MENDOZA, JJ.
Promulgated:
x --------------------------------------------------------------------------------------- x
DECISION
MENDOZA, J.:
Even early on, patients have consigned their lives to the skill of their doctors. Time and
again, it can be said that the most important goal of the medical profession is the
preservation of life and health of the people. Corollarily, when a physician departs from
his sacred duty and endangers instead the life of his patient, he must be made liable for
the resulting injury. This Court, as this case would show, cannot and will not let the act
go unpunished.[1]
This is a petition for review under Rule 45 of the Rules of Court challenging the August
29, 2008 Decision[2] of the Court of Appeals (CA), and its May 19, 2009 Resolution[3]
in CA-G.R. CR No. 29559, dismissing the appeal and affirming in toto the June 14,
2005 Decision[4] of the Regional Trial Court, Branch 43, Manila (RTC), finding the
accused guilty beyond reasonable doubt of simple imprudence resulting to serious
physical injuries.
THE FACTS
Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of
Investigation (NBI) against the petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr.
Marilou Bastan (Dr. Bastan), for their alleged neglect of professional duty which caused
her son, Roy Alfonso Santiago (Roy Jr.), to suffer serious physical injuries. Upon
investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was rushed to the
Manila Doctors Hospital for an emergency medical treatment; that an X-ray of the
victims ankle was ordered; that the X-ray result showed no fracture as read by Dr.
Jarcia; that Dr. Bastan entered the emergency room (ER) and, after conducting her own
examination of the victim, informed Mrs. Santiago that since it was only the ankle that
was hit, there was no need to examine the upper leg; that eleven (11) days later, Roy Jr.
developed fever, swelling of the right leg and misalignment of the right foot; that Mrs.
Santiago brought him back to the hospital; and that the X-ray revealed a right mid-tibial
fracture and a linear hairline fracture in the shaft of the bone.
The NBI indorsed the matter to the Office of the City Prosecutor of Manila for
preliminary investigation. Probable cause was found and a criminal case for reckless
imprudence resulting to serious physical injuries, was filed against Dr. Jarcia, Dr. Bastan
and Dr. Pamittan,[5] before the RTC, docketed as Criminal Case No. 01-196646.
On , the RTC found the petitioners guilty beyond reasonable doubt of the crime of Simple Imprudence
Resulting to Serious Physical Injuries. The decretal portion of the RTC decision reads:
WHEREFORE, premises considered, the Court finds accused DR. EMMANUEL JARCIA, JR.
and DR. MARILOU BASTAN GUILTY beyond reasonable doubt of the crime of SIMPLE
IMPRUDENCE RESULTING TO SERIOUS PHYSICAL INJURIES and are hereby sentenced
to suffer the penalty of ONE (1) MONTH and ONE (1) DAY to TWO (2) MONTHS and to
indemnify MRS. BELINDA SANTIAGO the amount of ₱3,850.00 representing medical
expenses without subsidiary imprisonment in case of insolvency and to pay the costs.
It appearing that Dr. Pamittan has not been apprehended nor voluntarily surrendered despite
warrant issued for her arrest, let warrant be issued for her arrest and the case against her be
ARCHIVED, to be reinstated upon her apprehension.
SO ORDERED.[6]
The RTC explained:
After a thorough and in depth evaluation of the evidence adduced by the prosecution and the
defense, this court finds that the evidence of the prosecution is the more credible, concrete
and sufficient to create that moral certainty in the mind of the Court that accused herein [are]
criminally responsible. The Court believes that accused are negligent when both failed to
exercise the necessary and reasonable prudence in ascertaining the extent of injury of Alfonso
Santiago, Jr.
However, the negligence exhibited by the two doctors does not approximate negligence of a
reckless nature but merely amounts to simple imprudence. Simple imprudence consists in the
lack of precaution displayed in those cases in which the damage impending to be caused is not
the immediate nor the danger clearly manifest. The elements of simple imprudence are as
follows.
1. that there is lack of precaution on the part of the offender;
and
2. that the damage impending to be caused is not immediate
of the danger is not clearly manifest.
Considering all the evidence on record, The Court finds the
accused guilty for simple imprudence resulting to physical
injuries. Under Article 365 of the Revised Penal Code, the
penalty provided for is arresto mayor in its minimum period.
[7]
Dissatisfied, the petitioners appealed to the CA.
