G.R. No.

L-65295 March 10, 1987

PHOENIX CONSTRUCTION, INC. and ARMANDO U. CARBONEL, petitioners,

vs.
THE INTERMEDIATE APPELLATE COURT and LEONARDO DIONISIO, respondents.

FELICIANO, J:

In the early morning of 15 November 1975 — at about 1:30 a.m. — private respondent
Leonardo Dionisio was on his way home — he lived in 1214-B Zamora Street, Bangkal,
Makati — from a cocktails-and-dinner meeting with his boss, the general manager of a
marketing corporation. During the cocktails phase of the evening, Dionisio had taken "a
shot or two" of liquor. Dionisio was driving his Volkswagen car and had just crossed the
intersection of General Lacuna and General Santos Streets at Bangkal, Makati, not far
from his home, and was proceeding down General Lacuna Street, when his car
headlights (in his allegation) suddenly failed. He switched his headlights on "bright" and
thereupon he saw a Ford dump truck looming some 2-1/2 meters away from his car. The
dump truck, owned by and registered in the name of petitioner Phoenix Construction Inc.
("Phoenix"), was parked on the right hand side of General Lacuna Street (i.e., on the right
hand side of a person facing in the same direction toward which Dionisio's car was
proceeding), facing the oncoming traffic. The dump truck was parked askew (not parallel
to the street curb) in such a manner as to stick out onto the street, partly blocking the way
of oncoming traffic. There were no lights nor any so-called "early warning" reflector
devices set anywhere near the dump truck, front or rear. The dump truck had earlier that
evening been driven home by petitioner Armando U. Carbonel, its regular driver, with the
permission of his employer Phoenix, in view of work scheduled to be carried out early the
following morning, Dionisio claimed that he tried to avoid a collision by swerving his car to
the left but it was too late and his car smashed into the dump truck. As a result of the
collision, Dionisio suffered some physical injuries including some permanent facial scars,
a "nervous breakdown" and loss of two gold bridge dentures.

Dionisio commenced an action for damages in the Court of First Instance of Pampanga
basically claiming that the legal and proximate cause of his injuries was the negligent
manner in which Carbonel had parked the dump truck entrusted to him by his employer
Phoenix. Phoenix and Carbonel, on the other hand, countered that the proximate cause
of Dionisio's injuries was his own recklessness in driving fast at the time of the accident,
while under the influence of liquor, without his headlights on and without a curfew pass.
Phoenix also sought to establish that it had exercised due rare in the selection and
supervision of the dump truck driver.

The trial court rendered judgment in favor of Dionisio and against Phoenix and Carbonel
and ordered the latter:

(1) To pay plaintiff jointly and severally the sum of P 15,000.00 for hospital bills and the
replacement of the lost dentures of plaintiff;

(2) To pay plaintiff jointly and severally the sum of P 1,50,000.-00 as loss of expected
income for plaintiff brought about the accident in controversy and which is the result of
the negligence of the defendants;

(3) To pay the plaintiff jointly and severally the sum of P 10,000. as moral damages for
the unexpected and sudden withdrawal of plaintiff from his lifetime career as a marketing
man; mental anguish, wounded feeling, serious anxiety, social humiliation, besmirched
reputation, feeling of economic insecurity, and the untold sorrows and frustration in life
experienced by plaintiff and his family since the accident in controversy up to the present
time;

(4) To pay plaintiff jointly and severally the sum of P 10,000.00 as damages for the
wanton disregard of defendants to settle amicably this case with the plaintiff before the
filing of this case in court for a smaller amount.

(5) To pay the plaintiff jointly and severally the sum of P 4,500.00 due as and for
attorney's fees; and

(6) The cost of suit. (Emphasis supplied)

Phoenix and Carbonel appealed to the Intermediate Appellate Court. That court in CA-
G.R. No. 65476 affirmed the decision of the trial court but modified the award of damages
to the following extent:

1. The award of P15,000.00 as compensatory damages was reduced to P6,460.71, the

latter being the only amount that the appellate court found the plaintiff to have proved as
actually sustained by him;

2. The award of P150,000.00 as loss of expected income was reduced

to P100,000.00, basically because Dionisio had voluntarily resigned his job such that, in
the opinion of the appellate court, his loss of income "was not solely attributable to the
accident in question;" and

3. The award of P100,000.00 as moral damages was held by the appellate court as
excessive and unconscionable and hence reduced to P50,000.00.

The award of P10,000.00 as exemplary damages and P4,500.00 as attorney's fees and
costs remained untouched.

This decision of the Intermediate Appellate Court is now before us on a petition for
review.

Both the trial court and the appellate court had made fairly explicit findings of fact relating
to the manner in which the dump truck was parked along General Lacuna Street on the
basis of which both courts drew the inference that there was negligence on the part of
Carbonel, the dump truck driver, and that this negligence was the proximate cause of the
accident and Dionisio's injuries. We note, however, that both courts failed to pass upon
the defense raised by Carbonel and Phoenix that the true legal and proximate cause of
the accident was not the way in which the dump truck had been parked but rather the
reckless way in which Dionisio had driven his car that night when he smashed into the
dump truck. The Intermediate Appellate Court in its questioned decision casually
conceded that Dionisio was "in some way, negligent" but apparently failed to see the
relevance of Dionisio's negligence and made no further mention of it. We have examined
the record both before the trial court and the Intermediate Appellate Court and we find
that both parties had placed into the record sufficient evidence on the basis of which the
trial court and the appellate court could have and should have made findings of fact
relating to the alleged reckless manner in which Dionisio drove his car that night. The
petitioners Phoenix and Carbonel contend that if there was negligence in the manner in
which the dump truck was parked, that negligence was merely a "passive and static
condition" and that private respondent Dionisio's recklessness constituted an intervening,
efficient cause determinative of the accident and the injuries he sustained. The need to
administer substantial justice as between the parties in this case, without having to
remand it back to the trial court after eleven years, compels us to address directly the
contention put forward by the petitioners and to examine for ourselves the record
pertaining to Dionisio's alleged negligence which must bear upon the liability, or extent of
liability, of Phoenix and Carbonel.

There are four factual issues that need to be looked into: (a) whether or not private
respondent Dionisio had a curfew pass valid and effective for that eventful night; (b)
whether Dionisio was driving fast or speeding just before the collision with the dump
truck; (c) whether Dionisio had purposely turned off his car's headlights before contact
with the dump truck or whether those headlights accidentally malfunctioned moments
before the collision; and (d) whether Dionisio was intoxicated at the time of the accident.

As to the first issue relating to the curfew pass, it is clear that no curfew pass was found
on the person of Dionisio immediately after the accident nor was any found in his car.
Phoenix's evidence here consisted of the testimony of Patrolman Cuyno who had taken
Dionisio, unconscious, to the Makati Medical Center for emergency treatment
immediately after the accident. At the Makati Medical Center, a nurse took off Dionisio's
clothes and examined them along with the contents of pockets together with Patrolman
Cuyno. 1 Private respondent Dionisio was not able to produce any curfew pass during the trial. Instead, he offered the
explanation that his family may have misplaced his curfew pass. He also offered a certification (dated two years after the
accident) issued by one Major Benjamin N. Libarnes of the Zone Integrated Police Intelligence Unit of Camp Olivas, San
Fernando, Pampanga, which was said to have authority to issue curfew passes for Pampanga and Metro Manila. This
certification was to the effect that private respondent Dionisio had a valid curfew pass. This certification did not, however,
specify any pass serial number or date or period of effectivity of the supposed curfew pass. We find that private respondent
Dionisio was unable to prove possession of a valid curfew pass during the night of the accident and that the preponderance
of evidence shows that he did not have such a pass during that night. The relevance of possession or non-possession of a
curfew pass that night lies in the light it tends to shed on the other related issues: whether Dionisio was speeding home and
whether he had indeed purposely put out his headlights before the accident, in order to avoid detection and possibly arrest
by the police in the nearby police station for travelling after the onset of curfew without a valid curfew pass.

On the second issue — whether or not Dionisio was speeding home that night — both
the trial court and the appellate court were completely silent.

The defendants in the trial court introduced the testimony of Patrolman Cuyno who was
at the scene of the accident almost immediately after it occurred, the police station where
he was based being barely 200 meters away. Patrolman Cuyno testified that people who
had gathered at the scene of the accident told him that Dionisio's car was "moving fast"
and did not have its headlights on. Dionisio, on the other hand, claimed that he was
2

travelling at a moderate speed at 30 kilometers per hour and had just crossed the
intersection of General Santos and General Lacuna Streets and had started to accelerate
when his headlights failed just before the collision took place. 3

Private respondent Dionisio asserts that Patrolman Cuyno's testimony was hearsay and
did not fag within any of the recognized exceptions to the hearsay rule since the facts he
testified to were not acquired by him through official information and had not been given
by the informants pursuant to any duty to do so. Private respondent's objection fails to
take account of the fact that the testimony of Patrolman Cuyno is admissible not under
the official records exception to the hearsay rule but rather as part of the res
4

gestae. Testimonial evidence under this exception to the hearsay rule consists of
5

excited utterances made on the occasion of an occurrence or event sufficiently startling

in nature so as to render inoperative the normal reflective thought processes of the
observer and hence made as a spontaneous reaction to the occurrence or event, and not
the result of reflective thought. 6

We think that an automobile speeding down a street and suddenly smashing into a
stationary object in the dead of night is a sufficiently startling event as to evoke
spontaneous, rather than reflective, reactions from observers who happened to be
around at that time. The testimony of Patrolman Cuyno was therefore admissible as part
of the res gestae and should have been considered by the trial court. Clearly, substantial
weight should have been ascribed to such testimony, even though it did not, as it could
not, have purported to describe quantitatively the precise velocity at winch Dionisio was
travelling just before impact with the Phoenix dump truck.

A third related issue is whether Dionisio purposely turned off his headlights, or whether
his headlights accidentally malfunctioned, just moments before the accident. The
Intermediate Appellate Court expressly found that the headlights of Dionisio's car went off
as he crossed the intersection but was non-committal as to why they did so. It is the
petitioners' contention that Dionisio purposely shut off his headlights even before he
reached the intersection so as not to be detected by the police in the police precinct
which he (being a resident in the area) knew was not far away from the intersection. We
believe that the petitioners' theory is a more credible explanation than that offered by
private respondent Dionisio — i.e., that he had his headlights on but that, at the crucial
moment, these had in some mysterious if convenient way malfunctioned and gone off,
although he succeeded in switching his lights on again at "bright" split seconds before
contact with the dump truck.

A fourth and final issue relates to whether Dionisio was intoxicated at the time of the
accident. The evidence here consisted of the testimony of Patrolman Cuyno to the effect
that private respondent Dionisio smelled of liquor at the time he was taken from his
smashed car and brought to the Makati Medical Center in an unconscious
condition. This testimony has to be taken in conjunction with the admission of Dionisio
7

that he had taken "a shot or two" of liquor before dinner with his boss that night. We do
not believe that this evidence is sufficient to show that Dionisio was so heavily under the
influence of liquor as to constitute his driving a motor vehicle per se an act of reckless
imprudence. There simply is not enough evidence to show how much liquor he had in
8

fact taken and the effects of that upon his physical faculties or upon his judgment or
mental alertness. We are also aware that "one shot or two" of hard liquor may affect
different people differently.

The conclusion we draw from the factual circumstances outlined above is that private
respondent Dionisio was negligent the night of the accident. He was hurrying home that
night and driving faster than he should have been. Worse, he extinguished his headlights
at or near the intersection of General Lacuna and General Santos Streets and thus did
not see the dump truck that was parked askew and sticking out onto the road lane.

Nonetheless, we agree with the Court of First Instance and the Intermediate Appellate
Court that the legal and proximate cause of the accident and of Dionisio's injuries was
the wrongful — or negligent manner in which the dump truck was parked in other words,
the negligence of petitioner Carbonel. That there was a reasonable relationship between
petitioner Carbonel's negligence on the one hand and the accident and respondent's
injuries on the other hand, is quite clear. Put in a slightly different manner, the collision of
Dionisio's car with the dump truck was a natural and foreseeable consequence of the
truck driver's negligence.

The petitioners, however, urge that the truck driver's negligence was merely a "passive
and static condition" and that private respondent Dionisio's negligence was an "efficient
intervening cause and that consequently Dionisio's negligence must be regarded as the
legal and proximate cause of the accident rather than the earlier negligence of Carbonel.
We note that the petitioners' arguments are drawn from a reading of some of the older
cases in various jurisdictions in the United States but we are unable to persuade
ourselves that these arguments have any validity for our jurisdiction. We note, firstly, that
even in the United States, the distinctions between "cause" and "condition" which the
'petitioners would have us adopt have already been "almost entirely discredited."
Professors and Keeton make this quite clear:
Cause and condition. Many courts have sought to distinguish between the active "cause"
of the harm and the existing "conditions" upon which that cause operated. If the
defendant has created only a passive static condition which made the damage possible,
the defendant is said not to be liable. But so far as the fact of causation is concerned, in
the sense of necessary antecedents which have played an important part in producing
the result it is quite impossible to distinguish between active forces and passive
situations, particularly since, as is invariably the case, the latter are the result of other
active forces which have gone before. The defendant who spills gasoline about the
premises creates a "condition," but the act may be culpable because of the danger of fire.
When a spark ignites the gasoline, the condition has done quite as much to bring about
the fire as the spark; and since that is the very risk which the defendant has created, the
defendant will not escape responsibility. Even the lapse of a considerable time during
which the "condition" remains static will not necessarily affect liability; one who digs a
trench in the highway may still be liable to another who fans into it a month
afterward. "Cause" and "condition" still find occasional mention in the decisions; but the
distinction is now almost entirely discredited. So far as it has any validity at all, it must
refer to the type of case where the forces set in operation by the defendant have come to
rest in a position of apparent safety, and some new force intervenes. But even in such
cases, it is not the distinction between "cause" and "condition" which is important but the
nature of the risk and the character of the intervening cause. 9

We believe, secondly, that the truck driver's negligence far from being a "passive and
static condition" was rather an indispensable and efficient cause. The collision between
the dump truck and the private respondent's car would in an probability not have
occurred had the dump truck not been parked askew without any warning lights or
reflector devices. The improper parking of the dump truck created an unreasonable risk
of injury for anyone driving down General Lacuna Street and for having so created this
risk, the truck driver must be held responsible. In our view, Dionisio's negligence,
although later in point of time than the truck driver's negligence and therefore closer to
the accident, was not an efficient intervening or independent cause. What the Petitioners
describe as an "intervening cause" was no more than a foreseeable consequent manner
which the truck driver had parked the dump truck. In other words, the petitioner truck
driver owed a duty to private respondent Dionisio and others similarly situated not to
impose upon them the very risk the truck driver had created. Dionisio's negligence was
not of an independent and overpowering nature as to cut, as it were, the chain of
causation in fact between the improper parking of the dump truck and the accident, nor to
sever the juris vinculum of liability. It is helpful to quote once more from Professor and
Keeton:

Foreseeable Intervening Causes. If the intervening cause is one which in ordinary human
experience is reasonably to be anticipated or one which the defendant has reason to
anticipate under the particular circumstances, the defendant may be negligence among
other reasons, because of failure to guard against it; or the defendant may be negligent
only for that reason. Thus one who sets a fire may be required to foresee that an
ordinary, usual and customary wind arising later wig spread it beyond the defendant's
own property, and therefore to take precautions to prevent that event. The person who
leaves the combustible or explosive material exposed in a public place may foresee the
risk of fire from some independent source. ... In all of these cases there is an intervening
cause combining with the defendant's conduct to produce the result and in each case the
defendant's negligence consists in failure to protect the plaintiff against that very risk.

Obviously the defendant cannot be relieved from liability by the fact that the risk or a
substantial and important part of the risk, to which the defendant has subjected the
plaintiff has indeed come to pass. Foreseeable intervening forces are within the scope
original risk, and hence of the defendant's negligence. The courts are quite generally
agreed that intervening causes which fall fairly in this category will not supersede the
defendant's responsibility.
Thus it has been held that a defendant will be required to anticipate the usual weather of
the vicinity, including all ordinary forces of nature such as usual wind or rain, or snow or
frost or fog or even lightning; that one who leaves an obstruction on the road or a railroad
track should foresee that a vehicle or a train will run into it; ...

The risk created by the defendant may include the intervention of the foreseeable
negligence of others. ... [The standard of reasonable conduct may require the defendant
to protect the plaintiff against 'that occasional negligence which is one of the ordinary
incidents of human life, and therefore to be anticipated.' Thus, a defendant who blocks
the sidewalk and forces the plaintiff to walk in a street where the plaintiff will be exposed
to the risks of heavy traffic becomes liable when the plaintiff is run down by a car, even
though the car is negligently driven; and one who parks an automobile on the highway
without lights at night is not relieved of responsibility when another negligently drives into
it. --- 10

We hold that private respondent Dionisio's negligence was "only contributory," that the
"immediate and proximate cause" of the injury remained the truck driver's "lack of due
care" and that consequently respondent Dionisio may recover damages though such
damages are subject to mitigation by the courts (Article 2179, Civil Code of the
Philippines).

