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cardiac arrest as a post-operative complication; 6 and 4) Dr.

Nieto Salvador, an expert


Republic of the Philippines witness who analyzed and explained the significance of the results of the pathological
SUPREME COURT study and autopsy conducted on Catherine's body by one Dr. Alberto Reyes. 7
Manila After the prosecution had rested its case, the defense was granted leave to file a
THIRD DIVISION demurrer to the evidence. 8 After failing to file the demurrer within the reglementary
period, Judge Manuel Yuzon, who had in the meantime taken over as presiding judge
G.R. No. 86890 January 21, 1994 of the sala where this case was pending, denied the defense motion for extension of
LEANDRO CARILLO, vs. PEOPLE OF THE PHILIPPINES time to file demurrer and declared the case submitted for decision. 9
On 19 September 1985, the trial court promulgated its decision convicting both the
FELICIANO, J.: accused of the crime charged. 10

Petitioner Dr. Leandro Carillo, an anesthetist, seeks review of the Decision of the On appeal, the Court of Appeals affirmed the judgment of conviction, and specified
Court of Appeals dated 28 November 1988, which affirmed his conviction by the that the civil liability of the two (2) accused was solidary in nature. 11
Regional Trial Court of the crime of simple negligence resulting in homicide, for the Petitioner Dr. Carillo alone filed the present Petition for Review with the Court,
death of his thirteen (13) year old patient Catherine Acosta. The trial court had seeking reversal of his conviction, or in the alternative, the grant of a new trial. Dr.
sentenced him to suffer the penalty of arresto mayor in its medium period (four [4] Madrid did not try to appeal further the Court of Appeals Decision. Accordingly, the
months' imprisonment), as well as to pay the heirs of his patient an indemnity of judgment of conviction became final insofar as the accused surgeon Dr. Madrid is
P30,000.00 for her death, P10,000.00 as reimbursement for actual expenses incurred, concerned.
P50,000.00 as moral damages and to pay the costs of the suit. The information filed
against petitioner and his co-accused, the surgeon Dr. Emilio Madrid, alleged the The facts of the case as established by the Court of Appeals are as follows:
following:
The deceased, Catherine Acosta, a 13 year old girl, daughter of spouses Domingo and
That on or about the 31st of May 1981, in the municipality of Paraaque, Metro Yolanda Acosta, complained to her father at about 10:30 o'clock in the morning of
Manila, Philippines and within the jurisdiction of this Honorable Court, the May 31, 1981 of pains in the lower part of her abdomen. Catherine was then brought
above-named accused, conspiring and confederating together and mutually to Dr. Elva Pea. Dra. Pea called for Dr. Emilio Madrid and the latter examined
helping and aiding with one another, without taking the necessary care and Catherine Acosta. According to Dr. Madrid, his findings might be appendicitis. Then
precaution to avoid injury to person, did then and there willfully, unlawfully and Dr. Pea told Catherine's parents to bring the child to the hospital in Baclaran so that
feloniously operate, in a reckless, careless and imprudent manner and neglected the child will be observed.
to exercise their respective medical knowhow and tasks and/or departed from the
recognized standard in their treatment, diagnosis of the condition, and operation At the Baclaran General Hospital, a nurse took blood sample form the child. The
of the patient, one Catherine Acosta, 13 years old, which negligence caused the findings became known at around 3:00 o'clock in the afternoon and the child was
death of the said Catherine Acosta. scheduled for operation at 5:00 o'clock in the afternoon. The operation took place at
5:45 p.m. because Dr. Madrid arrived only at that time.
Petitioner and Dr. Emilio Madrid entered pleas of not guilty at arraignment and the When brought inside the operating room, the child was feeling very well and they did
case proceeded to trail with Judge Job B. Madayag presiding. not subject the child to ECG (electrocardiogram) and X-ray. The appellant Dr. Emilio
Madrid, a surgeon, operated on Catherine. He was assisted by appellant, Dr. Leandro
The prosecution presented as its principal evidence the testimony of four (4) witnesses, Carillo, an anesthesiologists. During the operation, while Yolanda Acosta, Catherine's
namely: 1) Yolanda Acosta, Catherine's mother, who was able to observe the conduct mother, was staying outside the operating room, she "noticed something very
of the accused outside the operating theater before, during and after the appendectomy unfamiliar." The three nurses who assisted in the operation were going in and out of
procedure carried out on her daughter; 4 2) Domingo Acosta, Catherine's father, who the operating room, they were not carrying anything, but in going out of the operating
corroborated some parts of his wife's testimony; 5 3) Dr. Horacio Buendia, an expert room, they were already holding something.
witness who described before the trial court the relationship between a surgeon and an Yolanda asked one of the nurses if she could enter the operating room but she was
anesthetist in the course of a surgical operation, as well as define the likelihood of refused.
A After 15 or 30 minutes has lapsed at about 7:15 or 7:30, the child had developed
At around 6:30 p.m., Dr. Emilio Madrid went outside the operating room and Yolanda convulsion and stiffening of the body.
Acosta was allowed to enter the first door. Q When you observed convulsion and stiffening of the body, did you do anything?
A We requested the nurse who was attending to her to call for a doctor.
The appendicitis (sic) was shown to them by Dr. Madrid, because, according to Dr. Q And the nurse who was attending to the patient called for a doctor?
Madrid, they might be wondering because he was going to install drainage near the A They called for Dra. Pea, their family physician.
operating (sic) portion of the child. Q What transpired afterwards?
A What Dra. Pea did was call for Dr. Madrid and the cardiologist.
When asked, the doctor told them the child was already out of danger but the operation Q Did this doctor arrived?
was not yet finished. A Yes.
Q What transpired after the doctor arrived?
It has also been established that the deceased was not weighed before the A They examined the child.
administration of anesthesia on her. Q After they examined the child, did they inform you of the result of the examination?
A The cardiologist was the one whom informed us after he stepped out of the room
The operation was finished at 7:00 o'clock in the evening and when the child was when we followed him. The doctor told us that she suffered severe infection which
brought out from the operating room, she was observed to be shivering (nanginginig); went up to her head.
her heart beat was not normal; she was asleep and did not wake up; she was pale; and Q After you were informed of the result of his examination, what transpired next?
as if she had difficulty in breathing and Dr. Emilio Madrid suggested that she placed A According to them, they will do their best for the child and that they will call for Dr.
under oxygen tank; that oxygen was administered to the child when she was already Carillo.
in the room. Q Did Dr. Carillo arrived?
A At around 10:30 in the evening.
Witness Yolanda Acosta further testified that shortly before the child was transferred Q Did Dr. Carillo do anything when he arrived on 31 May 1981?
from the operating room to her room, she (witness) was requested by the A When he arrived, he noticed that there were two small bottles and big bottles of
anesthesiologist to go home and get a blanket. dextrose which were hanging above the bed of the child. Then he said, "What is this?
Christmas tree or what?" He told us that one bottle of dextrose be removed. And the
A portion of Yolanda Acosta's testimony on what happened when she returned to the big one will remain.
hospital are reproduced hereunder as follows: Q What happened after that?
A After that we talked to Dr. Carillo and asked him how did this happen to the child.
Q What happened afterward? Q What did Dr. Carillo reply (sic) to you?
A When I arrived in the hospital, my child was being transferred to her bed. A He answered "that is nothing, the child will regain consciousness and if the child
Q What else happened? will not regain consciousness, I will resign (sic) as a doctor." 12
Q I noticed that the heartbeat of my daughter was not normal. And I noticed that her (Emphasis supplied)
hospital gown is rising up and down. When Catherine remained unconscious until noontime the next day, a neurologist
Q What transpired after that? examined her and she was diagnosed as comatose. 13 Three (3) days later, Catherine
A I asked Dr. Madrid why it was like that, that the heartbeat of my daughter is not died without regaining consciousness. 14
normal. The Court of Appeals held that Catherine had suffered from an overdose of, or an
Q And did the doctor make any reply? adverse reaction to, anesthesia, particularly the arbitrary administration of Nubain, a
A The doctor said because of the lesion of the child. pain killer, without benefit of prior weighing of the patient's body mass, which weight
Q What else happened? determines the dosage of Nubain which can safely be given to a patient. 15 The Court
A After they have revived the heartbeat of the child, Dr. Carillo and Dr. Madrid left. of Appeals held that this condition triggered off a heart attack as a post-operative
Q Now do you remember what time was it when Dr. Carillo stepped out? complication, depriving Catherine's brain of oxygen, leading to the brain's
A Only a minute after they have transferred the child to the bed. hemorrhage. 16 The Court of Appeals identified such cardiac arrest as the immediate
Q What happened later on after Dr. Carillo and Dr. Madrid stepped out of the hospital? cause of Catherine's death. 17
appendix with peritonitis." 24 The concept of causation in general, and the cause of
The Court of Appeals found criminal negligence on the part of petitioner Dr. Carillo death in human beings in particular, are complex and difficult notions. What is fairly
and his co-accused Dr. Madrid, holding that both had failed to observe the required clear is that death, understood as a physical condition involving cessation of vital signs
standard of diligence in the examination of Catherine prior to the actual administration in the brain and heart, is preceded by a series of physiological events, any one of which
of anesthesia; 18 that it was "a bit rash" on the part of the accused Dr. Carillo "to have events can, with equal cogency, be described as a "cause of death". The Court of
administered Nubain without first weighing Catherine"; 19 and that it was an act of Appeals found that an overdose of, or an adverse reaction to, Nubain, an anesthetic or
negligence on the part of both doctors when, (a) they failed to monitor Catherine's pain-killing drug the appropriate dose of which depends on the body weight or mass
heartbeat after the operation and (b) they left the hospital immediately after reviving of the patient, had generated or triggered off cardiac arrest, which in turn led to lack
Catherine's heartbeat, depriving the latter of immediate and expert medical assistance of oxygen in Catherine's brain, which then brought about hemorrhaging in the brain.
when she suffered a heart attack approximately fifteen (15) to thirty (30) minutes later. Vital activity in the brain thereupon ceased. The medical evidence presented at the trial
20 was quite consistent with the findings of the Court of Appeals which concluded that
cardiac arrest was the cause of Catherine's death. 25
Since neither petitioner nor his co-accused presented evidence in their own behalf, the
present Petition seeks to question the soundness of the factual conclusions drawn by For his part, petitioner insists that cardiac arrest is not the only cause of oxygen-
the Court of Appeals, upon which the affirmance of petitioner's conviction was based. starvation of the brain, that septicemia with peritonitis or severe infection which had
Close examination of the instant Petition for Review shows that petitioner's main "gone up to the head" of Catherine was an equally efficient cause of deprivation of the
arguments are two-fold: (1) the Court of Appeals "completely brushed aside" and brain of oxygen and hence of brain hemorrhage. The medical testimony of the expert
"misapprehended" Catherine's death certificate and biopsy report which allegedly witnesses for the prosecution on which petitioner relies is also consistent with
showed that the cause of death was a ruptured appendix, which led to blood poisoning, petitioner's theory that septicemia with peritonitis was, or at least could have been, the
21 rather than faulty anesthetic treatment; and (2) there was no direct evidence of cause of Catherine's death. 26
record showing that Nubain was administered to Catherine either during the
appendectomy procedure or after such operation. Indeed, it appears to the Court that there was no medical proof submitted to the trial
court to show that one or the other "cause" was necessarily an exclusive cause of death
Two (2) related issues are thus posed for the Court's consideration. The first is whether in the case of Catherine Acosta; that an overdose or allergic reaction to Nubain could
the Court of Appeals so drastically "misapprehended" the relevant, operative facts in not have combined with septicemia and peritonitis in bringing about Catherine's death.
this case as to compel this Court to examine and resolve question(s) of fact which What is of critical importance for present purposes is not so much the identification of
would have a decisive significance for the disposition of the case. The rule is too firmly the "true cause" or "real cause" of Catherine's death but rather the set of circumstances
settled to require much documentation that only questions of law may be raised before which both the trial court and the Court of Appeals found constituted simple (as
this Court in a petition for review on certiorari, subject to certain well-known distinguished from reckless) negligence on the part of the two accused Dr. Madrid and
exceptions. 23 After careful scrutiny of petitioner's contentions before us and the Dr. Carillo leading to the death of Catherine.
record of this case, we do not believe that petitioner has shown "misapprehension of
facts" on the part of the Court of Appeals which would require this Court to overturn When the patient was wheeled out of the operating room after completion of surgery,
the judgment reached by the former. she manifested signs of medical instability (i.e., shivering, paleness, irregular
breathing and weak heart beat). 27 She was not brought to a properly equipped
The second issue is whether or not the findings of fact of the Court of Appeals recovery room, or intensive care until which the hospital lacked. 28 Such facilities and
adequately support the conclusion that petitioner Dr. Carillo was, along with Dr. their professional staffs, of which an anesthetist is commonly a part, are essential for
Madrid, guilty of simple negligence which resulted in homicide. Our review of the providing close observation and patient care while a post-surgery patient is recovering
record leads us to an affirmative answer. from the effects of anesthesia and while the normal protective mechanisms are still
dull or obtunded. 29 Instead, the patient was merely brought to her assigned hospital
Petitioner contends that the Court of Appeals seriously erred in finding that an bed and was provided oxygen on the instructions of Dr. Madrid then "revived" her
overdose of, or an allergic reaction to, the anesthetic drug Nubain had led to the death heartbeat. 30 Both doctors then left their patient and the hospital; approximately fifteen
of Catherine Acosta and that the true cause of Catherine's death was that set out in the minutes later, she suffered convulsions and cardiac arrest. 31
death certificate of Catherine: "Septicemia (or blood poisoning) due to perforated
The conduct of Dr. Madrid and of the petitioner constituted inadequate care of their indicated the abdication of medical responsibility on an extremely critical matter.
patient in view of her vulnerable condition. Both doctors failed to appreciate the Since petitioner anesthesiologist entered subsequent prescriptions or orders in the
serious condition of their patient whose adverse physical signs were quite manifest same order sheet, which were signed by him, at 7:15 p.m. on the same evening of 31
right after surgery. And after reviving her heartbeat, both doctors failed to monitor May 1981, he was in a position to appreciate the dangers inherent in the prior
their patient closely or extend further medical care to her; such conduct was especially prescription, which was within his (petitioner's) area of specialization, and to order
necessary in view of the inadequate, post-operative facilities of the hospital. We do measures to correct this anomaly and protect his patient's well-being. So far as the
not, of course, seek to hold petitioner responsible for the inadequate facilities of the condition of the evidence shows, he failed to do so. In sum, only a low level of
Baclaran General Hospital. We consider, however, that the inadequate nature of those diligence was exhibited by petitioner and Dr. Madrid in the prescription of medication
facilities did impose a somewhat higher standard of professional diligence upon the for their patient.
accused surgeon and anesthetist personally than would have been called for in a
modern fully-equipped hospital. As noted earlier, petitioner relied heavily in this proceeding on the testimony on cross-
examination of the expert witnesses for the prosecution to show that blood poisoning
While Dr. Madrid and a cardiologist were containing the patient's convulsions, and resulting from a ruptured appendix could also be responsible for the patient's death.
after the latter had diagnosed that infection had reached the patient's head, these two No suggestion has been made that the rupture of the patient's occurred prior to surgery.
(2) apparently after consultation, decided to call-in the petitioner. 32 There is here a After her blood sample was examined, the patient was merely diagnosed as a case of
strong implication that the patient's post-operative condition must have been appendicitis, without further elaboration. 40 No intensive preoperative preparations,
considered by the two (2) doctors as in some way related to the anesthetic treatment like the immediate administration of antibiotics, was thereafter undertaken on the
she had received from the petitioner either during or after the surgical procedure. patient. This is a standard procedure for patients who are, after being diagnosed,
suspected of suffering from a perforated appendix and consequent peritonitis. 41 The
Once summoned, petitioner anesthesiologist could not be readily found. When he mother also testified that petitioner anesthesiologist merely injected a drug, "pre-
finally appeared at 10:30 in the evening, he was evidently in a bad temper, commenting anesthesia" intended to put the patient to sleep, into the container of fluids being
critically on the dextrose bottles before ordering their removal. 33 This circumstance administered to her daughter intravenously at her room, prior to surgery. 42 We note
indicated he was not disposed to attend to this unexpected call, in violation of the further that the surgeon Dr. Madrid was forty-five minutes late in arriving at the
canons of his profession that as a physician, he should serve the interest of his patient operating theater. 43 Considering that delay in treatment of appendicitis increases the
"with the greatest of solicitude, giving them always his best talent and skill." 34 morbidity of the patient, 44 Dr. Madrid's conduct can only be explained by a pre-
Indeed, when petitioner finally saw his patient, he offered the unprofessional bluster operative diagnosis on his part that the condition of appendicitis was not yet attended
to the parents of Catherine that he would resign if the patient will not regain by complications (i.e., a ruptured appendix and peritonitis).
consciousness. 35 The canons of medical ethics require a physician to "attend to his
patients faithfully and conscientiously." He should secure for them all possible benefits The above circumstances do strongly indicate that the rupture of the patient's appendix
that may depend upon his professional skill and care. As the sole tribunal to adjudge occurred during the appendectomy procedure, that is, at a time and place the
the physician's failure to fulfill his obligation to his patient is, in most cases, his own operating room where the two (2) accused were in full control of the situation and
conscience, violation of this rule on his part is "discreditable and inexcusable". 36 could determine decisively what needed to be done in respect of the patient. 45 This
circumstance must be considered in conjunction with other related circumstances
Nubain was an experimental drug for anesthesia and post-operative pain and the which the prosecution had proven: that the patient was ambulatory when brought to
medical literature required that a patient be weighed first before it is administered and the operating room; 46 that she left the operating room two (2) hours later in obviously
warned that there was no (or inadequate) experience relating to the administration serious condition; and that an appendectomy accompanied or followed by sustained
thereof to a patient less that eighteen (18) ears of age. 37 Yet, the doctor's order sheet antibiotic treatment is a fairly common and generally accepted medical procedure for
(Exhibit "C") did not contain this precaution but instead directed a reader to apply the dealing with ruptured appendix and peritonitis, 47 a fact of which judicial note may be
drug only when warranted by the circumstances. 38 During the offer of Exhibit "C" taken.
by the prosecution, Dr. Madrid admitted that this prescription, which was unsigned, As early as in People v. Vistan, 48 the Court defined simple negligence, penalized
was made in his own handwriting. 39 It must be observed that the instruction was under what is now Article 365 of the Revised Penal Code, as "a mere lack of prevision
open-ended in that some other individual still had to determine if circumstances in a situation where either the threatened harm is not immediate or the danger not
existed warranting administration of the drug to the patient. The document thus openly visible." Put in a slightly different way, the gravamen of the offense of simple
negligence is the failure to exercise the diligence necessitated or called for the situation later, leads the Court to the conclusion, with moral certainty, that petitioner and Dr.
which was not immediately life-destructive but which culminated, in the present case, Madrid were guilty of simple negligence resulting in homicide.
in the death of a human being three (3) days later. Such failure to exercise the necessary In addition to the main arguments raised by petitioner earlier, he also raised an
degree of care and diligence is a negative ingredient of the offense charged. The rule ancillary, constitutional claim of denial of due process. He contends that he was
in such cases is that while the prosecution must prove the negative ingredient of the deprived of his right to have competent representation at trial, and to have his cause
offense, it needs only to present the best evidence procurable under the circumstances, adequately heard, because his counsel of record, Atty. Jose B. Puerto, was
in order to shift the burden of disproving or countering the proof of the negative "incompetent" and exhibited "gross negligence" by manifesting an intent to file a
ingredient to the accused, provided that such initial evidence establishes at least on a demurrer to the evidence, in failing to present evidence in his behalf and in omitting
prima facie basis the guilt of the accused. 49 This rule is particularly applicable where to file a defense memorandum for the benefit of Judge Yuzon, after the latter took
the negative ingredient of the offense is of such a nature or character as, under the over the case at the end of trial and before the Judge rendered his decision. 52
circumstances, to be especially within the knowledge or control of the accused. 50 In Petitioner submits he is entitled to a new trial. 53
the instant case, the Court is bound to observe that the events which occurred during These contentions do not persuade. An examination of the record indicates that Atty.
the surgical procedure (including whether or not Nubain had in fact been administered Puerto represented petitioner during trial with reasonable competence. Except for the
as an anesthesia immediately before or during the surgery) were peculiarly within the two hearing sessions when witnesses Domingo Acosta was cross-examined and
knowledge and control of Dr. Carillo and Dr. Madrid. It was, therefore, incumbent recross-examined by Atty. Puerto, petitioner was present during all the sessions when
upon the two (2) accused to overturn the prima facie case which the prosecution had the other prosecution witnesses were presented and during which Atty. Puerto
established, by reciting the measures which they had actually taken to prevent or to extensively cross-examined them in behalf of petitioner and Dr. Madrid. This counsel
counter the obviously serious condition of Catherine Acosta which was evident right elicited from the two (2) expert witnesses for the prosecution testimony favorable to
after surgery. This they failed or refused to do so. petitioner and which was relied upon by the latter in this proceeding. 54 The record
further indicates that if petitioner indeed entertained substantial doubts about the
Still another circumstance of which account must be taken is that both petitioner and capability of Atty. Puerto, he could have easily terminated the services of that counsel
Dr. Madrid failed to inform the parents of their minor patient of the nature of her and retained a new one, or sought from the trial court the appointment of counsel de
illness, or to explain to them either during the surgery (if feasible) or at any time after oficio, during the ample opportunity given from the time Atty. Puerto manifested his
the surgery, the events which comprised the dramatic deterioration of her condition intent to file a demurrer on 16 October 1985, to the submission of the case for decision
immediately after surgery as compared with her pre-surgery condition. To give a on 25 June 1986 and before the promulgation of judgment on 19 September 1986. 55
truthful explanation to the parents was a duty imposed upon them by the canons of During all this time, petitioner could have obtained leave of court to present evidence
their profession. 51 Petitioner should have explained to Catherine's parents the actual in his behalf in lieu of a demurrer, or to submit a memorandum for the defense. After
circumstances surrounding Catherine's death, how, in other words, a simple promulgation of the judgment of conviction, petitioner did not seek a new trial, but
appendectomy procedure upon an ambulatory patient could have led to such fatal permitted Atty. Puerto to obtain leave from the trial court to continue on bail during
consequences. the pendency of the proceedings before the Court of Appeals. 56 Indeed, petitioner
replaced Atty. Puerto as counsel only upon institution of the present petition.
By way of resume, in the case at bar, we consider that the chain of circumstances above Petitioner's constitutional objection is plainly an afterthought.
noted, namely: (1) the failure of petitioner and Dr. Madrid to appreciate the serious
post-surgery condition of their patient and to monitor her condition and provide close WHEREFORE, the Decision of the Court of Appeals dated 28 November 1988 is
patient care to her; (2) the summons of petitioner by Dr. Madrid and the cardiologist hereby AFFIRMED, subject only to the modification that the indemnity for the death
after the patient's heart attack on the very evening that the surgery was completed; (3) of Catherine Acosta is hereby increased to P50,000.00, in line with current
the low level of care and diligence exhibited by petitioner in failing to correct Dr. jurisprudence.
Madrid's prescription of Nubain for post-operative pain; (4) the extraordinary failure
or refusal of petitioner and Dr. Madrid to inform the parents of Catherine Acosta of SO ORDERED.
her true condition after surgery, in disregard of the requirements of the Code of
Medical Ethics; and (5) the failure of petitioner and Dr. Madrid to prove that they had
in fact exercised the necessary and appropriate degree of care and diligence to prevent
the sudden decline in the condition of Catherine Acosta and her death three (3) days
SECOND DIVISION Florencio died of complications of unknown cause, according to officials of the UST
Hospital.[2]
[G.R. No. 118141. September 5, 1997]
Not satisfied with the findings of the hospital, petitioner requested the National Bureau
LEONILA GARCIA-RUEDA, petitioner, vs. WILFREDO L. PASCASIO, of Investigation (NBI) to conduct an autopsy on her husbands body. Consequently, the
RAUL R. ARNAU, ABELARDO L. APORTADERA JR., Honorable NBI ruled that Florencios death was due to lack of care by the attending physician in
CONDRADO M. VASQUEZ, all of the Office of the Ombudsman; JESUS F. administering anaesthesia. Pursuant to its findings, the NBI recommended that Dr.
GUERRERO, PORFIRIO MACARAEG, and GREGORIO A. ARIZALA, all of Domingo Antonio and Dr. Erlinda Balatbat-Reyes be charged for Homicide through
the Office of the City Prosecutor, Manila, respondents. Reckless Imprudence before the Office of the City Prosecutor.
DECISION During the preliminary investigation, what transpired was a confounding series of
ROMERO, J.: events which we shall try to disentangle. The case was initially assigned to Prosecutor
Antonio M. Israel, who had to inhibit himself because he was related to the counsel of
May this Court review the findings of the Office of the Ombudsman? The general rule one of the doctors. As a result, the case was re-raffled to Prosecutor Norberto G. Leono
has been enunciated in Ocampo v. Ombudsman [1] which states: who was, however, disqualified on motion of the petitioner since he disregarded
prevailing laws and jurisprudence regarding preliminary investigation. The case was
In the exercise of its investigative power, this Court has consistently held that courts
then referred to Prosecutor Ramon O. Carisma, who issued a resolution recommending
will not interfere with the discretion of the fiscal or the Ombudsman to determine the
that only Dr. Reyes be held criminally liable and that the complaint against Dr. Antonio
specificity and adequacy of the averments of the offense charged. He may dismiss the
be dismissed.
complaint forthwith if he finds it to be insufficient in form and substance or if he
otherwise finds no ground to continue with the inquiry; or he may proceed with the The case took another perplexing turn when Assistant City Prosecutor Josefina Santos
investigation of the complaint if, in his view, it is in due and proper form. Sioson, in the interest of justice and peace of mind of the parties, recommended that
the case be re-raffled on the ground that Prosecutor Carisma was partial to the
Does the instant case warrant a departure from the foregoing general rule? When a
petitioner. Thus, the case was transferred to Prosecutor Leoncia R. Dimagiba, where a
patient dies soon after surgery under circumstances which indicate that the attending
volte face occurred again with the endorsement that the complaint against Dr. Reyes
surgeon and anaesthesiologist may have been guilty of negligence but upon their being
be dismissed and instead, a corresponding information be filed against Dr. Antonio.
charged, a series of nine prosecutors toss the responsibility of conducting a preliminary
Petitioner filed a motion for reconsideration, questioning the findings of Prosecutor
investigation to each other with contradictory recommendations, ping-pong style,
Dimagiba.
perhaps the distraught widow is not to be blamed if she finally decides to accuse the
City Prosecutors at the end of the line for partiality under the Anti-Graft and Corrupt Pending the resolution of petitioners motion for reconsideration regarding Prosecutor
Practices Act. Nor may she be entirely faulted for finally filing a petition before this Dimagibas resolution, the investigative pingpong continued when the case was again
Court against the Ombudsman for grave abuse of discretion in dismissing her assigned to another prosecutor, Eudoxia T. Gualberto, who recommended that Dr.
complaint against said City Prosecutors on the ground of lack of evidence. Much as Reyes be included in the criminal information of Homicide through Reckless
we sympathize with the bereaved widow, however, this Court is of the opinion that the Imprudence. While the recommendation of Prosecutor Gualberto was pending, the
general rule still finds application in instant case. In other words, the respondent case was transferred to Senior State Prosecutor Gregorio A. Arizala, who resolved to
Ombudsman did not commit grave abuse of discretion in deciding against filing the exonerate Dr. Reyes from any wrongdoing, a resolution which was approved by both
necessary information against public respondents of the Office of the City Prosecutor. City Prosecutor Porfirio G. Macaraeg and City Prosecutor Jesus F. Guerrero.
The following facts are borne out by the records. Aggrieved, petitioner filed graft charges specifically for violation of Section 3(e) of
Republic Act No. 3019 [3] against Prosecutors Guerrero, Macaraeg, and Arizala for
Florencio V. Rueda, husband of petitioner Leonila Garcia-Rueda, underwent surgical
manifest partiality in favor of Dr. Reyes before the Office of the Ombudsman.
operation at the UST hospital for the removal of a stone blocking his ureter. He was
However, on July 11, 1994, the Ombudsman issued the assailed resolution dismissing
attended by Dr. Domingo Antonio, Jr. who was the surgeon, while Dr. Erlinda
the complaint for lack of evidence.
Balatbat-Reyes was the anaesthesiologist. Six hours after the surgery, however,
In fine, petitioner assails the exercise of the discretionary power of the Ombudsman to Probable cause is a reasonable ground of presumption that a matter is, or may be, well
review the recommendations of the government prosecutors and to approve and founded, such a state of facts in the mind of the prosecutor as would lead a person of
disapprove the same. Petitioner faults the Ombudsman for, allegedly in grave abuse of ordinary caution and prudence to believe, or entertain an honest or strong suspicion,
discretion, refusing to find that there exists probable cause to hold public respondent that a thing is so. The term does not mean actual and positive cause nor does it import
City Prosecutors liable for violation of Section 3(e) of R.A. No. 3019. absolute certainty. It is merely based on opinion and reasonable belief. Thus, a finding
of probable cause does not require an inquiry into whether there is sufficient evidence
Preliminarily, the powers and functions of the Ombudsman have generally been to procure a conviction. It is enough that it is believed that the act or omission
categorized into the following: investigatory powers, prosecutory power, public complained of constitutes the offense charged. Precisely, there is a trial for the
assistance function, authority to inquire and obtain information, and function to adopt, reception of evidence of the prosecution in support of the charge.[10]
institute and implement preventive measures. [4]
In the instant case, no less than the NBI pronounced after conducting an autopsy that
As protector of the people, the Office of the Ombudsman has the power, function and there was indeed negligence on the part of the attending physicians in administering
duty to act promptly on complaints filed in any form or manner against public officials the anaesthesia. [11] The fact of want of competence or diligence is evidentiary in
and to investigate any act or omission of any public official when such act or omission nature, the veracity of which can best be passed upon after a full-blown trial for it is
appears to be illegal, unjust, improper or inefficient. [5] virtually impossible to ascertain the merits of a medical negligence case without
While the Ombudsman has the full discretion to determine whether or not a criminal extensive investigation, research, evaluation and consultations with medical experts.
case should be filed, this Court is not precluded from reviewing the Ombudsmans Clearly, the City Prosecutors are not in a competent position to pass judgment on such
action when there is an abuse of discretion, in which case Rule 65 of the Rules of Court a technical matter, especially when there are conflicting evidence and findings. The
may exceptionally be invoked pursuant to Section I, Article VIII of the 1987 bases of a partys accusation and defenses are better ventilated at the trial proper than
Constitution. [6] at the preliminary investigation.

In this regard, grave abuse of discretion has been defined as where a power is exercised A word on medical malpractice or negligence cases.
in an arbitrary or despotic manner by reason of passion or personal hostility so patent In its simplest terms, the type of lawsuit which has been called medical malpractice
and gross as to amount to evasion of positive duty or virtual refusal to perform a duty or, more appropriately, medical negligence, is that type of claim which a victim has
enjoined by, or in contemplation of law. [7] available to him or her to redress a wrong committed by a medical professional which
From a procedural standpoint, it is certainly odd why the successive transfers from one has caused bodily harm.
prosecutor to another were not sufficiently explained in the Resolution of the In order to successfully pursue such a claim, a patient must prove that a health care
Ombudsman. Being the proper investigating authority with respect to misfeasance, provider, in most cases a physician, either failed to do something which a reasonably
non-feasance and malfeasance of public officials, the Ombudsman should have been prudent health care provider would have done, or that he or she did something that a
more vigilant and assiduous in determining the reasons behind the buckpassing to reasonably prudent provider would not have done; and that that failure or action caused
ensure that no irregularity took place. injury to the patient.[12]
Whether such transfers were due to any outside pressure or ulterior motive is a matter Hence, there are four elements involved in medical negligence cases: duty, breach,
of evidence. One would have expected the Ombudsman, however, to inquire into what injury and proximate causation.
could hardly qualify as standard operating procedure, given the surrounding
circumstances of the case. Evidently, when the victim employed the services of Dr. Antonio and Dr. Reyes, a
physician-patient relationship was created. In accepting the case, Dr. Antonio and Dr.
While it is true that a preliminary investigation is essentially inquisitorial, and is often Reyes in effect represented that, having the needed training and skill possessed by
the only means to discover who may be charged with a crime, its function is merely to physicians and surgeons practicing in the same field, they will employ such training,
determine the existence of probable cause. [8] Probable cause has been defined as the care and skill in the treatment of their patients.[13] They have a duty to use at least the
existence of such fact and circumstances as would excite the belief, in a reasonable same level of care that any other reasonably competent doctor would use to treat a
mind, acting on the facts within the knowledge of the prosecution, that the person condition under the same circumstances. The breach of these professional duties of
charged was guilty of the crime for which he was prosecuted.[9] skill and care, or their improper performance, by a physician surgeon whereby the
patient is injured in body or in health, constitutes actionable malpractice.[14] While a party who feels himself aggrieved is at liberty to choose the appropriate
Consequently, in the event that any injury results to the patient from want of due care weapon from the armory, it is with no little surprise that this Court views the choice
or skill during the operation, the surgeons may be held answerable in damages for made by the complainant widow.
negligence.[15]
To our mind, the better and more logical remedy under the circumstances would have
Moreover, in malpractice or negligence cases involving the administration of been to appeal the resolution of the City Prosecutors dismissing the criminal complaint
anaesthesia, the necessity of expert testimony and the availability of the charge of res to the Secretary of Justice under the Department of Justices Order No. 223, [21]
ipsa loquitur to the plaintiff, have been applied in actions against anaesthesiologists to otherwise known as the 1993 Revised Rules on Appeals From Resolutions In
hold the defendant liable for the death or injury of a patient under excessive or Preliminary Investigations/Reinvestigations, as amended by Department Order No.
improper anaesthesia.[16] Essentially, it requires two-pronged evidence: evidence as 359, Section 1 of which provides:
to the recognized standards of the medical community in the particular kind of case,
and a showing that the physician in question negligently departed from this standard Section 1. What May Be Appealed. - Only resolutions of the Chief State
in his treatment.[17] Prosecutor/Regional State Prosecutor/Provincial or City Prosecutor dismissing a
criminal complaint may be the subject of an appeal to the Secretary of Justice except
Another element in medical negligence cases is causation which is divided into two as otherwise provided in Section 4 hereof.
inquiries: whether the doctors actions in fact caused the harm to the patient and
whether these were the proximate cause of the patients injury.[18] Indeed here, a What action may the Secretary of Justice take on the appeal? Section 9 of Order No.
causal connection is discernible from the occurrence of the victims death after the 223 states: The Secretary of Justice may reverse, affirm or modify the appealed
negligent act of the anaesthesiologist in administering the anesthesia, a fact which, if resolution. On the other hand, He may motu proprio or on motion of the appellee,
confirmed, should warrant the filing of the appropriate criminal case. To be sure, the dismiss outright the appeal on specified grounds. [22]
allegation of negligence is not entirely baseless. Moreover, the NBI deduced that the In exercising his discretion under the circumstances, the Ombudsman acted within his
attending surgeons did not conduct the necessary interview of the patient prior to the power and authority in dismissing the complaint against the Prosecutors and this Court
operation. It appears that the cause of the death of the victim could have been averted will not interfere with the same.
had the proper drug been applied to cope with the symptoms of malignant
hyperthermia. Also, we cannot ignore the fact that an antidote was readily available to WHEREFORE, in view of the foregoing, the instant petition is DISMISSED, without
counteract whatever deleterious effect the anaesthesia might produce. [19] Why these prejudice to the filing of an appeal by the petitioner with the Secretary of Justice
precautionary measures were disregarded must be sufficiently explained. assailing the dismissal of her criminal complaint by the respondent City Prosecutors.
No costs.
The City Prosecutors were charged with violating Section 3(e) of the Anti-Graft and
Corrupt Practices Act which requires the following facts: SO ORDERED.

1. The accused is a public officer discharging administrative or official functions or


private persons charged in conspiracy with them;

2. The public officer committed the prohibited act during the performance of his
official duty or in relation to his public position;

3. The public officer acted with manifest partiality, evident bad faith or gross,
inexcusable negligence; and

4. His action caused undue injury to the Government or any private party, or gave any
party any unwarranted benefit, advantage or preference to such parties. [20]

Why did the complainant, petitioner in instant case, elect to charge respondents under
the above law?
Mrs. Villegas is a married woman who submitted to Dr. Batiquin for prenatal care as
the latter's private patient sometime before September 21, 1988.

In the morning of September 21, 1988 Dr. Batiquin, with the assistance of Dr. Doris
THIRD DIVISION Teresita Sy who was also a Resident Physician at the same Hospital, C.I. and O.R.
Nurse Arlene Diones and some student nurses performed a simple cesarean section on
[G.R. No. 118231. July 5, 1996] Mrs. Villegas at the Negros Oriental Provincial Hospital and after 45 minutes Mrs.
Villegas delivered her first child, Rachel Acogido, at about 11:45 that morning.
DR. VICTORIA L. BATIQUIN and ALLAN BATIQUIN, petitioners, vs. Thereafter, Plaintiff remained confined at the Hospital until September 27, 1988
COURT OF APPEALS, SPOUSES QUEDO D. ACOGIDO and FLOTILDE G. during which period of confinement she was regularly visited by Dr. Batiquin. On
VILLEGAS, respondents. September 28, 1988, Mrs. Villegas checked out of the Hospital . . . and on the same
day she paid Dr. Batiquin, thru the latter's secretary, the amount of P1,500.00 as
DECISION "professional fee" . . . .

DAVIDE, JR., J.: Soon after leaving the Hospital Mrs. Villegas began to suffer abdominal pains and
complained of being feverish. She also gradually lost her appetite, so she consulted
Throughout history, patients have consigned their fates and lives to the skill of their Dr. Batiquin at the latter's polyclinic who prescribed for her certain medicines . . .
doctors. For a breach of this trust, men have been quick to demand retribution. Some which she had been taking up to December, 1988.
4,000 years ago, the Code of Hammurabi then already provided: "If a physician make
a deep incision upon a man with his bronze lancet and cause the man's death, or operate In the meantime, Mrs. Villegas was given a Medical Certificate by Dr. Batiquin on
on the eye socket of a man with his bronze lancet and destroy the man's eyes, they October 31, 1988 . . . certifying to her physical fitness to return to her work on
shall cut off his hand." Subsequently, Hippocrates wrote what was to become part of November 7, 1988. So, on the second week of November, 1988 Mrs. Villegas returned
the healer's oath: "I will follow that method of treatment which according to my ability to her work at the Rural Bank of Ayungon, Negros Oriental.
and judgment, I consider for the benefit of my patients, and abstain from whatever is The abdominal pains and fever kept on recurring and bothered Mrs. Villegas no end
deleterious and mischievous . . . . While I continue to keep this oath unviolated may it and despite the medications administered by Dr. Batiquin. When the pains become
be granted me to enjoy life and practice the art, respected by all men at all times but unbearable and she was rapidly losing weight she consulted Dr. Ma. Salud Kho at the
should I trespass and violate this oath, may the reverse be my lot." At present, the Holy Child's Hospital in Dumaguete City on January 20, 1989.
primary objective of the medical profession is the preservation of life and maintenance
of the health of the people. The evidence of Plaintiffs show that when Dr. Ma. Salud Kho examined Mrs. Villegas
at the Holy Child's Hospital on January 20, 1989 she found Mrs. Villegas to be
Needless to say then, when a physician strays from his sacred duty and endangers feverish, pale and was breathing fast. Upon examination she felt an abdominal mass
instead the life of his patient, he must be made to answer therefor. Although society one finger below the umbilicus which she suspected to be either a tumor of the uterus
today cannot and will not tolerate the punishment meted out by the ancients, neither or an ovarian cyst, either of which could be cancerous. She had an x-ray taken of Mrs.
will it and this Court, as this case would show, let the act go uncondemned. Villegas' chest, abdomen and kidney. She also took blood tests of Plaintiff. A blood
The petitioners appeal from the decision of the Court of Appeals of 11 May 1994 in count showed that Mrs. Villegas had [an] infection inside her abdominal cavity. The
CA-G.R. CV No. 30851, which reversed the decision of 21 December 1990 of Branch result of all those examinations impelled Dr. Kho to suggest that Mrs. Villegas submit
30 of the Regional Trial Court (RTC) of Negros Oriental in Civil Case No. 9492. to another surgery to which the latter agreed.

The facts, as found by the trial court, are as follows: When Dr. Kho opened the abdomen of Mrs. Villegas she found whitish-yellow
discharge inside, an ovarian cyst on each of the left and right ovaries which gave out
Dr. Batiquin was a Resident Physician at the Negros Oriental Provincial Hospital, pus, dirt and pus behind the uterus, and a piece of rubber materials on the right side of
Dumaguete City from January 9, 1978 to September 1989. Between 1987 and the uterus embedded on [sic] the ovarian cyst, 2 inches by 3/4 inch in size. This piece
September, 1989 she was also the Actg. Head of the Department of Obstetrics and of rubber material which Dr. Kho described as a "foreign body" looked like a piece of
Gynecology at the said Hospital. a "rubber glove" . . . and which is [sic] also "rubber-drain like . . . . It could have been
a torn section of a surgeon's gloves or could have come from other sources. And this appellant Flotilde became well and healthy. Appellant Flotilde's troubles were caused
foreign body was the cause of the infection of the ovaries and consequently of all the by the infection due to the "rubber" that was left inside her abdomen. Both appellants
discomfort suffered by Mrs. Villegas after her delivery on September 21, 1988. testified that after the operation made by appellee doctor, they did not go to any other
doctor until they finally decided to see another doctor in January, 1989 when she was
The piece of rubber allegedly found near private respondent Flotilde Villegas' uterus not getting any better under the care of appellee Dr. Batiquin . . . . Appellee Dr.
was not presented in court, and although Dr. Ma. Salud Kho testified that she sent it to Batiquin admitted on the witness stand that she alone decided when to close the
a pathologist in Cebu City for examination, it was not mentioned in the pathologist's operating area; that she examined the portion she operated on before closing the same
Surgical Pathology Report. . . . . Had she exercised due diligence, appellee Dr. Batiquin would have found the
Aside from Dr. Kho's testimony, the evidence which mentioned the piece of rubber rubber and removed it before closing the operating area.
are a Medical Certificate, a Progress Record, an Anesthesia Record, a Nurse's Record, The appellate court then ruled:
and a Physician's Discharge Summary. The trial court, however, regarded these
documentary evidence as mere hearsay, "there being no showing that the person or Appellants' evidence show[s] that they paid a total of P17,000.00 [deposit of P7,100.00
persons who prepared them are deceased or unable to testify on the facts therein stated (Exh. G-1-A) plus hospital and medical expenses together with doctor's fees in the
. . . . Except for the Medical Certificate (Exhibit "F"), all the above documents were total amount P9,900.00 (Exhs. G and G-2)] for the second operation that saved her
allegedly prepared by persons other than Dr. Kho, and she merely affixed her signature life.
on some of them to express her agreement thereto . . . ." The trial court also refused
to give weight to Dr. Kho's testimony regarding the subject piece of rubber as Dr. Kho For the miseries appellants endured for more than three (3) months, due to the
"may not have had first-hand knowledge" thereof, as could be gleaned from her negligence of appellee Dr. Batiquin, they are entitled to moral damages in the amount
statement, thus: of P100,000.00; exemplary damages in the amount of P20,000.00 and attorney's fees
in the amount of P25,000.00.
A . . . I have heard somebody that [sic] says [sic] there is [sic] a foreign body
that goes with the tissues but unluckily I don't know where the rubber was. The fact that appellant Flotilde can no longer bear children because her uterus and
ovaries were removed by Dr. Kho is not taken into consideration as it is not shown
The trial court deemed vital Dr. Victoria Batiquin's testimony that when she confronted that the removal of said organs were the direct result of the rubber left by appellee Dr.
Dr. Kho regarding the piece of rubber, "Dr. Kho answered that there was rubber indeed Batiquin near the uterus. What is established is that the rubber left by appellee cause
but that she threw it away." This statement, the trial court noted, was never denied nor infection, placed the life of appellant Flotilde in jeopardy and caused appellants fear,
disputed by Dr. Kho, leading it to conclude: worry and anxiety . . . .

There are now two different versions on the whereabouts of that offending "rubber" WHEREFORE, the appealed judgment, dismissing the complaint for
(1) that it was sent to the Pathologist in Cebu as testified to in Court by Dr. Kho and damages is REVERSED and SET ASIDE. Another judgment is hereby
(2) that Dr. Kho threw it away as told by her to Defendant. The failure of the Plaintiffs entered ordering defendants-appellees to pay plaintiffs-appellants the
to reconcile these two different versions serve only to weaken their claim against amounts of P17,000.00 as and for actual damages; P100,000.00 as and for
Defendant Batiquin. moral damages; P20,000.00 as and for exemplary damages; and P25,000.00
as and for attorney's fees plus the cost of litigation.
All told, the trial court held in favor of the petitioners herein.
SO ORDERED.
The Court of Appeals reviewed the entirety of Dr. Kho's testimony and, even without
admitting the private respondents' documentary evidence, deemed Dr. Kho's positive From the above judgment, the petitioners appealed to this Court claiming that the
testimony to definitely establish that a piece of rubber was found near private appellate court; (1) committed grave abuse of discretion by resorting to findings of
respondent Villegas' uterus. Thus, the Court of Appeals reversed the decision of the fact not supported by the evidence on record, and (2) exceeded its discretion,
trial court, holding: amounting to lack or excess of jurisdiction, when it gave credence to testimonies
punctured with contradictions and falsities.
4. The fault or negligence of appellee Dr. Batiquin is established by preponderance of
evidence. The trial court itself had narrated what happened to appellant Flotilde after The private respondents commented that the petition raised only questions of fact,
the cesarean operation made by appellee doctor . . . . After the second operation, which were not proper for review by this Court.
While the rule is that only questions of law may be raised in a petition for review on A Oh yes. I was not the only one who saw it.
certiorari, there are exceptions, among which are when the factual findings of the trial
court and the appellate court conflict, when the appealed decision is clearly The petitioners emphasize that the private respondents never reconciled Dr. Kho's
contradicted by the evidence on record, or when the appellate court misapprehended testimony with Dr. Batiquin's claim on the witness stand that when Dr. Batiquin
the facts. confronted Dr. Kho about the foreign body, the latter said that there was a piece of
rubber but that she threw it away. Although hearsay, Dr. Batiquin's claim was not
After deciphering the cryptic petition, we find that the focal point of the instant appeal objected to, and hence, the same is admissible but it carries no probative value.
is the appreciation of Dr. Kho's testimony. The petitioners contend that the Court of Nevertheless, assuming otherwise, Dr. Batiquin's statement cannot belie the fact that
Appeals misappreciated the following portion of Dr. Kho's testimony: Dr. Kho found a piece of rubber near private respondent Villegas' uterus. And even if
we were to doubt Dr. Kho as to what she did to the piece of rubber, i.e., whether she
Q What is the purpose of the examination? threw it away or sent it to Cebu City, we are not justified in distrusting her as to her
A Just in case, I was just thinking at the back of my mind, just in case this would recovery of a piece of rubber from private respondent Villegas' abdomen. On this
turn out to be a medico-legal case, I have heard somebody that [sic] says [sic] there is score, it is perfectly reasonable to believe the testimony of a witness with respect to
[sic] a foreign body that goes with the tissues but unluckily I don't know where the some facts and disbelieve his testimony with respect to other facts. And it has been
rubber was. It was not in the Lab, it was not in Cebu. (Italics supplied) aptly said that even when a witness is found to have deliberately falsified in some
material particulars, it is not required that the whole of his uncorroborated testimony
The petitioners prefer the trial court's interpretation of the above testimony, i.e., that be rejected, but such portions thereof deemed worthy of belief may be credited.
Dr. Kho's knowledge of the piece of rubber was based on hearsay. The Court of
Appeals, on the other hand, concluded that the underscored phrase was taken out of It is here worth nothing that the trial court paid heed to the following portions of Dr.
context by the trial court. According to the Court of Appeals, the trial court should Batiquin's testimony: that no rubber drain was used in the operation, and that there
have likewise considered the other portions of Dr. Kho's testimony, especially the was neither any tear on Dr. Batiquin's gloves after the operation nor blood smears on
following: her hands upon removing her gloves. Moreover, the trial court pointed out that the
absence of a rubber drain was corroborated by Dr. Doris Sy, Dr. Batiquin's assistant
Q So you did actually conduct the operation on her? during the operation on private respondent Villegas. But the trial court failed to
recognize that the assertions of Drs. Batiquin and Sy were denials or negative
A Yes, I did.
testimonies. Well-settled is the rule that positive testimony is stronger than negative
Q And what was the result? testimony. Of course, as the petitioners advocate, such positive testimony must come
from a credible source, which leads us to the second assigned error.
A Opening up her abdomen, there was whitish-yellow discharge inside the
abdomen, there was an ovarian cyst on the left and side and there was also an ovarian While the petitioners claim that contradictions and falsities punctured Dr. Kho's
cyst on the right which, on opening up or freeing it up from the uterus, turned out to testimony, a reading of the said testimony reveals no such infirmity and establishes
be pus. Both ovaries turned out . . . to have pus. And then, cleaning up the uterus, at Dr. Kho as a credible witness. Dr. Kho was frank throughout her turn on the witness
the back of the uterus it was very dirty, it was full of pus. And there was a [piece of] stand. Furthermore, no motive to state any untruth was ever imputed against Dr. Kho,
rubber, we found a [piece of] rubber on the right side. leaving her trustworthiness unimpaired. The trial court's following declaration shows
that while it was critical of the lack of care with which Dr. Kho handled the piece of
We agree with the Court of Appeals. The phrase relied upon by the trial court does not rubber, it was not prepared to doubt Dr. Kho's credibility, thus only supporting out
negate the fact that Dr. Kho saw a piece of rubber in private respondent Villegas' appraisal of Dr. Kho's trustworthiness:
abdomen, and that she sent it to a laboratory and then to Cebu City for examination by
a pathologist. Not even the Pathologist's Report, although devoid of any mention of a This is not to say that she was less than honest when she testified about her findings,
piece of rubber, could alter what Dr. Kho saw. Furthermore, Dr. Kho's knowledge of but it can also be said that she did not take the most appropriate precaution to preserve
the piece of rubber could not be based on other than firsthand knowledge for, as she that "piece of rubber" as an eloquent evidence of what she would reveal should there
asserted before the trial court: be a "legal problem" which she claim[s] to have anticipated.

Q But you are sure you have seen [the piece of rubber]?
Considering that we have assessed Dr. Kho to be a credible witness, her positive actual culprit or the exact cause of the foreign object finding its way into private
testimony [that a piece of rubber was indeed found in private respondent Villegas' respondent Villegas' body, which, needless to say, does not occur unless through the
abdomen] prevails over the negative testimony in favor of the petitioners. intervention of negligence. Second, since aside from the cesarean section, private
respondent Villegas underwent no other operation which could have caused the
As such, the rule of res ipsa loquitur comes to fore. This Court has had occasion to offending piece of rubber to appear in her uterus, it stands to reason that such could
delve into the nature and operation of this doctrine: only have been a by-product of the cesarean section performed by Dr. Batiquin. The
This doctrine [res ipsa loquitur] is stated thus: "Where the thing which causes injury petitioners, in this regard, failed to overcome the presumption of negligence arising
is shown to be under the management of the defendant, and the accident is such as in from resort to the doctrine of res ipsa loquitur. Dr. Batiquin is therefore liable for
the ordinary course of things does not happen if those who have the management use negligently leaving behind a piece of rubber in private respondent Villegas' abdomen
proper care, it affords reasonable evidence, in the absence of an explanation by the and for all the adverse effects thereof.
defendant, that the accident arose from want of care." Or as Black's Law Dictionary As a final word, this Court reiterates its recognition of the vital role the medical
puts it: profession plays in the lives of the people, and State's compelling interest to enact
Res ipsa loquitur. The thing speaks for itself. Rebuttable presumption or inference that measures to protect the public from "the potentially deadly effects of incompetence
defendant was negligent, which arises upon proof that [the] instrumentality causing and ignorance in those who would undertake to treat our bodies and minds for disease
injury was in defendant's exclusive control, and that the accident was one which or trauma." Indeed, a physician is bound to serve the interest of his patients "with the
ordinary does not happen in absence of negligence. Res ipsa loquitur is [a] rule of greatest of solicitude, giving them always his best talent and skill." Through her
evidence whereby negligence of [the] alleged wrongdoer may be inferred from [the] tortious conduct, the petitioner endangered the life of Flotilde Villegas, in violation of
mere fact that [the] accident happened provided [the] character of [the] accident and her profession's rigid ethical code and in contravention of the legal standards set forth
circumstances attending it lead reasonably to belief that in [the] absence of negligence for professionals, in the general, and members of the medical profession, in particular.
it would not have occurred and that thing which caused injury is shown to have been WHEREFORE, the challenged decision of 11 May 1994 of the Court of Appeals in
under [the] management and control of [the] alleged wrongdoer . . . . Under [this] CA-G.R. CV No. 30851 is hereby AFFIRMED in toto.
doctrine . . . the happening of an injury permits an inference of negligence where
plaintiff produces substantial evidence that [the] injury was caused by an agency or Costs against the petitioners.
instrumentality under [the] exclusive control and management of defendant, and that
the occurrence [sic] was such that in the ordinary course of things would not happen SO ORDERED.
if reasonable care had been used.

xxx xxx xxx

The doctrine of [r]es ipsa loquitur as a rule of evidence is peculiar to the law of
negligence which recognizes that prima facie negligence may be established without
direct proof and furnishes a substitute for specific proof of negligence. The doctrine is
not a rule of substantive law, but merely a mode of proof or a mere procedural
convenience. The rule, when applicable to the facts and circumstances of a particular
case, is not intended to and does not dispense with the requirement of proof of culpable
negligence on the party charged. It merely determines and regulates what shall be
prima facie evidence thereof and facilitates the burden of plaintiff of proving a breach
of the duty of due care. The doctrine can be invoked when and only when, under the
circumstances involved, direct evidence is absent and not readily available.

In the instant case, all the requisites for recourse to the doctrine are present. First, the
entire proceedings of the cesarean section were under the exclusive control of Dr.
Batiquin. In this light, the private respondents were bereft of direct evidence as to the
THIRD DIVISION guilty under Art. 365 of the Revised Penal Code, and she is hereby sentenced to suffer
the penalty of 2 months and 1 day imprisonment of arresto mayor with costs."[6]
[G.R. No. 122445. November 18, 1997]
The petitioner appealed her conviction to the Regional Trial Court (RTC) which
DR. NINEVETCH CRUZ, petitioner, vs. COURT OF APPEALS and LYDIA affirmed in toto the decision of the MTCC[7] prompting the petitioner to file a petition
UMALI, respondents. for review with the Court of Appeals but to no avail. Hence this petition for review on
DECISION certiorari assailing the decision promulgated by the Court of Appeals on October 24,
1995 affirming petitioner's conviction with modification that she is further directed to
FRANCISCO, J.: pay the heirs of Lydia Umali P50,000.00 as indemnity for her death.[8]
"Doctors are protected by a special law. They are not guarantors of care. They do not In substance, the petition brought before this Court raises the issue of whether or not
even warrant a good result. They are not insurers against mishap or unusual petitioner's conviction of the crime of reckless imprudence resulting in homicide,
consequences. Furthermore they are not liable for honest mistake of judgment"[1] arising from an alleged medical malpractice, is supported by the evidence on record.
The present case against petitioner is in the nature of a medical malpractice suit, which First the antecedent facts.
in simplest term is the type of claim which a victim has available to him or her to
redress a wrong committed by a medical professional which has cause bodily harm.[2] On March 22, 1991, prosecution witness, Rowena Umali De Ocampo, accompanied
In this jurisdiction, however, such claims are most often brought as a civil action for her mother to the Perpetual Help Clinic and General Hospital situated in Balagtas
damages under Article 2176 of the Civil Code,[3] and in some instances, as a criminal Street, San Pablo City, Laguna. They arrived at the said hospital at around 4:30 in the
case under Article 365 of the Revised Penal Code[4] with which the civil action for afternoon of the same day.[9] Prior to March 22, 1991, Lydia was examined by the
damages is impliedly instituted. It is via the latter type of action that the heirs of the petitioner who found a "myoma"[10] in her uterus, and scheduled her for a
deceased sought redress for the petitioner's alleged imprudence and negligence in hysterectomy operation on March 23, 1991.[11] Rowena and her mother slept in the
treating the deceased thereby causing her death. The petitioner and one Dr. Lina Ercillo clinic on the evening of March 22, 1991 as the latter was to be operated on the next
who was the attending anaesthesiologist during the operation of the deceased were day at 1:00 o'clock in the afternoon.[12] According to Rowena, she noticed that the
charged with "reckless imprudence and negligence resulting to (sic) homicide" in an clinic was untidy and the window and the floor were very dusty prompting her to ask
information which reads: the attendant for a rag to wipe the window and the floor with.[13] Because of the untidy
state of the clinic, Rowena tried to persuade her mother not to proceed with the
"That on or about March 23, 1991, in the City of San Pablo, Republic of the Philippines operation.[14] The following day, before her mother was wheeled into the operating
and within the jurisdiction of this Honorable Court, the accused abovenamed, being room, Rowena asked the petitioner if the operation could be postponed. The petitioner
then the attending anaesthesiologist and surgeon, respectively, did then and there, in a called Lydia into her office and the two had a conversation. Lydia then informed
negligence (sic), careless, imprudent, and incompetent manner, and failing to supply Rowena that the petitioner told her that she must be operated on as scheduled.[15]
or store sufficient provisions and facilities necessary to meet any and all exigencies
apt to arise before, during and/or after a surgical operation causing by such negligence, Rowena and her other relatives, namely her husband, her sister and two aunts waited
carelessness, imprudence, and incompetence, and causing by such failure, including outside the operating room while Lydia underwent operation. While they were waiting,
the lack of preparation and foresight needed to avert a tragedy, the untimely death of Dr. Ercillo went out of the operating room and instructed them to buy tagamet ampules
said Lydia Umali on the day following said surgical operation."[5] which Rowena's sister immediately bought. About one hour had passed when Dr.
Ercillo came out again this time to ask them to buy blood for Lydia. They bought type
Trial ensued after both the petitioner and Dr. Lina Ercillo pleaded not guilty to the "A" blood from the St. Gerald Blood Bank and the same was brought by the attendant
above-mentioned charge. On March 4, 1994, the Municipal Trial Court in Cities into the operating room. After the lapse of a few hours, the petitioner informed them
(MTCC) of San Pablo City rendered a decision, the dispositive portion of which is that the operation was finished. The operating staff then went inside the petitioner's
hereunder quoted as follows: clinic to take their snacks. Some thirty minutes after, Lydia was brought out of the
operating room in a stretcher and the petitioner asked Rowena and the other relatives
"WHEREFORE, the court finds the accused Dr. Lina Ercillo not guilty of the offense
to buy additional blood for Lydia. Unfortunately, they were not able to comply with
charged for insufficiency of evidence while her co-accused Dra. Ninevetch Cruz is
petitioner's order as there was no more type "A" blood available in the blood bank.
hereby held responsible for the death of Lydia Umali on March 24, 1991, and therefore
Thereafter, a person arrived to donate blood which was later transfused to Lydia.
Rowena then noticed her mother, who was attached to an oxygen tank, gasping for for such negligence. With respect to Dra. Lina Ercillo, the anaesthesiologist, there is
breath. Apparently the oxygen supply had run out and Rowena's husband together with no evidence to indicate that she should be held jointly liable with Dra. Cruz who
the driver of the accused had to go to the San Pablo District Hospital to get oxygen. actually did the operation."[23]
Lydia was given the fresh supply of oxygen as soon as it arrived.[16] But at around
10:00 o'clock P.M. she went into shock and her blood pressure dropped to 60/50. The RTC reiterated the abovementioned findings of the MTCC and upheld the latter's
Lydia's unstable condition necessitated her transfer to the San Pablo District Hospital declaration of "incompetency, negligence and lack of foresight and skill of appellant
so she could be connected to a respirator and further examined.[17] The transfer to the (herein petitioner) in handling the subject patient before and after the operation."[24]
San Pablo City District Hospital was without the prior consent of Rowena nor of the And likewise affirming the petitioner's conviction, the Court of Appeals echoed similar
other relatives present who found out about the intended transfer only when an observations, thus:
ambulance arrived to take Lydia to the San Pablo District Hospital. Rowena and her "x x x. While we may grant that the untidiness and filthiness of the clinic may not by
other relatives then boarded a tricycle and followed the ambulance.[18] itself indicate negligence, it nevertheless shows the absence of due care and
Upon Lydia's arrival at the San Pablo District Hospital, she was wheeled into the supervision over her subordinate employees. Did this unsanitary condition permeate
operating room and the petitioner and Dr. Ercillo re-operated on her because there was the operating room? Were the surgical instruments properly sterilized? Could the
blood oozing from the abdominal incision.[19] The attending physicians summoned conditions in the OR have contributed to the infection of the patient? Only the
Dr. Bartolome Angeles, head of the Obstetrics and Gynecology Department of the San petitioner could answer these, but she opted not to testify. This could only give rise to
Pablo District Hospital. However, when Dr. Angeles arrived, Lydia was already in the presumption that she has nothing good to testify on her defense. Anyway, the
shock and possibly dead as her blood pressure was already 0/0. Dr. Angeles then alleged "unverified statement of the prosecution witness" remains unchallenged and
informed petitioner and Dr. Ercillo that there was nothing he could do to help save the unrebutted.
patient.[20] While petitioner was closing the abdominal wall, the patient died.[21] Likewise undisputed is the prosecution's version indicating the following facts: that
Thus, on March 24, 1991, at 3:00 o'clock in the morning, Lydia Umali was pronounced the accused asked the patient's relatives to buy Tagamet capsules while the operation
dead. Her death certificate states "shock" as the immediate cause of death and was already in progress; that after an hour, they were also asked to buy type "A" blood
"Disseminated Intravascular Coagulation (DIC)" as the antecedent cause.[22] for the patient; that after the surgery, they were again asked to procure more type "A"
In convicting the petitioner, the MTCC found the following circumstances as sufficient blood, but such was not anymore available from the source; that the oxygen given to
basis to conclude that she was indeed negligent in the performance of the operation: the patient was empty; and that the son-in-law of the patient, together with a driver of
the petitioner, had to rush to the San Pablo City District Hospital to get the much-
"x x x, the clinic was untidy, there was lack of provision like blood and oxygen to needed oxygen. All these conclusively show that the petitioner had not prepared for
prepare for any contingency that might happen during the operation. The manner and any unforeseen circumstances before going into the first surgery, which was not
the fact that the patient was brought to the San Pablo District Hospital for reoperation emergency in nature, but was elective or pre-scheduled; she had no ready antibiotics,
indicates that there was something wrong in the manner in which Dra. Cruz conducted no prepared blood, properly typed and cross-matched, and no sufficient oxygen
the operation. There was no showing that before the operation, accused Dr. Cruz had supply.
conducted a cardio pulmonary clearance or any typing of the blood of the patient. It
was (sic) said in medical parlance that the "abdomen of the person is a temple of Moreover, there are a lot of questions that keep nagging Us. Was the patient given any
surprises" because you do not know the whole thing the moment it was open (sic) and cardio-pulmonary clearance, or at least a clearance by an internist, which are standard
surgeon must be prepared for any eventuality thereof. The patient (sic) chart which is requirements before a patient is subjected to surgery. Did the petitioner determine as
a public document was not presented because it is only there that we could determine part of the pre-operative evaluation, the bleeding parameters of the patient, such as
the condition of the patient before the surgery. The court also noticed in Exh. "F-1" bleeding time and clotting time? There is no showing that these were done. The
that the sister of the deceased wished to postpone the operation but the patient was petitioner just appears to have been in a hurry to perform the operation, even as the
prevailed upon by Dra. Cruz to proceed with the surgery. The court finds that Lydia family wanted the postponement to April 6, 1991. Obviously, she did not prepare the
Umali died because of the negligence and carelessness of the surgeon Dra. Ninevetch patient; neither did she get the family's consent to the operation. Moreover, she did not
Cruz because of loss of blood during the operation of the deceased for evident prepare a medical chart with instructions for the patient's care. If she did all these,
unpreparedness and for lack of skill, the reason why the patient was brought for proof thereof should have been offered. But there is none. Indeed, these are
operation at the San Pablo City District Hospital. As such, the surgeon should answer overwhelming evidence of recklessness and imprudence."[25]
This court, however, holds differently and finds the foregoing circumstances conjectures of laymen, including judges, but by the unquestionable knowledge of
insufficient to sustain a judgment of conviction against the petitioner for the crime of expert witnesses. For whether a physician or surgeon has exercised the requisite degree
reckless imprudence resulting in homicide. The elements of reckless imprudence are: of skill and care in the treatment of his patient is, in the generality of cases, a matter of
(1) that the offender does or fails to do an act; (2) that the doing or the failure to do expert opinion.[30] The deference of courts to the expert opinion of qualified
that act is voluntary; (3) that it be without malice; (4) that material damage results from physicians stems from its realization that the latter possess unusual technical skills
the reckless imprudence; and (5) that there is inexcusable lack of precaution on the which laymen in most instances are incapable of intelligently evaluating.[31] Expert
part of the offender, taking into consideration his employment or occupation, degree testimony should have been offered to prove that the circumstances cited by the courts
of intelligence, physical condition, and other circumstances regarding persons, time below are constitutive of conduct falling below the standard of care employed by other
and place. physicians in good standing when performing the same operation. It must be
remembered that when the qualifications of a physician are admitted, as in the instant
Whether or not a physician has committed an "inexcusable lack of precaution" in the case, there is an inevitable presumption that in proper cases he takes the necessary
treatment of his patient is to be determined according to the standard of care observed precaution and employs the best of his knowledge and skill in attending to his clients,
by other members of the profession in good standing under similar circumstances unless the contrary is sufficiently established.[32] This presumption is rebuttable by
bearing in mind the advanced state of the profession at the time of treatment or the expert opinion which is so sadly lacking in the case at bench.
present state of medical science.[26] In the recent case of Leonila Garcia-Rueda v.
Wilfred L. Pacasio, et. al.,[27] this Court stated that in accepting a case, a doctor in Even granting arguendo that the inadequacy of the facilities and untidiness of the
effect represents that, having the needed training and skill possessed by physicians and clinic; the lack of provisions; the failure to conduct pre-operation tests on the patient;
surgeons practicing in the same field, he will employ such training, care and skill in and the subsequent transfer of Lydia to the San Pablo Hospital and the reoperation
the treatment of his patients. He therefore has a duty to use at least the same level of performed on her by the petitioner do indicate, even without expert testimony, that
care that any other reasonably competent doctor would use to treat a condition under petitioner was recklessly imprudent in the exercise of her duties as a surgeon, no
the same circumstances. It is in this aspect of medical malpractice that expert cogent proof exists that any of these circumstances caused petitioner's death. Thus, the
testimony is essential to establish not only the standard of care of the profession but absence of the fourth element of reckless imprudence: that the injury to the person or
also that the physician's conduct in the treatment and care falls below such property was a consequence of the reckless imprudence.
standard.[28] Further, inasmuch as the causes of the injuries involved in malpractice
actions are determinable only in the light of scientific knowledge, it has been In litigations involving medical negligence, the plaintiff has the burden of establishing
recognized that expert testimony is usually necessary to support the conclusion as to appellant's negligence and for a reasonable conclusion of negligence, there must be
causation.[29] proof of breach of duty on the part of the surgeon as well as a casual connection of
such breach and the resulting death of his patient.[33] In Chan Lugay v. St Luke's
Immediately apparent from a review of the records of this case is the absence of any Hospital, Inc.,[34] where the attending physician was absolved of liability for the death
expert testimony on the matter of the standard of care employed by other physicians of the complainant's wife and newborn baby, this court held that:
of good standing in the conduct of similar operations. The prosecution's expert
witnesses in the persons of Dr. Floresto Arizala and Dr. Nieto Salvador, Jr. of the "In order that there may be a recovery for an injury, however, it must be shown that
National Bureau of Investigation (NBI) only testified as to the possible cause of death the 'injury for which recovery is sought must be the legitimate consequence of the
but did not venture to illuminate the court on the matter of the standard of care that wrong done; the connection between the negligence and the injury must be a direct
petitioner should have exercised. and natural sequence of events, unbroken by intervening efficient causes.' In other
words, the negligence must be the proximate cause of the injury. For, 'negligence, no
All three courts below bewail the inadequacy of the facilities of the clinic and its matter in what it consists, cannot create a right of action unless it is the proximate
untidiness; the lack of provisions such as blood, oxygen, and certain medicines; the cause of the injury complained of.' And 'the proximate cause of an injury is that cause,
failure to subject the patient to a cardio-pulmonary test prior to the operation; the which, in natural and continuous sequence, unbroken by any efficient intervening
omission of any form of blood typing before transfusion; and even the subsequent cause, produces the injury, and without which the result would not have occurred.'''[35]
transfer of Lydia to the San Pablo Hospital and the reoperation performed on her by (Underscoring supplied.)
the petitioner. But while it may be true that the circumstances pointed out by the courts
below seemed beyond cavil to constitute reckless imprudence on the part of the Dr. Arizala who conducted an autopsy on the body of the deceased summarized his
surgeon, this conclusion is still best arrived at not through the educated surmises nor findings as follows:
"Atty. Cachero: Q. How about the intestines and mesenteries are place (sic) with blood clots noted
between the mesenteric folds, will you please explain on (sic) this?
Q. You mentioned about your Autopsy Report which has been marked as Exh. "A-1- A. In the peritoneal cavity, they are mostly perritonial blood.
b". There appears here a signature above the typewritten name Floresto Arizala, Jr., Q. And what could have caused this blood?
whose signature is that? A. Well, ordinarily blood is found inside the blood vessel. Blood were (sic) outside as
A. That is my signature, sir. a result of the injuries which destroyed the integrity of the vessel allowing blood to sip
(sic) out, sir.
Q. Do you affirm the truth of all the contents of Exh. "A-1-b"? Q. By the nature of the postmortem findings indicated in Exh. A-1-B, can you tell the
court the cause of death?
A. Only as to the autopsy report no. 91-09, the time and place and everything after the
A. Yes, sir. The cause of death is: Gross findings are compatible with hemorrhagic
post mortem findings, sir.
shock.
Q. You mentioned on your "Post Mortem Findings" about surgical incision, 14:0 cm., Q. Can you tell the us what could have caused this hemorrhagic shock?
infraumbilical area, anterior abdominal area, midline, will you please explain that in A. Well hemorrhagic shock is the result of blood loss.
your own language? Q. What could have the effect of that loss of blood?
A. Unattended hemorrhage, sir.[36] (Underscoring supplied.)
A. There was incision wound (sic) the area just below the navel, sir. The foregoing was corroborated by Dr. Nieto Salvador:
"Q. And were you able to determine the cause of death by virtue of the examination of
Q. And the last paragraph of the postmortem findings which I read: Uterus, pear-
the specimen submitted by Dr. Arizala?
shaped and pale measuring 7.5 x 5.5 x 5.0 cm, with some surface nodulation of the
A. Without knowledge of the autopsy findings it would be difficult for me to determine
fundic area posteriorly. Cut-section shows diffusely pale myometrium with areas of
the cause of death, sir.
streak induration. The ovaries and adnexal structures are missing with the raw surfaces
Q. Have you examined the post mortem of Dr. Arizala?
patched with clotted blood. Surgical sutures were noted on the operative site.
A. Yes, sir, and by virtue of the autopsy report in connection with your pathology
Intestines and mesenteries are pale with blood clots noted between the mesentric folds. report.
Q. What could have caused the death of the victim?
Hemoperitonium: 300 s.s., A. This pathologic examination are (sic) compatible with the person who died, sir.
right paracolic gutter, Q. Will you explain to us the meaning of hemorrhagic compatible?
50 c.c., left paracolic gutter A. It means that a person died of blood loss. Meaning a person died of non-replacement
200 c.c., mesentric area, of blood and so the victim before she died there was shock of diminish of blood of the
100 c.c., right pelvic gutter circulation. She died most probably before the actual complete blood loss, sir.
stomach empty. Court: Is it possible doctor that the loss of the blood was due on (sic) operation?
Other visceral organs, pale.', A. Based on my pathology findings, sir.
will you please explain that on (sic) your own language or in ordinary Q. What could have caused this loss of blood?
A. Many, sir. A patient who have undergone surgery. Another may be a blood vessel
A. There was a uterus which was not attached to the adnexal structures namely ovaries
may be cut while on operation and this cause (sic) bleeding, or may be set in the course
which were not present and also sign of previous surgical operation and there were
of the operation, or may be (sic) he died after the operation. Of course there are other
(sic) clotted blood, sir.
cause (sic).
Q. How about the ovaries and adnexal structures? Atty. Cachero:
A. They are missing, sir.
Q. Especially so doctor when there was no blood replacement?
Q. You mean to say there are no ovaries?
A. During that time there are no ovaries, sir. A. Yes, sir."[37] (Underscoring supplied.)
Q. And there were likewise sign of surgical sutures?
A. Yes, sir. The testimonies of both doctors establish hemorrhage or hemorrhagic shock as the
cause of death. However, as likewise testified to by the expert witnesses in open court,
hemorrhage or hemorrhagic shock during surgery may be caused by several different a cut blood vessel; and (4) and a clotting defect known as DIC. It is significant to state
factors. Thus, Dr. Salvador's elaboration on the matter: at this juncture that the autopsy conducted by Dr. Arizala on the body of Lydia did not
reveal any untied or unsutured cut blood vessel nor was there any indication that the
"Atty. Pascual: tie or suture of a cut blood vessel had become loose thereby causing the
Q. Doctor, among the causes of hemorrhage that you mentioned you said that it could hemorrhage.[40] Hence the following pertinent portion of Dr. Arizala's testimony:
be at the moment of operation when one losses (sic) control of the presence, is that "Q: Doctor, in examining these structures did you know whether these were sutured
correct? During the operation there is lost (sic) of control of the cut vessel? ligature or plain ligature
A. Yes, sir.
Q. Or there is a failure to ligate a vessel of considerable size? A: Ligature, sir.
A. Yes, sir.
Q. Or even if the vessel were ligated the knot may have slipped later on? Q: We will explain that later on. Did you recall if the cut structures were tied by first
A. Yes, sir. suturing it and then tying a knot or the tie was merely placed around the cut structure
Q. And you also mentioned that it may be possible also to some clotting defect, is that and tied?
correct? A: I cannot recall, sir.
A. May be (sic)."[38] (Underscoring supplied).
Defense witness, Dr. Bu C. Castro also gave the following expert opinion: Q: As a matter of fact, you cannot recall because you did not even bothered (sic) to
"Q. Doctor even a patient after an operations (sic) would suffer hemorrage what would examine, is that correct?
be the possible causes of such hemorrage (sic)?
A: Well, I bothered enough to know that they were sutured, sir.
A. Among those would be what we call Intravascular Coagulation and this is the reason
for the bleeding, sir, which cannot be prevented by anyone, it will happen to anyone, Q: So, therefore, Doctor, you would not know whether any of the cut structures were
anytime and to any persons (sic), sir. not sutured or tied neither were you able to determine whether any loose suture was
COURT: found in the peritoneal cavity?
What do you think of the cause of the bleeding, the cutting or the operations done in A: I could not recall any loose sutured (sic), sir."[41]
the body?
On the other hand, the findings of all three doctors do not preclude the probability that
A. Not related to this one, the bleeding here is not related to any cutting or operation DIC caused the hemorrhage and consequently, Lydia's death. DIC which is a clotting
that I (sic) have done. defect creates a serious bleeding tendency and when massive DIC occurs as a
complication of surgery leaving raw surface, major hemorrhage occurs.[42] And as
Q. Aside from the DIC what could another causes (sic) that could be the cause for the
testified to by defense witness, Dr. Bu C. Castro, hemorrhage due to DIC "cannot be
hemorrhage or bleeding in a patient by an operations (sic)?
prevented, it will happen to anyone, anytime."[43] He testified further:
A. In general sir, if there was an operations (sic) and it is possible that the ligature in
"Q. Now, under the circumstance one of the possibility as you mentioned in (sic) DIC?
the suture was (sic) become (sic) loose, it is (sic) becomes loose if proven.
A. Yes, sir.
xxxxxxxxx
Q. And you mentioned that it cannot be prevented?
Q. If the person who performed an autopsy does not find any untight (sic) clot (sic)
blood vessel or any suture that become (sic) loose the cause of the bleeding could not A. Yes, sir.
be attributed to the fault of the subject?
Q. Can you even predict if it really happen (sic)?
A. Definitely, sir."[39] (Underscoring supplied.)
A. Possible, sir.
According to both doctors, the possible causes of hemorrhage during an operation are:
(1) the failure of the surgeon to tie or suture a cut blood vessel; (2) allowing a cut blood Q. Are there any specific findings of autopsy that will tell you whether this patient
vessel to get out of control; (3) the subsequent loosening of the tie or suture applied to suffered among such things as DIC?
A. Well, I did reserve because of the condition of the patient. liable for the death of Lydia Umali, for while a conviction of a crime requires proof
beyond reasonable doubt, only a preponderance of evidence is required to establish
Q. Now, Doctor you said that you went through the record of the deceased Lydia Umali civil liability.[45]
looking for the chart, the operated (sic) records, the post mortem findings on the
histophanic (sic) examination based on your examination of record, doctor, can you The petitioner is a doctor in whose hands a patient puts his life and limb. For
more or less says (sic) what part are (sic) concerned could have been the caused (sic) insufficiency of evidence this Court was not able to render a sentence of conviction
of death of this Lydia Umali? but it is not blind to the reckless and imprudent manner in which the petitioner carried
out her duties. A precious life has been lost and the circumstances leading thereto
A. As far as the medical record is concern (sic) the caused (sic) of death is dessimulated exacerbated the grief of those left behind. The heirs of the deceased continue to feel
(sic) Intra Vascular Coagulation or the DIC which resulted to hemorrhage or bleedings, the loss of their mother up to the present time[46] and this Court is aware that no
sir. amount of compassion and commiseration nor words of bereavement can suffice to
Q. Doctor based on your findings then there is knowing (sic) the doctor would say assuage the sorrow felt for the loss of a loved one. Certainly, the award of moral and
whether the doctor her (sic) has been (sic) fault? exemplary damages in favor of the heirs of Lydia Umali are proper in the instant case.