As earlier stated, the CA affirmed the RTC decision in toto. The Decision of the CA pertinently reads:
This Court holds concurrently and finds the foregoing circumstances sufficient to sustain a
judgment of conviction against the accused-appellants for the crime of simple imprudence
resulting in serious physical injuries. The elements of imprudence are: (1) that the offender
does or fails to do an act; (2) that the doing or the failure to do that act is voluntary; (3) that it
be without malice; (4) that material damage results from the imprudence; and (5) that there is
inexcusable lack of precaution on the part of the offender, taking into consideration his
employment or occupation, degree of intelligence, physical condition, and other
circumstances regarding persons, time and place.
Whether or not Dr. Jarcia and Dr. Bastan had committed an inexcusable lack of precaution in
the treatment of their patient is to be determined according to the standard of care observed
by other members of the profession in good standing under similar circumstances, bearing in
mind the advanced state of the profession at the time of treatment or the present state of
medical science. In the case of Leonila Garcia-Rueda v. Pascasio, the Supreme Court stated
that, in accepting a case, a doctor in effect represents that, having the needed training and
skill possessed by physicians and surgeons practicing in the same field, he will employ such
training, care and skill in the treatment of his patients. He therefore has a duty to use at least
the same level of care that any other reasonably competent doctor would use to treat a
condition under the same circumstances.
In litigations involving medical negligence, the plaintiff has the burden of establishing
accused-appellants negligence, and for a reasonable conclusion of negligence, there must be
proof of breach of duty on the part of the physician as well as a causal connection of such
breach and the resulting injury of his patient. 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. Negligence,
no matter in what it consists, cannot create a right of action unless it is the proximate cause of
the injury complained of. 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.
In the case at bench, the accused-appellants questioned the imputation against them and
argued that there is no causal connection between their failure to diagnose the fracture and
the injury sustained by .
We are not convinced.
The prosecution is however after the cause which prolonged the pain and suffering of and not
on the failure of the accused-appellants to correctly diagnose the extent of the injury sustained
by .
For a more logical presentation of the discussion, we shall first consider the applicability of
the doctrine of res ipsa loquitur to the instant case. Res ipsa loquitur is a Latin phrase which
literally means the thing or the transaction speaks for itself. The doctrine of res ipsa loquitur
is simply a recognition of the postulate that, as a matter of common knowledge and
experience, the very nature of certain types of occurrences may justify an inference of
negligence on the part of the person who controls the instrumentality causing the injury in the
absence of some explanation by the accused-appellant who is charged with negligence. It is
grounded in the superior logic of ordinary human experience and, on the basis of such
experience or common knowledge, negligence may be deduced from the mere occurrence of
the accident itself. Hence, res ipsa loquitur is applied in conjunction with the doctrine of
common knowledge.
The specific acts of negligence was narrated by Mrs. Santiago who accompanied her son
during the latters ordeal at the hospital. She testified as follows:
Fiscal Formoso:
Q: Now, he is an intern did you not consult the doctors, Dr.
Jarcia or Dra. Pamittan to confirm whether you should go
home or not?
A: Dra. Pamittan was inside the cubicle of the nurses and I
asked her, you let us go home and you dont even clean the
wounds of my son.
Q: And what did she [tell] you?
A: They told me they will call a resident doctor, sir.
xxxxxxxxx
Q: Was there a resident doctor [who] came?
A: Yes, Sir. Dra. Bastan arrived.
Q: Did you tell her what you want on you to be done?
A: Yes, sir.
Q: What did you [tell] her?
A: I told her, sir, while she was cleaning the wounds of my
son, are you not going to x-ray up to the knee because my
son was complaining pain from his ankle up to the middle
part of the right leg.
Q: And what did she tell you?
A: According to Dra. Bastan, there is no need to x-ray
because it was the ankle part that was run over.
Q: What did you do or tell her?
A: I told her, sir, why is it that they did not examine[x] the
whole leg. They just lifted the pants of my son.
Q: So you mean to say there was no treatment made at all?
A: None, sir.
xxxxxxxxx
A: I just listened to them, sir. And I just asked if I will still
return my son.
xxxxxxxxx
Q: And you were present when they were called?
A: Yes, sir.
Q: And what was discussed then by Sis. Retoria?
A: When they were there they admitted that they have
mistakes, sir.
Still, before resort to the doctrine may be allowed, the following requisites must be
satisfactorily shown:
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; and
3. The possibility of contributing conduct which would make
the plaintiff responsible is eliminated.