Petitioners also ask us to apply what they refer to as the "last clear chance" doctrine. The
theory here of petitioners is that while the petitioner truck driver was negligent, private
respondent Dionisio had the "last clear chance" of avoiding the accident and hence his
injuries, and that Dionisio having failed to take that "last clear chance" must bear his own
injuries alone. The last clear chance doctrine of the common law was imported into our
jurisdiction by Picart vs. Smith 11 but it is a matter for debate whether, or to what extent, it has found its way into
the Civil Code of the Philippines. The historical function of that doctrine in the common law was to mitigate the harshness of
another common law doctrine or rule that of contributory negligence. 12 The common law rule of contributory negligence
prevented any recovery at all by a plaintiff who was also negligent, even if the plaintiff's negligence was relatively minor as
compared with the wrongful act or omission of the defendant. 13 The common law notion of last clear chance permitted
courts to grant recovery to a plaintiff who had also been negligent provided that the defendant had the last clear chance to
avoid the casualty and failed to do so. 14 Accordingly, it is difficult to see what role, if any, the common law last clear chance
doctrine has to play in a jurisdiction where the common law concept of contributory negligence as an absolute bar to
recovery by the plaintiff, has itself been rejected, as it has been in Article 2179 of the Civil Code of the Philippines. 15

Is there perhaps a general concept of "last clear chance" that may be extracted from its
common law matrix and utilized as a general rule in negligence cases in a civil law
jurisdiction like ours? We do not believe so. Under Article 2179, the task of a court, in
technical terms, is to determine whose negligence — the plaintiff's or the defendant's —
was the legal or proximate cause of the injury. That task is not simply or even primarily an
exercise in chronology or physics, as the petitioners seem to imply by the use of terms
like "last" or "intervening" or "immediate." The relative location in the continuum of time of
the plaintiff's and the defendant's negligent acts or omissions, is only one of the relevant
factors that may be taken into account. Of more fundamental importance are the nature
of the negligent act or omission of each party and the character and gravity of the risks
created by such act or omission for the rest of the community. The petitioners urge that
the truck driver (and therefore his employer) should be absolved from responsibility for
his own prior negligence because the unfortunate plaintiff failed to act with that increased
diligence which had become necessary to avoid the peril precisely created by the truck
driver's own wrongful act or omission. To accept this proposition is to come too close to
wiping out the fundamental principle of law that a man must respond for the forseeable
consequences of his own negligent act or omission. Our law on quasi-delicts seeks to
reduce the risks and burdens of living in society and to allocate them among the
members of society. To accept the petitioners' pro-position must tend to weaken the very
bonds of society.

Petitioner Carbonel's proven negligence creates a presumption of negligence on the part

of his employer Phoenix 16 in supervising its employees properly and adequately. The respondent appellate court
in effect found, correctly in our opinion, that Phoenix was not able to overcome this presumption of negligence. The
circumstance that Phoenix had allowed its truck driver to bring the dump truck to his home whenever there was work to be
done early the following morning, when coupled with the failure to show any effort on the part of Phoenix to supervise the
manner in which the dump truck is parked when away from company premises, is an affirmative showing of culpa in
vigilando on the part of Phoenix.

Turning to the award of damages and taking into account the comparative negligence of
private respondent Dionisio on one hand and petitioners Carbonel and Phoenix upon the
other hand, 17 we believe that the demands of substantial justice are satisfied by allocating most of the damages on a
20-80 ratio. Thus, 20% of the damages awarded by the respondent appellate court, except the award of P10,000.00 as
exemplary damages and P4,500.00 as attorney's fees and costs, shall be borne by private respondent Dionisio; only the
balance of 80% needs to be paid by petitioners Carbonel and Phoenix who shall be solidarity liable therefor to the former.
The award of exemplary damages and attorney's fees and costs shall be borne exclusively by the petitioners. Phoenix is of
course entitled to reimbursement from Carbonel. 18 We see no sufficient reason for disturbing the reduced award of
damages made by the respondent appellate court.

WHEREFORE, the decision of the respondent appellate court is modified by reducing the
aggregate amount of compensatory damages, loss of expected income and moral
damages private respondent Dionisio is entitled to by 20% of such amount. Costs against
the petitioners.

SO ORDERED.

[G.R. No. 171217]

DRA. RUBY SANGA-MIRANDA, Petitioner, v. NELSON CORTEJO, Respondent.

[G.R. No. 171228]

SAN JUAN DE DIOS HOSPITAL, Petitioner, v. NELSON CORTEJO, Respondent.

DECISION

BRION, J.:

We resolve the three (3) consolidated petitions for review on certiorari1 involving medical negligence,
commonly assailing the October 29, 2004 decision 2 and the January 12, 2006 resolution 3 of the Court
of Appeals (CA) in CA-G.R. CV No. 56400. This CA decision affirmed en toto the ruling of the Regional
Trial Court (RTC), Branch 134, Makati City.

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. 4

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. 5

After taking Edmer's medical history, Dr. Livelo took his vital signs, body 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 Edmer's blood was also taken for testing, typing, and for
purposes of administering antibiotics. Afterwards, Dr. Livelo gave Edmer an antibiotic medication to
lessen his fever and to loosen his phlegm.

Mrs. Cortejo did not know any doctor at SJDH. She used her Fortune Care card and was referred to an
accredited Fortune Care coordinator, who was then out of town. She was thereafter assigned to Dr.
Noel Casumpang (Dr. Casumpang), a pediatrician also accredited with Fortune Care. 8
At 5:30 in the afternoon of the same day, Dr. Casumpang for the first time examined Edmer in his
room. Using only a stethoscope, he confirmed the initial diagnosis of "Bronchopneumonia."9

At that moment, Mrs. Cortejo recalled entertaining doubts on the doctor's diagnosis. She immediately
advised Dr. Casumpang that Edmer had a high fever, and had no colds or cough 10 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, no phlegm."12

Dr. Casumpang next visited and examined Edmer at 9:00 in the morning the following day. 13 Still
suspicious about his son's illness, Mrs. Cortejo again called Dr. 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.
Cortejo that Edmer's illness is bronchopneumonia. 14

At around 11:30 in the morning of April 23, 1988, Edmer vomited "phlegm with blood
streak"15prompting the respondent (Edmer's father) to request for a doctor at the nurses' station. 16

Forty-five minutes later, Dr. Ruby Sanga-Miranda (Dr. Miranda), one of the resident physicians of
SJDH, arrived. She claimed that although aware that Edmer had vomited "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 for examination.

Thereafter, Dr. Miranda conducted a physical check-up covering Edmer's head, eyes, nose, throat,
lungs, skin and abdomen; and found that Edmer had a low-grade non-continuing fever, and rashes
that were not typical of dengue fever.17 Her medical findings state:
the patient's rapid breathing and then the lung showed
sibilant and the patient's nose is flaring which is a
sign that the patient is in respiratory 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
At 3:00 in the afternoon, Edmer once again vomited blood. Upon seeing Dr. Miranda, the respondent
showed her Edmer's blood specimen, and reported that Edmer had complained of severe stomach
pain and difficulty in moving his right leg.19

Dr. Miranda then examined Edmer's "sputum with blood" and noted that he was bleeding. Suspecting
that he could be afflicted with dengue, she inserted a plastic tube in his nose, drained the liquid from
his stomach with ice cold normal saline solution, and gave an instruction not to pull out the tube, or
give the patient any oral medication.

Dr. Miranda thereafter conducted a tourniquet test, which turned out to be negative. 20 She likewise
ordered the monitoring of the patient's blood pressure and some blood tests. Edmer's blood pressure
was later found to be normal.21

At 4:40 in the afternoon, Dr. Miranda called up Dr. Casumpang at his clinic and told him about
Edmer's condition.22 Upon being informed, Dr. Casumpang ordered several procedures done
including: hematocrit, hemoglobin, blood typing, blood transfusion and tourniquet tests.

The blood test results came at about 6:00 in the evening.

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 arrived at Edmer's room and he
recommended his transfer to the Intensive Care Unit (ICU), to which the respondent consented. Since
the ICU was then full, Dr. Casumpang suggested to the respondent that they hire a private nurse. The
respondent, however, insisted on transferring his son to Makati Medical Center.

After the respondent had signed the waiver, Dr. Casumpang, for the last time, checked 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 the driver was nowhere to be
found. This prompted him to hire a private ambulance that cost him P600.00. 23

At 12:00 midnight, Edmer, accompanied by his parents and by Dr. Casumpang, was transferred to
Makati Medical Center.

Dr. Casumpang immediately gave the attending physician the patient's clinical history and laboratory
exam results. Upon examination, the attending physician diagnosed "Dengue Fever Stage IV" that was
already in its irreversible stage.

Edmer died at 4:00 in the morning of April 24, 1988.24 His Death Certificate indicated the cause of
death as "Hypovolemic Shock/hemorrhagic shock;" "Dengue Hemorrhagic Fever Stage IV."

Believing that Edmer's death was caused by the negligent and erroneous diagnosis of his doctors, the
respondent instituted an action for damages against SJDH, and its attending physicians: Dr.
Casumpang and Dr. Miranda (collectively referred to as the "petitioners") before the RTC of Makati
City.

The Ruling of the Regional Trial Court

In a decision25 dated May 30, 1997, the RTC ruled in favor of the respondent, and awarded actual and
moral damages, plus attorney's fees and costs.

In ruling that the petitioning doctors were negligent, the RTC found untenable the petitioning doctors'
contention that Edmer's initial symptoms did not indicate dengue fever. It faulted them for heavily
relying on the chest x-ray result and for not considering the other manifestations that Edmer's parents
had relayed. It held that in diagnosing and treating an illness, the physician's conduct should be
judged not only by what he/she saw and knew, but also by what he/she could have reasonably seen
and known. It also observed that based on Edmer's signs and symptoms, his medical history and
physical examination, and also the information that the petitioning doctors gathered from his family
members, dengue fever was a reasonably foreseeable illness; yet, the petitioning doctors failed to
take a second look, much less, consider these indicators of dengue.

The trial court also found that aside from their self-serving testimonies, the petitioning 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 guilty of negligence.

The RTC also held SJDH solidarity liable with the petitioning doctors for damages 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 scrutinized and determined his
fitness, qualifications, and competence as a medical practitioner; and second, Dr. Miranda, as resident
physician, is an employee of SJDH because like Dr. Casumpang, the hospital, through its screening
committee, scrutinized and determined her qualifications, fitness, and competence before engaging
her services; the hospital also exercised control over her work.

The dispositive portion of the decision reads:

WHEREFORE, judgment is hereby rendered in favor of the
plaintiff and against the defendants, ordering the latter
to pay solidarity and severally plaintiff the following:

(1) Moral damages in the amount of P500,000.00;

(2) Costs of burial and funeral in the amount of

P45,000.00;

(3) Attorney's fees of P50,000.00; and

(4) Cost of this suit.

SO ORDERED.
The petitioners appealed the decision to the CA.

The Ruling of the Court of Appeals

In its decision dated October 29, 2004, the CA affirmed en toto the RTC's ruling, finding that SJDH
and its attending physicians failed to exercise the minimum medical care, attention, and treatment
expected of an ordinary doctor under like circumstances.

The CA found the petitioning doctors' failure to read even the most basic signs of "dengue fever"
expected of an ordinary doctor as medical negligence. The CA also considered the petitioning doctors'
testimonies as self-serving, noting that they presented no other evidence to prove that they exercised
due diligence in diagnosing Edmer's illness.
The CA likewise found Dr. Rodolfo Jaudian's (Dr. Jaudian) testimony admissible. It gave credence to
his opinion26 that: (1) given the exhibited symptoms of the patient, dengue fever should definitely be
considered, and bronchopneumonia could be reasonably ruled out; and (2) dengue fever could have
been detected earlier than 7:30 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.

On SJDH's solidary liability, the CA ruled that the hospital's liability is based on 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, all fulfill the employer-employee relationship
requirement under Article 2180.

Lastly, the CA held that SJDH failed to adduce evidence showing that it exercised the diligence of a
good father of a family in the hiring and the supervision of its physicians.

The petitioners separately moved to reconsider the CA decision, but the CA denied their motion in its
resolution of January 12, 2006; hence, the present consolidated petitions pursuant to Rule 45 of the
Rules of Court.

The Petitions

I. Dr. Casumpang's Position (G.R. No. 171127)

Dr. Casumpang contends that he gave his patient medical treatment and care to the best of his
abilities, and within the proper standard of care required from physicians under similar circumstances.
He claims that his initial diagnosis of bronchopneumonia was supported by the chest x-ray result.

Dr. Casumpang also contends that dengue fever occurs only after several days of 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 CA erred in
appreciating his testimony as an expert witness since he lacked the necessary training, skills, and
experience as a specialist in dengue fever cases.

II. Dr. Miranda's Position (G.R. No. 171217)

In her petition, Dr. Miranda faults the CA for holding her responsible for Edmer's wrong diagnosis,
stressing that the function of making the diagnosis and undertaking the medical treatment devolved
upon Dr. Casumpang, the doctor assigned to Edmer, and who confirmed "bronchopneumonia."

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 diagnosis of "Dengue
Hemorrhagic Fever." Furthermore, Edmer's Complete Blood Count (CBC) showed leukopenia and an
increase in balance as shown by the differential count, demonstrating that Edmer's infection, more or
less, is of bacterial and not viral in nature.

Dr. Miranda as well argued that there is no causal relation between the alleged erroneous diagnosis
and medication for "Bronchopneumonia," and Edmer's death due to "Dengue Hemorrhagic Fever."

Lastly, she claimed that Dr. Jaudian is not a qualified expert witness since he never presented any
evidence of formal residency training and fellowship status in Pediatrics.

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

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 hospital. SJDH alleges that
since it did not exercise control or supervision over the consultants' exercise of medical profession,
there is no employer-employee relationship between them, and consequently, Article 2180 of the Civil
Code does not apply.

SJDH likewise anchored the absence of, employer-employee relationship on the following
circumstances: (1) SJDH does not hire consultants; it only grants them privileges to admit patients in
the hospital through accreditation; (2) SJDH does not pay the consultants wages similar to an
ordinary employee; (3) the consultants earn 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
with adequate space in exchange for rental payment.

Furthermore, SJDH claims that the CA erroneously applied the control test when it treated the
hospital's practice of accrediting consultants as an exercise of control. It explained that the control
contemplated by law is that which the employer exercises over the: (i) end result; and the (ii) manner
and means to be used to reach this end, and not any kind of control, however significant, in
accrediting the consultants.

SJDH moreover contends that even if the petitioning doctors are considered employees 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 of a family in their selection and
supervision as shown by the following: (1) the adequate measures that the hospital undertakes to
ascertain the petitioning doctors' qualifications and medical competence; and (2) the documentary
evidence that the petitioning doctors presented to prove their competence in the field of pediatrics. 27

SJDH likewise faults the CA for ruling that the petitioning doctors are its agents, claiming that this
theory, aside from being inconsistent with the CA's finding of employment relationship, is unfounded
because: first, the petitioning doctors are independent contractors, not agents of SJDH; and second,
as a medical institution, SJDH cannot practice medicine, much more, extend its personality to
physicians to practice medicine on its behalf.

Lastly, SJDH maintains that the petitioning doctors arrived at an intelligently deduced and correct
diagnosis. It claimed that based on Edmer's signs and symptoms at the time 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 dengue fever, and accordingly, their failure to diagnose
dengue fever, does not constitute negligence on their part.

The Case for the Respondent

In his comment, the respondent submits that the issues the petitioners raised are mainly factual in
nature, which a petition for review on certiorari under Rule 45 of the Rules of Court does not allow.

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 failed to timely diagnose
Edmer's correct illness due to their non-observance of the proper and acceptable standard of medical
examination; (2) the petitioning doctors' medical examination was not comprehensive, as they were
always in a rush; and (3) the petitioning doctors employed a guessing game in diagnosing
bronchopneumonia.

The respondent also alleges that there is a causal connection between the petitioning doctors'
negligence and Edmer's untimely death, warranting the claim for damages.

The respondent, too, asserted that SJDH is also negligent because it was not equipped with proper
paging system, has no bronchoscope, and its doctors are not proportionate to the number of its
patients. He also pointed out that out of the seven resident physicians in the hospital, only two
resident physicians were doing rounds at the time of his son's confinement.

The Issues

The case presents to us the following issues:

1. Whether or not the petitioning doctors had committed "inexcusable lack of precaution" in
diagnosing and in treating the patient;

2. Whether or not the petitioner hospital is solidarity liable with the petitioning doctors;

3. Whether or not there is a causal connection between the petitioners' negligent act/omission
and the patient's resulting death; and

4. Whether or not the lower courts erred in considering Dr. Rodolfo Tabangcora Jaudian as an
expert witness.

Our Ruling

We find the petition partly meritorious.