ATTY. MALVEDA: WHEREFORE, premises considered, petitioner DR. NINEVETCH CRUZ is hereby
ACQUITTED of the crime of reckless imprudence resulting in homicide but is
We will moved (sic) to strike out the (sic) based on finding they just read the chart as ordered to pay the heirs of the deceased Lydia Umali the amount of FIFTY
well as the other record. THOUSAND PESOS (P50,000.00) as civil liability, ONE HUNDRED THOUSAND
PESOS (P100,000.00) as moral damages, and FIFTY THOUSAND PESOS
ATTY. PASCUAL:
(P50,000.00) as exemplary damages.
Precisely based on this examination.
Let the copy of this decision be furnished to the Professional Regulation Commission
ATTY. MALVEDA: (PRC) for appropriate action.

Not finding, there was no finding made. SO ORDERED.

COURT:

He is only reading the record.

ATTY. PASCUAL:

Yes, sir.

A. No, sir, there is no fault on the part of the surgeon, sir." [44]

This court has no recourse but to rely on the expert testimonies rendered by both
prosecution and defense witnesses that substantiate rather than contradict petitioner's
allegation that the cause of Lydia's death was DIC which, as attested to by an expert
witness, cannot be attributed to the petitioner's fault or negligence. The probability that
Lydia's death was caused by DIC was unrebutted during trial and has engendered in
the mind of this Court a reasonable doubt as to the petitioner's guilt. Thus, her acquittal
of the crime of reckless imprudence resulting in homicide. While we condole with the
family of Lydia Umali, our hands are bound by the dictates of justice and fair dealing
which hold inviolable the right of an accused to be presumed innocent until proven
guilty beyond reasonable doubt. Nevertheless, this Court finds the petitioner civilly
Republic of the Philippines examinations which included blood and urine tests (Exhs. "A" and "C") which
SUPREME COURT indicated she was fit for surgery.
Manila
FIRST DIVISION Through the intercession of a mutual friend, Dr. Buenviaje (TSN, January 13, 1988, p.
7), she and her husband Rogelio met for the first time Dr. Orlino Hozaka (should be
Hosaka; see TSN, February 20, 1990, p. 3), one of the defendants in this case, on June
G.R. No. 124354 December 29, 1999 10, 1985. They agreed that their date at the operating table at the DLSMC (another
defendant), would be on June 17, 1985 at 9:00 A.M.. Dr. Hosaka decided that she
ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as should undergo a "cholecystectomy" operation after examining the documents
natural guardians of the minors, ROMMEL RAMOS, ROY RODERICK (findings from the Capitol Medical Center, FEU Hospital and DLSMC) presented to
RAMOS and RON RAYMOND RAMOS vs. COURT OF APPEALS, DELOS him. Rogelio E. Ramos, however, asked Dr. Hosaka to look for a good
SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and DRA. anesthesiologist. Dr. Hosaka, in turn, assured Rogelio that he will get a good
PERFECTA GUTIERREZ, respondents. anesthesiologist. Dr. Hosaka charged a fee of P16,000.00, which was to include the
anesthesiologist's fee and which was to be paid after the operation (TSN, October 19,
1989, pp. 14-15, 22-23, 31-33; TSN, February 27, 1990, p. 13; and TSN, November
KAPUNAN, J.: 9, 1989, pp. 3-4, 10, 17).
The Hippocratic Oath mandates physicians to give primordial consideration to the A day before the scheduled date of operation, she was admitted at one of the rooms of
health and welfare of their patients. If a doctor fails to live up to this precept, he is the DLSMC, located along E. Rodriguez Avenue, Quezon City (TSN, October
made accountable for his acts. A mistake, through gross negligence or incompetence 19,1989, p. 11).
or plain human error, may spell the difference between life and death. In this sense,
the doctor plays God on his patient's fate. 1 At around 7:30 A.M. of June 17, 1985 and while still in her room, she was prepared
for the operation by the hospital staff. Her sister-in-law, Herminda Cruz, who was the
In the case at bar, the Court is called upon to rule whether a surgeon, an Dean of the College of Nursing at the Capitol Medical Center, was also there for moral
anesthesiologist and a hospital should be made liable for the unfortunate comatose support. She reiterated her previous request for Herminda to be with her even during
condition of a patient scheduled for cholecystectomy. 2 the operation. After praying, she was given injections. Her hands were held by
Herminda as they went down from her room to the operating room (TSN, January 13,
Petitioners seek the reversal of the decision 3 of the Court of Appeals, dated 29 May
1988, pp. 9-11). Her husband, Rogelio, was also with her (TSN, October 19, 1989, p.
1995, which overturned the decision 4 of the Regional Trial Court, dated 30 January
18). At the operating room, Herminda saw about two or three nurses and Dr. Perfecta
1992, finding private respondents liable for damages arising from negligence in the
Gutierrez, the other defendant, who was to administer anesthesia. Although not a
performance of their professional duties towards petitioner Erlinda Ramos resulting in
member of the hospital staff, Herminda introduced herself as Dean of the College of
her comatose condition.
Nursing at the Capitol Medical Center who was to provide moral support to the patient,
The antecedent facts as summarized by the trial court are reproduced hereunder: to them. Herminda was allowed to stay inside the operating room.

Plaintiff Erlinda Ramos was, until the afternoon of June 17, 1985, a 47-year old (Exh. At around 9:30 A.M., Dr. Gutierrez reached a nearby phone to look for Dr. Hosaka
"A") robust woman (TSN, October 19, 1989, p. 10). Except for occasional complaints who was not yet in (TSN, January 13, 1988, pp. 11-12). Dr. Gutierrez thereafter
of discomfort due to pains allegedly caused by the presence of a stone in her gall informed Herminda Cruz about the prospect of a delay in the arrival of Dr. Hosaka.
bladder (TSN, January 13, 1988, pp. 4-5), she was as normal as any other woman. Herminda then went back to the patient who asked, "Mindy, wala pa ba ang Doctor"?
Married to Rogelio E. Ramos, an executive of Philippine Long Distance Telephone The former replied, "Huwag kang mag-alaala, darating na iyon" (Ibid.).
Company, she has three children whose names are Rommel Ramos, Roy Roderick
Thereafter, Herminda went out of the operating room and informed the patient's
Ramos and Ron Raymond Ramos (TSN, October 19, 1989, pp. 5-6).
husband, Rogelio, that the doctor was not yet around (id., p. 13). When she returned
Because the discomforts somehow interfered with her normal ways, she sought to the operating room, the patient told her, "Mindy, inip na inip na ako, ikuha mo ako
professional advice. She was advised to undergo an operation for the removal of a ng ibang Doctor." So, she went out again and told Rogelio about what the patient said
stone in her gall bladder (TSN, January 13, 1988, p. 5). She underwent a series of (id., p. 15). Thereafter, she returned to the operating room.
At around 10:00 A.M., Rogelio E. Ramos was "already dying [and] waiting for the Doctors Gutierrez and Hosaka were also asked by the hospital to explain what
arrival of the doctor" even as he did his best to find somebody who will allow him to happened to the patient. The doctors explained that the patient had bronchospasm
pull out his wife from the operating room (TSN, October 19, 1989, pp. 19-20). He also (TSN, November 15, 1990, pp. 26-27).
thought of the feeling of his wife, who was inside the operating room waiting for the
doctor to arrive (ibid.). At almost 12:00 noon, he met Dr. Garcia who remarked that Erlinda Ramos stayed at the ICU for a month. About four months thereafter or on
he (Dr. Garcia) was also tired of waiting for Dr. Hosaka to arrive (id., p. 21). While November 15, 1985, the patient was released from the hospital.
talking to Dr. Garcia at around 12:10 P.M., he came to know that Dr. Hosaka arrived During the whole period of her confinement, she incurred hospital bills amounting to
as a nurse remarked, "Nandiyan na si Dr. Hosaka, dumating na raw." Upon hearing P93,542.25 which is the subject of a promissory note and affidavit of undertaking
those words, he went down to the lobby and waited for the operation to be completed executed by Rogelio E. Ramos in favor of DLSMC. Since that fateful afternoon of
(id., pp. 16, 29-30). June 17, 1985, she has been in a comatose condition. She cannot do anything. She
At about 12:15 P.M., Herminda Cruz, who was inside the operating room with the cannot move any part of her body. She cannot see or hear. She is living on mechanical
patient, heard somebody say that "Dr. Hosaka is already here." She then saw people means. She suffered brain damage as a result of the absence of oxygen in her brain for
inside the operating room "moving, doing this and that, [and] preparing the patient for four to five minutes (TSN, November 9, 1989, pp. 21-22). After being discharged from
the operation" (TSN, January 13, 1988, p. 16). As she held the hand of Erlinda Ramos, the hospital, she has been staying in their residence, still needing constant medical
she then saw Dr. Gutierrez intubating the hapless patient. She thereafter heard Dr. attention, with her husband Rogelio incurring a monthly expense ranging from
Gutierrez say, "ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki P8,000.00 to P10,000.00 (TSN, October 19, 1989, pp. 32-34). She was also diagnosed
ang tiyan" (id., p. 17). Because of the remarks of Dra. Gutierrez, she focused her to be suffering from "diffuse cerebral parenchymal damage" (Exh. "G"; see also TSN,
attention on what Dr. Gutierrez was doing. She thereafter noticed bluish discoloration December 21, 1989,
of the nailbeds of the left hand of the hapless Erlinda even as Dr. Hosaka approached p. 6). 5
her. She then heard Dr. Hosaka issue an order for someone to call Dr. Calderon,
another anesthesiologist (id., p. 19). After Dr. Calderon arrived at the operating room, Thus, on 8 January 1986, petitioners filed a civil case 6 for damages with the Regional
she saw this anesthesiologist trying to intubate the patient. The patient's nailbed Trial Court of Quezon City against herein private respondents alleging negligence in
became bluish and the patient was placed in a trendelenburg position a position the management and care of Erlinda Ramos.
where the head of the patient is placed in a position lower than her feet which is an
During the trial, both parties presented evidence as to the possible cause of Erlinda's
indication that there is a decrease of blood supply to the patient's brain (Id., pp. 19-20).
injury. Plaintiff presented the testimonies of Dean Herminda Cruz and Dr. Mariano
Immediately thereafter, she went out of the operating room, and she told Rogelio E.
Gavino to prove that the sustained by Erlinda was due to lack of oxygen in her brain
Ramos "that something wrong was . . . happening" (Ibid.). Dr. Calderon was then able
caused by the faulty management of her airway by private respondents during the
to intubate the patient (TSN, July 25, 1991, p. 9).
anesthesia phase. On the other hand, private respondents primarily relied on the expert
Meanwhile, Rogelio, who was outside the operating room, saw a respiratory machine testimony of Dr. Eduardo Jamora, a pulmonologist, to the effect that the cause of brain
being rushed towards the door of the operating room. He also saw several doctors damage was Erlinda's allergic reaction to the anesthetic agent, Thiopental Sodium
rushing towards the operating room. When informed by Herminda Cruz that (Pentothal).
something wrong was happening, he told her (Herminda) to be back with the patient
After considering the evidence from both sides, the Regional Trial Court rendered
inside the operating room (TSN, October 19, 1989, pp. 25-28).
judgment in favor of petitioners, to wit:
Herminda Cruz immediately rushed back, and saw that the patient was still in
After evaluating the evidence as shown in the finding of facts set forth earlier, and
trendelenburg position (TSN, January 13, 1988, p. 20). At almost 3:00 P.M. of that
applying the aforecited provisions of law and jurisprudence to the case at bar, this
fateful day, she saw the patient taken to the Intensive Care Unit (ICU).
Court finds and so holds that defendants are liable to plaintiffs for damages. The
About two days thereafter, Rogelio E. Ramos was able to talk to Dr. Hosaka. The latter defendants were guilty of, at the very least, negligence in the performance of their duty
informed the former that something went wrong during the intubation. Reacting to to plaintiff-patient Erlinda Ramos.
what was told to him, Rogelio reminded the doctor that the condition of his wife would
On the part of Dr. Perfecta Gutierrez, this Court finds that she omitted to exercise
not have happened, had he (Dr. Hosaka) looked for a good anesthesiologist (TSN,
reasonable care in not only intubating the patient, but also in not repeating the
October 19, 1989, p. 31).
administration of atropine (TSN, August 20, 1991, pp. 5-10), without due regard to the Private respondents seasonably interposed an appeal to the Court of Appeals. The
fact that the patient was inside the operating room for almost three (3) hours. For after appellate court rendered a Decision, dated 29 May 1995, reversing the findings of the
she committed a mistake in intubating [the] patient, the patient's nailbed became bluish trial court. The decretal portion of the decision of the appellate court reads:
and the patient, thereafter, was placed in trendelenburg position, because of the
decrease of blood supply to the patient's brain. The evidence further shows that the WHEREFORE, for the foregoing premises the appealed decision is hereby
hapless patient suffered brain damage because of the absence of oxygen in her REVERSED, and the complaint below against the appellants is hereby
(patient's) brain for approximately four to five minutes which, in turn, caused the ordered DISMISSED. The counterclaim of appellant De Los Santos Medical
patient to become comatose. Center is GRANTED but only insofar as appellees are hereby ordered to pay
the unpaid hospital bills amounting to P93,542.25, plus legal interest for
On the part of Dr. Orlino Hosaka, this Court finds that he is liable for the acts of Dr. justice must be tempered with mercy. SO ORDERED. 8
Perfecta Gutierrez whom he had chosen to administer anesthesia on the patient as part
of his obligation to provide the patient a good anesthesiologist', and for arriving for The decision of the Court of Appeals was received on 9 June 1995 by petitioner
the scheduled operation almost three (3) hours late. Rogelio Ramos who was mistakenly addressed as "Atty. Rogelio Ramos." No copy of
the decision, however, was sent nor received by the Coronel Law Office, then counsel
On the part of DLSMC (the hospital), this Court finds that it is liable for the acts of on record of petitioners. Rogelio referred the decision of the appellate court to a new
negligence of the doctors in their "practice of medicine" in the operating room. lawyer, Atty. Ligsay, only on 20 June 1995, or four (4) days before the expiration of
Moreover, the hospital is liable for failing through its responsible officials, to cancel the reglementary period for filing a motion for reconsideration. On the same day, Atty.
the scheduled operation after Dr. Hosaka inexcusably failed to arrive on time. Ligsay, filed with the appellate court a motion for extension of time to file a motion
for reconsideration. The motion for reconsideration was submitted on 4 July 1995.
In having held thus, this Court rejects the defense raised by defendants that they have However, the appellate court denied the motion for extension of time in its Resolution
acted with due care and prudence in rendering medical services to plaintiff-patient. For dated 25 July 1995. 9 Meanwhile, petitioners engaged the services of another counsel,
if the patient was properly intubated as claimed by them, the patient would not have Atty. Sillano, to replace Atty. Ligsay. Atty. Sillano filed on 7 August 1995 a motion
become comatose. And, the fact that another anesthesiologist was called to try to to admit the motion for reconsideration contending that the period to file the
intubate the patient after her (the patient's) nailbed turned bluish, belie their claim. appropriate pleading on the assailed decision had not yet commenced to run as the
Furthermore, the defendants should have rescheduled the operation to a later date. Division Clerk of Court of the Court of Appeals had not yet served a copy thereof to
This, they should have done, if defendants acted with due care and prudence as the the counsel on record. Despite this explanation, the appellate court still denied the
patient's case was an elective, not an emergency case. motion to admit the motion for reconsideration of petitioners in its Resolution, dated
xxx xxx xxx 29 March 1996, primarily on the ground that the fifteen-day (15) period for filing a
motion for reconsideration had already expired, to wit:
WHEREFORE, and in view of the foregoing, judgment is rendered in favor
of the plaintiffs and against the defendants. Accordingly, the latter are We said in our Resolution on July 25, 1995, that the filing of a Motion for
ordered to pay, jointly and severally, the former the following sums of Reconsideration cannot be extended; precisely, the Motion for Extension (Rollo, p.
money, to wit: 12) was denied. It is, on the other hand, admitted in the latter Motion that
1) the sum of P8,000.00 as actual monthly expenses for the plaintiff Erlinda plaintiffs/appellees received a copy of the decision as early as June 9, 1995.
Ramos reckoned from November 15, 1985 or in the total sum of P632,000.00 Computation wise, the period to file a Motion for Reconsideration expired on June 24.
as of April 15, 1992, subject to its being updated; The Motion for Reconsideration, in turn, was received by the Court of Appeals already
2) the sum of P100,000.00 as reasonable attorney's fees; on July 4, necessarily, the 15-day period already passed. For that alone, the latter
3) the sum of P800,000.00 by way of moral damages and the further sum of should be denied.
P200,000,00 by way of exemplary damages; and, Even assuming admissibility of the Motion for the Reconsideration, but after
4) the costs of the suit. considering the Comment/Opposition, the former, for lack of merit, is hereby
SO ORDERED. 7 DENIED.

SO ORDERED. 10
A copy of the above resolution was received by Atty. Sillano on 11 April 1996. The It is elementary that when a party is represented by counsel, all notices should be sent
next day, or on 12 April 1996, Atty. Sillano filed before this Court a motion for to the party's lawyer at his given address. With a few exceptions, notice to a litigant
extension of time to file the present petition for certiorari under Rule 45. The Court without notice to his counsel on record is no notice at all. In the present case, since a
granted the motion for extension of time and gave petitioners additional thirty (30) copy of the decision of the appellate court was not sent to the counsel on record of
days after the expiration of the fifteen-day (15) period counted from the receipt of the petitioner, there can be no sufficient notice to speak of. Hence, the delay in the filing
resolution of the Court of Appeals within which to submit the petition. The due date of the motion for reconsideration cannot be taken against petitioner. Moreover, since
fell on 27 May 1996. The petition was filed on 9 May 1996, well within the extended the Court of Appeals already issued a second Resolution, dated 29 March 1996, which
period given by the Court. superseded the earlier resolution issued on 25 July 1995, and denied the motion for
reconsideration of petitioner, we believed that the receipt of the former should be
Petitioners assail the decision of the Court of Appeals on the following grounds: considered in determining the timeliness of the filing of the present petition. Based on
I this, the petition before us was submitted on time.

IN PUTTING MUCH RELIANCE ON THE TESTIMONIES OF RESPONDENTS After resolving the foregoing procedural issue, we shall now look into the merits of
DRA. GUTIERREZ, DRA. CALDERON AND DR. JAMORA; the case. For a more logical presentation of the discussion we shall first consider the
issue on the applicability of the doctrine of res ipsa loquitur to the instant case.
II Thereafter, the first two assigned errors shall be tackled in relation to the res ipsa
loquitur doctrine.
IN FINDING THAT THE NEGLIGENCE OF THE RESPONDENTS DID NOT
CAUSE THE UNFORTUNATE COMATOSE CONDITION OF PETITIONER Res ipsa loquitur is a Latin phrase which literally means "the thing or the transaction
ERLINDA RAMOS; speaks for itself." The phrase "res ipsa loquitur'' is a maxim for the rule that the fact of
the occurrence of an injury, taken with the surrounding circumstances, may permit an
III
inference or raise a presumption of negligence, or make out a plaintiff's prima facie
IN NOT APPLYING THE DOCTRINE OF RES IPSA LOQUITUR. 11 case, and present a question of fact for defendant to meet with an explanation. 13
Where the thing which caused the injury complained of is shown to be under the
Before we discuss the merits of the case, we shall first dispose of the procedural issue management of the defendant or his servants and the accident is such as in ordinary
on the timeliness of the petition in relation to the motion for reconsideration filed by course of things does not happen if those who have its management or control use
petitioners with the Court of Appeals. In their proper care, it affords reasonable evidence, in the absence of explanation by the
defendant, that the accident arose from or was caused by the defendant's want of care.
Comment, 12 private respondents contend that the petition should not be given due
14
course since the motion for reconsideration of the petitioners on the decision of the
Court of Appeals was validly dismissed by the appellate court for having been filed The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a
beyond the reglementary period. We do not agree. matter of common knowledge and experience, the very nature of certain types of
occurrences may justify an inference of negligence on the part of the person who
A careful review of the records reveals that the reason behind the delay in filing the
controls the instrumentality causing the injury in the absence of some explanation by
motion for reconsideration is attributable to the fact that the decision of the Court of
the defendant who is charged with negligence. 15 It is grounded in the superior logic
Appeals was not sent to then counsel on record of petitioners, the Coronel Law Office.
of ordinary human experience and on the basis of such experience or common
In fact, a copy of the decision of the appellate court was instead sent to and received
knowledge, negligence may be deduced from the mere occurrence of the accident
by petitioner Rogelio Ramos on 9 June 1995 wherein he was mistakenly addressed as
itself. 16 Hence, res ipsa loquitur is applied in conjunction with the doctrine of
Atty. Rogelio Ramos. Based on the other communications received by petitioner
common knowledge.
Rogelio Ramos, the appellate court apparently mistook him for the counsel on record.
Thus, no copy of the decision of the counsel on record. Petitioner, not being a lawyer However, much has been said that res ipsa loquitur is not a rule of substantive law and,
and unaware of the prescriptive period for filing a motion for reconsideration, referred as such, does not create or constitute an independent or separate ground of liability. 17
the same to a legal counsel only on 20 June 1995. Instead, it is considered as merely evidentiary or in the nature of a procedural rule. 18
It is regarded as a mode of proof, or a mere procedural of convenience since it furnishes
a substitute for, and relieves a plaintiff of, the burden of producing specific proof of
negligence. 19 In other words, mere invocation and application of the doctrine does patient, without the aid of expert testimony, where the court from its fund of common
not dispense with the requirement of proof of negligence. It is simply a step in the knowledge can determine the proper standard of care. 30 Where common knowledge
process of such proof, permitting the plaintiff to present along with the proof of the and experience teach that a resulting injury would not have occurred to the patient if
accident, enough of the attending circumstances to invoke the doctrine, creating an due care had been exercised, an inference of negligence may be drawn giving rise to
inference or presumption of negligence, and to thereby place on the defendant the an application of the doctrine of res ipsa loquitur without medical evidence, which is
burden of going forward with the proof. 20 Still, before resort to the doctrine may be ordinarily required to show not only what occurred but how and why it occurred. 31
allowed, the following requisites must be satisfactorily shown: When the doctrine is appropriate, all that the patient must do is prove a nexus between
the particular act or omission complained of and the injury sustained while under the
1. The accident is of a kind which ordinarily does not occur in the absence of someone's custody and management of the defendant without need to produce expert medical
negligence; testimony to establish the standard of care. Resort to res ipsa loquitur is allowed
2. It is caused by an instrumentality within the exclusive control of the defendant or because there is no other way, under usual and ordinary conditions, by which the
defendants; and patient can obtain redress for injury suffered by him.

3. The possibility of contributing conduct which would make the plaintiff responsible Thus, courts of other jurisdictions have applied the doctrine in the following situations:
is eliminated. 21 leaving of a foreign object in the body of the patient after an operation, 32 injuries
sustained on a healthy part of the body which was not under, or in the area, of
In the above requisites, the fundamental element is the "control of instrumentality" treatment, 33 removal of the wrong part of the body when another part was intended,
which caused the damage. 22 Such element of control must be shown to be within the 34 knocking out a tooth while a patient's jaw was under anesthetic for the removal of
dominion of the defendant. In order to have the benefit of the rule, a plaintiff, in his tonsils, 35 and loss of an eye while the patient plaintiff was under the influence of
addition to proving injury or damage, must show a situation where it is applicable, and anesthetic, during or following an operation for appendicitis, 36 among others.
must establish that the essential elements of the doctrine were present in a particular
incident. 23 Nevertheless, despite the fact that the scope of res ipsa loquitur has been measurably
enlarged, it does not automatically apply to all cases of medical negligence as to
Medical malpractice 24 cases do not escape the application of this doctrine. Thus, res mechanically shift the burden of proof to the defendant to show that he is not guilty of
ipsa loquitur has been applied when the circumstances attendant upon the harm are the ascribed negligence. Res ipsa loquitur is not a rigid or ordinary doctrine to be
themselves of such a character as to justify an inference of negligence as the cause of perfunctorily used but a rule to be cautiously applied, depending upon the
that harm. 25 The application of res ipsa loquitur in medical negligence cases presents circumstances of each case. It is generally restricted to situations in malpractice cases
a question of law since it is a judicial function to determine whether a certain set of where a layman is able to say, as a matter of common knowledge and observation, that
circumstances does, as a matter of law, permit a given inference. 26 the consequences of professional care were not as such as would ordinarily have
followed if due care had been exercised. 37 A distinction must be made between the
Although generally, expert medical testimony is relied upon in malpractice suits to
failure to secure results, and the occurrence of something more unusual and not
prove that a physician has done a negligent act or that he has deviated from the standard
ordinarily found if the service or treatment rendered followed the usual procedure of
medical procedure, when the doctrine of res ipsa loquitur is availed by the plaintiff,
those skilled in that particular practice. It must be conceded that the doctrine of res
the need for expert medical testimony is dispensed with because the injury itself
ipsa loquitur can have no application in a suit against a physician or surgeon which
provides the proof of negligence. 27 The reason is that the general rule on the necessity
involves the merits of a diagnosis or of a scientific treatment. 38 The physician or
of expert testimony applies only to such matters clearly within the domain of medical
surgeon is not required at his peril to explain why any particular diagnosis was not
science, and not to matters that are within the common knowledge of mankind which
correct, or why any particular scientific treatment did not produce the desired result.
may be testified to by anyone familiar with the facts. 28 Ordinarily, only physicians
39 Thus, res ipsa loquitur is not available in a malpractice suit if the only showing is
and surgeons of skill and experience are competent to testify as to whether a patient
that the desired result of an operation or treatment was not accomplished. 40 The real
has been treated or operated upon with a reasonable degree of skill and care. However,
question, therefore, is whether or not in the process of the operation any extraordinary
testimony as to the statements and acts of physicians and surgeons, external
incident or unusual event outside of the routine performance occurred which is beyond
appearances, and manifest conditions which are observable by any one may be given
the regular scope of customary professional activity in such operations, which, if
by non-expert witnesses. 29 Hence, in cases where the res ipsa loquitur is applicable,
unexplained would themselves reasonably speak to the average man as the negligent
the court is permitted to find a physician negligent upon proper proof of injury to the
cause or causes of the untoward consequence. 41 If there was such extraneous
interventions, the doctrine of res ipsa loquitur may be utilized and the defendant is Normally, a person being put under anesthesia is not rendered decerebrate as a
called upon to explain the matter, by evidence of exculpation, if he could. 42 consequence of administering such anesthesia if the proper procedure was followed.
Furthermore, the instruments used in the administration of anesthesia, including the
We find the doctrine of res ipsa loquitur appropriate in the case at bar. As will endotracheal tube, were all under the exclusive control of private respondents, who are
hereinafter be explained, the damage sustained by Erlinda in her brain prior to a the physicians-in-charge. Likewise, petitioner Erlinda could not have been guilty of
scheduled gall bladder operation presents a case for the application of res ipsa loquitur. contributory negligence because she was under the influence of anesthetics which
A case strikingly similar to the one before us is Voss vs. Bridwell, 43 where the Kansas rendered her unconscious.
Supreme Court in applying the res ipsa loquitur stated: Considering that a sound and unaffected member of the body (the brain) is injured or
The plaintiff herein submitted himself for a mastoid operation and delivered his person destroyed while the patient is unconscious and under the immediate and exclusive
over to the care, custody and control of his physician who had complete and exclusive control of the physicians, we hold that a practical administration of justice dictates the
control over him, but the operation was never performed. At the time of submission application of res ipsa loquitur. Upon these facts and under these circumstances the
he was neurologically sound and physically fit in mind and body, but he suffered Court would be able to say, as a matter of common knowledge and observation, if
irreparable damage and injury rendering him decerebrate and totally incapacitated. The negligence attended the management and care of the patient. Moreover, the liability of
injury was one which does not ordinarily occur in the process of a mastoid operation the physicians and the hospital in this case is not predicated upon an alleged failure to
or in the absence of negligence in the administration of an anesthetic, and in the use secure the desired results of an operation nor on an alleged lack of skill in the diagnosis
and employment of an endoctracheal tube. Ordinarily a person being put under or treatment as in fact no operation or treatment was ever performed on Erlinda. Thus,
anesthesia is not rendered decerebrate as a consequence of administering such upon all these initial determination a case is made out for the application of the doctrine
anesthesia in the absence of negligence. Upon these facts and under these of res ipsa loquitur.
circumstances a layman would be able to say, as a matter of common knowledge and Nonetheless, in holding that res ipsa loquitur is available to the present case we are not
observation, that the consequences of professional treatment were not as such as would saying that the doctrine is applicable in any and all cases where injury occurs to a
ordinarily have followed if due care had been exercised. patient while under anesthesia, or to any and all anesthesia cases. Each case must be
Here the plaintiff could not have been guilty of contributory negligence because he viewed in its own light and scrutinized in order to be within the res ipsa loquitur
was under the influence of anesthetics and unconscious, and the circumstances are coverage.
such that the true explanation of event is more accessible to the defendants than to the Having in mind the applicability of the res ipsa loquitur doctrine and the presumption
plaintiff for they had the exclusive control of the instrumentalities of anesthesia. of negligence allowed therein, the Court now comes to the issue of whether the Court
Upon all the facts, conditions and circumstances alleged in Count II it is held that a of Appeals erred in finding that private respondents were not negligent in the care of
cause of action is stated under the doctrine of res ipsa loquitur. 44 Erlinda during the anesthesia phase of the operation and, if in the affirmative, whether
the alleged negligence was the proximate cause of Erlinda's comatose condition.
Indeed, the principles enunciated in the aforequoted case apply with equal force here. Corollary thereto, we shall also determine if the Court of Appeals erred in relying on
In the present case, Erlinda submitted herself for cholecystectomy and expected a the testimonies of the witnesses for the private respondents.
routine general surgery to be performed on her gall bladder. On that fateful day she
delivered her person over to the care, custody and control of private respondents who In sustaining the position of private respondents, the Court of Appeals relied on the
exercised complete and exclusive control over her. At the time of submission, Erlinda testimonies of Dra. Gutierrez, Dra. Calderon and Dr. Jamora. In giving weight to the
was neurologically sound and, except for a few minor discomforts, was likewise testimony of Dra. Gutierrez, the Court of Appeals rationalized that she was candid
physically fit in mind and body. However, during the administration of anesthesia and enough to admit that she experienced some difficulty in the endotracheal intubation 45
prior to the performance of cholecystectomy she suffered irreparable damage to her of the patient and thus, cannot be said to be covering her negligence with falsehood.
brain. Thus, without undergoing surgery, she went out of the operating room already The appellate court likewise opined that private respondents were able to show that
decerebrate and totally incapacitated. Obviously, brain damage, which Erlinda the brain damage sustained by Erlinda was not caused by the alleged faulty intubation
sustained, is an injury which does not normally occur in the process of a gall bladder but was due to the allergic reaction of the patient to the drug Thiopental Sodium
operation. In fact, this kind of situation does not in the absence of negligence of (Pentothal), a short-acting barbiturate, as testified on by their expert witness, Dr.
someone in the administration of anesthesia and in the use of endotracheal tube. Jamora. On the other hand, the appellate court rejected the testimony of Dean
Herminda Cruz offered in favor of petitioners that the cause of the brain injury was
traceable to the wrongful insertion of the tube since the latter, being a nurse, was Q: From whom did you hear those words "lumalaki ang tiyan"?
allegedly not knowledgeable in the process of intubation. In so holding, the appellate
court returned a verdict in favor of respondents physicians and hospital and absolved A: From Dra. Perfecta Gutierrez.
them of any liability towards Erlinda and her family. xxx xxx xxx
We disagree with the findings of the Court of Appeals. We hold that private Q: After hearing the phrase "lumalaki ang tiyan," what did you notice on the person of
respondents were unable to disprove the presumption of negligence on their part in the the patient?
care of Erlinda and their negligence was the proximate cause of her piteous condition.
A: I notice (sic) some bluish discoloration on the nailbeds of the left hand where I was
In the instant case, the records are helpful in furnishing not only the logical scientific at.
evidence of the pathogenesis of the injury but also in providing the Court the legal
nexus upon which liability is based. As will be shown hereinafter, private respondents' Q: Where was Dr. Orlino Ho[s]aka then at that particular time?
own testimonies which are reflected in the transcript of stenographic notes are replete
A: I saw him approaching the patient during that time.
of signposts indicative of their negligence in the care and management of Erlinda.
Q: When he approached the patient, what did he do, if any?
With regard to Dra. Gutierrez, we find her negligent in the care of Erlinda during the
anesthesia phase. As borne by the records, respondent Dra. Gutierrez failed to properly A: He made an order to call on the anesthesiologist in the person of Dr. Calderon.
intubate the patient. This fact was attested to by Prof. Herminda Cruz, Dean of the
Capitol Medical Center School of Nursing and petitioner's sister-in-law, who was in Q: Did Dr. Calderon, upon being called, arrive inside the operating room?
the operating room right beside the patient when the tragic event occurred. Witness
A: Yes sir.
Cruz testified to this effect:
Q: What did [s]he do, if any?
ATTY. PAJARES:
A: [S]he tried to intubate the patient.
Q: In particular, what did Dra. Perfecta Gutierrez do, if any on the patient?
Q: What happened to the patient?
A: In particular, I could see that she was intubating the patient.
A: When Dr. Calderon try (sic) to intubate the patient, after a while the patient's nailbed
Q: Do you know what happened to that intubation process administered by Dra.
became bluish and I saw the patient was placed in trendelenburg position.
Gutierrez?
xxx xxx xxx
ATTY. ALCERA:
Q: Do you know the reason why the patient was placed in that trendelenburg position?
She will be incompetent Your Honor.
A: As far as I know, when a patient is in that position, there is a decrease of blood
COURT:
supply to the brain. 46
Witness may answer if she knows.
xxx xxx xxx
A: As have said, I was with the patient, I was beside the stretcher holding the left hand
The appellate court, however, disbelieved Dean Cruz's testimony in the trial court by
of the patient and all of a sudden heard some remarks coming from Dra. Perfecta
declaring that:
Gutierrez herself. She was saying "Ang hirap ma-intubate nito, mali yata ang
pagkakapasok. O lumalaki ang tiyan. A perusal of the standard nursing curriculum in our country will show that intubation
is not taught as part of nursing procedures and techniques. Indeed, we take judicial
xxx xxx xxx
notice of the fact that nurses do not, and cannot, intubate. Even on the assumption that
ATTY. PAJARES: she is fully capable of determining whether or not a patient is properly intubated,
witness Herminda Cruz, admittedly, did not peep into the throat of the patient. (TSN,
July 25, 1991, p. 13). More importantly, there is no evidence that she ever auscultated DRA. GUTIERREZ:
the patient or that she conducted any type of examination to check if the endotracheal
tube was in its proper place, and to determine the condition of the heart, lungs, and A: Yes sir.
other organs. Thus, witness Cruz's categorical statements that appellant Dra. Gutierrez Q: Did you pull away the tube immediately?
failed to intubate the appellee Erlinda Ramos and that it was Dra. Calderon who
succeeded in doing so clearly suffer from lack of sufficient factual bases. 47 A: You do not pull the . . .

In other words, what the Court of Appeals is trying to impress is that being a nurse, Q: Did you or did you not?
and considered a layman in the process of intubation, witness Cruz is not competent
A: I did not pull the tube.
to testify on whether or not the intubation was a success.
Q: When you said "mahirap yata ito," what were you referring to?
We do not agree with the above reasoning of the appellate court. Although witness
Cruz is not an anesthesiologist, she can very well testify upon matters on which she is A: "Mahirap yata itong i-intubate," that was the patient.
capable of observing such as, the statements and acts of the physician and surgeon,
external appearances, and manifest conditions which are observable by any one. 48 Q: So, you found some difficulty in inserting the tube?
This is precisely allowed under the doctrine of res ipsa loquitur where the testimony
A: Yes, because of (sic) my first attempt, I did not see right away. 51
of expert witnesses is not required. It is the accepted rule that expert testimony is not
necessary for the proof of negligence in non-technical matters or those of which an Curiously in the case at bar, respondent Dra. Gutierrez made the haphazard defense
ordinary person may be expected to have knowledge, or where the lack of skill or want that she encountered hardship in the insertion of the tube in the trachea of Erlinda
of care is so obvious as to render expert testimony unnecessary. 49 We take judicial because it was positioned more anteriorly (slightly deviated from the normal anatomy
notice of the fact that anesthesia procedures have become so common, that even an of a person) 52 making it harder to locate and, since Erlinda is obese and has a short
ordinary person can tell if it was administered properly. As such, it would not be too neck and protruding teeth, it made intubation even more difficult.
difficult to tell if the tube was properly inserted. This kind of observation, we believe,
does not require a medical degree to be acceptable. The argument does not convince us. If this was indeed observed, private respondents
adduced no evidence demonstrating that they proceeded to make a thorough
At any rate, without doubt, petitioner's witness, an experienced clinical nurse whose assessment of Erlinda's airway, prior to the induction of anesthesia, even if this would
long experience and scholarship led to her appointment as Dean of the Capitol Medical mean postponing the procedure. From their testimonies, it appears that the observation
Center School at Nursing, was fully capable of determining whether or not the was made only as an afterthought, as a means of defense.
intubation was a success. She had extensive clinical experience starting as a staff nurse
in Chicago, Illinois; staff nurse and clinical instructor in a teaching hospital, the FEU- The pre-operative evaluation of a patient prior to the administration of anesthesia is
NRMF; Dean of the Laguna College of Nursing in San Pablo City; and then Dean of universally observed to lessen the possibility of anesthetic accidents. Pre-operative
the Capitol Medical Center School of Nursing. 50 Reviewing witness Cruz' statements, evaluation and preparation for anesthesia begins when the anesthesiologist reviews the
we find that the same were delivered in a straightforward manner, with the kind of patient's medical records and visits with the patient, traditionally, the day before
detail, clarity, consistency and spontaneity which would have been difficult to elective surgery. 53 It includes taking the patient's medical history, review of current
fabricate. With her clinical background as a nurse, the Court is satisfied that she was drug therapy, physical examination and interpretation of laboratory data. 54 The
able to demonstrate through her testimony what truly transpired on that fateful day. physical examination performed by the anesthesiologist is directed primarily toward
the central nervous system, cardiovascular system, lungs and upper airway. 55 A
Most of all, her testimony was affirmed by no less than respondent Dra. Gutierrez who thorough analysis of the patient's airway normally involves investigating the
admitted that she experienced difficulty in inserting the tube into Erlinda's trachea, to following: cervical spine mobility, temporomandibular mobility, prominent central
wit: incisors, diseased or artificial teeth, ability to visualize uvula and the thyromental
distance. 56 Thus, physical characteristics of the patient's upper airway that could
ATTY. LIGSAY:
make tracheal intubation difficult should be studied. 57 Where the need arises, as when
Q: In this particular case, Doctora, while you were intubating at your first attempt (sic), initial assessment indicates possible problems (such as the alleged short neck and
you did not immediately see the trachea?
protruding teeth of Erlinda) a thorough examination of the patient's airway would go Erlinda's case was elective and this was known to respondent Dra. Gutierrez. Thus,
a long way towards decreasing patient morbidity and mortality. she had all the time to make a thorough evaluation of Erlinda's case prior to the
operation and prepare her for anesthesia. However, she never saw the patient at the
In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda for the first bedside. She herself admitted that she had seen petitioner only in the operating room,
time on the day of the operation itself, on 17 June 1985. Before this date, no prior and only on the actual date of the cholecystectomy. She negligently failed to take
consultations with, or pre-operative evaluation of Erlinda was done by her. Until the advantage of this important opportunity. As such, her attempt to exculpate herself must
day of the operation, respondent Dra. Gutierrez was unaware of the physiological fail.
make-up and needs of Erlinda. She was likewise not properly informed of the possible
difficulties she would face during the administration of anesthesia to Erlinda. Having established that respondent Dra. Gutierrez failed to perform pre-operative
Respondent Dra. Gutierrez' act of seeing her patient for the first time only an hour evaluation of the patient which, in turn, resulted to a wrongful intubation, we now
before the scheduled operative procedure was, therefore, an act of exceptional determine if the faulty intubation is truly the proximate cause of Erlinda's comatose
negligence and professional irresponsibility. The measures cautioning prudence and condition.
vigilance in dealing with human lives lie at the core of the physician's centuries-old
Hippocratic Oath. Her failure to follow this medical procedure is, therefore, a clear Private respondents repeatedly hammered the view that the cerebral anoxia which led
indicia of her negligence. to Erlinda's coma was due to bronchospasm 59 mediated by her allergic response to
the drug, Thiopental Sodium, introduced into her system. Towards this end, they
Respondent Dra. Gutierrez, however, attempts to gloss over this omission by playing presented Dr. Jamora, a Fellow of the Philippine College of Physicians and Diplomate
around with the trial court's ignorance of clinical procedure, hoping that she could get of the Philippine Specialty Board of Internal Medicine, who advanced private
away with it. Respondent Dra. Gutierrez tried to muddle the difference between an respondents' theory that the oxygen deprivation which led to anoxic encephalopathy,
elective surgery and an emergency surgery just so her failure to perform the required 60 was due to an unpredictable drug reaction to the short-acting barbiturate. We find
pre-operative evaluation would escape unnoticed. In her testimony she asserted: the theory of private respondents unacceptable.

ATTY. LIGSAY: First of all, Dr. Jamora cannot be considered an authority in the field of anesthesiology
simply because he is not an anesthesiologist. Since Dr. Jamora is a pulmonologist, he
Q: Would you agree, Doctor, that it is good medical practice to see the patient a day could not have been capable of properly enlightening the court about anesthesia
before so you can introduce yourself to establish good doctor-patient relationship and practice and procedure and their complications. Dr. Jamora is likewise not an
gain the trust and confidence of the patient? allergologist and could not therefore properly advance expert opinion on allergic-
DRA. GUTIERREZ: mediated processes. Moreover, he is not a pharmacologist and, as such, could not have
been capable, as an expert would, of explaining to the court the pharmacologic and
A: As I said in my previous statement, it depends on the operative procedure of the toxic effects of the supposed culprit, Thiopental Sodium (Pentothal).
anesthesiologist and in my case, with elective cases and normal cardio-pulmonary
clearance like that, I usually don't do it except on emergency and on cases that have an The inappropriateness and absurdity of accepting Dr. Jamora's testimony as an expert
abnormalities (sic). 58 witness in the anesthetic practice of Pentothal administration is further supported by
his own admission that he formulated his opinions on the drug not from the practical
However, the exact opposite is true. In an emergency procedure, there is hardly enough experience gained by a specialist or expert in the administration and use of Sodium
time available for the fastidious demands of pre-operative procedure so that an Pentothal on patients, but only from reading certain references, to wit:
anesthesiologist is able to see the patient only a few minutes before surgery, if at all.
Elective procedures, on the other hand, are operative procedures that can wait for days, ATTY. LIGSAY:
weeks or even months. Hence, in these cases, the anesthesiologist possesses the luxury Q: In your line of expertise on pulmonology, did you have any occasion to use
of time to be at the patient's beside to do a proper interview and clinical evaluation. pentothal as a method of management?
There is ample time to explain the method of anesthesia, the drugs to be used, and their
possible hazards for purposes of informed consent. Usually, the pre-operative DR. JAMORA:
assessment is conducted at least one day before the intended surgery, when the patient
is relaxed and cooperative. A: We do it in conjunction with the anesthesiologist when they have to intubate our
patient.
Q: But not in particular when you practice pulmonology? No evidence of stridor, skin reactions, or wheezing some of the more common
accompanying signs of an allergic reaction appears on record. No laboratory data
A: No. were ever presented to the court.
Q: In other words, your knowledge about pentothal is based only on what you have In any case, private respondents themselves admit that Thiopental induced, allergic-
read from books and not by your own personal application of the medicine pentothal? mediated bronchospasm happens only very rarely. If courts were to accept private
A: Based on my personal experience also on pentothal. respondents' hypothesis without supporting medical proof, and against the weight of
available evidence, then every anesthetic accident would be an act of God. Evidently,
Q: How many times have you used pentothal? the Thiopental-allergy theory vigorously asserted by private respondents was a mere
afterthought. Such an explanation was advanced in order to advanced in order to
A: They used it on me. I went into bronchospasm during my appendectomy.
absolve them of any and all responsibility for the patient's condition.
Q: And because they have used it on you and on account of your own personal
In view of the evidence at hand, we are inclined to believe petitioners' stand that it was
experience you feel that you can testify on pentothal here with medical authority?
the faulty intubation which was the proximate cause of Erlinda's comatose condition.
A: No. That is why I used references to support my claims. 61
Proximate cause has been defined as that which, in natural and continuous sequence,
An anesthetic accident caused by a rare drug-induced bronchospasm properly falls unbroken by any efficient intervening cause, produces injury, and without which the
within the fields of anesthesia, internal medicine-allergy, and clinical pharmacology. result would not have occurred. 64 An injury or damage is proximately caused by an
The resulting anoxic encephalopathy belongs to the field of neurology. While act or a failure to act, whenever it appears from the evidence in the case, that the act
admittedly, many bronchospastic-mediated pulmonary diseases are within the or omission played a substantial part in bringing about or actually causing the injury
expertise of pulmonary medicine, Dr. Jamora's field, the anesthetic drug-induced, or damage; and that the injury or damage was either a direct result or a reasonably
allergic mediated bronchospasm alleged in this case is within the disciplines of probable consequence of the act or omission. 65 It is the dominant, moving or
anesthesiology, allergology and pharmacology. On the basis of the foregoing producing cause.
transcript, in which the pulmonologist himself admitted that he could not testify about
Applying the above definition in relation to the evidence at hand, faulty intubation is
the drug with medical authority, it is clear that the appellate court erred in giving
undeniably the proximate cause which triggered the chain of events leading to
weight to Dr. Jamora's testimony as an expert in the administration of Thiopental
Erlinda's brain damage and, ultimately, her comatosed condition.
Sodium.
Private respondents themselves admitted in their testimony that the first intubation was
The provision in the rules of evidence 62 regarding expert witnesses states:
a failure. This fact was likewise observed by witness Cruz when she heard respondent
Sec. 49. Opinion of expert witness. The opinion of a witness on a matter requiring Dra. Gutierrez remarked, "Ang hirap ma-intubate nito, mali yata ang pagkakapasok.
special knowledge, skill, experience or training which he is shown to possess, may be O lumalaki ang tiyan." Thereafter, witness Cruz noticed abdominal distention on the
received in evidence. body of Erlinda. The development of abdominal distention, together with respiratory
embarrassment indicates that the endotracheal tube entered the esophagus instead of
Generally, to qualify as an expert witness, one must have acquired special knowledge the respiratory tree. In other words, instead of the intended endotracheal intubation
of the subject matter about which he or she is to testify, either by the study of what actually took place was an esophageal intubation. During intubation, such
recognized authorities on the subject or by practical experience. 63 Clearly, Dr. Jamora distention indicates that air has entered the gastrointestinal tract through the esophagus
does not qualify as an expert witness based on the above standard since he lacks the instead of the lungs through the trachea. Entry into the esophagus would certainly
necessary knowledge, skill, and training in the field of anesthesiology. Oddly, apart cause some delay in oxygen delivery into the lungs as the tube which carries oxygen
from submitting testimony from a specialist in the wrong field, private respondents' is in the wrong place. That abdominal distention had been observed during the first
intentionally avoided providing testimony by competent and independent experts in intubation suggests that the length of time utilized in inserting the endotracheal tube
the proper areas. (up to the time the tube was withdrawn for the second attempt) was fairly significant.
Due to the delay in the delivery of oxygen in her lungs Erlinda showed signs of
Moreover, private respondents' theory, that Thiopental Sodium may have produced
cyanosis. 66 As stated in the testimony of Dr. Hosaka, the lack of oxygen became
Erlinda's coma by triggering an allergic mediated response, has no support in evidence.
apparent only after he noticed that the nailbeds of Erlinda were already blue. 67
However, private respondents contend that a second intubation was executed on We now discuss the responsibility of the hospital in this particular incident. The unique
Erlinda and this one was successfully done. We do not think so. No evidence exists on practice (among private hospitals) of filling up specialist staff with attending and
record, beyond private respondents' bare claims, which supports the contention that visiting "consultants," 74 who are allegedly not hospital employees, presents problems
the second intubation was successful. Assuming that the endotracheal tube finally in apportioning responsibility for negligence in medical malpractice cases. However,
found its way into the proper orifice of the trachea, the same gave no guarantee of the difficulty is only more apparent than real.
oxygen delivery, the hallmark of a successful intubation. In fact, cyanosis was again
observed immediately after the second intubation. Proceeding from this event In the first place, hospitals exercise significant control in the hiring and firing of
(cyanosis), it could not be claimed, as private respondents insist, that the second consultants and in the conduct of their work within the hospital premises. Doctors who
intubation was accomplished. Even granting that the tube was successfully inserted apply for "consultant" slots, visiting or attending, are required to submit proof of
during the second attempt, it was obviously too late. As aptly explained by the trial completion of residency, their educational qualifications; generally, evidence of
court, Erlinda already suffered brain damage as a result of the inadequate oxygenation accreditation by the appropriate board (diplomate), evidence of fellowship in most
of her brain for about four to five minutes. 68 cases, and references. These requirements are carefully scrutinized by members of the
hospital administration or by a review committee set up by the hospital who either
The above conclusion is not without basis. Scientific studies point out that intubation accept or reject the application. 75 This is particularly true with respondent hospital.
problems are responsible for one-third (1/3) of deaths and serious injuries associated
with anesthesia. 69 Nevertheless, ninety-eight percent (98%) or the vast majority of After a physician is accepted, either as a visiting or attending consultant, he is normally
difficult intubations may be anticipated by performing a thorough evaluation of the required to attend clinico-pathological conferences, conduct bedside rounds for clerks,
patient's airway prior to the operation. 70 As stated beforehand, respondent Dra. interns and residents, moderate grand rounds and patient audits and perform other tasks
Gutierrez failed to observe the proper pre-operative protocol which could have and responsibilities, for the privilege of being able to maintain a clinic in the hospital,
prevented this unfortunate incident. Had appropriate diligence and reasonable care and/or for the privilege of admitting patients into the hospital. In addition to these, the
been used in the pre-operative evaluation, respondent physician could have been much physician's performance as a specialist is generally evaluated by a peer review
more prepared to meet the contingency brought about by the perceived anatomic committee on the basis of mortality and morbidity statistics, and feedback from
variations in the patient's neck and oral area, defects which would have been easily patients, nurses, interns and residents. A consultant remiss in his duties, or a consultant
overcome by a prior knowledge of those variations together with a change in who regularly falls short of the minimum standards acceptable to the hospital or its
technique. 71 In other words, an experienced anesthesiologist, adequately alerted by a peer review committee, is normally politely terminated.
thorough pre-operative evaluation, would have had little difficulty going around the In other words, private hospitals, hire, fire and exercise real control over their attending
short neck and protruding teeth. 72 Having failed to observe common medical and visiting "consultant" staff. While "consultants" are not, technically employees, a
standards in pre-operative management and intubation, respondent Dra. Gutierrez' point which respondent hospital asserts in denying all responsibility for the patient's
negligence resulted in cerebral anoxia and eventual coma of Erlinda. condition, the control exercised, the hiring, and the right to terminate consultants all
We now determine the responsibility of respondent Dr. Orlino Hosaka as the head of fulfill the important hallmarks of an employer-employee relationship, with the
the surgical team. As the so-called "captain of the ship," 73 it is the surgeon's exception of the payment of wages. In assessing whether such a relationship in fact
responsibility to see to it that those under him perform their task in the proper manner. exists, the control test is determining. Accordingly, on the basis of the foregoing, we
Respondent Dr. Hosaka's negligence can be found in his failure to exercise the proper rule that for the purpose of allocating responsibility in medical negligence cases, an
authority (as the "captain" of the operative team) in not determining if his employer-employee relationship in effect exists between hospitals and their attending
anesthesiologist observed proper anesthesia protocols. In fact, no evidence on record and visiting physicians. This being the case, the question now arises as to whether or
exists to show that respondent Dr. Hosaka verified if respondent Dra. Gutierrez not respondent hospital is solidarily liable with respondent doctors for petitioner's
properly intubated the patient. Furthermore, it does not escape us that respondent Dr. condition. 76
Hosaka had scheduled another procedure in a different hospital at the same time as The basis for holding an employer solidarily responsible for the negligence of its
Erlinda's cholecystectomy, and was in fact over three hours late for the latter's employee is found in Article 2180 of the Civil Code which considers a person
operation. Because of this, he had little or no time to confer with his anesthesiologist accountable not only for his own acts but also for those of others based on the former's
regarding the anesthesia delivery. This indicates that he was remiss in his professional responsibility under a relationship of patria potestas. 77 Such responsibility ceases
duties towards his patient. Thus, he shares equal responsibility for the events which when the persons or entity concerned prove that they have observed the diligence of a
resulted in Erlinda's condition. good father of the family to prevent damage. 78 In other words, while the burden of
proving negligence rests on the plaintiffs, once negligence is shown, the burden shifts bankruptcy. However, the provisions of the Civil Code on actual or compensatory
to the respondents (parent, guardian, teacher or employer) who should prove that they damages present us with some difficulties.
observed the diligence of a good father of a family to prevent damage.
Well-settled is the rule that actual damages which may be claimed by the plaintiff are
In the instant case, respondent hospital, apart from a general denial of its responsibility those suffered by him as he has duly proved. The Civil Code provides:
over respondent physicians, failed to adduce evidence showing that it exercised the
diligence of a good father of a family in the hiring and supervision of the latter. It failed Art. 2199. Except as provided by law or by stipulation, one is entitled to an adequate
to adduce evidence with regard to the degree of supervision which it exercised over its compensation only for such pecuniary loss suffered by him as he has duly proved.
physicians. In neglecting to offer such proof, or proof of a similar nature, respondent Such compensation is referred to as actual or compensatory damages.
hospital thereby failed to discharge its burden under the last paragraph of Article 2180. Our rules on actual or compensatory damages generally assume that at the time of
Having failed to do this, respondent hospital is consequently solidarily responsible litigation, the injury suffered as a consequence of an act of negligence has been
with its physicians for Erlinda's condition. completed and that the cost can be liquidated. However, these provisions neglect to
Based on the foregoing, we hold that the Court of Appeals erred in accepting and take into account those situations, as in this case, where the resulting injury might be
relying on the testimonies of the witnesses for the private respondents. Indeed, as continuing and possible future complications directly arising from the injury, while
shown by the above discussions, private respondents were unable to rebut the certain to occur, are difficult to predict.
presumption of negligence. Upon these disquisitions we hold that private respondents In these cases, the amount of damages which should be awarded, if they are to
are solidarily liable for damages under Article 2176 79 of the Civil Code. adequately and correctly respond to the injury caused, should be one which
We now come to the amount of damages due petitioners. The trial court awarded a compensates for pecuniary loss incurred and proved, up to the time of trial; and one
total of P632,000.00 pesos (should be P616,000.00) in compensatory damages to the which would meet pecuniary loss certain to be suffered but which could not, from the
plaintiff, "subject to its being updated" covering the period from 15 November 1985 nature of the case, be made with certainty. 80 In other words, temperate damages can
up to 15 April 1992, based on monthly expenses for the care of the patient estimated and should be awarded on top of actual or compensatory damages in instances where
at P8,000.00. the injury is chronic and continuing. And because of the unique nature of such cases,
no incompatibility arises when both actual and temperate damages are provided for.
At current levels, the P8000/monthly amount established by the trial court at the time The reason is that these damages cover two distinct phases.
of its decision would be grossly inadequate to cover the actual costs of home-based
care for a comatose individual. The calculated amount was not even arrived at by As it would not be equitable and certainly not in the best interests of the
looking at the actual cost of proper hospice care for the patient. What it reflected were administration of justice for the victim in such cases to constantly come before the
the actual expenses incurred and proved by the petitioners after they were forced to courts and invoke their aid in seeking adjustments to the compensatory damages
bring home the patient to avoid mounting hospital bills. previously awarded temperate damages are appropriate. The amount given as
temperate damages, though to a certain extent speculative, should take into account
And yet ideally, a comatose patient should remain in a hospital or be transferred to a the cost of proper care.
hospice specializing in the care of the chronically ill for the purpose of providing a
proper milieu adequate to meet minimum standards of care. In the instant case for In the instant case, petitioners were able to provide only home-based nursing care for
instance, Erlinda has to be constantly turned from side to side to prevent bedsores and a comatose patient who has remained in that condition for over a decade. Having
hypostatic pneumonia. Feeding is done by nasogastric tube. Food preparation should premised our award for compensatory damages on the amount provided by petitioners
be normally made by a dietitian to provide her with the correct daily caloric at the onset of litigation, it would be now much more in step with the interests of justice
requirements and vitamin supplements. Furthermore, she has to be seen on a regular if the value awarded for temperate damages would allow petitioners to provide optimal
basis by a physical therapist to avoid muscle atrophy, and by a pulmonary therapist to care for their loved one in a facility which generally specializes in such care. They
prevent the accumulation of secretions which can lead to respiratory complications. should not be compelled by dire circumstances to provide substandard care at home
without the aid of professionals, for anything less would be grossly inadequate. Under
Given these considerations, the amount of actual damages recoverable in suits arising the circumstances, an award of P1,500,000.00 in temperate damages would therefore
from negligence should at least reflect the correct minimum cost of proper care, not be reasonable. 81
the cost of the care the family is usually compelled to undertake at home to avoid
In Valenzuela vs. Court of Appeals, 82 this Court was confronted with a situation Meanwhile, the actual physical, emotional and financial cost of the care of petitioner
where the injury suffered by the plaintiff would have led to expenses which were would be virtually impossible to quantify. Even the temperate damages herein awarded
difficult to estimate because while they would have been a direct result of the injury would be inadequate if petitioner's condition remains unchanged for the next ten years.
(amputation), and were certain to be incurred by the plaintiff, they were likely to arise
only in the future. We awarded P1,000,000.00 in moral damages in that case. We recognized, in Valenzuela that a discussion of the victim's actual injury would not
even scratch the surface of the resulting moral damage because it would be highly
Describing the nature of the injury, the Court therein stated: speculative to estimate the amount of emotional and moral pain, psychological damage
and injury suffered by the victim or those actually affected by the victim's condition.
As a result of the accident, Ma. Lourdes Valenzuela underwent a traumatic amputation 84 The husband and the children, all petitioners in this case, will have to live with the
of her left lower extremity at the distal left thigh just above the knee. Because of this, day to day uncertainty of the patient's illness, knowing any hope of recovery is close
Valenzuela will forever be deprived of the full ambulatory functions of her left to nil. They have fashioned their daily lives around the nursing care of petitioner,
extremity, even with the use of state of the art prosthetic technology. Well beyond the altering their long term goals to take into account their life with a comatose patient.
period of hospitalization (which was paid for by Li), she will be required to undergo They, not the respondents, are charged with the moral responsibility of the care of the
adjustments in her prosthetic devise due to the shrinkage of the stump from the process victim. The family's moral injury and suffering in this case is clearly a real one. For
of healing. the foregoing reasons, an award of P2,000,000.00 in moral damages would be
These adjustments entail costs, prosthetic replacements and months of physical and appropriate.
occupational rehabilitation and therapy. During the lifetime, the prosthetic devise will Finally, by way of example, exemplary damages in the amount of P100,000.00 are
have to be replaced and readjusted to changes in the size of her lower limb effected by hereby awarded. Considering the length and nature of the instant suit we are of the
the biological changes of middle-age, menopause and aging. Assuming she reaches opinion that attorney's fees valued at P100,000.00 are likewise proper.
menopause, for example, the prosthetic will have to be adjusted to respond to the
changes in bone resulting from a precipitate decrease in calcium levels observed in the Our courts face unique difficulty in adjudicating medical negligence cases because
bones of all post-menopausal women. In other words, the damage done to her would physicians are not insurers of life and, they rarely set out to intentionally cause injury
not only be permanent and lasting, it would also be permanently changing and or death to their patients. However, intent is immaterial in negligence cases because
adjusting to the physiologic changes which her body would normally undergo through where negligence exists and is proven, the same automatically gives the injured a right
the years. The replacements, changes, and adjustments will require corresponding to reparation for the damage caused.
adjustive physical and occupational therapy. All of these adjustments, it has been
documented, are painful. Established medical procedures and practices, though in constant flux are devised for
the purpose of preventing complications. A physician's experience with his patients
xxx xxx xxx would sometimes tempt him to deviate from established community practices, and he
may end a distinguished career using unorthodox methods without incident. However,
A prosthetic devise, however technologically advanced, will only allow a reasonable when failure to follow established procedure results in the evil precisely sought to be
amount of functional restoration of the motor functions of the lower limb. The sensory averted by observance of the procedure and a nexus is made between the deviation and
functions are forever lost. The resultant anxiety, sleeplessness, psychological injury, the injury or damage, the physician would necessarily be called to account for it. In
mental and physical pain are inestimable. 83 the case at bar, the failure to observe pre-operative assessment protocol which would
The injury suffered by Erlinda as a consequence of private respondents' negligence is have influenced the intubation in a salutary way was fatal to private respondents' case.
certainly much more serious than the amputation in the Valenzuela case. WHEREFORE, the decision and resolution of the appellate court appealed from are
Petitioner Erlinda Ramos was in her mid-forties when the incident occurred. She has hereby MODIFIED so as to award in favor of petitioners, and solidarily against
been in a comatose state for over fourteen years now. The burden of care has so far private respondents the following: 1) P1,352,000.00 as actual damages computed as
been heroically shouldered by her husband and children, who, in the intervening years of the date of promulgation of this decision plus a monthly payment of P8,000.00 up
have been deprived of the love of a wife and a mother. to the time that petitioner Erlinda Ramos expires or miraculously survives; 2)
P2,000,000.00 as moral damages, 3) P1,500,000.00 as temperate damages; 4)
P100,000.00 each as exemplary damages and attorney's fees; and, 5) the costs of the
suit. SO ORDERED.
SECOND DIVISION chloromycetin, Dr. Blanes ordered the first five hundred milligrams of said antibiotic
to be administered on Jorge at around 9:00 p.m. A second dose was administered on
[G.R. No. 130547. October 3, 2000] Jorge about three hours later just before midnight.
LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and minors LLOYD and At around 1:00 a.m. of January 9, 1987, Dr. Blanes was called as Jorges temperature
KRISTINE, all surnamed REYES, represented by their mother, LEAH rose to 41C. The patient also experienced chills and exhibited respiratory distress,
ALESNA REYES, petitioners, vs. SISTERS OF MERCY HOSPITAL, SISTER nausea, vomiting, and convulsions. Dr. Blanes put him under oxygen, used a suction
ROSE PALACIO, DR. MARVIE BLANES, and DR. MARLYN RICO, machine, and administered hydrocortisone, temporarily easing the patients
respondents. convulsions. When he regained consciousness, the patient was asked by Dr. Blanes
DECISION whether he had a previous heart ailment or had suffered from chest pains in the past.
Jorge replied he did not.[5] After about 15 minutes, however, Jorge again started to
MENDOZA, J.: vomit, showed restlessness, and his convulsions returned. Dr. Blanes re-applied the
emergency measures taken before and, in addition, valium was administered. Jorge,
This is a petition for review of the decision[1] of the Court of Appeals in CA-G.R. CV
however, did not respond to the treatment and slipped into cyanosis, a bluish or
No. 36551 affirming the decision of the Regional Trial Court, Branch IX, Cebu City
purplish discoloration of the skin or mucous membrane due to deficient oxygenation
which dismissed a complaint for damages filed by petitioners against respondents.
of the blood. At around 2:00 a.m., Jorge died. He was forty years old. The cause of his
The facts are as follows: death was Ventricular Arrythemia Secondary to Hyperpyrexia and typhoid fever.