In the above requisites, the fundamental element is the control of the instrumentality which
caused the damage. Such element of control must be shown to be within the dominion of the
accused-appellants. In order to have the benefit of the rule, a plaintiff, in addition to proving
injury or damage, must show a situation where it is applicable and must establish that the
essential elements of the doctrine were present in a particular incident. The early treatment of
the leg of would have lessen his suffering if not entirely relieve him from the fracture. A boy of
tender age whose leg was hit by a vehicle would engender a well-founded belief that his
condition may worsen without proper medical attention. As junior residents who only practice
general surgery and without specialization with the case consulted before them, they should
have referred the matter to a specialist. This omission alone constitutes simple imprudence on
their part. When Mrs. Santiago insisted on having another x-ray of her child on the upper part
of his leg, they refused to do so. The mother would not have asked them if they had no
exclusive control or prerogative to request an x-ray test. Such is a fact because a radiologist
would only conduct the x-ray test upon request of a physician.
The testimony of Mrs. Santiago was corroborated by a bone specialist Dr. Tacata. He further
testified based on his personal knowledge, and not as an expert, as he examined himself the
child Roy. He testified as follows:
Fiscal Macapagal:
Q: And was that the correct respon[se] to the medical
problem that was presented to Dr. Jarcia and Dra. Bastan?
A: I would say at that stage, yes. Because they have
presented the patient and the history. At sabi nila,
nadaanan lang po ito. And then, considering their year of
residency they are still junior residents, and they are not
also orthopedic residents but general surgery residents, its
entirely different thing. Because if you are an orthopedic
resident, I am not trying to saybut if I were an orthopedic
resident, there would be more precise and accurate decision
compare to a general surgery resident in so far as involved.
Q: You mean to say there is no supervisor attending the
emergency room?
A: At the emergency room, at the Manila Doctors Hospital,
the supervisor there is a consultant that usually comes from
a family medicine. They see where a certain patient have to
go and then if they cannot manage it, they refer it to the
consultant on duty. Now at that time, I dont [know] why
they dont.Because at that time, I think, it is the decision.
Since the x-rays.
Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to
whether a patient has been treated or operated upon with a reasonable degree of skill and
care. However, testimony as to the statements and acts of physicians, external appearances,
and manifest conditions which are observable by any one may be given by non-expert
witnesses. Hence, in cases where the res ipsa loquitur is applicable, the court is permitted to
find a physician negligent upon proper proof of injury to the patient, without the aid of expert
testimony, where the court from its fund of common knowledge can determine the proper
standard of care. Where common knowledge and experience teach that a resulting injury
would not have occurred to the patient if due care had been exercised, an inference of
negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur
without medical evidence, which is ordinarily required to show not only what occurred but
how and why it occurred. In the case at bench, we give credence to the testimony of Mrs.
Santiago by applying the doctrine of res ipsa loquitur.
Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be
cautiously applied, depending upon the circumstances of each case. It is generally restricted to
situations in malpractice cases where a layman is able to say, as a matter of common
knowledge and observation, that the consequences of professional care were not as such as
would ordinarily have followed if due care had been exercised. A distinction must be made
between the failure to secure results and the occurrence of something more unusual and not
ordinarily found if the service or treatment rendered followed the usual procedure of those
skilled in that particular practice. The latter circumstance is the primordial issue that
confronted this Court and we find application of the doctrine of res ipsa loquitur to be in
order.
WHEREFORE, in view of the foregoing, the appeal in this case is hereby DISMISSED and the
assailed decision of the trial court finding accused-appellants guilty beyond reasonable doubt
of simple imprudence resulting in serious physical injuries is hereby AFFIRMED in toto.
SO ORDERED.[8]
The petitioners filed a motion for reconsideration, but it was denied by the CA in its Resolution.
GROUNDS-
1. IN AFFIRMING ACCUSED-PETITIONERS CONVICTION, THE COURT OF APPEALS
ERRED IN NOT HOLDING THAT THE ACTUAL, DIRECT, IMMEDIATE, AND
PROXIMATE CAUSE OF THE PHYSICAL INJURY OF THE PATIENT (FRACTURE OF
THE LEG BONE OR TIBIA), WHICH REQUIRED MEDICAL ATTENDANCE FOR MORE
THAN THIRTY (30) DAYS AND INCAPACITATED HIM FROM PERFORMING HIS
CUSTOMARY DUTY DURING THE SAME PERIOD OF TIME, WAS THE VEHICULAR
ACCIDENT WHERE THE PATIENTS RIGHT LEG WAS HIT BY A TAXI, NOT THE
FAILURE OF THE ACCUSED-PETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG
TO AN X-RAY EXAMINATION.
