v.
CA
FACTS:
At
about
9:15
in
the
evening
of
16
September
1995,
Raymond
S.
Olavere
(Raymond),
a
victim
of
a
stabbing
incident,
was
rushed
to
the
emergency
room
of
the
Bicol
Regional
Medical
Center
(BRMC).
There,
Raymond
was
attended
to
by
Nurse
Balares
and
Dr.
Realuyo
the
emergency
room
resident
physician.
Subsequently,
the
parents
of
Raymond
the
spouses
Deogenes
Olavere
(Deogenes)
and
Fe
R.
Serrano
arrived
at
the
BRMC.
They
were
accompanied
by
one
Andrew
Olavere,
the
uncle
of
Raymond.
After
extending
initial
medical
treatment
to
Raymond,
Dr.
Realuyo
recommended
that
the
patient
undergo
"emergency
exploratory
laparotomy."
Dr.
Realuyo
then
requested
the
parents
of
Raymond
to
procure
500
cc
of
type
"O"
blood
needed
for
the
operation.
Complying
with
the
request,
Deogenes
and
Andrew
Olavere
went
to
the
Philippine
National
Red
Cross
to
secure
the
required
blood.
At
10:30
P.M.,
Raymond
was
wheeled
inside
the
operating
room.
During
that
time,
the
hospital
surgeons,
Drs.
Zafe
and
Cereno,
were
busy
operating
on
gunshot
victim
Charles
Maluluy-on.
Assisting
them
in
the
said
operation
was
Dr.
Rosalina
Tatad
(Dr.
Tatad),
who
was
the
only
senior
anesthesiologist
on
duty
at
BRMC
that
night.
Dr.
Tatad
also
happened
to
be
the
head
of
Anesthesiology
Department
of
the
BRMC.
Just
before
the
operation
on
Maluluy-on
was
finished,
another
emergency
case
involving
Lilia
Aguila,
a
woman
who
was
giving
birth
to
triplets,
was
brought
to
the
operating
room.
At
10:59
P.M.,
the
operation
on
Charles
Maluluy-on
was
finished.
By
that
time,
however,
Dr.
Tatad
was
already
working
with
the
obstetricians
who
will
perform
surgery
on
Lilia
Aguila.
There
being
no
other
available
anesthesiologist
to
assist
them,
Drs.
Zafe
and
Cereno
decided
to
defer
the
operation
on
Raymond.
Drs.
Zafe
and
Cereno,
in
the
meantime,
proceeded
to
examine
Raymond
and
they
found
that
the
latters
blood
pressure
was
normal
and
"nothing
in
him
was
significant."
Dr.
Cereno
reported
that
based
on
the
xray
result
he
interpreted,
the
fluid
inside
the
thoracic
cavity
of
Raymond
was
minimal
at
around
200-300
cc.
At
11:15
P.M.,
Deogenes
and
Andrew
Olavere
returned
to
the
BRMC
with
a
bag
containing
the
requested
500
cc
type
"O"
blood.
They
handed
over
the
bag
of
blood
to
Dr.
Realuyo.
After
Dr.
Tatad
finished
her
work
with
the
Lilia
Aguila
operation,
petitioners
immediately
started
their
operation
on
Raymond
at
around
12:15
A.M.
of
17
September
1995.
Upon
opening
of
Raymonds
thoracic
cavity,
they
found
that
3,200
cc
of
blood
was
stocked
therein.
The
blood
was
evacuated
and
petitioners
found
a
puncture
at
the
inferior
pole
of
the
left
lung.
In
his
testimony,
Dr.
Cereno
stated
that
considering
the
loss
of
blood
suffered
by
Raymond,
he
did
not
immediately
transfuse
blood
because
he
had
to
control
the
bleeders
first.
Blood
was
finally
transfused
on
Raymond
at
1:40
A.M.
At
1:45
A.M.,
while
the
operation
was
on-going,
Raymond
suffered
a
cardiac
arrest.
The
operation
ended
at
1:50
A.M.
and
Raymond
was
pronounced
dead
at
2:30
A.M.
Raymonds
death
certificate
indicated
that
the
immediate
cause
of
death
was
"hypovolemic
shock"
or
the
cessation
of
the
functions
of
the
organs
of
the
body
due
to
loss
of
blood.
Claiming
that
there
was
negligence
on
the
part
of
those
who
attended
to
their
son,
the
parents
of
Raymond,
on
25
October
1995,
filed
before
the
RTC,
Branch
22,
Naga
City
a
complaint
for
damages7
against
Nurse
Balares,
Dr.
Realuyo
and
attending
surgeons
Dr.
Cereno
and
Dr.