Petitioner Leah Alesna Reyes is the wife of the late Jorge Reyes. The other petitioners, On June 3, 1987, petitioners filed before the Regional Trial Court of Cebu City a
namely, Rose Nahdja, Johnny, Lloyd, and Kristine, all surnamed Reyes, were their complaint[6]for damages against respondents Sisters of Mercy, Sister Rose Palacio,
children. Five days before his death on January 8, 1987, Jorge had been suffering from Dr. Marvie Blanes, Dr. Marlyn Rico, and nurse Josephine Pagente. On September 24,
a recurring fever with chills. After he failed to get relief from some home medication 1987, petitioners amended their complaint to implead respondent Mercy Community
he was taking, which consisted of analgesic, antipyretic, and antibiotics, he decided to Clinic as additional defendant and to drop the name of Josephine Pagente as defendant
see the doctor. since she was no longer connected with respondent hospital. Their principal contention
was that Jorge did not die of typhoid fever.[7] Instead, his death was due to the
On January 8, 1987, he was taken to the Mercy Community Clinic by his wife. He was wrongful administration of chloromycetin. They contended that had respondent
attended to by respondent Dr. Marlyn Rico, resident physician and admitting physician doctors exercised due care and diligence, they would not have recommended and
on duty, who gave Jorge a physical examination and took his medical history. She rushed the performance of the Widal Test, hastily concluded that Jorge was suffering
noted that at the time of his admission, Jorge was conscious, ambulatory, oriented, from typhoid fever, and administered chloromycetin without first conducting
coherent, and with respiratory distress.[2] Typhoid fever was then prevalent in the sufficient tests on the patients compatibility with said drug. They charged respondent
locality, as the clinic had been getting from 15 to 20 cases of typhoid per month.[3] clinic and its directress, Sister Rose Palacio, with negligence in failing to provide
Suspecting that Jorge could be suffering from this disease, Dr. Rico ordered a Widal adequate facilities and in hiring negligent doctors and nurses.[8]
Test, a standard test for typhoid fever, to be performed on Jorge. Blood count, routine
urinalysis, stool examination, and malarial smear were also made.[4] After about an Respondents denied the charges. During the pre-trial conference, the parties agreed to
hour, the medical technician submitted the results of the test from which Dr. Rico limit the issues on the following: (1) whether the death of Jorge Reyes was due to or
concluded that Jorge was positive for typhoid fever. As her shift was only up to 5:00 caused by the negligence, carelessness, imprudence, and lack of skill or foresight on
p.m., Dr. Rico indorsed Jorge to respondent Dr. Marvie Blanes. the part of defendants; (2) whether respondent Mercy Community Clinic was negligent
in the hiring of its employees; and (3) whether either party was entitled to damages.
Dr. Marvie Blanes attended to Jorge at around six in the evening. She also took Jorges The case was then heard by the trial court during which, in addition to the testimonies
history and gave him a physical examination. Like Dr. Rico, her impression was that of the parties, the testimonies of doctors as expert witnesses were presented.
Jorge had typhoid fever. Antibiotics being the accepted treatment for typhoid fever,
she ordered that a compatibility test with the antibiotic chloromycetin be done on Petitioners offered the testimony of Dr. Apolinar Vacalares, Chief Pathologist at the
Jorge. Said test was administered by nurse Josephine Pagente who also gave the patient Northern Mindanao Training Hospital, Cagayan de Oro City. On January 9, 1987, Dr.
a dose of triglobe. As she did not observe any adverse reaction by the patient to Vacalares performed an autopsy on Jorge Reyes to determine the cause of his death.
However, he did not open the skull to examine the brain. His findings[9] showed that
the gastro-intestinal tract was normal and without any ulceration or enlargement of the II. THE HONORABLE COURT OF APPEALS COMMITTED REVERSIBLE
nodules. Dr. Vacalares testified that Jorge did not die of typhoid fever. He also stated ERROR WHEN IT MADE AN UNFOUNDED ASSUMPTION THAT THE
that he had not seen a patient die of typhoid fever within five days from the onset of LEVEL OF MEDICAL PRACTICE IS LOWER IN ILIGAN CITY.
the disease.
III. THE HONORABLE COURT OF APPEALS GRAVELY ERRED WHEN IT
For their part, respondents offered the testimonies of Dr. Peter Gotiong and Dr. Ibarra RULED FOR A LESSER STANDARD OF CARE AND DEGREE OF DILIGENCE
Panopio. Dr. Gotiong is a diplomate in internal medicine whose expertise is FOR MEDICAL PRACTICE IN ILIGAN CITY WHEN IT APPRECIATE[D] NO
microbiology and infectious diseases. He is also a consultant at the Cebu City Medical DOCTORS NEGLIGENCE IN THE TREATMENT OF JORGE REYES.
Center and an associate professor of medicine at the South Western University College
of Medicine in Cebu City. He had treated over a thousand cases of typhoid patients. Petitioners action is for medical malpractice. This is a particular form of negligence
According to Dr. Gotiong, the patients history and positive Widal Test results ratio of which consists in the failure of a physician or surgeon to apply to his practice of
1:320 would make him suspect that the patient had typhoid fever. As to Dr. Vacalares medicine that degree of care and skill which is ordinarily employed by the profession
observation regarding the absence of ulceration in Jorges gastro-intestinal tract, Dr. generally, under similar conditions, and in like surrounding circumstances.[12] In
Gotiong said that such hyperplasia in the intestines of a typhoid victim may be order to successfully pursue such a claim, a patient must prove that the physician or
microscopic. He noted that since the toxic effect of typhoid fever may lead to surgeon either failed to do something which a reasonably prudent physician or surgeon
meningitis, Dr. Vacalares autopsy should have included an examination of the would have done, or that he or she did something that a reasonably prudent physician
brain.[10] or surgeon would not have done, and that the failure or action caused injury to the
patient.[13] There are thus four elements involved in medical negligence cases,
The other doctor presented was Dr. Ibarra Panopio, a member of the American Board namely: duty, breach, injury, and proximate causation.
of Pathology, examiner of the Philippine Board of Pathology from 1978 to 1991,
fellow of the Philippine Society of Pathologist, associate professor of the Cebu In the present case, there is no doubt that a physician-patient relationship existed
Institute of Medicine, and chief pathologist of the Andres Soriano Jr. Memorial between respondent doctors and Jorge Reyes. Respondents were thus duty-bound to
Hospital in Toledo City. Dr. Panopio stated that although he was partial to the use of use at least the same level of care that any reasonably competent doctor would use to
the culture test for its greater reliability in the diagnosis of typhoid fever, the Widal treat a condition under the same circumstances. It is breach of this duty which
Test may also be used. Like Dr. Gotiong, he agreed that the 1:320 ratio in Jorges case constitutes actionable malpractice.[14] As to this aspect of medical malpractice, the
was already the maximum by which a conclusion of typhoid fever may be made. No determination of the reasonable level of care and the breach thereof, expert testimony
additional information may be deduced from a higher dilution.[11] He said that Dr. is essential. Inasmuch as the causes of the injuries involved in malpractice actions are
Vacalares autopsy on Jorge was incomplete and thus inconclusive. determinable only in the light of scientific knowledge, it has been recognized that
expert testimony is usually necessary to support the conclusion as to causation.[15]
On September 12, 1991, the trial court rendered its decision absolving respondents
from the charges of negligence and dismissing petitioners action for damages. The trial Res Ipsa Loquitur
court likewise dismissed respondents counterclaim, holding that, in seeking damages There is a case when expert testimony may be dispensed with, and that is under the
from respondents, petitioners were impelled by the honest belief that Jorges death was doctrine of res ipsa loquitur. As held in Ramos v. Court of Appeals:[16]
due to the latters negligence.
Although generally, expert medical testimony is relied upon in malpractice suits to
Petitioners brought the matter to the Court of Appeals. On July 31, 1997, the Court of prove that a physician has done a negligent act or that he has deviated from the standard
Appeals affirmed the decision of the trial court. medical procedure, when the doctrine of res ipsa loquitor is availed by the plaintiff,
Hence this petition. the need for expert medical testimony is dispensed with because the injury itself
provides the proof of negligence. The reason is that the general rule on the necessity
Petitioners raise the following assignment of errors: of expert testimony applies only to such matters clearly within the domain of medical
science, and not to matters that are within the common knowledge of mankind which
I. THE HONORABLE COURT OF APPEALS COMMITTED A REVERSIBLE may be testified to by anyone familiar with the facts. Ordinarily, only physicians and
ERROR WHEN IT RULED THAT THE DOCTRINE OF RES IPSA LOQUITUR surgeons of skill and experience are competent to testify as to whether a patient has
IS NOT APPLICABLE IN THE INSTANT CASE. been treated or operated upon with a reasonable degree of skill and care. However,
testimony as to the statements and acts of physicians and surgeons, external anesthesiologist. Taking judicial notice that anesthesia procedures had become so
appearances, and manifest conditions which are observable by any one may be given common that even an ordinary person could tell if it was administered properly, we
by non-expert witnesses. Hence, in cases where the res ipsa loquitur is applicable, the allowed the testimony of a witness who was not an expert. In this case, while it is true
court is permitted to find a physician negligent upon proper proof of injury to the that the patient died just a few hours after professional medical assistance was
patient, without the aid of expert testimony, where the court from its fund of common rendered, there is really nothing unusual or extraordinary about his death. Prior to his
knowledge can determine the proper standard of care. Where common knowledge and admission, the patient already had recurring fevers and chills for five days unrelieved
experience teach that a resulting injury would not have occurred to the patient if due by the analgesic, antipyretic, and antibiotics given him by his wife. This shows that he
care had been exercised, an inference of negligence may be drawn giving rise to an had been suffering from a serious illness and professional medical help came too late
application of the doctrine of res ipsa loquitur without medical evidence, which is for him.
ordinarily required to show not only what occurred but how and why it occurred. When
the doctrine is appropriate, all that the patient must do is prove a nexus between the Respondents alleged failure to observe due care was not immediately apparent to a
particular act or omission complained of and the injury sustained while under the layman so as to justify application of res ipsa loquitur. The question required expert
custody and management of the defendant without need to produce expert medical opinion on the alleged breach by respondents of the standard of care required by the
testimony to establish the standard of care. Resort to res ipsa loquitor is allowed circumstances. Furthermore, on the issue of the correctness of her diagnosis, no
because there is no other way, under usual and ordinary conditions, by which the presumption of negligence can be applied to Dr. Marlyn Rico. As held in Ramos:
patient can obtain redress for injury suffered by him. . . . . Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a
Thus, courts of other jurisdictions have applied the doctrine in the following situations: rule to be cautiously applied, depending upon the circumstances of each case. It is
leaving of a foreign object in the body of the patient after an operation, injuries generally restricted to situations in malpractice cases where a layman is able to say, as
sustained on a healthy part of the body which was not under, or in the area, of a matter of common knowledge and observation, that the consequences of professional
treatment, removal of the wrong part of the body when another part was intended, care were not as such as would ordinarily have followed if due care had been exercised.
knocking out a tooth while a patients jaw was under anesthetic for the removal of his A distinction must be made between the failure to secure results, and the occurrence
tonsils, and loss of an eye while the patient was under the influence of anesthetic, of something more unusual and not ordinarily found if the service or treatment
during or following an operation for appendicitis, among others.[17] rendered followed the usual procedure of those skilled in that particular practice. It
must be conceded that the doctrine of res ipsa loquitur can have no application in a
Petitioners asserted in the Court of Appeals that the doctrine of res ipsa loquitur applies suit against a physician or a surgeon which involves the merits of a diagnosis or of a
to the present case because Jorge Reyes was merely experiencing fever and chills for scientific treatment. The physician or surgeon is not required at his peril to explain
five days and was fully conscious, coherent, and ambulant when he went to the why any particular diagnosis was not correct, or why any particular scientific treatment
hospital. Yet, he died after only ten hours from the time of his admission. did not produce the desired result.[20]

This contention was rejected by the appellate court. Specific Acts of Negligence

Petitioners now contend that all requisites for the application of res ipsa loquitur were We turn to the question whether petitioners have established specific acts of
present, namely: (1) the accident was of a kind which does not ordinarily occur unless negligence allegedly committed by respondent doctors.
someone is negligent; (2) the instrumentality or agency which caused the injury was
under the exclusive control of the person in charge; and (3) the injury suffered must Petitioners contend that: (1) Dr. Marlyn Rico hastily and erroneously relied upon the
not have been due to any voluntary action or contribution of the person injured.[18] Widal test, diagnosed Jorges illness as typhoid fever, and immediately prescribed the
administration of the antibiotic chloromycetin;[21] and (2) Dr. Marvie Blanes erred in
The contention is without merit. We agree with the ruling of the Court of Appeals. In ordering the administration of the second dose of 500 milligrams of chloromycetin
the Ramos case, the question was whether a surgeon, an anesthesiologist, and a barely three hours after the first was given.[22] Petitioners presented the testimony of
hospital should be made liable for the comatose condition of a patient scheduled for Dr. Apolinar Vacalares, Chief Pathologist of the Northern Mindanao Training
cholecystectomy.[19] In that case, the patient was given anesthesia prior to her Hospital, Cagayan de Oro City, who performed an autopsy on the body of Jorge Reyes.
operation. Noting that the patient was neurologically sound at the time of her Dr. Vacalares testified that, based on his findings during the autopsy, Jorge Reyes did
operation, the Court applied the doctrine of res ipsa loquitur as mental brain damage not die of typhoid fever but of shock undetermined, which could be due to allergic
does not normally occur in a gallblader operation in the absence of negligence of the reaction or chloromycetin overdose. We are not persuaded.
First. While petitioners presented Dr. Apolinar Vacalares as an expert witness, we do triggered by her allergic response to a drug,[25] and not due to faulty intubation by the
not find him to be so as he is not a specialist on infectious diseases like typhoid fever. anesthesiologist. As the issue was whether the intubation was properly performed by
Furthermore, although he may have had extensive experience in performing autopsies, an anesthesiologist, we rejected the opinion of the pulmonologist on the ground that
he admitted that he had yet to do one on the body of a typhoid victim at the time he he was not: (1) an anesthesiologist who could enlighten the court about anesthesia
conducted the postmortem on Jorge Reyes. It is also plain from his testimony that he practice, procedure, and their complications; nor (2) an allergologist who could
has treated only about three cases of typhoid fever. Thus, he testified that:[23] properly advance expert opinion on allergic mediated processes; nor (3) a
pharmacologist who could explain the pharmacologic and toxic effects of the drug
ATTY. PASCUAL: allegedly responsible for the bronchospasms.
Q Why? Have you not testified earlier that you have never seen a patient who died of Second. On the other hand, the two doctors presented by respondents clearly were
typhoid fever? experts on the subject. They vouched for the correctness of Dr. Marlyn Ricos
A In autopsy. But, that was when I was a resident physician yet. diagnosis. Dr. Peter Gotiong, a diplomate whose specialization is infectious diseases
and microbiology and an associate professor at the Southwestern University College
Q But you have not performed an autopsy of a patient who died of typhoid fever? of Medicine and the Gullas College of Medicine, testified that he has already treated
over a thousand cases of typhoid fever.[26] According to him, when a case of typhoid
A I have not seen one.
fever is suspected, the Widal test is normally used,[27] and if the 1:320 results of the
Q And you testified that you have never seen a patient who died of typhoid fever within Widal test on Jorge Reyes had been presented to him along with the patients history,
five days? his impression would also be that the patient was suffering from typhoid fever.[28] As
to the treatment of the disease, he stated that chloromycetin was the drug of choice.[29]
A I have not seen one. He also explained that despite the measures taken by respondent doctors and the
intravenous administration of two doses of chloromycetin, complications of the
Q How many typhoid fever cases had you seen while you were in the general practice
disease could not be discounted. His testimony is as follows:[30]
of medicine?
ATTY. PASCUAL:
A In our case we had no widal test that time so we cannot consider that the typhoid
fever is like this and like that. And the widal test does not specify the time of the Q If with that count with the test of positive for 1 is to 320, what treatment if any would
typhoid fever. be given?
Q The question is: how many typhoid fever cases had you seen in your general practice A If those are the findings that would be presented to me, the first thing I would
regardless of the cases now you practice? consider would be typhoid fever.
A I had only seen three cases. Q And presently what are the treatments commonly used?
Q And that was way back in 1964? A Drug of choice of chloramphenical.
A Way back after my training in UP. Q Doctor, if given the same patient and after you have administered chloramphenical
about 3 1/2 hours later, the patient associated with chills, temperature - 41oC, what
Q Clinically?
could possibly come to your mind?
A Way back before my training.
A Well, when it is change in the clinical finding, you have to think of complication.
He is thus not qualified to prove that Dr. Marlyn Rico erred in her diagnosis. Both
Q And what will you consider on the complication of typhoid?
lower courts were therefore correct in discarding his testimony, which is really
inadmissible. A One must first understand that typhoid fever is toximia. The problem is
complications are caused by toxins produced by the bacteria . . . whether you have
In Ramos, the defendants presented the testimony of a pulmonologist to prove that
suffered complications to think of -- heart toxic myocardities; then you can consider a
brain injury was due to oxygen deprivation after the patient had bronchospasms[24]
toxic meningitis and other complications and perforations and bleeding in the ilium.
Q Even that 40-year old married patient who received medication of chloromycetin of Indeed, the standard contemplated is not what is actually the average merit among all
500 milligrams intravenous, after the skin test, and received a second dose of known practitioners from the best to the worst and from the most to the least
chloromycetin of 500 miligrams, 3 hours later, the patient developed chills . . . rise in experienced, but the reasonable average merit among the ordinarily good
temperature to 41oC, and then about 40 minutes later the temperature rose to 100oF, physicians.[37] Here, Dr. Marlyn Rico did not depart from the reasonable standard
cardiac rate of 150 per minute who appeared to be coherent, restless, nauseating, with recommended by the experts as she in fact observed the due care required under the
seizures: what significance could you attach to these clinical changes? circumstances. Though the Widal test is not conclusive, it remains a standard
diagnostic test for typhoid fever and, in the present case, greater accuracy through
A I would then think of toxemia, which was toxic meningitis and probably a toxic repeated testing was rendered unobtainable by the early death of the patient. The
meningitis because of the high cardiac rate. results of the Widal test and the patients history of fever with chills for five days, taken
Q Even if the same patient who, after having given intramuscular valium, became with the fact that typhoid fever was then prevalent as indicated by the fact that the
conscious and coherent about 20 minutes later, have seizure and cyanosis and rolling clinic had been getting about 15 to 20 typhoid cases a month, were sufficient to give
of eyeballs and vomitting . . . and death: what significance would you attach to this upon any doctor of reasonable skill the impression that Jorge Reyes had typhoid fever.
development? Dr. Rico was also justified in recommending the administration of the drug
A We are probably dealing with typhoid to meningitis. chloromycetin, the drug of choice for typhoid fever. The burden of proving that Jorge
Reyes was suffering from any other illness rested with the petitioners. As they failed
Q In such case, Doctor, what finding if any could you expect on the post-mortem to present expert opinion on this, preponderant evidence to support their contention is
examination? clearly absent.
A No, the finding would be more on the meninges or covering of the brain. Third. Petitioners contend that respondent Dr. Marvie Blanes, who took over from Dr.
Rico, was negligent in ordering the intravenous administration of two doses of 500
Q And in order to see those changes would it require opening the skull?
milligrams of chloromycetin at an interval of less than three hours. Petitioners claim
A Yes. that Jorge Reyes died of anaphylactic shock[38] or possibly from overdose as the
second dose should have been administered five to six hours after the first, per
As regards Dr. Vacalares finding during the autopsy that the deceaseds gastro- instruction of Dr. Marlyn Rico. As held by the Court of Appeals, however:
intestinal tract was normal, Dr. Rico explained that, while hyperplasia[31] in the
payers patches or layers of the small intestines is present in typhoid fever, the same That chloromycetin was likewise a proper prescription is best established by medical
may not always be grossly visible and a microscope was needed to see the texture of authority. Wilson, et. al., in Harrisons Principle of Internal Medicine, 12th ed. write
the cells.[32] that chlorampenicol (which is the generic of chloromycetin) is the drug of choice for
typhoid fever and that no drug has yet proven better in promoting a favorable clinical
Respondents also presented the testimony of Dr. Ibarra T. Panopio who is a member response. Chlorampenicol (Chloromycetin) is specifically indicated for bacterial
of the Philippine and American Board of Pathology, an examiner of the Philippine meningitis, typhoid fever, rickettsial infections, bacteriodes infections, etc. (PIMS
Board of Pathology, and chief pathologist at the MetroCebu Community Hospital, Annual, 1994, p. 211) The dosage likewise including the first administration of five
Perpetual Succor Hospital, and the Andres Soriano Jr. Memorial Medical Center. He hundred milligrams (500 mg.) at around nine oclock in the evening and the second
stated that, as a clinical pathologist, he recognized that the Widal test is used for dose at around 11:30 the same night was still within medically acceptable limits, since
typhoid patients, although he did not encourage its use because a single test would the recommended dose of chloromycetin is one (1) gram every six (6) hours. (cf.
only give a presumption necessitating that the test be repeated, becoming more Pediatric Drug Handbook, 1st Ed., Philippine Pediatric Society, Committee on
conclusive at the second and third weeks of the disease.[33] He corroborated Dr. Therapeutics and Toxicology, 1996). The intravenous route is likewise correct.
Gotiongs testimony that the danger with typhoid fever is really the possible (Mansser, ONick, Pharmacology and Therapeutics) Even if the test was not
complications which could develop like perforation, hemorrhage, as well as liver and administered by the physician-on-duty, the evidence introduced that it was Dra. Blanes
cerebral complications.[34] As regards the 1:320 results of the Widal test on Jorge who interpreted the results remain uncontroverted. (Decision, pp. 16-17) Once more,
Reyes, Dr. Panopio stated that no additional information could be obtained from a this Court rejects any claim of professional negligence in this regard.
higher ratio.[35] He also agreed with Dr. Gotiong that hyperplasia in the payers
patches may be microscopic.[36] ....
As regards anaphylactic shock, the usual way of guarding against it prior to the called it, the reasonable skill and competence . . . that a physician in the same or similar
administration of a drug, is the skin test of which, however, it has been observed: Skin locality . . . should apply.
testing with haptenic drugs is generally not reliable. Certain drugs cause nonspecific
histamine release, producing a weal-and-flare reaction in normal individuals. WHEREFORE, the instant petition is DENIED and the decision of the Court of
Immunologic activation of mast cells requires a polyvalent allergen, so a negative skin Appeals is AFFIRMED.
test to a univalent haptenic drug does not rule out anaphylactic sensitivity to that drug. SO ORDERED.
(Terr, Anaphylaxis and Urticaria in Basic and Clinical Immunology, p. 349) What all
this means legally is that even if the deceased suffered from an anaphylactic shock,
this, of itself, would not yet establish the negligence of the appellee-physicians for all
that the law requires of them is that they perform the standard tests and perform
standard procedures. The law cannot require them to predict every possible reaction to
all drugs administered. The onus probandi was on the appellants to establish, before
the trial court, that the appellee-physicians ignored standard medical procedure,
prescribed and administered medication with recklessness and exhibited an absence of
the competence and skills expected of general practitioners similarly situated.[39]

Fourth. Petitioners correctly observe that the medical profession is one which, like the
business of a common carrier, is affected with public interest. Moreover, they assert
that since the law imposes upon common carriers the duty of observing extraordinary
diligence in the vigilance over the goods and for the safety of the passengers,[40]
physicians and surgeons should have the same duty toward their patients.[41] They
also contend that the Court of Appeals erred when it allegedly assumed that the level
of medical practice is lower in Iligan City, thereby reducing the standard of care and
degree of diligence required from physicians and surgeons in Iligan City.

The standard of extraordinary diligence is peculiar to common carriers. The Civil Code
provides:

Art. 1733. Common carriers, from the nature of their business and for reasons of public
policy, are bound to observe extraordinary diligence in the vigilance over the goods
and for the safety of the passengers transported by them, according to the
circumstances of each case. . . .

The practice of medicine is a profession engaged in only by qualified individuals. It is


a right earned through years of education, training, and by first obtaining a license
from the state through professional board examinations. Such license may, at any time
and for cause, be revoked by the government. In addition to state regulation, the
conduct of doctors is also strictly governed by the Hippocratic Oath, an ancient code
of discipline and ethical rules which doctors have imposed upon themselves in
recognition and acceptance of their great responsibility to society. Given these
safeguards, there is no need to expressly require of doctors the observance of
extraordinary diligence. As it is now, the practice of medicine is already conditioned
upon the highest degree of diligence. And, as we have already noted, the standard
contemplated for doctors is simply the reasonable average merit among ordinarily
good physicians. That is reasonable diligence for doctors or, as the Court of Appeals
EN BANC Ruez, Sr. and Ruez, Jr.[1] arrived at the emergency room of the Manila
Doctors Hospital at around 10:00 p.m. after which Ruez, Sr. underwent a C.T.
A.M. No. 2005-08-SC December 9, 2005 Scan. The C.T. Scan revealed a blood clot necessitating him to be admitted for
treatment and observation. The following morning he suffered a stroke and
SAMUEL R. RUEZ, JR. vs. MARYBETH V. JURADO for a moment was on flat line. The doctors were able to revive him and
thereafter he was transferred to the intensive care unit. Unfortunately, Ruez
DECISION Sr. never recovered from his ailment and, on September 12, 2005, he passed
away due to medical complications.[2]
AZCUNA, J.:
On February 15, 2005, Ruez, Jr. filed a letter-complaint with the Office
It is unfortunate that this administrative case involves co-workers in
of the Chief Justice regarding the alleged lack of attention given to his father
this Court. Complainant, Samuel R. Ruez, Jr. (Ruez, Jr.), is Chief of the
by Dr. Jurado. Specifically, he claims that Dr. Jurado merely advised his father
Clearance Section, Checks Disbursement Division of the FMO-OCA and is the
to go to the hospital and then allowed him to travel to Manila Doctors Hospital
son of the aggrieved party, Samuel V. Ruez, Sr. (Ruez, Sr.), Driver I for the
despite the availability of an ambulance at the disposal of the clinic. Ruez, Jr.
Motorpool, Property Division of the OCA. Respondent is Dr. Marybeth V.
submits that his father would not have suffered a stroke if not for the neglect
Jurado (Dr. Jurado), Medical Officer IV of the Medical and Dental Services. All
of Dr. Jurado.
three were working for the Court at the time of the incident in issue.
The letter-complaint was referred to Atty. Eden T. Candelaria, Deputy Clerk
The parties agree that on January 12, 2005, at around 4:20 p.m., Ruez, of Court and Chief of Administrative Services, for investigation. Atty.
Sr. arrived by himself at this Courts clinic complaining of dizziness. His blood Candelaria required Dr. Jurado to submit her comment to the letter-complaint.
pressure and pulse rate were taken by the reception nurse and were registered The comment was submitted on March 18, 2005, together with supporting
at 210/100 mmHg and 112 beats a minute, respectively. What transpired next affidavits from respondents witnesses. This was followed by Ruez, Jr.s reply
is disputed. Ruez, Jr. alleged that despite his fathers medical condition, he was to the comment on April 12, 2005 and Dr. Jurados rejoinder on April 22, 2005. [3]
merely advised to go to a hospital and then allowed to walk out of the clinic
on his own. Dr. Jurado, on the other hand, maintained that after being Atty. Candelaria submitted her report on June 17, 2005. The report gave
informed of Ruez, Sr.s blood pressure and heart rate, she instructed the nurse credence to the account of Dr. Jurado that Ruez, Sr. was given Capoten,
to administer one tablet of Capoten 25mg, an emergency drug that quickly informed that he should be hospitalized and that the ambulance was placed
lowers a patients blood pressure. She then informed Ruez, Sr. that he will be on standby to take him there. These factual findings of Atty. Candelaria appear
taken to the hospital, after which she immediately instructed the ambulance to be supported by the affidavits of the clinics personnel, including the
driver, Mr. Jacinto, to stand by for hospital conduction. Minutes later, after ambulance driver, who witnessed the events that happened between Ruez, Sr.
having taken Capoten and being given a chance to rest, Ruez, Sr. stood up and and Dr. Jurado.
walked out saying, Doktora, hanap lang ho ako ng kasama. Dr. Jurado said she
waited for him to return but he failed to show up. She asked Mr. Almarza, a The issue now for the Court to resolve is whether, given the accepted facts,
nurse at the clinic, to look for Ruez, Sr. but he was unable to locate him. there is cause to hold Dr. Jurado administratively liable. Atty. Candelaria is
satisfied that Dr. Jurado provided Ruez, Sr. proper treatment inside the clinic.
According to Ruez, Jr., after being informed of his fathers condition, However, in her opinion, Dr. Jurados actions after Ruez, Sr. had left were less
he rushed him to the Manila Doctors Hospital. There, Ruez, Sr. was treated in than the required diligence of a good father of a family. We quote below the
the emergency room for approximately four hours before he was discharged analysis of Atty. Candelaria:
at around 8:30 p.m. and allowed to go home. However, prior to reaching their
house in Balintawak, Caloocan City, Ruez, Sr. began experiencing nausea, . . . Records will clearly show that minutes after Mr.
abnormal palpitation and uneasiness and had to be brought back to the Ruez, Sr. left the clinic, Dr. Jurado also left the clinic to go
hospital. home. This is shown by her time out registered in the
Chronolog Machine on the said date which was 4:31 p.m. and
her inclusion in the list of passengers of Shuttle Bus No. 6. As medical profession were also expected to act in the manner illustrated by Atty.
an efficient and intelligent doctor, Dr. Jurado should have at Candelaria, i.e., to exert all efforts to determine the whereabouts of Ruez, Sr.,
least personally exerted all her efforts to determine the inform his relatives or turn his case over to a doctor who was available after
whereabouts of Mr. Ruez, Sr. because of his condition and office hours.
again at the very least informed his relatives in the Court in
order that they too take the necessary action that very Article II, Section 1 of the Code of Medical Ethics of the Medical
moment. Or in the alternative, if indeed, Dr. Jurado may have Profession in the Philippines states:
been in a hurry at that time to do some errands, she should
have at least[,] again, turned Mr. Ruez over the a [d]octor who A physician should attend to his patients faithfully
was willing to be left behind after office hours. These however and conscientiously. He should secure for them all possible
never happened. All that she relied on was the fact that there benefits that may depend upon his professional skill and care.
was an emergency treatment and an order for hospital As the sole tribunal to adjudge the physicians failure to fulfill
conduction but [the same] didnt materialize and [she] put his obligation to his patients is, in most cases, his own
[the] blame on Mr. Ruez, Sr. As admitted by complainant, Mr. conscience, violation of this rule on his part is discreditable
Ruez, Sr., is a mere driver and perhaps may have no and inexcusable.
knowledge at all of the consequences of his 210/100 blood
pressure and since he sought refuge from the [c]linic, the A doctors duty to his patient is not required to be extraordinary.[8] The
clinic, particularly Dr. Jurado[,] should have made him feel standard contemplated for doctors is simply the reasonable average merit
safe and secure in the said place. . . . among ordinarily good physicians, i.e. reasonable skill and competence.[9] We
are persuaded that Dr. Jurado fulfilled such a standard when she treated Ruez,
Atty. Candelaria recommends that Dr. Jurado be held liable for simple neglect Sr. inside the clinic. But what of Dr. Jurados conduct after Ruez, Sr. left the
of duty and suspended for one (1) month and (1) day. She further recommends clinic and failed to return?
that, in light of what happened, Dr. Prudencio Banzon, SC Senior Staff Officer,
Medical and Dental Services, be directed to prepare a flexi-time schedule (until It has been held that a patient cannot attribute to a physician damages
5:30 p.m.) for all doctors and nurses in the clinic to enable it to provide resulting from his own failure to follow his advice, even though he was
immediate and proper attention in case of any emergency medical situation. ignorant of the consequences which would result from his failure. [10] If a
patient leaves the hospital contrary to instructions, the physician is not liable
The Court does not agree that the acts or omission of Dr. Jurado amount to for subsequent events.[11] There is no expectation from doctors that they track
simple neglect of duty. Simple neglect of duty is defined as failure to give down each patient who apparently missed their appointments or force them
proper attention to a task expected of an employee resulting from either to comply with their directives. After all, a person is still the master of his own
carelessness or indifference[4] or signifies a disregard of duty resulting from body.[12]
carelessness or indifference.[5] In Philippine Retirement Authority,[6] it was stated,
The Court has decided the following, inter alia, as constituting the less grave Dr. Jurado may have allowed Ruez, Sr. to walk out of the clinic despite
offense of Simple Neglect of Duty: delay in the transmittal of court records, delay her earlier diagnosis of his condition. By that time Ruez, Sr.s condition had
in responding to written queries, and delay of more than one (1) year and temporarily stabilized and she did not have the authority to stop him just as
seven (7) months in furnishing a party with a copy of the courts decision. In other doctors have no power, save in certain instances (such as when the law
all the instances cited by the Court, respondents had the duty or were expected makes treatment compulsory due to some communicable disease[13] or when
to do certain acts which they failed to do. How do we determine what acts are consent is withheld by a minor but non-treatment would be detrimental or
expected of Dr. Jurado? Atty. Candelarias report cites the applicable yardstick: when the court of competent jurisdiction orders the treatment), to force
a physician or surgeon is expected to apply in his practice of medicine that patients into staying under their care. Dr. Jurado relied on Ruez, Sr.s
degree of care and skill which is ordinarily employed by the profession, representation that he would return in order to be brought to the hospital but
generally, and under similar conditions.[7] Therefore, to find Dr. Jurado liable made no undertaking to wait for him beyond the clinic hours or to look for
for simple neglect of duty the Court has to be convinced that those in the him if he did not return. Thus, when Ruez, Sr. failed to show up as of closing
time, and could not be found by the male nurse who looked for him at her
instructions, Dr. Jurado had reason to think that he had decided to disregard
her medical advice, which he in fact did when he and Ruez, Jr. decided to go
to the hospital on their own. Ruez, Sr., still of sound mind, had the right to
accept or ignore his doctors recommendation. Dr. Jurado was obligated to care
for Ruez, Sr. when the latter asked for medical treatment, which she did, but
when he left on his own accord Dr. Jurado was not expected, much less duty-
bound, to seek out her patient and continue being his doctor.

Some people may interpret Dr. Jurados inaction as indifference, while


others may view the same as just proper. Some would applaud Dr. Jurados
dedication had she done all the things mentioned by Atty. Candelaria and yet
others would see them as still insufficient. There will always be a divergence
of opinions as to how Dr. Jurado should have conducted herself but the Court
must distinguish between acts that deserve to be emulated or disdained and
those that deserve sanctions. The former is largely a matter of opinion while
the latter can only be imposed if there was a failure to perform a clear duty,
expectation or obligation. People may frown upon certain behaviors and
chastise others for having less compassion, but it does not necessarily follow
that those acts translate to neglect of duty, misconduct or negligence.

Dr. Jurado could have exerted greater efforts by searching all over the
compound for Ruez, Sr. but the fact remains that these were not part of her
duties nor were they expected from her. Simple neglect of duty presupposes a
task expected of an employee. Thus, it cannot be present if there was no
expected task on her part. That said, the Court wishes to exhort Dr. Jurado,
and all personnel in its clinic, not to be satisfied with merely fulfilling the
minimum, but to go for the magis, the best service they can render by way of
being exemplars for their fellow workers in the Court.

WHEREFORE, the Court finds no reason to hold Dr. Jurado liable for simple
neglect of duty, and, therefore, DISMISSES the complaint for lack of merit.
As recommended by Atty. Eden T. Candelaria, Deputy Clerk of Court and
Chief of Administrative Services, Dr. Prudencio Banzon, Senior Staff Officer,
Medical and Dental Services, is DIRECTED to prepare a flexi-time schedule
for all doctors and nurses in the clinic to further develop its capability to
provide immediate and proper attention in emergency medical situations, and
to submit the same to Atty. Candelaria in 30 days from receipt of a copy of this
decision which should be served upon him forthwith.

SO ORDERED.
Republic of the Philippines Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an
SUPREME COURT internal examination of Corazon. Dr. Uy then called up Dr. Estrada to notify him of
Manila her findings.
THIRD DIVISION
Based on the Doctor's Order Sheet,11 around 3:00 a.m., Dr. Estrada ordered for 10
G.R. No. 142625 December 19, 2006 mg. of valium to be administered immediately by intramuscular injection. Dr. Estrada
later ordered the start of intravenous administration of syntocinon admixed with
ROGELIO P. NOGALES, for himself and on behalf of the minors, ROGER dextrose, 5%, in lactated Ringers' solution, at the rate of eight to ten micro-drops per
ANTHONY, ANGELICA, NANCY, and MICHAEL CHRISTOPHER, all minute.
surnamed NOGALES, petitioners, vs. CAPITOL MEDICAL CENTER, DR.
OSCAR ESTRADA, DR. ELY VILLAFLOR, DR. ROSA UY, DR. JOEL According to the Nurse's Observation Notes,12 Dr. Joel Enriquez ("Dr. Enriquez"), an
ENRIQUEZ, DR. PERPETUA LACSON, DR. NOE ESPINOLA, and NURSE J. anesthesiologist at CMC, was notified at 4:15 a.m. of Corazon's admission.
DUMLAO, respondents. Subsequently, when asked if he needed the services of an anesthesiologist, Dr. Estrada
refused. Despite Dr. Estrada's refusal, Dr. Enriquez stayed to observe Corazon's
DECISION condition.
CARPIO, J.: At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10
The Case a.m., Corazon's bag of water ruptured spontaneously. At 6:12 a.m., Corazon's cervix
was fully dilated. At 6:13 a.m., Corazon started to experience convulsions.
This petition for review1 assails the 6 February 1998 Decision2 and 21 March 2000
Resolution3 of the Court of Appeals in CA-G.R. CV No. 45641. The Court of Appeals At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfate.
affirmed in toto the 22 November 1993 Decision4 of the Regional Trial Court of However, Dr. Ely Villaflor ("Dr. Villaflor"), who was assisting Dr. Estrada,
Manila, Branch 33, finding Dr. Oscar Estrada solely liable for damages for the death administered only 2.5 grams of magnesium sulfate.
of his patient, Corazon Nogales, while absolving the remaining respondents of any At 6:22 a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract
liability. The Court of Appeals denied petitioners' motion for reconsideration. Corazon's baby. In the process, a 1.0 x 2.5 cm. piece of cervical tissue was allegedly
The Facts 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.
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 years Payumo.
old, was under the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada")
beginning on her fourth month of pregnancy or as early as December 1975. While At 6:27 a.m., Corazon began to manifest moderate vaginal bleeding which rapidly
Corazon was on her last trimester of pregnancy, Dr. Estrada noted an increase in her became profuse. Corazon's blood pressure dropped from 130/80 to 60/40 within five
blood pressure and development of leg edema5 indicating preeclampsia,6 which is a minutes. There was continuous profuse vaginal bleeding. The assisting nurse
dangerous complication of pregnancy.7 administered hemacel through a gauge 19 needle as a side drip to the ongoing
intravenous injection of dextrose.
Around midnight of 25 May 1976, Corazon started to experience mild labor pains
prompting Corazon and Rogelio Nogales ("Spouses Nogales") to see Dr. Estrada at his At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with bottled blood.
home. After examining Corazon, Dr. Estrada advised her immediate admission to the It took approximately 30 minutes for the CMC laboratory, headed by Dr. Perpetua
Capitol Medical Center ("CMC"). Lacson ("Dr. Lacson"), to comply with Dr. Estrada's order and deliver the blood.

On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the staff nurse At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-Gynecology
noted the written admission request8 of Dr. Estrada. Upon Corazon's admission at the Department of the CMC, was apprised of Corazon's condition by telephone. Upon
CMC, Rogelio Nogales ("Rogelio") executed and signed the "Consent on Admission being informed that Corazon was bleeding profusely, Dr. Espinola ordered immediate
and Agreement"9 and "Admission Agreement."10 Corazon was then brought to the hysterectomy. Rogelio was made to sign a "Consent to Operation."13
labor room of the CMC.
Due to the inclement weather then, Dr. Espinola, who was fetched from his residence On the part of nurse Dumlao, there is no showing that when she administered the
by an ambulance, arrived at the CMC about an hour later or at 9:00 a.m. He examined hemacel as a side drip, she did it on her own. If the correct procedure was directly thru
the patient and ordered some resuscitative measures to be administered. Despite Dr. the veins, it could only be because this was what was probably the orders of Dr.
Espinola's efforts, Corazon died at 9:15 a.m. The cause of death was "hemorrhage, Estrada.
post partum."14
While the evidence of the plaintiffs shows that Dr. Noe Espinola, who was the Chief
On 14 May 1980, petitioners filed a complaint for damages15 with the Regional Trial of the Department of Obstetrics and Gynecology who attended to the patient Mrs.
Court16 of Manila against CMC, Dr. Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr. Nogales, it was only at 9:00 a.m. That he was able to reach the hospital because of
Lacson, Dr. Espinola, and a certain Nurse J. Dumlao for the death of Corazon. typhoon Didang (Exhibit 2). While he was able to give prescription in the manner
Petitioners mainly contended that defendant physicians and CMC personnel were Corazon Nogales may be treated, the prescription was based on the information given
negligent in the treatment and management of Corazon's condition. Petitioners charged to him by phone and he acted on the basis of facts as presented to him, believing in
CMC with negligence in the selection and supervision of defendant physicians and good faith that such is the correct remedy. He was not with Dr. Estrada when the
hospital staff. patient was brought to the hospital at 2:30 o'clock a.m. So, whatever errors that Dr.
Estrada committed on the patient before 9:00 o'clock a.m. are certainly the errors of
For failing to file their answer to the complaint despite service of summons, the trial Dr. Estrada and cannot be the mistake of Dr. Noe Espinola. His failure to come to the
court declared Dr. Estrada, Dr. Enriquez, and Nurse Dumlao in default.17 CMC, Dr. hospital on time was due to fortuitous event.
Villaflor, Dr. Uy, Dr. Espinola, and Dr. Lacson filed their respective answers denying
and opposing the allegations in the complaint. Subsequently, trial ensued. On the part of Dr. Joel Enriquez, while he was present in the delivery room, it is not
incumbent upon him to call the attention of Dr. Estrada, Dra. Villaflor and also of
After more than 11 years of trial, the trial court rendered judgment on 22 November Nurse Dumlao on the alleged errors committed by them. Besides, as anesthesiologist,
1993 finding Dr. Estrada solely liable for damages. The trial court ruled as follows: he has no authority to control the actuations of Dr. Estrada and Dra. Villaflor. For the
The victim was under his pre-natal care, apparently, his fault began from his incorrect Court to assume that there were errors being committed in the presence of Dr. Enriquez
and inadequate management and lack of treatment of the pre-eclamptic condition of would be to dwell on conjectures and speculations.
his patient. It is not disputed that he misapplied the forceps in causing the delivery On the civil liability of Dr. Perpetua Lacson, [s]he is a hematologist and in-charge of
because it resulted in a large cervical tear which had caused the profuse bleeding which the blood bank of the CMC. The Court cannot accept the theory of the plaintiffs that
he also failed to control with the application of inadequate injection of magnesium there was delay in delivering the blood needed by the patient. It was testified, that in
sulfate by his assistant Dra. Ely Villaflor. Dr. Estrada even failed to notice the order that this blood will be made available, a laboratory test has to be conducted to
erroneous administration by nurse Dumlao of hemacel by way of side drip, instead of determine the type of blood, cross matching and other matters consistent with medical
direct intravenous injection, and his failure to consult a senior obstetrician at an early science so, the lapse of 30 minutes maybe considered a reasonable time to do all of
stage of the problem. these things, and not a delay as the plaintiffs would want the Court to believe.
On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr. Joel Enriquez, Dr. Admittedly, Dra. Rosa Uy is a resident physician of the Capitol Medical Center. She
Lacson, Dr. Espinola, nurse J. Dumlao and CMC, the Court finds no legal justification was sued because of her alleged failure to notice the incompetence and negligence of
to find them civilly liable. Dr. Estrada. However, there is no evidence to support such theory. No evidence was
On the part of Dra. Ely Villaflor, she was only taking orders from Dr. Estrada, the adduced to show that Dra. Rosa Uy as a resident physician of Capitol Medical Center,
principal physician of Corazon Nogales. She can only make suggestions in the manner had knowledge of the mismanagement of the patient Corazon Nogales, and that
the patient maybe treated but she cannot impose her will as to do so would be to notwithstanding such knowledge, she tolerated the same to happen.
substitute her good judgment to that of Dr. Estrada. If she failed to correctly diagnose In the pre-trial order, plaintiffs and CMC agreed that defendant CMC did not have any
the true cause of the bleeding which in this case appears to be a cervical laceration, it hand or participation in the selection or hiring of Dr. Estrada or his assistant Dra. Ely
cannot be safely concluded by the Court that Dra. Villaflor had the correct diagnosis Villaflor as attending physician[s] of the deceased. In other words, the two (2) doctors
and she failed to inform Dr. Estrada. No evidence was introduced to show that indeed were not employees of the hospital and therefore the hospital did not have control over
Dra. Villaflor had discovered that there was laceration at the cervical area of the their professional conduct. When Mrs. Nogales was brought to the hospital, it was an
patient's internal organ. emergency case and defendant CMC had no choice but to admit her. Such being the
case, there is therefore no legal ground to apply the provisions of Article 2176 and respective comments. Petitioners are foregoing further claims against respondents Dr.
2180 of the New Civil Code referring to the vicarious liability of an employer for the Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao.
negligence of its employees. If ever in this case there is fault or negligence in the
treatment of the deceased on the part of the attending physicians who were employed The Court noted that Dr. Estrada did not appeal the decision of the Court of Appeals
by the family of the deceased, such civil liability should be borne by the attending affirming the decision of the Regional Trial Court. Accordingly, the decision of the
physicians under the principle of "respondeat superior". Court of Appeals, affirming the trial court's judgment, is already final as against Dr.
Oscar Estrada.
WHEREFORE, premises considered, judgment is hereby rendered finding defendant
Dr. Estrada of Number 13 Pitimini St. San Francisco del Monte, Quezon City civilly Petitioners filed a motion for reconsideration25 of the Court's 9 September 2002
liable to pay plaintiffs: 1) By way of actual damages in the amount of P105,000.00; 2) Resolution claiming that Dr. Enriquez, Dr. Villaflor and Nurse Dumlao were notified
By way of moral damages in the amount of P700,000.00; 3) Attorney's fees in the of the petition at their counsels' last known addresses. Petitioners reiterated their
amount of P100,000.00 and to pay the costs of suit. imputation of negligence on these respondents. The Court denied petitioners' Motion
for Reconsideration in its 18 February 2004 Resolution.26
For failure of the plaintiffs to adduce evidence to support its [sic] allegations against
the other defendants, the complaint is hereby ordered dismissed. While the Court looks The Court of Appeals' Ruling
with disfavor the filing of the present complaint against the other defendants by the In its Decision of 6 February 1998, the Court of Appeals upheld the trial court's ruling.
herein plaintiffs, as in a way it has caused them personal inconvenience and slight The Court of Appeals rejected petitioners' view that the doctrine in Darling v.
damage on their name and reputation, the Court cannot accepts [sic] however, the Charleston Community Memorial Hospital27 applies to this case. According to the
theory of the remaining defendants that plaintiffs were motivated in bad faith in the Court of Appeals, the present case differs from the Darling case since Dr. Estrada is
filing of this complaint. For this reason defendants' counterclaims are hereby ordered an independent contractor-physician whereas the Darling case involved a physician
dismissed. and a nurse who were employees of the hospital.
SO ORDERED.18 Citing other American cases, the Court of Appeals further held that the mere fact that
Petitioners appealed the trial court's decision. Petitioners claimed that aside from Dr. a hospital permitted a physician to practice medicine and use its facilities is not
Estrada, the remaining respondents should be held equally liable for negligence. sufficient to render the hospital liable for the physician's negligence.28 A hospital is
Petitioners pointed out the extent of each respondent's alleged liability. not responsible for the negligence of a physician who is an independent contractor.29

On 6 February 1998, the Court of Appeals affirmed the decision of the trial court.19 The Court of Appeals found the cases of Davidson v. Conole30 and Campbell v. Emma
Petitioners filed a motion for reconsideration which the Court of Appeals denied in its Laing Stevens Hospital31 applicable to this case. Quoting Campbell, the Court of
Resolution of 21 March 2000.20 Appeals stated that where there is no proof that defendant physician was an employee
of defendant hospital or that defendant hospital had reason to know that any acts of
Hence, this petition. malpractice would take place, defendant hospital could not be held liable for its failure
to intervene in the relationship of physician-patient between defendant physician and
Meanwhile, petitioners filed a Manifestation dated 12 April 200221 stating that plaintiff.
respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao "need no
longer be notified of the petition because they are absolutely not involved in the issue On the liability of the other respondents, the Court of Appeals applied the "borrowed
raised before the [Court], regarding the liability of [CMC]."22 Petitioners stressed that servant" doctrine considering that Dr. Estrada was an independent contractor who was
the subject matter of this petition is the liability of CMC for the negligence of Dr. merely exercising hospital privileges. This doctrine provides that once the surgeon
Estrada.23 enters the operating room and takes charge of the proceedings, the acts or omissions
of operating room personnel, and any negligence associated with such acts or
The Court issued a Resolution dated 9 September 200224 dispensing with the omissions, are imputable to the surgeon.32 While the assisting physicians and nurses
requirement to submit the correct and present addresses of respondents Dr. Estrada, may be employed by the hospital, or engaged by the patient, they normally become
Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao. The Court stated that with the filing the temporary servants or agents of the surgeon in charge while the operation is in
of petitioners' Manifestation, it should be understood that they are claiming only progress, and liability may be imposed upon the surgeon for their negligent acts under
against respondents CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy who have filed their the doctrine of respondeat superior.33
The Court of Appeals concluded that since Rogelio engaged Dr. Estrada as the no pre-existing contractual relation between the parties, is called a quasi-delict and is
attending physician of his wife, any liability for malpractice must be Dr. Estrada's sole governed by the provisions of this Chapter.
responsibility.
Similarly, in the United States, a hospital which is the employer, master, or principal
While it found the amount of damages fair and reasonable, the Court of Appeals held of a physician employee, servant, or agent, may be held liable for the physician's
that no interest could be imposed on unliquidated claims or damages. negligence under the doctrine of respondeat superior.34

The Issue In the present case, petitioners maintain that CMC, in allowing Dr. Estrada to practice
and admit patients at CMC, should be liable for Dr. Estrada's malpractice. Rogelio
Basically, the issue in this case is whether CMC is vicariously liable for the negligence claims that he knew Dr. Estrada as an accredited physician of CMC, though he
of Dr. Estrada. The resolution of this issue rests, on the other hand, on the discovered later that Dr. Estrada was not a salaried employee of the CMC.35 Rogelio
ascertainment of the relationship between Dr. Estrada and CMC. The Court also further claims that he was dealing with CMC, whose primary concern was the
believes that a determination of the extent of liability of the other respondents is treatment and management of his wife's condition. Dr. Estrada just happened to be the
inevitable to finally and completely dispose of the present controversy. specific person he talked to representing CMC.36 Moreover, the fact that CMC made
The Ruling of the Court Rogelio sign a Consent on Admission and Admission Agreement37 and a Consent to
Operation printed on the letterhead of CMC indicates that CMC considered Dr. Estrada
The petition is partly meritorious. as a member of its medical staff.
On the Liability of CMC On the other hand, CMC disclaims liability by asserting that Dr. Estrada was a mere
visiting physician and that it admitted Corazon because her physical condition then
Dr. Estrada's negligence in handling the treatment and management of Corazon's
was classified an emergency obstetrics case.38
condition which ultimately resulted in Corazon's death is no longer in issue. Dr.
Estrada did not appeal the decision of the Court of Appeals which affirmed the ruling CMC alleges that Dr. Estrada is an independent contractor "for whose actuations CMC
of the trial court finding Dr. Estrada solely liable for damages. Accordingly, the would be a total stranger." CMC maintains that it had no control or supervision over
finding of the trial court on Dr. Estrada's negligence is already final. Dr. Estrada in the exercise of his medical profession.
Petitioners maintain that CMC is vicariously liable for Dr. Estrada's negligence based The Court had the occasion to determine the relationship between a hospital and a
on Article 2180 in relation to Article 2176 of the Civil Code. These provisions consultant or visiting physician and the liability of such hospital for that physician's
pertinently state: negligence in Ramos v. Court of Appeals,39 to wit:
Art. 2180. The obligation imposed by article 2176 is demandable not only for one's In the first place, hospitals exercise significant control in the hiring and firing of
own acts or omissions, but also for those of persons for whom one is responsible. consultants and in the conduct of their work within the hospital premises. Doctors who
apply for "consultant" slots, visiting or attending, are required to submit proof of
xxxx
completion of residency, their educational qualifications; generally, evidence of
Employers shall be liable for the damages caused by their employees and household accreditation by the appropriate board (diplomate), evidence of fellowship in most
helpers acting within the scope of their assigned tasks, even though the former are not cases, and references. These requirements are carefully scrutinized by members of the
engaged in any business or industry. hospital administration or by a review committee set up by the hospital who either
accept or reject the application. This is particularly true with respondent hospital.
xxxx
After a physician is accepted, either as a visiting or attending consultant, he is normally
The responsibility treated of in this article shall cease when the persons herein required to attend clinico-pathological conferences, conduct bedside rounds for clerks,
mentioned prove that they observed all the diligence of a good father of a family to interns and residents, moderate grand rounds and patient audits and perform other tasks
prevent damage. and responsibilities, for the privilege of being able to maintain a clinic in the hospital,
and/or for the privilege of admitting patients into the hospital. In addition to these, the
Art. 2176. Whoever by act or omission causes damage to another, there being fault or
physician's performance as a specialist is generally evaluated by a peer review
negligence, is obliged to pay for the damage done. Such fault or negligence, if there is
committee on the basis of mortality and morbidity statistics, and feedback from
patients, nurses, interns and residents. A consultant remiss in his duties, or a consultant In general, a hospital is not liable for the negligence of an independent contractor-
who regularly falls short of the minimum standards acceptable to the hospital or its physician. There is, however, an exception to this principle. The hospital may be liable
peer review committee, is normally politely terminated. if the physician is the "ostensible" agent of the hospital.44 This exception is also
known as the "doctrine of apparent authority."45 In Gilbert v. Sycamore Municipal
In other words, private hospitals, hire, fire and exercise real control over their attending Hospital,46 the Illinois Supreme Court explained the doctrine of apparent authority in
and visiting "consultant" staff. While "consultants" are not, technically employees, a this wise:
point which respondent hospital asserts in denying all responsibility for the patient's
condition, the control exercised, the hiring, and the right to terminate consultants all [U]nder the doctrine of apparent authority a hospital can be held vicariously liable for
fulfill the important hallmarks of an employer-employee relationship, with the the negligent acts of a physician providing care at the hospital, regardless of whether
exception of the payment of wages. In assessing whether such a relationship in fact the physician is an independent contractor, unless the patient knows, or should have
exists, the control test is determining. Accordingly, on the basis of the foregoing, we known, that the physician is an independent contractor. The elements of the action
rule that for the purpose of allocating responsibility in medical negligence cases, an have been set out as follows:
employer-employee relationship in effect exists between hospitals and their attending
and visiting physicians. This being the case, the question now arises as to whether or "For a hospital to be liable under the doctrine of apparent authority, a plaintiff must
not respondent hospital is solidarily liable with respondent doctors for petitioner's show that: (1) the hospital, or its agent, acted in a manner that would lead a reasonable
condition. 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
The basis for holding an employer solidarily responsible for the negligence of its of authority, the plaintiff must also prove that the hospital had knowledge of and
employee is found in Article 2180 of the Civil Code which considers a person acquiesced in them; and (3) the plaintiff acted in reliance upon the conduct of the
accountable not only for his own acts but also for those of others based on the former's hospital or its agent, consistent with ordinary care and prudence."
responsibility under a relationship of patria potestas. x x x40 (Emphasis supplied)
The element of "holding out" on the part of the hospital does not require an express
While the Court in Ramos did not expound on the control test, such test essentially representation by the hospital that the person alleged to be negligent is an employee.
determines whether an employment relationship exists between a physician and a Rather, the element is satisfied if the hospital holds itself out as a provider of
hospital based on the exercise of control over the physician as to details. Specifically, emergency room care without informing the patient that the care is provided by
the employer (or the hospital) must have the right to control both the means and the independent contractors.
details of the process by which the employee (or the physician) is to accomplish his
task.41 The element of justifiable reliance on the part of the plaintiff is satisfied if the plaintiff
relies upon the hospital to provide complete emergency room care, rather than upon a
After a thorough examination of the voluminous records of this case, the Court finds specific physician.
no single evidence pointing to CMC's exercise of control over Dr. Estrada's treatment
and management of Corazon's condition. It is undisputed that throughout Corazon's The doctrine of apparent authority essentially involves two factors to determine the
pregnancy, she was under the exclusive prenatal care of Dr. Estrada. At the time of liability of an independent-contractor physician.
Corazon's admission at CMC and during her delivery, it was Dr. Estrada, assisted by The first factor focuses on the hospital's manifestations and is sometimes described as
Dr. Villaflor, who attended to Corazon. There was no showing that CMC had a part in an inquiry whether the hospital acted in a manner which would lead a reasonable
diagnosing Corazon's condition. While Dr. Estrada enjoyed staff privileges at CMC, person to conclude that the individual who was alleged to be negligent was an
such fact alone did not make him an employee of CMC.42 CMC merely allowed Dr. employee or agent of the hospital.47 In this regard, the hospital need not make express
Estrada to use its facilities43 when Corazon was about to give birth, which CMC representations to the patient that the treating physician is an employee of the hospital;
considered an emergency. Considering these circumstances, Dr. Estrada is not an rather a representation may be general and implied.48
employee of CMC, but an independent contractor.
The doctrine of apparent authority is a species of the doctrine of estoppel. Article 1431
The question now is whether CMC is automatically exempt from liability considering of the Civil Code provides that "[t]hrough estoppel, an admission or representation is
that Dr. Estrada is an independent contractor-physician. rendered conclusive upon the person making it, and cannot be denied or disproved as
against the person relying thereon." Estoppel rests on this rule: "Whenever a party has,
by his own declaration, act, or omission, intentionally and deliberately led another to
believe a particular thing true, and to act upon such belief, he cannot, in any litigation free the Surgeon, his assistants, anesthesiologists, the Capitol Medical Center and/or
arising out of such declaration, act or omission, be permitted to falsify it."49 its staff, from any and all claims of whatever kind of nature, arising from directly or
indirectly, or by reason of said operation or operations, treatment, or emergency
In the instant case, CMC impliedly held out Dr. Estrada as a member of its medical measures, or intervention of the Surgeon, his assistants, anesthesiologists, the Capitol
staff. Through CMC's acts, CMC clothed Dr. Estrada with apparent authority thereby Medical Center and/or its staff.52 (Emphasis supplied)
leading the Spouses Nogales to believe that Dr. Estrada was an employee or agent of
CMC. CMC cannot now repudiate such authority. Without any indication in these consent forms that Dr. Estrada was an independent
contractor-physician, the Spouses Nogales could not have known that Dr. Estrada was
First, CMC granted staff privileges to Dr. Estrada. CMC extended its medical staff and an independent contractor. Significantly, no one from CMC informed the Spouses
facilities to Dr. Estrada. Upon Dr. Estrada's request for Corazon's admission, CMC, Nogales that Dr. Estrada was an independent contractor. On the contrary, Dr. Atencio,
through its personnel, readily accommodated Corazon and updated Dr. Estrada of her who was then a member of CMC Board of Directors, testified that Dr. Estrada was
condition. part of CMC's surgical staff.53
Second, CMC made Rogelio sign consent forms printed on CMC letterhead. Prior to Third, Dr. Estrada's referral of Corazon's profuse vaginal bleeding to Dr. Espinola,
Corazon's admission and supposed hysterectomy, CMC asked Rogelio to sign release who was then the Head of the Obstetrics and Gynecology Department of CMC, gave
forms, the contents of which reinforced Rogelio's belief that Dr. Estrada was a member the impression that Dr. Estrada as a member of CMC's medical staff was collaborating
of CMC's medical staff.50 The Consent on Admission and Agreement explicitly with other CMC-employed specialists in treating Corazon.
provides:
The second factor focuses on the patient's reliance. It is sometimes characterized as an
KNOW ALL MEN BY THESE PRESENTS: inquiry on whether the plaintiff acted in reliance upon the conduct of the hospital or
I, Rogelio Nogales, of legal age, a resident of 1974 M. H. Del Pilar St., Malate Mla., its agent, consistent with ordinary care and prudence.54
being the father/mother/brother/sister/spouse/relative/ guardian/or person in custody The records show that the Spouses Nogales relied upon a perceived employment
of Ma. Corazon, and representing his/her family, of my own volition and free will, do relationship with CMC in accepting Dr. Estrada's services. Rogelio testified that he
consent and submit said Ma. Corazon to Dr. Oscar Estrada (hereinafter referred to as and his wife specifically chose Dr. Estrada to handle Corazon's delivery not only
Physician) for cure, treatment, retreatment, or emergency measures, that the Physician, because of their friend's recommendation, but more importantly because of Dr.
personally or by and through the Capitol Medical Center and/or its staff, may use, Estrada's "connection with a reputable hospital, the [CMC]."55 In other words, Dr.
adapt, or employ such means, forms or methods of cure, treatment, retreatment, or Estrada's relationship with CMC played a significant role in the Spouses Nogales'
emergency measures as he may see best and most expedient; that Ma. Corazon and I decision in accepting Dr. Estrada's services as the obstetrician-gynecologist for
will comply with any and all rules, regulations, directions, and instructions of the Corazon's delivery. Moreover, as earlier stated, there is no showing that before and
Physician, the Capitol Medical Center and/or its staff; and, that I will not hold liable during Corazon's confinement at CMC, the Spouses Nogales knew or should have
or responsible and hereby waive and forever discharge and hold free the Physician, the known that Dr. Estrada was not an employee of CMC.
Capitol Medical Center and/or its staff, from any and all claims of whatever kind of
nature, arising from directly or indirectly, or by reason of said cure, treatment, or Further, the Spouses Nogales looked to CMC to provide the best medical care and
retreatment, or emergency measures or intervention of said physician, the Capitol support services for Corazon's delivery. The Court notes that prior to Corazon's fourth
Medical Center and/or its staff. pregnancy, she used to give birth inside a clinic. Considering Corazon's age then, the
Spouses Nogales decided to have their fourth child delivered at CMC, which Rogelio
x x x x51 (Emphasis supplied) regarded one of the best hospitals at the time.56 This is precisely because the Spouses
While the Consent to Operation pertinently reads, thus: Nogales feared that Corazon might experience complications during her delivery
which would be better addressed and treated in a modern and big hospital such as
I, ROGELIO NOGALES, x x x, of my own volition and free will, do consent and CMC. Moreover, Rogelio's consent in Corazon's hysterectomy to be performed by a
submit said CORAZON NOGALES to Hysterectomy, by the Surgical Staff and different physician, namely Dr. Espinola, is a clear indication of Rogelio's confidence
Anesthesiologists of Capitol Medical Center and/or whatever succeeding operations, in CMC's surgical staff.
treatment, or emergency measures as may be necessary and most expedient; and, that
I will not hold liable or responsible and hereby waive and forever discharge and hold
CMC's defense that all it did was "to extend to [Corazon] its facilities" is untenable. Espinola, Dr. Lacson, and Dr. Uy, who have filed their comments, the Court deems it
The Court cannot close its eyes to the reality that hospitals, such as CMC, are in the proper to resolve the individual liability of the remaining respondents to put an end
business of treatment. In this regard, the Court agrees with the observation made by finally to this more than two-decade old controversy.
the Court of Appeals of North Carolina in Diggs v. Novant Health, Inc.,57 to wit:
a) Dr. Ely Villaflor
"The conception that the hospital does not undertake to treat the patient, does not
undertake to act through its doctors and nurses, but undertakes instead simply to Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause of Corazon's
procure them to act upon their own responsibility, no longer reflects the fact. Present bleeding and to suggest the correct remedy to Dr. Estrada.60 Petitioners assert that it
day hospitals, as their manner of operation plainly demonstrates, do far more than was Dr. Villaflor's duty to correct the error of Nurse Dumlao in the administration of
furnish facilities for treatment. They regularly employ on a salary basis a large staff of hemacel.
physicians, nurses and internes [sic], as well as administrative and manual workers, The Court is not persuaded. Dr. Villaflor admitted administering a lower dosage of
and they charge patients for medical care and treatment, collecting for such services, magnesium sulfate. However, this was after informing Dr. Estrada that Corazon was
if necessary, by legal action. Certainly, the person who avails himself of 'hospital no longer in convulsion and that her blood pressure went down to a dangerous level.61
facilities' expects that the hospital will attempt to cure him, not that its nurses or other At that moment, Dr. Estrada instructed Dr. Villaflor to reduce the dosage of
employees will act on their own responsibility." x x x (Emphasis supplied) magnesium sulfate from 10 to 2.5 grams. Since petitioners did not dispute Dr.
Likewise unconvincing is CMC's argument that petitioners are estopped from claiming Villaflor's allegation, Dr. Villaflor's defense remains uncontroverted. Dr. Villaflor's
damages based on the Consent on Admission and Consent to Operation. Both release act of administering a lower dosage of magnesium sulfate was not out of her own
forms consist of two parts. The first part gave CMC permission to administer to volition or was in contravention of Dr. Estrada's order.
Corazon any form of recognized medical treatment which the CMC medical staff b) Dr. Rosa Uy
deemed advisable. The second part of the documents, which may properly be
described as the releasing part, releases CMC and its employees "from any and all Dr. Rosa Uy's alleged negligence consisted of her failure (1) to call the attention of Dr.
claims" arising from or by reason of the treatment and operation. Estrada on the incorrect dosage of magnesium sulfate administered by Dr. Villaflor;
(2) to take corrective measures; and (3) to correct Nurse Dumlao's wrong method of
The documents do not expressly release CMC from liability for injury to Corazon due hemacel administration.
to negligence during her treatment or operation. Neither do the consent forms
expressly exempt CMC from liability for Corazon's death due to negligence during The Court believes Dr. Uy's claim that as a second year resident physician then at
such treatment or operation. Such release forms, being in the nature of contracts of CMC, she was merely authorized to take the clinical history and physical examination
adhesion, are construed strictly against hospitals. Besides, a blanket release in favor of of Corazon.62 However, that routine internal examination did not ipso facto make Dr.
hospitals "from any and all claims," which includes claims due to bad faith or gross Uy liable for the errors committed by Dr. Estrada. Further, petitioners' imputation of
negligence, would be contrary to public policy and thus void. negligence rests on their baseless assumption that Dr. Uy was present at the delivery
room. Nothing shows that Dr. Uy participated in delivering Corazon's baby. Further,
Even simple negligence is not subject to blanket release in favor of establishments like it is unexpected from Dr. Uy, a mere resident physician at that time, to call the attention
hospitals but may only mitigate liability depending on the circumstances.58 When a of a more experienced specialist, if ever she was present at the delivery room.
person needing urgent medical attention rushes to a hospital, he cannot bargain on
equal footing with the hospital on the terms of admission and operation. Such a person c) Dr. Joel Enriquez
is literally at the mercy of the hospital. There can be no clearer example of a contract
Petitioners fault Dr. Joel Enriquez also for not calling the attention of Dr. Estrada, Dr.
of adhesion than one arising from such a dire situation. Thus, the release forms of
Villaflor, and Nurse Dumlao about their errors.63 Petitioners insist that Dr. Enriquez
CMC cannot relieve CMC from liability for the negligent medical treatment of
should have taken, or at least suggested, corrective measures to rectify such errors.
Corazon.
The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field of
On the Liability of the Other Respondents
expertise is definitely not obstetrics and gynecology. As such, Dr. Enriquez was not
Despite this Court's pronouncement in its 9 September 200259 Resolution that the expected to correct Dr. Estrada's errors. Besides, there was no evidence of Dr.
filing of petitioners' Manifestation confined petitioners' claim only against CMC, Dr.
Enriquez's knowledge of any error committed by Dr. Estrada and his failure to act hemacel administration was introduced. Therefore, there is no basis to hold Nurse
upon such observation. Dumlao liable for negligence.

d) Dr. Perpetua Lacson On the Award of Interest on Damages

Petitioners fault Dr. Perpetua Lacson for her purported delay in the delivery of blood The award of interest on damages is proper and allowed under Article 2211 of the
Corazon needed.64 Petitioners claim that Dr. Lacson was remiss in her duty of Civil Code, which states that in crimes and quasi-delicts, interest as a part of the
supervising the blood bank staff. damages may, in a proper case, be adjudicated in the discretion of the court.68

As found by the trial court, there was no unreasonable delay in the delivery of blood WHEREFORE, the Court PARTLY GRANTS the petition. The Court finds
from the time of the request until the transfusion to Corazon. Dr. Lacson competently respondent Capitol Medical Center vicariously liable for the negligence of Dr. Oscar
explained the procedure before blood could be given to the patient.65 Taking into Estrada. The amounts of P105,000 as actual damages and P700,000 as moral damages
account the bleeding time, clotting time and cross-matching, Dr. Lacson stated that it should each earn legal interest at the rate of six percent (6%) per annum computed
would take approximately 45-60 minutes before blood could be ready for from the date of the judgment of the trial court. The Court affirms the rest of the
transfusion.66 Further, no evidence exists that Dr. Lacson neglected her duties as head Decision dated 6 February 1998 and Resolution dated 21 March 2000 of the Court of
of the blood bank. Appeals in CA-G.R. CV No. 45641.

e) Dr. Noe Espinola SO ORDERED.