2. THE COURT OF APPEALS ERRED IN DISREGARDING ESTABLISHED FACTS
CLEARLY NEGATING PETITIONERS ALLEGED NEGLIGENCE OR IMPRUDENCE.
SIGNIFICANTLY, THE COURT OF APPEALS UNJUSTIFIABLY DISREGARDED THE
OPINION OF THE PROSECUTIONS EXPERT WITNESS, DR. CIRILO TACATA, THAT
PETITIONERS WERE NOT GUILTY OF NEGLIGENCE OR IMPRUDENCE COMPLAINED
OF.
3. THE COURT OF APPEALS ERRED IN HOLDING THAT THE FAILURE OF
PETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY EXAMINATION
PROLONGED THE PAIN AND SUFFERING OF THE PATIENT, SUCH CONCLUSION
BEING UNSUPPORTED BY, AND EVEN CONTRARY TO, THE EVIDENCE ON RECORD.
4. ASSUMING ARGUENDO THAT THE PATIENT EXPERIENCED PROLONGED PAIN AND
SUFFERING, THE COURT OF APPEALS ERRED IN NOT HOLDING THAT THE ALLEGED
PAIN AND SUFFERING WERE DUE TO THE UNJUSTIFIED FAILURE OF THE PATIENTS
MOTHER, A NURSE HERSELF, TO IMMEDIATELY BRING THE PATIENT BACK TO THE
HOSPITAL, AS ADVISED BY THE PETITIONERS, AFTER HE COMPLAINED OF SEVERE
PAIN IN HIS RIGHT LEG WHEN HE REACHED HOME AFTER HE WAS SEEN BY
PETITIONERS AT THE HOSPITAL. THUS, THE PATIENTS ALLEGED INJURY
(PROLONGED PAIN AND SUFFERING) WAS DUE TO HIS OWN MOTHERS ACT OR
OMISSION.
5. THE COURT OF APPEALS ERRED IN NOT HOLDING THAT NO PHYSICIAN-PATIENT
RELATIONSHIP EXISTED BETWEEN PETITIONERS AND PATIENT ALFONSO
SANTIAGO, JR., PETITIONERS NOT BEING THE LATTERS ATTENDING PHYSICIAN AS
THEY WERE MERELY REQUESTED BY THE EMERGENCY ROOM (ER) NURSE TO SEE
THE PATIENT WHILE THEY WERE PASSING BY THE ER FOR THEIR LUNCH.
6. THE COURT OF APPEALS GRAVELY ERRED IN NOT ACQUITTING ACCUSED-
PETITIONERS OF THE CRIME CHARGED.[9]
The foregoing can be synthesized into two basic issues: [1] whether or not the doctrine of res ipsa
loquitur is applicable in this case; and [2] whether or not the petitioners are liable for criminal
negligence.
The CA is correct in finding that there was negligence on the part of the petitioners.
After a perusal of the records, however, the Court is not convinced that the petitioners
are guilty of criminal negligence complained of. The Court is also of the view that the
CA erred in applying the doctrine of res ipsa loquitur in this particular case.
As to the Application of
The Doctrine of Res Ipsa Loquitur
This doctrine of res ipsa loquitur means "Where the thing which causes injury is shown
to be under the management of the defendant, and the accident is such as in the ordinary
course of things does not happen if those who have the management use proper care, it
affords reasonable evidence, in the absence of an explanation by the defendant, that the
accident arose from want of care." The Black's Law Dictionary defines the said doctrine.
Thus:
The thing speaks for itself. Rebuttable presumption or inference that defendant was negligent,
which arises upon proof that the instrumentality causing injury was in defendant's exclusive
control, and that the accident was one which ordinarily does not happen in absence of
negligence. Res ipsa loquitur is a rule of evidence whereby negligence of the alleged
wrongdoer may be inferred from the mere fact that the accident happened provided the
character of the accident and circumstances attending it lead reasonably to belief that in the
absence of negligence it would not have occurred and that thing which caused injury is shown
to have been under the management and control of the alleged wrongdoer. Under this
doctrine, the happening of an injury permits an inference of negligence where plaintiff
produces substantial evidence that the injury was caused by an agency or instrumentality
under the exclusive control and management of defendant, and that the occurrence was such
that in the ordinary course of things would not happen if reasonable care had been used.[10]
The doctrine of res ipsa loquitur as a rule of evidence is unusual to the law of negligence
which recognizes that prima facie negligence may be established without direct proof
and furnishes a substitute for specific proof of negligence. The doctrine, however, is not
a rule of substantive law, but merely a mode of proof or a mere procedural convenience.