A Petition for Review on Certiorari under Rule 45 of the Rules of Court is Limited to Questions of Law.

The settled rule is that the Court's jurisdiction in a petition for review on certiorari under Rule 45 of
the Rules of Court is limited only to the review of pure questions of law. It is not the Court's function
to inquire on the veracity of the appellate court's factual findings and conclusions; this Court is not a
trier of facts.31

A question of law arises when there is doubt as to what the law is on a certain state of facts, while
there is a question of fact when the doubt arises as to the truth or falsity of the alleged facts. 32

These consolidated petitions before us involve mixed questions of fact and law. As a rule, we do
not resolve questions of fact. However, in determining the legal question of whether the respondent is
entitled to claim damages under Article 2176 of the Civil Code for the petitioners' alleged medical
malpractice, the determination of the factual issues - i.e., whether the petitioning doctors were
grossly negligent in diagnosing the patient's illness, whether there is causal relation between the
petitioners' act/omission and the patient's resulting death, and whether Dr. Jaudian is qualified as an
expert witness- must necessarily be resolved. We resolve these factual questions solely for the
purpose of determining the legal issues raised.

Medical Malpractice Suit as a Specialized Area of Tort Law

The claim for damages is based on the petitioning doctors' negligence in diagnosing 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 medical professionals who caused bodily harm to, or the
death of, a patient.33 As the term is used, the suit is brought whenever a medical practitioner or
health care provider fails to meet the standards demanded by his profession, or deviates from this
standard, and causes injury to the patient.

To successfully pursue a medical malpractice suit, the plaintiff (in this case, the deceased patient's
heir) must prove that the doctor either failed to do what a reasonably prudent doctor would have
done, or did what a reasonably prudent doctor would not have done; and the act or omission had
caused injury to the patient.34 The patient's heir/s bears the burden of proving his/her cause of action.

The Elements of a Medical Malpractice Suit

The elements of medical negligence are: (1) duty; (2) breach; (3) injury; and (4) proximate
causation.

Duty refers to the standard of behavior that imposes restrictions on one's conduct. 35 It requires proof
of professional relationship between the physician and the patient. Without the professional
relationship, a physician owes no duty to the patient, and cannot therefore incur any liability.

A physician-patient relationship is created when a patient engages the services of a physician, 36 and
the latter accepts or agrees to provide care to the patient. 37 The establishment of this relationship is
consensual,38 and the acceptance by the physician essential. The mere fact that an individual
approaches a physician and seeks diagnosis, advice or treatment does not create the duty of care
unless the physician agrees.39

The consent needed to create the relationship does not always need to be express. 40 In the absence of
an express agreement, a physician-patient relationship may be implied from the physician's
affirmative action to diagnose and/or treat a patient, or in his participation in such diagnosis and/or
treatment.41The usual illustration would be the case of a patient who goes to a hospital or a clinic, and
is examined and treated by the doctor. In this case, we can infer, based on the established and
customary practice in the medical community that a patient-physician relationship exists.

Once a physician-patient relationship is established, the legal duty of care follows. The doctor
accordingly becomes duty-bound to use at least the same standard of care that a reasonably
competent doctor would use to treat a medical condition under similar circumstances.

Breach of duty occurs when the doctor fails to comply with, or improperly performs his duties under
professional standards. This determination is both factual and legal, and is specific to each individual
case.42

If the patient, as a result of the breach of duty, is injured in body or in health, actionable malpractice
is committed, entitling the patient to damages.43

To successfully claim damages, the patient must lastly prove the causal relation between the
negligence and the injury. This connection must be direct, natural, and should be unbroken by any
intervening efficient causes. In other words, the negligence must be the proximate cause of the
injury.44The injury or damage is proximately caused by the physician's negligence when it appears,
based on the evidence and the expert testimony, that the negligence played an integral part in
causing the injury or damage, and that the injury or damage was either a direct result, or a
reasonably probable consequence of the physician's negligence. 45

a. The Relationship Between Dr. Casumpang and Edmer

In the present case, the physician-patient relationship between Dr. Casumpang and Edmer was
created when the latter's parents sought the medical services of Dr. Casumpang, and the latter
knowingly accepted Edmer as a patient. Dr. Casumpang's acceptance is implied from his affirmative
examination, diagnosis and treatment of Edmer. On the other hand, Edmer's parents, on their son's
behalf, manifested their consent by availing of the benefits of their health care plan, and by accepting
the hospital's assigned doctor without objections.

b. The Relationship Between Dr. Miranda and Edmer

With respect to Dr. Miranda, her professional relationship with Edmer arose when she assumed the
obligation to provide resident supervision over the latter. As second year resident doctor tasked to do
rounds and assist other physicians, Dr. Miranda is deemed to have agreed to the creation of
physician-patient relationship with the hospital's patients when she participated in the diagnosis and
prescribed a course of treatment for Edmer.

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 prescribed treatment and participated in
the diagnosis of Edmer's medical condition. Her affirmative acts amounted to her acceptance of the
physician-patient relationship, and incidentally, the legal duty of care that went with it.

In Jarcia, Jr. v. People of the Philippines,46 the Court found the doctors who merely passed by and
were requested to attend to the patient, liable for medical malpractice. It held that a physician-patient
relationship was established when they examined the patient, and later assured the mother that
everything was fine.

In the US case of Mead v. Legacy Health System,47 the Court also considered the 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 doctor's affirmative action.

Likewise, in Wax v. Johnson,48 the court found that a physician-patient relationship was formed
between a physician who "contracts, agrees, undertakes, or otherwise assumes" the obligation to
provide resident supervision at a teaching hospital, and the patient with whom the doctor had no
direct or indirect contract.

Standard of Care and Breach of Duty

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 are highly technical in
nature, requiring the presentation of expert witnesses to provide guidance to the court on matters
clearly falling within the domain of medical science, and legal, insofar as the Court, after evaluating
the expert testimonies, and guided by medical literature, learned treatises, and its fund of common
knowledge, ultimately determines whether breach of duty took place.

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 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 physician's conduct in the treatment of care falls below such standard. 50

In the present case, expert testimony is crucial in determining first, the standard medical
examinations, tests, and procedures that the attending physicians should have undertaken in the
diagnosis and treatment of dengue fever; and second, the dengue fever signs and symptoms that the
attending physicians should have noticed and considered.

Both the RTC and the CA relied largely on Dr. Jaudian's expert testimony on dengue diagnosis and
management to support their finding that the petitioning doctors were guilty of breach of duty of care.

Dr. Jaudian testified that Edmer's rapid breathing, chest and stomach pain, fever, and the presence of
blood in his saliva are classic symptoms of dengue fever. According to him, if the patient was admitted
for chest pain, abdominal pain, and difficulty in breathing coupled with fever, dengue fever should
definitely be considered;51 if the patient spits coffee ground with the presence of blood, and the
patient's platelet count drops to 47,000, it becomes a clear case of dengue fever, and
bronchopneumonia can be reasonably ruled out.52

Furthermore, the standard of care according to Dr. Jaudian is to administer oxygen 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 transfusion, monitoring of the
patient every 30 minutes, hemostatic to stop bleeding, and oxygen if there is difficulty in breathing.54

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.

Dr. Casumpang's Negligence

a. Negligence in the Diagnosis

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 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 showed that Edmer had low breath and voluntary
submission, and that he was up and about playing basketball. 56 He based his diagnosis of
bronchopneumonia on the following observations: "difficulty in breathing, clearing run nostril, harsh
breath sound, tight air, and sivilant sound."57

It will be recalled that during Dr. Casumpang's first and second visits to Edmer, he already had
knowledge of Edmer's laboratory test result (CBC), medical history, and symptoms (i.e., fever,
rashes, rapid breathing, chest and stomach pain, throat irritation, difficulty in breathing, and traces of
blood in the sputum). However, these information did not lead Dr. Casumpang to the
possibility that Edmer could be suffering from either dengue fever, or dengue hemorrhagic
fever, as he clung to his diagnosis of broncho pneumonia. This means that given the symptoms
exhibited, Dr. Casumpang already ruled out the possibility of other diseases like dengue.

In other words, it was lost on Dr. Casumpang that the characteristic symptoms of dengue (as Dr.
Jaudian testified) are: patient's rapid breathing; chest and stomach pain; fever; and the presence of
blood in his saliva. All these manifestations were present 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 to have considered the patient's other manifestations in ruling
out dengue fever or 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 information that could
have been material in detecting dengue fever. This is evident from the testimony of Mrs. Cortejo:
TSN, Mrs. Cortejo, November 27, 1990

Now, when Dr. Casumpang visited your son for the first time at
Q:
5:30 p.m., what did he do, if any?
He examined my son by using stethoscope and after that, he
A: confirmed to me that my son was suffering from broncho
pneumonia.
After he confirmed that your son was suffering
Q:
broncho pneumonia, what did you say if any?
Again, I told Dr. Casumpang, how come it was broncho
A:
pneumonia when my son has no cough or colds.
What was the answer of Dr. Casumpang to your
Q:
statement?

xxxx

And then, Dr. Casumpang answered "THAT'S THE USUAL

A:
BRONCHO PNEUMONIA, NO COLDS, NO PHLEGM."
Q: How long did Dr. Casumpang stay in your son's room?
A: He stayed for a minute or 2.

xxxx

Q: When Dr. Casumpang arrived at 9:00 o'clock a.m. on April

Q:
23, what did you tell him, if any?

xxxx
 I told Dr. Casumpang... After examining my son using
stethoscope and nothing more, I told Dr. Casumpang
A:
about the traces of blood in my son's sputum and I told
him what is all about and he has throat irritation.
Q: What did he tell you?
He just nodded his head but he did not take the initiative
A:
of looking at the throat of my son.
Q: So what happened after that?
I also told Dr. Casumpang about his chest pain and also
A:
stomach pain.
So what did Dr. Casumpang do after you have narrated all
Q:
these complaints of your son?
Nothing. He also noticed the rapid breathing of my son
A: and my son was almost moving because of rapid
breathing and he is swaying in the bed.
Do you know what action was taken by Dr. Casumpang
Q: when you told him that your son is experiencing a rapid
breathing?
No action. He just asked me if my son has an asthma but I
A:
said none.
So how long did Dr. Casumpang stay and attended your
Q:
son on April 23?
More or less two (2) minutes then I followed him up to
A:
the door and I repeated about the fever of my son.
What did he tell you, if any, regarding that information
Q:
you gave him that your son had a fever?
He said, that is broncho pneumonia, It's only being active
A:
now. [Emphasis supplied]
We also find it strange why Dr. Casumpang did not even bother to check Edmer's throat despite
knowing that as early as 9:00 in the morning of April 23, 1988, Edmer had blood streaks in his
sputum. Neither did Dr. Casumpang order confirmatory tests 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 showed that Dr. Casumpang merely assumed, without confirmatory physical
examination, that bronchopneumonia caused the bleeding.

Dr. Jaudian likewise opined that Dr. Casumpang's medical examination was not comprehensive
enough to reasonably lead to a correct diagnosis.60 Dr. Casumpang only used a stethoscope in coming
up with the diagnosis that Edmer was suffering from bronchopneumonia; he never confirmed this
finding with the use of a bronchoscope. Furthermore, Dr. Casumpang based his diagnosis largely on
the chest x-ray result that is generally inconclusive.61

Significantly, it was only at around 5:00 in the afternoon of April 23, 1988 (after Edmer's third
episode of bleeding) that Dr. Casumpang ordered the conduct of 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 the evening, confirming that Edmer's illness had developed to
"Dengue Hemorrhagic Fever" and (2) Dr. Jaudian's testimony that "dengue fever could have been
detected earlier than 7:30 in the evening of April 23, 1988 because the symptoms were already
evident."62

In Spouses Flores v. Spouses Pineda,63 a case involving a medical malpractice suit, the Court ruled
that the petitioner doctors were negligent because they failed to immediately order tests to confirm
the patient's illness. Despite the doctors' suspicion that the patient could be suffering from diabetes,
the former still proceeded to the D&C operation. In that case, expert testimony showed that tests
should have been ordered immediately on admission to the hospital in view of the symptoms
presented. The Court held:
 When a patient exhibits symptoms typical of a particular
disease, these symptoms should, at the very least, alert
the physician of the possibility that the patient may be
afflicted with the suspected disease.
The Court also ruled that reasonable prudence would have shown that diabetes and its 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 to hyperglycemic/diabetic patients.

Similarly, in Jarcia,64 involving the negligence of the doctors in failing to exercise reasonable prudence
in ascertaining the extent of the patient's injuries, this Court declared that:
In failing to perform an extensive medical
examination to determine the extent of Roy Jr.'s
injuries, Dr. Jarcia and Dr. Bastan were remiss of
their duties as members of the medical
profession. Assuming for the sake of argument that they
did not have the capacity to make such thorough
evaluation at that stage, they should have referred the
patient to another doctor with sufficient training and
experience instead of assuring him and his mother that
everything was all right. [Emphasis supplied]
Even assuming that Edmer's symptoms completely coincided with the diagnosis of bronchopneumonia
(so that this diagnosis could not be considered "wrong"), we still find Dr. Casumpang guilty of
negligence.

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 cases is to
decide - based on the evidence adduced and expert opinion presented - whether a breach of duty took
place.

Second, we clarify that a wrong diagnosis is not by itself medical malpractice. 65 Physicians
are generally not liable for damages resulting from a bona fide error of judgment. Nonetheless, when
the physician's erroneous diagnosis was the result of negligent conduct (e.g., neglect of medical
history, failure to order the appropriate tests, failure to recognize symptoms), it becomes an evidence
of medical malpractice.

Third, we also note that medicine is not an exact science; 66 and doctors, or even specialists, are not
expected to give a 100% accurate diagnosis in treating patients who come to their clinic for
consultations. Error is possible as the exercise of judgment is called for in considering and reading the
exhibited symptoms, the results of tests, and in arriving at definitive conclusions. But in doing all
these, the doctor must have acted according to acceptable medical practice standards.

In the present case, evidence on record established that in confirming the diagnosis of
bronchopneumonia, Dr. Casumpang selectively appreciated some and not all of the symptoms
presented, and failed to promptly conduct the appropriate tests to confirm his findings. In sum, Dr.
Casumpang failed to timely detect dengue fever, which failure, especially when reasonable prudence
would have shown that indications of dengue were evident and/or foreseeable, constitutes negligence.

a. Negligence in the Treatment and Management of Dengue

Apart from failing to promptly detect dengue fever, Dr. Casumpang also failed to promptly undertake
the proper medical management needed for this disease.

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 analgesic, and infusion of
fluids or dextrose;67 and once the patient had twice vomited 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 in breathing.68

Dr. Casumpang failed to measure up to these standards. The evidence strongly suggests that he
ordered a transfusion of platelet concentrate instead of blood 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 antibiotic therapy and complete physical examination.

Dr. Casumpang's testimony states:

 Now, after entertaining - After considering that the patient
Q: Edmer Cortero was already suffering from dengue hemorrhagic
fever, what did you do, if any?
We ordered close monitoring of the blood pressure, the
A:
cardiac rate and respiratory rate of the patient.
Q: Now, was your instructions carried on?
A: Yes, sir.
Q: What was the blood pressure of the patient?
During those times, the blood pressure of the patient was even
A:
normal during those times.
Q: How about the respiratory rate?
The respiratory rate was fast because the patient in the
A:
beginning since admission had difficulty in breathing.
Then, after that, what did you do with the patient?
Q:
Doctor?
We transfused platelet concentrate and at the same time,
A:
we monitor [sic] the patient.
Q: Then, who monitor [sic] the patient?
A: The pediatric resident on duty at that time.
Q: Now, what happened after that?
While monitoring the patient, all his vital signs were ________;
Q: his blood pressure was normal so we continued with the
supportive management at that time.
Q: Now, after that?
In the evening of April 23, 1988,1 stayed in the hospital and I
was informed by the pediatric resident on duty at around 11:15
A:
in the evening that the blood pressure of the patient went down
to .60 palpatory.
Q: What did you do upon receipt of that information?
I immediately went up to the room of the patient and we
A: changed the IV fluid from the present fluid which was D5
0.3 sodium chloride to lactated ringers solution.
You mean to say you increased the dengue [sic] of the
Q:
intervenus [sic] fluid?
We changed the IV fluid because lactated ringers was
necessary to resume the volume and to bring back the
A:
blood pressure, to increase the blood pressure. [Emphasis
supplied]
Although Dr. Casumpang presented the testimonies of Dr. Rodolfo Jagonap and Dr. Ellewelyn Pasion
(Dr. Pasion), Personnel Officer and Medical Director of SJDH, 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 action that Dr. Jaudian established in his expert opinion. We cannot
consider them expert witnesses either for the sole reason that they did not testify on the standard of
care in dengue cases.69

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 prudence and due diligence in
handling Edmer's case. Aside from being self-serving, 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 prudent medical procedure under the circumstances in diagnosing
and treating Edmer.
Dr. Miranda is Not Liable for Negligence

In considering the case of Dr. Miranda, the junior resident physician who was on-duty at the time of
Edmer's confinement, we see the need to draw distinctions between the responsibilities and
corresponding liability of Dr. Casumpang, as the attending physician, and that of Dr. Miranda.