Petitioners argue that Dr. Espinola should not have ordered immediate hysterectomy
without determining the underlying cause of Corazon's bleeding. Dr. Espinola should
have first considered the possibility of cervical injury, and advised a thorough
examination of the cervix, instead of believing outright Dr. Estrada's diagnosis that the
cause of bleeding was uterine atony.

Dr. Espinola's order to do hysterectomy which was based on the information he


received by phone is not negligence. The Court agrees with the trial court's observation
that Dr. Espinola, upon hearing such information about Corazon's condition, believed
in good faith that hysterectomy was the correct remedy. At any rate, the hysterectomy
did not push through because upon Dr. Espinola's arrival, it was already too late. At
the time, Corazon was practically dead.

f) Nurse J. Dumlao

In Moore v. Guthrie Hospital Inc.,67 the US Court of Appeals, Fourth Circuit, held
that to recover, a patient complaining of injuries allegedly resulting when the nurse
negligently injected medicine to him intravenously instead of intramuscularly had to
show that (1) an intravenous injection constituted a lack of reasonable and ordinary
care; (2) the nurse injected medicine intravenously; and (3) such injection was the
proximate cause of his injury.

In the present case, there is no evidence of Nurse Dumlao's alleged failure to follow
Dr. Estrada's specific instructions. Even assuming Nurse Dumlao defied Dr. Estrada's
order, there is no showing that side-drip administration of hemacel proximately caused
Corazon's death. No evidence linking Corazon's death and the alleged wrongful
Republic of the Philippines discharge. After a series of medical examinations, Dr. Miguel Ampil, petitioner in
SUPREME COURT G.R. No. 127590, diagnosed her to be suffering from "cancer of the sigmoid."
Manila
FIRST DIVISION On April 11, 1984, Dr. Ampil, assisted by the medical staff4 of the Medical City
Hospital, performed an anterior resection surgery on Natividad. He found that the
G.R. No. 126297 January 31, 2007 malignancy in her sigmoid area had spread on her left ovary, necessitating the removal
of certain portions of it. Thus, Dr. Ampil obtained the consent of Natividads husband,
PROFESSIONAL SERVICES, INC., Petitioner, vs. NATIVIDAD and Enrique Agana, to permit Dr. Juan Fuentes, respondent in G.R. No. 126467, to perform
ENRIQUE AGANA, Respondents. hysterectomy on her.

x-----------------------x After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed
the operation and closed the incision.
G.R. No. 126467 January 31, 2007
However, the operation appeared to be flawed. In the corresponding Record of
NATIVIDAD (Substituted by her children MARCELINO AGANA III, Operation dated April 11, 1984, the attending nurses entered these remarks:
ENRIQUE AGANA, JR., EMMA AGANA ANDAYA, JESUS AGANA, and
RAYMUND AGANA) and ENRIQUE AGANA, Petitioners, vs. JUAN "sponge count lacking 2
FUENTES, Respondent.
"announced to surgeon searched (sic) done but to no avail continue for closure."
x- - - - - - - - - - - - - - - - - - - -- - - - x
On April 24, 1984, Natividad was released from the hospital. Her hospital and medical
G.R. No. 127590 January 31, 2007 bills, including the doctors fees, amounted to P60,000.00.

MIGUEL AMPIL, Petitioner, vs. NATIVIDAD AGANA and ENRIQUE After a couple of days, Natividad complained of excruciating pain in her anal region.
AGANA, Respondents. She consulted both Dr. Ampil and Dr. Fuentes about it. They told her that the pain was
the natural consequence of the surgery. Dr. Ampil then recommended that she consult
DECISION an oncologist to examine the cancerous nodes which were not removed during the
SANDOVAL-GUTIERREZ, J.: operation.

Hospitals, having undertaken one of mankinds most important and delicate On May 9, 1984, Natividad, accompanied by her husband, went to the United States
endeavors, must assume the grave responsibility of pursuing it with appropriate care. to seek further treatment. After four months of consultations and laboratory
The care and service dispensed through this high trust, however technical, complex examinations, Natividad was told she was free of cancer. Hence, she was advised to
and esoteric its character may be, must meet standards of responsibility commensurate return to the Philippines.
with the undertaking to preserve and protect the health, and indeed, the very lives of On August 31, 1984, Natividad flew back to the Philippines, still suffering from pains.
those placed in the hospitals keeping.1 Two weeks thereafter, her daughter found a piece of gauze protruding from her vagina.
Assailed in these three consolidated petitions for review on certiorari is the Court of Upon being informed about it, Dr. Ampil proceeded to her house where he managed
Appeals Decision2 dated September 6, 1996 in CA-G.R. CV No. 42062 and CA-G.R. to extract by hand a piece of gauze measuring 1.5 inches in width. He then assured her
SP No. 32198 affirming with modification the Decision3 dated March 17, 1993 of the that the pains would soon vanish.
Regional Trial Court (RTC), Branch 96, Quezon City in Civil Case No. Q-43322 and Dr. Ampils assurance did not come true. Instead, the pains intensified, prompting
nullifying its Order dated September 21, 1993. Natividad to seek treatment at the Polymedic General Hospital. While confined there,
The facts, as culled from the records, are: Dr. Ramon Gutierrez detected the presence of another foreign object in her vagina --
a foul-smelling gauze measuring 1.5 inches in width which badly infected her vaginal
On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital vault. A recto-vaginal fistula had formed in her reproductive organs which forced stool
(Medical City Hospital) because of difficulty of bowel movement and bloody anal to excrete through the vagina. Another surgical operation was needed to remedy the
damage. Thus, in October 1984, Natividad underwent another surgery.
On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, SO ORDERED.
Quezon City a complaint for damages against the Professional Services, Inc. (PSI),
owner of the Medical City Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of
Case No. Q-43322. They alleged that the latter are liable for negligence for leaving Appeals, docketed as CA-G.R. CV No. 42062.
two pieces of gauze inside Natividads body and malpractice for concealing their acts Incidentally, on April 3, 1993, the Aganas filed with the RTC a motion for a partial
of negligence. execution of its Decision, which was granted in an Order dated May 11, 1993.
Meanwhile, Enrique Agana also filed with the Professional Regulation Commission Thereafter, the sheriff levied upon certain properties of Dr. Ampil and sold them for
(PRC) an administrative complaint for gross negligence and malpractice against Dr. P451,275.00 and delivered the amount to the Aganas.
Ampil and Dr. Fuentes, docketed as Administrative Case No. 1690. The PRC Board Following their receipt of the money, the Aganas entered into an agreement with PSI
of Medicine heard the case only with respect to Dr. Fuentes because it failed to acquire and Dr. Fuentes to indefinitely suspend any further execution of the RTC Decision.
jurisdiction over Dr. Ampil who was then in the United States. However, not long thereafter, the Aganas again filed a motion for an alias writ of
On February 16, 1986, pending the outcome of the above cases, Natividad died and execution against the properties of PSI and Dr. Fuentes. On September 21, 1993, the
was duly substituted by her above-named children (the Aganas). RTC granted the motion and issued the corresponding writ, prompting Dr. Fuentes to
file with the Court of Appeals a petition for certiorari and prohibition, with prayer for
On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding preliminary injunction, docketed as CA-G.R. SP No. 32198. During its pendency, the
PSI, Dr. Ampil and Dr. Fuentes liable for negligence and malpractice, the decretal part Court of Appeals issued a Resolution5 dated October 29, 1993 granting Dr. Fuentes
of which reads: prayer for injunctive relief.

WHEREFORE, judgment is hereby rendered for the plaintiffs ordering the defendants On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No.
PROFESSIONAL SERVICES, INC., DR. MIGUEL AMPIL and DR. JUAN 42062.
FUENTES to pay to the plaintiffs, jointly and severally, except in respect of the award
for exemplary damages and the interest thereon which are the liabilities of defendants Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision6
Dr. Ampil and Dr. Fuentes only, as follows: in Administrative Case No. 1690 dismissing the case against Dr. Fuentes. The Board
held that the prosecution failed to show that Dr. Fuentes was the one who left the two
1. As actual damages, the following amounts: pieces of gauze inside Natividads body; and that he concealed such fact from
Natividad.
a. The equivalent in Philippine Currency of the total of US$19,900.00 at the rate of
P21.60-US$1.00, as reimbursement of actual expenses incurred in the United States of On September 6, 1996, the Court of Appeals rendered its Decision jointly disposing
America; of CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198, thus:

b. The sum of P4,800.00 as travel taxes of plaintiffs and their physician daughter; WHEREFORE, except for the modification that the case against defendant-appellant
Dr. Juan Fuentes is hereby DISMISSED, and with the pronouncement that defendant-
c. The total sum of P45,802.50, representing the cost of hospitalization at Polymedic appellant Dr. Miguel Ampil is liable to reimburse defendant-appellant Professional
Hospital, medical fees, and cost of the saline solution; Services, Inc., whatever amount the latter will pay or had paid to the plaintiffs-
2. As moral damages, the sum of P2,000,000.00; appellees, the decision appealed from is hereby AFFIRMED and the instant appeal
DISMISSED.
3. As exemplary damages, the sum of P300,000.00;
Concomitant with the above, the petition for certiorari and prohibition filed by herein
4. As attorneys fees, the sum of P250,000.00; defendant-appellant Dr. Juan Fuentes in CA-G.R. SP No. 32198 is hereby GRANTED
and the challenged order of the respondent judge dated September 21, 1993, as well as
5. Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove, from date of filing
the alias writ of execution issued pursuant thereto are hereby NULLIFIED and SET
of the complaint until full payment; and
ASIDE. The bond posted by the petitioner in connection with the writ of preliminary
6. Costs of suit. injunction issued by this Court on November 29, 1993 is hereby cancelled.
Costs against defendants-appellants Dr. Miguel Ampil and Professional Services, Inc. Dr. Ampils arguments are purely conjectural and without basis. Records show that he
did not present any evidence to prove that the American doctors were the ones who
SO ORDERED. put or left the gauzes in Natividads body. Neither did he submit evidence to rebut the
Only Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolution7 correctness of the record of operation, particularly the number of gauzes used. As to
dated December 19, 1996. the alleged negligence of Dr. Fuentes, we are mindful that Dr. Ampil examined his
(Dr. Fuentes) work and found it in order.
Hence, the instant consolidated petitions.
The glaring truth is that all the major circumstances, taken together, as specified by
In G.R. No. 126297, PSI alleged in its petition that the Court of Appeals erred in the Court of Appeals, directly point to Dr. Ampil as the negligent party, thus:
holding that: (1) it is estopped from raising the defense that Dr. Ampil is not its
employee; (2) it is solidarily liable with Dr. Ampil; and (3) it is not entitled to its First, it is not disputed that the surgeons used gauzes as sponges to control the bleeding
counterclaim against the Aganas. PSI contends that Dr. Ampil is not its employee, but of the patient during the surgical operation.
a mere consultant or independent contractor. As such, he alone should answer for his Second, immediately after the operation, the nurses who assisted in the surgery noted
negligence. in their report that the sponge count (was) lacking 2; that such anomaly was
In G.R. No. 126467, the Aganas maintain that the Court of Appeals erred in finding announced to surgeon and that a search was done but to no avail prompting Dr.
that Dr. Fuentes is not guilty of negligence or medical malpractice, invoking the Ampil to continue for closure x x x.
doctrine of res ipsa loquitur. They contend that the pieces of gauze are prima facie Third, after the operation, two (2) gauzes were extracted from the same spot of the
proofs that the operating surgeons have been negligent. body of Mrs. Agana where the surgery was performed.
Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of Appeals erred in An operation requiring the placing of sponges in the incision is not complete until the
finding him liable for negligence and malpractice sans evidence that he left the two sponges are properly removed, and it is settled that the leaving of sponges or other
pieces of gauze in Natividads vagina. He pointed to other probable causes, such as: foreign substances in the wound after the incision has been closed is at least prima
(1) it was Dr. Fuentes who used gauzes in performing the hysterectomy; (2) the facie negligence by the operating surgeon.8 To put it simply, such act is considered so
attending nurses failure to properly count the gauzes used during surgery; and (3) the inconsistent with due care as to raise an inference of negligence. There are even legions
medical intervention of the American doctors who examined Natividad in the United of authorities to the effect that such act is negligence per se.9
States of America.
Of course, the Court is not blind to the reality that there are times when danger to a
For our resolution are these three vital issues: first, whether the Court of Appeals erred patients life precludes a surgeon from further searching missing sponges or foreign
in holding Dr. Ampil liable for negligence and malpractice; second, whether the Court objects left in the body. But this does not leave him free from any obligation. Even if
of Appeals erred in absolving Dr. Fuentes of any liability; and third, whether PSI may it has been shown that a surgeon was required by the urgent necessities of the case to
be held solidarily liable for the negligence of Dr. Ampil. leave a sponge in his patients abdomen, because of the dangers attendant upon delay,
I - G.R. No. 127590 still, it is his legal duty to so inform his patient within a reasonable time thereafter by
advising her of what he had been compelled to do. This is in order that she might seek
Whether the Court of Appeals Erred in Holding Dr. Ampil relief from the effects of the foreign object left in her body as her condition might
permit. The ruling in Smith v. Zeagler10 is explicit, thus:
Liable for Negligence and Malpractice.
The removal of all sponges used is part of a surgical operation, and when a physician
Dr. Ampil, in an attempt to absolve himself, gears the Courts attention to other
or surgeon fails to remove a sponge he has placed in his patients body that should be
possible causes of Natividads detriment. He argues that the Court should not discount
removed as part of the operation, he thereby leaves his operation uncompleted and
either of the following possibilities: first, Dr. Fuentes left the gauzes in Natividads
creates a new condition which imposes upon him the legal duty of calling the new
body after performing hysterectomy; second, the attending nurses erred in counting
condition to his patients attention, and endeavoring with the means he has at hand to
the gauzes; and third, the American doctors were the ones who placed the gauzes in
minimize and avoid untoward results likely to ensue therefrom.
Natividads body.
Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. of care, and the burden of proof is shifted to him to establish that he has observed due
Worse, he even misled her that the pain she was experiencing was the ordinary care and diligence.14
consequence of her operation. Had he been more candid, Natividad could have taken
the immediate and appropriate medical remedy to remove the gauzes from her body. From the foregoing statements of the rule, the requisites for the applicability of the
To our mind, what was initially an act of negligence by Dr. Ampil has ripened into a doctrine of res ipsa loquitur are: (1) the occurrence of an injury; (2) the thing which
deliberate wrongful act of deceiving his patient. caused the injury was under the control and management of the defendant; (3) the
occurrence was such that in the ordinary course of things, would not have happened if
This is a clear case of medical malpractice or more appropriately, medical negligence. those who had control or management used proper care; and (4) the absence of
To successfully pursue this kind of case, a patient must only prove that a health care explanation by the defendant. Of the foregoing requisites, the most instrumental is the
provider either failed to do something which a reasonably prudent health care provider "control and management of the thing which caused the injury."15
would have done, or that he did something that a reasonably prudent provider would
not have done; and that failure or action caused injury to the patient.11 Simply put, the We find the element of "control and management of the thing which caused the injury"
elements are duty, breach, injury and proximate causation. Dr, Ampil, as the lead to be wanting. Hence, the doctrine of res ipsa loquitur will not lie.
surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividads It was duly established that Dr. Ampil was the lead surgeon during the operation of
body before closure of the incision. When he failed to do so, it was his duty to inform Natividad. He requested the assistance of Dr. Fuentes only to perform hysterectomy
Natividad about it. Dr. Ampil breached both duties. Such breach caused injury to when he (Dr. Ampil) found that the malignancy in her sigmoid area had spread to her
Natividad, necessitating her further examination by American doctors and another left ovary. Dr. Fuentes performed the surgery and thereafter reported and showed his
surgery. That Dr. Ampils negligence is the proximate cause12 of Natividads injury work to Dr. Ampil. The latter examined it and finding everything to be in order,
could be traced from his act of closing the incision despite the information given by allowed Dr. Fuentes to leave the operating room. Dr. Ampil then resumed operating
the attending nurses that two pieces of gauze were still missing. That they were later on Natividad. He was about to finish the procedure when the attending nurses informed
on extracted from Natividads vagina established the causal link between Dr. Ampils him that two pieces of gauze were missing. A "diligent search" was conducted, but the
negligence and the injury. And what further aggravated such injury was his deliberate misplaced gauzes were not found. Dr. Ampil then directed that the incision be closed.
concealment of the missing gauzes from the knowledge of Natividad and her family. During this entire period, Dr. Fuentes was no longer in the operating room and had, in
II - G.R. No. 126467 fact, left the hospital.

Whether the Court of Appeals Erred in Absolving Under the "Captain of the Ship" rule, the operating surgeon is the person in complete
charge of the surgery room and all personnel connected with the operation. Their duty
Dr. Fuentes of any Liability is to obey his orders.16 As stated before, Dr. Ampil was the lead surgeon. In other
words, he was the "Captain of the Ship." That he discharged such role is evident from
The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes on his following conduct: (1) calling Dr. Fuentes to perform a hysterectomy; (2)
the ground that it is contrary to the doctrine of res ipsa loquitur. According to them, examining the work of Dr. Fuentes and finding it in order; (3) granting Dr. Fuentes
the fact that the two pieces of gauze were left inside Natividads body is a prima facie permission to leave; and (4) ordering the closure of the incision. To our mind, it was
evidence of Dr. Fuentes negligence. this act of ordering the closure of the incision notwithstanding that two pieces of gauze
We are not convinced. remained unaccounted for, that caused injury to Natividads body. Clearly, the control
and management of the thing which caused the injury was in the hands of Dr. Ampil,
Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule that the fact not Dr. Fuentes.
of the occurrence of an injury, taken with the surrounding circumstances, may permit
an inference or raise a presumption of negligence, or make out a plaintiffs prima facie In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not
case, and present a question of fact for defendant to meet with an explanation.13 Stated per se create or constitute an independent or separate ground of liability, being a mere
differently, where the thing which caused the injury, without the fault of the injured, evidentiary rule.17 In other words, mere invocation and application of the doctrine
is under the exclusive control of the defendant and the injury is such that it should not does not dispense with the requirement of proof of negligence. Here, the negligence
have occurred if he, having such control used proper care, it affords reasonable was proven to have been committed by Dr. Ampil and not by Dr. Fuentes.
evidence, in the absence of explanation that the injury arose from the defendants want
III - G.R. No. 126297 The responsibility treated of in this article shall cease when the persons herein
mentioned prove that they observed all the diligence of a good father of a family to
Whether PSI Is Liable for the Negligence of Dr. Ampil prevent damage.
The third issue necessitates a glimpse at the historical development of hospitals and A prominent civilist commented that professionals engaged by an employer, such as
the resulting theories concerning their liability for the negligence of physicians. physicians, dentists, and pharmacists, are not "employees" under this article because
Until the mid-nineteenth century, hospitals were generally charitable institutions, the manner in which they perform their work is not within the control of the latter
providing medical services to the lowest classes of society, without regard for a (employer). In other words, professionals are considered personally liable for the fault
patients ability to pay.18 Those who could afford medical treatment were usually or negligence they commit in the discharge of their duties, and their employer cannot
treated at home by their doctors.19 However, the days of house calls and philanthropic be held liable for such fault or negligence. In the context of the present case, "a hospital
health care are over. The modern health care industry continues to distance itself from cannot be held liable for the fault or negligence of a physician or surgeon in the
its charitable past and has experienced a significant conversion from a not-for-profit treatment or operation of patients."21
health care to for-profit hospital businesses. Consequently, significant changes in The foregoing view is grounded on the traditional notion that the professional status
health law have accompanied the business-related changes in the hospital industry. and the very nature of the physicians calling preclude him from being classed as an
One important legal change is an increase in hospital liability for medical malpractice. agent or employee of a hospital, whenever he acts in a professional capacity.22 It has
Many courts now allow claims for hospital vicarious liability under the theories of been said that medical practice strictly involves highly developed and specialized
respondeat superior, apparent authority, ostensible authority, or agency by estoppel. knowledge,23 such that physicians are generally free to exercise their own skill and
20 judgment in rendering medical services sans interference.24 Hence, when a doctor
In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of practices medicine in a hospital setting, the hospital and its employees are deemed to
the Civil Code, which reads: subserve him in his ministrations to the patient and his actions are of his own
responsibility.25
Art. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done. Such fault or negligence, if there is The case of Schloendorff v. Society of New York Hospital26 was then considered an
no pre-existing contractual relation between the parties, is called a quasi-delict and is authority for this view. The "Schloendorff doctrine" regards a physician, even if
governed by the provisions of this Chapter. employed by a hospital, as an independent contractor because of the skill he exercises
and the lack of control exerted over his work. Under this doctrine, hospitals are exempt
A derivative of this provision is Article 2180, the rule governing vicarious liability from the application of the respondeat superior principle for fault or negligence
under the doctrine of respondeat superior, thus: committed by physicians in the discharge of their profession.
ART. 2180. The obligation imposed by Article 2176 is demandable not only for ones However, the efficacy of the foregoing doctrine has weakened with the significant
own acts or omissions, but also for those of persons for whom one is responsible. developments in medical care. Courts came to realize that modern hospitals are
increasingly taking active role in supplying and regulating medical care to patients. No
x x x x x x
longer were a hospitals functions limited to furnishing room, food, facilities for
The owners and managers of an establishment or enterprise are likewise responsible treatment and operation, and attendants for its patients. Thus, in Bing v. Thunig,27 the
for damages caused by their employees in the service of the branches in which the New York Court of Appeals deviated from the Schloendorff doctrine, noting that
latter are employed or on the occasion of their functions. modern hospitals actually do far more than provide facilities for treatment. Rather,
they regularly employ, on a salaried basis, a large staff of physicians, interns, nurses,
Employers shall be liable for the damages caused by their employees and household administrative and manual workers. They charge patients for medical care and
helpers acting within the scope of their assigned tasks even though the former are not treatment, even collecting for such services through legal action, if necessary. The
engaged in any business or industry. court then concluded that there is no reason to exempt hospitals from the universal rule
of respondeat superior.
x x x x x x
In our shores, the nature of the relationship between the hospital and the physicians is
rendered inconsequential in view of our categorical pronouncement in Ramos v. Court
of Appeals28 that for purposes of apportioning responsibility in medical negligence present case serves as a perfect platform to test the applicability of these doctrines,
cases, an employer-employee relationship in effect exists between hospitals and their thus, enriching our jurisprudence.
attending and visiting physicians. This Court held:
Apparent authority, or what is sometimes referred to as the "holding
"We now discuss the responsibility of the hospital in this particular incident. The
unique practice (among private hospitals) of filling up specialist staff with attending out" theory, or doctrine of ostensible agency or agency by estoppel,29 has its origin
and visiting "consultants," who are allegedly not hospital employees, presents from the law of agency. It imposes liability, not as the result of the reality of a
problems in apportioning responsibility for negligence in medical malpractice cases. contractual relationship, but rather because of the actions of a principal or an employer
However, the difficulty is more apparent than real. in somehow misleading the public into believing that the relationship or the authority
exists.30 The concept is essentially one of estoppel and has been explained in this
In the first place, hospitals exercise significant control in the hiring and firing of manner:
consultants and in the conduct of their work within the hospital premises. Doctors who
apply for consultant slots, visiting or attending, are required to submit proof of "The principal is bound by the acts of his agent with the apparent authority which he
completion of residency, their educational qualifications, generally, evidence of knowingly permits the agent to assume, or which he holds the agent out to the public
accreditation by the appropriate board (diplomate), evidence of fellowship in most as possessing. The question in every case is whether the principal has by his voluntary
cases, and references. These requirements are carefully scrutinized by members of the act placed the agent in such a situation that a person of ordinary prudence, conversant
hospital administration or by a review committee set up by the hospital who either with business usages and the nature of the particular business, is justified in presuming
accept or reject the application. x x x. that such agent has authority to perform the particular act in question.31

After a physician is accepted, either as a visiting or attending consultant, he is normally The applicability of apparent authority in the field of hospital liability was upheld long
required to attend clinico-pathological conferences, conduct bedside rounds for clerks, time ago in Irving v. Doctor Hospital of Lake Worth, Inc.32 There, it was explicitly
interns and residents, moderate grand rounds and patient audits and perform other tasks stated that "there does not appear to be any rational basis for excluding the concept of
and responsibilities, for the privilege of being able to maintain a clinic in the hospital, apparent authority from the field of hospital liability." Thus, in cases where it can be
and/or for the privilege of admitting patients into the hospital. In addition to these, the shown that a hospital, by its actions, has held out a particular physician as its agent
physicians performance as a specialist is generally evaluated by a peer review and/or employee and that a patient has accepted treatment from that physician in the
committee on the basis of mortality and morbidity statistics, and feedback from reasonable belief that it is being rendered in behalf of the hospital, then the hospital
patients, nurses, interns and residents. A consultant remiss in his duties, or a consultant will be liable for the physicians negligence.
who regularly falls short of the minimum standards acceptable to the hospital or its Our jurisdiction recognizes the concept of an agency by implication or estoppel.
peer review committee, is normally politely terminated. Article 1869 of the Civil Code reads:
In other words, private hospitals, hire, fire and exercise real control over their attending ART. 1869. Agency may be express, or implied from the acts of the principal, from
and visiting consultant staff. While consultants are not, technically employees, x x his silence or lack of action, or his failure to repudiate the agency, knowing that another
x, the control exercised, the hiring, and the right to terminate consultants all fulfill the person is acting on his behalf without authority.
important hallmarks of an employer-employee relationship, with the exception of the
payment of wages. In assessing whether such a relationship in fact exists, the control In this case, PSI publicly displays in the lobby of the Medical City Hospital the names
test is determining. Accordingly, on the basis of the foregoing, we rule that for the and specializations of the physicians associated or accredited by it, including those of
purpose of allocating responsibility in medical negligence cases, an employer- Dr. Ampil and Dr. Fuentes. We concur with the Court of Appeals conclusion that it
employee relationship in effect exists between hospitals and their attending and "is now estopped from passing all the blame to the physicians whose names it proudly
visiting physicians. " paraded in the public directory leading the public to believe that it vouched for their
skill and competence." Indeed, PSIs act is tantamount to holding out to the public that
But the Ramos pronouncement is not our only basis in sustaining PSIs liability. Its Medical City Hospital, through its accredited physicians, offers quality health care
liability is also anchored upon the agency principle of apparent authority or agency by services. By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their
estoppel and the doctrine of corporate negligence which have gained acceptance in the qualifications, the hospital created the impression that they were its agents, authorized
determination of a hospitals liability for negligent acts of health professionals. The to perform medical or surgical services for its patients. As expected, these patients,
Natividad being one of them, accepted the services on the reasonable belief that such
were being rendered by the hospital or its employees, agents, or servants. The trial other jurisdictions held that a hospitals corporate negligence extends to permitting a
court correctly pointed out: physician known to be incompetent to practice at the hospital.37 With the passage of
time, more duties were expected from hospitals, among them: (1) the use of reasonable
x x x regardless of the education and status in life of the patient, he ought not be care in the maintenance of safe and adequate facilities and equipment; (2) the selection
burdened with the defense of absence of employer-employee relationship between the and retention of competent physicians; (3) the overseeing or supervision of all persons
hospital and the independent physician whose name and competence are certainly who practice medicine within its walls; and (4) the formulation, adoption and
certified to the general public by the hospitals act of listing him and his specialty in enforcement of adequate rules and policies that ensure quality care for its patients.38
its lobby directory, as in the case herein. The high costs of todays medical and health Thus, in Tucson Medical Center, Inc. v. Misevich,39 it was held that a hospital,
care should at least exact on the hospital greater, if not broader, legal responsibility for following the doctrine of corporate responsibility, has the duty to see that it meets the
the conduct of treatment and surgery within its facility by its accredited physician or standards of responsibilities for the care of patients. Such duty includes the proper
surgeon, regardless of whether he is independent or employed."33 supervision of the members of its medical staff. And in Bost v. Riley,40 the court
The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like concluded that a patient who enters a hospital does so with the reasonable expectation
PSI, are capable of acting only through other individuals, such as physicians. If these that it will attempt to cure him. The hospital accordingly has the duty to make a
accredited physicians do their job well, the hospital succeeds in its mission of offering reasonable effort to monitor and oversee the treatment prescribed and administered by
quality medical services and thus profits financially. Logically, where negligence mars the physicians practicing in its premises.
the quality of its services, the hospital should not be allowed to escape liability for the In the present case, it was duly established that PSI operates the Medical City Hospital
acts of its ostensible agents. for the purpose and under the concept of providing comprehensive medical services to
We now proceed to the doctrine of corporate negligence or corporate responsibility. the public. Accordingly, it has the duty to exercise reasonable care to protect from
harm all patients admitted into its facility for medical treatment. Unfortunately, PSI
One allegation in the complaint in Civil Case No. Q-43332 for negligence and failed to perform such duty. The findings of the trial court are convincing, thus:
malpractice is that PSI as owner, operator and manager of Medical City Hospital, "did
not perform the necessary supervision nor exercise diligent efforts in the supervision x x x PSIs liability is traceable to its failure to conduct an investigation of the matter
of Drs. Ampil and Fuentes and its nursing staff, resident doctors, and medical interns reported in the nota bene of the count nurse. Such failure established PSIs part in the
who assisted Drs. Ampil and Fuentes in the performance of their duties as surgeons."34 dark conspiracy of silence and concealment about the gauzes. Ethical considerations,
Premised on the doctrine of corporate negligence, the trial court held that PSI is if not also legal, dictated the holding of an immediate inquiry into the events, if not for
directly liable for such breach of duty. the benefit of the patient to whom the duty is primarily owed, then in the interest of
arriving at the truth. The Court cannot accept that the medical and the healing
We agree with the trial court. professions, through their members like defendant surgeons, and their institutions like
PSIs hospital facility, can callously turn their backs on and disregard even a mere
Recent years have seen the doctrine of corporate negligence as the judicial answer to
probability of mistake or negligence by refusing or failing to investigate a report of
the problem of allocating hospitals liability for the negligent acts of health
such seriousness as the one in Natividads case.
practitioners, absent facts to support the application of respondeat superior or apparent
authority. Its formulation proceeds from the judiciarys acknowledgment that in these It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the
modern times, the duty of providing quality medical service is no longer the sole assistance of the Medical City Hospitals staff, composed of resident doctors, nurses,
prerogative and responsibility of the physician. The modern hospitals have changed and interns. As such, it is reasonable to conclude that PSI, as the operator of the
structure. Hospitals now tend to organize a highly professional medical staff whose hospital, has actual or constructive knowledge of the procedures carried out,
competence and performance need to be monitored by the hospitals commensurate particularly the report of the attending nurses that the two pieces of gauze were
with their inherent responsibility to provide quality medical care.35 missing. In Fridena v. Evans,41 it was held that a corporation is bound by the
knowledge acquired by or notice given to its agents or officers within the scope of
The doctrine has its genesis in Darling v. Charleston Community Hospital.36 There,
their authority and in reference to a matter to which their authority extends. This means
the Supreme Court of Illinois held that "the jury could have found a hospital negligent,
that the knowledge of any of the staff of Medical City Hospital constitutes knowledge
inter alia, in failing to have a sufficient number of trained nurses attending the patient;
of PSI. Now, the failure of PSI, despite the attending nurses report, to investigate and
failing to require a consultation with or examination by members of the hospital staff;
inform Natividad regarding the missing gauzes amounts to callous negligence. Not
and failing to review the treatment rendered to the patient." On the basis of Darling,
only did PSI breach its duties to oversee or supervise all persons who practice medicine One final word. Once a physician undertakes the treatment and care of a patient, the
within its walls, it also failed to take an active step in fixing the negligence committed. law imposes on him certain obligations. In order to escape liability, he must possess
This renders PSI, not only vicariously liable for the negligence of Dr. Ampil under that reasonable degree of learning, skill and experience required by his profession. At
Article 2180 of the Civil Code, but also directly liable for its own negligence under the same time, he must apply reasonable care and diligence in the exercise of his skill
Article 2176. In Fridena, the Supreme Court of Arizona held: and the application of his knowledge, and exert his best judgment.

x x x In recent years, however, the duty of care owed to the patient by the hospital has WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of
expanded. The emerging trend is to hold the hospital responsible where the hospital the Court of Appeals in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198.
has failed to monitor and review medical services being provided within its walls. See
Kahn Hospital Malpractice Prevention, 27 De Paul . Rev. 23 (1977). Costs against petitioners PSI and Dr. Miguel Ampil.

Among the cases indicative of the emerging trend is Purcell v. Zimbelman, 18 Ariz. SO ORDERED.
App. 75,500 P. 2d 335 (1972). In Purcell, the hospital argued that it could not be held
liable for the malpractice of a medical practitioner because he was an independent
contractor within the hospital. The Court of Appeals pointed out that the hospital had
created a professional staff whose competence and performance was to be monitored
and reviewed by the governing body of the hospital, and the court held that a hospital
would be negligent where it had knowledge or reason to believe that a doctor using the
facilities was employing a method of treatment or care which fell below the recognized
standard of care.

Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hospital
has certain inherent responsibilities regarding the quality of medical care furnished to
patients within its walls and it must meet the standards of responsibility commensurate
with this undertaking. Beeck v. Tucson General Hospital, 18 Ariz. App. 165, 500 P.
2d 1153 (1972). This court has confirmed the rulings of the Court of Appeals that a
hospital has the duty of supervising the competence of the doctors on its staff. x x x.

x x x x x x

In the amended complaint, the plaintiffs did plead that the operation was performed at
the hospital with its knowledge, aid, and assistance, and that the negligence of the
defendants was the proximate cause of the patients injuries. We find that such general
allegations of negligence, along with the evidence produced at the trial of this case,
are sufficient to support the hospitals liability based on the theory of negligent
supervision."

Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for
damages, let it be emphasized that PSI, apart from a general denial of its responsibility,
failed to adduce evidence showing that it exercised the diligence of a good father of a
family in the accreditation and supervision of the latter. In neglecting to offer such
proof, PSI failed to discharge its burden under the last paragraph of Article 2180 cited
earlier, and, therefore, must be adjudged solidarily liable with Dr. Ampil. Moreover,
as we have discussed, PSI is also directly liable to the Aganas.
such burn.[8] He dismissed the likelihood that the wound was caused by a blood
pressure cuff as the scar was not around the arm, but just on one side of the arm.[9]
SECOND DIVISION
On May 22, 1992, Noras injury was referred to a plastic surgeon at the Dr. Jesus
G.R. No. 160889 April 27, 2007 Delgado Memorial Hospital for skin grafting.[10] Her wound was covered with skin
DR. MILAGROS L. CANTRE vs. SPS. JOHN DAVID Z. GO and NORA S. GO, sourced from her abdomen, which consequently bore a scar as well. About a year after,
on April 30, 1993, scar revision had to be performed at the same hospital.[11] The
DECISION surgical operation left a healed linear scar in Noras left arm about three inches in
length, the thickest portion rising about one-fourth (1/4) of an inch from the surface of
QUISUMBING, J.: the skin. The costs of the skin grafting and the scar revision were shouldered by the
hospital.[12]
For review on certiorari are the Decision[1] dated October 3, 2002 and Resolution[2]
dated November 19, 2003 of the Court of Appeals in CA-G.R. CV No. 58184, which Unfortunately, Noras arm would never be the same. Aside from the unsightly mark,
affirmed with modification the Decision[3] dated March 3, 1997 of the Regional Trial the pain in her left arm remains. When sleeping, she has to cradle her wounded arm.
Court of Quezon City, Branch 98, in Civil Case No. Q-93-16562. Her movements now are also restricted. Her children cannot play with the left side of
her body as they might accidentally bump the injured arm, which aches at the slightest
The facts, culled from the records, are as follows:
touch.
Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and Gynecology at the
Thus, on June 21, 1993, respondent spouses filed a complaint[13] for damages against
Dr. Jesus Delgado Memorial Hospital. She was the attending physician of respondent
petitioner, Dr. Abad, and the hospital. Finding in favor of respondent spouses, the trial
Nora S. Go, who was admitted at the said hospital on April 19, 1992.
court decreed:
At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy.
In view of the foregoing consideration, judgment is hereby rendered in favor
However, at around 3:30 a.m., Nora suffered profuse bleeding inside her womb due to
of the plaintiffs and against the defendants, directing the latters, (sic) jointly
some parts of the placenta which were not completely expelled from her womb after
and severally
delivery. Consequently, Nora suffered hypovolemic shock, resulting in a drop in her
(a) to pay the sum of Five Hundred Thousand Pesos (P500,000.00) in
blood pressure to 40 over 0. Petitioner and the assisting resident physician performed
moral damages;
various medical procedures to stop the bleeding and to restore Noras blood pressure.
(b) to pay the sum of One Hundred Fifty Thousand Pesos (P150,000.00)
Her blood pressure was frequently monitored with the use of a sphygmomanometer.
exemplary damages;
While petitioner was massaging Noras uterus for it to contract and stop bleeding, she
(c) to pay the sum of Eighty Thousand Pesos (P80,000.00) nominal
ordered a droplight to warm Nora and her baby.[4] Nora remained unconscious until
damages;
she recovered.
(d) to pay Fifty Thousand Pesos (P50,000.00) for and as attorneys fees;
While in the recovery room, her husband, respondent John David Z. Go noticed a fresh and
gaping wound two and a half (2 ) by three and a half (3 ) inches in the inner portion of (e) to pay Six Thousand Pesos (P6,000.00) litigation expenses.
her left arm, close to the armpit.[5] He asked the nurses what caused the injury. He SO ORDERED.[14]
was informed it was a burn. Forthwith, on April 22, 1992, John David filed a request
for investigation.[6] In response, Dr. Rainerio S. Abad, the medical director of the Petitioner, Dr. Abad, and the hospital all appealed to the Court of Appeals, which
hospital, called petitioner and the assisting resident physician to explain what affirmed with modification the trial court decision, thus:
happened. Petitioner said the blood pressure cuff caused the injury.
WHEREFORE, in view of all the foregoing, and finding no reversible error in
On May 7, 1992, John David brought Nora to the National Bureau of Investigation for the appealed Decision dated March 3, 1997 of Branch 98 of the Regional Trial
a physical examination, which was conducted by medico-legal officer Dr. Floresto Court of Quezon City in Civil Case No. Q-93-16562, the same is hereby
Arizala, Jr.[7] The medico-legal officer later testified that Noras injury appeared to be AFFIRMED, with the following MODIFICATIONS:
a burn and that a droplight when placed near the skin for about 10 minutes could cause
1. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay IV.
plaintiffs-appellees John David Go and Nora S. Go the sum of P200,000.00
as moral damages; WHETHER OR NOT THE COURT OF APPEALS COMMITTED GRAVE
2. Deleting the award [of] exemplary damages, attorneys fees and expenses ABUSE OF ITS DISCRETION WHEN IT MADE A RULING ON THE
of litigation; RESPONDENTS INJURY QUOTING THE TESTIMONY OF SOMEONE WHO
3. Dismissing the complaint with respect to defendants-appellants Dr. WAS NOT PRESENT AND HAS NOT SEEN THE ORIGINAL, FRESH INJURY
Rainerio S. Abad and Delgado Clinic, Inc.; OF RESPONDENT MRS. NORA GO;
4. Dismissing the counterclaims of defendants-appellants for lack of merit; V.
and
5. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay the WHETHER OR NOT THE COURT OF APPEALS GRAVELY ABUSING ITS
costs. DISCRETION RULED THAT PETITIONER DRA. CANTRE SHOULD HAVE
SO ORDERED.[15] INTENDED TO INFLICT THE INJURY TO SAVE THE LIFE OF RESPONDENT
MRS. GO;

Petitioners motion for reconsideration was denied by the Court of Appeals. Hence, the VI.
instant petition assigning the following as errors and issues:
WHETHER OR NOT THE LOWER COURT AND THE COURT [OF] APPEALS
I. COMMITTED GRAVE ABUSE OF DISCRETION WHEN, CONTRARY TO THE
DETAILED PROCEDURES DONE BY PETITIONER, BOTH RULED THAT
WHETHER OR NOT, THE LOWER COURT, AND THE COURT OF APPEALS THE RESPONDENT WAS LEFT TO THE CARE OF THE NURSING STAFF;
COMMITTED GRAVE ABUSE OF THEIR DISCRETION WHEN,
NOTWITHSTANDING THAT BOTH PARTIES HAVE RESTED THEIR VII.
RESPECTIVE CASES, THE LOWER COURT ADMITTED THE ADDITIONAL
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF
EXHIBITS FURTHER OFFERED BY RESPONDENTS NOT TESTIFIED TO BY
DISCRETION WHEN, CONTRARY TO THE MEDICAL PURPOSES OF
ANY WITNESS AND THIS DECISION OF THE LOWER COURT WAS
COSMETIC SURGERY, IT RULED THAT THE COSMETIC SURGERY MADE
UPHELD BY THE COURT OF APPEALS LIKEWISE COMMITTING GRAVE
THE SCARS EVEN MORE UGLY AND DECLARED THE COSMETIC
ABUSE OF DISCRETION;
SURGERY A FAILURE;
II.
VIII.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF
WHETHER OR NOT THE LOWER COURT GRAVELY ABUSE OF (SIC)
ITS DISCRETION WHEN, CONTRARY TO PREPONDERANCE OF EVIDENCE
DISCRETION WHEN, CONTRARY TO RESPONDENTS CONTRARY
PRESENTED BY THE PETITIONER, IT RULED THAT THE PETITIONER HAS
TESTIMONIES AND THE ABSENCE OF ANY TESTIMONY, IT RULED THAT
NOT AMPLY SHOWED THAT THE DROPLIGHT DID NOT TOUCH THE
THEY ARE ENTITLED TO DAMAGES AND WHICH WAS UPHELD,
BODY OF MRS. NORA GO, AND THIS DECISION OF THE LOWER COURT
ALTHOUGH MODIFIED, BY THE COURT OF APPEALS LIKEWISE ABUSING
WAS UPHELD BY THE COURT OF APPEALS LIKEWISE COMMITTING
ITS DISCRETION.[16]
GRAVE ABUSE OF DISCRETION;
Petitioner contends that additional documentary exhibits not testified to by any witness
III.
are inadmissible in evidence because they deprived her of her constitutional right to
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF confront the witnesses against her. Petitioner insists the droplight could not have
ITS DISCRETION WHEN, CONTRARY TO PREPONDERANCE OF EVIDENCE touched Noras body. She maintains the injury was due to the constant taking of Noras
PRESENTED BY THE PETITIONER, IT RULED THAT PETITIONER DRA. blood pressure. Petitioner also insinuates the Court of Appeals was misled by the
CANTRE WAS NOT ABLE TO AMPLY EXPLAIN HOW THE INJURY testimony of the medico-legal officer who never saw the original injury before plastic
(BLISTERS) IN THE LEFT INNER ARM OF RESPONDENT MRS. GO CAME surgery was performed. Finally, petitioner stresses that plastic surgery was not
ABOUT;
intended to restore respondents injury to its original state but rather to prevent further
complication.
1. The accident is of a kind which ordinarily does not occur in the absence of someones
Respondents, however, counter that the genuineness and due execution of the negligence;
additional documentary exhibits were duly admitted by petitioners counsel.
Respondents point out that petitioners blood pressure cuff theory is highly improbable, 2. It is caused by an instrumentality within the exclusive control of the defendant or
being unprecedented in medical history and that the injury was definitely caused by defendants; and
the droplight. At any rate, they argue, even if the injury was brought about by the blood 3. The possibility of contributing conduct which would make the plaintiff responsible
pressure cuff, petitioner was still negligent in her duties as Noras attending physician. is eliminated.[18]
Simply put, the threshold issues for resolution are: (1) Are the questioned additional As to the first requirement, the gaping wound on Noras arm is certainly not an ordinary
exhibits admissible in evidence? (2) Is petitioner liable for the injury suffered by occurrence in the act of delivering a baby, far removed as the arm is from the organs
respondent Nora Go? Thereafter, the inquiry is whether the appellate court committed involved in the process of giving birth. Such injury could not have happened unless
grave abuse of discretion in its assailed issuances. negligence had set in somewhere
As to the first issue, we agree with the Court of Appeals that said exhibits are Second, whether the injury was caused by the droplight or by the blood pressure cuff
admissible in evidence. We note that the questioned exhibits consist mostly of Noras is of no moment. Both instruments are deemed within the exclusive control of the
medical records, which were produced by the hospital during trial pursuant to a physician in charge under the captain of the ship doctrine. This doctrine holds the
subpoena duces tecum. Petitioners counsel admitted the existence of the same when surgeon in charge of an operation liable for the negligence of his assistants during the
they were formally offered for admission by the trial court. In any case, given the time when those assistants are under the surgeons control.[19] In this particular case,
particular circumstances of this case, a ruling on the negligence of petitioner may be it can be logically inferred that petitioner, the senior consultant in charge during the
made based on the res ipsa loquitur doctrine even in the absence of such additional delivery of Noras baby, exercised control over the assistants assigned to both the use
exhibits. of the droplight and the taking of Noras blood pressure. Hence, the use of the droplight
Petitioners contention that the medico-legal officer who conducted Noras physical and the blood pressure cuff is also within petitioners exclusive control
examination never saw her original injury before plastic surgery was performed is Third, the gaping wound on Noras left arm, by its very nature and considering her
without basis and contradicted by the records. Records show that the medico-legal condition, could only be caused by something external to her and outside her control
officer conducted the physical examination on May 7, 1992, while the skin grafting as she was unconscious while in hypovolemic shock. Hence, Nora could not, by any
and the scar revision were performed on Nora on May 22, 1992 and April 30, 1993, stretch of the imagination, have contributed to her own injury.
respectively.
Petitioners defense that Noras wound was caused not by the droplight but by the
Coming now to the substantive matter, is petitioner liable for the injury suffered by constant taking of her blood pressure, even if the latter was necessary given her
respondent Nora Go? condition, does not absolve her from liability. As testified to by the medico-legal
The Hippocratic Oath mandates physicians to give primordial consideration to the officer, Dr. Arizala, Jr., the medical practice is to deflate the blood pressure cuff
well-being of their patients. If a doctor fails to live up to this precept, he is accountable immediately after each use. Otherwise, the inflated band can cause injury to the patient
for his acts. This notwithstanding, courts face a unique restraint in adjudicating similar to what could have happened in this case. Thus, if Noras wound was caused by
medical negligence cases because physicians are not guarantors of care and, they never the blood pressure cuff, then the taking of Noras blood pressure must have been done
set out to intentionally cause injury to their patients. However, intent is immaterial in so negligently as to have inflicted a gaping wound on her arm,[20] for which petitioner
negligence cases because where negligence exists and is proven, it automatically gives cannot escape liability under the captain of the ship doctrine.
the injured a right to reparation for the damage caused.[17] Further, petitioners argument that the failed plastic surgery was not intended as a
In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere cosmetic procedure, but rather as a measure to prevent complication does not help her
existence of an injury to justify a presumption of negligence on the part of the person case. It does not negate negligence on her part.
who controls the instrument causing the injury, provided that the following requisites
concur:
Based on the foregoing, the presumption that petitioner was negligent in the exercise
of her profession stands unrebutted. In this connection, the Civil Code provides:

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

ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious
anxiety, besmirched reputation, wounded feelings, moral shock, social humiliation,
and similar injury. Though incapable of pecuniary computation, moral damages may
be recovered if they are the proximate result of the defendants wrongful act or
omission.

Clearly, under the law, petitioner is obliged to pay Nora for moral damages suffered
by the latter as a proximate result of petitioners negligence.

We note, however, that petitioner has served well as Noras obstetrician for her past
three successful deliveries. This is the first time petitioner is being held liable for
damages due to negligence in the practice of her profession. The fact that petitioner
promptly took care of Noras wound before infection and other complications set in is
also indicative of petitioners good intentions. We also take note of the fact that Nora
was suffering from a critical condition when the injury happened, such that saving her
life became petitioners elemental concern. Nonetheless, it should be stressed that all
these could not justify negligence on the part of petitioner.

Hence, considering the specific circumstances in the instant case, we find no grave
abuse of discretion in the assailed decision and resolution of the Court of Appeals.
Further, we rule that the Court of Appeals award of Two Hundred Thousand Pesos
(P200,000) as moral damages in favor of respondents and against petitioner is just and
equitable.[21]

WHEREFORE, the petition is DENIED. The Decision dated October 3, 2002 and
Resolution dated November 19, 2003 of the Court of Appeals in CA-G.R. CV No.
58184 are AFFIRMED.

No pronouncement as to costs.

SO ORDERED.
SECOND DIVISION laparoscopic procedure. She failed to consider the time difference between Hawaii and
the Philippines, however.

In its Answer,[4] the St. Lukes Medical Center contended that the spouses have no
October 11, 2007 G.R. No. 172406 cause of action against it since it performed the pre-operative procedures without
CONCEPCION ILAO-ORETA vs. SPOUSES EVA MARIE and BENEDICTO delay, and any cause of action they have would be against Dr. Ilao-Oreta.
NOEL RONQUILLO, By Decision[5] of March 9, 2001, Branch 84 of the Batangas RTC, finding that the
DECISION failure of the doctor to arrive on time was not intentional, awarded Eva Marie only
actual damages in the total amount of P9,939 and costs of suit. It found no adequate
CARPIO MORALES, J.: proof that Noel had been deprived of any job contract while attending to his wife in
the hospital.
Respondents, spouses Eva Marie Ronquillo (Eva Marie) and Noel Benedicto (Noel)
Ronquillo (the Ronquillo spouses or the spouses), had not been blessed with a child On appeal by the spouses, the Court of Appeals, by Decision[6] of April 21, 2006,
despite several years of marriage. They thus consulted petitioner, Dr. Concepcion Ilao- finding Dr. Ilao-Oreta grossly negligent,[7] modified the trial courts decision as
Oreta (Dr. Ilao-Oreta), an obstetrician-gynecologist-consultant at the St. Lukes follows:
Medical Center where she was, at the time material to the case, the chief of the
Reproductive Endocrinology and Infertility Section. WHEREFORE, the trial Courts decision dated March 9, 2001 is affirmed,
subject to the modification that the amount of actual damages, for which
Upon Dr. Ilao-Oretas advice, Eva Marie agreed to undergo a laparoscopic procedure both defendants-appellees are jointly and severally liable to plaintiffs-
whereby a laparascope would be inserted through the patients abdominal wall to get a appellants, is increased to P16,069.40. Furthermore, defendant-appellee
direct view of her internal reproductive organ in order to determine the real cause of Dr. Ilao-Oreta is also held liable to pay plaintiff-appellants the following:
her infertility.
(a) P50,000.00 as moral damages;
The procedure was scheduled on April 5, 1999 at 2:00 p.m., to be performed by Dr. (b) P25,000.00 as exemplary damages; and
Ilao-Oreta. At around 7:00 a.m. of said date, Eva Marie, accompanied by her husband (c) P20,000.00 as attorneys fees.
Noel, checked in at the St. Lukes Medical Center and underwent pre-operative SO ORDERED.[8] (Underscoring supplied)
procedures including the administration of intravenous fluid and enema.
Hence, the present Petition for Review[9] of Dr. Ilao-Oreta raising the following
Dr. Ilao-Oreta did not arrive at the scheduled time for the procedure, however, and no arguments:
prior notice of its cancellation was received. It turned out that the doctor was on a
return flight from Hawaii to, and arrived at 10:00 p.m. of April 5, 1999 in, Manila. The court a quo erred in finding petitioner to have acted with gross negligence and
awarding moral damages to respondents.[10]
On May 18, 1999, the Ronquillo spouses filed a complaint[1] against Dr. Ilao-Oreta
and the St. Lukes Medical Center for breach of professional and service contract and The court a quo erred in awarding Exemplary Damages to respondents.[11
for damages before the Regional Trial Court (RTC) of Batangas City. They prayed for The court a quo [erred] in awarding Attorneys Fees to respondents.[12]
the award of actual damages including alleged loss of income of Noel while
accompanying his wife to the hospital, moral damages, exemplary damages, the costs The court a quo erred in increasing the award of actual damages in favor of
of litigation, attorneys fees, and other available reliefs and remedies.[2] respondents.[13]

In her Answer,[3] Dr. Ilao-Oreta gave her side of the case as follows: She went on a Gross negligence implies a want or absence of or failure to exercise slight care or
honeymoon to Hawaii and was scheduled to leave Hawaii at 3:00 p.m. of April 4, 1999 diligence, or the entire absence of care. It evinces a thoughtless disregard of
for Manila. Aware that her trip from Hawaii to Manila would take about 12 hours, consequences without exerting any effort to avoid them.[14] It is characterized by want
inclusive of a stop-over at the Narita Airport in Japan, she estimated that she would of even slight care, acting or omitting to act in a situation where there is a duty to act,
arrive in Manila in the early morning of April 5, 1999. She thus believed in utmost not inadvertently but willfully and intentionally with a conscious indifference to
good faith that she would be back in Manila in time for the scheduled conduct of the consequences in so far as other persons may be affected.[15]
The records show that before leaving for Hawaii, Dr. Ilao-Oreta left an admitting order ATTY LONTOK: May we move, your Honor, for the striking out of the answer, this
with her secretary for one of the spouses to pick up, apprised Eva Marie of the is purely hearsay.
necessary preparations for the procedure, and instructed the hospital staff to perform
pre-operative treatments.[16] These acts of the doctor reflect an earnest intention to COURT: Remain on the record.
perform the procedure on the day and time scheduled. WITNESS [DR. ILAO-ORETA]: . . . and then Mr. Ronquillo told me Im sorry, Dra.,
The records also show that on realizing that she missed the scheduled procedure, Dr. we cannot re-schedule the surgery.[17] (Underscoring supplied)
Ilao-Oreta, upon arrival in Manila, immediately sought to rectify the same, thus: Noel admitted that indeed Dr. Ilao-Oreta called him up after she arrived in Manila as
[ATTY SINJAN] Q: So, can you tell us the reason why you missed that operation? related by her.[18]

[DR. ILAO-ORETA] A: When I scheduled her for the surgery, I looked at my ticket The evidence then shows that Dr. Ilao-Oreta, who had traveled more than twice to the
and so I was to leave Hawaii on April 4 at around 4:00 oclock in the afternoon, so I United States where she obtained a fellowship in Reproductive Endocrinology and
was computing 12 hours of travel including stop-over, then probably I would be in Infertility was indeed negligent when she scheduled to perform professional service at
Manila early morning of April 5, then I have so much time and I can easily do the case 2:00 p.m. on April 5, 1999 without considering the time difference between the
at 2:00 oclock, you know it skipped my mind the change in time. Philippines and Hawaii.

Q: So when you arrived at 10:00 [PM] in Manila, what did you do? The doctors act did not, however, reflect gross negligence as defined above. Her
argument that Although petitioner failed to take into consideration the time difference
A: I called immediately the hospital and I talked with the nurses, I asked about the between the Philippines and Hawaii, the situation then did not present any clear and
patient, Mrs. Ronquillo, and they told me that she has already left at around 7:00. apparent harm or injury that even a careless person may perceive. Unlike in situations
where the Supreme Court had found gross negligence to exist, petitioner could not
Q: And after calling the hospital, what happened? have been conscious of any foreseeable danger that may occur since she actually
A: I wanted to call the plaintiffs, but I didnt have their number at that time, so in the believed that she would make it to the operation that was elective in nature, the only
morning I went to my office early at 8:00 and looked for her chart, because her purpose of which was to determine the real cause of infertility and not to treat and cure
telephone number was written in the chart. So, I called them right away. a life threatening disease. Thus, in merely fixing the date of her appointment with
respondent Eva Marie Ronquillo, petitioner was not in the pursuit or performance of
Q: Were you able to contact them? conduct which any ordinary person may deem to probably and naturally result in
injury,[19] (Underscoring in original) thus persuades.
A: I was able to reach Mr. Ronquillo.
It bears noting that when she was scheduling the date of her performance of the
Q: In the course of your conversation, what did you tell Mr. Ronquillo?
procedure, Dr. Ilao-Oreta had just gotten married and was preparing for her
A: I apologized to him, I said I was sorry about the time that I missed the surgery, and honeymoon,[20] and it is of common human knowledge that excitement attends its
I told him that I can do the case right that same day without Mrs. Ronquillo having to preparations. Her negligence could then be partly attributed to human frailty which
undergo another [b]arium enema. rules out its characterization as gross.

Q: What else did you tell him, if any? The doctors negligence not being gross, the spouses are not entitled to recover moral
damages.
A: I asked him whether I can talk with Mrs. Ronquillo because I wanted to apologize
to her personally. Neither are the spouses entitled to recover exemplary damages in the absence of a
showing that Dr. Ilao-Oreta acted in a wanton, fraudulent, reckless, oppressive or
Q: And what did he say? malevolent manner,[21] nor to award of attorneys fees as, contrary to the finding of
the Court of Appeals that the spouses were compelled to litigate and incur expenses to
A: I could hear on the background that Mrs. Ronquillo was shouting angrily that she
protect their interest,[22] the records show that they did not exert enough efforts to
didnt want to talk to me, and that she didnt want re-scheduling of the surgery . . .
settle the matter before going to court. Eva Marie herself testified:
ATTY. SINJIAN: fuel expenses is an unsigned listing.[26] As the fuel and food expenses are not
adequately substantiated, they cannot be included in the computation of the amount of
Q: Isnt it true that before instituting this present case, you did not make any demand actual damages. So Premiere Development Bank v. Court of Appeals[27] instructs:
on Dr. Ilao-Oreta regarding the claims which you have allegedly incurred, because of
the failed laparoscopic surgery operation? In the instant case, the actual damages were proven through the sole testimony of
Themistocles Ruguero, the vice president for administration of Panacor. In his
A [EVA MARIE]: I will tell the truth. Dr. Augusto Reyes of St. Lukes . . . testimony, the witness affirmed that Panacor incurred losses, specifically, in terms of
Q: But did you demand? training and seminars, leasehold acquisition, procurement of vehicles and office
equipment without, however, adducing receipts to substantiate the same. The
A: No, I did not demand because documentary evidence marked as Exhibit W, which was an ordinary private writing
allegedly itemizing the capital expenditures and losses from the failed operation of
ATTY. SINJIAN: That will be all, your Honor.
Panacor, was not testified to by any witness to ascertain the veracity of its content.
ATTY. LONTOK: The witness is still explaining. Although the lower court fixed the sum of P4,520,000.00 as the total expenditures
incurred by Panacor, it failed to show how and in what manner the same were
WITNESS: Im explaining first. Dr. Augusto Reyes told me that he will hold the substantiated by the claimant with reasonable certainty. Hence, the claim for actual
meeting for me and Dr. Oreta to settle things and reimburse all the money that I spent damages should be received with extreme caution since it is only based on bare
from the hospital, and he even suggested Dr. Oreta to personally talk to me. assertion without support from independent evidence. Premieres failure to prove actual
expenditure consequently conduces to a failure of its claim. In determining actual
ATTY. SINJIAN:
damages, the court cannot rely on mere assertions, speculations, conjectures or
Q: So it was to Dr. Augusto Reyes that you talked? guesswork but must depend on competent proof and on the best evidence obtainable
regarding the actual amount of loss.[28] (Underscoring supplied)
A: Yes.
The list of expenses cannot replace receipts when they should have been issued as a
Q: But you did not demand anything or write to Dr. Oreta? matter of course in business transactions[29] as in the case of purchase of gasoline and
of food.
A: No.
The documented claim for hospital and medical expenses of the spouses is detailed in
Q: Before instituting this case?
the Statement of Account issued by the hospital, the pertinent entries of which read:
A: No.[23] (Underscoring supplied)
xxxx
Finally, Dr. Ilao-Oretas prayer for the reduction of actual damages is well-taken.
GROSS HOSPITAL CHARGES 2,416.50
Article 2201 of the Civil Code provides:
4/5/1999 1699460 DEPOSITOFFICIAL
In contracts and quasi-contracts, the damages for which the obligor who acted in good RECEIPT (5,000.00)
faith is liable shall be those which are the natural and probable consequences of the (5,000.00)
breach of the obligation, and which the parties have foreseen or could have reasonably ________
foreseen at the time the obligation was constituted. 4/5/1999 SECOND 0284893 UNUSED MED 0439534 (65.55)
FLOOR HINOX 500 MG CAP
In fixing the amount of actual damages, the Court of Appeals and the trial court SECOND 0284894 UNUSED MED 0439893 (62.25)
included expenses which the spouses incurred prior to April 5, 1999 when the breach FLOOR PHENERGAN 2 ML
of contract complained of occurred.[24] The Court of Appeals also included the 50MG ______ (127.80)
alleged P300 spent on fuel consumption from the spouses residence at San Pascual, BALANCE DUE (2,711.30)[30]
Batangas to the St. Lukes Medical Center in Quezon City and the alleged P500 spent =======
on food in the hospital canteen, both of which are unsubstantiated by independent or
competent proof.[25] The only piece of documentary evidence supporting the food and
As extrapolated from the above-quoted entries in the Statement of Account, P2,288.70
(the gross hospital charges of P2,416.50 less the unused medicine in the amount of
P127.80) was debited from the P5,000 deposit[31] to thus leave a balance of the
deposit in the amount of P2,711.30, which the trial court erroneously denominated as
confinement fee. The remaining balance of P2,711.30 was the amount refundable to
the spouses.

Following Eastern Shipping Lines, Inc. v. Court of Appeals,[32] this Court awards
interest on the actual damages to be paid by Dr. Ilao-Oreta at the rate of 6% per annum
from the time of the filing of the complaint on May 18, 1999, and at 12% per annum
from the finality of this judgment until its satisfaction.

WHEREFORE, the petition is GRANTED. The decision appealed from is


MODIFIED in that :

1) The award to respondents-spouses Noel and Eva Marie Ronquillo of actual damages
is REDUCED to P2,288.70, to bear interest at a rate of 6% per annum from the time
of the filing of the complaint on May 18, 1999 and, upon finality of this judgment, at
the rate of 12% per annum until satisfaction; and

2. The award of moral and exemplary damages and attorneys fees is DELETED.

SO ORDERED.
SECOND DIVISION BACKGROUND FACTS

G.R. No. 158996 November 14, 2008 Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto. Domingo,
Nueva Ecija. She consulted on April 17, 1987 her townmate, Dr. Fredelicto Flores,
SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA FLORES, regarding her medical condition. She complained of general body weakness, loss of
VS. SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO, and appetite, frequent urination and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto
FLORENCIO, CANDIDA, MARTA, GODOFREDO, BALTAZAR and initially interviewed the patient and asked for the history of her monthly period to
LUCENA, all surnamed PINEDA, as heirs of the deceased TERESITA S. analyze the probable cause of the vaginal bleeding. He advised her to return the
PINEDA, and UNITED DOCTORS MEDICAL CENTER, INC., following week or to go to the United Doctors Medical Center (UDMC) in Quezon
DECISION City for a general check-up. As for her other symptoms, he suspected that Teresita
might be suffering from diabetes and told her to continue her medications.[4]
BRION, J.
Teresita did not return the next week as advised. However, when her condition
This petition involves a medical negligence case that was elevated to this Court persisted, she went to further consult Dr. Flores at his UDMC clinic on April 28, 1987,
through an appeal by certiorari under Rule 45 of the Rules of Court. The petition assails travelling for at least two hours from Nueva Ecija to Quezon City with her sister,
the Decision[1] of the Court of Appeals (CA) in CA G.R. CV No. 63234, which Lucena Pineda. They arrived at UDMC at around 11:15 a.m.. Lucena later testified
affirmed with modification the Decision[2] of the Regional Trial Court (RTC) of that her sister was then so weak that she had to lie down on the couch of the clinic
Nueva Ecija, Branch 37 in Civil Case No. SD-1233. The dispositive portion of the while they waited for the doctor. When Dr. Fredelicto arrived, he did a routine check-
assailed CA decision states: up and ordered Teresitas admission to the hospital. In the admission slip, he directed
the hospital staff to prepare the patient for an on call D&C[5] operation to be
WHEREFORE, premises considered, the assailed Decision of the Regional
performed by his wife, Dr. Felicisima Flores (Dr. Felicisima). Teresita was brought to
Trial Court of Baloc, Sto. Domingo, Nueva Ecija, Branch 37 is hereby
her hospital room at around 12 noon; the hospital staff forthwith took her blood and
AFFIRMED but with modifications as follows:
1) Ordering defendant-appellants Dr. and Dra. Fredelicto A. Flores and the urine samples for the laboratory tests[6] which Dr. Fredelicto ordered.
United Doctors Medical Center, Inc. to jointly and severally pay the plaintiff- At 2:40 p.m. of that same day, Teresita was taken to the operating room. It was only
appellees heirs of Teresita Pineda, namely, Spouses Dominador Pineda and
then that she met Dr. Felicisima, an obstetrician and gynecologist. The two doctors Dr.
Virginia Saclolo and Florencio, Candida, Marta, Godofredo, Baltazar and
Felicisima and Dr. Fredelicto, conferred on the patients medical condition, while the
Lucena, all surnamed Pineda, the sum of P400,000.00 by way of moral
damages; resident physician and the medical intern gave Dr. Felicisima their own briefings. She
2) Ordering the above-named defendant-appellants to jointly and severally also interviewed and conducted an internal vaginal examination of the patient which
pay the above-named plaintiff-appellees the sum of P100,000.00 by way of lasted for about 15 minutes. Dr. Felicisima thereafter called up the laboratory for the
exemplary damages; results of the tests. At that time, only the results for the blood sugar (BS), uric acid
3) Ordering the above-named defendant-appellants to jointly and severally determination, cholesterol determination, and complete blood count (CBC) were
pay the above-named plaintiff-appellees the sum of P36,000.00 by way of available. Teresitas BS count was 10.67mmol/l[7] and her CBC was 109g/l.[8]
actual and compensatory damages; and
4) Deleting the award of attorneys fees and costs of suit. Based on these preparations, Dr. Felicisima proceeded with the D&C operation with
SO ORDERED. Dr. Fredelicto administering the general anesthesia. The D&C operation lasted for
about 10 to 15 minutes. By 3:40 p.m., Teresita was wheeled back to her room.
While this case essentially involves questions of facts, we opted for the requested
review in light of questions we have on the findings of negligence below, on the A day after the operation (or on April 29, 1987), Teresita was subjected to an
awarded damages and costs, and on the importance of this type of ruling on medical ultrasound examination as a confirmatory procedure. The results showed that she had
practice.[3] an enlarged uterus and myoma uteri.[9] Dr. Felicisima, however, advised Teresita that
she could spend her recovery period at home. Still feeling weak, Teresita opted for
hospital confinement.
Teresitas complete laboratory examination results came only on that day (April 29, to proceed with the D&C operation was an honest mistake of judgment or one
1987). Teresitas urinalysis showed a three plus sign (+++) indicating that the sugar in amounting to negligence.
her urine was very high. She was then placed under the care of Dr. Amado Jorge, an
internist. Elements of a Medical Negligence Case

By April 30, 1987, Teresitas condition had worsened. She experienced difficulty in A medical negligence case is a type of claim to redress a wrong committed by a
breathing and was rushed to the intensive care unit. Further tests confirmed that she medical professional, that has caused bodily harm to or the death of a patient. There
was suffering from Diabetes Mellitus Type II.[10] Insulin was administered on the are four elements involved in a medical negligence case, namely: duty, breach, injury,
patient, but the medication might have arrived too late. Due to complications induced and proximate causation.[14]
by diabetes, Teresita died in the morning of May 6, 1987.[11] Duty refers to the standard of behavior which imposes restrictions on ones
Believing that Teresitas death resulted from the negligent handling of her medical conduct.[15] The standard in turn refers to the amount of competence associated with
needs, her family (respondents) instituted an action for damages against Dr. Fredelicto the proper discharge of the profession. A physician is expected to use at least the same
Flores and Dr. Felicisima Flores (collectively referred to as the petitioner spouses) level of care that any other reasonably competent doctor would use under the same
before the RTC of Nueva Ecija. circumstances. Breach of duty occurs when the physician fails to comply with these
professional standards. If injury results to the patient as a result of this breach, the
The RTC ruled in favor of Teresitas family and awarded actual, moral, and exemplary physician is answerable for negligence.[16]
damages, plus attorneys fees and costs.[12] The CA affirmed the judgment, but
modified the amount of damages awarded and deleted the award for attorneys fees and As in any civil action, the burden to prove the existence of the necessary elements rests
costs of suit.[13] with the plaintiff.[17] To successfully pursue a claim, the plaintiff must prove by
preponderance of evidence that, one, the physician either failed to do something which
Through this petition for review on certiorari, the petitioner spouses Dr. Fredelicto a reasonably prudent health care provider would have done, or that he did something
(now deceased) and Dr. Felicisima Flores allege that the RTC and CA committed a that a reasonably prudent provider would not have done; and two, the failure or action
reversible error in finding them liable through negligence for the death of Teresita caused injury to the patient.[18] Expert testimony is therefore essential since the
Pineda. factual issue of whether a physician or surgeon has exercised the requisite degree of
skill and care in the treatment of his patient is generally a matter of expert opinion.[19]
ASSIGNMENT OF ERRORS
Standard of Care and Breach of Duty
The petitioner spouses contend that they exercised due care and prudence in the
performance of their duties as medical professionals. They had attended to the patient D&C is the classic gynecologic procedure for the evaluation and possible therapeutic
to the best of their abilities and undertook the management of her case based on her treatment for abnormal vaginal bleeding.[20] That this is the recognized procedure is
complaint of an on-and-off vaginal bleeding. In addition, they claim that nothing on confirmed by Drs. Salvador Nieto (Dr. Nieto) and Joselito Mercado (Dr. Mercado),
record shows that the death of Teresita could have been averted had they employed the expert witnesses presented by the respondents:
means other than what they had adopted in the ministration of the patient.
DR. NIETO: [W]hat I know among obstetricians, if there is bleeding, they perform
THE COURTS RULING what we call D&C for diagnostic purposes

We do not find the petition meritorious. xxx xxx xxx

The respondents claim for damages is predicated on their allegation that the decision Q: So are you trying to tell the Court that D&C can be a diagnostic treatment?
of the petitioner spouses to proceed with the D&C operation, notwithstanding
Teresitas condition and the laboratory test results, amounted to negligence. On the A: Yes, sir. Any doctor knows this.[21] Dr. Mercado, however, objected with respect
other hand, the petitioner spouses contend that a D&C operation is the proper and to the time the D&C operation should have been conducted in Teresitas case. He
accepted procedure to address vaginal bleeding the medical problem presented to opined that given the blood sugar level of Teresita, her diabetic condition should have
them. Given that the patient died after the D&C, the core issue is whether the decision been addressed first:

Q: Why do you consider the time of performance of the D&C not appropriate?
Third, the petitioner spouses cannot claim that their principal concern was the vaginal
bleeding and should not therefore be held accountable for complications coming from
A: Because I have read the record and I have seen the urinalysis, [there is] spillage in other sources. This is a very narrow and self-serving view that even reflects on their
the urine, and blood sugar was 10.67 competence.
Q: What is the significance of the spillage in the urine? Taken together, we find that reasonable prudence would have shown that diabetes and
A: It is a sign that the blood sugar is very high. its complications were foreseeable harm that should have been taken into consideration
by the petitioner spouses. If a patient suffers from some disability that increases the
Q: Does it indicate sickness? magnitude of risk to him, that disability must be taken into account so long as it is or
should have been known to the physician.[29] And when the patient is exposed to an
A: 80 to 95% it means diabetes mellitus. The blood sugar was 10.67.
increased risk, it is incumbent upon the physician to take commensurate and adequate
xxx xxx xxx precautions.