Zafe.
the
case
against
dr
realuyo
and
balares
was
dismissed.
Dr.
cereno
and
dr
zafe
found
guilty
and
ordered
to
pay
for
damages.
The
trial
court
found
petitioners
negligent
in
not
immediately
conducting
surgery
on
Raymond.
It
noted
that
petitioners
have
already
finished
operating
on
Charles
Maluluy-on
as
early
as
10:30
in
the
evening,
and
yet
they
only
started
the
operation
on
Raymond
at
around
12:15
early
morning
of
the
following
day.
The
trial
court
held
that
had
the
surgery
been
performed
promptly,
Raymond
would
not
have
lost
so
much
blood
and,
therefore,
could
have
been
saved.10
The
trial
court
also
held
that
the
non-availability
of
Dr.
Tatad
after
the
operation
on
Maluluy-on
was
not
a
sufficient
excuse
for
the
petitioners
to
not
immediately
operate
on
Raymond.
It
called
attention
to
the
testimony
of
Dr.
Tatad
herself,
which
disclosed
the
possibility
of
calling
a
standby
anesthesiologist
in
that
situation.
The
trial
court
opined
that
the
petitioners
could
have
just
requested
for
the
standby
anesthesiologist
from
Dr.
Tatad,
but
they
did
not.
Lastly,
the
trial
court
faulted
petitioners
for
the
delay
in
the
transfusion
of
blood
on
Raymond.
On
appeal,
the
CA
in
a
decision
dated
21
February
2005
affirmed
in
toto
the
judgment
rendered
by
the
RTC
finding
herein
petitioners
guilty
of
gross
negligence
in
the
performance
of
their
duties
and
awarding
damages
to
private
respondents.
ISSUE:
Whether
or
not
Dr.
Cereno
and
Dr.
Zafe
are
guilty
of
gross
negligence
in
the
performance
of
their
duties.
HELD:
No.
Causation
Not
Proven
In
medical
negligence
cases,
it
is
settled
that
the
complainant
has
the
burden
of
establishing
breach
of
duty
on
the
part
of
the
doctors
or
surgeons.
It
must
be
proven
that
such
breach
of
duty
has
a
causal
connection
to
the
resulting
death
of
the
patient.
A
verdict
in
malpractice
action
cannot
be
based
on
speculation
or
conjecture.
Causation
must
be
proven
within
a
reasonable
medical
probability
based
upon
competent
expert
testimony.
The
parents
of
Raymond
failed
in
this
respect.
Aside
from
their
failure
to
prove
negligence
on
the
part
of
the
petitioners,
they
also
failed
to
prove
that
it
was
petitioners
fault
that
caused
the
injury.
Their
cause
stands
on
the
mere
assumption
that
Raymonds
life
would
have
been
saved
had
petitioner
surgeons
immediately
operated
on
him;
had
the
blood
been
cross-matched
immediately
and
had
the
blood
been
transfused
immediately.
There
was,
however,
no
proof
presented
that
Raymonds
life
would
have
been
saved
had
those
things
been
done.
Those
are
mere
assumptions
and
cannot
guarantee
their
desired
result.
Such
cannot
be
made
basis
of
a
decision
in
this
case,
especially
considering
that
the
name,
reputation
and
career
of
petitioners
are
at
stake.
The
Court
understands
the
parents
grief
over
their
sons
death.
That
notwithstanding,
it
cannot
hold
petitioners
liable.
It
was
noted
that
Raymond,
who
was
a
victim
of
a
stabbing
incident,
had
multiple
wounds
when
brought
to
the
hospital.
Upon
opening
of
his
thoracic
cavity,
it
was
discovered
that
there
was
gross
bleeding
inside
the
body.
Thus,
the
need
for
petitioners
to
control
first
what
was
causing
the
bleeding.
Despite
the
situation
that
evening
i.e.
numerous
patients
being
brought
to
the
hospital
for
emergency
treatment
considering
that
it
was
the
height
of
the
Peafrancia
Fiesta,
it
was
evident
that
petitioners
exerted
earnest
efforts
to
save
the
life
of
Raymond.
It
was
just
unfortunate
that
the
loss
of
his
life
was
not
prevented.
In
the
case
of
Dr.
Cruz
v.
CA,
it
was
held
that
doctors
are
protected
by
a
special
law.
They
are
not
guarantors
of
care.
They
do
not
even
warrant
a
good
result.
They
are
not
insurers
against
mishaps
or
unusual
consequences.
Furthermore,
they
are
not
liable
for
honest
mistake
of
judgment"
This
Court
affirms
the
ruling
of
the
CA
that
the
BRMC
is
not
an
indispensible
party.
