RAMOS vs.

COURT OF APPEALS
G.R. No. 124354. December 29, 1999.

Ponente: Kapunan

FACTS:
Erlinda Ramos underwent a surgical procedure to remove stone from her gall bladder
(cholecystectomy). They hired Dr. Hosaka, a surgeon, to conduct the surgery at the De Los
Santos Medical Center (DLSMC). Hosaka assured them that he would find a good
anesthesiologist. But the operation did not go as planned, Dr. Hosaka arrived 3 hours late
for the operation, Dra. Gutierrez, the anesthesiologist “botched” the administration of the
anesthesia causing Erlinda to go into a coma and suffer brain damage. The botched
operation was witnessed by Herminda Cruz, sister in law of Erlinda and Dean of College of
Nursing of Capitol Medical Center.

The family of Ramos (petitioners) sued the hospital, the surgeon and the anesthesiologist
for damages. The petitioners showed expert testimony showing that Erlinda's condition was
caused by the anesthesiologist in not exercising reasonable care in “intubating” Erlinda.
Eyewitnesses heard the anesthesiologist saying “Ang hirap ma-intubate nito, mali yata ang
pagkakapasok. O lumalaki ang tiyan.”

Diagnostic tests prior to surgery showed that Erlinda was robust and fit to undergo surgery.

The RTC held that the anesthesiologist ommitted to exercise due care in intubating the
patient, the surgeon was remiss in his obligation to provide a “good anesthesiologist” and
for arriving 3 hours late and the hospital is liable for the negligence of the doctors and for
not cancelling the operation after the surgeon failed to arrive on time. The surgeon,
anesthesiologist and the DLSMC were all held jointly and severally liable for damages to
petitioners. The CA reversed the decision of the Trial Court.

ISSUES: Whether or not the private respondents were negligent and thereby caused the
comatose condition of Ramos.

HELD:
Yes, private respondents were all negligent and are solidarily liable for the damages.

RATIO:

Res ipsa loquitur – a procedural or evidentiary rule which means “the thing or the
transaction speaks for itself.” It is a maxim for the rule that the fact of the occurrence of an
injury, taken with the surrounding circumstances, may permit an inference or raise a
presumption of negligence, or make out a plaintiff’s prima facie case, and present a
question of fact for defendant to meet with an explanation, where ordinarily in a medical
malpractice case, the complaining party must present expert testimony to prove that the
attending physician was negligent.

This doctrine finds application in this case. On the day of the operation, Erlinda Ramos
already surrendered her person to the private respondents who had complete and exclusive
control over her. Apart from the gallstone problem, she was neurologically sound and fit.
Then, after the procedure, she was comatose and brain damaged—res ipsa loquitur!—the
thing speaks for itself!
Negligence – Private respondents were not able to disprove the presumption of negligence
on their part in the care of Erlinda and their negligence was the proximate cause of her
condition. One need not be an anesthesiologist in order to tell whether or not the intubation
was a success. [res ipsa loquitur applies here]. The Supreme Court also found that the
anesthesiologist only saw Erlinda for the first time on the day of the operation which
indicates unfamiliarity with the patient and which is an act of negligence and irresponsibility.

The head surgeon, Dr. Hosaka was also negligent. He failed to exercise the proper authority
as the “captain of the ship” in determining if the anesthesiologist observed the proper
protocols. Also, because he was late, he did not have time to confer with the
anesthesiologist regarding the anesthesia delivery.

The hospital failed to adduce evidence showing that it exercised the diligence of a good
father of the family in hiring and supervision of its doctors (Art. 2180). The hospital was
negligent since they are the one in control of the hiring and firing of their “consultants”.
While these consultants are not employees, hospitals still exert significant controls on the
selection and termination of doctors who work there which is one of the hallmarks of an
employer-employee reationship. Thus, the hospital was allocated a share in the liability.

Damages – temperate damages can and should be awarded on top of actual or

compensatory damages in instances where the injury is chronic and continuing.
Thursday, December 6, 2012

NOGALES vs CAPITOL MEDICAL CENTER Case Digest

ROGELIO NOGALES vs. CAPITOL MEDICAL CENTER et al.
G.R. No. 142625
December 19, 2006

Facts: Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 years old, was
under the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada") beginning on her fourth month
of pregnancy or as early as December 1975. Around midnight of 25 May 1976, Corazon started to
experience mild labor pains prompting Corazon and Rogelio Nogales ("Spouses Nogales") to see Dr.
Estrada at his home. After examining Corazon, Dr. Estrada advised her immediate admission to the
Capitol Medical Center ("CMC"). t 6:13 a.m., Corazon started to experience convulsionsAt 6:22 a.m.,
Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract Corazon's baby. In the process, a
1.0 x 2.5 cm. piece of cervical tissue was allegedly torn.At 6:27 a.m., Corazon began to manifest
moderate vaginal bleeding which rapidly became profuse. Corazon died at 9:15 a.m. The cause of
death was "hemorrhage, post partum.