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 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 and on the
action to be taken.

The attending physician, on the other hand, is primarily responsible for managing the resident's
exercise of duties. While attending and resident physicians share the collective responsibility to deliver
safe and appropriate care to the patients, 74 it is the attending physician who assumes the principal
responsibility of patient care.75 Because he/she exercises a supervisory role over the resident, and is
ultimately 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 of the attending
physician. These relative burdens and distinctions, however, do not translate to immunity from the
legal duty of care for residents,76 or from the responsibility arising from their own negligent act.

In Jenkins v. Clark,77 the Ohio Court of Appeals held that the applicable standard of care in medical
malpractice cases involving first-year residents was that of a reasonably prudent physician and not
that of interns. According to Jenkins:
It is clear that the standard of care required of
physicians is not an individualized one but of physicians
in general in the community. In order to establish
medical malpractice, it must be shown by a preponderance
of the evidence that a physician did 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 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 of such doing or
failing to do such thing or things.

We note that the standard of instruction given by the

court was indeed a proper one. It clearly informed the
jury that the medical care required is that of
reasonably careful physicians or hospital emergency
room operators, not of interns or
residents. [Emphasis supplied]
A decade later, Centman v. Cobb,78 affirmed the Jenkins ruling and held that interns 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 Indiana Court held that although a first-year
resident practices under a temporary medical permit, he/she impliedly contracts that he/she has the
reasonable and ordinary qualifications of her profession and that he/she will exercise reasonable skill,
diligence, and care in treating the patient.

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 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 of supervision of the attending physician
over her, and the shared responsibility between her and the attending physicians.

In this case, before Dr. Miranda attended to Edmer, both Dr. Livelo and Dr. Casumpang had
diagnosed Edmer with bronchopneumonia. In her testimony, Dr. Miranda admitted that she had been
briefed about Edmer's condition, his medical history, and initial diagnosis; 79 and based on these pieces
of information, she confirmed the, finding of bronchopneumonia.

Dr. Miranda likewise duly reported to Dr. Casumpang, who admitted receiving updates regarding
Edmer's condition.80 There is also evidence supporting Dr. Miranda's claim that she extended diligent
care to Edmer. In fact, when she suspected - 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 notified Dr. Casumpang about the incident. Indubitably, her medical assistance led to the
finding of dengue fever.

We note however, that during Edmer's second episode of bleeding, 81 Dr. Miranda failed to immediately
examine and note the cause of the blood specimen. Like Dr. Casumpang, she merely assumed that
the blood in Edmer's phlegm was caused by bronchopneumonia. Her testimony states:
TSN, June 8, 1993:

Let us get this clear, you said that the father told you the patient
Q:
cocked [sic] out phlegm.
A: With blood streak.
Now, you stated specimen, were you not able to examine
Q:
the specimen?
No, sir, I did not because according to the father he wash
A:
[sic] his hands.

xxxx

Now, from you knowledge, what does that indicate if the patient
Q:
expels a phlegm and blood streak?
If a patient cocked [sic] out phlegm then the specimen could
A:
have come from the lung alone.82 [Emphasis supplied]

xxxx

TSN, June 17, 1993:

Now, in the first meeting you had, when that was relayed to you
Q: by the father that Edmer Cortejo had coughed out blood, what
medical action did you take?
I examined the patient and I thought that, that coughed out
A:
phlegm was a product of broncho pneumonia.

xxxx

So what examination did you specifically conduct to see that

Q:
there was no internal bleeding?
At that time I did not do anything to determine the cause
of coughing of the blood because I presumed that it was a
A: mucous (sic) produced by broncho pneumonia, And
besides the patient did not even show any signs of any
other illness at that time.[83
Based on her statements we find that Dr. Miranda was not entirely faultless. Nevertheless, her
failure to discern the import of Edmer's second bleeding does not necessarily amount to
negligence as the respondent himself admitted that Dr. Miranda failed to examine the blood
specimen because he washed it away. In addition, considering the diagnosis previously made by two
doctors, and the uncontroverted fact that the burden of final diagnosis pertains to the attending
physician (in this case, Dr. Casumpang), we believe that Dr. Miranda's error was merely an honest
mistake of judgment influenced in no small measure by her status in the hospital hierarchy; hence,
she should not be held liable for medical negligence.

Dr. Jaudian 's Professional Competence and Credibility

One of the critical issues the petitioners raised in the proceedings before the lower court and before
this Court was Dr. Jaudian's competence and credibility as an expert witness. The petitioners tried to
discredit his expert testimony on the ground that he lacked the proper training and fellowship status
in pediatrics.

Criteria in Qualifying as an Expert Witness

The competence of an expert witness is a matter for the trial court to decide upon in the exercise of
its discretion. The test of qualification is necessarily a relative one, 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 knowledge experience and practical training that qualify
him/her to explain highly technical medical matters to the Court.

In Ramos v. Court of Appeals,85 the Court found the expert witness, who is a pulmonologist, not
qualified to testify on the field of anesthesiology. Similarly, in Cereno v. Court of Appeals,86 a 2012
case involving medical negligence, the Court excluded the testimony of an expert witness whose
specialty was anesthesiology, and concluded that an anesthesiologist cannot be considered an expert
in the field of surgery or even in surgical practices and diagnosis.

Interestingly in this case, Dr. Jaudian, the expert witness was admittedly not a pediatrician but a
practicing physician who specializes in pathology. 87 He likewise does not possess any formal residency
training in pediatrics. Nonetheless, both the lower courts found his knowledge acquired through study
and practical experience sufficient to advance an expert opinion on dengue-related cases.

We agree with the lower courts.

A close scrutiny of Ramos and Cereno reveals that the Court primarily based the witnesses'
disqualification to testify as an expert on their incapacity to shed light on the standard of care that
must be observed by the defendant-physicians. That the expert witnesses' specialties do not match
the physicians' practice area only constituted, at most, one of the considerations that should not be
taken out of context. After all, the sole function of a medical expert witness, regardless of his/her
specialty, is to afford assistance to the courts on medical matters, and to explain the medical facts in
issue.

Furthermore, there was no reasonable indication in Ramos and Cereno that the expert witnesses
possess a sufficient familiarity with the standard of care applicable to the physicians' specialties.

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 specialist.

In Brown v. Sims,88 a neurosurgeon was found competent to give expert testimony regarding a
gynecologist's standard of pre-surgical care. In that case, the court held that since negligence was not
predicated on the gynecologist's negligent performance 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.

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 surgeon's opinion on the "immediate
need for decompression" need not come from a specialist in neurosurgery. The court held that:
It is well established that "the testimony of a qualified
medical doctor cannot be excluded simply because he is
not a specialist x x x." The matter of "x x x training
and specialization of the witness goes to the weight
rather than admissibility x x x."

x x x x

It did not appear to the court that a medical doctor had

to be a specialist in neurosurgery to express the
opinions permitted to be expressed by plaintiffs'
 doctors, e.g., the 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 execution of the neurosurgery. The
medical testimony supported plaintiffs' theory of
negligence and causation. (Citations omitted)
In another case,90 the court declared that it is the specialist's knowledge of the requisite subject
matter, rather than his/her specialty that determines his/her qualification to testify.

Also in Evans v. Ohanesian,91 the court set a guideline in qualifying an expert witness:
To qualify a witness as a medical expert, it must be
shown that the witness (1) has the required
professional knowledge, learning and skill of the
subject under inquiry 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
disclosed sufficient knowledge of the subject to entitle
his opinion to go to the jury, the question of the degree
of his knowledge goes more to the weight of the evidence
than to its admissibility.

x x x x

Nor is it critical whether a medical expert is a general

practitioner or a specialist so long as he exhibits
knowledge of the subject. Where a duly licensed and
practicing physician has gained knowledge of the
standard of care applicable to a specialty in which
he is not directly engaged but as to which he has an
opinion based on education, experience, observation,
or association wit that specialty, his opinion is
competent. (Emphasis supplied)
Finally, Brown v. Mladineo92 adhered to the principle that the witness' familiarity, and not the
classification by title or specialty, which should control issues regarding the expert witness'
qualifications:
The general rule as to expert testimony in medical
malpractice actions is that "a specialist in a particular
branch within a profession will not be required." Most
courts allow a doctor to testify if they are satisfied of
his familiarity with the standards of a specialty, though
he may not practice the specialty himself. One court
explained that "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)
Application to the Present Case

In the case and the facts before us, we find that Dr. Jaudian is competent to testify on the standard of
care in dengue fever cases.

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 pediatrics, had been practicing medicine
for 16 years, and had handled not less than 50 dengue related cases.
As a licensed medical practitioner specializing in pathology, who had practical and relevant exposure
in pediatrics and dengue related cases, we are convinced that Dr. Jaudian demonstrated sufficient
familiarity with the standard of care to be applied in dengue fever cases. Furthermore, we agree that
he possesses knowledge and experience sufficient to qualify him to speak with authority on the
subject.

The Causation Between Dr. Casumpang's Negligent Act/Omission, and the Patient's Resulting Death
was Adequately Proven

Dr. Jaudian's testimony strongly suggests that due to Dr. Casumpang's failure to timely diagnose
Edmer with dengue, the latter was not immediately given the proper treatment. In fact, even after Dr.
Casumpang had discovered Edmer's real illness, he still failed to promptly perform the standard
medical procedure. We agree with these findings.

As the respondent had pointed out, dengue fever, if left untreated, could be a life threatening disease.
As in any fatal diseases, it requires immediate medical attention. 93 With the correct and timely
diagnosis, coupled with the proper medical management, dengue fever is not a life-threatening
disease and could easily be cured.94

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 directly related to early and proper
management of the illness.95

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 delayed diagnosis, he also failed to
promptly manage Edmer's illness. Had he immediately conducted confirmatory tests, (i.e., tourniquet
tests and series of blood tests) and promptly administered the proper care and management needed
for dengue fever, the risk of complications or even death, could have been substantially reduced.

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, established the causal link between Dr. Casumpang's
negligence and the injury.

Based on these considerations, we rule that the respondent successfully proved the element of
causation.

Liability of SJDH

We now discuss the liability of the hospital.

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 fell short of its duty of
providing its patients with the necessary facilities and equipment as shown by the following
circumstances:
(a) SJDH was not equipped with proper paging system;

the number of its doctors is not proportionate to the number of

(b)
patients;

(c) SJDH was not equipped with a bronchoscope;

when Edmer's oxygen was removed, the medical staff did not
(d)
immediately provide him with portable oxygen;

when Edmer was about to be transferred to another hospital,

(e)
SJDH's was not ready and had no driver; and

despite Edmer's critical condition, there was no doctor attending

(f) to him from 5:30 p.m. of April 22, to 9:00 a.m. of April 23,
1988.
SJDH on the other hand disclaims liability by claiming that the petitioning doctors are not its
employees but are mere consultants and independent contractors.

We affirm the hospital's liability not on the basis of Article 2180 of the Civil Code, but on the basis of
the doctrine of apparent authority or agency by estoppel.

There is No Employer-Employee Relationship Between SJDH and the Petitioning Doctors

In determining whether an employer-employee relationship exists between the parties, the following
elements must be present: (1) selection and engagement of services; (2) 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

Control, which is the most crucial among the elements, is not present in this case.

Based on the records, no evidence exists showing that SJDH exercised any degree of control over the
means, methods of procedure and manner by which the petitioning doctors conducted and performed
their medical profession. SJDH did not control their diagnosis and treatment. Likewise, no evidence
was presented to show that SJDH monitored, supervised, or directed the petitioning doctors in the
treatment and management of Edmer's case. In these lights, the petitioning doctors were not
employees of SJDH, but were mere independent contractors.

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

Despite the absence of employer-employee relationship between SJDH and the petitioning doctors,
SJDH is not free from liability.98

As a rule, hospitals are not liable for the negligence of its independent contractors. However, it may
be found liable if the physician or independent contractor acts as an ostensible agent of the hospital.
This exception is also known as the "doctrine of apparent authority."99

The US case of Gilbert v. Sycamore Municipal Hospital100 abrogated the hospitals' immunity to
vicarious liability of independent contractor physicians. In that case, the Illinois Supreme Court held
that under the doctrine of apparent authority, hospitals could be found vicariously liable for the
negligence of an independent contractor:
Therefore, we hold that, under the doctrine of apparent
authority, a hospital can be held vicariously liable for
the negligent acts of a physician providing care at the
hospital, regardless of whether the physician is an
independent contractor, unless the patient knows, or
should have known, that the physician is an independent
contractor. The elements of the action have been set out
as follows:
For a hospital to be liable under the
doctrine of apparent authority, a plaintiff
must show that: (1) the hospital, or its
agent, acted in a manner that would lead
a reasonable person to conclude that the
individual who was alleged to be
negligent was an employee or agent of the
hospital; (2) where the acts of the agent
create the appearance of authority, the
plaintiff must also prove that the
hospital had knowledge of and acquiesced
in them; and (3) the plaintiff acted in
reliance upon the conduct of the hospital
or its agent, consistent with ordinary
care and prudence. (Emphasis supplied)
The doctrine was applied in Nogales v. Capitol Medical Center101 where this Court, through
the ponenciaof Associate Justice Antonio T. Carpio, discussed the two factors in determining hospital
liability as follows:
 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
person to conclude that the individual who was alleged to
be negligent was an employee or agent of the hospital. In
this regard, the hospital need not make express
representations to the patient that the treating
physician is an employee of the hospital; rather a
representation may be general and implied.

x x x x

The second factor focuses on the patient's reliance. It

is sometimes characterized as an 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)
In sum, a hospital can be held vicariously liable for the negligent acts of a physician (or an
independent contractor) providing care at the hospital if the plaintiff can prove these two
factors: first, the hospital's manifestations; and second, the patient's reliance.

a. Hospital's manifestations

It involves an inquiry on whether the hospital acted in a manner that would lead a 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 make express representations to the patient that the
physician or independent contractor is an employee of the hospital; representation may be general
and implied.102

In Pamperin v. Trinity Memorial Hospital,103 questions were raised on "what acts by 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 be proven without the express
representation by the hospital, the court relied on several cases from other jurisdictions, and held
that:
the hospital, by providing emergency room care and by failing to
advise patients that they were being treated by the hospital's
(1)
agent and not its employee, has created the appearance of
agency; and

patients entering the hospital through the emergency room,

(2) could properly assume that the treating doctors and staff of the
hospital were acting on its behalf.
In this case, the court considered the act of the hospital of holding itself out as provider of complete
medical care, and considered the hospital to have impliedly created the appearance of authority.

b. Patient's reliance

It involves an inquiry on whether the plaintiff acted in reliance on the conduct of the hospital or
its agent, consistent with ordinary care and prudence.104

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 whether the plaintiff is looking to the
hospital merely as a place for his/her personal physician to provide medical care.105

Thus, this requirement is deemed satisfied if the plaintiff can prove that he/she relied upon the
hospital to provide care and treatment, rather than upon a specific physician. In this case, we shall
limit the determination of the hospital's apparent authority to Dr. Casumpang, in view of our finding
that Dr. Miranda is not liable for negligence.

SJDH Clothed Dr. Casumpang With Apparent Authority

SJDH impliedly held out and clothed Dr. Casumpang with apparent authority leading the respondent
to believe that he is an employee or agent of the hospital.

Based on the records, the respondent relied on SJDH rather than upon Dr. Casumpang, to care and
treat his son Edmer. His testimony during trial showed that he and his wife did not know any doctors
at SJDH; they also did not know that Dr. Casumpang was 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 or even to Dr. Miranda, but to SJDH.

Significantly, the respondent had relied on SJDH's representation of Dr. Casumpang's authority. To
recall, when Mrs. Cortejo presented her Fortune Care card, she was 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 both instances, SJDH through its agent failed to advise Mrs.
Cortejo that Dr. Casumpang is an independent contractor.

Mrs. Cortejo accepted Dr. Casumpang's services on the reasonable belief that such were being
provided by SJDH or its employees, agents, or servants. By referring Dr. 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 staff. SJDH cannot now disclaim liability
since there is no showing that Mrs. Cortejo or the respondent knew, or should have known, that Dr.
Casumpang is only an independent contractor of the hospital. In this case, estoppel has already set in.

We also stress that Mrs. Cortejo's use of health care plan (Fortune Care) did not affect 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 Fortune Care. Thus, her use of health care plan in
this case only limited the choice of doctors (or coverage of services, amount etc.) and not the liability
of doctors or the hospital.

WHEREFORE, premises considered, this Court PARTLY GRANTS the consolidated petitions. The
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 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 AFFIRMSthe rest of the Decision dated October 29, 2004 and the Resolution dated January
12, 2006 in CA-G.R. CV No. 56400.

SO ORDERED.