The
core
issue
as
agreed
upon
by
the
parties
and
stated
in
the
pre-trial
order
is
whether
petitioners
were
negligent
in
the
performance
of
their
duties.
It
pertains
to
acts/omissions
of
petitioners
for
which
they
could
be
held
liable.
The
cause
of
action
against
petitioners
may
be
prosecuted
fully
and
the
determination
of
their
liability
may
be
arrived
at
without
impleading
the
hospital
where
they
are
employed.
As
such,
the
BRMC
cannot
be
considered
an
indispensible
party
without
whom
no
final
determination
can
be
had
of
an
action.
BATIQUIN
V
COURT
OF
APPEALS
FACTS:
Mrs.
Villegas
submitted
to
Dr.
Batiquin
for
prenatal
care
as
the
latter's
private
patient
sometime
before
September
21,1988.
In
the
morning
of
September
21,
1988
Dr.
Batiquin,
along
with
other
physicians
and
nurses,
performed
a
caesarean
operation
on
Mrs.
Villegas
and
successfully
delivered
the
latters
baby.
After
leaving
the
hospital,
Mrs.
Villegas
began
to
suffer
abdominal
pains
and
complained
of
being
feverish.
She
also
gradually
lost
her
appetite,
so
she
consulted
Dr.
Batiquin
at
the
latter's
polyclinic
who
prescribed
for
her
certain
medicines.
However,
the
pains
still
kept
recurring.
She
then
consulted
Dr.Ma.
Salud
Kho.
After
examining
her,
Dr
Kho
suggested
that
Mrs.Villegas
submit
to
another
surgery.-
When
Dr.
Kho
opened
the
abdomen
of
Mrs.
Villegas
she
found
whitish-yellow
discharge
inside,
an
ovarian
cyst
on
each
of
the
left
and
right
ovaries
which
gave
out
pus,
dirt
and
pus
behind
the
uterus,
and
a
piece
of
rubber
material
on
the
right
side
of
the
uterus,
embedded
on
the
ovarian
cyst.
The
piece
of
rubber
appeared
to
be
a
part
of
a
rubber
glove.
This
was
the
cause
of
all
of
the
infection
of
the
ovaries
and
consequently
of
all
the
discomfort
suffered
by
Mrs.
Villegas.
The
piece
of
rubber
allegedly
found
was
not
presented
in
court,
and
Dr.
Kho
testified
that
she
sent
it
to
a
pathologist
in
Cebu
City
for
examination.
Aside
from
Dr.
Kho's
testimony,
the
evidence
which
mentioned
the
piece
of
rubber
are
a
Medical
Certificate,
a
Progress
Record,
an
Anaesthesia
Record,
a
Nurse's
Record,
and
a
Physician's
Discharge
Summary.
The
trial
court,
however,
regarded
these
documentary
evidence
as
mere
hearsay,
"there
being
no
showing
that
the
person
or
persons
who
prepared
them
are
deceased
or
unable
to
testify
on
the
facts
therein
stated-
There
was
also
doubts
as
to
the
whereabouts
of
the
piece
of
rubber,
as
2
versions
arose
from
Dr.
Khos
testimony:
1)
that
it
was
sent
to
the
Pathologist
in
Cebu
as
testified
to
in
Court
by
Dr.
Kho
and
(2)
that
Dr.
Kho
threw
it
away
as
told
by
her
to
Defendant.
The
failure
of
the
Plaintiffs
to
reconcile
these
two
different
versions
served
only
to
weaken
their
claim
against
Defendant
Batiquin.
The
trial
court
ruled
in
favor
of
the
defendants.
The
CA
reversed
the
decision.
ISSUE:
Whether
or
not
Dr.
Batiquin
is
liable
HELD:
The
focal
point
of
the
appeal
is
Dr.
Khos
testimony.
There
were
inconsistencies
within
her
own
testimony,
which
led
to
the
different
decision
of
the
RTC
and
CA.
The
CA
was
correct
in
saying
that
the
trial
court
erred
when
it
isolated
the
disputed
portion
of
Dr.
Khos
testimony
and
did
not
consider
it
with
other
portions
of
Dr.
Khos
testimony.
Also,
the
phrase
relied
upon
by
the
trial
court
does
not
negate
the
fact
that
Dr.
Kho
saw
a
piece
of
rubber
in
private
respondent
Villegas'
abdomen,
and
that
she
sent
it
to
a
laboratory
and
then
to
Cebu
City
for
examination
by
a
pathologist.
Furthermore,
Dr.
Kho's
knowledge
of
the
piece
of
rubber
could
not
be
based
on
other
than
first
hand
knowledge
for,
as
she
asserted
before
the
trial
court.