Issue: Whether or not CMC is vicariously liable for the negligence of Dr. Estrada.

Ruling: Private hospitals, hire, fire and exercise real control over their attending and visiting
"consultant" staff. The basis for holding an employer solidarily responsible for the negligence of its
employee is found in Article 2180 of the Civil Code which considers a person accountable not only for
his own acts but also for those of others based on the former's responsibility under a relationship of
patria potestas.

In general, a hospital is not liable for the negligence of an independent contractor-physician. There is,
however, an exception to this principle. The hospital may be liable if the physician is the "ostensible"
agent of the hospital. This exception is also known as the "doctrine of apparent authority”.

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. In the instant case, CMC impliedly
held out Dr. Estrada as a member of its medical staff. Through CMC's acts, CMC clothed Dr. Estrada
with apparent authority thereby leading the Spouses Nogales to believe that Dr. Estrada was an
employee or agent of CMC.
PSI VS AGANA (GR NO. 126297 JANUARY 31, 2007)

Professional Services Inc. vs Agana

GR No. 126297 January 31, 2007

Facts: On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital because of difficulty of
bowel movement and bloody anal discharge. After a series of medical examinations, Dr. Miguel Ampil diagnosed her
to be suffering from Cancer of the sigmoid. On April 11, 1984, Dr. Ampil assisted by the medical staff of the Medical
City Hospital performed an Anterior resection surgery on Natividad. He found that the malignancy on her sigmoid
area had spread on her left ovary, necessitating the removal of certain portions of it. Thus, Dr. Ampil obtained the
consent of Natividad’s husband, Enrique Agana, to permit Dr. Juan Fuentes to perform hysterectomy on her. After
Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and closed the incision
after searching for the missing 2 gauzes as indicated by the assisting nurses but failed to locate it. After a couple of
days, Natividad complained of excruciating pains in her anal region but Dr. Ampil said it is a natural consequence of
the operation/surgery and recommended that she consult an oncologist to examine the cancerous nodes which were
not removed during the operation. Natividad and her husband went to the US to seek further treatment and she was
declared free from cancer. A piece of gauze portruding from Natividad’s vagina was found by her daughter which was
then removed by hand by Dr. Ampil and assured that the pains will vanished. However, it didn’t. The pains intensified
prompting Natividad to seek treatment at the Polymedic General Hospital. While confined there, Dr. Ramon Guttierez
detected the presence of another foreign object in her vagina – a foul smelling gauze measuring 1.5 inches in width
which badly infected her vagina. A recto-vaginal fistula had forced stool to excrete through her vagina. Another
surgical operation was needed to remedy the damage.

Issue: Whether or not Dr. Ampil and Fuentes are liable for medical malpractice and the PSI for damages due to the
negligence of the said doctors.

Held: Yes. No. Yes. An operation requiring the placing of sponges in the incision is not complete until the sponges
are properly removed and it is settled that the leaving of sponges or other foreign substances in the wound after the
incision has been closed is at least prima facie negligence by the operating surgeon. To put it simply, such act is
considered so inconsistent with due care as to raise inference of negligence. There are even legions of authorities to
the effect that such act is negligence per se.

This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully pursue this
kind of case, a patient must only prove that a health care provider either failed to do something which a reasonably
prudent health care provider would have done, or that he did something that a reasonably prudent provider would not
have done; and that failure or action caused injury to the patient. Simply puts the elements are duty, breach, injury,
and proximate causation. Dr. Ampil, as the lead surgeon, had the duty to remove all foreign objects, such as gauzes,
from Natividad’s body before closure of the incision. When he failed to do so, it was his duty to inform Natividad
about it. Dr. Ampil breached both duties. Such breach caused injury to Natividad, necessitating her further examination
by American doctors and another surgery. That Dr. Ampil’s negligence is the proximate cause of Natividad’s injury
could be traced from his act of closing the incision despite the information given by the attending nurses that 2 pieces
of gauze were still missing. That they were later on extracted from Natividad’s vagina established the causal link
between Dr. Ampil’s negligence and the injury. And what further aggravated such injury was his deliberate
concealment of this missing gauzes from the knowledge of Natividad and her family.

The requisites for the applicability of the doctrine of RES IPSA LIQUITOR are:

1. Occurrence of an injury;
2. The thing which caused the injury was under the control and management of the defendant;
3. The occurrence was such that in the ordinary course of things would not have happened if those
who had control or management used proper care, and;
4. The absence of explanation by the defendant
Of the foregoing, the most instrumental is the “Control and management of the thing which caused the injury.”

Under the “Captain of the ship” rule, the operating surgeon is the person in complete charge of the surgery room and
all personnel connected with the operation.

The knowledge of any of the staff of Medical City constitutes knowledge of PSI.

The doctrine of corporate responsibility, has the duty to see that it meets the standards of responsibilities for the care
of patients. Such duty includes the proper supervision of the members of its medical staff. The hospital accordingly
has the duty to make a reasonable effort to monitor and over see the treatment prescribed and administered by the
physician practicing in its premises.