[G.R. No. 143363. February 6, 2002]

ST. MARYS ACADEMY, petitioner, vs. WILLIAM CARPITANOS

and LUCIA S. CARPITANOS, GUADA DANIEL, JAMES
DANIEL II, JAMES DANIEL, SR., and VIVENCIO
VILLANUEVA, respondents.

DECISION
PARDO, J.:

The Case

The case is an appeal via certiorari from the decision of the [1]

Court of Appeals as well as the resolution denying reconsideration,

holding petitioner liable for damages arising from an accident that
resulted in the death of a student who had joined a campaign to visit
the public schools in Dipolog City to solicit enrollment.

The Facts

The facts, as found by the Court of Appeals, are as follows:

Claiming damages for the death of their only son, Sherwin Carpitanos,
spouses William Carpitanos and Lucia Carpitanos filed on June 9, 1995 a
case against James Daniel II and his parents, James Daniel Sr. and Guada
Daniel, the vehicle owner, Vivencio Villanueva and St. Marys Academy
before the Regional Trial Court of Dipolog City.

On 20 February 1997, Branch 6 of

the Regional Trial Court of Dipolog City rendered its decision the
dispositive portion of which reads as follows:

WHEREFORE, PREMISES CONSIDERED, judgment is hereby rendered

in the following manner:

1. Defendant St. Marys Academy of Dipolog City, is hereby ordered to pay

plaintiffs William Carpitanos and Luisa Carpitanos, the following sums of
money:

a. FIFTY THOUSAND PESOS (P50,000.00) indemnity for the loss

of life of Sherwin S. Carpitanos;
b. FORTY THOUSAND PESOS (P40,000.00) actual damages
incurred by plaintiffs for burial and related expenses;
c. TEN THOUSAND PESOS (P10,000.00) for attorneys fees;
d. FIVE HUNDRED THOUSAND PESOS (P500,000.00) for moral
damages; and to pay costs.

2. Their liability being only subsidiary, defendants James Daniel, Sr. and
Guada Daniel are hereby ordered to pay herein plaintiffs the amount of
damages above-stated in the event of insolvency of principal obligor St.
Marys Academy of Dipolog City;

3. Defendant James Daniel II, being a minor at the time of the commission
of the tort and who was under special parental authority of defendant St.
Marys Academy, is ABSOLVED from paying the above-stated damages,
same being adjudged against defendants St. Marys Academy, and
subsidiarily, against his parents;
4. Defendant Vivencio Villanueva is hereby ABSOLVED of any
liability. His counterclaim not being in order as earlier discussed in this
decision, is hereby DISMISSED.

IT IS SO ORDERED. (Decision, pp. 32-33; Records, pp. 205-206).

From the records it appears that from 13 to 20 February 1995, defendant-

appellant St. Marys Academy of Dipolog City conducted an enrollment
drive for the school year 1995-1996. A facet of the enrollment campaign
was the visitation of schools from where prospective enrollees were
studying. As a student of St. Marys Academy, Sherwin Carpitanos was part
of the campaigning group. Accordingly, on the fateful day, Sherwin, along
with other high school students were riding in a Mitsubishi jeep owned by
defendant Vivencio Villanueva on their way to Larayan Elementary School,
Larayan, Dapitan City. The jeep was driven by James Daniel II then 15
years old and a student of the same school. Allegedly, the latter drove the
jeep in a reckless manner and as a result the jeep turned turtle.

Sherwin Carpitanos died as a result of the injuries he sustained from the

accident.[2]

In due time, petitioner St. Marys academy appealed the decision

to the Court of Appeals. [3]

On February 29, 2000, the Court of Appeals promulgated a

decision reducing the actual damages to P25,000.00 but otherwise
affirming the decision a quo, in toto. [4]

On February 29, 2000, petitioner St. Marys Academy filed a

motion for reconsideration of the decision. However, on May 22,
2000, the Court of Appeals denied the motion. [5]

Hence, this appeal. [6]

The Issues

1) Whether the Court of Appeals erred in holding the petitioner liable for
damages for the death of Sherwin Carpitanos.
2) Whether the Court of Appeals erred in affirming the award of moral
damages against the petitioner.

The Courts Ruling

We reverse the decision of the Court of Appeals.

 The Court of Appeals held petitioner St. Marys Academy liable for
the death of Sherwin Carpitanos under Articles 218 and 219 of the
[7] [8]

Family Code, pointing out that petitioner was negligent in allowing a

minor to drive and in not having a teacher accompany the minor
students in the jeep.
Under Article 218 of the Family Code, the following shall have
special parental authority over a minor child while under their
supervision, instruction or custody: (1) the school, its administrators
and teachers; or (2) the individual, entity or institution engaged in
child care. This special parental authority and responsibility applies to
all authorized activities, whether inside or outside the premises of the
school, entity or institution. Thus, such authority and responsibility
applies to field trips, excursions and other affairs of the pupils and
students outside the school premises whenever authorized by the
school or its teachers. [9]

Under Article 219 of the Family Code, if the person under custody
is a minor, those exercising special parental authority are principally
and solidarily liable for damages caused by the acts or omissions of
the unemancipated minor while under their supervision, instruction,
or custody. [10]

However, for petitioner to be liable, there must be a finding that

the act or omission considered as negligent was the proximate cause
of the injury caused because the negligence must have a causal
connection to the accident. [11]

In order that there may be a recovery for an injury, however, 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. In other words, the negligence must be the
proximate cause of the injury. For, negligence, no matter in what it consists,
cannot create a right of action unless it is the proximate cause of the injury
complained of. And the proximate cause of an injury is that cause, which, in
natural and continuous sequence, unbroken by any efficient intervening
cause, produces the injury, and without which the result would not have
occurred.[12]

In this case, the respondents failed to show that the negligence of

petitioner was the proximate cause of the death of the victim.
Respondents Daniel spouses and Villanueva admitted that the
immediate cause of the accident was not the negligence of petitioner
or the reckless driving of James Daniel II, but the detachment of the
steering wheel guide of the jeep.
 In their comment to the petition, respondents Daniel spouses and
Villanueva admitted the documentary exhibits establishing that the
cause of the accident was the detachment of the steering wheel
guide of the jeep. Hence, the cause of the accident was not the
recklessness of James Daniel II but the mechanical defect in the jeep
of Vivencio Villanueva. Respondents, including the spouses
Carpitanos, parents of the deceased Sherwin Carpitanos, did not
dispute the report and testimony of the traffic investigator who stated
that the cause of the accident was the detachment of the steering
wheel guide that caused the jeep to turn turtle.
Significantly, respondents did not present any evidence to show
that the proximate cause of the accident was the negligence of the
school authorities, or the reckless driving of James Daniel II. Hence,
the respondents reliance on Article 219 of the Family Code that those
given the authority and responsibility under the preceding Article shall
be principally and solidarily liable for damages caused by acts or
omissions of the unemancipated minor was unfounded.
Further, there was no evidence that petitioner school allowed the
minor James Daniel II to drive the jeep of respondent Vivencio
Villanueva. It was Ched Villanueva, grandson of respondent Vivencio
Villanueva, who had possession and control of the jeep. He was
driving the vehicle and he allowed James Daniel II, a minor, to drive
the jeep at the time of the accident.
Hence, liability for the accident, whether caused by the
negligence of the minor driver or mechanical detachment of the
steering wheel guide of the jeep, must be pinned on the minors
parents primarily. The negligence of petitioner St. Marys Academy
was only a remote cause of the accident. Between the remote cause
and the injury, there intervened the negligence of the minors parents
or the detachment of the steering wheel guide of the jeep.

The proximate cause of an injury is that cause, which, in natural and

continuous sequence, unbroken by any efficient intervening cause, produces
the injury, and without which the result would not have occurred. [13]

Considering that the negligence of the minor driver or the

detachment of the steering wheel guide of the jeep owned by
respondent Villanueva was an event over which petitioner St. Marys
Academy had no control, and which was the proximate cause of the
accident, petitioner may not be held liable for the death resulting from
such accident.
 Consequently, we find that petitioner likewise cannot be held
liable for moral damages in the amount of P500,000.00 awarded by
the trial court and affirmed by the Court of Appeals.
Though incapable of pecuniary computation, moral damages may
be recovered if they are the proximate result of the defendants
wrongful act or omission. In this case, the proximate cause of the
[14]

accident was not attributable to petitioner.

For the reason that petitioner was not directly liable for the
accident, the decision of the Court of Appeals ordering petitioner to
pay death indemnity to respondent Carpitanos must be
deleted.Moreover, the grant of attorneys fees as part of damages is
the exception rather than the rule. The power of the court to award
[15]

attorneys fees under Article 2208 of the Civil Code demands factual,
legal and equitable justification. Thus, the grant of attorneys fees
[16]

against the petitioner is likewise deleted.

Incidentally, there was no question that the registered owner of
the vehicle was respondent Villanueva. He never denied and in fact
admitted this fact. We have held that the registered owner of any
vehicle, even if not used for public service, would primarily be
responsible to the public or to third persons for injuries caused the
latter while the vehicle was being driven on the highways or streets.
Hence, with the overwhelming evidence presented by petitioner and
[17]

the respondent Daniel spouses that the accident occurred because of

the detachment of the steering wheel guide of the jeep, it is not the
school, but the registered owner of the vehicle who shall be held
responsible for damages for the death of Sherwin Carpitanos.

The Fallo

WHEREFORE, the Court REVERSES and SETS ASIDE the

decision of the Court of Appeals and that of the trial court. The
[18] [19]

Court remands the case to the trial court for determination of the
liability of defendants, excluding petitioner St. Marys
Academy, Dipolog City.
No costs.
SO ORDERED.
EN BANC

[G.R. No. 70890. September 18, 1992.]

CRESENCIO LIBI * and AMELIA YAP LIBI, Petitioners, v. HON. INTERMEDIATE APPELLATE
COURT, FELIPE GOTIONG and SHIRLEY GOTIONG, Respondents.
 Alex Y. Tan, for Petitioners.

Mario D. Ortiz and Danilo V. Ortiz for Private Respondents.

SYLLABUS

1. CIVIL LAW; QUASI DELICT; LIABILITY OF PARENTS FOR CIVIL LIABILITY ARISING FROM CRIMINAL
OFFENSES COMMITTED BY THEIR MINOR CHILDREN; RULE. — The parents are and should be held
primarily liable for the civil liability arising from criminal offenses committed by their minor children
under their legal authority or control, or who live in their company, unless it is proven that the former
acted with the diligence of a good father of a family to prevent such damages. That primary liability is
premised on the provisions of Article 101 of the Revised Penal Code with respect to damages ex
delicto caused by their children 9 years of age or under, or over 9 but under 15 years of age who
acted without discernment; and, with regard to their children over 9 but under 15 years of age who
acted with discernment, or 15 years or over but under 21 years of age, such primary liability shall be
imposed pursuant to Article 2180 of the Civil Code. Under said Article 2180, the enforcement of such
liability shall be effected against the father and, in case of his death or incapacity, the mother. This
was amplified by the Child and Youth Welfare Code which provides that the same shall devolve upon
the father and, in case of his death or incapacity, upon the mother or, in case of her death or
incapacity, upon the guardian, but the liability may also be voluntarily assumed by a relative or family
friend of the youthful offender. However, under the Family Code, this civil liability is now, without such
alternative qualification, the responsibility of the parents and those who exercise parental authority
over the minor offender. For civil liability arising from quasi-delicts committed by minors, the same
rules shall apply in accordance with Articles 2180 and 2182 of the Civil Code, as so modified.

DECISION

REGALADO, J.:

One of the ironic verities of life, it has been said, is that sorrow is sometimes a touchstone of love. A
tragic illustration is provided by the instant case, wherein two lovers died while still in the prime of
their years, a bitter episode for those whose lives they have touched. While we cannot expect to
award complete assuagement to their families through seemingly prosaic legal verbiage, this
disposition should at least terminate the acrimony and rancor of an extended judicial contest resulting
from the unfortunate occurrence.

In this final denouement of the judicial recourse the stages whereof were alternately initiated by the
parties, petitioners are now before us seeking the reversal of the judgment of respondent court
promulgated on January 2, 1985 in AC-G.R. CV No. 69060 with the following decretal portion: jgc:chanrobles.com.ph

"WHEREFORE, the decision of the lower court dismissing plaintiff’s complaint is hereby reversed; and
instead, judgment is hereby rendered sentencing defendants, jointly and solidarily, to pay to plaintiffs
the following amounts: chanrobles.com : virtual law library

1. Moral damages, P30,000.000;

2. Exemplary damages, P10,000.00;

3. Attorney’s fees, P20,000.00, and costs.

However, denial of defendants-appellees’ counterclaims is affirmed." 1

Synthesized from the findings of the lower courts, it appears that respondent spouses are the
legitimate parents of Julie Ann Gotiong who, at the time of the deplorable incident which took place
and from which she died on January 14, 1979, was an 18-year old first year commerce student of the
University of San Carlos, Cebu City; while petitioners are the parents of Wendell Libi, then a minor
between 18 and 19 years of age living with his aforesaid parents, and who also died in the same event
on the same date.

For more than two (2) years before their deaths, Julie Ann Gotiong and Wendell Libi were sweethearts
until December, 1978 when Julie Ann broke up her relationship with Wendell after she supposedly
found him to be sadistic and irresponsible. During the first and second weeks of January, 1979,
Wendell kept pestering Julie Ann with demands for reconciliation but the latter persisted in her
refusal, prompting the former to resort to threats against her. In order to avoid him, Julie Ann stayed
in the house of her best friend, Malou Alfonso, at the corner of Maria Cristina and Juana Osmeña
Streets, Cebu City, from January 7 to 13, 1978.

On January 14, 1979, Julie Ann and Wendell died, each from a single gunshot wound inflicted with the
same firearm, a Smith and Wesson revolver licensed in the name of petitioner Cresencio Libi, which
was recovered from the scene of the crime inside the residence of private respondents at the corner of
General Maxilom and D. Jakosalem streets of the same city.

Due to the absence of an eyewitness account of the circumstances surrounding the death of both
minors, their parents, who are the contending parties herein, posited their respective theories drawn
from their interpretation of circumstantial evidence, available reports, documents and evidence of
physical facts.

Private respondents, bereaved over the death of their daughter, submitted that Wendell caused her
death by shooting her with the aforesaid firearm and, thereafter, turning the gun on himself to
commit suicide. On the other hand, Petitioners, puzzled and likewise distressed over the death of their
son, rejected the imputation and contended that an unknown third party, whom Wendell may have
displeased or antagonized by reason of his work as a narcotics informer of the Constabulary Anti-
Narcotics Unit (CANU), must have caused Wendell’s death and then shot Julie Ann to eliminate any
witness and thereby avoid identification.
chanrobles.com:cralaw:red

As a result of the tragedy, the parents of Julie Ann filed Civil Case No. R-17774 in the then Court of
First Instance of Cebu against the parents of Wendell to recover damages arising from the latter’s
vicarious liability under Article 2180 of the Civil Code. After trial, the court below rendered judgment
on October 20, 1980 as follows: jgc:chanrobles.com.ph

"WHEREFORE, premises duly considered, judgment is hereby rendered dismissing plaintiffs’ complaint
for insufficiency of the evidence. Defendants’ counterclaim is likewise denied for lack of sufficient
merit." 2

On appeal to respondent court, said judgment of the lower court dismissing the complaint of therein
plaintiffs-appellants was set aside and another judgment was rendered against defendants-appellees
who, as petitioners in the present appeal by certiorari, now submit for resolution the following issues
in this case:chanrob1es virtual 1aw library

1. Whether or not respondent court correctly reversed the trial court in accordance with established
decisional laws; and

2. Whether or not Article 2180 of the Civil Code was correctly interpreted by respondent court to
make petitioners liable for vicarious liability. 3

In the proceedings before the trial court, Dr. Jesus P. Cerna, Police Medico-Legal Officer of Cebu,
submitted his findings and opinions on some postulates for determining whether or not the gunshot
wound was inflicted on Wendell Libi by his own suicidal act. However, undue emphasis was placed by
the lower court on the absence of gunpowder or tattooing around the wound at the point of entry of
the bullet. It should be emphasized, however, that this is not the only circumstance to be taken into
account in the determination of whether it was suicide or not.