RAMOS
v.
Court
of
Appeals
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
plaintiffs
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
damagedres
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.
CASUMPANG
v.
CORTEJO
G.R.
No.
171127
|
March
11,
2015
FACTS:
On
April
22,
1988,
at
about
11:30
in
the
morning,
Mrs.
Cortejo
brought
her
11-
year
old
son,
Edmer,
to
the
Emergency
Room
of
the
San
Juan
de
Dios
Hospital
(SJDH)
because
of
difficulty
in
breathing,
chest
pain,
stomach
pain,
and
fever.
Thereafter,
she
was
referred
and
assigned
to
Dr.
Casumpang,
a
pediatrician.
At
5:30
in
the
afternoon
of
the
same
day,
Dr.
Casumpang,
upon
examination
using
only
a
stethoscope,
confirmed
the
diagnosis
of
Bronchopneumonia.
Mrs.
Cortejo
immediately
advised
Dr.
Casumpang
that
Edmer
had
a
high
fever,
and
had
no
colds
or
cough
but
Dr.
Casumpang
merely
told
her
that
her
son's
bloodpressure
is
just
being
active
and
remarked
that
that's
the
usual
bronchopneumonia,
no
colds,
no
phlegm.
Dr.
Casumpang
next
visited
the
following
day.
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
and
reassured
Mrs.
Cortejo
that
Edmer's
illness
is
bronchopneumonia.
At
around
11:30
in
the
morning
of
April
23,
1988,
Edmer
vomited
phlegm
with
blood
streak
prompting
the
Edmer's
father
to
request
for
a
doctor.
Later,
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.
She
then
advised
the
respondent
to
preserve
the
specimen
for
examination.
Thereafter,
Dr.
Miranda
conducted
a
check-up
on
Edmer
and
found
that
Edmer
had
a
low-grade
fever
and
rashes.
At
3:00
in
the
afternoon,
Edmer
once
again
vomited
blood.
Dr.
Miranda
then
examined
Edmer's
sputum
with
blood
and
noted
that
he
was
bleeding.
Suspecting
that
he
could
be
afflicted
with
dengue,
Dr.
Miranda
conducted
a
tourniquet
test,
which
turned
out
to
be
negative.
Dr.
Miranda
then
called
up
Dr.
Casumpang
at
his
clinic
and
told
him
about
Edmer's
condition.
Upon
being
informed,
Dr.
Casumpang
ordered
several
procedures
done.
Dr.
Miranda
advised
Edmer's
parents
that
the
blood
test
results
showed
that
Edmer
was
suffering
from
Dengue
Hemorrhagic
Fever.
Dr.
Casumpang
recommended
Edmers
transfer
to
the
ICU,
but
since
the
ICU
was
then
full,
the
respondent,
insisted
on
transferring
his
son
to
Makati
Medical
Center.
At
12:00
midnight,
Edmer,
accompanied
by
his
parents
and
by
Dr.
Casumpang,
was
transferred
to
Makati
Medical
Center.
Upon
examination,
the
attending
physician
diagnosed
Dengue
Fever
Stage
IV
that
was
already
in
its
irreversible
stage.
Edmer
died
at
4:00
in
the
morning
of
April
24,
1988.
His
Death
Certificate
indicated
the
cause
of
death
as
Hypovolemic
Shock/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.
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.
Dr.
Miranda
argued
that
the
function
of
making
the
diagnosis
and
undertaking
the
medical
treatment
devolved
upon
Dr.
Casumpang,
the
doctor
assigned
to
Edmer.
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.
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;
hence,
Article
2180
of
the
Civil
Code
does
not
apply.
ISSUES:
1. W/N
Casumpang
had
committed
inexcusable
lack
of
precaution
in
diagnosing
and
in
treating
the
patient
2. W/N
Miranda
had
committed
inexcusable
lack
of
precaution
in
diagnosing
and
in
treating
the
patient
3. W/N
Whether
or
not
the
petitioner
hospital
is
solidarity
liable
with
the
petitioner
doctors
4. W/N
or
not
there
is
a
causal
connection
between
the
petitioners'
negligent
act/omission
and
the
patient's
resulting
death
HELD/RATIO:
1. YES,
Casumpang
was
negligent.
Even
assuming
that
Edmer's
symptoms
completely
coincided
with
the
diagnosis
of
bronchopneumonia,
we
still
find
Dr.
Casumpang
guilty
of
negligence.
Wrong
diagnosis
is
not
by
itself
medical
malpractice.
