoppel has already set in. PAs OT crime: rape RTC: Guilty CA: affirmed SC: affirmed, Reclusion Perpetua Victim: AAA, 14 y.0 Prosecution’s Version: In the afternoon of June 2, 2002, AAA, along with her friends Sabanag and Sinangote, went to the house of her grandmother to ‘attend @ dance event. At around 8:30pm, during the dance, Sabanag and Sinangote danced with Alverio but AAA did not. At 2 a.m., AAA noticed that her friends were no longer at the dance so she decided to go home to her grandmother's house. As she was ‘nearing the barangay hall, Alverio suddenly appeared and took hold of AAA, She tried to resist him but he was too strong and he ‘managed to pull her away. AAA started to cry while she was being dragged towards the back of the barangay hall. There, Alverio held her hair, undressed her, and started to kiss her. AAA kept on resisting and even punched Alverio after he kissed her, at which point, Alverio told her that it was painful and that he might retaliate if she continued, This caused AAA to stop resisting and Alverio then proceeded to insert his penis in her vagina repeatedly, After having carnal knowledge with her, Alverio stood up and put on his clothes, He warned AAA that if she told anyone about what happened, he will kill her. After threatening her, he left. During this entice incident, Alverio was armed with a knife which he used to poke AAX's side. Dazed, AAA could not muster enough strength to go home. She just sat on the road beside the barangay hall until § a.m. when her Uncle Intoy passed by. He brought her home to her parents but she did not tell him anything, Upon reaching home, AAA told her parents about what happened. Version of the Defense: Alverio was in the barangay chapel with his friend, Toledo, waiting for the dance to begin. At 8:30 pm, the dance started. He danced with some persons whose names he could no longer recall. But he ‘categorically remembered that he did not see AMA in the dance area. At 12:00 mn, Alverio and Toledo walked home to Toledo's hhouse, where Alverio was staying. Upon reaching home, they slept ‘and woke up at 5:302.m Issuer Is Alverio guilty beyond reasonable doubt of rape? (a) Is the trial court for giving credence to the sole testimony of the victim? (b) Should the medical certificate presented be considered as corroborative evidence though it wos not testified to by the signatory himself? vEs. (2) YES. “in cases involving the prosecution for forcible rape, corroboration of the victim's testimony is nat a necessary condition to a convition for rape where the victim’s testimony is credible, or clear and convincing or sufficient to prove the elements of the offense beyond a reasonable doubt." More importantly, courts generally give full credence to the testimony of a complainant for tape, especially one who is only 2 minor. The victim testified in a steadfast and straightforward manner. It is strikingly clear from the transcript that AAA's testimony was very coherent and candid. (2) YES. Medical evidence is dispensable and merely corroborative in proving the crime of rape. Besides, a medical certificate is not even necessary to prove the crime of rape. The gravamen of rape is carnal knowledge of @ woman through force and intimidation. The elements needed to prove the crime of rape under paragraph (a) of Article 266-A of the RPC are: (1) the offender is a man; (2) the offender had carnal knowledge of a woman; and (3) the act is accomplished by using force or intimidation. All these elements were sufficiently proved by the prosecution. The testimony of AAA overwhelmingly proves that Alverio raped her with the use of force and intimidation. Furthermore, Alverio's defense of alibi cannot stand versus the positive identification of AAA. Nothing is more settled in criminal law jurisprudence than the rule that alibi and denial cannot prevail over the positive and categorical testimony and identification of the accused by the complainant. Fara FACTS: The facts hark back to the afternoon of October 17, 1996, at ‘around 4 oclock, when the body of six-year old Jennifer Domantay ‘was found sprawled amidst a bamboo grove in Gullig, Malasiqu, Pangasinan. The child’s body bore several stab wounds. Jennifer had bbeen missing since lunch time, ‘The medical examination conducted the following day by Or. Macaranas, the rural health physician of Malasiqui, showed that Jennifer died of multiple organ failure and hypovolemic shock secondary to 38 stab wounds at the back. Dr. Macaranas found no lacerations or signs of inflammation of the outer and inner labia and ‘the vaginal walls ofthe victim’s genitalia, although the vaginal canal easily admitted the little finger with minimal resistance. Noting possible commission of acts of lasciviousness, Dr. Macaranas recommended an autopsy by a medico-legal expert ofthe NBI. ‘The investigation by the Malasiqui police pointed to accused- appellant Bernardino Domantay, a cousin of the victim's frandfather, as the lone suspect in the gruesome crime. On the basis of the post-mortem findings of Or. Macaranas, SPO4 Carpizo, the PNP chief investigator at Malasiqui, fled, on October 21, 1996, a criminal complaint for murder against accused-appellant before the MTC-Malasiqui. On October 25, 1996, Dr. Bandonill, medico-legal ‘expert of the NBI, performed an autopsy on the embalmed body of Jennifer. The result of his examination of the victim's genitalia Indicated that the chile's hymen had been completely lacerated on the right side. Based on this finding, SPO4 Carpizo amended the ‘criminal complaint against accused-eppellant to rape with homicide. During trial, Dr. Bandonil, the NBI medico-tegal_ who conducted an autopsy of the victim on October 25, 1996, testified that Jennifer Domantay died as a result of the numerous stab wounds she sustained on her back, the average depth of which was, six inches, He opined that the wounds were probably caused by @ pointed sharp-edged instrument. He also noted contusions on the forehead, neck, and breast bone of the victim. As for the results of the genital examination of the victim, Dr. Bandonill said he found tat the laceration on the right side of the hymen was caused within 24 hours of her death, He added that the genital area showed signs of inflammation. ‘rial court found accused-appellant guilty as charged. Hence, this appeal. ISSUE: WON the autopsy report indicating that the child's hymen had been completely lacerated on the right side is sufficient to warrant the conviction of the accused on the crime of Rape with Homicide. HELD: NO. There is no sufficient evidence to hold accused-appellant juilty of raping Jennifer Oomantay. As the victim here was six yearsLEGAL MEDICINE ‘old, only carnal knowledge had to be proved to establish rape. Carnal knowledge is defined as the act of a man having sexual intercourse or sexual bodily connections with a woman. For this purpose, it is enough If there was even the slightest contact of the male sex organ with the labia of the victim's genitalia. However, there must be proof, by director indirect evidence, of such contact. br, Ronald Bandonills report on the genital examination he had performed on the deceased reads: GENITAL EXAMINATION; showed a complete laceration of the right side of the hymen. The surrounding genital area shows signs of inflamation REMARKS: 1) Findings at the genital area indicate the probability of penetration of that area by a hard, rigid instrument. Hiymenal laceration is not necessary to prove rape; neither does its presence prove its commission. As held in People v. Uli, 2 medical certificate or the testimony of the physician is presented not to prove that the victim was raped but to show that the latter hhad lost her virginity. Consequently, standing alone, a physician's finding that the hymen of the alleged victim was lacorated does not prove rape. It is only when this is corroborated by other ‘evidence proving carnal knowledge that rape may be deemed to have been established. ‘This conclusion is based on the medically accepted fact that 2 hhymenal tear may be caused by objects other than the male sex ‘organ or may arise from other causes. Dr. Bandonill himself admitted this. He opined that the laceration had been inflicted ‘within 24 hours of the victim’s death and that the inflammation was due to a trauma in that area. When asked by the private prosecutor whether the lacerations of the hymen could have been caused by the insertion of a male organ he said this was possible. But he also said when questioned by the defense that the lacerations could have been caused by something blunt other than the male organ. Court has sustained @ number of convictions for rape with homicide based on purely circumstantial evidence, In those instances, however, the prosecution was able to present other tell tale signs of rape such as the location and description of the victim's clothing’s, especially her undergarments, the position of the body when found and the like.In People v. Mocolino, for instance, the Court affirmed a conviction for the rape of a two year-old child on the basis of circumstantial evidence. In the case at bar, there is no circumstantial evidence from which to infer that accused-appellant ‘sexually abused the vitim, The only citcumstance from which such inference might be made is that accused-appellant was seen with ‘the vietim walking toward the place where the gir's body was found, Maybe he raped the girl. Maybe he did not. Maybe he simply inserted a blunt object into her organ, thus causing the lacerations Jn the hymen, Otherwise, there is no circumstance from which it might reasonably be inferred that he abused her, e.g., that he was zipping up his pants, that there was spermatozoa in the girs vaginal canal. Indeed, the very autopsy report of Dr. Sandonill miltates, ‘against the finding of rape. In describing the stab wounds on the body of the victim, he testified: (Ajfter examining the body | took rote that there were several stab wounds . .. these were all found at the back area si ... extending from the back shoulder down to the lower back area from the left to the right. Considering the relative physical positions of the accused and the victim in crimes of rape, the usual location of the external bodily injuries of the vietim is on the face, neck, and anterior portion of her body. Although it is aot unnatural to find contusions on the posterior side, these are usually caused by the downward pressure ‘on the victim's body during the sexual assault It is unquestionably