COURT: In other words, the operation conducted on the patient, your opinion, that it Taking into account Teresitas high blood sugar,[30] Dr. Mendoza opined that the
is inappropriate? attending physician should have postponed the D&C operation in order to conduct a
confirmatory test to make a conclusive diagnosis of diabetes and to refer the case to
A: The timing of [when] the D&C [was] done, based on the record, in my personal an internist or diabetologist. This was corroborated by Dr. Delfin Tan (Dr. Tan), an
opinion, that D&C should be postponed a day or two.[22] obstetrician and gynecologist, who stated that the patients diabetes should have been
managed by an internist prior to, during, and after the operation.[31]
The petitioner spouses countered that, at the time of the operation, there was nothing
to indicate that Teresita was afflicted with diabetes: a blood sugar level of 10.67mmol/l Apart from bleeding as a complication of pregnancy, vaginal bleeding is only rarely
did not necessarily mean that she was a diabetic considering that this was random so heavy and life-threatening that urgent first-aid measures are required.[32] Indeed,
blood sugar;[23] there were other factors that might have caused Teresitas blood sugar the expert witnesses declared that a D&C operation on a hyperglycemic patient may
to rise such as the taking of blood samples during lunchtime and while patient was be justified only when it is an emergency case when there is profuse vaginal bleeding.
being given intra-venous dextrose.[24] Furthermore, they claim that their principal In this case, we choose not to rely on the assertions of the petitioner spouses that there
concern was to determine the cause of and to stop the vaginal bleeding. was profuse bleeding, not only because the statements were self-serving, but also
because the petitioner spouses were inconsistent in their testimonies. Dr. Fredelicto
The petitioner spouses contentions, in our view, miss several points. First, as early as
testified earlier that on April 28, he personally saw the bleeding,[33] but later on said
April 17, 1987, Teresita was already suspected to be suffering from diabetes.[25] This
that he did not see it and relied only on Teresitas statement that she was bleeding.[34]
suspicion again arose right before the D&C operation on April 28, 1987 when the
He went on to state that he scheduled the D&C operation without conducting any
laboratory result revealed Teresitas increased blood sugar level.[26] Unfortunately, the
physical examination on the patient.
petitioner spouses did not wait for the full medical laboratory results before proceeding
with the D&C, a fact that was never considered in the courts below. Second, the The likely story is that although Teresita experienced vaginal bleeding on April 28, it
petitioner spouses were duly advised that the patient was experiencing general body was not sufficiently profuse to necessitate an immediate emergency D&C operation.
weakness, loss of appetite, frequent urination, and thirst all of which are classic Dr. Tan[35] and Dr. Mendoza[36] both testified that the medical records of Teresita
symptoms of diabetes.[27] When a patient exhibits symptoms typical of a particular failed to indicate that there was profuse vaginal bleeding. The claim that there was
disease, these symptoms should, at the very least, alert the physician of the possibility profuse vaginal bleeding although this was not reflected in the medical records strikes
that the patient may be afflicted with the suspected disease: us as odd since the main complaint is vaginal bleeding. A medical record is the only
document that maintains a long-term transcription of patient care and as such, its
[Expert testimony for the plaintiff showed that] tests should have been ordered
maintenance is considered a priority in hospital practice. Optimal record-keeping
immediately on admission to the hospital in view of the symptoms presented, and that
includes all patient inter-actions. The records should always be clear, objective, and
failure to recognize the existence of diabetes constitutes negligence.[28]
up-to-date.[37] Thus, a medical record that does not indicate profuse medical bleeding
speaks loudly and clearly of what it does not contain.
That the D&C operation was conducted principally to diagnose the cause of the vaginal As Dr. Tan testified, the patients hyperglycemic condition should have been managed
bleeding further leads us to conclude that it was merely an elective procedure, not an not only before and during the operation, but also immediately after. Despite the
emergency case. In an elective procedure, the physician must conduct a thorough pre- possibility that Teresita was afflicted with diabetes, the possibility was casually
operative evaluation of the patient in order to adequately prepare her for the operation ignored even in the post-operative evaluation of the patient; the concern, as the
and minimize possible risks and complications. The internist is responsible for petitioner spouses expressly admitted, was limited to the complaint of vaginal
generating a comprehensive evaluation of all medical problems during the pre- bleeding. Interestingly, while the ultrasound test confirmed that Teresita had a myoma
operative evaluation.[38] in her uterus, she was advised that she could be discharged a day after the operation
and that her recovery could take place at home. This advice implied that a day after
The aim of pre-operative evaluation is not to screen broadly for undiagnosed disease, the operation and even after the complete laboratory results were submitted, the
but rather to identify and quantify comorbidity that may impact on the operative petitioner spouses still did not recognize any post-operative concern that would require
outcome. This evaluation is driven by findings on history and physical examination the monitoring of Teresitas condition in the hospital.
suggestive of organ system dysfunctionThe goal is to uncover problem areas that may
require further investigation or be amenable to preoperative optimization. The above facts, point only to one conclusion that the petitioner spouses failed, as
medical professionals, to comply with their duty to observe the standard of care to be
If the preoperative evaluation uncovers significant comorbidity or evidence of poor given to hyperglycemic/diabetic patients undergoing surgery. Whether this breach of
control of an underlying disease process, consultation with an internist or medical duty was the proximate cause of Teresitas death is a matter we shall next determine.
specialist may be required to facilitate the work-up and direct management. In this
process, communication between the surgeons and the consultants is essential to define Injury and Causation
realistic goals for this optimization process and to expedite surgical management.[39]
[Emphasis supplied.] As previously mentioned, the critical and clinching factor in a medical negligence case
is proof of the causal connection between the negligence which the evidence
Significantly, the evidence strongly suggests that the pre-operative evaluation was less established and the plaintiffs injuries;[45] the plaintiff must plead and prove not only
than complete as the laboratory results were fully reported only on the day following that he had been injured and defendant has been at fault, but also that the defendants
the D&C operation. Dr. Felicisima only secured a telephone report of the preliminary fault caused the injury. A verdict in a malpractice action cannot be based on
laboratory result prior to the D&C. This preliminary report did not include the 3+ status speculation or conjecture. Causation must be proven within a reasonable medical
of sugar in the patients urine[40] a result highly confirmatory of diabetes. probability based upon competent expert testimony.[46]

Because the D&C was merely an elective procedure, the patients uncontrolled The respondents contend that unnecessarily subjecting Teresita to a D&C operation
hyperglycemia presented a far greater risk than her on-and-off vaginal bleeding. The without adequately preparing her, aggravated her hyperglycemic state and caused her
presence of hyperglycemia in a surgical patient is associated with poor clinical untimely demise. The death certificate of Teresita lists down the following causes of
outcomes, and aggressive glycemic control positively impacts on morbidity and death:
mortality.[41] Elective surgery in people with uncontrolled diabetes should preferably
be scheduled after acceptable glycemic control has been achieved.[42] According to Immediate cause: Cardiorespiratory arrest
Dr. Mercado, this is done by administering insulin on the patient.[43] Antecedent cause: Septicemic shock, ketoacidocis
Underlying cause: Diabetes Mellitus II
The management approach in this kind of patients always includes insulin therapy in Other significant conditions contributing to death: Renal Failure Acute[47]
combination with dextrose and potassium infusion. Insulin xxx promotes glucose
uptake by the muscle and fat cells while decreasing glucose production by the liver
xxx. The net effect is to lower blood glucose levels.[44] Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C
operation is a form of physical stress. Dr. Mendoza explained how surgical stress can
The prudent move is to address the patients hyperglycemic state immediately and aggravate the patients hyperglycemia: when stress occurs, the diabetics body,
promptly before any other procedure is undertaken. In this case, there was no evidence especially the autonomic system, reacts by secreting hormones which are counter-
that insulin was administered on Teresita prior to or during the D&C operation. Insulin regulatory; she can have prolonged hyperglycemia which, if unchecked, could lead to
was only administered two days after the operation. death.[48] Medical literature further explains that if the blood sugar has become very
high, the patient becomes comatose (diabetic coma). When this happens over several
days, the body uses its own fat to produce energy, and the result is high levels of waste These findings lead us to the conclusion that the decision to proceed with the D&C
products (called ketones) in the blood and urine (called diabetic ketoacidiosis, a operation, notwithstanding Teresitas hyperglycemia and without adequately preparing
medical emergency with a significant mortality).[49] This was apparently what her for the procedure, was contrary to the standards observed by the medical
happened in Teresitas case; in fact, after she had been referred to the internist Dr. Jorge, profession. Deviation from this standard amounted to a breach of duty which resulted
laboratory test showed that her blood sugar level shot up to 14.0mmol/l, way above in the patients death. Due to this negligent conduct, liability must attach to the
the normal blood sugar range. Thus, between the D&C and death was the diabetic petitioner spouses.
complication that could have been prevented with the observance of standard medical
precautions. The D&C operation and Teresitas death due to aggravated diabetic Liability of the Hospital
condition is therefore sufficiently established. In the proceedings below, UDMC was the spouses Flores co-defendant. The RTC
The trial court and the appellate court pinned the liability for Teresitas death on both found the hospital jointly and severally liable with the petitioner spouses, which
the petitioner spouses and this Court finds no reason to rule otherwise. However, we decision the CA affirmed. In a Resolution dated August 28, 2006, this Court however
clarify that Dr. Fredelictos negligence is not solely the act of ordering an on call D&C denied UDMCs petition for review on certiorari. Since UDMCs appeal has been
operation when he was mainly an anaesthesiologist who had made a very cursory denied and they are not parties to this case, we find it unnecessary to delve on the
examination of the patients vaginal bleeding complaint. Rather, it was his failure from matter. Consequently, the RTCs decision, as affirmed by the CA, stands.
the very start to identify and confirm, despite the patients complaints and his own Award of Damages
suspicions, that diabetes was a risk factor that should be guarded against, and his
participation in the imprudent decision to proceed with the D&C operation despite his Both the trial and the appellate court awarded actual damages as compensation for the
early suspicion and the confirmatory early laboratory results. The latter point comes pecuniary loss the respondents suffered. The loss was presented in terms of the hospital
out clearly from the following exchange during the trial: bills and expenses the respondents incurred on account of Teresitas confinement and
death. The settled rule is that a plaintiff is entitled to be compensated for proven
Q: On what aspect did you and your wife consult [with] each other? pecuniary loss.[52] This proof the respondents successfully presented. Thus, we affirm
A: We discussed on the finding of the laboratory [results] because the hemoglobin was the award of actual damages of P36,000.00 representing the hospital expenses the
below normal, the blood sugar was elevated, so that we have to evaluate these patient incurred.
laboratory results what it means. In addition to the award for actual damages, the respondent heirs of Teresita are
Q: So it was you and your wife who made the evaluation when it was phoned in? likewise entitled to P50,000.00 as death indemnity pursuant to Article 2206 of the
Civil Code, which states that the amount of damages for death caused by a xxx quasi-
A: Yes, sir. delict shall be at least three thousand pesos,[53] even though there may have been
mitigating circumstances xxx. This is a question of law that the CA missed in its
Q: Did your wife, before performing D&C ask your opinion whether or not she can decision and which we now decide in the respondents favor.
proceed?
The same article allows the recovery of moral damages in case of death caused by a
A: Yes, anyway, she asked me whether we can do D&C based on my experience. quasi-delict and enumerates the spouse, legitimate or illegitimate ascendants or
Q: And your answer was in the positive notwithstanding the elevation of blood sugar? descendants as the persons entitled thereto. Moral damages are designed to
compensate the claimant for the injury suffered, that is, for the mental anguish, serious
A: Yes, sir, it was both our disposition to do the D&C. [Emphasis supplied.][50] anxiety, wounded feelings which the respondents herein must have surely felt with the
unexpected loss of their daughter. We affirm the appellate courts award of
If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not being an
P400,000.00 by way of moral damages to the respondents.
internist or a diabetologist (for which reason he referred Teresita to Dr. Jorge),[51] he
should have likewise refrained from making a decision to proceed with the D&C We similarly affirm the grant of exemplary damages. Exemplary damages are imposed
operation since he was niether an obstetrician nor a gynecologist. by way of example or correction for the public good.[54] Because of the petitioner
spouses negligence in subjecting Teresita to an operation without first recognizing and
addressing her diabetic condition, the appellate court awarded exemplary damages to
the respondents in the amount of P100,000.00. Public policy requires such imposition
to suppress the wanton acts of an offender.[55] We therefore affirm the CAs award as
an example to the medical profession and to stress that the public good requires stricter
measures to avoid the repetition of the type of medical malpractice that happened in
this case.

With the award of exemplary damages, the grant of attorneys fees is legally in
order.[56] We therefore reverse the CA decision deleting these awards, and grant the
respondents the amount of P100,000.00 as attorneys fees taking into consideration the
legal route this case has taken.

WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003 in CA


G.R. CV No. 63234 finding petitioner spouses liable for negligent medical practice.
We likewise AFFIRM the awards of actual and compensatory damages of P36,000.00;
moral damages of P400,000.00; and exemplary damages of P100,000.00.

We MODIFY the CA Decision by additionally granting an award of P50,000.00 as


death indemnity and by reversing the deletion of the award of attorneys fees and costs
and restoring the award of P100,000.00 as attorneys fees. Costs of litigation are
adjudged against petitioner spouses.

To summarize, the following awards shall be paid to the family of the late Teresita
Pineda:

1. The sum of P36,000.00 by way of actual and compensatory damages;


2. The sum of P50,000.00 by way of death indemnity;
3. The sum of P400,000.00 by way of moral damages;
4. The sum of P100,000.00 by way of exemplary damages;
5. The sum of P100,000.00 by way of attorneys fees; and
6. Costs.

SO ORDERED.
On November 7, 1994, Editha and her husband Claro Ramolete (respondents) filed a
Complaint[7] for Gross Negligence and Malpractice against petitioner before the
Republic of the Philippines Professional Regulations Commission (PRC).
Supreme Court
Manila Respondents alleged that Edithas hysterectomy was caused by petitioners unmitigated
THIRD DIVISION negligence and professional incompetence in conducting the D&C procedure and the
petitioners failure to remove the fetus inside Edithas womb.[8] Among the alleged acts
of negligence were: first, petitioners failure to check up, visit or administer medication
on Editha during her first day of confinement at the LMC;[9] second, petitioner
G.R. No. 159132 December 18, 2008 recommended that a D&C procedure be performed on Editha without conducting any
FE CAYAO-LASAM VS. SPOUSES CLARO and EDITHA RAMOLETE internal examination prior to the procedure;[10] third, petitioner immediately
suggested a D&C procedure instead of closely monitoring the state of pregnancy of
Editha.[11]
DECISION In her Answer,[12] petitioner denied the allegations of negligence and incompetence
with the following explanations: upon Edithas confirmation that she would seek
AUSTRIA-MARTINEZ, J.:
admission at the LMC, petitioner immediately called the hospital to anticipate the
Before the Court is a Petition for Review on Certiorari under Rule 45 of the Rules of arrival of Editha and ordered through the telephone the medicines Editha needed to
Court filed by Dr. Fe Cayao-Lasam (petitioner) seeking to annul the Decision[1] dated take, which the nurses carried out; petitioner visited Editha on the morning of July 28,
July 4, 2003 of the Court of Appeals (CA) in CA-G.R. SP No. 62206. 1994 during her rounds; on July 29, 1994, she performed an internal examination on
Editha and she discovered that the latters cervix was already open, thus, petitioner
The antecedent facts: discussed the possible D&C procedure, should the bleeding become more profuse; on
July 30 1994, she conducted another internal examination on Editha, which revealed
On July 28, 1994, respondent, three months pregnant Editha Ramolete (Editha) was
that the latters cervix was still open; Editha persistently complained of her vaginal
brought to the Lorma Medical Center (LMC) in San Fernando, La Union due to vaginal
bleeding and her passing out of some meaty mass in the process of urination and bowel
bleeding. Upon advice of petitioner relayed via telephone, Editha was admitted to the
movement; thus, petitioner advised Editha to undergo D&C procedure which the
LMC on the same day. A pelvic sonogram[2] was then conducted on Editha revealing
respondents consented to; petitioner was very vocal in the operating room about not
the fetus weak cardiac pulsation.[3] The following day, Edithas repeat pelvic
being able to see an abortus;[13] taking the words of Editha to mean that she was
sonogram[4] showed that aside from the fetus weak cardiac pulsation, no fetal
passing out some meaty mass and clotted blood, she assumed that the abortus must
movement was also appreciated. Due to persistent and profuse vaginal bleeding,
have been expelled in the process of bleeding; it was Editha who insisted that she
petitioner advised Editha to undergo a Dilatation and Curettage Procedure (D&C) or
wanted to be discharged; petitioner agreed, but she advised Editha to return for check-
raspa.
up on August 5, 1994, which the latter failed to do.
On July 30, 1994, petitioner performed the D&C procedure. Editha was discharged
Petitioner contended that it was Edithas gross negligence and/or omission in insisting
from the hospital the following day.
to be discharged on July 31, 1994 against doctors advice and her unjustified failure to
On September 16, 1994, Editha was once again brought at the LMC, as she was return for check-up as directed by petitioner that contributed to her life-threatening
suffering from vomiting and severe abdominal pains. Editha was attended by Dr. condition on September 16, 1994; that Edithas hysterectomy was brought about by her
Beatriz de la Cruz, Dr. Victor B. Mayo and Dr. Juan V. Komiya. Dr. Mayo allegedly very abnormal pregnancy known as placenta increta, which was an extremely rare and
informed Editha that there was a dead fetus in the latters womb. After, Editha very unusual case of abdominal placental implantation. Petitioner argued that whether
underwent laparotomy,[5] she was found to have a massive intra-abdominal or not a D&C procedure was done by her or any other doctor, there would be no
hemorrhage and a ruptured uterus. Thus, Editha had to undergo a procedure for difference at all because at any stage of gestation before term, the uterus would rupture
hysterectomy[6] and as a result, she has no more chance to bear a child. just the same.
On March 4, 1999, the Board of Medicine (the Board) of the PRC rendered a 1. THE COURT OF APPEALS ERRED ON A QUESTION OF LAW IN HOLDING
Decision,[14] exonerating petitioner from the charges filed against her. The Board THAT THE PROFESSIONAL REGULATION[S] COMMISSION (PRC) WAS
held: EXCLUDED AMONG THE QUASI-JUDICIAL AGENCIES CONTEMPLATED
UNDER RULE 43 OF THE RULES OF CIVIL PROCEDURE;
Based on the findings of the doctors who conducted the laparotomy on Editha, hers is
a case of Ectopic Pregnancy Interstitial. This type of ectopic pregnancy is one that is 2. EVEN ASSUMING, ARGUENDO, THAT PRC WAS EXCLUDED FROM THE
being protected by the uterine muscles and manifestations may take later than four (4) PURVIEW OF RULE 43 OF THE RULES OF CIVIL PROCEDURE, THE
months and only attributes to two percent (2%) of ectopic pregnancy cases. PETITIONER WAS NOT PRECLUDED FROM FILING A PETITION FOR
CERTIORARI WHERE THE DECISION WAS ALSO ISSUED IN EXCESS OF OR
When complainant Editha was admitted at Lorma Medical Center on July 28, 1994 WITHOUT JURISDICTION, OR WHERE THE DECISION WAS A PATENT
due to vaginal bleeding, an ultra-sound was performed upon her and the result of the NULLITY;
Sonogram Test reveals a morbid fetus but did not specify where the fetus was located.
Obstetricians will assume that the pregnancy is within the uterus unless so specified 3. HEREIN RESPONDENTS-SPOUSES ARE NOT ALLOWED BY LAW TO
by the Sonologist who conducted the ultra-sound. Respondent (Dr. Lasam) cannot be APPEAL FROM THE DECISION OF THE BOARD OF MEDICINE TO THE
faulted if she was not able to determine that complainant Editha is having an ectopic PROFESSIONAL REGULATION[S] COMMISSION;
pregnancy interstitial. The D&C conducted on Editha is necessary considering that her
cervix is already open and so as to stop the profuse bleeding. Simple curettage cannot 4. THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF DISCRETION
remove a fetus if the patient is having an ectopic pregnancy, since ectopic pregnancy IN DENYING FOR IMPROPER FORUM THE PETITION FOR
is pregnancy conceived outside the uterus and curettage is done only within the uterus. REVIEW/PETITION FOR CERTIORARI WITHOUT GOING OVER THE MERITS
Therefore, a more extensive operation needed in this case of pregnancy in order to OF THE GROUNDS RELIED UPON BY THE PETITIONER;
remove the fetus.[15] 5. PRCS GRAVE OMISSION TO AFFORD HEREIN PETITONER A CHANCE
Feeling aggrieved, respondents went to the PRC on appeal. On November 22, 2000, TO BE HEARD ON APPEAL IS A CLEAR VIOLATION OF HER
the PRC rendered a Decision[16] reversing the findings of the Board and revoking CONSTITUTIONAL RIGHT TO DUE PROCESS AND HAS THE EFFECT OF
petitioners authority or license to practice her profession as a physician.[17] RENDERING THE JUDGMENT NULL AND VOID;

Petitioner brought the matter to the CA in a Petition for Review under Rule 43 of the 6. COROLLARY TO THE FOURTH ASSIGNED ERROR, PRC COMMITTED
Rules of Court. Petitioner also dubbed her petition as one for certiorari[18] under Rule GRAVE ABUSE OF DISCRETION, AMOUNTING TO LACK OF JURISDICTION,
65 of the Rules of Court. IN ACCEPTING AND CONSIDERING THE MEMORANDUM ON APPEAL
WITHOUT PROOF OF SERVICE TO HEREIN PETITIONER, AND IN
In the Decision dated July 4, 2003, the CA held that the Petition for Review under VIOLATION OF ART. IV, SEC. 35 OF THE RULES AND REGULATIONS
Rule 43 of the Rules of Court was an improper remedy, as the enumeration of the GOVERNING THE REGULATION AND PRACTICE OF PROFESSIONALS;
quasi-judicial agencies in Rule 43 is exclusive.[19] PRC is not among the quasi-
judicial bodies whose judgment or final orders are subject of a petition for review to 7. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN REVOKING
the CA, thus, the petition for review of the PRC Decision, filed at the CA, was PETITIONERS LICENSE TO PRACTICE MEDICINE WITHOUT AN EXPERT
improper. The CA further held that should the petition be treated as a petition for TESTIMONY TO SUPPORT ITS CONCLUSION AS TO THE CAUSE OF
certiorari under Rule 65, the same would still be dismissed for being improper and RESPONDENT EDITHAT [SIC] RAMOLETES INJURY;
premature. Citing Section 26[20] of Republic Act (R.A.) No. 2382 or the Medical Act 8. PRC COMMITTED AN EVEN GRAVER ABUSE OF DISCRETION IN
of 1959, the CA held that the plain, speedy and adequate remedy under the ordinary TOTALLY DISREGARDING THE FINDING OF THE BOARD OF MEDICINE,
course of law which petitioner should have availed herself of was to appeal to the WHICH HAD THE NECESSARY COMPETENCE AND EXPERTISE TO
Office of the President.[21] ESTABLISH THE CAUSE OF RESPONDENT EDITHAS INJURY, AS WELL AS
Hence, herein petition, assailing the decision of the CA on the following grounds: THE TESTIMONY OF THE EXPERT WITNESS AUGUSTO MANALO, M.D.
;[and]
9. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN MAKING Moreover, Section 35 of the Rules and Regulations Governing the Regulation and
CONCLUSIONS OF FACTS THAT WERE NOT ONLY UNSUPPORTED BY Practice of Professionals cited by petitioner was subsequently amended to read:
EVIDENCE BUT WERE ACTUALLY CONTRARY TO EVIDENCE ON
RECORD.[22] 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
The Court will first deal with the procedural issues. whose decision shall be final and executory. Interlocutory order shall not be appealable
to the Commission. (Amended by Res. 174, Series of 1990).[27] (Emphasis supplied)
Petitioner claims that the law does not allow complainants to appeal to the PRC from
the decision of the Board. She invokes Article IV, Section 35 of the Rules and Whatever doubt was created by the previous provision was settled with said
Regulations Governing the Regulation and Practice of Professionals, which provides: amendment. It is 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
Sec. 35. The respondent may appeal the decision of the Board within thirty days from prescribed by law.[28] In this case, the clear intent of the amendment is to render the
receipt thereof to the Commission whose decision shall be final. Complainant, when right to appeal from a decision of the Board available to both complainants and
allowed by law, may interpose an appeal from the Decision of the Board within the respondents.
same period. (Emphasis supplied)
Such conclusion is bolstered by the fact that in 2006, the PRC issued Resolution No.
Petitioner asserts that a careful reading of the above law indicates that while the 06-342(A), or the New Rules of Procedure in Administrative Investigations in the
respondent, as a matter of right, may appeal the Decision of the Board to the Professional Regulations Commission and the Professional Regulatory Boards, which
Commission, the complainant may interpose an appeal from the decision of the Board provides for the method of appeal, to wit:
only when so allowed by law.[23] Petitioner cited Section 26 of Republic Act No.
2382 or The Medical Act of 1959, to wit: Sec. 1. Appeal; Period Non-Extendible.- The decision, order or resolution of the Board
shall be final and executory after the lapse of fifteen (15) days from receipt of the
Section 26. Appeal from judgment. The decision of the Board of Medical Examiners decision, order or resolution without an appeal being perfected or taken by either the
(now Medical Board) shall automatically become final thirty days after the date of its respondent or the complainant. A party aggrieved by the decision, order or resolution
promulgation unless the respondent, during the same period, has appealed to the may file a notice of appeal from the decision, order or resolution of the Board to the
Commissioner of Civil Service (now Professional Regulations Commission) and later Commission within fifteen (15) days from receipt thereof, and serving upon the
to the Office of the President of the Philippines. If the final decision is not satisfactory, adverse party a notice of appeal together with the appellants brief or memorandum on
the respondent may ask for a review of the case, or may file in court a petition for appeal, and paying the appeal and legal research fees. x x x[29]
certiorari.
The above-stated provision does not qualify whether only the complainant or
Petitioner posits that the reason why the Medical Act of 1959 allows only the respondent may file an appeal; rather, the new rules provide that a party aggrieved may
respondent in an administrative case to file an appeal with the Commission while the file a notice of appeal. Thus, either the complainant or the respondent who has been
complainant is not allowed to do so is double jeopardy. Petitioner is of the belief that aggrieved by the decision, order or resolution of the Board may appeal to the
the revocation of license to practice a profession is penal in nature.[24 Commission. It is an elementary rule that when the law speaks in clear and categorical
The Court does not agree. language, there is no need, in the absence of legislative intent to the contrary, for any
interpretation.[30] Words and phrases used in the statute should be given their plain,
For one, the principle of double jeopardy finds no application in administrative cases. ordinary, and common usage or meaning.[31]
Double jeopardy attaches only: (1) upon a valid indictment; (2) before a competent
court; (3) after arraignment; (4) when a valid plea has been entered; and (5) when the Petitioner also submits that appeals from the decisions of the PRC should be with the
defendant was acquitted or convicted, or the case was dismissed or otherwise CA, as Rule 43[32] of the Rules of Court was precisely formulated and adopted to
terminated without the express consent of the accused.[25] These elements were not provide for a uniform rule of appellate procedure for quasi-judicial agencies.[33]
present in the proceedings before the Board of Medicine, as the proceedings involved Petitioner further contends that a quasi-judicial body is not excluded from the purview
in the instant case were administrative and not criminal in nature. The Court has of Rule 43 just because it is not mentioned therein.[34]
already held that double jeopardy does not lie in administrative cases.[26]
On this point, the Court agrees with the petitioner. Anent 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
Sec. 1, Rule 43 of the Rules of Court provides: of Edithas injury. Petitioner avers that in cases of medical malpractice, expert
Section 1. Scope. - This Rule shall apply to appeals from judgments or final orders of testimony is necessary to support the conclusion as to the cause of the injury.[41]
the Court of Tax Appeals, and from awards, judgments, final orders or resolutions of Medical malpractice is a particular form of negligence which consists in the failure of
or authorized by any quasi-judicial agency in the exercise of its quasi-judicial a physician or surgeon to apply to his practice of medicine that degree of care and skill
functions. Among these agencies are the Civil Service Commission, Central Board of which is ordinarily employed by the profession generally, under similar conditions,
Assessment Appeals, Securities and Exchange Commission, Office of the President, and in like surrounding circumstances.[42] In order to successfully pursue such a
Land Registration Authority, Social Security Commission, Civil Aeronautics Board, claim, a patient must prove that the physician or surgeon either failed to do something
Bureau of Patents, Trademarks and Technology Transfer, National Electrification which a reasonably prudent physician or surgeon would not have done, and that the
Administration, Energy Regulatory Board, National Telecommunications failure or action caused injury to the patient.[43]
Commission, Department of Agrarian Reform under Republic Act No. 6657,
Government Service Insurance System, Employees Compensation Commission, There are four elements involved in medical negligence cases: duty, breach, injury and
Agricultural Inventions Board, Insurance Commission, Philippine Atomic Energy proximate causation.[44 ]
Commission, Board of Investments, Construction Industry Arbitration Commission,
and voluntary arbitrators authorized by law. (Emphasis supplied) A physician-patient relationship was created when Editha employed the services of the
petitioner. As Edithas physician, petitioner was duty-bound to use at least the same
Indeed, the PRC is not expressly mentioned as one of the agencies which are expressly level of care that any reasonably competent doctor would use to treat a condition under
enumerated under Section 1, Rule 43 of the Rules of Court. However, its absence from the same circumstances.[45] The breach of these professional duties of skill and care,
the enumeration does not, by this fact alone, imply its exclusion from the coverage of or their improper performance by a physician surgeon, whereby the patient is injured
said Rule.[35] The Rule expressly provides that it should be applied to appeals from in body or in health, constitutes actionable malpractice.[46] As to this aspect of
awards, judgments final orders or resolutions of any quasi-judicial agency in the medical malpractice, the determination of the reasonable level of care and the breach
exercise of its quasi-judicial functions. The phrase among these agencies confirms that thereof, expert testimony is essential.[47] Further, inasmuch as the causes of the
the enumeration made in the Rule is not exclusive to the agencies therein listed.[36] injuries involved in malpractice actions are determinable only in the light of scientific
knowledge, it has been recognized that expert testimony is usually necessary to support
Specifically, the Court, in Yang v. Court of Appeals,[37] ruled that Batas Pambansa the conclusion as to causation.[48]
(B.P.) Blg. 129[38] conferred upon the CA exclusive appellate jurisdiction over
appeals from decisions of the PRC. The Court held: In the present case, respondents did not present any expert testimony to support their
claim that petitioner failed to do something which a reasonably prudent physician or
The law has since been changed, however, at least in the matter of the particular court surgeon would have done.
to which appeals from the Commission should be taken. On August 14, 1981, Batas
Pambansa Bilang 129 became effective and in its Section 29, conferred on the Court Petitioner, on the other hand, presented the testimony of Dr. Augusto M. Manalo, who
of Appeals exclusive appellate jurisdiction over all final judgments, decisions, was clearly an expert on the subject.
resolutions, orders or awards of Regional Trial Courts and quasi-judicial agencies,
instrumentalities, boards or commissions except those falling under the appellate Generally, to qualify as an expert witness, one must have acquired special knowledge
jurisdiction of the Supreme Court. x x x. In virtue of BP 129, appeals from the of the subject matter about which he or she is to testify, either by the study of
Professional Regulations Commission are now exclusively cognizable by the Court of recognized authorities on the subject or by practical experience.[49]
Appeals.[39] (Emphasis supplied) Dr. Manalo specializes in gynecology and obstetrics, authored and co-authored various
Clearly, the enactment of B.P. Blg. 129, the precursor of the present Rules of Civil publications on the subject, and is a professor at the University of the Philippines.[50]
Procedure,[40] lodged with the CA such jurisdiction over the appeals of decisions According to him, his diagnosis of Edithas case was Ectopic Pregnancy Interstitial
made by the PRC. (also referred to as Cornual), Ruptured.[51] In stating that the D&C procedure was not
the proximate cause of the rupture of Edithas uterus resulting in her hysterectomy, Dr.
Manalo testified as follows:
Atty. Hidalgo: A: From what I have removed, yes. But in this particular case, I think it was assumed
that it was part of the meaty mass which was expelled at the time she was urinating
Q: Doctor, we want to be clarified on this matter. The complainant had testified here and flushed in the toilet. So theres no way.
that the D&C was the proximate cause of the rupture of the uterus. The condition which
she found herself in on the second admission. Will you please tell us whether that is Q: There was [sic] some portions of the fetal parts that were removed?
true or not?
A: No, it was described as scanty scraping if I remember it rightscanty.
A: Yah, I do not think so for two reasons. One, as I have said earlier, the instrument
cannot reach the site of the pregnancy, for it to further push the pregnancy outside the Q: And you would not mind checking those scant or those little parts that were
uterus. And, No. 2, I was thinking a while ago about another reason- well, why I dont removed?
think so, because it is the triggering factor for the rupture, it could havethe rupture A: Well, the fact that it was described means, I assume that it was checked, no. It was
could have occurred much earlier, right after the D&C or a few days after the D&C. described as scanty and the color also, I think was described. Because it would be very
Q: In this particular case, doctor, the rupture occurred to have happened minutes prior unusual, even improbable that it would not be examined, because when you scrape,
to the hysterectomy or right upon admission on September 15, 1994 which is about 1 the specimens are right there before your eyes. Its in front of you. You can touch it. In
months after the patient was discharged, after the D&C was conducted. Would you tell fact, some of them will stick to the instrument and therefore to peel it off from the
us whether there is any relation at all of the D&C and the rupture in this particular instrument, you have to touch them. So, automatically they are examined closely.
instance? Q: As a matter of fact, doctor, you also give telephone orders to your patients through
A: I dont think so for the two reasons that I have just mentioned- that it would not be telephone?
possible for the instrument to reach the site of pregnancy. And, No. 2, if it is because A: Yes, yes, we do that, especially here in Manila because you know, sometimes a
of the D&C that rupture could have occurred earlier.[52] (Emphases supplied) doctor can also be tied-up somewhere and if you have to wait until he arrive at a certain
Clearly, from the testimony of the expert witness and the reasons given by him, it is place before you give the order, then it would be a lot of time wasted. Because if you
evident that the D&C procedure was not the proximate cause of the rupture of Edithas know your patient, if you have handled your patient, some of the symptoms you can
uterus interpret that comes with practice. And, I see no reason for not allowing telephone
orders unless it is the first time that you will be encountering the patient. That you have
During his cross-examination, Dr. Manalo testified on how he would have addressed no idea what the problem is.
Edithas condition should he be placed in a similar circumstance as the petitioner. He
stated: Q: But, doctor, do you discharge patients without seeing them?

Atty. Ragonton: A: Sometimes yes, depending on how familiar I am with the patient. We are on the
question of telephone orders. I am not saying that that is the idle [sic] thing to do, but
Q: Doctor, as a practicing OB-Gyne, when do you consider that you have done a good, I think the reality of present day practice somehow justifies telephone orders. I have
correct and ideal dilatation and curettage procedure? patients whom I have justified and then all of a sudden, late in the afternoon or late in
the evening, would suddenly call they have decided that they will go home inasmuch
A: Well, if the patient recovers. If the patient gets well. Because even after the as they anticipated that I will discharge them the following day. So, I just call and ask
procedure, even after the procedure you may feel that you have scraped everything, our resident on duty or the nurse to allow them to go because I have seen that patient
the patient stops bleeding, she feels well, I think you should still have some and I think I have full grasp of her problems. So, thats when I make this telephone
reservations, and wait a little more time orders. And, of course before giving that order I ask about how she feels.[53]
Q: If you were the OB-Gyne who performed the procedure on patient Editha Ramolete, (Emphases supplied)
would it be your standard practice to check the fetal parts or fetal tissues that were From the foregoing testimony, it is clear that the D&C procedure was conducted in
allegedly removed? accordance with the standard practice, with the same level of care that any reasonably
competent doctor would use to treat a condition under the same circumstances, and
that there was nothing irregular in the way the petitioner dealt with Editha.
determine Edithas health condition and applied the corresponding treatment which
could have prevented the rupture of Edithas uterus. The D&C procedure having been
Medical malpractice, in our jurisdiction, is often brought as a civil action for damages conducted in accordance with the standard medical practice, it is clear that Edithas
under Article 2176[54] of the Civil Code. The defenses in an action for damages, omission was the proximate cause of her own injury and not merely a contributory
provided for under Article 2179 of the Civil Code are: negligence on her part.
Art. 2179. When the plaintiffs own negligence was the immediate and proximate cause Contributory negligence is the act or omission amounting to want of ordinary care on
of his injury, he cannot recover damages. But if his negligence was only contributory, the part of the person injured, which, concurring with the defendants negligence, is the
the immediate and proximate cause of the injury being the defendants lack of due care, proximate cause of the injury.[59] Difficulty seems to be apprehended in deciding
the plaintiff may recover damages, but the courts shall mitigate the damages to be which acts of the injured party shall be considered immediate causes of the
awarded. accident.[60] Where the immediate cause of an accident resulting in an injury is the
Proximate cause has been defined as that which, in natural and continuous sequence, plaintiffs own act, which contributed to the principal occurrence as one of its
unbroken by any efficient intervening cause, produces injury, and without which the determining factors, he cannot recover damages for the injury.[61] Again, based on
result would not have occurred.[55] An injury or damage is proximately caused by an the evidence presented in the present case under review, in which no negligence can
act or a failure to act, whenever it appears from the evidence in the case that the act or be attributed to the petitioner, the immediate cause of the accident resulting in Edithas
omission played a substantial part in bringing about or actually causing the injury or injury was her own omission when she did not return for a follow-up check up, in
damage; and that the injury or damage was either a direct result or a reasonably defiance of petitioners orders. The immediate cause of Edithas injury was her own act;
probable consequence of the act or omission.[56] thus, she cannot recover damages from the injury

In the present case, the Court notes the findings of the Board of Medicine: Lastly, petitioner asserts that her right to due process was violated because she was
never informed by either respondents or by the PRC that an appeal was pending before
When complainant was discharged on July 31, 1994, herein respondent advised her to the PRC.[62] Petitioner claims that a verification with the records section of the PRC
return on August 4, 1994 or four (4) days after the D&C. This advise was clear in revealed that on April 15, 1999, respondents filed a Memorandum on Appeal before
complainants Discharge Sheet. However, complainant failed to do so. This being the the PRC, which did not attach the actual registry receipt but was merely indicated
case, the chain of continuity as required in order that the doctrine of proximate cause therein.[63]
can be validly invoked was interrupted. Had she returned, the respondent could have
examined her thoroughly.[57] x x x (Emphases supplied) Respondents, on the other hand avers that if the original registry receipt was not
attached to the Memorandum on Appeal, PRC would not have entertained the appeal
Also, in the testimony of Dr. Manalo, he stated further that assuming that there was in or accepted such pleading for lack of notice or proof of service on the other party.[64]
fact a misdiagnosis, the same would have been rectified if Editha followed the Also, the registry receipt could not be appended to the copy furnished to petitioners
petitioners order to return for a check-up on August 4, 1994. Dr. Manalo stated: former counsel, because the registry receipt was already appended to the original copy
of the Memorandum of Appeal filed with PRC.[65]
Granting that the obstetrician-gynecologist has been misled (justifiably) up to thus
point that there would have been ample opportunity to rectify the misdiagnosis, had It is a well-settled rule that when service of notice is an issue, the rule is that the person
the patient returned, as instructed for her follow-up evaluation. It was one and a half alleging that the notice was served must prove the fact of service. The burden of
months later that the patient sought consultation with another doctor. The continued proving notice rests upon the party asserting its existence.[66] In the present case,
growth of an ectopic pregnancy, until its eventual rupture, is a dynamic process. Much respondents did not present any proof that petitioner was served a copy of the
change in physical findings could be expected in 1 months, including the emergence Memorandum on Appeal. Thus, respondents were not able to satisfy the burden of
of suggestive ones.[58] proving that they had in fact informed the petitioner of the appeal proceedings before
the PRC.
It is undisputed that Editha did not return for a follow-up evaluation, in defiance of the
petitioners advise. Editha omitted the diligence required by the circumstances which In EDI-Staffbuilders International, Inc. v. National Labor Relations Commission,[67]
could have avoided the injury. The omission in not returning for a follow-up evaluation in which the National Labor Relations Commission failed to order the private
played a substantial part in bringing about Edithas own injury. Had Editha returned, respondent to furnish the petitioner a copy of the Appeal Memorandum, the Court held
petitioner could have conducted the proper medical tests and procedure necessary to that said failure deprived the petitioner of procedural due process guaranteed by the
Constitution, which could have served as basis for the nullification of the proceedings
in the appeal. The same holds true in the case at bar. The Court finds that the failure
of the respondents to furnish the petitioner a copy of the Memorandum of Appeal
submitted to the PRC constitutes a violation of due process. Thus, the proceedings
before the PRC were null and void.

All told, doctors are protected by a special rule of law. They are not guarantors of care.
They are not insurers against mishaps or unusual consequences[68] specially so if the
patient herself did not exercise the proper diligence required to avoid the injury.

WHEREFORE, the petition is GRANTED. The assailed Decision of the Court of


Appeals dated July 4, 2003 in CA-GR SP No. 62206 is hereby REVERSED and SET
ASIDE. The Decision of the Board of Medicine dated March 4, 1999 exonerating
petitioner is AFFIRMED. No pronouncement as to costs.

SO ORDERED.
THIRD DIVISION

G. R. No. 178763 April 21, 2009 As instructed, Peter went back to Dr. Tuao on 9 September 1988. Upon examination,
Dr. Tuao told Peter that the sore eyes in the latters right eye had already cleared
PETER PAUL PATRICK LUCAS, FATIMA GLADYS LUCAS, ABBEYGAIL up and he could discontinue the Spersacet-C. However, the same eye developed
DECISION Epidemic Kerato Conjunctivitis (EKC),[7] a viral infection. To address the new
problem with Peters right eye, Dr. Tuao prescribed to the former a steroid-based eye
drop called Maxitrol,[8] a dosage of six (6) drops per day.[9] To recall, Peter had
already been using Maxitrol prior to his consult with Dr. Tuao.
CHICO-NAZARIO, J.:
On 21 September 1988, Peter saw Dr. Tuao for a follow-up consultation. After
In this petition for review on certiorari[1] under Rule 45 of the Revised Rules of Court,
examining both of Peters eyes, Dr. Tuao instructed the former to taper down[10] the
petitioners Peter Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and
dosage of Maxitrol, because the EKC in his right eye had already resolved. Dr. Tuao
Gillian Lucas seek the reversal of the 27 September 2006 Decision[2] and 3 July 2007
specifically cautioned Peter that, being a steroid, Maxitrol had to be withdrawn
Resolution,[3] both of the Court of Appeals in CA-G.R. CV No. 68666, entitled Peter
gradually; otherwise, the EKC might recur.[11]
Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian Lucas v.
Prospero Ma. C. Tuao. Complaining of feeling as if there was something in his eyes, Peter returned to Dr.
Tuao for another check-up on 6 October 1988. Dr. Tuao examined Peters eyes and
In the questioned decision and resolution, the Court of Appeals affirmed the 14 July
found that the right eye had once more developed EKC. So, Dr. Tuao instructed Peter
2000 Decision of the Regional Trial Court (RTC), Branch 150, Makati City,
to resume the use of Maxitrol at six (6) drops per day.
dismissing the complaint filed by petitioners in a civil case entitled, Peter Paul Patrick
Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian Lucas v. Prospero Ma. C. On his way home, Peter was unable to get a hold of Maxitrol, as it was out of stock.
Tuao, docketed as Civil Case No. 92-2482. Consequently, Peter was told by Dr. Tuano to take, instead, Blephamide[12] another
steroid-based medication, but with a lower concentration, as substitute for the
From the record of the case, the established factual antecedents of the present petition
unavailable Maxitrol, to be used three (3) times a day for five (5) days; two (2) times
are:
a day for five (5) days; and then just once a day.[13]
Sometime in August 1988, petitioner Peter Paul Patrick Lucas (Peter) contracted sore
Several days later, on 18 October 1988, Peter went to see Dr. Tuao at his clinic,
eyes in his right eye.
alleging severe eye pain, feeling as if his eyes were about to pop-out, a headache
On 2 September 1988, complaining of a red right eye and swollen eyelid, Peter made and blurred vision. Dr. Tuao examined Peters eyes and discovered that the EKC was
use of his health care insurance issued by Philamcare Health Systems, Inc. again present in his right eye. As a result, Dr. Tuao told Peter to resume the maximum
(Philamcare), for a possible consult. The Philamcare Coordinator, Dr. Edwin Oca, dosage of Blephamide.
M.D., referred Peter to respondent, Dr. Prospero Ma. C. Tuao, M.D. (Dr. Tuao), an
Dr. Tuao saw Peter once more at the formers clinic on 4 November 1988. Dr.
ophthalmologist at St. Lukes Medical Center, for an eye consult.
Tuaos examination showed that only the periphery of Peters right eye was positive
Upon consultation with Dr. Tuao, Peter narrated that it had been nine (9) days since for EKC; hence, Dr. Tuao prescribed a lower dosage of Blephamide.
the problem with his right eye began; and that he was already taking Maxitrol to
It was also about this time that Fatima Gladys Lucas (Fatima), Peters spouse, read the
address the problem in his eye. According to Dr. Tuao, he performed ocular routine
accompanying literature of Maxitrol and found therein the following warning against
examination on Peters eyes, wherein: (1) a gross examination of Peters eyes and
the prolonged use of such steroids:
their surrounding area was made; (2) Peters visual acuity were taken; (3) Peters eyes
were palpated to check the intraocular pressure of each; (4) the motility of Peters eyes WARNING:
was observed; and (5) the ophthalmoscopy[4] on Peters eyes was used. On that
particular consultation, Dr. Tuao diagnosed that Peter was suffering from Prolonged use may result in glaucoma, with damage to the optic nerve, defects in
conjunctivitis[5] or sore eyes. Dr. Tuao then prescribed Spersacet-C[6] eye drops visual acuity and fields of vision, and posterior, subcapsular cataract
for Peter and told the latter to return for follow-up after one week. formation. Prolonged use may suppress the host response and thus increase the hazard
of secondary ocular infractions, in those diseases causing thinning of the cornea or Upon waking in the morning of 13 December 1988, Peter had no vision in his right
sclera, perforations have been known to occur with the use of topical steroids. In acute eye. Fatima observed that Peters right eye appeared to be bloody and swollen.[15]
purulent conditions of the eye, steroids may mask infection or enhance existing Thus, spouses Peter and Fatima rushed to the clinic of Dr. Tuao. Peter reported to Dr.
infection. If these products are used for 10 days or longer, intraocular pressure should Tuao that he had been suffering from constant headache in the afternoon and blurring
be routinely monitored even though it may be difficult in children and uncooperative of vision.
patients.
Upon examination, Dr. Tuao noted the hardness of Peters right eye. With the use of
Employment of steroid medication in the treatment of herpes simplex requires great a tonometer[16] to verify the exact intraocular pressure[17] (IOP) of Peters eyes, Dr.
caution. Tuao discovered that the tension in Peters right eye was 39.0 Hg, while that of his
left was 17.0 Hg.[18] Since the tension in Peters right eye was way over the normal
xxxx IOP, which merely ranged from 10.0 Hg to 21.0 Hg,[19] Dr. Tuao ordered[20] him
ADVERSE REACTIONS: to immediately discontinue the use of Maxitrol and prescribed to the latter Diamox[21]
and Normoglaucon, instead.[22] Dr. Tuao also required Peter to go for daily check-
Adverse reactions have occurred with steroid/anti-infective combination drugs which up in order for the former to closely monitor the pressure of the latters eyes.
can be attributed to the steroid component, the anti-infective component, or the
combination. Exact incidence figures are not available since no denominator of treated On 15 December 1988, the tonometer reading of Peters right eye yielded a high
patients is available. normal level, i.e., 21.0 Hg. Hence, Dr. Tuao told Peter to continue using Diamox and
Normoglaucon. But upon Peters complaint of stomach pains and tingling sensation
Reactions occurring most often from the presence of the anti-infective ingredients are in his fingers,[23] Dr. Tuao discontinued Peters use of Diamox.[24]
allergic sensitizations. The reactions due to the steroid component in decreasing order
to frequency are elevation of intra-ocular pressure (IOP) with possible development of Peter went to see another ophthalmologist, Dr. Ramon T. Batungbacal (Dr.
glaucoma, infrequent optic nerve damage; posterior subcapsular cataract formation; Batungbacal), on 21 December 1988, who allegedly conducted a complete
and delayed wound healing. ophthalmological examination of Peters eyes. Dr. Batungbacals diagnosis was
Glaucoma[25] O.D.[26] He recommended Laser Trabeculoplasty[27] for Peters right
Secondary infection: The development of secondary has occurred after use of eye.
combination containing steroids and antimicrobials. Fungal infections of the correa
are particularly prone to develop coincidentally with long-term applications of When Peter returned to Dr. Tuao on 23 December 1988,[28] the tonometer measured
steroid. The possibility of fungal invasion must be considered in any persistent corneal the IOP of Peters right eye to be 41.0 Hg,[29] again, way above normal. Dr. Tuao
ulceration where steroid treatment has been used. addressed the problem by advising Peter to resume taking Diamox along with
Normoglaucon.
Secondary bacterial ocular infection following suppression of host responses also
occurs. During the Christmas holidays, Peter supposedly stayed in bed most of the time and
was not able to celebrate the season with his family because of the debilitating effects
On 26 November 1988, Peter returned to Dr. Tuaos clinic, complaining of feeling of Diamox.[30
worse.[14] It appeared that the EKC had spread to the whole of Peters right eye yet
again. Thus, Dr. Tuao instructed Peter to resume the use of Maxitrol. Petitioners On 28 December 1988, during one of Peters regular follow-ups with Dr. Tuao, the
averred that Peter already made mention to Dr. Tuao during said visit of the above- doctor conducted another ocular routine examination of Peters eyes. Dr. Tuao noted
quoted warning against the prolonged use of steroids, but Dr. Tuao supposedly the recurrence of EKC in Peters right eye. Considering, however, that the IOP of
brushed aside Peters concern as mere paranoia, even assuring him that the former was Peters right eye was still quite high at 41.0 Hg, Dr. Tuao was at a loss as to how to
taking care of him (Peter). balance the treatment of Peters EKC vis--vis the presence of glaucoma in the same
eye. Dr. Tuao, thus, referred Peter to Dr. Manuel B. Agulto, M.D. (Dr. Agulto),
Petitioners further alleged that after Peters 26 November 1988 visit to Dr. Tuao, another ophthalmologist specializing in the treatment of glaucoma.[31] Dr. Tuaos
Peter continued to suffer pain in his right eye, which seemed to progress, with the letter of referral to Dr. Agulto stated that:
ache intensifying and becoming more frequent.
Referring to you Mr. Peter Lucas for evaluation & possible management. I initially Just two days later, on 2 January 1989, the IOP of Peters right eye remained elevated
saw him Sept. 2, 1988 because of conjunctivitis. The latter resolved and he developed at 21.0 Hg,[42] as he had been without Diamox for the past three (3) days.
EKC for which I gave Maxitrol. The EKC was recurrent after stopping steroid drops.
Around 1 month of steroid treatment, he noted blurring of vision & pain on the R. On 4 January 1989, Dr. Tuao conducted a visual field study[43] of Peters eyes,
however, I continued the steroids for the sake of the EKC. A month ago, I noted iris which revealed that the latter had tubular vision[44] in his right eye, while that of his
atrophy, so I took the IOP and it was definitely elevated. I stopped the steroids left eye remained normal. Dr. Tuao directed Peter to religiously use the Diamox and
immediately and has (sic) been treating him medically. Normoglaucon, as the tension of the latters right eye went up even further to 41.0 Hg
in just a matter of two (2) days, in the meantime that Timolol B.I.D. and Depifrin
It seems that the IOP can be controlled only with oral Diamox, and at the moment, the were still not available in the market. Again, Dr. Tuao advised Peter to come for
EKC has recurred and Im in a fix whether to resume the steroid or not considering regular check-up so his IOP could be monitored.
that the IOP is still uncontrolled.[32]
Obediently, Peter went to see Dr. Tuao on the 7th, 13th, 16th and 20th of January
On 29 December 1988, Peter went to see Dr. Agulto at the latters clinic. Several tests 1989 for check-up and IOP monitoring.
were conducted thereat to evaluate the extent of Peters condition. Dr. Agulto wrote
Dr. Tuao a letter containing the following findings and recommendations: In the interregnum, however, Peter was prodded by his friends to seek a second
medical opinion. On 13 January 1989, Peter consulted Dr. Jaime Lapuz, M.D. (Dr.
Thanks for sending Peter Lucas. On examination conducted vision was 20/25 R and Lapuz), an ophthalmologist, who, in turn, referred Peter to Dr. Mario V. Aquino, M.D.
20/20L. Tension curve 19 R and 15 L at 1210 H while on Normoglaucon BID OD & (Dr. Aquino), another ophthalmologist who specializes in the treatment of glaucoma
Diamox tab every 6h po. and who could undertake the long term care of Peters eyes.

Slit lamp evaluation[33] disclosed subepithelial corneal defect outer OD. There was According to petitioners, after Dr. Aquino conducted an extensive evaluation of
circumferential peripheral iris atrophy, OD. The lenses were clear. Peters eyes, the said doctor informed Peter that his eyes were relatively normal,
though the right one sometimes manifested maximum borderline tension. Dr. Aquino
Funduscopy[34] showed vertical cup disc of 0.85 R and 0.6 L with temporal slope also confirmed Dr. Tuaos diagnosis of tubular vision in Peters right eye. Petitioners
R>L. claimed that Dr. Aquino essentially told Peter that the latters condition would require
Zeiss gonioscopy[35] revealed basically open angles both eyes with occasional lifetime medication and follow-ups.
PAS,[36] OD. In May 1990 and June 1991, Peter underwent two (2) procedures of laser
Rolly, I feel that Peter Lucas has really sustained significant glaucoma damage. I trabeculoplasty to attempt to control the high IOP of his right eye.
suggest that we do a baseline visual fields and push medication to lowest possible Claiming to have steroid-induced glaucoma[45] and blaming Dr. Tuao for the same,
levels. If I may suggest further, I think we should prescribe Timolol[37] BID[38] OD Peter, joined by: (1) Fatima, his spouse[46]; (2) Abbeygail, his natural child[47]; and
in lieu of Normoglaucon. If the IOP is still inadequate, we may try Depifrin[39] BID (3) Gillian, his legitimate child[48] with Fatima, instituted on 1 September 1992, a
OD (despite low PAS). Im in favor of retaining Diamox or similar CAI.[40] civil complaint for damages against Dr. Tuao, before the RTC, Branch 150, Quezon
If fields show further loss in say 3 mos. then we should consider trabeculoplasty. City. The case was docketed as Civil Case No. 92-2482.

I trust that this approach will prove reasonable for you and Peter.[41] In their Complaint, petitioners specifically averred that as the direct consequence of
[Peters] prolonged use of Maxitrol, [he] suffered from steroid induced glaucoma
Peter went to see Dr. Tuao on 31 December 1988, bearing Dr. Agultos which caused the elevation of his intra-ocular pressure. The elevation of the intra-
aforementioned letter. Though Peters right and left eyes then had normal IOP of 21.0 ocular pressure of [Peters right eye] caused the impairment of his vision which
Hg and 17.0 Hg, respectively, Dr. Tuao still gave him a prescription for Timolol impairment is not curable and may even lead to total blindness.[49]
B.I.D. so Peter could immediately start using said medication. Regrettably, Timolol
B.I.D. was out of stock, so Dr. Tuao instructed Peter to just continue using Diamox Petitioners additionally alleged that the visual impairment of Peters right eye caused
and Normoglaucon in the meantime. him and his family so much grief. Because of his present condition, Peter now needed
close medical supervision forever; he had already undergone two (2) laser surgeries,
with the possibility that more surgeries were still needed in the future; his career in
sports casting had suffered and was continuing to suffer;[50] his anticipated income But granting for the sake of argument that the steroid treatment of [Peters] EKC
had been greatly reduced as a result of his limited capacity; he continually suffered caused the steroid induced glaucoma,[59] Dr. Tuao argued that
from headaches, nausea, dizziness, heart palpitations, rashes, chronic rhinitis,
sinusitis,[51] etc.; Peters relationships with his spouse and children continued to be [S]uch condition, i.e., elevated intraocular pressure, is temporary. As soon as the
strained, as his condition made him highly irritable and sensitive; his mobility and intake of steroids is discontinued, the intraocular pressure automatically is reduced.
social life had suffered; his spouse, Fatima, became the breadwinner in the family;[52] Thus, [Peters] glaucoma can only be due to other causes not attributable to steroids,
and his two children had been deprived of the opportunity for a better life and certainly not attributable to [his] treatment of more than three years ago x x x.
educational prospects. Collectively, petitioners lived in constant fear of Peter From a medical point of view, as revealed by more current examination of [Peter], the
becoming completely blind.[53] latters glaucoma can only be long standing glaucoma, open angle glaucoma, because
In the end, petitioners sought pecuniary award for their supposed pain and suffering, of the large C:D ratio. The steroids provoked the latest glaucoma to be revealed earlier
which were ultimately brought about by Dr. Tuaos grossly negligent conduct in as [Peter] remained asymptomatic prior to steroid application. Hence, the steroid
prescribing to Peter the medicine Maxitrol for a period of three (3) months, without treatment was in fact beneficial to [Peter] as it revealed the incipient open angle
monitoring Peters IOP, as required in cases of prolonged use of said medicine, and glaucoma of [Peter] to allow earlier treatment of the same.[60]
notwithstanding Peters constant complaint of intense eye pain while using the In a Decision dated 14 July 2000, the RTC dismissed Civil Case No. 92-2482 for
same. Petitioners particularly prayed that Dr. Tuao be adjudged liable for the insufficiency of evidence.[61] The decretal part of said Decision reads:
following amounts:
Wherefore, premises considered, the instant complaint is dismissed for insufficiency
1. The amount of P2,000,000.00 to plaintiff Peter Lucas as and by way of of evidence. The counter claim (sic) is likewise dismissed in the absence of bad faith
compensation for his impaired vision. or malice on the part of plaintiff in filing the suit.[62]
2. The amount of P300,000.00 to spouses Lucas as and by way of actual damages
plus such additional amounts that may be proven during trial. The RTC opined that petitioners failed to prove by preponderance of evidence that Dr.
3. The amount of P1,000,000.00 as and by way of moral damages Tuao was negligent in his treatment of Peters condition. In particular, the record of
4. The amount of P500,000.00 as and by way of exemplary damages. the case was bereft of any evidence to establish that the steroid medication and its
5. The amount of P200,000.00 as and by way of attorneys fees plus costs of suit.[54] dosage, as prescribed by Dr. Tuao, caused Peters glaucoma. The trial court reasoned
that the recognized standards of the medical community has not been established in
In rebutting petitioners complaint, Dr. Tuao asserted that the treatment made by this case, much less has causation been established to render [Tuao]
[him] more than three years ago has no causal connection to [Peters] present glaucoma liable.[63] According to the RTC:
or condition.[55] Dr. Tuao explained that [d]rug-induced glaucoma is temporary
[Petitioners] failed to establish the duty required of a medical practitioner against
and curable, steroids have the side effect of increasing intraocular pressure. Steroids
which Peter Pauls treatment by defendant can be compared with. They did not present
are prescribed to treat Epidemic Kerato Conjunctivitis or EKC which is an infiltration
any medical expert or even a medical doctor to convince and expertly explain to the
of the cornea as a result of conjunctivitis or sore eyes.[56] Dr. Tuao also clarified
court the established norm or duty required of a physician treating a patient, or whether
that (1) [c]ontrary to [petitioners] fallacious claim, [he] did NOT continually
the non taking (sic) by Dr. Tuao of Peter Pauls pressure a deviation from the norm
prescribe the drug Maxitrol which contained steroids for any prolonged period[57]
or his non-discovery of the glaucoma in the course of treatment constitutes negligence.
and [t]he truth was the Maxitrol was discontinued x x x as soon as EKC disappeared
It is important and indispensable to establish such a standard because once it is
and was resumed only when EKC reappeared[58]; (2) the entire time he was treating
established, a medical practitioner who departed thereof breaches his duty and
Peter, he continually monitored the intraocular pressure of [Peters eyes] by palpating
commits negligence rendering him liable. Without such testimony or enlightenment
the eyes and by putting pressure on the eyeballs, and no hardening of the same could
from an expert, the court is at a loss as to what is then the established norm of duty of
be detected, which meant that there was no increase in the tension or IOP, a possible
a physician against which defendants conduct can be compared with to determine
side reaction to the use of steroid medications; and (3) it was only on 13 December
negligence.[64]
1988 that Peter complained of a headache and blurred vision in his right eye, and upon
measuring the IOP of said eye, it was determined for the first time that the IOP of the The RTC added that in the absence of any medical evidence to the contrary, this
right eye had an elevated value. court cannot accept [petitioners] claim that the use of steroid is the proximate cause
of the damage sustained by [Peters] eye.[65]
Correspondingly, the RTC accepted Dr. Tuaos medical opinion that Peter Paul must I.
have been suffering from normal tension glaucoma, meaning, optic nerve damage was
happening but no elevation of the eye pressure is manifested, that the steroid treatment THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN
actually unmasked the condition that resulted in the earlier treatment of the glaucoma. AFFIRMING THE DECISION OF THE TRIAL COURT DISMISSING THE
There is nothing in the record to contradict such testimony. In fact, plaintiffs Exhibit PETITIONERS COMPLAINT FOR DAMAGES AGAINST THE RESPONDENT
S even tends to support them. ON THE GROUND OF INSUFFICIENCY OF EVIDENCE;

Undaunted, petitioners appealed the foregoing RTC decision to the Court of II.
Appeals. Their appeal was docketed as CA-G.R. CV No. 68666. THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN
On 27 September 2006, the Court of Appeals rendered a decision in CA-G.R. CV No. DISMISSING THE PETITIONERS COMPLAINT FOR DAMAGES AGAINST
68666 denying petitioners recourse and affirming the appealed RTC Decision. The THE RESPONDENT ON THE GROUND THAT NO MEDICAL EXPERT WAS
fallo of the judgment of the appellate court states: PRESENTED BY THE PETITIONERS TO PROVE THEIR CLAIM FOR
MEDICAL NEGLIGENCE AGAINST THE RESPONDENT; AND
WHEREFORE, the Decision appealed from is AFFIRMED.[66]
III.
The Court of Appeals faulted petitioners because they
THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN
[D]id not present any medical expert to testify that Dr. Tuanos prescription of NOT FINDING THE RESPONDENT LIABLE TO THE PETITIONERS FOR
Maxitrol and Blephamide for the treatment of EKC on Peters right eye was not proper ACTUAL, MORAL AND EXEMPLARY DAMAGES, ASIDE FROM
and that his palpation of Peters right eye was not enough to detect adverse reaction to ATTORNEYS FEES, COSTS OF SUIT, AS A RESULT OF HIS GROSS
steroid. Peter testified that Dr. Manuel Agulto told him that he should not have used NEGLIGENCE.[69]
steroid for the treatment of EKC or that he should have used it only for two (2) weeks,
as EKC is only a viral infection which will cure by itself. However, Dr. Agulto was A reading of the afore-quoted reversible errors supposedly committed by the Court of
not presented by [petitioners] as a witness to confirm what he allegedly told Peter and, Appeals in its Decision and Resolution would reveal that petitioners are fundamentally
therefore, the latters testimony is hearsay. Under Rule 130, Section 36 of the Rules of assailing the finding of the Court of Appeals that the evidence on record is insufficient
Court, a witness can testify only to those facts which he knows of his own personal to establish petitioners entitlement to any kind of damage. Therefore, it could be said
knowledge, x x x. Familiar and fundamental is the rule that hearsay testimony is that the sole issue for our resolution in the Petition at bar is whether the Court of
inadmissible as evidence.[67] Appeals committed reversible error in affirming the judgment of the RTC that
petitioners failed to prove, by preponderance of evidence, their claim for damages
Like the RTC, the Court of Appeals gave great weight to Dr. Tuaos medical against Dr. Tuao.
judgment, specifically the latters explanation that:
Evidently, said issue constitutes a question of fact, as we are asked to revisit anew the
[W]hen a doctor sees a patient, he cannot determine whether or not the latter would factual findings of the Court of Appeals, as well as of the RTC. In effect, petitioners
react adversely to the use of steroids, that it was only on December 13, 1989, when would have us sift through the evidence on record and pass upon whether there is
Peter complained for the first time of headache and blurred vision that he observed sufficient basis to establish Dr. Tuaos negligence in his treatment of Peters eye
that the pressure of the eye of Peter was elevated, and it was only then that he suspected condition. This question clearly involves a factual inquiry, the determination of which
that Peter belongs to the 5% of the population who reacts adversely to steroids.[68] is not within the ambit of this Courts power of review under Rule 45 of the 1997 Rules
Civil Procedure, as amended.[70]
Petitioners Motion for Reconsideration was denied by the Court of Appeals in a
Resolution dated 3 July 2007. Elementary is the principle that this Court is not a trier of facts; only errors of law are
generally reviewed in petitions for review on certiorari criticizing decisions of the
Hence, this Petition for Review on Certiorari under Rule 45 of the Revised Rules of Court of Appeals. Questions of fact are not entertained.[71]
Court premised on the following assignment of errors:
Nonetheless, the general rule that only questions of law may be raised on appeal in a For lack of a specific law geared towards the type of negligence committed by
petition for review under Rule 45 of the Rules of Court admits of certain exceptions, members of the medical profession, such claim for damages is almost always anchored
including the circumstance when the finding of fact of the Court of Appeals is on the alleged violation of Article 2176 of the Civil Code, which states that:
premised on the supposed absence of evidence, but is contradicted by the evidence on
record. Although petitioners may not explicitly invoke said exception, it may be ART. 2176. Whoever by act or omission causes damage to another, there being fault
gleaned from their allegations and arguments in the instant Petition. or negligence, is obliged to pay for the damage done. Such fault or negligence, if there
is no pre-existing contractual relation between the parties, is called a quasi-delict and
Petitioners contend, that [c]ontrary to the findings of the Honorable Court of Appeals, is governed by the provisions of this Chapter.
[they] were more than able to establish that: Dr. Tuao ignored the standard medical
procedure for ophthalmologists, administered medication with recklessness, and In medical negligence cases, also called medical malpractice suits, there exist a
exhibited an absence of competence and skills expected from him.[72] Petitioners physician-patient relationship between the doctor and the victim. But just like any
reject the necessity of presenting expert and/or medical testimony to establish (1) the other proceeding for damages, four essential (4) elements i.e., (1) duty; (2) breach; (3)
standard of care respecting the treatment of the disorder affecting Peters eye; and (2) injury; and (4) proximate causation,[76] must be established by the plaintiff/s. All the
whether or not negligence attended Dr. Tuaos treatment of Peter, because, in their four (4) elements must co-exist in order to find the physician negligent and, thus, liable
words for damages.