Physicians
are
generally
not
liable
for
damages
resulting
from
a
bona
fide
error
of
judgment
and
from
acting
according
to
acceptable
medical
practice
standards.
Nonetheless,
when
the
physician's
erroneous
diagnosis
was
the
result
of
negligent
conduct,
it
becomes
an
evidence
of
medical
malpractice.
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.
Apart
from
failing
to
promptly
detect
dengue
fever,
Dr.
Casumpang
also
failed
to
promptly
undertake
the
proper
medical
management
needed
for
this
disease.
Dr.
Casumpang
failed
to
measure
up
to
the
acceptable
medical
standards
in
diagnosing
and
treating
dengue
fever.
Dr.
Casumpang's
claim
that
he
exercised
prudence
and
due
diligence
in
handling
Edmer's
case,
sside
from
being
self-serving,
is
not
supported
by
competent
evidence.
He
failed,
as
a
medical
professional,
to
observe
the
most
prudent
medical
procedure
under
the
circumstances
in
diagnosing
and
treating
Edmer.
2. No,
Dr.
Miranda
is
not
liable
for
negligence.
We
find
that
Dr.
Miranda
was
not
independently
negligent.
Although
she
was
subject
to
the
same
standard
of
care
applicable
to
attending
physicians,
as
a
resident
physician,
she
merely
operates
as
a
subordinate
who
usually
refer
to
the
attending
physician
on
the
decision
to
be
made
and
on
the
action
to
be
taken.
We
also
believe
that
a
finding
of
negligence
should
also
depend
on
several
competing
factors.
In
this
case,
before
Dr.
Miranda
attended
to
Edmer,
Dr.
Casumpang
had
diagnosed
Edmer
with
bronchopneumonia.
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,
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.
Dr.
Miranda's
error
was
merely
an
honest
mistake
of
judgment;
hence,
she
should
not
be
held
liable
for
medical
negligence.
3. Yes,
causal
connection
between
the
petitioners'
negligence
and
the
patient's
resulting
death
was
established
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,
and
promptly
administered
the
proper
care
and
management
needed
for
dengue
fever,
the
risk
of
complications
or
even
death,
could
have
been
substantially
reduced.
That
Edmer
later
died
of
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.
The
element
of
causation
is
successfully
proven.
4. YES,
SJDH
is
solidarily
liable.
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.
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.
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
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.
NOGALES
v.
CAPITOL
MEDICAL
CENTER
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.
While
Corazon
was
on
her
last
trimester
of
pregnancy,
Dr.
Estrada
noted
an
increase
in
her
blood
pressure
and
development
of
leg
edema
indicating
preeclampsia,
which
is
a
dangerous
complication
of
pregnancy.
Around
midnight
of
25
May
1976,
Corazon
started
to
experience
mild
labor
pains
prompting
Corazon
and
Rogelio
Nogales
(Spouses
Nogales)
to
see
Dr.
Estrada
at
his
home.
After
examining
Corazon,
Dr.
Estrada
advised
her
immediate
admission
to
the
Capitol
Medical
Center
(CMC).
The
following
day,
Corazon
was
admitted
at
2:30
a.m.
at
the
CMC
after
the
staff
nurse
noted
the
written
admission
request
of
Dr.
Estrada.
Upon
Corazons
admission
at
the
CMC,
Rogelio
Nogales
(Rogelio)
executed
and
signed
the
Consent
on
Admission
and
Agreement
and
Admission
Agreement.
Corazon
was
then
brought
to
the
labor
room
of
the
CMC.
Corazon
died
at
9:15
a.m.
The
cause
of
death
was
hemorrhage,
post
partum.
Petitioners
filed
a
complaint
for
damages
with
the
Regional
Trial
Court
of
Manila
against
CMC,
Dr.
Estrada,
and
the
rest
of
CMC
medical
staff
for
the
death
of
Corazon.
In
their
defense,
CMC
pointed
out
that
Dr.
Estrada
was
a
consultant
to
be
considered
as
an
independent-contractor,
and
that
no
employer-employee
relationship
existed
between
the
former
and
the
latter.
After
more
than
11
years
of
trial,
the
trial
court
rendered
judgment
on
22
November
1993
finding
Dr.
Estrada
solely
liable
for
damages.
Petitioners
appealed
the
trial
courts
decision.
Petitioners
claimed
that
aside
from
Dr.
Estrada,
the
remaining
respondents
should
be
held
equally
liable
for
negligence.
Petitioners
pointed
out
the
extent
of
each
respondents
alleged
liability.
On
appeal,
the
Court
of
Appeals
affirmed
the
trial
courts
ruling
and
applied
the
borrowed
servant
doctrine
to
release
the
liability
of
other
medical
staff.