different when, ag in this case, all the stab wounds (except for a ‘minor cut in the lower left leg) had their entry points at the back ‘unning from the upper left shoulder to the lower right buttocks. WHEREFORE, the judgment of the trial court is SET ASIDE and another one is rendered FINDING accused-appellant guilty of homicide with the aggravating circumstance of abuse of superior strength TOR CORPORATION vs. NLRC TM FACTS: The respondent was hired by the petitioner as an automotive mechanic at the service department of the petitioner company. During his employment, he received various awards for his exemplary performance. OnSeptember 22, 1997, the respondent made a phone call to Rosita dela Cruz, the company nurse, and informed her that he had to take a sick leave as he had @ painful and unbearable toothache. The next day, he again phoned Dela Cruz and told her that he could not report for work because he still had to consult a doctor. Finding that the respondent's ailment was due to a tooth inflammation, the doctor referred him to a dentist for further management. Dr. Rodolfo Pamor, a dentist, then scheduled the respondents tooth extraction on September 27, 1997 but on that day the Inflammation has not yet subsided so the dentist rescheduled it on another date. The dentist advised him to rest for the time being so he was not able to report for work. ‘Meanwhile, Mr. Dumagan, 2 company security guard, visited the respondent in his house upon the company’s instruction and confirmed that the latter was il. On October 2, 1997, the petitioner issued an Inter Office Memorandum terminating the services of the respondent for having incurred more than five (5) consecutive absences without proper notification. The petitioner considered the consecutive absences of the respondent as abandonment of office under Section 6.1.2, Article ill of the Company Rules. On October 4, 1997, Dr. Pamor successfully extracted the respondents tooth. AS soon as he had recovered, the respondent reported for work, but ‘was denied entry into the company’s premises. He was informed ‘that his employment had already been terminated. The petitioner avers that the respondent's absences were unauthorized, and that the latter failed to notify the petitioner in writing of such absences, the reasons therefor, and his (respondents) whereabouts as prescribed by the company rules which led to his dismissal from ‘work. Moreover, the petitioner's posits that respondent's dismissal was justified on the ground of gross and habitual neglect of duties ‘as found in the Labor Code. ISSUE: WON the respondent was terminated fora just cause. RULING: No. The termination by respondent-appellee of complainant's service despite knowledge of complainants ailment, {as shown by the telephone cals made by the latter to the company nurse and the actual confirmation made by respondents company guard who personally visited complainants residence clearly establishes the illegality of complainants dismissal. From the facts of this case, itis only but reasonable to conclude that complainant's service was, indeed, terminated without legal or valid cause. Where the law protects the right of employer to validly exercise management prerogative such as to terminate the services of an employee, such exercise must be with legal cause as enumerated in Article 282 of the Labor Code or by authorized cause as defined in {ticle 283 of the Labor Code. The company rules do not require that the notice of an employee's absence and the reasons therefor be in writing and for such notice to be given to any specific office ‘and/or employee of the petitioner. Hence, the notice may be verbal; it is enough then that an officer or employee of the petitioner, competent and cesponsible enough to receive such notice for and in behalf of the petitioner, was informed of such absence and the corresponding reason. This, the respondent complied. ‘While the records do not reveal that the respondent filed the required leave of absence for the period during which he suffered froma toothache, he immediately reported for work upon recovery, armed with medical certificates to attest to the cause of his ‘absence, While it is true that the petitioner had objected to the veracity of the medical certificates because of lack of notarization, itLEGAL MEDICINE hhas been said that verification of documents is not necessary in lrder that the said documents could be considered as substantial evidence. The medical certificates were properly signed by the physicians; hence, they bear all the earmarks of regularity in their issuance ane are entited to full probative weight. ‘The petitioner, likewise falled to prove the factual basis for its dismissal of the respondent on the ground of gross and habitual negligence. The petitioner has not sufficiently shown that the respondent had willfully disobeyed the company rules and regulation. The petitioner also failed to prove that the respondent abandoned his job. The bare fact that the respondent incurred excusable and unavoidable absences does not amount to an abandonment of his employment. Petition is dismissed. G EE) Facts: Sometime in December 2002, AAA's parents attended a wedding celebration

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