It is true that said witness declared that he found no evidence of contact or close-contact of an
explosive discharge in the entrance wound. However, as pointed out by private respondents, the body
of deceased Wendell Libi must have been washed at the funeral parlor, considering the hasty
interment thereof a little after eight (8) hours from the occurrence wherein he died. Dr. Cerna himself
could not categorically state that the body of Wendell Libi was left untouched at the funeral parlor
before he was able to conduct his autopsy. It will also be noted that Dr. Cerna was negligent in not
conducting a paraffin test on Wendell Libi, hence possible evidence of gunpowder residue on Wendell’s
hands was forever lost when Wendell was hastily buried. cralawnad

More specifically, Dr. Cerna testified that he conducted an autopsy on the body of Wendell Libi about
eight (8) hours after the incident or, to be exact, eight (8) hours and twenty (20) minutes based on
the record of death; that when he arrived at the Cosmopolitan Funeral Homes, the body of the
deceased was already on the autopsy table and in the stage of rigor mortis; and that said body was
not washed, but it was dried. 4 However, on redirect examination, he admitted that during the 8-hour
interval, he never saw the body nor did he see whether said body was wiped or washed in the area of
the wound on the head which he examined because the deceased was inside the morgue. 5 In fact, on
cross-examination, he had earlier admitted that as far as the entrance of the wound, the trajectory of
the bullet and the exit of the wound are concerned, it is possible that Wendell Libi shot himself. 6

He further testified that the muzzle of the gun was not pressed on the head of the victim and that he
found no burning or singeing of the hair or extensive laceration on the gunshot wound of entrance
which are general characteristics of contact or near-contact fire. On direct examination, Dr. Cerna
nonetheless made these clarification: jgc:chanrobles.com.ph
"Q Is it not a fact that there are certain guns which are so made that there would be no black residue
or tattooing that could result from these guns because they are what we call clean?

A Yes, sir. I know that there are what we call smokeless powder.

ATTY. ORTIZ: chanrob1es virtual 1aw library

Q Yes. So, in cases, therefore, of guns where the powder is smokeless, those indications that you said
may not rule out the possibility that the gun was closer than 24 inches, is that correct?

A If the . . . assuming that the gun used was .. the bullet used was a smokeless powder.

Q At any rate, doctor, from . . . disregarding those other matters that you have noticed, the singeing,
etc., from the trajectory, based on the trajectory of the bullet as shown in your own sketch, is it not a
fact that the gun could have been fired by the person himself, the victim himself, Wendell Libi,
because it shows a point of entry a little above the right ear and point of exit a little above that, to be
very fair and on your oath?

A As far as the point of entrance is concerned and as far as the trajectory of the bullet is concerned
and as far as the angle or the manner of fire is concerned, it could have been fired by the victim." 7

As shown by the evidence, there were only two used bullets 8 found at the scene of the crime, each of
which were the bullets that hit Julie Ann Gotiong and Wendell Libi, respectively. Also, the sketch
prepared by the Medico-Legal Division of the National Bureau of Investigation, 9 shows that there is
only one gunshot wound of entrance located at the right temple of Wendell Libi. The necropsy report
prepared by Dr. Cerna states: chanrob1es virtual 1aw library

x x x

"Gunshot wound, ENTRANCE, ovaloid, 0.5 x 0.4 cm., with contusion collar widest inferiorly by 0.2 cm.,
edges inverted, oriented upward, located at the head, temporal region, right, 2.8 cms. behind and 5.5
cms. above right external auditory meatus, directed slightly forward, upward and to the left, involving
skin and soft tissues, making a punch-in fracture on the temporal bone, right, penetrating cranial
cavity, lacerating extensively along its course the brain tissues, fracturing parietal bone, left, and
finally making an EXIT wound, irregular, 2.0 x 1.8 cms., edges (e)verted, parietal region, left, 2.0
cms. behind and 12.9 cms. above left external auditory meatus. chanrobles virtualawlibrary chanrobles.com:chanrobles.com.ph

x x x

"Evidence of contact or close-contact fire, such as burning around the gunshot wound of entrance,
gunpowder tatooing (sic), smudging, singeing of hair, extensive laceration or bursting of the gunshot
wound of entrance, or separation of the skin from the underlying tissue, are absent." 10

On cross-examination, Dr. Cerna demonstrated his theory which was made of record, thus: jgc:chanrobles.com.ph

"Q Now, will you please use yourself as Wendell Libi, and following the entrance of the wound, the
trajectory of the bullet and the exit of the wound, and measuring yourself 24 inches, will you please
indicate to the Honorable Court how would it have been possible for Wendell Libi to kill himself? Will
you please indicate the 24 inches?

WITNESS: chanrob1es virtual 1aw library

A Actually, sir, the 24 inches is approximately one arm’s length.

ATTY. SENINING: chanrob1es virtual 1aw library

I would like to make of record that the witness has demonstrated by extending his right arm almost
straight towards his head." 11

Private respondents assail the fact that the trial court gave credence to the testimonies of defendants’
witnesses Lydia Ang and James Enrique Tan, the first being a resident of an apartment across the
street from the Gotiongs and the second, a resident of the house adjacent to the Gotiong residence,
who declared having seen a "shadow" of a person at the gate of the Gotiong house after hearing shots
therefrom.

On cross-examination, Lydia Ang testified that the apartment where she was staying faces the gas
station; that it is the second apartment; that from her window she can see directly the gate of the
Gotiongs and, that there is a firewall between her apartment and the gas station. 12 After seeing a
man jump from the gate of the Gotiongs to the rooftop of the Tans, she called the police station but
the telephone lines were busy. Later on, she talked with James Enrique Tan and told him that she saw
a man leap from the gate towards his rooftop. 13

However, James Enrique Tan testified that he saw a "shadow" on top of the gate of the Gotiongs, but
denied having talked with anyone regarding what he saw. He explained that he lives in a duplex house
with a garden in front of it; that his house is next to Felipe Gotiong’s house; and he further gave the
following answers to these questions: chanrobles.com : virtual law library

"ATTY. ORTIZ: (TO WITNESS).

Q What is the height of the wall of the Gotiong’s in relation to your house?

WITNESS: chanrob1es virtual 1aw library

A It is about 8 feet.

ATTY. ORTIZ: (TO WITNESS)

Q And where were you looking from?

WITNESS: chanrob1es virtual 1aw library

A From upstairs in my living room.

ATTY. ORTIZ (TO WITNESS)

Q From Your living room window, is that correct?

WITNESS: chanrob1es virtual 1aw library

A Yes, but not very clear because the wall is high." 14

Analyzing the foregoing testimonies, we agree with respondent court that the same do not inspire
credence as to the reliability and accuracy of the witnesses’ observations, since the visual perceptions
of both were obstructed by high walls in their respective houses in relation to the house of herein
private respondents. On the other hand, witness Manolo Alfonso, testifying on rebuttal, attested
without contradiction that he and his sister, Malou Alfonso, were waiting for Julie Ann Gotiong when
they heard her scream; that when Manolo climbed the fence to see what was going on inside the
Gotiong house, he heard the first shot; and, not more than five (5) seconds later, he heard another
shot. Consequently, he went down from the fence and drove to the police station to report the
incident. 15 Manolo’s direct and candid testimony establishes and explains the fact that it was he
whom Lydia Ang and James Enrique Tan saw as the "shadow" of a man at the gate of the Gotiong
house.

We have perforce to reject petitioners’ effete and unsubstantiated pretension that it was another man
who shot Wendell and Julie Ann. It is significant that the Libi family did not even point to or present
any suspect in the crime nor did they file any case against any alleged "John Doe." Nor can we sustain
the trial court’s dubious theory that Wendell Libi did not die by his own hand because of the
overwhelming evidence — testimonial, documentary and pictorial — the confluence of which point to
Wendell as the assailant of Julie Ann, his motive being revenge for her rejection of his persistent pleas
for a reconciliation. chanrobles.com:cralaw:red

Petitioners’ defense that they had exercised the due diligence of a good father of a family, hence they
should not be civilly liable for the crime committed by their minor son, is not borne out by the
evidence on record either.

Petitioner Amelita Yap Libi, mother of Wendell, testified that her husband, Cresencio Libi, owns a gun
which he kept in a safety deposit box inside a drawer in their bedroom. Each of these petitioners holds
a key to the safety deposit box and Amelita’s key is always in her bag, all of which facts were known
to Wendell. They have never seen their son Wendell taking or using the gun. She admitted, however,
that on that fateful night the gun was no longer in the safety deposit box. 16 We, accordingly, cannot
but entertain serious doubts that petitioner spouses had really been exercising the diligence of a good
father of a family by safely locking the fatal gun away. Wendell could not have gotten hold thereof
unless one of the keys to the safety deposit box was negligently left lying around or he had free
access to the bag of his mother where the other key was.

The diligence of a good father of a family required by law in a parent and child relationship consists, to
a large extent, of the instruction and supervision of the child. Petitioners were gravely remiss in their
duties as parents in not diligently supervising the activities of their son, despite his minority and
immaturity, so much so that it was only at the time of Wendell’s death that they allegedly discovered
that he was a CANU agent and that Cresencio’s gun was missing from the safety deposit box. Both
parents were sadly wanting in their duty and responsibility in monitoring and knowing the activities of
their children who, for all they know, may be engaged in dangerous work such as being drug
informers, 17 or even drug users. Neither was a plausible explanation given for the photograph of
Wendell, with a handwritten dedication to Julie Ann at the back thereof, 18 holding upright what
clearly appears as a revolver and on how or why he was in possession of that firearm.

In setting aside the judgment of the court a quo and holding petitioners civilly liable, as explained at
the start of this opinion, respondent court waved aside the protestations of diligence on the part of
petitioners and had this to say: jgc:chanrobles.com.ph

". . . It is still the duty of parents to know the activity of their children who may be engaged in this
dangerous activity involving the menace of drugs. Had the defendants-appellees been diligent in
supervising the activities of their son, Wendell, and in keeping said gun from his reach, they could
have prevented Wendell from killing Julie Ann Gotiong. Therefore, appellants are liable under Article
2180 of the Civil Code which provides: chanrob1es virtual 1aw library

‘The father, and in case of his death or incapacity, the mother, are responsible for the damages
caused by their minor children who live in their company.’

"Having been grossly negligent in preventing Wendell Libi from having access to said gun which was
allegedly kept in a safety deposit box, defendants-appellees are subsidiarily liable for the natural
consequence of the criminal act of said minor who was living in their company. This vicarious liability
of herein defendants-appellees has been reiterated by the Supreme Court in many cases, prominent
of which is the case of Fuellas v. Cadano, et. al. (L-14409, Oct. 31, 1961, 3 SCRA 361-367), which
held that:chanrob1es virtual 1aw library

‘The subsidiary liability of parents for damages caused by their minor children imposed by Article 2180
of the New Civil Code covers obligations arising from both quasi-delicts and criminal offenses.’

‘The subsidiary liability of parent’s arising from the criminal acts of their minor children who acted with
discernment is determined under the provisions of Article 2180, N.C.C. and under Article 101 of the
Revised Penal Code, because to hold that the former only covers obligations which arise from quasi-
delicts and not obligations which arise from criminal offenses, would result in the absurdity that while
for an act where mere negligence intervenes the father or mother may stand subsidiarily liable for the
damages caused by his or her son, no liability would attach if the damage is caused with criminal
intent.’ (3 SCRA 361-362).

". . . In the instant case, minor son of herein defendants-appellees, Wendell Libi somehow got hold of
the key to the drawer where said gun was kept under lock without defendant-spouses ever knowing
that said gun had been missing from that safety box since 1978 when Wendell Libi had) a picture
taken wherein he proudly displayed said gun and dedicated this picture to his sweetheart, Julie Ann
Gotiong; also since then, Wendell Libi was said to have kept said gun in his car, in keeping up with his
supposed role of a CANU agent . . ." chanrobles lawlibrary : rednad

x x x

"Based on the foregoing discussions of the assigned errors, this Court holds that the lower court was
not correct in dismissing herein plaintiffs-appellants’ complaint because as preponderantly shown by
evidence, defendants-appellees utterly failed to exercise all the diligence of a good father of the family
in preventing their minor son from committing this crime by means of the gun of defendants-
appellees which was freely accessible to Wendell Libi for they have not regularly checked whether said
gun was still under lock, but learned that it was missing from the safety deposit box only after the
crime had been committed." (Emphases ours.) 19

We agree with the conclusion of respondent court that petitioners should be held liable for the civil
liability based on what appears from all indications was a crime committed by their minor son. We
take this opportunity, however, to digress and discuss its ratiocination therefor on jurisprudential dicta
which we feel require clarification.

In imposing sanctions for the so-called vicarious liability of petitioners, respondent court cites Fuellas
v. Cadano, Et. Al. 20 which supposedly holds that" (t)he subsidiary liability of parents for damages
caused by their minor children imposed by Article 2180 of the New Civil Code covers obligations
arising from both quasi-delicts and criminal offenses," followed by an extended quotation ostensibly
from the same case explaining why under Article 2180 of the Civil Code and Article 101 of the Revised
Penal Code parents should assume subsidiary liability for damages caused by their minor children. The
quoted passages are set out two paragraphs back, with pertinent underscoring for purposes of the
discussion hereunder. chanrobles law library

Now, we do not have any objection to the doctrinal rule holding, the parents liable, but the
categorization of their liability as being subsidiary, and not primary, in nature requires a hard second
look considering previous decisions of this court on the matter which warrant comparative analyses.
Our concern stems from our readings that if the liability of the parents for crimes or quasi-delicts of
their minor children is subsidiary, then the parents can neither invoke nor be absolved of civil liability
on the defense that they acted with the diligence of a good father of a family to prevent damages. On
the other hand, if such liability imputed to the parents is considered direct and primary, that diligence
would constitute a valid and substantial defense.

We believe that the civil liability of parents for quasi-delicts of their minor children, as contemplated in
Article 2180 of the Civil Code, is primary and not subsidiary. In fact, if we apply Article 2194 of said
code which provides for solidary liability of joint tortfeasors, the persons responsible for the act or
omission, in this case the minor and the father and, in case of his death of incapacity, the mother, are
solidarily liable. Accordingly, such parental liability is primary and not subsidiary, hence the last
paragraph of Article 2180 provides that" (t)he responsibility treated of in this article shall cease when
the persons herein mentioned prove that they observed all the diligence of a good father of a family to
prevent damages." cralaw virtua1aw library

We are also persuaded that the liability of the parents for felonies committed by their minor children is
likewise primary, not subsidiary. Article 101 of the Revised Penal Code provides: jgc:chanrobles.com.ph

"ARTICLE 101. Rules regarding civil liability in certain cases. —

x x x

First. In cases of subdivisions . . . 2, and 3 of Article 12, the civil liability for acts committed by . . . a
person under nine years of age, or by one over nine but under fifteen years of age, who has acted
without discernment, shall devolve upon those having such person under their legal authority or
control, unless it appears that there was no fault or negligence on their part." (Emphasis supplied.)
21

Accordingly, just like the rule in Article 2180 of the Civil Code, under the foregoing provision the civil
liability of the parents for crimes committed by their minor children is likewise direct and primary, and
also subject to the defense of lack of fault or negligence on their part, that is, the exercise of the
diligence of a good father of a family.

That in both quasi-delicts and crimes the parents primarily respond for such damages is buttressed by
the corresponding provisions in both codes that the minor transgressor shall be answerable or shall
respond with his own property only in the absence or in case of insolvency of the former. Thus, for
civil liability ex quasi delicto of minors, Article 2182 of the Civil Code states that" (i)f the minor
causing damage has no parents or guardian, the minor . . . shall be answerable with his own property
in an action against him where a guardian ad litem shall be appointed." For civil liability ex delicto of
minors, an equivalent provision is found in the third paragraph of Article 101 of the Revised Penal
Code, to wit: jgc:chanrobles.com.ph

"Should there be no person having such . . . minor under his authority, legal guardianship or control,
or if such person be insolvent, said . . . minor shall respond with (his) own property, excepting
property exempt from execution, in accordance with civil law." cralaw virtua1aw library

The civil liability of parents for felonies committed by their minor children contemplated in the
aforesaid rule in Article 101 of the Revised Penal Code in relation to Article 2180 of the Civil Code has,
aside from the aforecited case of Fuellas, been the subject of a number of cases adjudicated by this
Court, viz.: Exconde v. Capuno, Et Al., 22 Araneta v. Arreglado, 23 Salen, Et. Al. v. Balce, 24 Paleyan,
etc., Et. Al. v. Bangkili, Et Al., 25 and Elcano, et al, v. Hill, Et. Al. 26 Parenthetically, the aforesaid
cases were basically on the issue of the civil liability of parents for crimes committed by their minor
children over 9 but under 15 years of age, who acted with discernment, and also of minors 15 years
of aye or over, since these situations are not covered by Article 101, Revised Penal Code. In both
instances, this Court held that the issue of parental civil liability should be resolved in accordance with
the provisions of Article 2180 of the Civil Code for the reasons well expressed in Salen and adopted in
the cases hereinbefore enumerated that to hold that the civil liability under Article 2180 would apply
only to quasi-delicts and not to criminal offenses would result in the absurdity that in an act involving
mere negligence the parents would be liable but not where the damage is caused with criminal intent.
In said cases, however, there are unfortunate variances resulting in a regrettable inconsistency in the
Court’s determination of whether the liability of the parents, in cases involving either crimes or quasi-
delicts of their minor children, is primary or subsidiary.

In Exconde, where the 15-year old minor was convicted of double homicide through reckless
imprudence, in a separate civil action arising from the crime the minor and his father were held jointly
and severally liable for failure of the latter to prove the diligence of a good father of a family. The
same liability in solidum and, therefore, primary liability was imposed in a separate civil action in
Araneta on the parents and their 14-year old son who was found guilty of frustrated homicide, but on
the authority of Article 2194 of the Civil Code providing for solidary responsibility of two or more
persons who are liable for a quasi-delict.