This
doctrine
provides
that
once
the
surgeon
enters
the
operating
room
and
takes
charge
of
the
proceedings,
the
acts
or
omissions
of
operating
room
personnel,
and
any
negligence
associated
with
such
acts
or
omissions,
are
imputable
to
the
surgeon.
While
the
assisting
physicians
and
nurses
may
be
employed
by
the
hospital,
or
engaged
by
the
patient,
they
normally
become
the
temporary
servants
or
agents
of
the
surgeon
in
charge
while
the
operation
is
in
progress,
and
liability
may
be
imposed
upon
the
surgeon
for
their
negligent
acts
under
the
doctrine
of
respondeat
superior.
ISSUE:
Whether
CMC
is
vicariously
liable
for
the
negligence
of
Dr.
Estrada
as
its
attending
independent-contractor
physician
considering
that
facts
of
the
instant
case.
HELD:
YES.
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.xxx
The
doctrine
of
apparent
authority
essentially
involves
two
factors
to
determine
the
liability
of
an
independent-contractor
physician.
The
first
factor
focuses
on
the
hospitals
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.
xxx
The
second
factor
focuses
on
the
patients
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.
xxx
In
the
instant
case,
CMC
impliedly
held
out
Dr.
Estrada
as
a
member
of
its
medical
staff.
Through
CMCs
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.
CMC
cannot
now
repudiate
such
authority.
The
records
show
that
the
Spouses
Nogales
relied
upon
a
perceived
employment
relationship
with
CMC
in
accepting
Dr.
Estradas
services.
Rogelio
testified
that
he
and
his
wife
specifically
chose
Dr.
Estrada
to
handle
Corazons
delivery
not
only
because
of
their
friends
recommendation,
but
more
importantly
because
of
Dr.
Estradas
connection
with
a
reputable
hospital,
the
[CMC].
In
other
words,
Dr.
Estradas
relationship
with
CMC
played
a
significant
role
in
the
Spouses
Nogales
decision
in
accepting
Dr.
Estradas
services
as
the
obstetrician-gynecologist
for
Corazons
delivery.
Moreover,
as
earlier
stated,
there
is
no
showing
that
before
and
during
Corazons
confinement
at
CMC,
the
Spouses
Nogales
knew
or
should
have
known
that
Dr.
Estrada
was
not
an
employee
of
CMC.
xxx
CMCs
defense
that
all
it
did
was
to
extend
to
[Corazon]
its
facilities
is
untenable.
The
Court
cannot
close
its
eyes
to
the
reality
that
hospitals,
such
as
CMC,
are
in
the
business
of
treatment.
xxx
The
Court
finds
respondent
Capitol
Medical
Center
vicariously
liable
for
the
negligence
of
Dr.
Oscar
Estrada.
The
amounts
of
P105,000
as
actual
damages
and
P700,000
as
moral
damages
should
each
earn
legal
interest
at
the
rate
of
six
percent
(6%)
per
annum
computed
from
the
date
of
the
judgment
of
the
trial
court.
The
Court
affirms
the
rest
of
the
Decision
dated
6
February
1998
and
Resolution
dated
21
March
2000
of
the
Court
of
Appeals
in
CA-G.R.
CV
No.
45641.
PROFESSIONAL
SERVICES
v.
AGANA
FACTS
Natividad
Agana
was
rushed
to
Medical
City
because
of
difficulty
of
bowel
movement
and
bloody
anal
discharge.
Dr.
Ampil
diagnosed
her
to
be
suffering
from
cancer
of
the
sigmoid.
Dr.
Ampil
performed
an
anterior
resection
surgery
on
her,
and
finding
that
the
malignancy
spread
on
her
left
ovary,
he
obtained
the
consent
of
her
husband,
Enrique,
to
permit
Dr.
Fuentes
to
perform
hysterectomy
on
her.
After
the
hysterectomy,
Dr.
Fuentes
showed
his
work
to
Dr.
Ampil,
who
examined
it
and
found
it
in
order,
so
he
allowed
Dr.
Fuentes
to
leave
the
operating
room.
Dr.
Ampil
was
about
to
complete
the
procedure
when
the
attending
nurses
made
some
remarks
on
the
Record
of
Operation:
sponge
count
lacking
2;
announced
to
surgeon
search
done
but
to
no
avail
continue
for
closure
(two
pieces
of
gauze
were
missing).
A
diligent
search
was
conducted
but
they
could
not
be
found.
Dr.
Ampil
then
directed
that
the
incision
be
closed.
A
couple
of
days
after,
she
complained
of
pain
in
her
anal
region,
but
the
doctors
told
her
that
it
was
just
a
natural
consequence
of
the
surgery.