That Dr. Tuao was grossly negligent in the treatment of Peters simple eye ailment is When a patient engages the services of a physician, a physician-patient relationship is
a simple case of cause and effect. With mere documentary evidence and based on the generated. And in accepting a case, the physician, for all intents and purposes,
facts presented by the petitioners, respondent can readily be held liable for damages represents that he has the needed training and skill possessed by physicians and
even without any expert testimony. In any case, however, and contrary to the finding surgeons practicing in the same field; and that he will employ such training, care, and
of the trial court and the Court of Appeals, there was a medical expert presented by the skill in the treatment of the patient.[77] Thus, in treating his patient, a physician is
petitioner showing the recklessness committed by [Dr. Tuao] Dr. Tuao himself. under a duty to [the former] to exercise that degree of care, skill and diligence which
[Emphasis supplied.] physicians in the same general neighborhood and in the same general line of practice
ordinarily possess and exercise in like cases.[78] Stated otherwise, the physician has
They insist that Dr. Tuao himself gave sufficient evidence to establish his gross the duty to use at least the same level of care that any other reasonably competent
negligence that ultimately caused the impairment of the vision of Peters right eye,[73] physician would use to treat the condition under similar circumstances.
i.e., that [d]espite [Dr. Tuaos] knowledge that 5% of the population reacts adversely
to Maxitrol, [he] had no qualms whatsoever in prescribing said steroid to Peter without This standard level of care, skill and diligence is a matter best addressed by expert
first determining whether or not the (sic) Peter belongs to the 5%.[74] medical testimony, because the standard of care in a medical malpractice case is a
matter peculiarly within the knowledge of experts in the field.[79]
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 There is breach of duty of care, skill and diligence, or the improper performance of
of fact made therein. such duty, by the attending physician when the patient is injured in body or in health
[and this] constitutes the actionable malpractice.[80] Proof of such breach must
Petitioners position, in sum, is that Peters glaucoma is the direct result of Dr. Tuaos likewise rest upon the testimony of an expert witness that the treatment accorded to
negligence in his improper administration of the drug Maxitrol; thus, [the latter] the patient failed to meet the standard level of care, skill and diligence which
should be liable for all the damages suffered and to be suffered by [petitioners].[75] physicians in the same general neighborhood and in the same general line of practice
Clearly, the present controversy is a classic illustration of a medical negligence case ordinarily possess and exercise in like cases.
against a physician based on the latters professional negligence. In this type of suit,
the patient or his heirs, in order to prevail, is required to prove by preponderance of Even so, proof of breach of duty on the part of the attending physician is insufficient,
evidence that the physician failed to exercise that degree of skill, care, and learning for there must be a causal connection between said breach and the resulting injury
possessed by other persons in the same profession; and that as a proximate result of sustained by the patient. Put in another way, in order that there may be a recovery for
such failure, the patient or his heirs suffered damages. an injury, it must be shown that the injury for which recovery is sought must be the
legitimate consequence of the wrong done; the connection between the negligence and
the injury must be a direct and natural sequence of events, unbroken by intervening
efficient causes;[81] that is, the negligence must be the proximate cause of the injury.
And the proximate cause of an injury is that cause, which, in the natural and continuous
sequence, unbroken by any efficient intervening cause, produces the injury, and Petitioners maintain that Dr. Tuao failed to follow in Peters case the required
without which the result would not have occurred.[82] procedure for the prolonged use of Maxitrol. But what is actually the required
procedure in situations such as in the case at bar? To be precise, what is the standard
Just as with the elements of duty and breach of the same, in order to establish the operating procedure when ophthalmologists prescribe steroid medications which,
proximate cause [of the injury] by a preponderance of the evidence in a medical admittedly, carry some modicum of risk?
malpractice action, [the patient] must similarly use expert testimony, because the
question of whether the alleged professional negligence caused [the patients] injury Absent a definitive standard of care or diligence required of Dr. Tuao under the
is generally one for specialized expert knowledge beyond the ken of the average circumstances, we have no means to determine whether he was able to comply with
layperson; using the specialized knowledge and training of his field, the experts role the same in his diagnosis and treatment of Peter. This Court has no yardstick upon
is to present to the [court] a realistic assessment of the likelihood that [the physicians] which to evaluate or weigh the attendant facts of this case to be able to state with
alleged negligence caused [the patients] injury.[83] confidence that the acts complained of, indeed, constituted negligence and, thus,
should be the subject of pecuniary reparation.
From the foregoing, it is apparent that medical negligence cases are best proved by
opinions of expert witnesses belonging in the same general neighborhood and in the Petitioners assert that prior to prescribing Maxitrol, Dr. Tuao should have determined
same general line of practice as defendant physician or surgeon. The deference of first whether Peter was a steroid responder.[87] Yet again, petitioners did not
courts to the expert opinion of qualified physicians [or surgeons] stems from the present any convincing proof that such determination is actually part of the standard
formers realization that the latter possess unusual technical skills which laymen in operating procedure which ophthalmologists should unerringly follow prior to
most instances are incapable of intelligently evaluating;[84] hence, the prescribing steroid medications
indispensability of expert testimonies. In contrast, Dr. Tuao was able to clearly explain that what is only required of
In the case at bar, there is no question that a physician-patient relationship developed ophthalmologists, in cases such as Peters, is the conduct of standard tests/procedures
between Dr. Tuao and Peter when Peter went to see the doctor on 2 September 1988, known as ocular routine examination,[88] composed of five (5) tests/procedures
seeking a consult for the treatment of his sore eyes. Admittedly, Dr. Tuao, an specifically, gross examination of the eyes and the surrounding area; taking of the
ophthalmologist, prescribed Maxitrol when Peter developed and had recurrent EKC. visual acuity of the patient; checking the intraocular pressure of the patient; checking
Maxitrol or neomycin/polymyxin B sulfates/dexamethasone ophthalmic ointment is a the motility of the eyes; and using ophthalmoscopy on the patients eye and he did
multiple-dose anti-infective steroid combination in sterile form for topical all those tests/procedures every time Peter went to see him for follow-up consultation
application.[85] It is the drug which petitioners claim to have caused Peters and/or check-up.
glaucoma. We cannot but agree with Dr. Tuaos assertion that when a doctor sees a patient, he
However, as correctly pointed out by the Court of Appeals, [t]he onus probandi was cannot determine immediately whether the latter would react adversely to the use of
on the patient to establish before the trial court that the physicians ignored standard steroids; all the doctor can do is map out a course of treatment recognized as correct
medical procedure, prescribed and administered medication with recklessness and by the standards of the medical profession. It must be remembered that a physician is
exhibited an absence of the competence and skills expected of general practitioners not an insurer of the good result of treatment. The mere fact that the patient does not
similarly situated.[86] Unfortunately, in this case, there was absolute failure on the get well or that a bad result occurs does not in itself indicate failure to exercise due
part of petitioners to present any expert testimony to establish: (1) the standard of care care.[89] The result is not determinative of the performance [of the physician] and he
to be implemented by competent physicians in treating the same condition as Peters is not required to be infallible.[90]
under similar circumstances; (2) that, in his treatment of Peter, Dr. Tuao failed in his Moreover, that Dr. Tuao saw it fit to prescribe Maxitrol to Peter was justified by the
duty to exercise said standard of care that any other competent physician would use in fact that the latter was already using the same medication when he first came to see
treating the same condition as Peters under similar circumstances; and (3) that the Dr. Tuao on 2 September 1988 and had exhibited no previous untoward reaction to
injury or damage to Peters right eye, i.e., his glaucoma, was the result of his use of that particular drug. [91]
Maxitrol, as prescribed by Dr. Tuao. Petitioners failure to prove the first element
alone is already fatal to their cause.
Also, Dr. Tuao categorically denied petitioners claim that he never monitored the That Dr. Tuao has the necessary training and skill to practice his chosen field is
tension of Peters eyes while the latter was on Maxitrol. Dr. Tuao testified that he beyond cavil. Petitioners do not dispute Dr. Tuaos qualifications that he has been
palpated Peters eyes every time the latter came for a check-up as part of the doctors a physician for close to a decade and a half at the time Peter first came to see him; that
ocular routine examination, a fact which petitioners failed to rebut. Dr. Tuaos he has had various medical training; that he has authored numerous papers in the field
regular conduct of examinations and tests to ascertain the state of Peters eyes negate of ophthalmology, here and abroad; that he is a Diplomate of the Philippine Board of
the very basis of petitioners complaint for damages. As to whether Dr. Tuaos Ophthalmology; that he occupies various teaching posts (at the time of the filing of the
actuations conformed to the standard of care and diligence required in like present complaint, he was the Chair of the Department of Ophthalmology and an
circumstances, it is presumed to have so conformed in the absence of evidence to the Associate Professor at the University of the Philippines-Philippine General Hospital
contrary. and St. Lukes Medical Center, respectively); and that he held an assortment of
positions in numerous medical organizations like the Philippine Medical Association,
Even if we are to assume that Dr. Tuao committed negligent acts in his treatment of Philippine Academy of Ophthalmology, Philippine Board of Ophthalmology,
Peters condition, the causal connection between Dr. Tuaos supposed negligence and Philippine Society of Ophthalmic Plastic and Reconstructive Surgery, Philippine
Peters injury still needed to be established. The critical and clinching factor in a Journal of Ophthalmology, Association of Philippine Ophthalmology Professors, et
medical negligence case is proof of the causal connection between the negligence al.
which the evidence established and the plaintiffs injuries.[92] The plaintiff must
plead and prove not only that he has been injured and defendant has been at fault, but It must be remembered that when the qualifications of a physician are admitted, as in
also that the defendants fault caused the injury. A verdict in a malpractice action the instant case, there is an inevitable presumption that in proper cases, he takes the
cannot be based on speculation or conjecture. Causation must be proven within a necessary precaution and employs the best of his knowledge and skill in attending to
reasonable medical probability based upon competent expert testimony.[93] his clients, unless the contrary is sufficiently established.[98] In making the judgment
call of treating Peters EKC with Maxitrol, Dr. Tuao took the necessary precaution
The causation between the physicians negligence and the patients injury may only by palpating Peters eyes to monitor their IOP every time the latter went for a check-
be established by the presentation of proof that Peters glaucoma would not have up, and he employed the best of his knowledge and skill earned from years of training
occurred but for Dr. Tuaos supposed negligent conduct. Once more, petitioners and practice.
failed in this regard.
In contrast, without supporting expert medical opinions, petitioners bare assertions of
Dr. Tuao does not deny that the use of Maxitrol involves the risk of increasing a negligence on Dr. Tuaos part, which resulted in Peters glaucoma, deserve scant
patients IOP. In fact, this was the reason why he made it a point to palpate Peters credit.
eyes every time the latter went to see him -- so he could monitor the tension of Peters
eyes. But to say that said medication conclusively caused Peters glaucoma is purely Our disposition of the present controversy might have been vastly different had
speculative. Peter was diagnosed with open-angle glaucoma. This kind of glaucoma is petitioners presented a medical expert to establish their theory respecting Dr. Tuaos
characterized by an almost complete absence of symptoms and a chronic, insidious so-called negligence. In fact, the record of the case reveals that petitioners counsel
course.[94] In open-angle glaucoma, halos around lights and blurring of vision do not recognized the necessity of presenting such evidence. Petitioners even gave an
occur unless there has been a sudden increase in the intraocular vision.[95] Visual undertaking to the RTC judge that Dr. Agulto or Dr. Aquino would be presented. Alas,
acuity remains good until late in the course of the disease.[96] Hence, Dr. Tuao no follow-through on said undertaking was made.
claims that Peters glaucoma can only be long standing x x x because of the large
C:D[97] ratio, and that [t]he steroids provoked the latest glaucoma to be revealed The plaintiff in a civil case has the burden of proof as he alleges the affirmative of the
earlier was a blessing in disguise as [Peter] remained asymptomatic prior to steroid issue. However, in the course of trial in a civil case, once plaintiff makes out a prima
application. facie case in his favor, the duty or the burden of evidence shifts to defendant to
controvert plaintiffs prima facie case; otherwise, a verdict must be returned in favor
Who between petitioners and Dr. Tuao is in a better position to determine and of plaintiff.[99] The party having the burden of proof must establish his case by a
evaluate the necessity of using Maxitrol to cure Peters EKC vis--vis the attendant preponderance of evidence.[100] The concept of preponderance of evidence refers
risks of using the same? to evidence which is of greater weight or more convincing than that which is offered
in opposition to it;[101] in the last analysis, it means probability of truth. It is evidence
which is more convincing to the court as worthy of belief than that which is offered in
opposition thereto.[102] Rule 133, Section 1 of the Revised Rules of Court provides
the guidelines for determining preponderance of evidence, thus:

In civil cases, the party having the burden of proof must establish his case by a
preponderance of evidence. In determining where the preponderance or superior
weight of evidence on the issues involved lies the court may consider all the facts and
circumstances of the case, the witnesses manner of testifying, their intelligence, their
means and opportunity of knowing the facts to which they are testifying, the nature of
the facts to which they testify, the probability or improbability of their testimony, their
interest or want of interest, and also their personal credibility so far as the same
legitimately appear upon the trial. The court may also consider the number of
witnesses, though the preponderance is not necessarily with the greater number.

Herein, the burden of proof was clearly upon petitioners, as plaintiffs in the lower
court, to establish their case by a preponderance of evidence showing a reasonable
connection between Dr. Tuaos alleged breach of duty and the damage sustained by
Peters right eye. This, they did not do. In reality, petitioners complaint for damages
is merely anchored on a statement in the literature of Maxitrol identifying the risks of
its use, and the purported comment of Dr. Agulto another doctor not presented as
witness before the RTC concerning the prolonged use of Maxitrol for the treatment
of EKC.

It seems basic that what constitutes proper medical treatment is a medical question that
should have been presented to experts. If no standard is established through expert
medical witnesses, then courts have no standard by which to gauge the basic issue of
breach thereof by the physician or surgeon. The RTC and Court of Appeals, and even
this Court, could not be expected to determine on its own what medical technique
should have been utilized for a certain disease or injury. Absent expert medical
opinion, the courts would be dangerously engaging in speculations.

All told, we are hard pressed to find Dr. Tuao liable for any medical negligence or
malpractice where there is no evidence, in the nature of expert testimony, to establish
that in treating Peter, Dr. Tuao failed to exercise reasonable care, diligence and skill
generally required in medical practice. Dr. Tuaos testimony, that his treatment of
Peter conformed in all respects to standard medical practice in this locality, stands
unrefuted. Consequently, the RTC and the Court of Appeals correctly held that they
had no basis at all to rule that petitioners were deserving of the various damages prayed
for in their Complaint.

WHEREFORE, premises considered, the instant petition is DENIED for lack of


merit. The assailed Decision dated 27 September 2006 and Resolution dated 3 July
2007, both of the Court of Appeals in CA-G.R. CV No. 68666, are hereby
AFFIRMED. No cost.

SO ORDERED.
EN BANC On February 21, 1994, respondents filed a damage suit[7] against petitioner, Dr. Leo
Marbella, Mr. Jose Ledesma, a certain Dr. Arriete and SLMC. Respondents charged
G.R. No. 165279 June 7, 2011 them with negligence and disregard of Angelicas safety, health and welfare by their
DR. RUBI LI VS. SPOUSES REYNALDO and LINA SOLIMAN, as careless administration of the chemotherapy drugs, their failure to observe the essential
parents/heirs of deceased Angelica Soliman, precautions in detecting early the symptoms of fatal blood platelet decrease and
stopping early on the chemotherapy, which bleeding led to hypovolemic shock that
DECISION caused Angelicas untimely demise. Further, it was specifically averred that petitioner
assured the respondents that Angelica would recover in view of 95% chance of healing
VILLARAMA, JR., J.: with chemotherapy (Magiging normal na ang anak nyo basta ma-chemo. 95% ang
Challenged in this petition for review on certiorari is the Decision[1] dated June 15, healing) and when asked regarding the side effects, petitioner mentioned only slight
2004 as well as the Resolution[2] dated September 1, 2004 of the Court of Appeals vomiting, hair loss and weakness (Magsusuka ng kaunti. Malulugas ang buhok.
(CA) in CA-G.R. CV No. 58013 which modified the Decision[3] dated September 5, Manghihina). Respondents thus claimed that they would not have given their consent
1997 of the Regional Trial Court of Legazpi City, Branch 8 in Civil Case No. 8904. to chemotherapy had petitioner not falsely assured them of its side effects.

The factual antecedents: In her answer,[8] petitioner denied having been negligent in administering the
chemotherapy drugs to Angelica and asserted that she had fully explained to
On July 7, 1993, respondents 11-year old daughter, Angelica Soliman, underwent a respondents how the chemotherapy will affect not only the cancer cells but also the
biopsy of the mass located in her lower extremity at the St. Lukes Medical Center patients normal body parts, including the lowering of white and red blood cells and
(SLMC). Results showed that Angelica was suffering from osteosarcoma, osteoblastic platelets. She claimed that what happened to Angelica can be attributed to malignant
type,[4] a high-grade (highly malignant) cancer of the bone which usually afflicts tumor cells possibly left behind after surgery. Few as they may be, these have the
teenage children. Following this diagnosis and as primary intervention, Angelicas right capacity to compete for nutrients such that the body becomes so weak structurally
leg was amputated by Dr. Jaime Tamayo in order to remove the tumor. As adjuvant (cachexia) and functionally in the form of lower resistance of the body to combat
treatment to eliminate any remaining cancer cells, and hence minimize the chances of infection. Such infection becomes uncontrollable and triggers a chain of events (sepsis
recurrence and prevent the disease from spreading to other parts of the patients body or septicemia) that may lead to bleeding in the form of Disseminated Intravascular
(metastasis), chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo referred Coagulation (DIC), as what the autopsy report showed in the case of Angelica.
Angelica to another doctor at SLMC, herein petitioner Dr. Rubi Li, a medical
oncologist. Since the medical records of Angelica were not produced in court, the trial and
appellate courts had to rely on testimonial evidence, principally the declarations of
On August 18, 1993, Angelica was admitted to SLMC. However, she died on petitioner and respondents themselves. The following chronology of events was
September 1, 1993, just eleven (11) days after the (intravenous) administration of the gathered:
first cycle of the chemotherapy regimen. Because SLMC refused to release a death
certificate without full payment of their hospital bill, respondents brought the cadaver On July 23, 1993, petitioner saw the respondents at the hospital after Angelicas surgery
of Angelica to the Philippine National Police (PNP) Crime Laboratory at Camp Crame and discussed with them Angelicas condition. Petitioner told respondents that
for post-mortem examination. The Medico-Legal Report issued by said institution Angelica should be given two to three weeks to recover from the operation before
indicated the cause of death as Hypovolemic shock secondary to multiple organ starting chemotherapy. Respondents were apprehensive due to financial constraints as
hemorrhages and Disseminated Intravascular Coagulation.[5] Reynaldo earns only from P70,000.00 to P150,000.00 a year from his jewelry and
watch repairing business.[9] Petitioner, however, assured them not to worry about her
On the other hand, the Certificate of Death[6] issued by SLMC stated the cause of professional fee and told them to just save up for the medicines to be used.
death as follows:
Petitioner claimed that she explained to respondents that even when a tumor is
Immediate cause : a. Osteosarcoma, Status Post AKA removed, there are still small lesions undetectable to the naked eye, and that adjuvant
Antecedent cause : b. (above knee amputation) chemotherapy is needed to clean out the small lesions in order to lessen the chance of
Underlying cause : c. Status Post Chemotherapy the cancer to recur. She did not give the respondents any assurance that chemotherapy
will cure Angelicas cancer. During these consultations with respondents, she explained
the following side effects of chemotherapy treatment to respondents: (1) falling hair;
(2) nausea and vomiting; (3) loss of appetite; (4) low count of white blood cells permission to bring their child home. Later in the evening, Angelica passed black stool
[WBC], red blood cells [RBC] and platelets; (5) possible sterility due to the effects on and reddish urine.[26] Petitioner countered that there was no record of blackening of
Angelicas ovary; (6) damage to the heart and kidneys; and (7) darkening of the skin stools but only an episode of loose bowel movement (LBM). Petitioner also testified
especially when exposed to sunlight. She actually talked with respondents four times, that what Angelica complained of was carpo-pedal spasm, not convulsion or epileptic
once at the hospital after the surgery, twice at her clinic and the fourth time when attack, as respondents call it (petitioner described it in the vernacular as naninigas ang
Angelicas mother called her through long distance.[10] This was disputed by kamay at paa). She then requested for a serum calcium determination and stopped the
respondents who countered that petitioner gave them assurance that there is 95% chemotherapy. When Angelica was given calcium gluconate, the spasm and numbness
chance of healing for Angelica if she undergoes chemotherapy and that the only side subsided.[27]
effects were nausea, vomiting and hair loss.[11] Those were the only side-effects of
chemotherapy treatment mentioned by petitioner.[12] The following day, August 23, petitioner yielded to respondents request to take
Angelica home. But prior to discharging Angelica, petitioner requested for a repeat
On July 27, 1993, SLMC discharged Angelica, with instruction from petitioner that serum calcium determination and explained to respondents that the chemotherapy will
she be readmitted after two or three weeks for the chemotherapy. be temporarily stopped while she observes Angelicas muscle twitching and serum
calcium level. Take-home medicines were also prescribed for Angelica, with
On August 18, 1993, respondents brought Angelica to SLMC for chemotherapy, instructions to respondents that the serum calcium test will have to be repeated after
bringing with them the results of the laboratory tests requested by petitioner: Angelicas seven days. Petitioner told respondents that she will see Angelica again after two
chest x-ray, ultrasound of the liver, creatinine and complete liver function tests.[13] weeks, but respondents can see her anytime if any immediate problem arises.[28]
Petitioner proceeded with the chemotherapy by first administering hydration fluids to
Angelica.[14] However, Angelica remained in confinement because while still in the premises of
SLMC, her convulsions returned and she also had LBM. Angelica was given oxygen
The following day, August 19, petitioner began administering three chemotherapy and administration of calcium continued.[29]
drugs Cisplatin,[15] Doxorubicin[16] and Cosmegen[17] intravenously. Petitioner
was supposedly assisted by her trainees Dr. Leo Marbella[18] and Dr. Grace The next day, August 24, respondents claimed that Angelica still suffered from
Arriete.[19] In his testimony, Dr. Marbella denied having any participation in convulsions. They also noticed that she had a fever and had difficulty breathing.[30]
administering the said chemotherapy drugs.[20] Petitioner insisted it was carpo-pedal spasm, not convulsions. She verified that at
around 4:50 that afternoon, Angelica developed difficulty in breathing and had fever.
On the second day of chemotherapy, August 20, respondents noticed reddish She then requested for an electrocardiogram analysis, and infused calcium gluconate
discoloration on Angelicas face.[21] They asked petitioner about it, but she merely on the patient at a stat dose. She further ordered that Angelica be given Bactrim,[31] a
quipped, Wala yan. Epekto ng gamot.[22] Petitioner recalled noticing the skin rashes synthetic antibacterial combination drug,[32] to combat any infection on the childs
on the nose and cheek area of Angelica. At that moment, she entertained the possibility body.[33]
that Angelica also had systemic lupus and consulted Dr. Victoria Abesamis on the
matter.[23] By August 26, Angelica was bleeding through the mouth. Respondents also saw blood
on her anus and urine. When Lina asked petitioner what was happening to her
On the third day of chemotherapy, August 21, Angelica had difficulty breathing and daughter, petitioner replied, Bagsak ang platelets ng anak mo. Four units of platelet
was thus provided with oxygen inhalation apparatus. This time, the reddish concentrates were then transfused to Angelica. Petitioner prescribed Solucortef.
discoloration on Angelicas face had extended to her neck, but petitioner dismissed it Considering that Angelicas fever was high and her white blood cell count was low,
again as merely the effect of medicines.[24] Petitioner testified that she did not see any petitioner prescribed Leucomax. About four to eight bags of blood, consisting of
discoloration on Angelicas face, nor did she notice any difficulty in the childs packed red blood cells, fresh whole blood, or platelet concentrate, were transfused to
breathing. She claimed that Angelica merely complained of nausea and was given ice Angelica. For two days (August 27 to 28), Angelica continued bleeding, but petitioner
chips.[25] claimed it was lesser in amount and in frequency. Petitioner also denied that there were
On August 22, 1993, at around ten oclock in the morning, upon seeing that their child gadgets attached to Angelica at that time.[34]
could not anymore bear the pain, respondents pleaded with petitioner to stop the On August 29, Angelica developed ulcers in her mouth, which petitioner said were
chemotherapy. Petitioner supposedly replied: Dapat 15 Cosmegen pa iyan. Okay, lets blood clots that should not be removed. Respondents claimed that Angelica passed
observe. If pwede na, bigyan uli ng chemo. At this point, respondents asked petitioners
about half a liter of blood through her anus at around seven oclock that evening, which While he was seeking the release of Angelicas cadaver from SLMC, Reynaldo claimed
petitioner likewise denied. that petitioner acted arrogantly and called him names. He was asked to sign a
promissory note as he did not have cash to pay the hospital bill.[43]
On August 30, Angelica continued bleeding. She was restless as endotracheal and
nasogastric tubes were inserted into her weakened body. An aspiration of the Respondents also presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-Legal
nasogastric tube inserted to Angelica also revealed a bloody content. Angelica was Officer of the PNP-Crime Laboratory who conducted the autopsy on Angelicas
given more platelet concentrate and fresh whole blood, which petitioner claimed cadaver, and Dr. Melinda Vergara Balmaceda who is a Medical Specialist employed
improved her condition. Petitioner told Angelica not to remove the endotracheal tube at the Department of Health (DOH) Operations and Management Services.
because this may induce further bleeding.[35] She was also transferred to the intensive
care unit to avoid infection. Testifying on the findings stated in her medico-legal report, Dr. Vergara noted the
following: (1) there were fluids recovered from the abdominal cavity, which is not
The next day, respondents claimed that Angelica became hysterical, vomited blood normal, and was due to hemorrhagic shock secondary to bleeding; (2) there was
and her body turned black. Part of Angelicas skin was also noted to be shredding by hemorrhage at the left side of the heart; (3) bleeding at the upper portion of and areas
just rubbing cotton on it. Angelica was so restless she removed those gadgets attached adjacent to, the esophagus; (4) lungs were heavy with bleeding at the back and lower
to her, saying Ayaw ko na; there were tears in her eyes and she kept turning her head. portion, due to accumulation of fluids; (4) yellowish discoloration of the liver; (5)
Observing her daughter to be at the point of death, Lina asked for a doctor but the latter kidneys showed appearance of facial shock on account of hemorrhages; and (6)
could not answer her anymore.[36] At this time, the attending physician was Dr. reddishness on external surface of the spleen. All these were the end result of
Marbella who was shaking his head saying that Angelicas platelets were down and hypovolemic shock secondary to multiple organ hemorrhages and disseminated
respondents should pray for their daughter. Reynaldo claimed that he was introduced intravascular coagulation. Dr. Vergara opined that this can be attributed to the
to a pediatrician who took over his daughters case, Dr. Abesamis who also told him to chemical agents in the drugs given to the victim, which caused platelet reduction
pray for his daughter. Angelica continued to have difficulty in her breathing and blood resulting to bleeding sufficient to cause the victims death. The time lapse for the
was being suctioned from her stomach. A nurse was posted inside Angelicas room to production of DIC in the case of Angelica (from the time of diagnosis of sarcoma) was
assist her breathing and at one point they had to revive Angelica by pumping her chest. too short, considering the survival rate of about 3 years. The witness conceded that the
Thereafter, Reynaldo claimed that Angelica already experienced difficulty in urinating victim will also die of osteosarcoma even with amputation or chemotherapy, but in
and her bowel consisted of blood-like fluid. Angelica requested for an electric fan as this case Angelicas death was not caused by osteosarcoma. Dr. Vergara admitted that
she was in pain. Hospital staff attempted to take blood samples from Angelica but were she is not a pathologist but her statements were based on the opinion of an oncologist
unsuccessful because they could not even locate her vein. Angelica asked for a fruit whom she had interviewed. This oncologist supposedly said that if the victim already
but when it was given to her, she only smelled it. At this time, Reynaldo claimed he had DIC prior to the chemotherapy, the hospital staff could have detected it.[44]
could not find either petitioner or Dr. Marbella. That night, Angelica became hysterical
and started removing those gadgets attached to her. At three oclock in the morning of On her part, Dr. Balmaceda declared that it is the physicians duty to inform and explain
September 1, a priest came and they prayed before Angelica expired. Petitioner finally to the patient or his relatives every known side effect of the procedure or therapeutic
came back and supposedly told respondents that there was malfunction or bogged- agents to be administered, before securing the consent of the patient or his relatives to
down machine.[37] such procedure or therapy. The physician thus bases his assurance to the patient on his
personal assessment of the patients condition and his knowledge of the general effects
By petitioners own account, Angelica was merely irritable that day (August 31). of the agents or procedure that will be allowed on the patient. Dr. Balmaceda stressed
Petitioner noted though that Angelicas skin was indeed sloughing off.[38] She stressed that the patient or relatives must be informed of all known side effects based on studies
that at 9:30 in the evening, Angelica pulled out her endotracheal tube.[39] On and observations, even if such will aggravate the patients condition.[45]
September 1, exactly two weeks after being admitted at SLMC for chemotherapy,
Angelica died.[40] The cause of death, according to petitioner, was septicemia, or Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelicas lower
overwhelming infection, which caused Angelicas other organs to fail.[41] Petitioner extremity, testified for the defendants. He explained that in case of malignant tumors,
attributed this to the patients poor defense mechanism brought about by the cancer there is no guarantee that the ablation or removal of the amputated part will completely
itself.[42] cure the cancer. Thus, surgery is not enough. The mortality rate of osteosarcoma at the
time of modern chemotherapy and early diagnosis still remains at 80% to 90%.
Usually, deaths occur from metastasis, or spread of the cancer to other vital organs like
the liver, causing systemic complications. The modes of therapy available are the
removal of the primary source of the cancerous growth and then the residual cancer representation of appellee Dr. Rubi Li that there were only three possible side-effects
cells or metastasis should be treated with chemotherapy. Dr. Tamayo further explained of the treatment. However, all sorts of painful side-effects resulted from the treatment
that patients with osteosarcoma have poor defense mechanism due to the cancer cells including the premature death of Angelica. The appellants were clearly and totally
in the blood stream. In the case of Angelica, he had previously explained to her parents unaware of these other side-effects which manifested only during the chemotherapy
that after the surgical procedure, chemotherapy is imperative so that metastasis of these treatment. This was shown by the fact that every time a problem would take place
cancer cells will hopefully be addressed. He referred the patient to petitioner because regarding Angelicas condition (like an unexpected side-effect manifesting itself), they
he felt that petitioner is a competent oncologist. Considering that this type of cancer is would immediately seek explanation from Dr. Rubi Li. Surely, those unexpected side-
very aggressive and will metastasize early, it will cause the demise of the patient effects culminating in the loss of a love[d] one caused the appellants so much trouble,
should there be no early intervention (in this case, the patient developed sepsis which pain and suffering.
caused her death). Cancer cells in the blood cannot be seen by the naked eye nor
detected through bone scan. On cross-examination, Dr. Tamayo stated that of the more On this point therefore, [w]e find defendant-appellee Dr. Rubi Li negligent which
than 50 child patients who had osteogenic sarcoma he had handled, he thought that would entitle plaintiffs-appellants to their claim for damages.
probably all of them died within six months from amputation because he did not see xxxx
them anymore after follow-up; it is either they died or had seen another doctor.[46]
WHEREFORE, the instant appeal is hereby GRANTED. Accordingly, the
In dismissing the complaint, the trial court held that petitioner was not liable for assailed decision is hereby modified to the extent that defendant-appellee Dr.
damages as she observed the best known procedures and employed her highest skill Rubi Li is ordered to pay the plaintiffs-appellants the following amounts:
and knowledge in the administration of chemotherapy drugs on Angelica but despite 1. Actual damages of P139,064.43, plus P9,828.00 for funeral expenses;
all efforts said patient died. It cited the testimony of Dr. Tamayo who testified that he 2. Moral damages of P200,000.00;
considered petitioner one of the most proficient in the treatment of cancer and that the 3. Exemplary damages of P50,000.00;
patient in this case was afflicted with a very aggressive type of cancer necessitating 4. Attorneys fee of P30,000.00.
chemotherapy as adjuvant treatment. Using the standard of negligence laid down in SO ORDERED.[49] (Emphasis supplied.)
Picart v. Smith,[47] the trial court declared that petitioner has taken the necessary
precaution against the adverse effect of chemotherapy on the patient, adding that a Petitioner filed a motion for partial reconsideration which the appellate court denied.
wrong decision is not by itself negligence. Respondents were ordered to pay their
unpaid hospital bill in the amount of P139,064.43.[48] Hence, this petition.

Respondents appealed to the CA which, while concurring with the trial courts finding Petitioner assails the CA in finding her guilty of negligence in not explaining to the
that there was no negligence committed by the petitioner in the administration of respondents all the possible side effects of the chemotherapy on their child, and in
chemotherapy treatment to Angelica, found that petitioner as her attending physician holding her liable for actual, moral and exemplary damages and attorneys fees.
failed to fully explain to the respondents all the known side effects of chemotherapy. Petitioner emphasized that she was not negligent in the pre-chemotherapy procedures
The appellate court stressed that since the respondents have been told of only three and in the administration of chemotherapy treatment to Angelica.
side effects of chemotherapy, they readily consented thereto. Had petitioner made
On her supposed non-disclosure of all possible side effects of chemotherapy, including
known to respondents those other side effects which gravely affected their child -- such
death, petitioner argues that it was foolhardy to imagine her to be all-
as carpo-pedal spasm, sepsis, decrease in the blood platelet count, bleeding, infections
knowing/omnipotent. While the theoretical side effects of chemotherapy were
and eventual death -- respondents could have decided differently or adopted a different
explained by her to the respondents, as these should be known to a competent doctor,
course of action which could have delayed or prevented the early death of their child.
petitioner cannot possibly predict how a particular patients genetic make-up, state of
The CA thus declared: mind, general health and body constitution would respond to the treatment. These are
obviously dependent on too many known, unknown and immeasurable variables, thus
Plaintiffs-appellants child was suffering from a malignant disease. The attending requiring that Angelica be, as she was, constantly and closely monitored during the
physician recommended that she undergo chemotherapy treatment after surgery in treatment. Petitioner asserts that she did everything within her professional
order to increase her chances of survival. Appellants consented to the chemotherapy competence to attend to the medical needs of Angelica.
treatment because they believed in Dr. Rubi Lis representation that the deceased would
have a strong chance of survival after chemotherapy and also because of the
Citing numerous trainings, distinctions and achievements in her field and her current In this case, both the trial and appellate courts concurred in finding that the alleged
position as co-director for clinical affairs of the Medical Oncology, Department of negligence of petitioner in the administration of chemotherapy drugs to respondents
Medicine of SLMC, petitioner contends that in the absence of any clear showing or child was not proven considering that Drs. Vergara and Balmaceda, not being
proof, she cannot be charged with negligence in not informing the respondents all the oncologists or cancer specialists, were not qualified to give expert opinion as to
side effects of chemotherapy or in the pre-treatment procedures done on Angelica. whether petitioners lack of skill, knowledge and professional competence in failing to
observe the standard of care in her line of practice was the proximate cause of the
As to the cause of death, petitioner insists that Angelica did not die of platelet depletion patients death. Furthermore, respondents case was not at all helped by the non-
but of sepsis which is a complication of the cancer itself. Sepsis itself leads to bleeding production of medical records by the hospital (only the biopsy result and medical bills
and death. She explains that the response rate to chemotherapy of patients with were submitted to the court). Nevertheless, the CA found petitioner liable for her
osteosarcoma is high, so much so that survival rate is favorable to the patient. failure to inform the respondents on all possible side effects of chemotherapy before
Petitioner then points to some probable consequences if Angelica had not undergone securing their consent to the said treatment.
chemotherapy. Thus, without chemotherapy, other medicines and supportive
treatment, the patient might have died the next day because of massive infection, or The doctrine of informed consent within the context of physician-patient relationships
the cancer cells might have spread to the brain and brought the patient into a coma, or goes far back into English common law. As early as 1767, doctors were charged with
into the lungs that the patient could have been hooked to a respirator, or into her the tort of battery (i.e., an unauthorized physical contact with a patient) if they had not
kidneys that she would have to undergo dialysis. Indeed, respondents could have spent gained the consent of their patients prior to performing a surgery or procedure. In the
as much because of these complications. The patient would have been deprived of the United States, the seminal case was Schoendorff v. Society of New York Hospital[53]
chance to survive the ailment, of any hope for life and her quality of life surely which involved unwanted treatment performed by a doctor. Justice Benjamin
compromised. Since she had not been shown to be at fault, petitioner maintains that Cardozos oft-quoted opinion upheld the basic right of a patient to give consent to any
the CA erred in holding her liable for the damages suffered by the respondents.[50] medical procedure or treatment: Every human being of adult years and sound mind
has a right to determine what shall be done with his own body; and a surgeon who
The issue to be resolved is whether the petitioner can be held liable for failure to fully performs an operation without his patients consent, commits an assault, for which he
disclose serious side effects to the parents of the child patient who died while is liable in damages.[54] From a purely ethical norm, informed consent evolved into a
undergoing chemotherapy, despite the absence of finding that petitioner was negligent general principle of law that a physician has a duty to disclose what a reasonably
in administering the said treatment. prudent physician in the medical community in the exercise of reasonable care would
The petition is meritorious. disclose to his patient as to whatever grave risks of injury might be incurred from a
proposed course of treatment, so that a patient, exercising ordinary care for his own
The type of lawsuit which has been called medical malpractice or, more appropriately, welfare, and faced with a choice of undergoing the proposed treatment, or alternative
medical negligence, is that type of claim which a victim has available to him or her to treatment, or none at all, may intelligently exercise his judgment by reasonably
redress a wrong committed by a medical professional which has caused bodily harm. balancing the probable risks against the probable benefits.[55]
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 Subsequently, in Canterbury v. Spence[56] the court observed that the duty to disclose
prudent health care provider would have done, or that he or she did something that a should not be limited to medical usage as to arrogate the decision on revelation to the
reasonably prudent provider would not have done; and that that failure or action caused physician alone. Thus, respect for the patients right of self-determination on particular
injury to the patient.[51] therapy demands a standard set by law for physicians rather than one which physicians
may or may not impose upon themselves.[57] The scope of disclosure is premised on
This Court has recognized that medical negligence cases are best proved by opinions the fact that patients ordinarily are persons unlearned in the medical sciences.
of expert witnesses belonging in the same general neighborhood and in the same Proficiency in diagnosis and therapy is not the full measure of a physicians
general line of practice as defendant physician or surgeon. The deference of courts to responsibility. It is also his duty to warn of the dangers lurking in the proposed
the expert opinion of qualified physicians stems from the formers realization that the treatment and to impart information which the patient has every right to expect. Indeed,
latter possess unusual technical skills which laymen in most instances are incapable of the patients reliance upon the physician is a trust of the kind which traditionally has
intelligently evaluating, hence the indispensability of expert testimonies.[52] exacted obligations beyond those associated with armslength transactions.[58] The
physician is not expected to give the patient a short medical education, the disclosure
rule only requires of him a reasonable explanation, which means generally informing
the patient in nontechnical terms as to what is at stake; the therapy alternatives open treatment and amputation of Angelicas lower extremity, that her immune system was
to him, the goals expectably to be achieved, and the risks that may ensue from already weak on account of the malignant tumor in her knee. When petitioner informed
particular treatment or no treatment.[59] As to the issue of demonstrating what risks the respondents beforehand of the side effects of chemotherapy which includes
are considered material necessitating disclosure, it was held that experts are lowered counts of white and red blood cells, decrease in blood platelets, possible
unnecessary to a showing of the materiality of a risk to a patients decision on treatment, kidney or heart damage and skin darkening, there is reasonable expectation on the part
or to the reasonably, expectable effect of risk disclosure on the decision. Such of the doctor that the respondents understood very well that the severity of these side
unrevealed risk that should have been made known must further materialize, for effects will not be the same for all patients undergoing the procedure. In other words,
otherwise the omission, however unpardonable, is without legal consequence. And, as by the nature of the disease itself, each patients reaction to the chemical agents even
in malpractice actions generally, there must be a causal relationship between the with pre-treatment laboratory tests cannot be precisely determined by the physician.
physicians failure to divulge and damage to the patient.[60] That death can possibly result from complications of the treatment or the underlying
cancer itself, immediately or sometime after the administration of chemotherapy
Reiterating the foregoing considerations, Cobbs v. Grant[61] deemed it as integral part drugs, is a risk that cannot be ruled out, as with most other major medical procedures,
of physicians overall obligation to patient, the duty of reasonable disclosure of but such conclusion can be reasonably drawn from the general side effects of
available choices with respect to proposed therapy and of dangers inherently and chemotherapy already disclosed.
potentially involved in each. However, the physician is not obliged to discuss
relatively minor risks inherent in common procedures when it is common knowledge As a physician, petitioner can reasonably expect the respondents to have considered
that such risks inherent in procedure of very low incidence. Cited as exceptions to the the variables in the recommended treatment for their daughter afflicted with a life-
rule that the patient should not be denied the opportunity to weigh the risks of surgery threatening illness. On the other hand, it is difficult to give credence to respondents
or treatment are emergency cases where it is evident he cannot evaluate data, and claim that petitioner told them of 95% chance of recovery for their daughter, as it was
where the patient is a child or incompetent.[62] The court thus concluded that the unlikely for doctors like petitioner who were dealing with grave conditions such as
patients right of self-decision can only be effectively exercised if the patient possesses cancer to have falsely assured patients of chemotherapys success rate. Besides,
adequate information to enable him in making an intelligent choice. The scope of the informed consent laws in other countries generally require only a reasonable
physicians communications to the patient, then must be measured by the patients need, explanation of potential harms, so specific disclosures such as statistical data, may not
and that need is whatever information is material to the decision. The test therefore for be legally necessary.[65]
determining whether a potential peril must be divulged is its materiality to the patients
decision.[63] The element of ethical duty to disclose material risks in the proposed medical treatment
cannot thus be reduced to one simplistic formula applicable in all instances. Further,
Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that for in a medical malpractice action based on lack of informed consent, the plaintiff must
liability of the physician for failure to inform patient, there must be causal relationship prove both the duty and the breach of that duty through expert testimony.[66] Such
between physicians failure to inform and the injury to patient and such connection expert testimony must show the customary standard of care of physicians in the same
arises only if it is established that, had revelation been made, consent to treatment practice as that of the defendant doctor.[67]
would not have been given.
In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medical
There are four essential elements a plaintiff must prove in a malpractice action based Specialist of the DOHs Operational and Management Services charged with receiving
upon the doctrine of informed consent: (1) the physician had a duty to disclose material complaints against hospitals, does not qualify as expert testimony to establish the
risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and standard of care in obtaining consent for chemotherapy treatment. In the absence of
proximate result of the failure to disclose, the patient consented to treatment she expert testimony in this regard, the Court feels hesitant in defining the scope of
otherwise would not have consented to; and (4) plaintiff was injured by the proposed mandatory disclosure in cases of malpractice based on lack of informed consent, much
treatment. The gravamen in an informed consent case requires the plaintiff to point to less set a standard of disclosure that, even in foreign jurisdictions, has been noted to
significant undisclosed information relating to the treatment which would have altered be an evolving one.
her decision to undergo it.[64]
As society has grappled with the juxtaposition between personal autonomy and the
Examining the evidence on record, we hold that there was adequate disclosure of medical profession's intrinsic impetus to cure, the law defining adequate disclosure has
material risks inherent in the chemotherapy procedure performed with the consent of undergone a dynamic evolution. A standard once guided solely by the ruminations of
Angelicas parents. Respondents could not have been unaware in the course of initial physicians is now dependent on what a reasonable person in the patients position
regards as significant. This change in perspective is especially important as medical
breakthroughs move practitioners to the cutting edge of technology, ever encountering
new and heretofore unimagined treatments for currently incurable diseases or ailments.
An adaptable standard is needed to account for this constant progression.
Reasonableness analyses permeate our legal system for the very reason that they are
determined by social norms, expanding and contracting with the ebb and flow of
societal evolution.

As we progress toward the twenty-first century, we now realize that the legal standard
of disclosure is not subject to construction as a categorical imperative. Whatever
formulae or processes we adopt are only useful as a foundational starting point; the
particular quality or quantity of disclosure will remain inextricably bound by the facts
of each case. Nevertheless, juries that ultimately determine whether a physician
properly informed a patient are inevitably guided by what they perceive as the common
expectation of the medical consumera reasonable person in the patients position when
deciding to accept or reject a recommended medical procedure.[68] (Emphasis
supplied.)

WHEREFORE, the petition for review on certiorari is GRANTED. The Decision


dated June 15, 2004 and the Resolution dated September 1, 2004 of the Court of
Appeals in CA-G.R. CV No. 58013 are SET ASIDE.

The Decision dated September 5, 1997 of the Regional Trial Court of Legazpi City,
Branch 8, in Civil Case No. 8904 is REINSTATED and UPHELD.

No costs.

SO ORDERED.
Republic of the Philippines
Supreme Court
Manila EXHIBIT A the certified photocopy of the X-ray Request form dated December 12,
SECOND DIVISION 1996, which is also marked as Annex 2 as it was actually originally the Annex to x x
x Dr. Pedro Lantin, IIIs counter affidavit filed with the City Prosecutor of Pasig City
in connection with the criminal complaint filed by [Romeo Sioson] with the said
G.R. No. 177407 February 9, 2011 office, on which are handwritten entries which are the interpretation of the results of
the ultrasound examination. Incidentally, this exhibit happens to be the same as or
RICO ROMMEL ATIENZA VS. BOARD OF MEDICINE and EDITHA identical to the certified photocopy of the document marked as Annex 2 to the Counter-
SIOSON Affidavit dated March 15, 2000, filed by x x x Dr. Pedro Lantin, III, on May 4, 2000,
DECISION with this Honorable Board in answer to this complaint;

NACHURA, J.: EXHIBIT B the certified photo copy of the X-ray request form dated January 30,
1997, which is also marked as Annex 3 as it was actually likewise originally an Annex
Before us is a petition for review on certiorari under Rule 45 of the Rules of Court, to x x x Dr. Pedro Lantin, IIIs counter-affidavit filed with the Office of the City
assailing the Decision[1] dated September 22, 2006 of the Court of Appeals (CA) in Prosecutor of Pasig City in connection with the criminal complaint filed by the herein
CA-G.R. SP No. 87755. The CA dismissed the petition for certiorari filed by petitioner complainant with the said office, on which are handwritten entries which are the
Rico Rommel Atienza (Atienza), which, in turn, assailed the Orders[2] issued by interpretation of the results of the examination. Incidentally, this exhibit happens to be
public respondent Board of Medicine (BOM) in Administrative Case No. 1882. also the same as or identical to the certified photo copy of the document marked as
Annex 3 which is likewise dated January 30, 1997, which is appended as such Annex
The facts, fairly summarized by the appellate court, follow.
3 to the counter-affidavit dated March 15, 2000, filed by x x x Dr. Pedro Lantin, III on
Due to her lumbar pains, private respondent Editha Sioson went to Rizal Medical May 4, 2000, with this Honorable Board in answer to this complaint.
Center (RMC) for check-up on February 4, 1995. Sometime in 1999, due to the same
EXHIBIT C the certified photocopy of the X-ray request form dated March 16, 1996,
problem, she was referred to Dr. Pedro Lantin III of RMC who, accordingly, ordered
which is also marked as Annex 4, on which are handwritten entries which are the
several diagnostic laboratory tests. The tests revealed that her right kidney is normal.
interpretation of the results of the examination.
It was ascertained, however, that her left kidney is non-functioning and non-
visualizing. Thus, she underwent kidney operation in September, 1999. EXHIBIT D the certified photocopy of the X-ray request form dated May 20, 1999,
which is also marked as Annex 16, on which are handwritten entries which are the
On February 18, 2000, private respondents husband, Romeo Sioson (as complainant),
interpretation of the results of the examination. Incidentally, this exhibit appears to be
filed a complaint for gross negligence and/or incompetence before the [BOM] against
the draft of the typewritten final report of the same examination which is the document
the doctors who allegedly participated in the fateful kidney operation, namely: Dr.
appended as Annexes 4 and 1 respectively to the counter-affidavits filed by x x x Dr.
Judd dela Vega, Dr. Pedro Lantin, III, Dr. Gerardo Antonio Florendo and petitioner
Judd dela Vega and Dr. Pedro Lantin, III in answer to the complaint. In the case of Dr.
Rico Rommel Atienza.
dela Vega however, the document which is marked as Annex 4 is not a certified
It was alleged in the complaint that the gross negligence and/or incompetence photocopy, while in the case of Dr. Lantin, the document marked as Annex 1 is a
committed by the said doctors, including petitioner, consists of the removal of private certified photocopy. Both documents are of the same date and typewritten contents are
respondents fully functional right kidney, instead of the left non-functioning and non- the same as that which are written on Exhibit D.
visualizing kidney
Petitioner filed his comments/objections to private respondents [Editha Siosons]
The complaint was heard by the [BOM]. After complainant Romeo Sioson presented formal offer of exhibits. He alleged that said exhibits are inadmissible because the
his evidence, private respondent Editha Sioson, also named as complainant there, filed same are mere photocopies, not properly identified and authenticated, and intended to
her formal offer of documentary evidence. Attached to the formal offer of establish matters which are hearsay. He added that the exhibits are incompetent to
documentary evidence are her Exhibits A to D, which she offered for the purpose of prove the purpose for which they are offered.
proving that her kidneys were both in their proper anatomical locations at the time she
was operated. She described her exhibits, as follows:
Dispositions of the Board of Medicine WHICH CAN RESULT IN THE DEPRIVATION OF PROFESSIONAL LICENSE
A PROPERTY RIGHT OR ONES LIVELIHOOD.[4]
The formal offer of documentary exhibits of private respondent [Editha
Sioson] was admitted by the [BOM] per its Order dated May 26, 2004. It reads: We find no reason to depart from the ruling of the CA.

The Formal Offer of Documentary Evidence of [Romeo Sioson], the Petitioner is correct when he asserts that a petition for certiorari is the proper remedy
Comments/Objections of [herein petitioner] Atienza, [therein respondents] De to assail the Orders of the BOM, admitting in evidence the exhibits of Editha. As the
la Vega and Lantin, and the Manifestation of [therein] respondent Florendo are assailed Orders were interlocutory, these cannot be the subject of an appeal separate
hereby ADMITTED by the [BOM] for whatever purpose they may serve in the from the judgment that completely or finally disposes of the case.[5] At that stage,
resolution of this case. where there is no appeal, or any plain, speedy, and adequate remedy in the ordinary
course of law, the only and remaining remedy left to petitioner is a petition for
Let the hearing be set on July 19, 2004 all at 1:30 p.m. for the reception of the certiorari under Rule 65 of the Rules of Court on the ground of grave abuse of
evidence of the respondents. discretion amounting to lack or excess of jurisdiction.
SO ORDERED. However, the writ of certiorari will not issue absent a showing that the BOM has acted
Petitioner moved for reconsideration of the abovementioned Order basically on the without or in excess of jurisdiction or with grave abuse of discretion. Embedded in the
same reasons stated in his comment/objections to the formal offer of exhibits. CAs finding that the BOM did not exceed its jurisdiction or act in grave abuse of
discretion is the issue of whether the exhibits of Editha contained in her Formal Offer
The [BOM] denied the motion for reconsideration of petitioner in its Order dated of Documentary Evidence are inadmissible.
October 8, 2004. It concluded that it should first admit the evidence being offered so
that it can determine its probative value when it decides the case. According to the Petitioner argues that the exhibits formally offered in evidence by Editha: (1) violate
Board, it can determine whether the evidence is relevant or not if it will take a look at the best evidence rule; (2) have not been properly identified and authenticated; (3) are
it through the process of admission. x x x.[3] completely hearsay; and (4) are incompetent to prove their purpose. Thus, petitioner
contends that the exhibits are inadmissible evidence.
Disagreeing with the BOM, and as previously adverted to, Atienza filed a petition for
certiorari with the CA, assailing the BOMs Orders which admitted Editha Siosons WE DISAGREE.
(Edithas) Formal Offer of Documentary Evidence. The CA dismissed the petition for To begin with, it is well-settled that the rules of evidence are not strictly applied in
certiorari for lack of merit. proceedings before administrative bodies such as the BOM.[6] Although trial courts
Hence, this recourse positing the following issues: are enjoined to observe strict enforcement of the rules of evidence,[7] in connection
with evidence which may appear to be of doubtful relevancy, incompetency, or
I. PROCEDURAL ISSUE: admissibility, we have held that:
WHETHER PETITIONER ATIENZA AVAILED OF THE PROPER REMEDY [I]t is the safest policy to be liberal, not rejecting them on doubtful or technical
WHEN HE FILED THE PETITION FOR CERTIORARI DATED 06 DECEMBER grounds, but admitting them unless plainly irrelevant, immaterial or incompetent, for
2004 WITH THE COURT OF APPEALS UNDER RULE 65 OF THE RULES OF the reason that their rejection places them beyond the consideration of the court, if they
COURT TO ASSAIL THE ORDERS DATED 26 MAY 2004 AND 08 OCTOBER are thereafter found relevant or competent; on the other hand, their admission, if they
2004 OF RESPONDENT BOARD. turn out later to be irrelevant or incompetent, can easily be remedied by completely
discarding them or ignoring them.[8]
II. SUBSTANTIVE ISSUE:
From the foregoing, we emphasize the distinction between the admissibility of
WHETHER THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE
evidence and the probative weight to be accorded the same pieces of evidence. PNOC
ERROR AND DECIDED A QUESTION OF SUBSTANCE IN A WAY NOT IN
Shipping and Transport Corporation v. Court of Appeals[9] teaches: Admissibility of
ACCORDANCE WITH LAW AND THE APPLICABLE DECISIONS OF THE
evidence refers to the question of whether or not the circumstance (or evidence) is to
HONORABLE COURT WHEN IT UPHELD THE ADMISSION OF
be considered at all. On the other hand, the probative value of evidence refers to the
INCOMPETENT AND INADMISSIBLE EVIDENCE BY RESPONDENT BOARD,
question of whether or not it proves an issue.
Second, petitioners insistence that the admission of Edithas exhibits violated his kidneys before, and at the time of, her operation, as with most human beings, were in
substantive rights leading to the loss of his medical license is misplaced. Petitioner their proper anatomical locations
mistakenly relies on Section 20, Article I of the Professional Regulation Commission
Rules of Procedure, which reads Third, contrary to the assertion of petitioner, the best evidence rule is inapplicable.
Section 3 of Rule 130 provides:
Section 20. Administrative investigation shall be conducted in accordance with these
Rules. The Rules of Court shall only apply in these proceedings by analogy or on a 1. Best Evidence Rule
suppletory character and whenever practicable and convenient. Technical errors in the Sec. 3. Original document must be produced; exceptions. When the subject of
admission of evidence which do not prejudice the substantive rights of either party inquiry is the contents of a document, no evidence shall be admissible other
shall not vitiate the proceedings.[10] than the original document itself, except in the following cases:
(a) When the original has been lost or destroyed, or cannot be produced in
As pointed out by the appellate court, the admission of the exhibits did not prejudice court, without bad faith on the part of the offeror;
the substantive rights of petitioner because, at any rate, the fact sought to be proved (b) When the original is in the custody or under the control of the party against
thereby, that the two kidneys of Editha were in their proper anatomical locations at the whom the evidence is offered, and the latter fails to produce it after reasonable
time she was operated on, is presumed under Section 3, Rule 131 of the Rules of Court: notice;
(c) When the original consists of numerous accounts or other documents which
Sec. 3. Disputable presumptions. The following presumptions are satisfactory if cannot be examined in court without great loss of time and the fact sought to
uncontradicted, but may be contradicted and overcome by other evidence: be established from them is only the general result of the whole; and
xxxx (d) When the original is a public record in the custody of a public officer or is
recorded in a public office.
(y) That things have happened according to the ordinary course of nature and the
ordinary habits of life. The subject of inquiry in this case is whether respondent doctors before the BOM are
liable for gross negligence in removing the right functioning kidney of Editha instead
The exhibits are certified photocopies of X-ray Request Forms dated December 12,
of the left non-functioning kidney, not the proper anatomical locations of Edithas
1996, January 30, 1997, March 16, 1996, and May 20, 1999, filed in connection with
kidneys. As previously discussed, the proper anatomical locations of Edithas kidneys
Edithas medical case. The documents contain handwritten entries interpreting the
at the time of her operation at the RMC may be established not only through the
results of the examination. These exhibits were actually attached as annexes to Dr.
exhibits offered in evidence.
Pedro Lantin IIIs counter affidavit filed with the Office of the City Prosecutor of Pasig
City, which was investigating the criminal complaint for negligence filed by Editha Finally, these exhibits do not constitute hearsay evidence of the anatomical locations
against the doctors of Rizal Medical Center (RMC) who handled her surgical of Edithas kidneys. To further drive home the point, the anatomical positions, whether
procedure. To lay the predicate for her case, Editha offered the exhibits in evidence to left or right, of Edithas kidneys, and the removal of one or both, may still be established
prove that her kidneys were both in their proper anatomical locations at the time of her through a belated ultrasound or x-ray of her abdominal area.
operation.
In fact, the introduction of secondary evidence, such as copies of the exhibits, is
The fact sought to be established by the admission of Edithas exhibits, that her kidneys allowed.[15] Witness Dr. Nancy Aquino testified that the Records Office of RMC no
were both in their proper anatomical locations at the time of her operation, need not longer had the originals of the exhibits because [it] transferred from the previous
be proved as it is covered by mandatory judicial notice.[11] building, x x x to the new building.[16] Ultimately, since the originals cannot be
produced, the BOM properly admitted Edithas formal offer of evidence and, thereafter,
Unquestionably, the rules of evidence are merely the means for ascertaining the truth
the BOM shall determine the probative value thereof when it decides the case.
respecting a matter of fact.[12] Thus, they likewise provide for some facts which are
established and need not be proved, such as those covered by judicial notice, both WHEREFORE, the petition is DENIED. The Decision of the Court of Appeals in
mandatory and discretionary.[13] Laws of nature involving the physical sciences, CA-G.R. SP No. 87755 is AFFIRMED. Costs against petitioner.
specifically biology,[14] include the structural make-up and composition of living
things such as human beings. In this case, we may take judicial notice that Edithas SO ORDERED.
Republic of the Philippines When his damaged urethra could not be fully repaired and reconstructed, Hanzs
SUPREME COURT parents brought a criminal charge against the petitioner for reckless imprudence
Manila resulting to serious physical injuries. On April 17, 1997, the information3 was filed in
FIRST DIVISION the Municipal Trial Court in Cities of Oroquieta City (MTCC), to which the latter
pleaded not guilty on May 22, 1998.4 Under the order of April 30, 1999, the case was
G.R. No. 163753 January 15, 2014 transferred to the RTC pursuant to Supreme Court Circular No. 11-99.5

DR. ENCARNACION C. LUMANTAS, M.D., Petitioner, vs. HANZ CALAPIZ, At the trial, the Prosecution presented several witnesses, including Dr. Rufino Agudera
REPRESENTED BY HIS PARENTS, HILARIO CALAPIZ, JR. and HERLITA as an expert witness and as the physician who had operated on Hanz twice to repair
CALAPIZ, Respondent. the damaged urethra. Dr. Agudera testified that Hanz had been diagnosed to have
urethral stricture and cavernosal injury left secondary to trauma that had necessitated
DECISION the conduct of two operations to strengthen and to lengthen the urethra. Although
BERSAMIN, J.: satisfactorily explaining that the injury to the urethra had been caused by trauma, Dr.
Agudera could not determine the kind of trauma that had caused the injury.
The acquittal of the accused does not necessarily mean his absolution from civil
liability. In his defense, the petitioner denied the charge. He contended that at the time of his
examination of Hanz on January 16, 1995, he had found an accumulation of pus at the
The Case vicinity of the appendix two to three inches from the penis that had required immediate
surgical operation; that after performing the appendectomy, he had circumcised Hanz
In this appeal, an accused desires the reversal of the decision promulgated on February
with his parents consent by using a congo instrument, thereby debunking the parents
20, 2003,1 whereby the Court of Appeals (CA) affirmed the judgment rendered on
claim that their child had been cauterized; that he had then cleared Hanz on January
August 6, 1999 by the Regional Trial Court (RTC), Branch 13, in Oroquieta City
27, 1995 once his fever had subsided; that he had found no complications when Hanz
ordering him to pay moral damages despite his acquittal of the crime of reckless
returned for his follow up check-up on February 2, 1995; and that the abscess
imprudence resulting in serious physical injuries charged against him.2
formation between the base and the shaft of the penis had been brought about by
Antecedents Hanzs burst appendicitis.

On January 16, 1995, Spouses Hilario Calapiz, Jr. and Herlita Calapiz brought their 8- Ruling of the RTC
year-old son, Hanz Calapiz (Hanz), to the Misamis Occidental Provincial Hospital,
In its decision rendered on August 6, 1999,6 the RTC acquitted the petitioner of the
Oroquieta City, for an emergency appendectomy. Hanz was attended to by the
crime charged for insufficiency of the evidence. It held that the Prosecutions evidence
petitioner, who suggested to the parents that Hanz also undergo circumcision at no
did not show the required standard of care to be observed by other members of the
added cost to spare him the pain. With the parents consent, the petitioner performed
medical profession under similar circumstances. Nonetheless, the RTC ruled that the
the coronal type of circumcision on Hanz after his appendectomy. On the following
petitioner was liable for moral damages because there was a preponderance of
day, Hanz complained of pain in his penis, which exhibited blisters. His testicles were
evidence showing that Hanz had received the injurious trauma from his circumcision
swollen. The parents noticed that the child urinated abnormally after the petitioner
by the petitioner. The decision disposed as follows:
forcibly removed the catheter, but the petitioner dismissed the abnormality as normal.
On January 30, 1995, Hanz was discharged from the hospital over his parents WHEREFORE, for insufficiency of evidence, this court renders judgment
protestations, and was directed to continue taking antibiotics. acquitting the accused, Dr. Encarnacion Lumantas, of reckless imprudence
resulting in serious physical injuries, but ordering him to pay Hanz Calapiz
On February 8, 1995, Hanz was confined in a hospital because of the abscess formation
P50,000.00 as moral damages. No costs.
between the base and the shaft of his penis. Presuming that the ulceration was brought
about by Hanzs appendicitis, the petitioner referred him to Dr. Henry Go, an urologist, SO ORDERED.
who diagnosed the boy to have a damaged urethra. Thus, Hanz underwent cystostomy,
and thereafter was operated on three times to repair his damaged urethra.
Ruling of the CA criminal case unless the court finds and declares that the fact from which the civil
liability might arise did not exist.
On appeal, the CA affirmed the RTC,7 sustaining the award of moral damages. It
opined that even if the petitioner had been acquitted of the crime charged, the acquittal Although it found the Prosecutions evidence insufficient to sustain a judgment of
did not necessarily mean that he had not incurred civil liability considering that the conviction against the petitioner for the crime charged, the RTC did not err in
Prosecution had preponderantly established the sufferings of Hanz as the result of the determining and adjudging his civil liability for the same act complained of based on
circumcision. mere preponderance of evidence.12 In this connection, the Court reminds that the
acquittal for insufficiency of the evidence did not require that the complainants
The petitioner moved for reconsideration, but the CA denied the motion on April 28, recovery of civil liability should be through the institution of a separate civil action for
2004.8 Hence, this appeal. that purpose.13
Issue The petitioners contention that he could not be held civilly liable because there was
Whether the CA erred in affirming the petitioners civil liability despite his acquittal no proof of his negligence deserves scant consideration. The failure of the Prosecution
of the crime of reckless imprudence resulting in serious physical injuries. to prove his criminal negligence with moral certainty did not forbid a finding against
him that there was preponderant evidence of his negligence to hold him civilly
Ruling liable.14 With the RTC and the CA both finding that Hanz had sustained the injurious
trauma from the hands of the petitioner on the occasion of or incidental to the
The petition for review lacks merit.
circumcision, and that the trauma could have been avoided, the Court must concur
It is axiomatic that every person criminally liable for a felony is also civilly liable.9 with their uniform findings. In that regard, the Court need not analyze and weigh again
Nevertheless, the acquittal of an accused of the crime charged does not necessarily the evidence considered in the proceedings a quo. The Court, by virtue of its not being
extinguish his civil liability. In Manantan v. Court of Appeals,10 the Court elucidates a trier of facts, should now accord the highest respect to the factual findings of the trial
on the two kinds of acquittal recognized by our law as well as on the different effects court as affirmed by the CA in the absence of a clear showing by the petitioner that
of acquittal on the civil liability of the accused, viz: such findings were tainted with arbitrariness, capriciousness or palpable error.