However, in Salen, the father was declared subsidiarily liable for damages arising from the conviction
of his son, who was over 15 but less than 18 years of age, by applying Article 2180 but, this time,
disregarding Article 2194 of the Civil Code. In the present case, as already explained, the petitioners
herein were also held liable but supposedly in line with Fuellas which purportedly declared the parents
subsidiarily liable for the civil liability for serious physical injuries committed by their 13-year old son.
On the other hand, in Paleyan, the mother and her 19-year old son were adjudged solidarily liable for
damages arising from his conviction for homicide by the application of Article 2180 of the Civil Code
since this is likewise not covered by Article 101 of the Revised Penal Code. Finally, in Elcano, although
the son was acquitted in a homicide charge due to "lack of intent, coupled with mistake," it was ruled
that while under Article 2180 of the Civil Code there should be solidary liability for damages, since the
son, "although married, was living with his father and getting subsistence from him at the time of the
occurrence," but "is now of age, as a matter of equity" the father was only held subsidiarily liable.

It bears stressing, however, that the Revised Penal Code provides for subsidiary liability only for
persons causing damages under the compulsion of irresistible force or under the impulse of an
uncontrollable fear; 27 innkeepers, tavernkeepers and proprietors of establishments; 28 employers,
teachers, persons and corporations engaged in industry; 29 and principals, accomplices and
accessories for the unpaid civil liability of their co-accused in the other classes. 30

Also, coming back to respondent court’s reliance on Fuellas in its decision in the present case, it is not
exactly accurate to say that Fuellas provided for subsidiary liability of the parents therein. A careful
scrutiny shows that what respondent court quoted verbatim in its decision now on appeal in the
present case, and which it attributed to Fuellas, was the syllabus on the law report of said case which
spoke of "subsidiary" liability. However, such categorization does not specifically appear in the text of
the decision in Fuellas. In fact, after reviewing therein the cases of Exconde, Araneta and Salen and
the discussions in said cases of Article 101 of the Revised Penal Code in relation to Article 2180 of the
Civil Code, this Court concluded its decision in this wise: jgc:chanrobles.com.ph

"Moreover, the case at bar was decided by the Court of Appeals on the basis of evidence submitted
therein by both parties, independent of the criminal case. And responsibility for fault or negligence
under Article 2176 upon which the present action was instituted, is entirely separate and distinct from
the civil liability arising from fault or negligence under the Penal Code (Art. 2177), and having in mind
the reasons behind the law as heretofore stated, any discussion as to the minor’s criminal
responsibility is of no moment." cralaw virtua1aw library

Under the foregoing considerations, therefore, we hereby rule that the parents are and should be held
primarily liable for the civil liability arising from criminal offenses committed by their minor children
under their legal authority or control, or who live in their company, unless it is proven that the former
acted with the diligence of a good father of a family to prevent such damages. That primary liability is
premised on the provisions of Article 101 of the Revised Penal Code with respect to damages ex
delicto caused by their children 9 years of age or under, or over 9 but under 15 years of age who
acted without discernment; and, with regard to their children over 9 but under 15 years of age who
acted with discernment, or 15 years or over but under 21 years of age, such primary liability shall be
imposed pursuant to Article 2180 of the Civil Code. 31

Under said Article 2180, the enforcement of such liability shall be effected against the father and, in
case of his death or incapacity, the mother. This was amplified by the Child and Youth Welfare Code
which provides that the same shall devolve upon the father and, in case of his death or incapacity,
upon the mother or, in case of her death or incapacity, upon the guardian, but the liability may also
be voluntarily assumed by a relative or family friend of the youthful offender. 32 However, under the
Family Code, this civil liability is now, without such alternative qualification, the responsibility of the
parents and those who exercise parental authority over the minor offender. 33 For civil liability arising
from quasi-delicts committed by minors, the same rules shall apply in accordance with Articles 2180
and 2182 of the Civil Code, as so modified.

In the case at bar, whether the death of the hapless Julie Ann Gotiong was caused by a felony or a
quasi-delict committed by Wendell Libi, respondent court did not err in holding petitioners liable for
damages arising therefrom. Subject to the preceding modifications of the premises relied upon by it
therefor and on the bases of the legal imperatives herein explained, we conjoin in its findings that said
petitioners failed to duly exercise the requisite diligentissimi patris familias to prevent such damages.

ACCORDINGLY, the instant Petition is DENIED and the assailed judgment of respondent Court of
Appeals is hereby AFFIRMED, with costs against petitioners.

SO ORDERED.

G.R. No. 191018

CARLOS BORROMEO, Petitioner,
vs.
FAMILY CARE HOSPITAL, INC. and RAMON S. INSO, M.D., Respondents.

DECISION

BRION, J.:

Carlos Borromeo lost his wife Lillian when she died after undergoing a routine
appendectomy. The hospital and the attending surgeon submit that Lillian bled to death
due to a rare, life-threatening condition that prevented her blood from clotting normally.
Carlos believes, however, that the hospital and the surgeon were simply negligent in the
care of his late wife.

On January 22, 2010, the Court of Appeals (CA) in CA-G.R CV No. 89096 dismissed 1

Carlos' complaint and thus reversed the April 10, 2007 decision of the Regional Trial
Court (RTC) in Civil Case No. 2000-603-MK which found the respondents liable for
2

medical negligence.

The present petition for review on certiorari seeks to reverse the CA’s January 22, 2010
decision.

ANTECEDENTS

The petitioner, Carlos Borromeo, was the husband of the late Lilian V. Borromeo (Lilian).
Lilian was a patient of the respondent Family Care Hospital, Inc. (Family Care) under the
care of respondent Dr. Ramon Inso (Dr. Inso).

On July 13, 1999, the petitioner brought his wife to the Family Care Hospital because she
had been complaining of acute pain at the lower stomach area and fever for two days.
She was admitted at the hospital and placed under the care of Dr. Inso.

Dr. Inso suspected that Lilian might be suffering from acute appendicitis. However, there
was insufficient data to rule out other possible causes and to proceed with an
appendectomy. Thus, he ordered Lilian’s confinement for testing and evaluation.

Over the next 48 hours, Lilian underwent multiple tests such as complete blood count,
urinalysis, stool exam, pelvic ultrasound, and a pregnancy test. However, the tests were
not conclusive enough to confirm that she had appendicitis.

Meanwhile, Lilian’s condition did not improve. She suffered from spiking fever and her
abdominal pain worsened. The increasing tenderness of her stomach, which was
previously confined to her lower right side, had also extended to her lower left side. Lilian
abruptly developed an acute surgical abdomen.

On July 15, 1999, Dr. Inso decided to conduct an exploratory laparotomy on Lilian
because of the findings on her abdomen and his fear that she might have a ruptured
appendix. Exploratory laparotomy is a surgical procedure involving a large incision on the
abdominal wall that would enable Dr. Inso to examine the abdominal cavity and identify
the cause of Lilian’s symptoms. After explaining the situation, Dr. Inso obtained the
patient’s consent to the laparotomy.

At around 3:45 P.M., Lilian was brought to the operating room where Dr. Inso conducted
the surgery. During the operation, Dr. Inso confirmed that Lilian was suffering from acute
appendicitis. He proceeded to remove her appendix which was already infected and
congested with pus.

The operation was successful. Lilian’s appearance and vital signs improved. At around
7:30 P.M., Lilian was brought back to her private room from the recovery room.

At around 1:30 A.M. on July 16, 1999, roughly six hours after Lilian was brought back to
her room, Dr. Inso was informed that her blood pressure was low. After assessing her
condition, he ordered the infusion of more intravenous (IV) fluids which somehow raised
her blood pressure.

Despite the late hour, Dr. Inso remained in the hospital to monitor Lilian’s condition.
Subsequently, a nurse informed him that Lilian was becoming restless. Dr. Inso
immediately went to Lilian and saw that she was quite pale. He immediately requested a
blood transfusion.

Lilian did not respond to the blood transfusion even after receiving two 500 cc-units of
blood. Various drugs, such as adrenaline or epinephrine, were administered.

Eventually, an endotracheal tube connected to an oxygen tank was inserted into Lilian to
ensure her airway was clear and to compensate for the lack of circulating oxygen in her
body from the loss of red blood cells. Nevertheless, her condition continued to
deteriorate.

Dr. Inso observed that Lilian was developing petechiae in various parts of her
body. Petechiae are small bruises caused by bleeding under the skin whose presence
indicates a blood-coagulation problem – a defect in the ability of blood to clot. At this
point, Dr. Inso suspected that Lilian had Disseminated Intravascular Coagulation (DIC), a
blood disorder characterized by bleeding in many parts of her body caused by the
consumption or the loss of the clotting factors in the blood. However, Dr. Inso did not
have the luxury to conduct further tests because the immediate need was to resuscitate
Lilian.

Dr. Inso and the nurses performed cardiopulmonary resuscitation (CPR) on Lilian. Dr.
Inso also informed her family that there may be a need to re-operate on her, but she
would have to be put in an Intensive Care Unit (ICU). Unfortunately, Family Care did not
have an ICU because it was only a secondary hospital and was not required by the
Department of Health to have one. Dr. Inso informed the petitioner that Lilian would have
to be transferred to another hospital.

At around 3:30 A.M., Dr. Inso personally called the Perpetual Help Medical Center to
arrange Lilian’s transfer, but the latter had no available bed in its ICU. Dr. Inso then
personally coordinated with the Muntinlupa Medical Center (MMC) which had an
available bed.

At around 4:00 A.M., Lilian was taken to the MMC by ambulance accompanied by the
resident doctor on duty and a nurse. Dr. Inso followed closely behind in his own vehicle.

Upon reaching the MMC, a medical team was on hand to resuscitate Lilian. A nasogastric
tube (NGT) was inserted and IV fluids were immediately administered to her. Dr. Inso
asked for a plasma expander. Unfortunately, at around 10:00 A.M., Lilian passed away
despite efforts to resuscitate her.

At the request of the petitioner, Lilian’s body was autopsied at the Philippine National
Police (PNP) Camp Crame Crime Laboratory. Dr. Emmanuel Reyes (Dr. Reyes), the
medico-legal assigned to the laboratory, conducted the autopsy. Dr. Reyes summarized
his notable findings as:

x x x I opened up the body and inside the abdominal cavity which you call peritoneal
cavity there were 3,000 ml of clot and unclot blood accumulated thereat. The peritoneal
cavity was also free from any adhesion. Then, I opened up the head and the brain
revealed paper white in color and the heart revealed abundant petechial hemorrhages
from the surface and it was normal. The valvular leaflets were soft and pliable, and of
course, the normal color is reddish brown as noted. And the coronary arteries which
supply the heart were normal and unremarkable. Next, the lungs appears [sic]
hemorrhagic. That was the right lung while the left lung was collapsed and paled. For the
intestines, I noted throughout the entire lengths of the small and large intestine were
hemorrhagic areas. Noted absent is the appendix at the ileo-colic area but there were
continuous suture repair done thereat. However, there was a 0.5 x 0.5 cm opening or left
unrepaired at that time. There was an opening on that repair site. Meaning it was not
repaired. There were also at that time clot and unclot blood found adherent thereon. The
liver and the rest of the visceral organs were noted exhibit [sic] some degree of pallor but
were otherwise normal. The stomach contains one glassful about 400 to 500 ml. 3

Dr. Reyes concluded that the cause of Lilian’s death was hemorrhage due to bleeding
petechial blood vessels: internal bleeding. He further concluded that the internal bleeding
was caused by the 0.5 x 0.5 cm opening in the repair site. He opined that the bleeding
could have been avoided if the site was repaired with double suturing instead of the
single continuous suture repair that he found.

Based on the autopsy, the petitioner filed a complaint for damages against Family Care
and against Dr. Inso for medical negligence.

During the trial, the petitioner presented Dr. Reyes as his expert witness. Dr. Reyes
testified as to his findings during the autopsy and his opinion that Lilian’s death could
have been avoided if Dr. Inso had repaired the site with double suture rather than a
single suture.

However, Dr. Reyes admitted that he had very little experience in the field of pathology
and his only experience was an on-the-job training at the V. Luna Hospital where he was
only on observer status. He further admitted that he had no experience in appendicitis or
appendectomy and that Lilian’s case was his first autopsy involving a death from
appendectomy.

Moreover, Dr. Reyes admitted that he was not intelligently guided during the autopsy
because he was not furnished with clinical, physical, gross, histopath, and laboratory
information that were important for an accurate conclusion. Dr. Reyes also admitted that
an appendical stump is initially swollen when sutured and that the stitches may loosen
during the healing process when the initial swelling subside.

In their defense, Dr. Inso and Family Care presented Dr. Inso, and expert witnesses Dr.
Celso Ramos (Dr. Ramos) and Dr. Herminio Hernandez (Dr. Hernandez).

Dr. Ramos is a practicing pathologist with over 20 years of experience. He is an

associate professor at the Department of Surgery of the Fatima Medical Center, the
Manila Central University, and the Perpetual Help Medical Center. He is a Fellow of the
Philippine College of Surgeons, a Diplomate of the Philippine Board of Surgery, and a
Fellow of the Philippine Society of General Surgeons.

Dr. Ramos discredited Dr. Reyes’ theory that the 0.5 x 0.5 cm opening at the repair site
caused Lilian’s internal bleeding. According to Dr. Ramos, appendical vessels measure
only 0.1 to 0.15 cm, a claim that was not refuted by the petitioner. If the 0.5 x 0.5 cm
opening had caused Lilian’s hemorrhage, she would not have survived for over 16 hours;
she would have died immediately, within 20 to 30 minutes, after surgery.

Dr. Ramos submitted that the cause of Lilian’s death was hemorrhage due to DIC, a
blood disorder that leads to the failure of the blood to coagulate. Dr. Ramos considered
the abundant petechial hemorrhage in the myocardic sections and the hemorrhagic right
lung; the multiple bleeding points indicate that Lilian was afflicted with DIC.

Meanwhile, Dr. Hernandez is a general surgeon and a hospital administrator who had
been practicing surgery for twenty years as of the date of his testimony.

Dr. Hernandez testified that Lilian’s death could not be attributed to the alleged wrong
suturing. He submitted that the presence of blood in the lungs, in the stomach, and in the
entire length of the bowels cannot be reconciled with Dr. Reyes’ theory that the
hemorrhage resulted from a single-sutured appendix.

Dr. Hernandez testified that Lilian had uncontrollable bleeding in the microcirculation as a
result of DIC. In DIC, blood oozes from very small blood vessels because of a problem in
the clotting factors of the blood vessels. The microcirculation is too small to be seen by
the naked eye; the red cell is even smaller than the tip of a needle. Therefore, the alleged
wrong suturing could not have caused the amount of hemorrhaging that caused Lilian’s
death.

Dr. Hernandez further testified that the procedure that Dr. Inso performed was consistent
with the usual surgical procedure and he would not have done anything differently. 4

The petitioner presented Dr. Rudyard Avila III (Dr. Avila) as a rebuttal witness. Dr. Avila,
also a lawyer, was presented as an expert in medical jurisprudence. Dr. Avila testified
that between Dr. Reyes who autopsied the patient and Dr. Ramos whose findings were
based on medical records, greater weight should be given to Dr. Reyes’ testimony.

On April 10, 2007, the RTC rendered its decision awarding the petitioner P88,077.50 as
compensatory damages; P50,000.00 as death indemnity; P3,607,910.30 as loss of
earnings; P50,000.00 as moral damages; P30,000.00 as exemplary damages;
P50,000.00 as attorney’s fees, and the costs of the suit.

The RTC relied on Dr. Avila’s opinion and gave more weight to Dr. Reyes’ findings
regarding the cause of Lilian’s death. It held that Dr. Inso was negligent in using a single
suture on the repair site causing Lilian’s death by internal hemorrhage. It applied the
doctrine of res ipsa loquitur, holding that a patient’s death does not ordinarily occur during
an appendectomy.

The respondents elevated the case to the CA and the appeal was docketed as CA-G.R.
CV No. 89096.

On January 22, 2010, the CA reversed the RTC’s decision and dismissed the complaint.
The CA gave greater weight to the testimonies of Dr. Hernandez and Dr. Ramos over the
findings of Dr. Reyes because the latter was not an expert in pathology, appendectomy,
nor in surgery. It disregarded Dr. Avila’s opinion because the basic premise of his
testimony was that the doctor who conducted the autopsy is a pathologist of equal or of
greater expertise than Dr. Ramos or Dr. Hernandez.

The CA held that there was no causal connection between the alleged omission of Dr.
Inso to use a double suture and the cause of Lilian’s death. It also found that Dr. Inso did,
in fact, use a double suture ligation with a third silk reinforcement ligation on the repair
site which, as Dr. Reyes admitted on cross-examination, loosened up after the initial
swelling of the stump subsided.