Dr.
Ampil
recommended
that
she
consult
an
oncologist
to
examine
the
cancerous
nodes
which
were
not
removed
during
the
operation.
After
months
of
consultations
and
examinations
in
the
US,
she
was
told
that
she
was
free
of
cancer.
Weeks
after
coming
back,
her
daughter
found
a
piece
of
gauze
(1.5
in)
protruding
from
her
vagina,
so
Dr.
Ampil
manually
extracted
this,
assuring
Natividad
that
the
pains
will
go
away.
However,
the
pain
worsened,
so
she
sought
treatment
at
a
hospital,
where
another
1.5
in
piece
of
gauze
was
found
in
her
vagina.
She
underwent
another
surgery.
Sps.
Agana
filed
a
complaint
for
damages
against
PSI
(owner
of
Medical
City),
Dr.
Ampil,
and
Dr.
Fuentes,
alleging
that
the
latter
are
liable
for
negligence
for
leaving
2
pieces
of
gauze
in
Natividads
body,
and
malpractice
for
concealing
their
acts
of
negligence.
Enrique
Agana
also
filed
an
administrative
complaint
for
gross
negligence
and
malpractice
against
the
two
doctors
with
the
PRC
(although
only
the
case
against
Dr.
Fuentes
was
heard
since
Dr.
Ampil
was
abroad).
Pending
the
outcome
of
the
cases,
Natividad
died
(now
substituted
by
her
children).
RTC
found
PSI
and
the
two
doctors
liable
for
negligence
and
malpractice.
PRC
dismissed
the
case
against
Dr.
Fuentes.
CA
dismissed
only
the
case
against
Fuentes.
ISSUE
AND
HOLDING
1. WON
CA
erred
in
holding
Dr.
Ampil
liable
for
negligence
and
malpractice.
NO;
DR.
AMPIL
IS
GUILTY
2. WON
CA
erred
in
absolving
Dr.
Fuentes
of
any
liability.
NO
3. WON
PSI
may
be
held
solidarily
liable
for
Dr.
Ampils
negligence.
YES
RATIO
DR.
AMPIL
IS
LIABLE
FOR
NEGLIGENCE
AND
MALPRACTICE
His
arguments
are
without
basis
[did
not
prove
that
the
American
doctors
were
the
ones
who
put
/
left
the
gauzes;
did
not
submit
evidence
to
rebut
the
correctness
of
the
operation
record
(re:
number
of
gauzes
used);
re:
Dr.
Fuentes
alleged
negligence,
Dr.
Ampil
examined
his
work
and
found
it
in
order].
Leaving
foreign
substances
in
the
wound
after
incision
has
been
closed
is
at
least
prima
facie
negligence
by
the
operating
surgeon.
Even
if
it
has
been
shown
that
a
surgeon
was
required
to
leave
a
sponge
in
his
patients
abdomen
because
of
the
dangers
attendant
upon
delay,
still,
it
is
his
legal
duty
to
inform
his
patient
within
a
reasonable
time
by
advising
her
of
what
he
had
been
compelled
to
do,
so
she
can
seek
relief
from
the
effects
of
the
foreign
object
left
in
her
body
as
her
condition
might
permit.
Whats
worse
in
this
case
is
that
he
misled
her
by
saying
that
the
pain
was
an
ordinary
consequence
of
her
operation.
Medical
negligence;
standard
of
diligence
To
successfully
pursue
this
case
of
medical
negligence,
a
patient
must
only
prove
that
a
health
care
provider
either
failed
to
do
something
[or
did
something]
which
a
reasonably
prudent
health
care
provider
would
have
done
[or
wouldnt
have
done],
and
that
the
failure
or
action
caused
injury
to
the
patient.
Duty
to
remove
all
foreign
objects
from
the
body
before
closure
of
the
incision;
if
he
fails
to
do
so,
it
was
his
duty
to
inform
the
patient
about
it
Breach
failed
to
remove
foreign
objects;
failed
to
inform
patient
Injury
suffered
pain
that
necessitated
examination
and
another
surgery
Proximate
Causation
breach
caused
this
injury;
could
be
traced
from
his
act
of
closing
the
incision
despite
information
given
by
the
attendant
nurses
that
2
pieces
of
gauze
were
still
missing;
what
established
causal
link:
gauze
pieces
later
extracted
from
patients
vagina
DR.
FUENTES
NOT
LIABLE
The
res
ipsa
loquitur
[thing
speaks
for
itself]
argument
of
the
Aganas
does
not
convince
the
court.