Our law recognizes two kinds of acquittal, with different effects on the civil liability Every person is entitled to the physical integrity of his body.1wphi1 Although we
of the accused.1wphi1 First is an acquittal on the ground that the accused is not the have long advocated the view that any physical injury, like the loss or diminution of
author of the act or omission complained of. This instance closes the door to civil the use of any part of ones body, is not equatable to a pecuniary loss, and is not
liability, for a person who has been found to be not the perpetrator of any act or susceptible of exact monetary estimation, civil damages should be assessed once that
omission cannot and can never be held liable for such act or omission. There being no integrity has been violated. The assessment is but an imperfect estimation of the true
delict, civil liability ex delicto is out of the question, and the civil action, if any, which value of ones body. The usual practice is to award moral damages for the physical
may be instituted must be based on grounds other than the delict complained of. This injuries sustained.15 In Hanzs case, the undesirable outcome of the circumcision
is the situation contemplated in Rule 111 of the Rules of Court. The second instance performed by the petitioner forced the young child to endure several other procedures
is an acquittal based on reasonable doubt on the guilt of the accused. In this case, even on his penis in order to repair his damaged urethra. Surely, his physical and moral
if the guilt of the accused has not been satisfactorily established, he is not exempt from sufferings properly warranted the amount of P50,000.00 awarded as moral damages.
civil liability which may be proved by preponderance of evidence only. Many years have gone by since Hanz suffered the injury. Interest of 6% per annum should then be imposed
on the award as a sincere means of adjusting the value of the award to a level that is not only reasonable but
The Rules of Court requires that in case of an acquittal, the judgment shall state just and commensurate. Unless we make the adjustment in the permissible manner by prescribing legal
"whether the evidence of the prosecution absolutely failed to prove the guilt of the interest on the award, his sufferings would be unduly compounded. For that purpose, the reckoning of
accused or merely failed to prove his guilt beyond reasonable doubt. In either case, the interest should be from the filing of the criminal information on April 17, 1997, the making of the judicial
demand for the liability of the petitioner.
judgment shall determine if the act or omission from which the civil liability might
arise did not exist."11 WHEREFORE, the Court AFFIRMS the decision promulgated on February 20, 2003, with the
modification that legal interest of 6% per annum to start from April 17, 1997 is imposed on the award
Conformably with the foregoing, therefore, the acquittal of an accused does not of:P50,000.00 as moral damages; and ORDERS the petitioner to pay the costs of suit.
prevent a judgment from still being rendered against him on the civil aspect of the
SO ORDERED.
Republic of the Philippines As per Certificate of Death issued by accused Dr. Antonio P. Cabugao, to the damage
SUPREME COURT and prejudice of the legal heirs of said deceased RODOLFO PALMA, JR. and other
Manila consequential damages relative thereto.
THIRD DIVISION
CONTRARY to Article 365, 1st par. of the Revised Penal Code.
G.R. No. 163879 July 30, 2014 Dagupan City, Philippines, January 29, 2001.
DR. ANTONIO P. CABUGAO, Petitioner, vs. PEOPLE OF THE PHILIPPINES Arising from the same events, the Court resolved to consolidate these cases.4 The
and SPOUSES RODOLFO M. PALMA and ROSARIO F. PALMA, facts, as culled from the records, are as follows:
Respondents.
On June 14, 2000, at around 4 o'clock in the afternoon, ten (10)-year old Rodolfo F.
x-----------------------x Palma, Jr. (JR) complained of abdominal pain to his mother, Rosario Palma. At 5
G.R. No. 165805 oclock that same afternoon, Palma's mother and father, Atty. Rodolfo Palma Sr.,
brought JR to the clinic of accused Dr. Cabugao. Dr. Cabugao, a general practitioner,
DR. CLENIO YNZON, Petitioner, vs. PEOPLE OF THE PHILIPPINES and specializing in family medicine gave medicines for the pain and told Palma's parents
SPOUSES RODOLFO M. PALMA AND ROSARIO F. PALMA, Respondents. to call him up if his stomach pains continue. Due to persistent abdominal pains, at 4:30
in the early morning of June 15, 2000, they returned to Dr. Cabugao, who advised
DECISION them to bring JR to the Nazareth General Hospital in Dagupan City, for confinement.
PERALTA, J.: JR was admitted at the said hospital at 5:30 in the morning.5

Before this Court are appeals via Rule 45 from the Decision1 dated June 4, 2004 of Blood samples were taken from JR for laboratory testing. The complete blood count
the Court of Appeals in CA-G.R. CR No. 27293, affirming the Decision2 dated conveyed the following result: wbc 27.80 x 10 9/L; lymphocytes 0.10 and
February 28,2003 of the Regional Trial Court (RTC), convicting appellant Dr. Antonio neutrophils 0.90. Diagnostic ultrasound was likewise conducted on the patient's
P. Cabugao (Dr. Cabugao) and Dr. Clenio Ynzon (Dr. Ynzon) of the crime of Reckless lower abdomen by radiologist, Dr. Ricky V. Querubin, with the following findings:
Imprudence Resulting to Homicide. Normal liver, bile ducts, gallbladder, pancreas, spleen, kidneys and urinary bladder.
The Information3 alleged There is no free peritoneal fluid.
That on or about June 17, 2000in the City of Dagupan, Philippines, and within the There is localized tenderness in the paraumbilical region, more so in the supra and
jurisdiction of this Honorable Court, the abovenamed accused, DR. ANTONIO right paraumbilical areas.
P.CABUGAO and DR. CLENIO YNZON, being then the attending physicians of one
RODOLFO PALMA, JR., a minor 10 years old, confederating and acting jointly with There is a vague elongated hypoechoic focus in the right periumbilical region roughly
one another, did, then and there, willfully, unlawfully and feloniously fail through about 47 x 18 mm surrounded by undistended gas-filled bowels. This is suggestive of
negligence, carelessness and imprudence to perform immediate operation upon their an inflammatory process wherein appendiceal or periappendiceal pathology cannot be
patient, RODOLFO PALMA, JR. of acute appendicitis, when they, the said excluded. Clinical correlation is essential."6
physicians, should have been done so considering that examinations conducted upon
their patient Rodolfo Palma, Jr. seriously manifest to do so, causing by such Dr. Cabugao did a rectal examination noting the following: "rectal: good sphincter,
negligence, carelessness, and imprudence the victim, RODOLFO PALMA JR., to die negative tenderness, negative mass." The initial impression was Acute Appendicitis,7
due to: and hence, he referred the case to his co-accused, Dr. Ynzon, a surgeon.8 In the later
part of the morning of June 15, 2000, Dr. Ynzon went to the hospital and readthe CBC
"CARDIORESPIRATORY ARREST, METABOLIC ENCEPHALOPATHY, and ultrasound results. The administration of massive antibiotics and pain reliever to
SEPTICEMIA (ACUTE APPENDICITIS), CEREBRAL ANEURYSM RUPTURED JR were ordered. Thereafter, JR was placed on observation for twenty-four (24) hours.
(?)"
In the morning of June 16, 2000, JR complained again of abdominal pain and his
parents noticed a swelling in his scrotum. In the afternoon of the same day, JR vomited
out greenish stuff three (3) times and had watery bowels also three (3) times. The period of observation, the accused relinquished their duty and thereby were unable to
nurses on-duty relayed JR's condition to Dr. Ynzon who merely gave orders via give the proper and correct evaluation as to the real condition of JR. In situations where
telephone.9 Accused continued medications to alleviate JR's abdominal spasms and massive infection is going on as shown by the aggressive medication of antibiotics,
diarrhea. By midnight, JR again vomited twice, had loose bowel movements and was the condition of the patient is serious which necessitated personal, not delegated,
unable to sleep. The following morning, June 17,2000, JR's condition worsened, he attention of attending physicians, namely JR and the accused in this case.
had a running fever of 38C. JR's fever remained uncontrolled and he became
unconscious, he was given Aeknil (1 ampule) and Valium (1 ampule). JR's condition xxxx
continued to deteriorate that by 2 o'clock in the afternoon, JR's temperature soared to Throughout the course of the hospitalization and treatment of JR, the accused failed to
42C, had convulsions and finally died. address the acute appendicitis which was the initial diagnosis. They did not take steps
The Death Certificate10 dated June 19, 2000 prepared by Dr. Cabugao indicated the to find out if indeed acute appendicitis was what was causing the massive infection
following causes of death: that was ongoing inside the body of JR even when the inflammatory process was
located at the paraumbilical region where the appendix can be located. x x x
Immediate cause: CARDIORESPIRATORY ARREST
Antecedent cause: METABOLIC ENCEPHALOPATHY There may have been other diseases but the records do not show that the accused took
Underlying cause: SEPTICEMIA (ACUTE APPENDICITIS) steps to find ou twhat disease exactly was plaguing JR. It was their duty to find out the
Other significant conditions contributing to death: disease causing the health problem of JR, but they did not perform any process of
CEREBRAL ANEURYSM RUPTURED (?) elimination. Appendicitis, according to expert testimonies, could be eliminated only
by surgery but no surgery was done by the accused. But the accused could not have
No post-mortem examination was conducted on JR. On February 1, 2001, an found out the real disease of JR because they were treating merely and exclusively the
Information was filed against accused for reckless imprudence resulting to homicide. symptoms by means of the different medications to arrest the manifested symptoms.
At their arraignment, both accused, duly assisted by counsel, pleaded not guilty to the In fact, by treating the symptoms alone, the accused were recklessly and wantonly
charge. ignoring the same as signs of the graver health problem of JR. This gross negligence
on the part of the accused allowed the infection to spread inside the body of JR
On February 28, 2003, in convicting both the accused, the trial court found the unabated. The infection obviously spread so fast and was so massive that within a
following circumstances as sufficient basis to conclude that accused were indeed period of only two and a half (2 ) days from the day of admission to the hospital on
negligent in the performance of their duties: June 15, 2000, JR who was otherwise healthy died [of] Septicemia (Acute
Appendicitis) on June 17, 2000.11
It is unquestionable that JR was under the medical care of the accused from the time
of his admission for confinement at the Nazareth General Hospital until his death. On June 4, 2004, in affirming the accused' conviction, the Court of Appeals gave
Upon his admission, the initial working diagnosis was to consider acute appendicitis. similar observations, to wit:
To assist the accused in the consideration of acute appendicitis, Dr. Cabugao requested
for a complete blood count (CBC) and a diagnostic ultrasound on JR. The findings of The foregoing expert testimony clearly revealed such want of reasonable skill and care
the CBC and ultrasound showed that an inflammatory process or infection was going on the part of JR's attending physicians, appellants Dr. Cabugao and Dr. Ynzon in
on inside the body of JR. Said inflammatory process was happening in the neglecting to monitor effectively and sufficiently the developments/changes during the
periumbilical region where the appendix could be located. The initial diagnosis of observation period and act upon the situation after said 24-hour period when his
acute appendicitis appears to be a distinct possibility. x x x. abdominal pain subsisted, his condition even worsened with the appearance of more
serious symptoms of nausea, vomiting and diarrhea. Considering the brief visit only
Dr. Ynzon ordered medications to treat the symptoms being manifested by JR. made on regular rounds, the records clearly show such gross negligence in failing to
Thereafter, he ordered that JR be observed for 24 hours. However, the accused, as the take appropriate steps to determine the real cause of JR's abdominal pain so that the
attending physicians, did not personally monitor JR in order to check on subtle changes crucial decision to perform surgery (appendectomy) had even been ruled out precisely
that may occur. Rather, they left the monitoring and actual observation to resident because of the inexcusable neglect to undertake such efficient diagnosis by process of
physicians who are just on residency training and in doing so, they substituted their elimination, as correctly pointed out by the trial court. As has been succinctly
own expertise, skill and competence with those of physicians who are merely new emphasized by Dr. Mateo, acute appendicitis was the working diagnosis, and with the
doctors still on training. Not having personally observed JR during this 24-hour critical emergence of symptoms after the 24-hour observation (high fever, vomiting, diarrhea)
still, appellants ruled out surgery, not even considering exploratory laparoscopy. Dr. DECISION SEEMS TO HAVE TREATED BOTH ACCUSED DOCTORS TO BE
Mateo also expressed the opinion that the decision to operate could have been made IN CONSPIRACY;
after the result of the ultrasound test, considering that acute appendicitis was the initial
diagnosis by Dr. Cabugao after he had conducted a rectal examination. III

Medical records buttress the trial court's finding that in treating JR, appellants have WHETHER PETITIONER DR. CABUGAO IS A GENERAL PRACTITIONER
demonstrated indifference and neglect of the patient's condition as a serious case. (NOT A SURGEON) AND HAVE EXCLUDED SURGERY FROM THE LIMITS
Indeed, appendicitis remains a clinical emergency and a surgical disease, as correctly OFHIS PRACTICE, AND IT WAS NOT AND NEVER HIS DUTY TO OPERATE
underscored by Dr. Mateo, a practicing surgeon who has already performed over a THE PATIENT RODOLFO PALMA JR., THAT WAS WHY HE REFERRED
thousand appendectomy. In fact, appendectomy is the only rational therapy for acute SUBJECT PATIENT TO A SURGEON, DR. CLENIO YNZON;
appendicitis; it avoids clinical deterioration and may avoid chronic or recurrent IV
appendicitis. Although difficult, prompt recognition and immediate treatment of the
disease prevent complications. Under the factual circumstances, the inaction, neglect WHETHER THE DEFENSE NEVER STATED THAT THERE IS GUARANTEE
and indifference of appellants who, after the day of admission and after being apprised THAT DOING SURGERY WOULD HAVE SAVED THE PATIENT;
of the ongoing infection from the CBC and initial diagnosis as acute appendicitis from
V
rectal examination and ultrasound test and only briefly visited JR once during regular
rounds and gave medication orders by telephone constitutes gross negligence leading WHETHER THE WITNESSES FOR THE PROSECUTION INCLUDING
to the continued deterioration of the patient, his infection having spread in so fast a PROSECUTION'S EXPERT WITNESSES EVER DECLARED/TESTIFIED THAT
pace that he died within just two and a half (2 ) days stay in the hospital. Authorities PETITIONER DR. CABUGAO HAD THE DUTY TO PERFORM IMMEDIATE
state that if the clinical picture is unclear a short period of 4 to 6 hours of watchful OPERATION ON RODOLFO PALMA, JR., AND THEY FAILED TO
waiting and a CT scan may improve diagnostic accuracy and help to hasten diagnosis. STATE/SHOW THAT THE PROXIMATE CAUSE OF DEATH OF JR WAS
Even assuming that JR's case had an atypical presentation in view of the location of ACUTE APPENDICITIS;
his appendix, laboratory tests could have helped to confirm diagnosis, as Dr. Mateo
opined that the possibility of JR having a retrocecal appendicitis should have been a VI
strong consideration. Lamentably, however, as found by the trial court, appellants had
WHETHER THE EXPERT WITNESSES PRESENTED BY THE PROSECUTION
not taken steps towards correct diagnosis and demonstrated laxity even when JR was
EVER QUESTIONED THE MANAGEMENT AND CARE APPLIED BY
already running a high fever in the morning of June 17, 2000 and continued vomiting
PETITIONER DR. CABUGAO;
with diarrhea, his abdominal pain becoming more intense. This is the reason why
private complainants were not even apprised of the progress of appellants' diagnosis VII
appellants have nothing to report because they did nothing towards the end and merely
gave medications to address the symptoms.12 WHETHER THE EXPERT WITNESSES PRESENTED BY THE DEFENSE ARE
UNANIMOUS IN APPROVING THE METHOD OF TREATMENT APPLIED BY
Thus, these appeals brought before this Court raising the following arguments: BOTH ACCUSED DOCTORS ON SUBJECT PATIENT, AND THEY
DECLARED/AFFIRMED THAT THEY WOULD FIRST PLACE SUBJECT THE
I
PATIENT UNDER OBSERVATION, AND WOULD NOT PERFORM
WHETHER THE CAUSE OF ACCUSATION AS CONTAINED IN THE IMMEDIATE OPERATION;
INFORMATION IS "FAILURE TO PERFORM IMMEDIATE OPERATION UPON
VIII
THE PATIENT ROFOLFO PALMA JR. OF ACUTE APPENDICITIS;
WHETHER THE CONVICTION OF PETITIONER DR. YNZON WAS
II
ESTABLISHED WITH THE REQUIRED QUANTUM OF PROOF BEYOND
WHETHER THE SUBJECT INFORMATION APPEARS TO HAVE ACCUSED REASONABLE DOUBT THAT THE PATIENT WAS SPECIFICALLY
BOTH ACCUSED DOCTORS OF CONSPIRACY AND THE APPEALED SUFFERING FROM AND DIED OF ACUTE APPENDICITIS; and
IX A Yes, sir.16

WHETHER THE FAILURE TO CONDUCT THE SPECIFIC SURGICAL xxxx


OPERATION KNOWN AS APPENDECTOMY CONSTITUTED CRIMINAL
NEGLIGENCE. COURT:

In a nutshell, the petition brought before this Court raises the issue of whether or not Q You stated a while ago doctor that you are going to [do] surgery to the patient, why
petitioners' conviction of the crime of reckless imprudence resulting in homicide, doctor, if you are not going to do surgery, what will happen?
arising from an alleged medical malpractice, is supported by the evidence on record. A If this would be appendicitis, the usual progress would be that it would be ruptured
Worth noting is that the assigned errors are actually factual in nature, which as a and generalized peritonitis and eventually septicemia, sir.
general rule, findings of fact of the trial court and the Court of Appeals are binding Q What do you mean by that doctor?
and conclusive upon this Court, and we will not normally disturb such factual findings
unless the findings of the court are palpably unsupported by the evidence on record or A That means that infection would spread throughout the body, sir.
unless the judgment itself is based on misapprehension of facts. In the instant case, we
Q If unchecked doctor, what will happen?
find the need to make certain exception.
A It will result to death.17
AS TO DR. YNZON'S LIABILITY:
xxxx
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 Q And what would have you done if you entertain other considerations from the time
on the part of the person performing or failing to perform such act.13 The elements of the patient was admitted?
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 A From the time the patient was admitted until the report of the sonologist, I would
material damage results from the reckless imprudence; and (5) that there is inexcusable have made a decision by then.
lack of precaution on the part of the offender, taking into consideration his
Q And when to decide the surgery would it be a particular exact time, would it be the
employment or occupation, degree of intelligence, physical condition, and other
same for all surgeons?
circumstances regarding persons, time and place.14
A If you are asking acute appendicitis, it would be about 24 hours because acute
With respect to Dr. Ynzon, all the requisites of the offense have been clearly
appendicitis is a 24-hour disease, sir.
established by the evidence on record. The court a quo and the appellate court were
one in concluding that Dr. Ynzon failed to observe the required standard of care Q. And would it be correct to say that it depends on the changes on the condition of
expected from doctors. the patient?
In the instant case, it was sufficiently established that to prevent certain death, it was A. Yes, sir.
necessary to perform surgery on JR immediately. Even the prosecutions own expert
witness, Dr. Antonio Mateo,15 testified during cross-examination that he would Q. So, are you saying more than 24 hours when there are changes?
perform surgery on JR:
A. If there are changes in the patient pointing towards appendicitis then you have to
ATTY. CASTRO: decide right there and then, sir.

Q. Given these data soft non-tender abdomen, ambulatory, watery diarrhea, Exhibit C Q. So if there are changes in the patient pointing to appendicitis?
which is the ultrasound result, with that laboratory would you operate the patient?
A. It depends now on what you are trying to wait for in the observation period, sir.
A Yes, I would do surgery.
Q. So precisely if the change is a condition which bring you in doubt that there is
Q And you should have done surgery with this particular case?" something else other than appendicitis, would you extend over a period of 24 hours?
A. It depends on the emergent development, sir. A. I will examine the patient thoroughly and it will depend on my physical examination
and that is probably every 4 to 6 hours, sir.20
Q. That is the point, if you are the attending physician and there is a change not
pointing to appendicitis, would you extend over a period of 24 hours? On cross-examination, Dr. Villaflor affirmed:

A. In 24 hours you have to decide, sir. Cross Exam. By Atty. Marteja:

xxxx Q. x x x However, there are corrections and admissions made at that time, your Honor,
do I understand that T/C does not mean ruled out but rather to consider the matter?
Q. And that is based on the assessment of the attending physician?
A. Yes, now that I have seen the records of the patient, it says here, impression and
A. Yes, sir.18 T/C means to consider the appendicitis.
Dr. Mateo further testified on cross-examination: Q. Isn't it that it is worth then to say that the initial working diagnosis on Rodolfo
ATTY. CASTRO: Palma, Jr., otherwise known as JR, to whom I shall now refer to as JR, the primary
consideration then is acute appendicitis, is that correct to say Doctor?
Q: So you will know yourself, as far as the record is concerned, because if you will
agree with me, you did not even touch the patient? A. I think so, that is the impression.

A. Yes, I based my opinion on what is put on record, sir. The records show that after Q. x x x Now if it is to be considered as the primary consideration in the initial working
the observation period, the abdominal pain is still there plus there are already other diagnosis, isn't it a fact that it has to be ruled out in order to consider it as not the
signs and symptoms which are not seen or noted. disease of JR?

Q. But insofar as you yourself not having touched the abdomen of the patient, would A. Yes. Sir.
you give a comment on that? Q. Isn't it a fact thatto rule out acute appendicitis as not the disease of JR, surgery or
A. Yes, based on the record, after 24 hours of observation, the pain apparently was operation must be done, isn't it Doctor?
still there and there was more vomiting and there was diarrhea. In my personal opinion, A. You have to correlate all the findings.
I think the condition of the patient was deteriorating.
Q. Is it yes or no, Doctor?
Q. Even though you have not touched the patient?
A. Yes.
A. I based on what was on the record, sir.19
Q. So, you are saying then that in order to rule out acute appendicitis there must be an
From the foregoing, it is clear that if JRs condition remained unchecked it would operation, that is right Doctor?
ultimately result in his death, as what actually happened in the present case. Another
expert witness for the defense, Dr. Vivencio Villaflor, Jr. testified on direct A. No, sir. If your diagnosis is to really determine if it is an acute appendicitis, you
examination that he would perform a personal and thorough physical examination of have to operate.21
the patient as frequent as every 4 to 6 hours, to wit:
xxxx
ATTY. CASTRO:
Q. Now Doctor, considering the infection, considering that there was a [symptom] that
Q. As an expert doctor, if you were faced with a history of abdominal pain with nausea, causes pain, considering that JR likewise was feverish and that he was vomiting, does
vomiting, fever, anurecia (sic), elevated white blood cell count, physical examination that not show a disease of acute appendicitis Doctor?
of a positive psoas sign, observation of the sonologist of abdominal tenderness and the
ultrasound findings of the probability of appendiceal (sic) pathology, what will you do A. Its possible.
if you have faced these problems, Doctor?
Q. So that if that is possible, are we getting the impression then Doctor what you have guilty of - his seemingly indifference to the deteriorating condition of JR that he as a
earlier mentioned that the only way to rule out the suspect which is acute appendicitis consequence, failed to exercise lack of precaution which eventually led to JR's death.
is by surgery, you have said that earlier Doctor, I just want any confirmation of it?
To be sure, whether or not a physician has committed an "inexcusable lack of
A. Yes, sir.22 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
Verily, whether a physician or surgeon has exercised the requisite degree of skill and circumstances bearing in mind the advanced state of the profession at the time of
care in the treatment of his patient is, in the generality of cases, a matter of expert treatment or the present state of medical science. In accepting a case, a doctor in effect
opinion. The deference of courts to the expert opinions of qualified physicians stems represents that, having the needed training and skill possessed by physicians and
from its realization that the latter possess unusual technical skills which laymen in surgeons practicing in the same field, he will employ such training, care and skill in
most instances are incapable of intelligently evaluating.23 From the testimonies of the the treatment of his patients. He, therefore, has a duty to use at least the same level of
expert witnesses presented, it was irrefutably proven that Dr. Ynzon failed to practice care that any other reasonably competent doctor would use to treat a condition under
that degree of skill and care required in the treatment of his patient. the same circumstances.26 Sadly, Dr. Ynzon did not display that degree of care and
As correctly observed by the appellate court, Dr. Ynzon revealed want of reasonable precaution demanded by the circumstances.
skill and care in attending to the needs of JR by neglecting to monitor effectively the AS TO DR. CABUGAO'S LIABILITY:
developments and changes on JR's condition during the observation period, and to act
upon the situation after the 24-hour period when his abdominal pain persisted and his Every criminal conviction requires of the prosecution to prove two things the fact
condition worsened. Lamentable, Dr. Ynzon appeared to have visited JR briefly only of the crime, i.e., the presence of all the elements of the crime for which the accused
during regular rounds in the mornings. He was not there during the crucial times on stands charged, and the fact that the accused is the perpetrator of the crime. Based on
June 16, 2000 when JR's condition started to deteriorate until JR's death. As the the above disquisitions, however, the prosecution failed to prove these two things. The
attending surgeon, he should be primarily responsible in monitoring the condition of Court is not convinced with moral certainty that Dr. Cabugao is guilty of reckless
JR, as he is in the best position considering his skills and experience to know if the imprudence as the elements thereof were not proven by the prosecution beyond a
patient's condition had deteriorated. While the resident-doctors-on duty could likewise reasonable doubt.
monitor the patients condition, he is the one directly responsible for the patient as the
attending surgeon. Indeed, it is reckless and gross negligence of duty to relegate his Both the trial court and the appellate court bewail the failure to perform appendectomy
personal responsibility to observe the condition of the patient. Again, acute on JR, or the failure to determine the source of infection which caused the deterioration
appendicitis was the working diagnosis, and with the emergence of graver symptoms of JR's condition. However, a review of the records fail to show that Dr. Cabugao is
after the 24-hour observation, Dr. Ynzon ruled out surgery for no apparent reason. We, in any position to perform the required appendectomy.
likewise, note that the records are devoid of showing of any reasonable cause which Immediately apparent from a review of the records of this case is the fact that Dr.
would lead Dr. Ynzon to overrule appendectomy despite the initial diagnosis of Cabugao is not a surgeon, but a general practitioner specializing in family medicine;27
appendicitis. Neitherwas there any showing that he was entertaining another diagnosis thus, even if he wanted to, he cannot do an operation, much less an appendectomy on
nor he took appropriate steps towards another diagnosis. JR. It is precisely for this reason why he referred JR to Dr. Ynzon after he suspected
Among the elements constitutive of reckless imprudence, what perhaps is most central appendicitis. Dr. Mateo, the prosecutions expert witness, emphasized the role of the
to a finding of guilt is the conclusive determination that the accused has exhibited, by surgeon during direct examination, to wit:
his voluntary act without malice, an inexcusable lack of precaution. It is that which ATTY. MARTEJA:
supplies the criminal intent so indispensable as to bring an act of mere negligence and
imprudence under the operation of the penal law. This is because a conscious Q. You had mentioned that under this circumstances and condition, you have
indifference to the consequences of the conduct is all that is required from the mentioned that surgery is the solution, would you have allowed then a 24 hour
standpoint of the frame of mind of the accused.24 Quasi offenses penalize the mental observation?
attitude or condition behind the act, the dangerous recklessness, the lack of care or
A. If there is a lingering doubt, in short period of observation of 18-24 hours can be
foresight, the "imprudencia punible," unlike willful offenses which punish the
allowed provided that there would be close monitoring of the patient, sir.
intentional criminal act.25 This is precisely where this Court found Dr. Ynzon to be
Q. Would you please tell us who would be doing the monitoring doctor? Q. So that if that is possible, are we getting the impression then Doctor what you have
earlier mentioned that the only way to rule out the suspect which is acute appendicitis
A. The best person should be the first examiner, the best surgeon, sir. is by surgery, you have said that earlier Doctor, I just want any confirmation of it?
Q. So that would you say that it is incumbent on the surgeon attending to the case to A. Yes, sir.30
have been the one to observe within the period of observation?
Neither do we find evidence that Dr. Cabugao has been negligent or lacked the
A. Yes, because he will be in the best position to observe the sudden changes in the necessary precaution in his performance of his duty as a family doctor. On the contrary,
condition of the patient, sir. a perusal of the medical records would show that during the 24-hour monitoring on
Q. And how often would in your experience doctor, how often would the surgeon re- JR, it was Dr. Cabugao who frequently made orders on the administration of antibiotics
assist (sic) the condition of the patient during the period of observation? and pain relievers. There was also repetitive instructions from Dr. Cabugao to refer JR
to Dr. Ynzon as it appeared that he is suspecting appendicitis. The referral of JR to Dr.
A. Most foreign authors would recommend every four (4) hours, some centers will Ynzon, a surgeon, is actually an exercise of precaution as he knew that appendicitis is
recommend hourly or every two hours but here in the Philippines, would recommend not within his scope of expertise. This clearly showed that he employed the best of his
for 4 to 6 hours, sir.28 knowledge and skill in attending to JR's condition, even after the referral of JR to Dr.
Ynzon. To be sure, the calculated assessment of Dr. Cabugao to refer JR to a surgeon
Dr. Cabugaos supervision does not cease upon his endorsement of his patient to the
who has sufficient training and experience to handle JRs case belies the finding that
surgeon. Here, Dr. Cabugao has shown to have exerted all efforts to monitor his patient
he displayed inexcusable lack of precaution in handling his patient.31
and under these circumstances he did not have any cause to doubt Dr. Ynzons
competence and diligence. Expert testimonies have been offered to prove the We likewise note that Dr. Cabugao was out of town when JR's condition began to
circumstances surrounding the case of JR and the need to perform an operation. deteriorate. Even so, before he left, he made endorsement and notified the resident-
Defense witness, Dr. Villaflor, on cross examination testified, to wit: doctor and nurses-on-duty that he will be on leave.
Q. Isn't it a fact that to rule out acute appendicitis as not the disease of JR, surgery or Moreover, while both appeared to be the attending physicians of JR during his hospital
operation must be done, isn't it Doctor? confinement, it cannot be said that the finding of guilt on Dr. Ynzon necessitates the
same finding on the co-accused Dr. Cabugao. Conspiracy is inconsistent with the idea
A. You have to [correlate] all the findings.
of a felony committed by means of culpa.32 Thus, the accused-doctors to be found
Q. Is it yes or no, Doctor? guilty of reckless imprudence resulting in homicide, it must be shown that both
accused-doctors demonstrated an act executed without malice or criminal intent but
A. Yes. with lack of foresight, carelessness, or negligence. Noteworthy, the evidence on record
clearly points to the reckless imprudence of Dr. Ynzon; however, the same cannot be
Q. So, you are saying then that in order to rule out acute appendicitis there must be an
said in Dr. Cabugao's case.
operation, that is right Doctor?
AS TO CIVIL LIABILITY
A. No, sir. If your diagnosis is to really determine if it is an acute appendicitis, you
have to operate.29 While this case is pending appeal, counsel for petitioner Dr. Ynzon informed the Court
that the latter died on December 23, 2011 due to "multi organ failure" as evidenced by
xxxx
a copy of death certificate.33 Thus, the effect of death, pending appeal of his
Q. Now Doctor, considering the infection, considering that there was a [symptom] that conviction of petitioner Dr. Ynzon with regard to his criminal and pecuniary liabilities
causes pain, considering that JR likewise was feverish and that he was vomiting, does should be in accordance to People v. Bayotas,34 wherein the Court laid down the rules
that not show a disease of acute appendicitis Doctor? in case the accused dies prior to final judgment:

A. Its possible. 1. Death of the accused pending appeal of his conviction extinguishes his criminal
liability as well as the civil liability based solely thereon. As opined by Justice
Regalado, in this regard, "the death of the accused prior to final judgment terminates
his criminal liability and only the civil liability directly arising from and based solely accused after proper substitution or against said estate, as the case may be. The heirs
on the offense committed, i.e.,civil liability ex delictoin senso strictiore." of the accused may be substituted for the deceased without requiring the appointment
of an executor or administrator and the court may appoint a guardian ad litem for the
2. Corollarily, the claim for civil liability survives notwithstanding the death of minor heirs.
accused, if the same may also be predicated on a source of obligation other than delict.
Article 1157 of the Civil Code enumerates these other sources of obligation from The court shall forthwith order said legal representative or representatives to appear
which the civil liability may arise as a result of the same act or omission: and be substituted within a period of thirty (30) days from notice.

a) Law A final judgment entered in favor of the offended party shall be enforced in the manner
especially provided in these rules for prosecuting claims against the estate of the
b) Contracts deceased.
c) Quasi-contracts If the accused dies before arraignment, the case shall be dismissed without prejudice
d) x x x x x x x x x to any civil action the offended party may file against the estate of the deceased.
(Emphases ours)
e) Quasi-delicts
In sum, upon the extinction of the criminal liability and the offended party desires to
3. Where the civil liability survives, as explained in Number 2 above, an action for recover damages from the same act or omission complained of, the party may file a
recovery therefor may be pursued but only by way of filing a separate civil action and separate civil action based on the other sources of obligation in accordance with
subject to Section 1, Rule 111 of the 1985 Rules on Criminal Procedure as amended. Section 4, Rule 111.37 If the same act or omission complained of arises from quasi-
This separate civil action may be enforced either against the executor/administrator or delict, as in this case, a separate civil action must be filed against the executor or
the estate of the accused, depending on the source of obligation upon which the same administrator of the estate of the accused, pursuant to Section 1, Rule 87 of the Rules
is based as explained above. of Court:38
4. Finally, the private offended party need not fear a forfeiture of his right to file this Section 1. Actions which may and which may not be brought against executor or
separate civil action by prescription, in cases where during the prosecution of the administrator. No action upon a claim for the recovery of money or debtor interest
criminal action and prior to its extinction, the private-offended party instituted together thereon shall be commenced against the executor or administrator; but to recover real
therewith the civil action. In such case, the statute of limitations on the civil liability or personal property, or an interest therein, from the estate, or to enforce a lien thereon,
is deemed interrupted during the pendency of the criminal case, conformably with and actions to recover damages for an injury to person or property, real or personal,
provisions of Article 1155 of the Civil Code, that should thereby avoid any may be commenced against him. (Emphases ours)
apprehension on a possible privation of right by prescription.35
Conversely, if the offended party desires to recover damages from the same act or
In view of the foregoing, it is clear that the death of the accused Dr. Ynzon pending omission complained of arising from contract, the filing of a separate civil action must
appeal of his conviction extinguishes his criminal liability. However, the recovery of be filed against the estate, pursuant to Section 5, Rule 86 of the Rules of Court, to wit:
civil liability subsists as the same is not based on delict but by contract and the reckless
imprudence he was guilty of under Article 365 of the Revised Penal Code.1wphi1 Section 5. Claims which must be filed under the notice. If not filed, barred; exceptions.
For this reason, a separate civil action may be enforced either against the All claims for money against the decent, arising from contract, express or implied,
executor/administrator or the estate of the accused, depending on the source of whether the same be due, not due, or contingent, all claims for funeral expenses and
obligation upon which the same is based,36 and in accordance with Section 4, Rule expense for the last sickness of the decedent, and judgment for money against the
111 of the Rules on Criminal Procedure, we quote: decent, must be filed within the time limited in the notice; otherwise they are barred
forever, except that they may be set forth as counterclaims in any action that the
Sec. 4. Effect of death on civil actions. The death of the accused after arraignment executor or administrator may bring against the claimants. Where an executor or
and during the pendency of the criminal action shall extinguish the civil liability administrator commences an action, or prosecutes an action already commenced by
arising from the delict. However, the independent civil action instituted under section the deceased in his lifetime, the debtor may set forth by answer the claims he has
3 of this Rule or which thereafter is instituted to enforce liability arising from other against the decedent, instead of presenting them independently to the court as herein
sources of obligation may be continued against the estate or legal representative of the provided, and mutual claims may be set off against each other in such action; and if
final judgment is rendered in favor of the defendant, the amount so determined shall
be considered the true balance against the estate, as though the claim had been
presented directly before the court in the administration proceedings. Claims not yet
due, or contingent, may be approved at their present value.

As a final note, we reiterate that the policy against double recovery requires that only
one action be maintained for the same act or omission whether the action is brought
against the executor or administrator, or the estate.39 The heirs of JR must choose
which of the available causes of action for damages they will bring.

WHEREFORE, premises considered, petitioner DR. ANTONIO P. CABUGAO is


hereby ACQUITTED of the crime of reckless imprudence resulting to homicide.

Due to the death of accused Dr. Clenio Ynzon prior to the disposition of this case, his
criminal liability is extinguished; however, his civil liability subsists. A separate civil
action may be filed either against the executor/administrator, or the estate of Dr.
Ynzon, depending on the source of obligation upon which the same are based.

SO ORDERED.
Republic of the Philippines p.m. on February 12, 1992, Carmen had her second operation. Later in the evening,
SUPREME COURT Dr. Norma informed Pedrito that "everything was going on fine with [his] wife." 7
Manila
The condition of Carmen, however, did not improve. It instead worsened that on
THIRD DIVISION February 13, 1992, she vomited dark red blood. At 9:30 p.m. on the same day, Carmen
died.8 Per her certificate of death upon information provided by the hospital,the
immediate cause of Carmens death was "cardio-respiratory arrest secondary to
G.R. No. 192973 September 29, 2014 cerebro vascular accident, hypertension and chronic nephritis induced by pregnancy." 9
An autopsy Report10 prepared by Dr. Richard Patilano(Dr. Patilano), Medico-Legal
PEDRITO DELA TORRE, Petitioner, vs. DR. ARTURO IMBUIDO, DRA. Officer-Designate of Olongapo City, however, provided that the cause of Carmens
NORMA IMBUIDO in their capacity as owners and operators of DIVINE death was "shock due to peritonitis, severe, with multiple intestinal adhesions; Status
SPIRIT GENERAL HOSPITAL and/or DR. NESTOR PASAMBA, Respondents. post C[a]esarian Section and Exploratory Laparotomy."

RESOLUTION Pedrito claimed in his complaint that the respondents "failed to exercise the degree of
diligence required of them" as members of the medical profession, and were "negligent
for practicing surgery on [Carmen] in the most unskilled, ignorant and cruel manner,
REYES, J.:
x x x[.]"11
This resolves the petition for review on certiorari1 filed by petitioner Pedrito Dela
In their answer12 to the complaint, the respondents argued that they "observed the
Torre (Pedrito) assailing the Decision2 dated December 15, 2009 and Resolution3
required standard of medical care in attending to the needs of Carmen."13 The
dated July 27, 2010 of the Court of Appeals (CA) in CA-G.R. CV No. 78534.
respondents explained that Carmen was admitted in Divine Spirit General Hospital for
"pregnancy in labor and pre-eclampsia." Her condition was closely monitored during
The case stemmed from a complaint4 for damages filed by Pedrito against herein her confinement. A caesarian section operation became necessary, as she manifested
respondents Dr. ArturoImbuido and Dr. Norma Imbuido (Dr. Norma), in their capacity no significant progress for the spontaneous delivery of her baby. 14 No unusual events
as the ownersand operators of the Divine Spirit General Hospital in Olongapo City, were observed during the course of Carmens caesarian section operation. The second
and Dr. Nestor Pasamba (Dr. Nestor) (respondents). Pedrito alleged in his complaint surgery, however, became necessary due to suspected intestinal obstruction and
that he was married to one Carmen Castillo Dela Torre(Carmen), who died while adhesions. This procedure was fully explained to Carmen and Pedrito prior to its
admitted at the Divine Spirit General Hospital on February 13, 1992. Carmen was due conduct. During the second operation, the diagnosis of intestinal obstruction and
to give birth on February 2,1992 and was brought at around 11:30 p.m. on that day by adhesion was confirmed but resolved by her doctors. Despite the observance of due
Pedrito to the Divine Spirit General Hospital. When Carmen still had not delivered her care by the doctors, however, Carmen died on February 13, 1992.15
baby at the expected time, Dr. Norma discussed with Pedrito the possibility of a
caesarean section operation.5
The respondents included in their answer a counterclaim for P48,515.58 as unpaid
hospital charges, professional fees and medicines, P3,000,000.00 for moral damages,
At around 3:00 p.m. on February 3, 1992, Carmen was brought to the hospitals P1,500,000.00 for exemplary damages, and attorneys fees. 16
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 wifes delivery of
After the pre-trial conference, trial proper ensued. To support his claim, Pedrito
a baby boy. In the early morning of February 4, 1992, Carmen experienced abdominal
presented the testimony of Dr. Patilano, the medicolegal officer who conducted an
pain and difficulty in urinating. She was diagnosed to be suffering from urinary tract
infection (UTI), and was prescribed medications by Dr. Norma. On February 10, 1992, autopsy on the body of Carmen upon a telephone request made by the City Health
Pedrito noticed that Carmens stomach was getting bigger, but Dr. Norma dismissed Officer of Olongapo City, Dr. Generoso Espinosa. Among Dr. Patilanos observations,
as narrated in the lower courts decision, were as follows:
the patients condition as mere flatulence (kabag).6

In the intestines, [Dr. Patilano] found outthat it was more reddish than the normal
When Carmens stomach still grewbigger despite medications, Dr. Norma advised
Pedrito of the possibility of a second operation on Carmen. Dr. Norma, however, condition which is supposed to bepinkish. There was presence of adhesions, meaning,
provided no detailson its purpose and the doctor who would perform it. At around 3:00 it sticks to each other and these areas were dilated. There were constricted areas. He
concluded that there might have been foreign organic matters in the intestines. He did
not see any swelling but assuming that there was, it would be concomitant to the 1.) the sum of Php 28,759.46 as actual damages;
enlargement. x x x He came to the conclusion that the cause of death was peritonitis,
with the multiple adhesions status in the post caesarian section. In connection with 2.) the sum of Fifty Thousand (Php 50,000.00) Pesos as indemnity for the death
peritonitis, this is the inflammation of the abdomen. This peritonitis in the abdominal of Carmen dela Torre;
cavity may be caused by several conditions which are supposed to be infections,
entrance of foreign bodies in the intestines in connection with ruptured peptic ulcer or
3.) the sum of Fifty Thousand (Php 50,000.00) Pesos as moral damages and the
[may be] somewhere in the spleen. The entrance of foreign object in the abdominal
further sum of Twenty Thousand (Php 20,000.00) Pesos as exemplary
cavities may cause severe infections of the intra-abdominal cavities resulting [in] damages;
multiple adhesions of the intestines. In cases of surgical operation, it [may be] due to
the conditions of the instruments used, the materials used in the operating room being
not aseptic and the ladies assisting the operation were not in uniform. x x x.17 4.) the sum of Twenty Thousand (Php 20,000.00) Pesos as attorneys fees; and

Dr. Patilano claimed that peritonitis could have been prevented through proper medical 5.) the costs of [suit].
procedures and medicines. He also stated that if the cause of Carmens death was
actually cerebro-vascular accident, there would have been ruptured blood vessels and SO ORDERED.25
blood clot in her head; but there were none in Carmens case. 18
Dissatisfied with the RTC ruling, the respondents appealed to the CA. On December
Among those who testified to refutePedritos claim was Dr. Nestor. He claimed that 15, 2009, the CA rendered its Decision reversing and setting aside the decision of the
when Carmen was referred to him on February 3, 1992, she was in full term uterine RTC. For the appellate court, it was not established that the respondents failed to
pregnancy, with pre-eclampsia, fetal distress and active labor pains. A caesarian exercisethe degree of diligence required of them by their profession as doctors. The
section operation became necessary to terminate the pregnancy for her safety. Carmen CA also granted the respondents counterclaim for the amount of P48,515.58, as it
was ready to go home four days after giving birth, but was advised by the doctors to held:
stay more because of her persistent hypertension.19
WHEREFORE, the Decision of the Regional Trial Court of Olongapo City dated
The second surgery performed on Carmen was necessary after she showed symptoms January 28, 2003 in Civil Case No. 165-0-92 is hereby REVERSED AND SET
of intestinal obstruction, which happens as the intestines get twisted due to adhesions ASIDE.
and the normal flow of intestinal contents are obstructed. For Dr. Nestor, this
occurrence was not preventable since any interference of the abdominal cavity would Plaintiff-appellee is directed to pay the unpaid balance for hospital bills, professional
irritate the serosa of the intestines, inviting adhesions that could cause obstruction. fees and other expenses in the amount of [P]48,515.58.
Surgery could remedy the adhesions and obstruction.20 Both Carmen and Pedrito gave
their written consent to this second procedure.21 SO ORDERED.26

Dr. Bienvenido G. Torres (Dr. Torres), Chief of the Medico-Legal Division of the Hence, this petition for review on certiorariin which Pedrito insists that the respondents
Philippine National Police (PNP) Crime Laboratory Service, 22 also testified for the should be held liable for the death of Carmen.
respondents.He claimed that based on Dr. Patilanos report, vital internal organs of
Carmen, such as her brain, lungs, kidneys, liver and adrenal glands, were not examined
The petition is denied.
during the autopsy.23

"[M]edical malpractice or, more appropriately, medical negligence, is that type of


On January 28, 2003, the Regional Trial Court (RTC) of Olongapo City, Branch 75,
claim which a victim has available to him or her to redress a wrong committed by a
rendered its Decision24 in favor of Pedrito. The trial court gave greater weight to the
medical professionalwhich has caused bodily harm." In order to successfully pursue
testimony of Dr. Patilano and thus disposed of the case as follows:
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
WHEREFORE, premises considered, judgment is hereby rendered in favor of the reasonably prudent health care provider would have done, or that he or she did
plaintiff and against the defendants, ordering the latter to pay jointly and severally, the something that a reasonably prudent provider would not have done; and that failure or
former, the following sums of money, to wit: action caused injury to the patient." 27
The Court emphasized in Lucas, et al. v. Tuao28 that in medical negligence cases, On the other hand, the CA pointed out that Dr. Nestor, a surgeon, possessed the
there is a physician-patient relationship between the doctor and the victim, but just like reasonable degree of learning, skill and experience required by his profession for the
in any other proceeding for damages, four essential elements must be established by treatment ofCarmen. The respondents also emphasized in their pleadings beforethe
the plaintiff, namely: (1) duty; (2) breach; (3) injury; and (4) proximate causation. All RTC that Dr. Nestor had his training and experience in surgery and obstetrics since
four elements must be present in order to find the physician negligent and, thus, liable 1970.1wphi1 Without sufficient proof from the claimant on a different degree of care,
for damages.29 skill and diligence that should be expected from the respondents, it could not be said
with certainty that a breachwas actually committed.
It is settled that a physicians duty tohis patient relates to his exercise of the degree of
care, skill and diligence which physicians in the same general neighborhood, and in Moreover, while Dr. Patilano opined that Carmen died of peritonitis which could be
the same general line of practice, ordinarily possess and exercise in like cases. There due to the poor state of the hospital equipment and medical supplies used during her
is breach of this duty when the patient is injured in body or in health. Proof of this operation, there was no sufficient proof that any such fault actually attended the
breach rests upon the testimony of an expert witness that the treatment accorded to the surgery of Carmen, caused her illness and resulted in her death. It is also significant
patient failed to meet the standard level of care, skill and diligence. To justify an award that the Chief of the Medico-Legal Division of the PNP Crime Laboratory Service, Dr.
of damages, the negligence of the doctor must be established to be the proximate cause Torres, testified before the trial court that based on the autopsy report issued by Dr.
of the injury.30 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
Through the instant petition, Pedritoseeks the reinstatement of the decision of the RTC Carmens vital organs such as her heart, lungs, uterus and brain during the autopsy.
whose finding of the respondents medical negligence depended mainly on the His findings were then inconclusive on the issue of the actual cause of Carmen's death,
testimony of Dr. Patilano. Upon review, however, the Court agrees with the CA that and the claim of negligence allegedly committed by the respondents.
the report and testimony of Dr. Patilano failed to justify Pedritos entitlement to the
damages awarded by the RTC. As the Court held in Spouses Flores v. Spouses Pineda, et al.,31 the critical and
clinching factor in a medical negligence case is proof of the causal connection between
For the trial court to give weightto Dr. Patilanos report, it was necessary to show first the negligence and the injuries. The claimant must prove not only the injury but also
Dr. Patilanos specialization and competence to testify on the degree of care, skill and the defendant's fault, and that such fault caused the injury. A verdict in a malpractice
diligence needed for the treatment of Carmens case. Considering that it was not duly action cannot be based on speculation or conjecture. Causation must be proven within
established that Dr. Patilano practiced and was an expert inthe fields that involved a reasonable medical probability based upon competent expert testimony,32 which the
Carmens condition, he could not have accurately identified the said degree of care, Court finds absent in the case at bar. As regards the respondents' counterclaim, the
skill, diligence and the medical procedures that should have been applied by her CA's award of P48,515.58 is sustained, considering that among the parties' stipulations
attending physicians. during the pre-trial indicated:

Similarly, such duty, degree of care, skill and diligence were not sufficiently 5. That at the time of the death of the patient Carmen C. dela Torrell there was an
established in this case because the testimony of Dr. Patilano was based solely on the unpaid balance for hospital bills, professional fees and other expenses in the amount
results of his autopsy on the cadaver of Carmen. His study and assessment were of P48,515.58, incurred by plaintiff when the patient was confined at said hospital
restrictedby limitations that denied his full evaluation of Carmens case. He could have from February 3 to 13, 1992.33
only deduced from the injuries apparent in Carmens body, and in the condition when
the body was examined. Judging from his testimony, Dr. Patilano did not even take WHEREFORE, the petition is DENIED. The Decision dated December 15, 2009 and
full consideration of the medical history of Carmen, her actual health condition at the Resolution dated July 27, 2010 of the Court of Appeals in CA-G.R. CV No. 78534 are
time of hospital admission, and her condition as it progressed while she was being AFFIRMED.
monitored and treated by the respondents. There was also no reference to the
respondents defense that the emergency caesarian section operation had to be SO ORDERED.
performed in order to protect the lives and safety of Carmen and her then unborn child.
For lack of sufficient information on Carmens health condition while still alive, Dr.
Patilano could not have fully evaluated the suitability of the respondents decisions in
handling Carmens medical condition as it turned critical.
Republic of the Philippines That on or about May 17, 1995, in the City of Manila, Philippines, the said accused,
SUPREME COURT being then an anesthesiologist at the Ospital ng Maynila, Malate, this City, and as such
Manila was tasked to administer the anesthesia on three-year old baby boy GERALD
ALBERT GERCAYO, represented by his mother, MA. LUZ GERCAYO, the former
FIRST DIVISION having been born with an imperforate anus [no anal opening] and was to undergo an
operation for anal opening [pull through operation], did then and there willfully,
unlawfully and feloniously fail and neglect to use the care and diligence as the best of
G.R. No. 192123 March 10, 2014
his judgment would dictate under said circumstance, by failing to monitor and regulate
properly the levels of anesthesia administered to said GERALD ALBERT GERCAYO
DR. FERNANDO P. SOLIDUM, Petitioner, vs. PEOPLE OF THE and using 100% halothane and other anesthetic medications, causing as a consequence
PHILIPPINES, Respondent. of his said carelessness and negligence, said GERALD ALBERT GERCAYO suffered
a cardiac arrest and consequently a defect called hypoxic encephalopathy meaning
DECISION insufficient oxygen supply in the brain, thereby rendering said GERALD ALBERT
GERCAYO incapable of moving his body, seeing, speaking or hearing, to his damage
BERSAMIN, J.: and prejudice.

This appeal is taken by a physician-anesthesiologist who has been pronounced guilty Contrary to law.14
of reckless imprudence resulting in serious physical injuries by the Regional Trial
Court (RTC) and the Court of Appeals (CA). He had been part of the team of The case was initially filed in the Metropolitan Trial Court of Manila, but was
anesthesiologists during the surgical pull-through operation conducted on a three-year transferred to the RTC pursuant to Section 5 of Republic Act No. 8369 (The Family
old patient born with an imperforate anus.1 Courts Act of 1997),15 where it was docketed as Criminal Case No. 01-190889.

The antecedents are as follows: Judgment of the RTC

Gerald Albert Gercayo (Gerald) was born on June 2, 1992 2 with an imperforate anus. On July 19, 2004, the RTC rendered its judgment finding Dr. Solidum guilty beyond
Two days after his birth, Gerald underwent colostomy, a surgical procedure to bring reasonable doubt of reckless imprudence resulting to serious physical injuries, 16
one end of the large intestine out through the abdominal wall, 3 enabling him to excrete decreeing:
through a colostomy bag attached to the side of his body. 4
WHEREFORE, premises considered, the Court finds accused DR.
On May 17, 1995, Gerald, then three years old, was admitted at the Ospital ng Maynila FERNANDO P. SOLIDUM GUILTY beyond reasonable doubt as principal
for a pull-through operation.5 Dr. Leandro Resurreccion headed the surgical team, and of the crime charged and is hereby sentenced to suffer the indeterminate
was assisted by Dr. Joselito Luceo, Dr. Donatella Valea and Dr. Joseph Tibio. The penalty of TWO (2) MONTHS and ONE (1) DAY of arresto mayor as
anesthesiologists included Dr. Marichu Abella, Dr. Arnel Razon and petitioner Dr. minimum to ONE (1) YEAR, ONE (1) MONTH and TEN (10) DAYS of
Fernando Solidum (Dr. Solidum).6 During the operation, Gerald experienced prision correccional as maximum and to indemnify, jointly and severally
bradycardia,7 and went into a coma.8 His coma lasted for two weeks,9 but he regained with the Ospital ng Maynila, Dr. Anita So and Dr. Marichu Abella, private
consciousness only after a month.10 He could no longer see, hear or move.11 complainant Luz Gercayo, the amount of P500,000.00 as moral damages and
P100,000.00 as exemplary damages and to pay the costs.
Agitated by her sons helpless and unexpected condition, Ma. Luz Gercayo (Luz)
lodged a complaint for reckless imprudence resulting in serious physical injuries with Accordingly, the bond posted by the accused for his provisional liberty is
the City Prosecutors Office of Manila against the attending physicians. 12 hereby CANCELLED.

Upon a finding of probable cause, the City Prosecutors Office filed an information SO ORDERED.17
solely against Dr. Solidum,13 alleging:
Upon motion of Dr. Anita So and Dr. Marichu Abella to reconsider their solidary be drawn giving rise to an application of the doctrine of res ipsa loquitur without
liability,18 the RTC excluded them from solidary liability as to the damages, modifying medical evidence, which is ordinarily required to show not only what occurred but
its decision as follows: how and why it occurred. When the doctrine is appropriate, all that the patient must
do is prove a nexus between the particular act or omission complained of and the injury
WHEREFORE, premises considered, the Court finds accused Dr. Fernando Solidum, sustained while under the custody and management of the defendant without need to
guilty beyond reasonable doubt as principal of the crime charged and is hereby produce expert medical testimony to establish the standard of care. Resort to res ipsa
sentenced to suffer the indeterminate penalty of two (2) months and one (1) day of loquitur is allowed because there is no other way, under usual and ordinary conditions,
arresto mayor as minimum to one (1) year, one (1) month and ten (10) days of prision by which the patient can obtain redress for injury suffered by him.
correccional as maximum and to indemnify jointly and severally with Ospital ng
Maynila, private complainant Luz Gercayo the amount of P500,000.00 as moral The lower court has found that such a nexus exists between the act complained of and
damages and P100,000 as exemplary damages and to pay the costs. the injury sustained, and in line with the hornbook rules on evidence, we will afford
the factual findings of a trial court the respect they deserve in the absence of a showing
Accordingly, the bond posted by the accused for his provisional liberty is hereby of arbitrariness or disregard of material facts that might affect the disposition of the
cancelled.19 case. People v. Paraiso 349 SCRA 335.

Decision of the CA The res ipsa loquitur test has been known to be applied in criminal cases. Although it
creates a presumption of negligence, it need not offend due process, as long as the
On January 20, 2010, the CA affirmed the conviction of Dr. Solidum, 20 pertinently accused is afforded the opportunity to go forward with his own evidence and prove
stating and ruling: that he has no criminal intent. It is in this light not inconsistent with the constitutional
presumption of innocence of an accused.
The case appears to be a textbook example of res ipsa loquitur.
IN VIEW OF THE FOREGOING, the modified decision of the lower court is
affirmed.
xxxx
SO ORDERED.21
x x x [P]rior to the operation, the child was evaluated and found fit to undergo a major
operation. As noted by the OSG, the accused himself testified that pre-operation tests
were conducted to ensure that the child could withstand the surgery. Except for his Dr. Solidum filed a motion for reconsideration, but the CA denied his motion on May
7, 2010.22
imperforate anus, the child 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 a hint that the nature of the operation itself was a Hence, this appeal.
causative factor in the events that finally led to hypoxia.
Issues
In short, the lower court has been left with no reasonable hypothesis except to attribute
the accident to a failure in the proper administration of anesthesia, the gravamen of the Dr. Solidum avers that:
charge in this case. The High Court elucidates in Ramos vs. Court of Appeals 321
SCRA 584 I.
THE HONORABLE COURT OF APPEALS ERRED IN AFFIRMING THE
In cases where the res ipsa loquitur is applicable, the court is permitted to find a DECISION OF THE LOWER COURT IN UPHOLDING THE PETITIONERS
physician negligent upon proper proof of injury to the patient, without the aid of expert CONVICTION FOR THE CRIME CHARGED BASED ON THE TRIAL
testimony, where the court from its fund of common knowledge can determine the COURTS OPINION, AND NOT ON THE BASIS OF THE FACTS
proper standard of care. ESTABLISHED DURING THE TRIAL. ALSO, THERE IS A CLEAR
MISAPPREHENSION OF FACTS WHICH IF CORRECTED, WILL RESULT
Where common knowledge and experience teach that a resulting injury would not have TO THE ACQUITTAL OF THE PETITIONER. FURTHER, THE HONORABLE
occurred to the patient if due care had been exercised, an inference of negligence may COURT ERRED IN AFFIRMING THE SAID DECISION OF THE LOWER
COURT, AS THIS BREACHES THE CRIMINAL LAW PRINCIPLE THAT
THE PROSECUTION MUST PROVE THE ALLEGATIONS OF THE the person who controls the instrumentality causing the injury in the absence of some
INFORMATION BEYOND REASONABLE DOUBT, AND NOT ON THE explanation by the defendant who is charged with negligence. It is grounded in the
BASIS OF ITS PRESUMPTIVE CONCLUSION. superior logic of ordinary human experience and on the basis of such experience or
common knowledge, negligence may be deduced from the mere occurrence of the
accident itself.

II. Hence, res ipsa loquitur is applied in conjunction with the doctrine of common
THE HONORABLE COURT OF APPEALS ERRED IN APPLYING THE knowledge."25
PRINCIPLE OF RES IPSA LOQUITOR (sic) WHEN THE DEFENSE WAS ABLE
TO PROVE THAT THERE IS NO NEGLIGENCE ON THE PART OF THE Jarcia, Jr. v. People26 has underscored that the doctrine is not a rule of substantive law,
PETITIONER, AND NO OVERDOSING IN THE APPLICATION OF THE but merely a mode of proof or a mere procedural convenience. The doctrine, when
ANESTHETIC AGENT BECAUSE THERE WAS NO 100% HALOTHANE applicable to the facts and circumstances of a given case, is not meant to and does not
ADMINISTERED TO THE CHILD, BUT ONLY ONE (1%) PERCENT AND THE dispense with the requirement of proof of culpable negligence against the party
APPLICATION THEREOF, WAS REGULATED BY AN ANESTHESIA charged. It merely determines and regulates what shall be prima facie evidence thereof,
MACHINE. THUS, THE APPLICATION OF THE PRINCIPLE OF RES IPSA and helps the plaintiff in proving a breach of the duty. The doctrine can be invoked
LOQUITOR (sic) CONTRADICTED THE ESTABLISHED FACTS AND THE when and only when, under the circumstances involved, direct evidence is absent and
LAW APPLICABLE IN THE CASE. not readily available.27

III. The applicability of the doctrine of res ipsa loquitur in medical negligence cases was
THE AWARD OF MORAL DAMAGES AND EXEMPLARY DAMAGES IS NOT significantly and exhaustively explained in Ramos v. Court of Appeals, 28 where the
JUSTIFIED THERE BEING NO NEGLIGENCE ON THE PART OF THE Court said
PETITIONER. ASSUMING THAT THE CHILD IS ENTITLED TO FINANCIAL
CONSIDERATION, IT SHOULD BE ONLY AS A FINANCIAL ASSISTANCE,
Medical malpractice cases do not escape the application of this doctrine. Thus, res ipsa
BECAUSE THERE WAS NO NEGLIGENCE, AND NO OVERDOSING OF loquitur has been applied when the circumstances attendant upon the harm are
ANESTHETIC AGENT AND AS SUCH, THE AWARD IS SO EXCESSIVE, AND
themselves of such a character as to justify an inference of negligence as the cause of
NO FACTUAL AND LEGAL BASIS.23
that harm. The application of res ipsa loquitur in medical negligence cases presents a
question of law since it is a judicial function to determine whether a certain set of
To simplify, the following are the issues for resolution, namely: (a) whether or not the circumstances does, as a matter of law, permit a given inference.
doctrine of res ipsa loquitur was applicable herein; and (b) whether or not Dr. Solidum
was liable for criminal negligence.
Although generally, expert medical testimony is relied upon in malpractice suits to
prove that a physician has done a negligent act or that he has deviated from the standard
Ruling medical procedure, when the doctrine of res ipsa loquitur is availed by the plaintiff,
the need for expert medical testimony is dispensed with because the injury itself
The appeal is meritorious. provides the proof of negligence. The reason is that the general rule on the necessity
of expert testimony applies only to such matters clearly within the domain of medical
Applicability of the Doctrine of Res Ipsa Loquitur science, and not to matters that are within the common knowledge of mankind which
may be testified to by anyone familiar with the facts. Ordinarily, only physicians and
Res ipsa loquitur is literally translated as "the thing or the transaction speaks for itself." surgeons of skill and experience are competent to testify as to whether a patient has
The doctrine res ipsa loquitur means that "where the thing which causes injury is been treated or operated upon with a reasonable degree of skill and care. However,
testimony as to the statements and acts of physicians and surgeons, external
shown to be under the management of the defendant, and the accident is such as in the
appearances, and manifest conditions which are observable by any one may be given
ordinary course of things does not happen if those who have the management use
by non-expert witnesses. Hence, in cases where the res ipsa loquitur is applicable, the
proper care, it affords reasonable evidence, in the absence of an explanation by the
court is permitted to find a physician negligent upon proper proof of injury to the
defendant, that the accident arose from want of care." 24 It is simply "a recognition of
the postulate that, as a matter of common knowledge and experience, the very nature patient, without the aid of expert testimony, where the court from its fund of common
of certain types of occurrences may justify an inference of negligence on the part of knowledge can determine the proper standard of care. Where common knowledge and
experience teach that a resulting injury would not have occurred to the patient if due In order to allow resort to the doctrine, therefore, the following essential requisites
care had been exercised, an inference of negligence may be drawn giving rise to an must first be satisfied, to wit: (1) the accident was of a kind that does not ordinarily
application of the doctrine of res ipsa loquitur without medical evidence, which is occur unless someone is negligent; (2) the instrumentality or agency that caused the
ordinarily required to show not only what occurred but how and why it occurred. When injury was under the exclusive control of the person charged; and (3) the injury
the doctrine is appropriate, all that the patient must do is prove a nexus between the suffered must not have been due to any voluntary action or contribution of the person
particular act or omission complained of and the injury sustained while under the injured.29
custody and management of the defendant without need to produce expert medical
testimony to establish the standard of care. Resort to res ipsa loquitur is allowed The Court considers the application here of the doctrine of res ipsa loquitur
because there is no other way, under usual and ordinary conditions, by which the inappropriate. Although it should be conceded without difficulty that the second and
patient can obtain redress for injury suffered by him. third elements were present, considering that the anesthetic agent and the instruments
were exclusively within the control of Dr. Solidum, and that the patient, being then
Thus, courts of other jurisdictions have applied the doctrine in the following situations: unconscious during the operation, could not have been guilty of contributory
leaving of a foreign object in the body of the patient after an operation, injuries negligence, the first element was undeniably wanting. Luz delivered Gerald to the care,
sustained on a healthy part of the body which was not under, or in the area, of custody and control of his physicians for a pull-through operation. Except for the
treatment, removal of the wrong part of the body when another part was intended, imperforate anus, Gerald was then of sound body and mind at the time of his
knocking out a tooth while a patients jaw was under anesthetic for the removal of his submission to the physicians. Yet, he experienced bradycardia during the operation,
tonsils, and loss of an eye while the patient plaintiff was under the influence of causing loss of his senses and rendering him immobile. Hypoxia, or the insufficiency
anesthetic, during or following an operation for appendicitis, among others. of oxygen supply to the brain that caused the slowing of the heart rate, scientifically
termed as bradycardia, would not ordinarily occur in the process of a pull-through
Nevertheless, despite the fact that the scope of res ipsa loquitur has been measurably operation, or during the administration of anesthesia to the patient, but such fact alone
enlarged, it does not automatically apply to all cases of medical negligence as to did not prove that the negligence of any of his attending physicians, including the
mechanically shift the burden of proof to the defendant to show that he is not guilty of anesthesiologists, had caused the injury. In fact, the anesthesiologists attending to him
the ascribed negligence. Res ipsa loquitur is not a rigid or ordinary doctrine to be had sensed in the course of the operation that the lack of oxygen could have been
perfunctorily used but a rule to be cautiously applied, depending upon the triggered by the vago-vagal reflex, prompting them to administer atropine to the
circumstances of each case. It is generally restricted to situations in malpractice cases patient.30
where a layman is able to say, as a matter of common knowledge and observation, that
the consequences of professional care were not as such as would ordinarily have This conclusion is not unprecedented. It was similarly reached in Swanson v.
followed if due care had been exercised. A distinction must be made between the Brigham,31 relevant portions of the decision therein being as follows:
failure to secure results, and the occurrence of something more unusual and not
ordinarily found if the service or treatment rendered followed the usual procedure of On January 7, 1973, Dr. Brigham admitted 15-year-old Randall Swanson to a hospital
those skilled in that particular practice. It must be conceded that the doctrine of res for the treatment of infectious mononucleosis. The patient's symptoms had included a
ipsa loquitur can have no application in a suit against a physician or surgeon which swollen throat and some breathing difficulty. Early in the morning of January 9 the
involves the merits of a diagnosis or of a scientific treatment. The physician or surgeon patient was restless, and at 1:30 a.m. Dr. Brigham examined the patient. His inspection
is not required at his peril to explain why any particular diagnosis was not correct, or of the patient's air passage revealed that it was in satisfactory condition. At 4:15 a.m.
why any particular scientific treatment did not produce the desired result. Thus, res Dr. Brigham received a telephone call from the hospital, advising him that the patient
ipsa loquitur is not available in a malpractice suit if the only showing is that the desired was having respiratory difficulty. The doctor ordered that oxygen be administered and
result of an operation or treatment was not accomplished. The real question, therefore, he prepared to leave for the hospital. Ten minutes later, 4:25 a.m., the hospital called
is whether or not in the process of the operation any extraordinary incident or unusual a second time to advise the doctor that the patient was not responding. The doctor
event outside of the routine performance occurred which is beyond the regular scope ordered that a medicine be administered, and he departed for the hospital. When he
of customary professional activity in such operations, which, if unexplained would arrived, the physician who had been on call at the hospital had begun attempts to revive
themselves reasonably speak to the average man as the negligent cause or causes of the patient. Dr. Brigham joined him in the effort, but the patient died.
the untoward consequence. If there was such extraneous intervention, the doctrine of
res ipsa loquitur may be utilized and the defendant is called upon to explain the matter,
The doctor who performed the autopsy concluded that the patient died between 4:25
by evidence of exculpation, if he could.
a.m. and 4:30 a.m. of asphyxia, as a result of a sudden, acute closing of the air passage.
He also found that the air passage had been adequate to maintain life up to 2 or 3
minutes prior to death. He did not know what caused the air passage to suddenly close.
(a) the anesthesia record A portion of the chart in the record was marked as
xxxx Exhibit 1-A and 1-B to indicate the administration at intervals of the anesthetic
It is a rare occurrence when someone admitted to a hospital for the treatment of agent.
infectious mononucleosis dies of asphyxiation. But that is not sufficient to invoke res
ipsa loquitur. The fact that the injury rarely occurs does not in itself prove that the (b) the clinical abstract A portion of this record that reads as follows was
injury was probably caused by someone's negligence. Mason v. Ellsworth, 3 Wn. App. marked Exhibit 3A. 3B Approximately 1 hour and 45 minutes through the
298, 474 P.2d 909 (1970). Nor is a bad result by itself enough to warrant the operation, patient was noted to have bradycardia (CR = 70) and ATSO4 0.2 mg
application of the doctrine. Nelson v. Murphy, 42 Wn.2d 737, 258 P.2d 472 (1953). was immediately administered. However, the bradycardia persisted, the
See 2 S. Speiser, The Negligence Case Res Ipsa Loquitur 24:10 (1972). The inhalational agent was shut off, and the patient was ventilated with 100% oxygen
evidence presented is insufficient to establish the first element necessary for and another dose of ATSO4 0.2 mg was given. However, the patient did not
application of res ipsa loquitur doctrine. The acute closing of the patients air passage respond until no cardiac rate can be auscultated and the surgeons were
and his resultant asphyxiation took place over a very short period of time. Under these immediately told to stop the operation. The patient was put on a supine position
circumstances it would not be reasonable to infer that the physician was negligent. and CPR was initiated. Patient was given 1 amp of epinephrine initially while
There was no palpably negligent act. The common experience of mankind does not continuously doing cardiac massage still with no cardiac rate appreciated;
suggest that death would not be expected without negligence. And there is no expert another ampule of epinephrine was given and after 45 secs, patients vital signs
medical testimony to create an inference that negligence caused the injury. returned to normal. The entire resuscitation lasted approximately 3-5 mins. The
surgeons were then told to proceed to the closure and the childs vital signs
Negligence of Dr. Solidum throughout and until the end of surgery were: BP = 110/70; CR = 116/min and
RR = 20-22 cycles/min (on assisted ventilation).
In view of the inapplicability of the doctrine of res ipsa loquitur, the Court next
determines whether the CA correctly affirmed the conviction of Dr. Solidum for Dr. Vertido points to the crucial passage in the clinical abstract that the patient was
criminal negligence. ventilated with 100% oxygen and another dose of ATSO4 when the bradycardia
persisted, but for one reason or another, he read it as 100% halothane. He was asked
Negligence is defined as the failure to observe for the protection of the interests of to read the anesthesia record on the percentage of the dosage indicated, but he could
another person that degree of care, precaution, and vigilance that the circumstances only sheepishly note I cant understand the number. There are no clues in the clinical
justly demand, whereby such other person suffers injury. 32 Reckless imprudence, on abstract on the quantity of the anesthetic agent used. It only contains the information
the other hand, consists of voluntarily doing or failing to do, without malice, an act that the anesthetic plan was to put the patient under general anesthesia using a
from which material damage results by reason of an inexcusable lack of precaution on nonrebreathing system with halothane as the sole anesthetic agent and that 1 hour and
the part of the person performing or failing to perform such act.33 45 minutes after the operation began, bradycardia occurred after which the inhalational
agent was shut off and the patient administered with 100% oxygen. It would be
apparent that the 100% oxygen that Dr. Vertido said should be read in lieu of 100%
Dr. Solidums conviction by the RTC was primarily based on his failure to monitor
halothane was the pure oxygen introduced after something went amiss in the operation
and properly regulate the level of anesthetic agent administered on Gerald by
and the halothane itself was reduced or shut off.
overdosing at 100% halothane. In affirming the conviction, the CA observed:

On the witness stand, Dr. Vertido made a significant turnaround. He affirmed the The key question remains what was the quantity of halothane used before
bradycardia set in?
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 The implication of Dr. Vertidos admission is that there was no overdose of the
child. He declared that he made a mistake in reporting a 100% halothane and said that anesthetic agent, and the accused Dr. Solidum stakes his liberty and reputation on this
based on the records it should have been 100% oxygen. 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 Drs. Abella and Razon to monitor
The records he was relying on, as he explains, are the following:
the operation. He insisted that he administered only a point 1% not 100% halothane,
receiving corroboration from Dr. Abella whose initial MA in the record should be
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 same circumstances. It is in this aspect of medical malpractice that expert testimony is
monitored the concentration of the agent during the operation. essential to establish not only the standard of care of the profession but also that the
physician's conduct in the treatment and care falls below such standard. Further,
But most compelling is Dr. Solidums interpretation of the anesthesia record itself, as inasmuch as the causes of the injuries involved in malpractice actions are determinable
he takes the bull by the horns, so to speak. In his affidavit, he says, reading from the only in the light of scientific knowledge, it has been recognized that expert testimony
record, that the quantity of halothane used in the operation is one percent (1%) is usually necessary to support the conclusion as to causation.
delivered at time intervals of 15 minutes. He studiedly mentions the concentration
of halothane as reflected in the anesthesia record (Annex D of the complaint-affidavit) xxxx
is only one percent (1%) The numbers indicated in 15 minute increments for In litigations involving medical negligence, the plaintiff has the burden of establishing
halothane is an indication that only 1% halothane is being delivered to the patient appellant's negligence and for a reasonable conclusion of negligence, there must be
Gerard Gercayo for his entire operation; The amount of halothane delivered in this proof of breach of duty on the part of the surgeon as well as a causal connection of
case which is only one percent cannot be summated because halothane is constantly such breach and the resulting death of his patient. In Chan Lugay v. St Luke's Hospital,
being rapidly eliminated by the body during the entire operation. Inc., where the attending physician was absolved of liability for the death of the
complainants wife and newborn baby, this Court held that:
xxxx
In finding the accused guilty, despite these explanations, the RTC argued that the "In order that there may be a recovery for an injury, however, it must be shown that
volte-face of Dr. Vertido on the question of the dosage of the anesthetic used on the the injury for which recovery is sought must be the legitimate consequence of the
child would not really validate the non-guilt of the anesthesiologist. Led to agree that wrong done; the connection between the negligence and the injury must be a direct
the halothane used was not 100% as initially believed, he was nonetheless unaware of and natural sequence of events, unbroken by intervening efficient causes. In other
the implications of the change in his testimony. The court observed that Dr. Vertido words, the negligence must be the proximate cause of the injury. For, negligence, no
had described the condition of the child as hypoxia which is deprivation of oxygen, a matter in what it consists, cannot create a right of action unless it is the proximate
diagnosis supported by the results of the CT Scan. All the symptoms attributed to a cause of the injury complained of. And the proximate cause of an injury is that cause,
failing central nervous system such as stupor, loss of consciousness, decrease in heart which, in natural and continuous sequence, unbroken by any efficient intervening
rate, loss of usual acuity and abnormal motor function, are manifestations of this cause, produces the injury, and without which the result would not have occurred."
condition or syndrome. But why would there be deprivation of oxygen if 100% oxygen
to 1% halothane was used? Ultimately, to the court, whether oxygen or halothane was An action upon medical negligence whether criminal, civil or administrative calls
the object of mistake, the detrimental effects of the operation are incontestable, and for the plaintiff to prove by competent evidence each of the following four elements,
they can only be led to one conclusion if the application of anesthesia was really namely: (a) the duty owed by the physician to the patient, as created by the physician-
closely monitored, the event could not have happened.34 patient relationship, to act in accordance with the specific norms or standards
established by his profession; (b) the breach of the duty by the physicians failing to
The Prosecution did not prove the elements of reckless imprudence beyond reasonable act in accordance with the applicable standard of care; (3) the causation, i.e., there
doubt because the circumstances cited by the CA were insufficient to establish that Dr. must be a reasonably close and causal connection between the negligent act or
Solidum had been guilty of inexcusable lack of precaution in monitoring the omission and the resulting injury; and (4) the damages suffered by the patient. 36
administration of the anesthetic agent to Gerald. The Court aptly explained in Cruz v.
Court of Appeals35 that: In the medical profession, specific norms or standards to protect the patient against
unreasonable risk, commonly referred to as standards of care, set the duty of the
Whether or not a physician has committed an "inexcusable lack of precaution" in the physician to act in respect of the patient. Unfortunately, no clear definition of the duty
treatment of his patient is to be determined according to the standard of care observed of a particular physician in a particular case exists. Because most medical malpractice
by other members of the profession in good standing under similar circumstances cases are highly technical, witnesses with special medical qualifications must provide
bearing in mind the advanced state of the profession at the time of treatment or the guidance by giving the knowledge necessary to render a fair and just verdict. As a
present state of medical science. In the recent case of Leonila Garcia-Rueda v. Wilfred result, the standard of medical care of a prudent physician must be determined from
L. Pacasio, et. al., this Court stated that in accepting a case, a doctor in effect represents expert testimony in most cases; and in the case of a specialist (like an anesthesiologist),
that, having the needed training and skill possessed by physicians and surgeons the standard of care by which the specialist is judged is the care and skill commonly
practicing in the same field, he will employ such training, care and skill in the possessed and exercised by similar specialists under similar circumstances. The
treatment of his patients. He therefore has a duty to use at least the same level of care specialty standard of care may be higher than that required of the general practitioner.37
that any other reasonably competent doctor would use to treat a condition under the
The standard of care is an objective standard by which the conduct of a physician sued WITNESS General Anesthetic Agent is a substance used in the conduction of
for negligence or malpractice may be measured, and it does not depend, therefore, on Anesthesia and in this case, halothane was used as a sole anesthetic agent.
any individual physicians own knowledge either. In attempting to fix a standard by
which a court may determine whether the physician has properly performed the xxxx
requisite duty toward the patient, expert medical testimony from both plaintiff and Q Now under paragraph two of page 1 of your report you mentioned that after one
defense experts is required. The judge, as the trier of fact, ultimately determines the hour and 45 minutes after the operation, the patient experienced a bradycardia or
standard of care, after listening to the testimony of all medical experts. 38 slowing of heart rate, now as a doctor, would you be able to tell this Honorable Court
as to what cause of the slowing of heart rate as to Gerald Gercayo?
Here, the Prosecution presented no witnesses with special medical qualifications in
anesthesia to provide guidance to the trial court on what standard of care was WITNESS Well honestly sir, I cannot give you the reason why there was a bradycardia
applicable. It would consequently be truly difficult, if not impossible, to determine of time because is some reason one way or another that might caused bradycardia.
whether the first three elements of a negligence and malpractice action were attendant.
FISCAL CABARON What could be the possible reason?
Although the Prosecution presented Dr. Benigno Sulit, Jr., an anesthesiologist himself
who served as the Chairman of the Committee on Ethics and Malpractice of the
A Well bradycardia can be caused by anesthetic agent itself and that is a possibility,
Philippine Society of Anesthesiologists that investigated the complaint against Dr.
were talking about possibility here.
Solidum, his testimony mainly focused on how his Committee had conducted the
investigation.39 Even then, the report of his Committee was favorable to Dr. Solidum,40
to wit: Q What other possibility do you have in mind, doctor?