The CA denied the applicability of the doctrine of res ipsa loquitur because the element of
causation between the instrumentality under the control and management of Dr. Inso and
the injury that caused Lilian’s death was absent; the respondents sufficiently established
that the cause of Lilian’s death was DIC.

On March 18, 2010, the petitioner filed the present petition for review on certiorari.

THE PETITION

The petitioner argues: (1) that Dr. Inso and Family Care were negligent in caring for Lilian
before, during, and after her appendectomy and were responsible for her death; and (2)
that the doctrine of res ipsa loquitur is applicable to this case.

In their Comment, the respondents counter: (1) that the issues raised by the petitioner
are not pure questions of law; (2) that they exercised utmost care and diligence in the
treatment of Lilian; (3) that Dr. Inso did not deviate from the standard of care observed
under similar circumstances by other members of the profession in good standing; (4)
that res ipsa loquitur is not applicable because direct evidence as to the cause of Lilian’s
death and the presence/absence of negligence is available; and (5) that doctors are not
guarantors of care and cannot be held liable for the death of their patients when they
exercised diligence and did everything to save the patient.

OUR RULING

The petition involves factual questions.

Under Section 1 of Rule 45, a petition for review on certiorari shall only raise questions of
law. The Supreme Court is not a trier of facts and it is not our function to analyze and
weigh evidence that the lower courts had already passed upon.

The factual findings of the Court of Appeals are, as a general rule, conclusive upon this
Court. However, jurisprudence has also carved out recognized exceptions 5 to this rule,
to wit: (1) when the findings are grounded entirely on speculation, surmises, or
conjectures; (2) when the inference made is manifestly mistaken, absurd, or
6

impossible; (3) when there is grave abuse of discretion; (4) when the judgment is based
7 8

on a misapprehension of facts; (5) when the findings of facts are conflicting; (6) when in
9 10

making its findings the Court of Appeals went beyond the issues of the case, or its
findings are contrary to the admissions of both the appellant and the appellee; (7) when11

the findings are contrary to those of the trial court’s; (8) when the findings are
12

conclusions without citation of specific evidence on which they are based; (9) when the
13

facts set forth in the petition as well as in the petitioner’s main and reply briefs are not
disputed by the respondent; (10) when the findings of fact are premised on the
14

supposed absence of evidence and contradicted by the evidence on record; and (11) 15

when the Court of Appeals manifestly overlooked certain relevant facts not disputed by
the parties, which, if properly considered, would justify a different conclusion. 16

Considering that the CA’s findings with respect to the cause of Lilian’s death contradict
those of the RTC, this case falls under one of the exceptions. The Court will thus give
due course to the petition to dispel any perception that we denied the petitioner justice.

The requisites of establishing medical malpractice

Whoever alleges a fact has the burden of proving it. This is a basic legal principle that
equally applies to civil and criminal cases. In a medical malpractice case, the plaintiff has
the duty of proving its elements, namely: (1) a duty of the defendant to his patient; (2) the
defendant’s breach of this duty; (3) injury to the patient; and (4) proximate
causation between the breach and the injury suffered. In civil cases, the plaintiff must
17

prove these elements by a preponderance of evidence.

A medical professional has the duty to observe the standard of care and exercise the
degree of skill, knowledge, and training ordinarily expected of other similarly trained
medical professionals acting under the same circumstances. A breach of the accepted
18

standard of care constitutes negligence or malpractice and renders the defendant liable
for the resulting injury to his patient.
19

The standard is based on the norm observed by other reasonably competent members of
the profession practicing the same field of medicine. Because medical malpractice
20

cases are often highly technical, expert testimony is usually essential to establish: (1) the
standard of care that the defendant was bound to observe under the circumstances; (2)
that the defendant’s conduct fell below the acceptable standard; and (3) that the
defendant’s failure to observe the industry standard caused injury to his patient.21

The expert witness must be a similarly trained and experienced physician. Thus, a
pulmonologist is not qualified to testify as to the standard of care required of an
anesthesiologist and an autopsy expert is not qualified to testify as a specialist in
22

infectious diseases. 23

The petitioner failed to present an expert witness.

In ruling against the respondents, the RTC relied on the findings of Dr. Reyes in the light
of Dr. Avila’s opinion that the former’s testimony should be given greater weight than the
findings of Dr. Ramos and Dr. Hernandez. On the other hand, the CA did not consider Dr.
Reyes or Dr. Avila as expert witnesses and disregarded their testimonies in favor of Dr.
Ramos and Dr. Hernandez. The basic issue, therefore, is whose testimonies should carry
greater weight?

We join and affirm the ruling of the CA.

Other than their conclusion on the culpability of the respondents, the CA and the RTC
have similar factual findings. The RTC ruled against the respondents based primarily on
the following testimony of Dr. Reyes.

Witness: Well, if I remember right during my residency in my extensive training,

during the operation of the appendix, your Honor, it should really be sutured twice which
we call double.

Court: What would be the result if there is only single?

Witness: We cannot guarranty [sic] the bleeding of the sutured blood vessels, your
Honor.

Court: So, the bleeding of the patient was caused by the single suture?

Witness: It is possible. 24

Dr. Reyes testified that he graduated from the Manila Central University (MCU) College
of Medicine and passed the medical board exams in 1994. He established his personal
25
practice at his house clinic before being accepted as an on-the-job trainee in the
Department of Pathology at the V. Luna Hospital in 1994. In January 1996, he joined the
PNP Medico-Legal Division and was assigned to the Crime Laboratory in Camp Crame.
He currently heads the Southern Police District Medico-Legal division. His primary
26

duties are to examine victims of violent crimes and to conduct traumatic autopsies to
determine the cause of death.

After having conducted over a thousand traumatic autopsies, Dr. Reyes can be
considered an expert in traumatic autopsies or autopsies involving violent deaths.
However, his expertise in traumatic autopsies does not necessarily make him an expert
in clinical and pathological autopsies or in surgery.

Moreover, Dr. Reyes’ cross-examination reveals that he was less than candid about his
qualifications during his initial testimony:

Atty. Castro: Dr. Reyes, you mentioned during your direct testimony last March 5, 2002
that you graduated in March of 1994, is that correct?

Witness: Yes, sir.

Atty. Castro: You were asked by Atty. Fajardo, the counsel for the plaintiff, when did you
finish your medical works, and you answered the following year of your graduation which
was in 1994?

Witness: Not in 1994, it was in 1984, sir.

Atty. Castro: And after you graduated Mr. Witness, were there further study that you
undergo after graduation? [sic]

Witness: It was during my service only at the police organization that I was given the
chance to attend the training, one year course.

Atty. Castro: Did you call that what you call a post graduate internship?

Witness: Residency.

Atty. Castro: Since you call that a post graduate, you were not undergo post graduate?
[sic]

Witness: I did.

Atty. Castro: Where did you undergo a post graduate internship?

Witness: Before I took the board examination in the year 1984, sir.

Atty. Castro: That was where?

Witness: MCU Hospital, sir.

Atty. Castro: After the post graduate internship that was the time you took the board
examination?

Witness: Yes, sir.

Atty. Castro: And I supposed that you did it for the first take?

Witness: Yes, sir.

Atty. Castro: Are you sure of that?

Witness: Yes, sir.

Atty. Castro: After you took the board examination, did you pursue any study?

Witness: During that time, no sir.

Atty. Castro: You also testified during the last hearing that "page 6 of March 5, 2002,
answer of the witness: then I was accepted as on the job training at the V. Luna Hospital
at the Department of Pathologist in 1994", could you explain briefly all of this Mr. witness?

Witness: I was given an order that I could attend the training only as a civilian not as a
member of the AFP because at that time they were already in the process of discharging
civilian from undergoing training.

Atty. Castro: So in the Department of Pathology, what were you assigned to?

Witness: Only as an observer status.

Atty. Castro: So you only observed.

Witness: Yes, sir.

Atty. Castro: And on the same date during your direct testimony on March 5, 2002, part of
which reads "well if I remember right during my residency in my extensive training during
the operation of the appendix," what do you mean by that Mr. witness?

Witness: I was referring to my internship, sir.

Atty. Castro: So this is not a residency training?

Witness: No, sir.

Atty. Castro: This is not a specialty training?

Witness: No, sir.

Atty. Castro: This was the time the year before you took the board examination?

Witness: That’s right, sir. Yes, sir.

Atty. Castro: You were not then a license[d] doctor?

Witness: No, sir.

Atty. Castro: And you also mentioned during the last hearing shown by page 8 of the
same transcript of the stenographic notes, dated March 5, 2002 and I quote "and that is
your residence assignment?", and you answered "yes, sir." What was the meaning of
your answer? What do you mean when you say yes, sir?
 xxxx

Witness: Okay, I stayed at the barracks of the Southern Police District Fort
Bonifacio.

Atty. Castro: So this is not referring to any kind of training?

Witness: No, sir.

Atty. Castro: This is not in anyway related to appendicitis?

Witness: No, sir. 27

Atty. Reyes appears to have inflated his qualifications during his direct testimony. First,
his "extensive training during [his] residency" was neither extensive actual training, nor
part of medical residency. His assignment to the V. Luna Hospital was not as an on-the-
job trainee but as a mere observer. This assignment was also before he
was actually licensed as a doctor. Dr. Reyes also loosely used the terms "residence" and
"residency" – terms that carry a technical meaning with respect to medical practice –
during his initial testimony to refer to (1) his physical place of dwelling and (2) his
28

internship before taking the medical board exams. This misled the trial court into
believing that he was more qualified to give his opinion on the matter than he actually
was.

Perhaps nothing is more telling about Dr. Reyes’ lack of expertise in the subject matter
than the petitioner’s counsel’s own admission during Dr. Reyes’ cross examination.

Atty. Castro: How long were you assigned to observe with the Department of Pathology?

Witness: Only 6 months, sir.

Atty. Castro: During your studies in the medical school, Mr. Witness, do you recall
attending or having participated or [sic] what you call motivity mortality complex?

Atty. Fajardo: Your honor, what is the materiality?

Atty. Castro: That is according to his background, your honor. This is a procedure which
could more or less measure his knowledge in autopsy proceedings when he was in
medical school and compared to what he is actually doing now.

Atty. Fajardo: The witness is not an expert witness, your honor.

Atty. Castro: He is being presented as an expert witness, your honor. 29

When Atty. Castro attempted to probe Dr. Reyes about his knowledge on the subject of
medical or pathological autopsies, Dr. Fajardo objected on the ground that Dr. Reyes was
not an expert in the field. His testimony was offered to prove that Dr. Inso was negligent
during the surgery without necessarily offering him as an expert witness.

Atty. Fajardo: x x x The purpose of this witness is to establish that there was negligence
on the surgical operation of the appendix or in the conduct of the appendectomy by the
defendant doctor on the deceased Lilian Villaran Borromeo. 30

Dr. Reyes is not an expert witness who could prove Dr. Inso’s alleged negligence. His
testimony could not have established the standard of care that Dr. Inso was expected to
observe nor assessed Dr. Inso’s failure to observe this standard. His testimony cannot be
relied upon to determine if Dr. Inso committed errors during the operation, the severity of
these errors, their impact on Lilian’s probability of survival, and the existence of other
diseases/conditions that might or might not have caused or contributed to Lilian’s death.

The testimony of Dr. Avila also has no probative value in determining whether Dr. Inso
was at fault. Dr. Avila testified in his capacity as an expert in medical jurisprudence, not
as an expert in medicine, surgery, or pathology. His testimony fails to shed any light on
the actual cause of Lilian’s death.

On the other hand, the respondents presented testimonies from Dr. Inso himself and from
two expert witnesses in pathology and surgery.

Dr. Ramos graduated from the Far Eastern University, Nicanor Reyes Medical
Foundation, in 1975. He took up his post-graduate internship at the Quezon Memorial
Hospital in Lucena City, before taking the board exams. After obtaining his professional
license, he underwent residency training in pathology at the Jose R. Reyes Memorial
Center from 1977 to 1980. He passed the examination in Anatomic, Clinical, and Physical
Pathology in 1980 and was inducted in 1981. He also took the examination in anatomic
pathology in 1981 and was inducted in 1982. 31

At the time of his testimony, Dr. Ramos was an associate professor in pathology at the
Perpetual Help Medical School in Biñan, Laguna, and at the De La Salle University in
Dasmariñas, Cavite. He was the head of the Batangas General Hospital Teaching and
Training Hospital where he also headed the Pathology Department. He also headed the
Perpetual Help General Hospital Pathology department. 32

Meanwhile, Dr. Hernandez at that time was a General Surgeon with 27 years of
experience as a General Practitioner and 20 years of experience as a General
Surgeon. He obtained his medical degree from the University of Santo Tomas before
1âwphi1

undergoing five years of residency training as a surgeon at the Veterans Memorial Center
hospital. He was certified as a surgeon in 1985. He also holds a master’s degree in
Hospital Administration from the Ateneo de Manila University. 33

He was a practicing surgeon at the: St. Luke’s Medical Center, Fatima Medical Center,
Unciano Medical Center in Antipolo, Manila East Medical Center of Taytay, and Perpetual
Help Medical Center in Biñan. He was also an associate professor at the Department of
34

Surgery at the Fatima Medical Center, the Manila Central University, and the Perpetual
Help Medical Center. He also chaired the Department of Surgery at the Fatima Medical
Center.35

Dr. Hernandez is a Fellow of the American College of Surgeons, the Philippine College of
Surgeons, and the Philippine Society of General Surgeons. He is a Diplomate of the
Philippine Board of Surgery and a member of the Philippine Medical Association and the
Antipolo City Medical Society.36

Dr. Hernandez affirmed that Dr. Inso did not deviate from the usual surgical
procedure. Both experts agreed that Lilian could not have died from bleeding of the
37

appendical vessel. They identified Lilian’s cause of death as massive blood loss resulting
from DIC.

To our mind, the testimonies of expert witnesses Dr. Hernandez and Dr. Ramos carry far
greater weight than that of Dr. Reyes. The petitioner’s failure to present expert witnesses
resulted in his failure to prove the respondents’ negligence. The preponderance of
evidence clearly tilts in favor of the respondents.
Res ipsa loquitur is not applicable when the failure to observe due care is not
immediately apparent to the layman.

The petitioner cannot invoke the doctrine of res ipsa loquitur to shift the burden of
evidence onto the respondent. Res ipsa loquitur, literally, "the thing speaks for itself;" is a
rule of evidence that presumes negligence from the very nature of the accident itself
using common human knowledge or experience.

The application of this rule requires: (1) that the accident was of a kind which does not
ordinarily occur unless someone is negligent; (2) that the instrumentality or agency which
caused the injury was under the exclusive control of the person charged with negligence;
and (3) that the injury suffered must not have been due to any voluntary action or
contribution from the injured person. The concurrence of these elements creates a
38

presumption of negligence that, if unrebutted, overcomes the plaintiff’s burden of proof.

This doctrine is used in conjunction with the doctrine of common knowledge. We have
applied this doctrine in the following cases involving medical practitioners:

a. Where a patient who was scheduled for a cholecystectomy (removal of gall stones) but
was otherwise healthy suffered irreparable brain damage after being administered
anesthesia prior to the operation. 39

b. Where after giving birth, a woman woke up with a gaping burn wound close to her left
armpit;40

c. The removal of the wrong body part during the operation; and

d. Where an operating surgeon left a foreign object (i.e., rubber gloves) inside the body of
the patient.41

The rule is not applicable in cases such as the present one where the defendant’s
alleged failure to observe due care is not immediately apparent to a layman. These 42

instances require expert opinion to establish the culpability of the defendant doctor. It is
also not applicable to cases where the actual cause of the injury had been identified or
established. 43

While this Court sympathizes with the petitioner’s loss, the petitioner failed to present
sufficient convincing evidence to establish: (1) the standard of care expected of the
respondent and (2) the fact that Dr. Inso fell short of this expected standard. Considering
further that the respondents established that the cause of Lilian’s uncontrollable bleeding
(and, ultimately, her death) was a medical disorder – Disseminated Intravascular
Coagulation – we find no reversible errors in the CA’s dismissal of the complaint on
appeal.

WHEREFORE, we hereby DENY the petition for lack of merit. No costs.

SO ORDERED.

ARTURO D. BRION
Associate Justice

WE CONCUR:
 ANTONIO T. CARPIO
Associate Justice
Chairperson

MARIANO C. DEL CASTILLO JOSE CATRAL MENDOZA

Associate Justice Associate Justice

MARVIC M.V.F. LEONEN

Associate Justice

ATTE S TATI O N

I attest that the conclusions in the above Decision had been reached in consultation
before the case was assigned to the writer of the opinion of the Court's Division.

ANTONIO T. CARPIO
Associate Justice
Chairperson

C E RTI F I CATI O N

Pursuant to Section 13, Article VIII of the Constitution and the Division Chairperson's
Attestation, I certify that the conclusions in the above Decision had been reached in
consultation before the case was assigned to the writer of the opinion of the Court's
Division.

MARIA LOURDES P.A. SERENO

Chief Justice