Mere
invocation
and
application
of
this
doctrine
does
not
dispense
with
the
requirement
of
proof
of
negligence.
Requisites
for
the
applicability
of
res
ipsa
loquitur
1. Occurrence
of
injury
2. Thing
which
caused
injury
was
under
the
control
and
management
of
the
defendant
[DR.
FUENTES]
LACKING
SINCE
CTRL+MGT
WAS
WITH
DR.
AMPIL
3. Occurrence
was
such
that
in
the
ordinary
course
of
things,
would
not
have
happened
if
those
who
had
control
or
management
used
proper
care
4. Absence
of
explanation
by
defendant
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.
That
Dr.
Ampil
discharged
such
role
is
evident
from
the
following:
He
called
Dr.
Fuentes
to
perform
a
hysterectomy
He
examined
Dr.
Fuentes
work
and
found
it
in
order
He
granted
Dr.
Fuentes
permission
to
leave
He
ordered
the
closure
of
the
incision
HOSPITAL
OWNER
PSI
SOLIDARILY
LIABLE
WITH
DR.
AMPIL
[NCC
2180],
AND
DIRECTLY
LIABLE
TO
SPS.
AGANAS
[NCC
2176]
Previously,
employers
cannot
be
held
liable
for
the
fault
or
negligence
of
its
professionals.
However,
this
doctrine
has
weakened
since
courts
came
to
realize
that
modern
hospitals
are
taking
a
more
active
role
in
supplying
and
regulating
medical
care
to
its
patients,
by
employing
staff
of
physicians,
among
others.
Hence,
there
is
no
reason
to
exempt
hospitals
from
the
universal
rule
of
respondeat
superior.
Here
are
the
Courts
bases
for
sustaining
PSIs
liability:
Ramos
v.
CA
doctrine
on
E-E
relationship
o For
purposes
of
apportioning
responsibility
in
medical
negligence
cases,
an
employer-employee
relationship
in
effect
exists
between
hospitals
and
their
attending
and
visiting
physicians.
[LABOR
LESSON:
power
to
hire,
fire,
power
of
control]
Agency
principle
of
apparent
authority
/
agency
by
estoppel
o Imposes
liability
because
of
the
actions
of
a
principal
or
employer
in
somehow
misleading
the
public
into
believing
that
the
relationship
or
the
authority
exists
[see
NCC
1869]
o PSI
publicly
displays
in
the
Medical
City
lobby
the
names
and
specializations
of
their
physicians.
Hence,
PSI
is
now
estopped
from
passing
all
the
blame
to
the
physicians
whose
names
it
proudly
paraded
in
the
public
directory,
leading
the
public
to
believe
that
it
vouched
for
their
skill
and
competence.
FACTS:
Nora
remained
unconscious
until
she
recovered.
While
in
the
recovery
room,
her
husband,
respondent
John
David
Z.
Go
noticed
a
fresh
gasping
wound
2
1/2
x
3
1/2
in
the
inner
portion
of
her
left
arm,
close
to
the
armpit.
He
asked
the
nurses
what
caused
the
injury.
He
was
informed,
it
was
a
burn.
An
investigation
was
filed
by
Noras
husband
and
found
out
from
the
petitioner
that
it
was
caused
by
the
blood
pressure
cuff,
however,
this
was
contrary
to
the
findings
from
a
medico-legal
report
which
stated
that
it
was
indeed
a
burn
and
that
a
drop
light
when
placed
near
a
skin
for
about
10mins
could
cause
such
burn.
Nora
was
referred
to
a
plastic
surgeon
from
the
hospital
and
skin
grafting
was
done
on
her
and
scar
revision
but
both
still
left
a
mark
on
Noras
arm
compelling
the
respondent
spouse
to
file
a
complaint
for
damages
against
petitioner.
ISSUE:
HELD:
In
cases,
involving
medical
negligence,
the
doctrine
of
res
ipsa
liquitor
allows
the
mere
existence
of
an
injury
to
justify
a
presumption
of
negligence
on
the
part
of
the
person
who
controls
the
instrument
causing
the
injury,
provided
that
the
following
requisites
concur:
1. The
accident
is
of
a
kind
which
ordinarily
does
not
occur
in
the
absence
of
someones
negligence;
2. It
is
caused
by
an
instrumentality
within
the
exclusive
control
of
the
defendant
or
defendants;
3. The
possibility
of
contributing
conduct
which
would
make
the
plaintiff
responsible
is
eliminated.
Under
the
the
captain
of
the
ship
doctrine,
the
surgeon
in
charge
of
the
operation
is
liable
for
the
negligence
of
his
assistants
during
the
time
when
those
are
under
the
surgeons
control.