Presented for review by this committee is the case of a 3 year old male who underwent A Well, because it was an operation, anything can happen within that situation.
a pull-thru operation and was administered general anesthesia by a team of anesthesia
residents. The patient, at the time when the surgeons was manipulating the recto- FISCAL CABARON Now, this representation would like to ask you about the slowing
sigmoid and pulling it down in preparation for the anastomosis, had bradycardia. The of heart rate, now what is the immediate cause of the slowing of the heart rate of a
anesthesiologists, sensing that the cause thereof was the triggering of the vago-vagal person?
reflex, administered atropine to block it but despite the administration of the drug in
two doses, cardiac arrest ensued. As the records show, prompt resuscitative measures WITNESS Well, one of the more practical reason why there is slowing of the heart
were administered and spontaneous cardiac function re-established in less than five rate is when you do a vagal reflex in the neck wherein the vagal receptors are located
(5) minutes and that oxygen was continuously being administered throughout, at the lateral part of the neck, when you press that, you produce the slowing of the
unfortunately, as later become manifest, patient suffered permanent irreversible brain heart rate that produce bradycardia.
damage.
Q I am pro[p]ounding to you another question doctor, what about the deficiency in the
In view of the actuations of the anaesthesiologists and the administration of supply of oxygen by the patient, would that also cause the slowing of the heart rate?
anaesthesia, the committee find that the same were all in accordance with the
universally accepted standards of medical care and there is no evidence of any fault or A Well that is a possibility sir, I mean not as slowing of the heart rate, if there is a
negligence on the part of the anaesthesiologists. hypoxia or there is a low oxygen level in the blood, the normal thing for the heart is to
pump or to do not a bradycardia but a to counter act the Hypoxia that is being
Dr. Antonio Vertido, a Senior Medico-Legal Officer of the National Bureau of experienced by the patient (sic).
Investigation, was also presented as a Prosecution witness, but his testimony
concentrated on the results of the physical examination he had conducted on Gerald, xxxx
as borne out by the following portions of his direct examination, to wit: Q Now, you made mention also doctor that the use of general anesthesia using 100%
halothane and other anesthetic medications probably were contributory to the
FISCAL CABARON Doctor, what do you mean by General Anesthetic Agent? production of hypoxia.

A Yes, sir in general sir.41


On cross-examination, Dr. Vertido expounded more specifically on his interpretation xxxx
of the anesthesia record and the factors that could have caused Gerald to experience ATTY. COMIA Doctor, my attention was called also when you said that there are so
bradycardia, viz: many factors that contributed to Hypoxia is that correct?

ATTY. COMIA I noticed in, may I see your report Doctor, page 3, will you kindly WITNESS Yes, sir.
read to this Honorable court your last paragraph and if you will affirm that as if it is
correct? Q I remember doctor, according to you there are so many factors that contributed to
what you call hypoxia and according to you, when this Gerald suffered hypoxia, there
A "The use of General Anesthesia, that is using 100% Halothane probably will be are other factors that might lead to this Hypoxia at the time of this operation is that
contributory to the production of Hypoxia and - - - -" correct?

ATTY COMIA And do you affirm the figure you mentioned in this Court Doctor? WITNESS The possibility is there, sir.

WITNESS Based on the records, I know the - - - Q And according to you, it might also be the result of such other, some or it might be
due to operations being conducted by the doctor at the time when the operation is being
Q 100%? done might also contribute to that hypoxia is that correct?

A 100% based on the records. A That is a possibility also.

Q I will show you doctor a clinical record. I am a lawyer I am not a doctor but will xxxx
you kindly look at this and tell me where is 100%, the word "one hundred" or 1-0-0, ATTY. COMIA How will you classify now the operation conducted to this Gerald,
will you kindly look at this Doctor, this Xerox copy if you can show to this Honorable Doctor?
Court and even to this representation the word "one hundred" or 1-0-0 and then call
me. WITNESS Well, that is a major operation sir.

xxxx Q In other words, when you say major operation conducted to this Gerald, there is a
ATTY. COMIA Doctor tell this Honorable Court where is that 100, 1-0-0 and if there possibility that this Gerald might [be] exposed to some risk is that correct?
is, you just call me and even the attention of the Presiding Judge of this Court. Okay,
you read one by one. A That is a possibility sir.

WITNESS Well, are you only asking 100%, sir? Q And which according to you that Gerald suffered hypoxia is that correct?

ATTY. COMIA Im asking you, just answer my question, did you see there 100% and A Yes, sir.
100 figures, tell me, yes or no?
Q And that is one of the risk of that major operation is that correct?
WITNESS Im trying to look at the 100%, there is no 100% there sir.
A That is the risk sir.42
ATTY. COMIA Okay, that was good, so you Honor please, may we request also
temporarily, because this is just a xerox copy presented by the fiscal, that the
At the continuation of his cross-examination, Dr. Vertido maintained that Geralds
percentage here that the Halothane administered by Dr. Solidum to the patient is 1%
operation for his imperforate anus, considered a major operation, had exposed him to
only so may we request that this portion, temporarily your Honor, we are marking this
the risk of suffering the same condition.43 He then corrected his earlier finding that
anesthesia record as our Exhibit 1 and then this 1% Halothane also be bracketed and
100% halothane had been administered on Gerald by saying that it should be 100%
the same be marked as our Exhibit "1-A". oxygen.44
Dr. Solidum was criminally charged for "failing to monitor and regulate properly the In criminal prosecutions, the civil action for the recovery of civil liability that is
levels of anesthesia administered to said Gerald Albert Gercayo and using 100% deemed instituted with the criminal action refers only to that arising from the offense
halothane and other anesthetic medications."45 However, the foregoing circumstances, charged.48 It is puzzling, therefore, how the RTC and the CA could have adjudged
taken together, did not prove beyond reasonable doubt that Dr. Solidum had been Ospital ng Maynila jointly and severally liable with Dr. Solidum for the damages
recklessly imprudent in administering the anesthetic agent to Gerald. Indeed, Dr. despite the obvious fact that Ospital ng Maynila, being an artificial entity, had not been
Vertidos findings did not preclude the probability that other factors related to Geralds charged along with Dr. Solidum. The lower courts thereby acted capriciously and
major operation, which could or could not necessarily be attributed to the whimsically, which rendered their judgment against Ospital ng Maynila void as the
administration of the anesthesia, had caused the hypoxia and had then led Gerald to product of grave abuse of discretion amounting to lack of jurisdiction.
experience bradycardia. Dr. Vertido revealingly concluded in his report, instead, that
"although the anesthesiologist followed the normal routine and precautionary Not surprisingly, the flawed decree raises other material concerns that the RTC and
procedures, still hypoxia and its corresponding side effects did occur." 46 the CA overlooked. We deem it important, then, to express the following observations
for the instruction of the Bench and Bar.
The existence of the probability about other factors causing the hypoxia has
engendered in the mind of the Court a reasonable doubt as to Dr. Solidums guilt, and For one, Ospital ng Maynila was not at all a party in the proceedings. Hence, its
moves us to acquit him of the crime of reckless imprudence resulting to serious fundamental right to be heard was not respected from the outset. The R TC and the CA
physical injuries. "A reasonable doubt of guilt," according to United States v. should have been alert to this fundamental defect. Verily, no person can be prejudiced
Youthsey:47 by a ruling rendered in an action or proceeding in which he was not made a party. Such
a rule would enforce the constitutional guarantee of due process of law.
x x x is a doubt growing reasonably out of evidence or the lack of it. It is not a captious
doubt; not a doubt engendered merely by sympathy for the unfortunate position of the Moreover, Ospital ng Maynila could be held civilly liable only when subsidiary
defendant, or a dislike to accept the responsibility of convicting a fellow man. If, liability would be properly enforceable pursuant to Article 103 of the Revised Penal
having weighed the evidence on both sides, you reach the conclusion that the Code. But the subsidiary liability seems far-fetched here. The conditions for subsidiary
defendant is guilty, to that degree of certainty as would lead you to act on the faith of liability to attach to Ospital ng Maynila should first be complied with. Firstly, pursuant
it in the most important and crucial affairs of your life, you may properly convict him. to Article 103 of the Revised Penal Code, Ospital ng Maynila must be shown to be a
Proof beyond reasonable doubt is not proof to a mathematical demonstration. It is not corporation "engaged in any kind of industry." The term industry means any
proof beyond the possibility of mistake. department or branch of art, occupation or business, especially one that employs labor
and capital, and is engaged in industry.49 However, Ospital ng Maynila, being a public
We have to clarify that the acquittal of Dr. Solidum would not immediately exempt hospital, was not engaged in industry conducted for profit but purely in charitable and
him from civil liability.1wphi1 But we cannot now find and declare him civilly liable humanitarian work.50 Secondly, assuming that Ospital ng Maynila was engaged in
because the circumstances that have been established here do not present the factual industry for profit, Dr. Solidum must be shown to be an employee of Ospital ng
and legal bases for validly doing so. His acquittal did not derive only from reasonable Maynila acting in the discharge of his duties during the operation on Gerald. Yet, he
doubt. There was really no firm and competent showing how the injury to Gerard had definitely was not such employee but a consultant of the hospital. And, thirdly,
been caused. That meant that the manner of administration of the anesthesia by Dr. assuming that civil liability was adjudged against Dr. Solidum as an employee (which
Solidum was not necessarily the cause of the hypoxia that caused the bradycardia did not happen here), the execution against him was unsatisfied due to his being
experienced by Gerard. Consequently, to adjudge Dr. Solidum civilly liable would be insolvent.
to speculate on the cause of the hypoxia. We are not allowed to do so, for civil liability
must not rest on speculation but on competent evidence. WHEREFORE, the Court GRANTS the petition for review on certiorari;
REVERSES AND SETS ASIDE the decision promulgated on January 20, 2010;
Liability of Ospital ng Maynila ACQUITS Dr. Fernando P. Solidum of the crime of reckless imprudence resulting to
serious physical injuries; and MAKES no pronouncement on costs of suit.
Although the result now reached has resolved the issue of civil liability, we have to
address the unusual decree of the RTC, as affirmed by the CA, of expressly holding SO ORDERED.
Ospital ng Maynila civilly liable jointly and severally with Dr. Solidum. The decree
was flawed in logic and in law.
The RTC awarded Nelson Cortejo (respondent) damages in the total amount of
P595,000.00, for the wrongful death of his son allegedly due to the medical negligence
of the petitioning doctors and the hospital

Factual Antecedents

The common factual antecedents are briefly summarized below.

On April 22, 1988, at about 11:30 in the morning, Mrs. Jesusa Cortejo brought her 11-
year old son, Edmer Cortejo (Edmer), to the Emergency Room of the San Juan de Dios
Hospital (SJDH) because of difficulty in breathing, chest pain, stomach pain, and
fever.

Dr. Ramoncito Livelo (Dr. Livelo) initially attended to and examined Edmer. In her
testimony, Mrs. Cortejo narrated that in the morning of April 20, 1988, Edmer had
developed a slight fever that lasted for one day; a few hours upon discovery, she
brought Edmer to their family doctor; and two hours after administering medications,
Edmer's fever had subsided.

After taking Edmer's medical history, Dr. Livelo took his vital signs, body
SECOND DIVISION temperature, and blood pressure.6 Based on these initial examinations and the chest x-
ray test that followed, Dr. Livelo diagnosed Edmer with "bronchopneumonia."7
G.R. No. 171127, March 11, 2015
Edmer's blood was also taken for testing, typing, and for purposes of administering
NOEL CASUMPANG, RUBY SANGA-MIRANDA AND SAN JUAN DE DIOS antibiotics. Afterwards, Dr. Livelo gave Edmer an antibiotic medication to lessen his
HOSPITAL, Petitioners, v. NELSON CORTEJO, Respondent. fever and to loosen his phlegm.

[G.R. No. 171217] Mrs. Cortejo did not know any doctor at SJDH. She used her Fortune Care card and
DRA. RUBY SANGA-MIRANDA, Petitioner, v. NELSON CORTEJO, was referred to an accredited Fortune Care coordinator, who was then out of town. She
Respondent. was thereafter assigned to Dr. Noel Casumpang (Dr. Casumpang), a pediatrician also
accredited with Fortune Care.8
[G.R. No. 171228]
At 5:30 in the afternoon of the same day, Dr. Casumpang for the first time examined
SAN JUAN DE DIOS HOSPITAL, Petitioner, v. NELSON CORTEJO,
Edmer in his room. Using only a stethoscope, he confirmed the initial diagnosis of
Respondent.
"Bronchopneumonia."9

At that moment, Mrs. Cortejo recalled entertaining doubts on the doctor's diagnosis.
DECISION
She immediately advised Dr. Casumpang that Edmer had a high fever, and had no
BRION, J.: colds or cough10 but Dr. Casumpang merely told her that her son's "bloodpressure is
just being active,"11 and remarked that "that's the usual bronchopneumonia, no colds,
We resolve the three (3) consolidated petitions for review on certiorari1 involving no phlegm."12
medical negligence, commonly assailing the October 29, 2004 decision2 and the
January 12, 2006 resolution3 of the Court of Appeals (CA) in CA-G.R. CV No. 56400. Dr. Casumpang next visited and examined Edmer at 9:00 in the morning the following
This CA decision affirmed en toto the ruling of the Regional Trial Court (RTC), day.13 Still suspicious about his son's illness, Mrs. Cortejo again called Dr.
Branch 134, Makati City Casumpang's attention and stated that Edmer had a fever, throat irritation, as well as
chest and stomach pain. Mrs. Cortejo also alerted Dr. Casumpang about the traces of
blood in Edmer's sputum. Despite these pieces of information, however, Dr.
Casumpang simply nodded, inquired if Edmer has an asthma, and reassured Mrs. (ICU), to which the respondent consented. Since the ICU was then full, Dr.
Cortejo that Edmer's illness is bronchopneumonia.14 Casumpang suggested to the respondent that they hire a private nurse. The respondent,
however, insisted on transferring his son to Makati Medical Center.
At around 11:30 in the morning of April 23, 1988, Edmer vomited "phlegm with blood
streak"15 prompting the respondent (Edmer's father) to request for a doctor at the After the respondent had signed the waiver, Dr. Casumpang, for the last time, checked
nurses' station.16 Edmer's condition, found that his blood pressure was stable, and noted that he was
"comfortable." The respondent requested for an ambulance but he was informed that
Forty-five minutes later, Dr. Ruby Sanga-Miranda (Dr. Miranda), one of the resident the driver was nowhere to be found. This prompted him to hire a private ambulance
physicians of SJDH, arrived. She claimed that although aware that Edmer had vomited that cost him P600.00.23
"phlegm with blood streak," she failed to examine the blood specimen because the
respondent washed it away. She then advised the respondent to preserve the specimen At 12:00 midnight, Edmer, accompanied by his parents and by Dr. Casumpang, was
for examination. transferred to Makati Medical Center.

Thereafter, Dr. Miranda conducted a physical check-up covering Edmer's head, eyes, Dr. Casumpang immediately gave the attending physician the patient's clinical history
nose, throat, lungs, skin and abdomen; and found that Edmer had a low-grade non- and laboratory exam results. Upon examination, the attending physician diagnosed
continuing fever, and rashes that were not typical of dengue fever.17 Her medical "Dengue Fever Stage IV" that was already in its irreversible stage.
findings state:
Edmer died at 4:00 in the morning of April 24, 1988.24 His Death Certificate indicated
the patient's rapid breathing and then the lung showed sibilant and the the cause of death as "Hypovolemic Shock/hemorrhagic shock;" "Dengue
patient's nose is flaring which is a sign that the patient is in respiratory Hemorrhagic Fever Stage IV."
distress; the abdomen has negative finding; the patient has low grade fever
and not continuing; and the rashes in the patient's skin were not "Herman's
Rash" and not typical of dengue fever.18 Believing that Edmer's death was caused by the negligent and erroneous diagnosis of
At 3:00 in the afternoon, Edmer once again vomited blood. Upon seeing Dr. Miranda, his doctors, the respondent instituted an action for damages against SJDH, and its
the respondent showed her Edmer's blood specimen, and reported that Edmer had attending physicians: Dr. Casumpang and Dr. Miranda (collectively referred to as the
complained of severe stomach pain and difficulty in moving his right leg.19 "petitioners") before the RTC of Makati City.

Dr. Miranda then examined Edmer's "sputum with blood" and noted that he was The Ruling of the Regional Trial Court
bleeding. Suspecting that he could be afflicted with dengue, she inserted a plastic tube In a decision25 dated May 30, 1997, the RTC ruled in favor of the respondent, and
in his nose, drained the liquid from his stomach with ice cold normal saline solution, awarded actual and moral damages, plus attorney's fees and costs.
and gave an instruction not to pull out the tube, or give the patient any oral medication.
In ruling that the petitioning doctors were negligent, the RTC found untenable the
Dr. Miranda thereafter conducted a tourniquet test, which turned out to be negative.20 petitioning doctors' contention that Edmer's initial symptoms did not indicate dengue
She likewise ordered the monitoring of the patient's blood pressure and some blood fever. It faulted them for heavily relying on the chest x-ray result and for not
tests. Edmer's blood pressure was later found to be normal.21 considering the other manifestations that Edmer's parents had relayed. It held that in
At 4:40 in the afternoon, Dr. Miranda called up Dr. Casumpang at his clinic and told diagnosing and treating an illness, the physician's conduct should be judged not only
him about Edmer's condition.22 Upon being informed, Dr. Casumpang ordered several by what he/she saw and knew, but also by what he/she could have reasonably seen and
procedures done including: hematocrit, hemoglobin, blood typing, blood transfusion known. It also observed that based on Edmer's signs and symptoms, his medical history
and tourniquet tests. and physical examination, and also the information that the petitioning doctors
gathered from his family members, dengue fever was a reasonably foreseeable illness;
The blood test results came at about 6:00 in the evening. yet, the petitioning doctors failed to take a second look, much less, consider these
indicators of dengue.
Dr. Miranda advised Edmer's parents that the blood test results showed that Edmer
was suffering from "Dengue Hemorrhagic Fever." One hour later, Dr. Casumpang The trial court also found that aside from their self-serving testimonies, the petitioning
arrived at Edmer's room and he recommended his transfer to the Intensive Care Unit doctors did not present other evidence to prove that they exercised the proper medical
attention in diagnosing and treating the patient, leading it to conclude that they were On SJDH's solidary liability, the CA ruled that the hospital's liability is based on
guilty of negligence. Article 2180 of the Civil Code. The CA opined that the control which the hospital
exercises over its consultants, the hospital's power to hire and terminate their services,
The RTC also held SJDH solidarity liable with the petitioning doctors for damages all fulfill the employer-employee relationship requirement under Article 2180.
based on the following findings of facts: first, Dr. Casumpang, as consultant, is an
ostensible agent of SJDH because before the hospital engaged his medical services, it Lastly, the CA held that SJDH failed to adduce evidence showing that it exercised the
scrutinized and determined his fitness, qualifications, and competence as a medical diligence of a good father of a family in the hiring and the supervision of its physicians.
practitioner; and second, Dr. Miranda, as resident physician, is an employee of SJDH
because like Dr. Casumpang, the hospital, through its screening committee, scrutinized The petitioners separately moved to reconsider the CA decision, but the CA denied
and determined her qualifications, fitness, and competence before engaging her their motion in its resolution of January 12, 2006; hence, the present consolidated
services; the hospital also exercised control over her work. petitions pursuant to Rule 45 of the Rules of Court.

The dispositive portion of the decision reads: The Petitions

WHEREFORE, judgment is hereby rendered in favor of the plaintiff and I. Dr. Casumpang's Position (G.R. No. 171127)
against the defendants, ordering the latter to pay solidarity and severally Dr. Casumpang contends that he gave his patient medical treatment and care to the
plaintiff the following: best of his abilities, and within the proper standard of care required from physicians
(1) Moral damages in the amount of P500,000.00; under similar circumstances. He claims that his initial diagnosis of bronchopneumonia
(2) Costs of burial and funeral in the amount of P45,000.00; was supported by the chest x-ray result.
(3) Attorney's fees of P50,000.00; and
(4) Cost of this suit.
SO ORDERED.
Dr. Casumpang also contends that dengue fever occurs only after several days of
The petitioners appealed the decision to the CA. confinement. He alleged that when he had suspected that Edmer might be suffering
from dengue fever, he immediately attended and treated him.

Dr. Casumpang likewise raised serious doubjs on Dr. Jaudian's credibility, arguing that
The Ruling of the Court of Appeals the CA erred in appreciating his testimony as an expert witness since he lacked the
In its decision dated October 29, 2004, the CA affirmed en toto the RTC's ruling, necessary training, skills, and experience as a specialist in dengue fever cases.
finding that SJDH and its attending physicians failed to exercise the minimum medical II. Dr. Miranda's Position (G.R. No. 171217)
care, attention, and treatment expected of an ordinary doctor under like circumstances.
In her petition, Dr. Miranda faults the CA for holding her responsible for Edmer's
The CA found the petitioning doctors' failure to read even the most basic signs of wrong diagnosis, stressing that the function of making the diagnosis and undertaking
"dengue fever" expected of an ordinary doctor as medical negligence. The CA also the medical treatment devolved upon Dr. Casumpang, the doctor assigned to Edmer,
considered the petitioning doctors' testimonies as self-serving, noting that they and who confirmed "bronchopneumonia."
presented no other evidence to prove that they exercised due diligence in diagnosing
Edmer's illness. Dr. Miranda also alleged that she exercised prudence in performing her duties as a
physician, underscoring that it was her professional intervention that led to the correct
The CA likewise found Dr. Rodolfo Jaudian's (Dr. Jaudian) testimony admissible. It diagnosis of "Dengue Hemorrhagic Fever." Furthermore, Edmer's Complete Blood
gave credence to his opinion26 that: (1) given the exhibited symptoms of the patient, Count (CBC) showed leukopenia and an increase in balance as shown by the
dengue fever should definitely be considered, and bronchopneumonia could be differential count, demonstrating that Edmer's infection, more or less, is of bacterial
reasonably ruled out; and (2) dengue fever could have been detected earlier than 7:30 and not viral in nature.
in the evening of April 23, 1988 because the symptoms were already evident; and
agreed with the RTC that the petitioning doctors should not have solely relied on the
chest-x-ray result, as it was not conclusive.
Dr. Miranda as well argued that there is no causal relation between the alleged Lastly, SJDH maintains that the petitioning doctors arrived at an intelligently deduced
erroneous diagnosis and medication for "Bronchopneumonia," and Edmer's death due and correct diagnosis. It claimed that based on Edmer's signs and symptoms at the time
to "Dengue Hemorrhagic Fever." of admission (i.e., one day fever,28bacterial infection,29 and lack of hemorrhagic
manifestations30), there was no reasonable indication yet that he was suffering from
Lastly, she claimed that Dr. Jaudian is not a qualified expert witness since he never dengue fever, and accordingly, their failure to diagnose dengue fever, does not
presented any evidence of formal residency training and fellowship status in constitute negligence on their part.
Pediatrics.

III. SJDH's Position (G.R. No. 171228)


The Case for the Respondent
SJDH, on the other hand, disclaims liability by asserting that Dr. Casumpang and Dr.
Miranda are mere independent contractors and "consultants" (not employees) of the In his comment, the respondent submits that the issues the petitioners raised are mainly
hospital. SJDH alleges that since it did not exercise control or supervision over the factual in nature, which a petition for review on certiorari under Rule 45 of the Rules
consultants' exercise of medical profession, there is no employer-employee of Court does not allow.
relationship between them, and consequently, Article 2180 of the Civil Code does not
apply. In any case, he contends that the petitioning doctors were negligent in conducting their
medical examination and diagnosis based on the following: (1) the petitioning doctors
SJDH likewise anchored the absence of, employer-employee relationship on the failed to timely diagnose Edmer's correct illness due to their non-observance of the
following circumstances: (1) SJDH does not hire consultants; it only grants them proper and acceptable standard of medical examination; (2) the petitioning doctors'
privileges to admit patients in the hospital through accreditation; (2) SJDH does not medical examination was not comprehensive, as they were always in a rush; and (3)
pay the consultants wages similar to an ordinary employee; (3) the consultants earn the petitioning doctors employed a guessing game in diagnosing bronchopneumonia.
their own professional fees directly from their patients; SJDH does not fire or terminate
their services; and (4) SJDH does not control or interfere with the manner and the
means the consultants use in the treatment of their patients. It merely provides them The respondent also alleges that there is a causal connection between the petitioning
with adequate space in exchange for rental payment. doctors' negligence and Edmer's untimely death, warranting the claim for damages.
Furthermore, SJDH claims that the CA erroneously applied the control test when it The respondent, too, asserted that SJDH is also negligent because it was not equipped
treated the hospital's practice of accrediting consultants as an exercise of control. It with proper paging system, has no bronchoscope, and its doctors are not proportionate
explained that the control contemplated by law is that which the employer exercises to the number of its patients. He also pointed out that out of the seven resident
over the: (i) end result; and the (ii) manner and means to be used to reach this end, and physicians in the hospital, only two resident physicians were doing rounds at the time
not any kind of control, however significant, in accrediting the consultants. of his son's confinement.
SJDH moreover contends that even if the petitioning doctors are considered employees The Issues
and not merely consultants of the hospital, SJDH cannot still be held solidarity liable
under Article 2180 of the Civil Code because it observed the diligence of a good father The case presents to us the following issues:
of a family in their selection and supervision as shown by the following: (1) the
Whether or not the petitioning doctors had committed "inexcusable lack of precaution"
adequate measures that the hospital undertakes to ascertain the petitioning doctors'
in diagnosing and in treating the patient;
qualifications and medical competence; and (2) the documentary evidence that the
petitioning doctors presented to prove their competence in the field of pediatrics.27 Whether or not the petitioner hospital is solidarity liable with the petitioning doctors;
SJDH likewise faults the CA for ruling that the petitioning doctors are its agents, Whether or not there is a causal connection between the petitioners' negligent
claiming that this theory, aside from being inconsistent with the CA's finding of act/omission and the patient's resulting death; and
employment relationship, is unfounded because: first, the petitioning doctors are
independent contractors, not agents of SJDH; and second, as a medical institution, Whether or not the lower courts erred in considering Dr. Rodolfo Tabangcora Jaudian
SJDH cannot practice medicine, much more, extend its personality to physicians to as an expert witness.
practice medicine on its behalf.
The Elements of a Medical Malpractice Suit

Our Ruling The elements of medical negligence are: (1) duty; (2) breach; (3) injury; and (4)
proximate causation.
We find the petition partly meritorious.
Duty refers to the standard of behavior that imposes restrictions on one's conduct.35 It
A Petition for Review on Certiorari under Rule 45 of the Rules of Court is Limited to requires proof of professional relationship between the physician and the patient.
Questions of Law. Without the professional relationship, a physician owes no duty to the patient, and
The settled rule is that the Court's jurisdiction in a petition for review on certiorari cannot therefore incur any liability.
under Rule 45 of the Rules of Court is limited only to the review of pure questions of A physician-patient relationship is created when a patient engages the services of a
law. It is not the Court's function to inquire on the veracity of the appellate court's physician,36 and the latter accepts or agrees to provide care to the patient.37 The
factual findings and conclusions; this Court is not a trier of facts.31 establishment of this relationship is consensual,38 and the acceptance by the physician
A question of law arises when there is doubt as to what the law is on a certain state of essential. The mere fact that an individual approaches a physician and seeks diagnosis,
facts, while there is a question of fact when the doubt arises as to the truth or falsity of advice or treatment does not create the duty of care unless the physician agrees.39
the alleged facts.32 The consent needed to create the relationship does not always need to be express.40
These consolidated petitions before us involve mixed questions of fact and law. As a In the absence of an express agreement, a physician-patient relationship may be
rule, we do not resolve questions of fact. However, in determining the legal question implied from the physician's affirmative action to diagnose and/or treat a patient, or in
of whether the respondent is entitled to claim damages under Article 2176 of the Civil his participation in such diagnosis and/or treatment.41 The usual illustration would be
Code for the petitioners' alleged medical malpractice, the determination of the factual the case of a patient who goes to a hospital or a clinic, and is examined and treated by
issues - i.e., whether the petitioning doctors were grossly negligent in diagnosing the the doctor. In this case, we can infer, based on the established and customary practice
patient's illness, whether there is causal relation between the petitioners' act/omission in the medical community that a patient-physician relationship exists.
and the patient's resulting death, and whether Dr. Jaudian is qualified as an expert Once a physician-patient relationship is established, the legal duty of care follows. The
witness - must necessarily be resolved. We resolve these factual questions solely for doctor accordingly becomes duty-bound to use at least the same standard of care that
the purpose of determining the legal issues raised. a reasonably competent doctor would use to treat a medical condition under similar
circumstances.

Medical Malpractice Suit as a Specialized Area of Tort Law 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,
The claim for damages is based on the petitioning doctors' negligence in diagnosing and is specific to each individual case.42
and treating the deceased Edmer, the child of the respondent. It is a medical
malpractice suit, an action available to victims to redress a wrong committed by If the patient, as a result of the breach of duty, is injured in body or in health, actionable
medical professionals who caused bodily harm to, or the death of, a patient.33 As the malpractice is committed, entitling the patient to damages.43
term is used, the suit is brought whenever a medical practitioner or health care provider To successfully claim damages, the patient must lastly prove the causal relation
fails to meet the standards demanded by his profession, or deviates from this standard, between the negligence and the injury. This connection must be direct, natural, and
and causes injury to the patient. should be unbroken by any intervening efficient causes. In other words, the negligence
To successfully pursue a medical malpractice suit, the plaintiff (in this case, the must be the proximate cause of the injury.44 The injury or damage is proximately
deceased patient's heir) must prove that the doctor either failed to do what a reasonably caused by the physician's negligence when it appears, based on the evidence and the
prudent doctor would have done, or did what a reasonably prudent doctor would not expert testimony, that the negligence played an integral part in causing the injury or
have done; and the act or omission had caused injury to the patient.34 The patient's damage, and that the injury or damage was either a direct result, or a reasonably
heir/s bears the burden of proving his/her cause of action. probable consequence of the physician's negligence.45
a. The Relationship Between Dr. Casumpang and Edmer A determination of whether or not the petitioning doctors met the required standard of
care involves a question of mixed fact and law; it is factual as medical negligence cases
In the present case, the physician-patient relationship between Dr. Casumpang and are highly technical in nature, requiring the presentation of expert witnesses to provide
Edmer was created when the latter's parents sought the medical services of Dr. guidance to the court on matters clearly falling within the domain of medical science,
Casumpang, and the latter knowingly accepted Edmer as a patient. Dr. Casumpang's and legal, insofar as the Court, after evaluating the expert testimonies, and guided by
acceptance is implied from his affirmative examination, diagnosis and treatment of medical literature, learned treatises, and its fund of common knowledge, ultimately
Edmer. On the other hand, Edmer's parents, on their son's behalf, manifested their determines whether breach of duty took place.
consent by availing of the benefits of their health care plan, and by accepting the
hospital's assigned doctor without objections. Whether or not Dr. Casumpang and Dr. Miranda committed a breach of duty is to be
measured by the yardstick of professional standards observed by the other members of
the medical profession in good standing under similar circumstances.49 It is in this
b. The Relationship Between Dr. Miranda and Edmer aspect of medical malpractice that expert testimony is essential to establish not only
the professional standards observed in the medical community, but also that the
With respect to Dr. Miranda, her professional relationship with Edmer arose when she physician's conduct in the treatment of care falls below such standard.50
assumed the obligation to provide resident supervision over the latter. As second year
resident doctor tasked to do rounds and assist other physicians, Dr. Miranda is deemed In the present case, expert testimony is crucial in determining first, the standard
to have agreed to the creation of physician-patient relationship with the hospital's medical examinations, tests, and procedures that the attending physicians should have
patients when she participated in the diagnosis and prescribed a course of treatment undertaken in the diagnosis and treatment of dengue fever; and second, the dengue
for Edmer. fever signs and symptoms that the attending physicians should have noticed and
considered.
The undisputed evidence shows that Dr. Miranda examined Edmer twice (at around
12:00 and 3:30 in the afternoon of April 23, 1988), and in both instances, she Both the RTC and the CA relied largely on Dr. Jaudian's expert testimony on dengue
prescribed treatment and participated in the diagnosis of Edmer's medical condition. diagnosis and management to support their finding that the petitioning doctors were
Her affirmative acts amounted to her acceptance of the physician-patient relationship, guilty of breach of duty of care.
and incidentally, the legal duty of care that went with it. Dr. Jaudian testified that Edmer's rapid breathing, chest and stomach pain, fever, and
In Jarcia, Jr. v. People of the Philippines,46 the Court found the doctors who merely the presence of blood in his saliva are classic symptoms of dengue fever. According
passed by and were requested to attend to the patient, liable for medical malpractice. to him, if the patient was admitted for chest pain, abdominal pain, and difficulty in
It held that a physician-patient relationship was established when they examined the breathing coupled with fever, dengue fever should definitely be considered;51 if the
patient, and later assured the mother that everything was fine. 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 bronchopneumonia can
In the US case of Mead v. Legacy Health System,47 the Court also considered the be reasonably ruled out.52
rendering of an opinion in the course of the patient's care as the doctor's assent to the
physician-patient relationship. It ruled that the relationship was formed because of the Furthermore, the standard of care according to Dr. Jaudian is to administer oxygen
doctor's affirmative action. inhalation, analgesic, and fluid infusion or dextrose.53 If the patient had twice vomited
fresh blood and thrombocytopenia has already occurred, the doctor should order blood
Likewise, in Wax v. Johnson,48 the court found that a physician-patient relationship transfusion, monitoring of the patient every 30 minutes, hemostatic to stop bleeding,
was formed between a physician who "contracts, agrees, undertakes, or otherwise and oxygen if there is difficulty in breathing.54
assumes" the obligation to provide resident supervision at a teaching hospital, and the
patient with whom the doctor had no direct or indirect contract. We find that Dr. Casumpang, as Edmer's attending physician, did not act according to
these standards and, hence, was guilty of breach of duty. We do not find Dr. Miranda
liable for the reasons discussed below.

Standard of Care and Breach of Duty

Dr. Casumpang's Negligence


a. Negligence in the Diagnosis A: And then, Dr. Casumpang answered "THAT'S THE USUAL BRONCHO
PNEUMONIA, NO COLDS, NO PHLEGM."
At the trial, Dr. Casumpang declared that a doctor's impression regarding a patient's
illness is 90% based on the physical examination, the information given by the patient Q: How long did Dr. Casumpang stay in your son's room?
or the latter's parents, and the patient's medical history.55 He testified that he did not
consider either dengue fever or dengue hemorrhagic fever because the patient's history A: He stayed for a minute or 2.
showed that Edmer had low breath and voluntary submission, and that he was up and xxxx
about playing basketball.56 He based his diagnosis of bronchopneumonia on the Q: When Dr. Casumpang arrived at 9:00 o'clock a.m. on April 23, what did you tell
following observations: "difficulty in breathing, clearing run nostril, harsh breath him, if any?
sound, tight air, and sivilant sound."57 xxxx
It will be recalled that during Dr. Casumpang's first and second visits to Edmer, he A: I told Dr. Casumpang... After examining my son using stethoscope and nothing
already had knowledge of Edmer's laboratory test result (CBC), medical history, and more, I told Dr. Casumpang about the traces of blood in my son's sputum and I told
symptoms (i.e., fever, rashes, rapid breathing, chest and stomach pain, throat irritation, him what is all about and he has throat irritation.
difficulty in breathing, and traces of blood in the sputum). However, these information Q: What did he tell you?
did not lead Dr. Casumpang to the possibility that Edmer could be suffering from either A: He just nodded his head but he did not take the initiative of looking at the throat of
dengue fever, or dengue hemorrhagic fever, as he clung to his diagnosis of broncho my son.
pneumonia. This means that given the symptoms exhibited, Dr. Casumpang already
ruled out the possibility of other diseases like dengue. Q: So what happened after that?

In other words, it was lost on Dr. Casumpang that the characteristic symptoms of A: I also told Dr. Casumpang about his chest pain and also stomach pain.
dengue (as Dr. Jaudian testified) are: patient's rapid breathing; chest and stomach pain;
Q: So what did Dr. Casumpang do after you have narrated all these complaints of your
fever; and the presence of blood in his saliva. All these manifestations were present
son?
and known to Dr. 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 A: Nothing. He also noticed the rapid breathing of my son and my son was almost
to have considered the patient's other manifestations in ruling out dengue fever or moving because of rapid breathing and he is swaying in the bed.
dengue hemorrhagic fever.58 To our mind, Dr. Casumpang selectively appreciated
some, and not all of the symptoms; worse, he casually ignored the pieces of Q: Do you know what action was taken by Dr. Casumpang when you told him that
information that could have been material in detecting dengue fever. This is evident your son is experiencing a rapid breathing?
from the testimony of Mrs. Cortejo:
A: No action. He just asked me if my son has an asthma but I said none.
TSN, Mrs. Cortejo, November 27, 1990
Q: So how long did Dr. Casumpang stay and attended your son on April 23?
Q: Now, when Dr. Casumpang visited your son for the first time at 5:30 p.m., what
A: More or less two (2) minutes then I followed him up to the door and I repeated
did he do, if any?
about the fever of my son.
A: He examined my son by using stethoscope and after that, he confirmed to me that
Q: What did he tell you, if any, regarding that information you gave him that your son
my son was suffering from broncho pneumonia.
had a fever?
Q: After he confirmed that your son was suffering broncho pneumonia, what did you
A: He said, that is broncho pneumonia, It's only being active now. [Emphasis supplied]
sayif any?
We also find it strange why Dr. Casumpang did not even bother to check Edmer's
A: Again, I told Dr. Casumpang, how come it was broncho pneumonia when my son
throat despite knowing that as early as 9:00 in the morning of April 23, 1988, Edmer
has no cough or colds.
had blood streaks in his sputum. Neither did Dr. Casumpang order confirmatory tests
Q: What was the answer of Dr. Casumpang to your statement? to confirm the source of bleeding. The Physician's Progress Notes59 stated: "Blood
streaks on phlegm can be due to bronchial irritation or congestion" which clearly medical profession. Assuming for the sake of argument that they did not have the
showed that Dr. Casumpang merely assumed, without confirmatory physical capacity to make such thorough evaluation at that stage, they should have referred the
examination, that bronchopneumonia caused the bleeding. patient to another doctor with sufficient training and experience instead of assuring
him and his mother that everything was all right. [Emphasis supplied]
Dr. Jaudian likewise opined that Dr. Casumpang's medical examination was not
comprehensive enough to reasonably lead to a correct diagnosis.60 Dr. Casumpang Even assuming that Edmer's symptoms completely coincided with the diagnosis of
only used a stethoscope in coming up with the diagnosis that Edmer was suffering bronchopneumonia (so that this diagnosis could not be considered "wrong"), we still
from bronchopneumonia; he never confirmed this finding with the use of a find Dr. Casumpang guilty of negligence.
bronchoscope. Furthermore, Dr. Casumpang based his diagnosis largely on the chest
x-ray result that is generally inconclusive.61 First, we emphasize that we do not decide the correctness of a doctor's diagnosis, or
the accuracy of the medical findings and treatment. Our duty in medical malpractice
Significantly, it was only at around 5:00 in the afternoon of April 23, 1988 (after cases is to decide - based on the evidence adduced and expert opinion presented -
Edmer's third episode of bleeding) that Dr. Casumpang ordered the conduct of whether a breach of duty took place.
hematocrit, hemoglobin, blood typing, blood transfusion and tourniquet tests. These
tests came too late, as proven by: (1) the blood test results that came at about 6:00 in Second, we clarify that a wrong diagnosis is not by itself medical malpractice.65
the evening, confirming that Edmer's illness had developed to "Dengue Hemorrhagic Physicians are generally not liable for damages resulting from a bona fide error of
Fever" and (2) Dr. Jaudian's testimony that "dengue fever could have been detected judgment. Nonetheless, when the physician's erroneous diagnosis was the result of
earlier than 7:30 in the evening of April 23, 1988 because the symptoms were already negligent conduct (e.g., neglect of medical history, failure to order the appropriate
evident."62 tests, failure to recognize symptoms), it becomes an evidence of medical malpractice.

In Spouses Flores v. Spouses Pineda,63 a case involving a medical malpractice suit, Third, we also note that medicine is not an exact science;66 and doctors, or even
the Court ruled that the petitioner doctors were negligent because they failed to specialists, are not expected to give a 100% accurate diagnosis in treating patients who
immediately order tests to confirm the patient's illness. Despite the doctors' suspicion come to their clinic for consultations. Error is possible as the exercise of judgment is
that the patient could be suffering from diabetes, the former still proceeded to the D&C called for in considering and reading the exhibited symptoms, the results of tests, and
operation. In that case, expert testimony showed that tests should have been ordered in arriving at definitive conclusions. But in doing all these, the doctor must have acted
immediately on admission to the hospital in view of the symptoms presented. The according to acceptable medical practice standards.
Court held: In the present case, evidence on record established that in confirming the diagnosis of
When a patient exhibits symptoms typical of a particular disease, these symptoms bronchopneumonia, Dr. Casumpang selectively appreciated some and not all of the
should, at the very least, alert the physician of the possibility that the patient may be symptoms presented, and failed to promptly conduct the appropriate tests to confirm
afflicted with the suspected disease. his findings. In sum, Dr. Casumpang failed to timely detect dengue fever, which
failure, especially when reasonable prudence would have shown that indications of
The Court also ruled that reasonable prudence would have shown that diabetes and its dengue were evident and/or foreseeable, constitutes negligence.
complications were foreseeable harm. However, the petitioner doctors failed to take
this into consideration and proceeded with the D&C operation. Thus, the Court ruled
that they failed to comply with their duty to observe the standard of care to be given a. Negligence in the Treatment and Management of Dengue
to hyperglycemic/diabetic patients.
Apart from failing to promptly detect dengue fever, Dr. Casumpang also failed to
Similarly, in Jarcia,64 involving the negligence of the doctors in failing to exercise promptly undertake the proper medical management needed for this disease.
reasonable prudence in ascertaining the extent of the patient's injuries, this Court
declared that: As Dr. Jaudian opined, the standard medical procedure once the patient had exhibited
the classic symptoms of dengue fever should have been: oxygen inhalation, use of
In failing to perform an extensive medical examination to determine the extent of Roy analgesic, and infusion of fluids or dextrose;67 and once the patient had twice vomited
Jr.'s injuries, Dr. Jarcia and Dr. Bastan were remiss of their duties as members of the fresh blood, the doctor should have ordered: blood transfusion, monitoring of the
patient every 30 minutes, hemostatic to stop bleeding, and oxygen if there is difficulty A: In the evening of April 23, 1988,1 stayed in the hospital and I was informed by the
in breathing.68 pediatric resident on duty at around 11:15 in the evening that the blood pressure of the
patient went down to .60 palpatory.
Dr. Casumpang failed to measure up to these standards. The evidence strongly
suggests that he ordered a transfusion of platelet concentrate instead of blood Q: What did you do upon receipt of that information?
transfusion. The tourniquet test was only conducted after Edmer's second episode of
bleeding, and the medical management (as reflected in the records) did not include A: I immediately went up to the room of the patient and we changed the IV fluid from
antibiotic therapy and complete physical examination. the present fluid which was D5 0.3 sodium chloride to lactated ringers solution.

Dr. Casumpang's testimony states: Q: You mean to say you increased the dengue [sic] of the intervenus [sic] fluid?

Q:Now, after entertaining - After considering that the patient Edmer Cortero was A: We changed the IV fluid because lactated ringers was necessary to resume the
already suffering from dengue hemorrhagic fever, what did you do, if any? volume and to bring back the blood pressure, to increase the blood pressure. [Emphasis
supplied]
A:We ordered close monitoring of the blood pressure, the cardiac rate and respiratory
rate of the patient. Although Dr. Casumpang presented the testimonies of Dr. Rodolfo Jagonap and Dr.
Ellewelyn Pasion (Dr. Pasion), Personnel Officer and Medical Director of SJDH,
Q:Now, was your instructions carried on? respectively as well as the testimonies of Dr. Livelo and Dr. Reyes (the radiologist
who read Edmer's chest x-ray result), these witnesses failed to dispute the standard of
A:Yes, sir. action that Dr. Jaudian established in his expert opinion. We cannot consider them
Q: What was the blood pressure of the patient? expert witnesses either for the sole reason that they did not testify on the standard of
care in dengue cases.69
A: During those times, the blood pressure of the patient was even normal during those
times.

Q: How about the respiratory rate? On the whole, after examining the totality of the adduced evidence, we find that the
lower courts correctly did not rely on Dr. Casumpang's claim that he exercised
A: The respiratory rate was fast because the patient in the beginning since admission prudence and due diligence in handling Edmer's case. Aside from being self-serving,
had difficulty in breathing. his claim is not supported by competent evidence. As the lower courts did, we rely on
the uncontroverted fact that he failed, as a medical professional, to observe the most
Q: Then, after that, what did you do with the patient? Doctor?
prudent medical procedure under the circumstances in diagnosing and treating Edmer.
A: We transfused platelet concentrate and at the same time, we monitor [sic] the
patient.
Dr. Miranda is Not Liable for Negligence
Q: Then, who monitor [sic] the patient?
In considering the case of Dr. Miranda, the junior resident physician who was on-duty
A: The pediatric resident on duty at that time.
at the time of Edmer's confinement, we see the need to draw distinctions between the
Q: Now, what happened after that? responsibilities and corresponding liability of Dr. Casumpang, as the attending
physician, and that of Dr. Miranda.
Q: While monitoring the patient, all his vital signs were ________; his blood pressure
was normal so we continued with the supportive management at that time. In his testimony, Dr. Pasion declared that resident applicants are generally doctors of
medicine licensed to practice in the Philippines and who would like to pursue a
Q: Now, after that? particular specialty.70 They are usually the front line doctors responsible for the first
contact with the patient. During the scope of the residency program,71 resident
physicians (or "residents")72 function under the supervision of attending physicians73
or of the hospital's teaching staff. Under this arrangement, residents operate merely as
subordinates who usually defer to the attending physician on the decision to be made of supervision of the attending physician over her, and the shared responsibility
and on the action to be taken. between her and the attending physicians.

The attending physician, on the other hand, is primarily responsible for managing the In this case, before Dr. Miranda attended to Edmer, both Dr. Livelo and Dr.
resident's exercise of duties. While attending and resident physicians share the Casumpang had diagnosed Edmer with bronchopneumonia. In her testimony, Dr.
collective responsibility to deliver safe and appropriate care to the patients,74 it is the Miranda admitted that she had been briefed about Edmer's condition, his medical
attending physician who assumes the principal responsibility of patient care.75 history, and initial diagnosis;79 and based on these pieces of information, she
Because he/she exercises a supervisory role over the resident, and is ultimately confirmed the, finding of bronchopneumonia.
responsible for the diagnosis and treatment of the patient, the standards applicable to
and the liability of the resident for medical malpractice is theoretically less than that Dr. Miranda likewise duly reported to Dr. Casumpang, who admitted receiving
of the attending physician. These relative burdens and distinctions, however, do not updates regarding Edmer's condition.80 There is also evidence supporting Dr.
translate to immunity from the legal duty of care for residents,76 or from the Miranda's claim that she extended diligent care to Edmer. In fact, when she suspected
responsibility arising from their own negligent act. - during Edmer's second episode of bleeding - that Edmer could be suffering from
dengue fever, she wasted no time in conducting the necessary tests, and promptly
In Jenkins v. Clark,77 the Ohio Court of Appeals held that the applicable standard of notified Dr. Casumpang about the incident. Indubitably, her medical assistance led to
care in medical malpractice cases involving first-year residents was that of a the finding of dengue fever.
reasonably prudent physician and not that of interns. According to Jenkins:
We note however, that during Edmer's second episode of bleeding,81 Dr. Miranda
It is clear that the standard of care required of physicians is not an individualized one failed to immediately examine and note the cause of the blood specimen. Like Dr.
but of physicians in general in the community. In order to establish medical Casumpang, she merely assumed that the blood in Edmer's phlegm was caused by
malpractice, it must be shown by a preponderance of the evidence that a physician did bronchopneumonia. Her testimony states:
some particular thing or things that a physician or surgeon of ordinary skill, care and
diligence would not have done under like or similar conditions or circumstances, or
that he failed or omitted to do some particular thing or things that a physician or TSN, June 8, 1993:
surgeon of ordinary skill, care and diligence would have done under like or similar
conditions or circumstances, and that the inquiry complained of was the direct result Q: Let us get this clear, you said that the father told you the patient cocked [sic] out
of such doing or failing to do such thing or things. phlegm.

We note that the standard of instruction given by the court was indeed a proper one. It A: With blood streak.
clearly informed the jury that the medical care required is that of reasonably careful
Q: Now, you stated specimen, were you not able to examine the specimen?
physicians or hospital emergency room operators, not of interns or residents.
[Emphasis supplied] A: No, sir, I did not because according to the father he wash [sic] his hands
A decade later, Centman v. Cobb,78 affirmed the Jenkins ruling and held that interns xxxx
and first-year residents are "practitioners of medicine required to exercise the same
standard of care applicable to physicians with unlimited licenses to practice." The Q: Now, from you knowledge, what does that indicate if the patient expels a phlegm
Indiana Court held that although a first-year resident practices under a temporary and blood streak?
medical permit, he/she impliedly contracts that he/she has the reasonable and ordinary
A: If a patient cocked [sic] out phlegm then the specimen could have come from the
qualifications of her profession and that he/she will exercise reasonable skill,
lung alone.82 [Emphasis supplied]
diligence, and care in treating the patient.
xxxx
We find that Dr. Miranda was not independently negligent. Although she had greater
patient exposure, and was' subject to the same standard of care applicable to attending TSN, June 17, 1993:
physicians, we believe that a finding of negligence should also depend on several
competing factors, among them, her authority to make her own diagnosis, the degree
Q: Now, in the first meeting you had, when that was relayed to you by the father that concluded that an anesthesiologist cannot be considered an expert in the field of
Edmer Cortejo had coughed out blood, what medical action did you take? surgery or even in surgical practices and diagnosis.

A: I examined the patient and I thought that, that coughed out phlegm was a product Interestingly in this case, Dr. Jaudian, the expert witness was admittedly not a
of broncho pneumonia. pediatrician but a practicing physician who specializes in pathology.87 He likewise
does not possess any formal residency training in pediatrics. Nonetheless, both the
xxxx lower courts found his knowledge acquired through study and practical experience
Q: So what examination did you specifically conduct to see that there was no internal sufficient to advance an expert opinion on dengue-related cases.
bleeding? WE AGREE WITH THE LOWER COURTS.
A: At that time I did not do anything to determine the cause of coughing of the blood A close scrutiny of Ramos and Cereno reveals that the Court primarily based the
because I presumed that it was a mucous (sic) produced by broncho pneumonia, And witnesses' disqualification to testify as an expert on their incapacity to shed light on
besides the patient did not even show any signs of any other illness at that time.[83 the standard of care that must be observed by the defendant-physicians. That the expert
Based on her statements we find that Dr. Miranda was not entirely faultless. witnesses' specialties do not match the physicians' practice area only constituted, at
Nevertheless, her failure to discern the import of Edmer's second bleeding does not most, one of the considerations that should not be taken out of context. After all, the
necessarily amount to negligence as the respondent himself admitted that Dr. Miranda sole function of a medical expert witness, regardless of his/her specialty, is to afford
failed to examine the blood specimen because he washed it away. In addition, assistance to the courts on medical matters, and to explain the medical facts in issue.
considering the diagnosis previously made by two doctors, and the uncontroverted fact Furthermore, there was no reasonable indication in Ramos and Cereno that the expert
that the burden of final diagnosis pertains to the attending physician (in this case, Dr. witnesses possess a sufficient familiarity with the standard of care applicable to the
Casumpang), we believe that Dr. Miranda's error was merely an honest mistake of physicians' specialties.
judgment influenced in no small measure by her status in the hospital hierarchy; hence,
she should not be held liable for medical negligence. US jurisprudence on medical malpractice demonstrated the trial courts' wide latitude
of discretion in allowing a specialist from another field to testify against a defendant
Dr. Jaudian 's Professional Competence and Credibility specialist.
One of the critical issues the petitioners raised in the proceedings before the lower In Brown v. Sims,88 a neurosurgeon was found competent to give expert testimony
court and before this Court was Dr. Jaudian's competence and credibility as an expert regarding a gynecologist's standard of pre-surgical care. In that case, the court held
witness. The petitioners tried to discredit his expert testimony on the ground that he that since negligence was not predicated on the gynecologist's negligent performance
lacked the proper training and fellowship status in pediatrics. of the operation, but primarily on the claim that the pre-operative histories and
physicals were inadequate, the neurosurgeon was competent to testify as an expert.

Criteria in Qualifying as an Expert Witness Frost v. Mayo Clinic89 also allowed an orthopedic surgeon to testify against a
neurologist in a medical malpractice action. The court considered that the orthopedic
The competence of an expert witness is a matter for the trial court to decide upon in surgeon's opinion on the "immediate need for decompression" need not come from a
the exercise of its discretion. The test of qualification is necessarily a relative one, specialist in neurosurgery. The court held that:
depending upon the subject matter of the investigation, and the fitness of the expert
witness.84 In our jurisdiction, the criterion remains to be the expert witness' special It is well established that "the testimony of a qualified medical doctor cannot be
knowledge experience and practical training that qualify him/her to explain highly excluded simply because he is not a specialist x x x." The matter of "x x x training and
technical medical matters to the Court. specialization of the witness goes to the weight rather than admissibility x x x."

In Ramos v. Court of Appeals,85 the Court found the expert witness, who is a xxxx
pulmonologist, not qualified to testify on the field of anesthesiology. Similarly, in It did not appear to the court that a medical doctor had to be a specialist in neurosurgery
Cereno v. Court of Appeals,86 a 2012 case involving medical negligence, the Court to express the opinions permitted to be expressed by plaintiffs' doctors, e.g., the
excluded the testimony of an expert witness whose specialty was anesthesiology, and immediate need for a decompression in the light of certain neurological deficits in a
post-laminectomy patient. As stated above, there was no issue as to the proper pediatrics, had been practicing medicine for 16 years, and had handled not less than
execution of the neurosurgery. The medical testimony supported plaintiffs' theory of 50 dengue related cases.
negligence and causation. (Citations omitted)
In another case,90 the court declared that it is the specialist's knowledge of the requisite As a licensed medical practitioner specializing in pathology, who had practical and
subject matter, rather than his/her specialty that determines his/her qualification to relevant exposure in pediatrics and dengue related cases, we are convinced that Dr.
testify. Jaudian demonstrated sufficient familiarity with the standard of care to be applied in
dengue fever cases. Furthermore, we agree that he possesses knowledge and
Also in Evans v. Ohanesian,91 the court set a guideline in qualifying an expert witness: experience sufficient to qualify him to speak with authority on the subject.

To qualify a witness as a medical expert, it must be shown that the witness (1) has the The Causation Between Dr. Casumpang's Negligent Act/Omission, and the Patient's
required professional knowledge, learning and skill of the subject under inquiry Resulting Death was Adequately Proven
sufficient to qualify him to speak with authority on the subject; and (2) is familiar with
the standard required of a physician under similar circumstances; where a witness has Dr. Jaudian's testimony strongly suggests that due to Dr. Casumpang's failure to timely
disclosed sufficient knowledge of the subject to entitle his opinion to go to the jury, diagnose Edmer with dengue, the latter was not immediately given the proper
the question of the degree of his knowledge goes more to the weight of the evidence treatment. In fact, even after Dr. Casumpang had discovered Edmer's real illness, he
than to its admissibility. still failed to promptly perform the standard medical procedure. We agree with these
findings.
xxxx
As the respondent had pointed out, dengue fever, if left untreated, could be a life
Nor is it critical whether a medical expert is a general practitioner or a specialist so threatening disease. As in any fatal diseases, it requires immediate medical
long as he exhibits knowledge of the subject. Where a duly licensed and practicing attention.93 With the correct and timely diagnosis, coupled with the proper medical
physician has gained knowledge of the standard of care applicable to a specialty in management, dengue fever is not a life-threatening disease and could easily be
which he is not directly engaged but as to which he has an opinion based on education, cured.94
experience, observation, or association wit that specialty, his opinion is competent.
(Emphasis supplied) Furthermore, as Dr. Jaudian testified, with adequate intensive care, the mortality rate
of dengue fever should fall to less than 2%. Hence, the survival of the patient is
Finally, Brown v. Mladineo92 adhered to the principle that the witness' familiarity, directly related to early and proper management of the illness.95
and not the classification by title or specialty, which should control issues regarding
the expert witness' qualifications: To reiterate, Dr. Casumpang failed to timely diagnose Edmer with dengue fever
despite the presence of its characteristic symptoms; and as a consequence of the
The general rule as to expert testimony in medical malpractice actions is that "a delayed diagnosis, he also failed to promptly manage Edmer's illness. Had he
specialist in a particular branch within a profession will not be required." Most courts immediately conducted confirmatory tests, (i.e., tourniquet tests and series of blood
allow a doctor to testify if they are satisfied of his familiarity with the standards of a tests) and promptly administered the proper care and management needed for dengue
specialty, though he may not practice the specialty himself. One court explained that fever, the risk of complications or even death, could have been substantially reduced.
"it is the scope of the witness' knowledge and not the artificial classification by title
that should govern the threshold question of admissibility. (Citations omitted) Furthermore, medical literature on dengue shows that early diagnosis and management
of dengue is critical in reducing the risk of complications and avoiding further spread
of the virus.96 That Edmer later died of "Hypovolemic Shock/hemorrhagic shock,"
"Dengue Hemorrhagic Fever Stage IV," a severe and fatal form of dengue fever,
Application to the Present Case established the causal link between Dr. Casumpang's negligence and the injury.
In the case and the facts before us, we find that Dr. Jaudian is competent to testify on Based on these considerations, we rule that the respondent successfully proved the
the standard of care in dengue fever cases. element of causation.
Although he specializes in pathology, it was established during trial that he had
attended not less than 30 seminars held by the Pediatric Society, had exposure in
Liability of SJDH
We now discuss the liability of the hospital. Despite the absence of employer-employee relationship between SJDH and the
petitioning doctors, SJDH is not free from liability.98
The respondent submits that SJDH should not only be held vicariously liable for the
petitioning doctors' negligence but also for its own negligence. He claims that SJDH As a rule, hospitals are not liable for the negligence of its independent contractors.
fell short of its duty of providing its patients with the necessary facilities and However, it may be found liable if the physician or independent contractor acts as an
equipment as shown by the following circumstances: ostensible agent of the hospital. This exception is also known as the "doctrine of
apparent authority."99
(a) SJDH was not equipped with proper paging system;
(b) the number of its doctors is not proportionate to the number of patients; The US case of Gilbert v. Sycamore Municipal Hospital100 abrogated the hospitals'
(c) SJDH was not equipped with a bronchoscope; immunity to vicarious liability of independent contractor physicians. In that case, the
(d) when Edmer's oxygen was removed, the medical staff did not immediately provide Illinois Supreme Court held that under the doctrine of apparent authority, hospitals
him with portable oxygen; could be found vicariously liable for the negligence of an independent contractor:
(e) when Edmer was about to be transferred to another hospital, SJDH's was not ready
and had no driver; and Therefore, we hold that, under the doctrine of apparent authority, a hospital can be
(f)despite Edmer's critical condition, there was no doctor attending to him from 5:30 held vicariously liable for the negligent acts of a physician providing care at the
p.m. of April 22, to 9:00 a.m. of April 23, 1988. hospital, regardless of whether the physician is an independent contractor, unless the
patient knows, or should have known, that the physician is an independent contractor.
SJDH on the other hand disclaims liability by claiming that the petitioning doctors are The elements of the action have been set out as follows:
not its employees but are mere consultants and independent contractors. For a hospital to be liable under the doctrine of apparent authority, a plaintiff must
We affirm the hospital's liability not on the basis of Article 2180 of the Civil Code, but show that: (1) the hospital, or its agent, acted in a manner that would lead a reasonable
on the basis of the doctrine of apparent authority or agency by estoppel. 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
There is No Employer-Employee Relationship Between SJDH and the Petitioning of authority, the plaintiff must also prove that the hospital had knowledge of and
Doctors acquiesced in them; and (3) the plaintiff acted in reliance upon the conduct of the
hospital or its agent, consistent with ordinary care and prudence. (Emphasis supplied)

The doctrine was applied in Nogales v. Capitol Medical Center101 where this Court,
In determining whether an employer-employee relationship exists between the parties, through the ponencia of Associate Justice Antonio T. Carpio, discussed the two factors
the following elements must be present: (1) selection and engagement of services; (2) in determining hospital liability as follows:
payment of wages; (3) the power to hire and fire; and (4) the power to control not only
the end to be achieved, but the means to be used in reaching such an end.97 The first factor focuses on the hospital's manifestations and is sometimes described as
an inquiry whether the hospital acted in a manner which would lead a reasonable
Control, which is the most crucial among the elements, is not present in this case. person to conclude that the individual who was alleged to be negligent was an
Based on the records, no evidence exists showing that SJDH exercised any degree of employee or agent of the hospital. In this regard, the hospital need not make express
control over the means, methods of procedure and manner by which the petitioning representations to the patient that the treating physician is an employee of the hospital;
doctors conducted and performed their medical profession. SJDH did not control their rather a representation may be general and implied.
diagnosis and treatment. Likewise, no evidence was presented to show that SJDH xxxx
monitored, supervised, or directed the petitioning doctors in the treatment and
management of Edmer's case. In these lights, the petitioning doctors were not The second factor focuses on the patient's reliance. It is sometimes characterized as an
employees of SJDH, but were mere independent contractors. inquiry on whether the plaintiff acted in reliance upon the conduct of the hospital or
its agent, consistent with ordinary care and prudence. (Citation omitted)

SJDH is Solidarity Liable Based on The Principle of Agency or Doctrine of


Apparent Authority
In sum, a hospital can be held vicariously liable for the negligent acts of a physician In this case, we shall limit the determination of the hospital's apparent authority to Dr.
(or an independent contractor) providing care at the hospital if the plaintiff can prove Casumpang, in view of our finding that Dr. Miranda is not liable for negligence.
these two factors: first, the hospital's manifestations; and second, the patient's reliance.

SJDH Clothed Dr. Casumpang With Apparent Authority


a. Hospital's manifestations
SJDH impliedly held out and clothed Dr. Casumpang with apparent authority leading
It involves an inquiry on whether the hospital acted in a manner that would lead a the respondent to believe that he is an employee or agent of the hospital.
reasonable person to conclude that the individual alleged to be negligent was an
employee or agent of the hospital. As pointed out in Nogales, the hospital need not Based on the records, the respondent relied on SJDH rather than upon Dr. Casumpang,
make express representations to the patient that the physician or independent to care and treat his son Edmer. His testimony during trial showed that he and his wife
contractor is an employee of the hospital; representation may be general and did not know any doctors at SJDH; they also did not know that Dr. Casumpang was
implied.102 an independent contractor. They brought their son to SJDH for diagnosis because of
their family doctor's referral. The referral did not specifically point to Dr. Casumpang
In Pamperin v. Trinity Memorial Hospital,103 questions were raised on "what acts by or even to Dr. Miranda, but to SJDH.
the hospital or its agent are sufficient to lead a reasonable person to conclude that the
individual was an agent of the hospital." In ruling that the hospital's manifestations can Significantly, the respondent had relied on SJDH's representation of Dr. Casumpang's
be proven without the express representation by the hospital, the court relied on several authority. To recall, when Mrs. Cortejo presented her Fortune Care card, she was
cases from other jurisdictions, and held that: initially referred to the Fortune Care coordinator, who was then out of town. She was
thereafter referred to Dr. Casumpang, who is also accredited with Fortune Care. In
(1) the hospital, by providing emergency room care and by failing to advise patients both instances, SJDH through its agent failed to advise Mrs. Cortejo that Dr.
that they were being treated by the hospital's agent and not its employee, has created Casumpang is an independent contractor.
the appearance of agency; and
Mrs. Cortejo accepted Dr. Casumpang's services on the reasonable belief that such
(2) patients entering the hospital through the emergency room, could properly assume were being provided by SJDH or its employees, agents, or servants. By referring Dr.
that the treating doctors and staff of the hospital were acting on its behalf. Casumpang to care and treat for Edmer, SJDH impliedly held out Dr. Casumpang, not
only as an accredited member of Fortune Care, but also as a member of its medical
In this case, the court considered the act of the hospital of holding itself out as provider staff. SJDH cannot now disclaim liability since there is no showing that Mrs. Cortejo
of complete medical care, and considered the hospital to have impliedly created the or the respondent knew, or should have known, that Dr. Casumpang is only an
appearance of authority. independent contractor of the hospital. In this case, estoppel has already set in.

We also stress that Mrs. Cortejo's use of health care plan (Fortune Care) did not affect
b. Patient's reliance SJDH's liability. The only effect of the availment of her Fortune Care card benefits is
that her choice of physician is limited only to physicians who are accredited with
It involves an inquiry on whether the plaintiff acted in reliance on the conduct of the Fortune Care. Thus, her use of health care plan in this case only limited the choice of
hospital or its agent, consistent with ordinary care and prudence.104 doctors (or coverage of services, amount etc.) and not the liability of doctors or the
hospital.
In Pamperin, the court held that the important consideration in determining the
patient's reliance is: whether the plaintiff is seeking care from the hospital itself or WHEREFORE, premises considered, this Court PARTLY GRANTS the consolidated petitions. The
whether the plaintiff is looking to the hospital merely as a place for his/her personal Court finds Dr. Noel Casumpang and San Juan de Dios Hospital solidarity liable for negligent medical
practice. We SET ASIDE the finding of liability as to Dr. Ruby Sanga-Miranda. The amounts of P45,000.00
physician to provide medical care.105 as actual damages and P500,000.00 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. The Court AFFIRMS the rest of
Thus, this requirement is deemed satisfied if the plaintiff can prove that he/she relied the Decision dated October 29, 2004 and the Resolution dated January 12, 2006 in CA-G.R. CV No. 56400.
upon the hospital to provide care and treatment, rather than upon a specific physician.
SO ORDERED.
Republic of the Philippines The NBI indorsed the matter to the Office of the City Prosecutor of Manila for
Supreme Court preliminary investigation. Probable cause was found and a criminal case for reckless
Manila imprudence resulting to serious physical injuries, was filed against Dr. Jarcia, Dr.
THIRD DIVISION Bastan and Dr. Pamittan,[5] before the RTC, docketed as Criminal Case No. 01-
196646.

G.R. No. 187926 February 15, 2012 On June 14, 2005, the RTC found the petitioners guilty beyond reasonable doubt of
the crime of Simple Imprudence Resulting to Serious Physical Injuries. The decretal
Dr. Emmanuel Jarcia, Jr. and Dr. Marilou Bastan, VS. PEOPLE OF THE portion of the RTC decision reads:
PHILIPPINES,
WHEREFORE, premises considered, the Court finds accused DR.
DECISION EMMANUEL JARCIA, JR. and DR. MARILOU BASTAN GUILTY
MENDOZA, J.: beyond reasonable doubt of the crime of SIMPLE IMPRUDENCE
RESULTING TO SERIOUS PHYSICAL INJURIES and are hereby
Even early on, patients have consigned their lives to the skill of their doctors. Time sentenced to suffer the penalty of ONE (1) MONTH and ONE (1) DAY to
and again, it can be said that the most important goal of the medical profession is the TWO (2) MONTHS and to indemnify MRS. BELINDA SANTIAGO the
preservation of life and health of the people. Corollarily, when a physician departs amount of 3,850.00 representing medical expenses without subsidiary
from his sacred duty and endangers instead the life of his patient, he must be made imprisonment in case of insolvency and to pay the costs.
liable for the resulting injury. This Court, as this case would show, cannot and will not
let the act go unpunished.[1] It appearing that Dr. Pamittan has not been apprehended nor voluntarily
surrendered despite warrant issued for her arrest, let warrant be issued for
This is a petition for review under Rule 45 of the Rules of Court challenging the August her arrest and the case against her be ARCHIVED, to be reinstated upon
29, 2008 Decision[2] of the Court of Appeals (CA), and its May 19, 2009 her apprehension.
Resolution[3] in CA-G.R. CR No. 29559, dismissing the appeal and affirming in toto
the June 14, 2005 Decision[4] of the Regional Trial Court, Branch 43, Manila (RTC), SO ORDERED.[6]
finding the accused guilty beyond reasonable doubt of simple imprudence resulting to The RTC explained:
serious physical injuries.
After a thorough and in depth evaluation of the evidence adduced by the prosecution
THE FACTS and the defense, this court finds that the evidence of the prosecution is the more
Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of credible, concrete and sufficient to create that moral certainty in the mind of the Court
Investigation (NBI) against the petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and that accused herein [are] criminally responsible. The Court believes that accused are
Dr. Marilou Bastan (Dr. Bastan), for their alleged neglect of professional duty which negligent when both failed to exercise the necessary and reasonable prudence in
caused her son, Roy Alfonso Santiago (Roy Jr.), to suffer serious physical injuries. ascertaining the extent of injury of Alfonso Santiago, Jr.
Upon investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was rushed However, the negligence exhibited by the two doctors does not approximate
to the Manila Doctors Hospital for an emergency medical treatment; that an X-ray of negligence of a reckless nature but merely amounts to simple imprudence. Simple
the victims ankle was ordered; that the X-ray result showed no fracture as read by Dr. imprudence consists in the lack of precaution displayed in those cases in which the
Jarcia; that Dr. Bastan entered the emergency room (ER) and, after conducting her damage impending to be caused is not the immediate nor the danger clearly manifest.
own examination of the victim, informed Mrs. Santiago that since it was only the ankle The elements of simple imprudence are as follows.
that was hit, there was no need to examine the upper leg; that eleven (11) days later,
Roy Jr. developed fever, swelling of the right leg and misalignment of the right foot; 1. that there is lack of precaution on the part of the offender; and
that Mrs. Santiago brought him back to the hospital; and that the X-ray revealed a right 2. that the damage impending to be caused is not immediate of the danger is not
mid-tibial fracture and a linear hairline fracture in the shaft of the bone. clearly manifest.
Considering all the evidence on record, The Court finds the accused guilty for simple In the case at bench, the accused-appellants questioned the imputation against them
imprudence resulting to physical injuries. Under Article 365 of the Revised Penal and argued that there is no causal connection between their failure to diagnose the
Code, the penalty provided for is arresto mayor in its minimum period.[7] fracture and the injury sustained by Roy.

Dissatisfied, the petitioners appealed to the CA. WE ARE NOT CONVINCED.

As earlier stated, the CA affirmed the RTC decision in toto. The August 29, 2008 The prosecution is however after the cause which prolonged the pain and suffering of
Decision of the CA pertinently reads: Roy and not on the failure of the accused-appellants to correctly diagnose the extent
of the injury sustained by Roy.
This Court holds concurrently and finds the foregoing circumstances sufficient to
sustain a judgment of conviction against the accused-appellants for the crime of simple For a more logical presentation of the discussion, we shall first consider the
imprudence resulting in serious physical injuries. The elements of imprudence are: (1)