The rule, when applicable to the facts and circumstances of a given case, is not meant to
and does not dispense with the requirement of proof of culpable negligence on the party
charged. It merely determines and regulates what shall be prima facie evidence thereof
and helps the plaintiff in proving a breach of the duty. The doctrine can be invoked when
and only when, under the circumstances involved, direct evidence is absent and not
readily available.[11]
The requisites for the application of the doctrine of res ipsa loquitur are: (1) the accident
was of a kind which does not ordinarily occur unless someone is negligent; (2) the
instrumentality or agency which caused the injury was under the exclusive control of the
person in charge; and (3) the injury suffered must not have been due to any voluntary
action or contribution of the person injured.[12]
In this case, the circumstances that caused patient Roy Jr.s injury and the series of tests
that were supposed to be undergone by him to determine the extent of the injury suffered
were not under the exclusive control of Drs. Jarcia and Bastan. It was established that
they are mere residents of the at that time who attended to the victim at the emergency
room.[13] While it may be true that the circumstances pointed out by the courts below
seem doubtless to constitute reckless imprudence on the part of the petitioners, this
conclusion is still best achieved, not through the scholarly assumptions of a layman like
the patients mother, but by the unquestionable knowledge of expert witness/es. As to
whether the petitioners have exercised the requisite degree of skill and care in treating
patient Roy, Jr. is generally a matter of expert opinion.
The elements of simple negligence are: (1) that there is lack of precaution on the part of
the offender, and (2) that the damage impending to be caused is not immediate or the
danger is not clearly manifest.[16]
In this case, the Court is not convinced with moral certainty that the petitioners are
guilty of reckless imprudence or simple negligence. The elements thereof were not
proved by the prosecution beyond reasonable doubt.
The testimony of Dr. Cirilo R. Tacata (Dr. Tacata), a specialist in pediatric orthopedic,
although pointing to some medical procedures that could have been done by Dr. Jarcia
and Dr. Bastan, as physicians on duty, was not clear as to whether the injuries suffered
by patient Roy Jr. were indeed aggravated by the petitioners judgment call and their
diagnosis or appreciation of the condition of the victim at the time they assessed him.
Thus:
Q: Will you please tell us, for the record, doctor, what is your specialization?
A: At present I am the chairman department of orthopedic in UP-PGH and I had special
training in pediatric orthopedic for two (2) years.
Q: In June 1998, doctor, what was your position and what was your specialization at that
time?
A: Since 1980, I have been specialist in pediatric orthopedic.
Q: When Alfonso Santiago, Jr. was brought to you by his mother, what did you do by way of
physicians as first step?
A: As usual, I examined the patient physically and, at that time as I have said, the patient
could not walk so I [began] to suspect that probably he sustained a fracture as a result of a
vehicular accident. So I examined the patient at that time, the involved leg, I dont know if that
is left or right, the involved leg then was swollen and the patient could not walk, so I requested
for the x-ray of [the] lower leg.
Q: What part of the leg, doctor, did you request to be examined?
A: If we refer for an x-ray, usually, we suspect a fracture whether in approximal, middle or
lebistal tinial, we usually x-ray the entire extremity.
Q: And what was the result?
A: Well, I can say that it was a spiral fracture of the mid-tibial, it is the bigger bone of the leg.
Q: And when you say spiral, doctor, how long was this fracture?
A: When we say spiral, it is a sort of letter S, the length was about six (6) to eight (8)
centimeters.
Q: Mid-tibial, will you please point to us, doctor, where the tibial is?
(Witness pointing to his lower leg)
A: The tibial is here, there are two bones here, the bigger one is the tibial and the smaller one
is the fibula. The bigger one is the one that get fractured.
Q: And in the course of your examination of Alfonso Santiago, Jr. did you ask for the history of
such injury?
A: Yes, actually, that was a routine part of our examination that once a patient comes in,
before we actually examine the patient, we request for a detailed history. If it is an accident,
then, we request for the exact mechanism of injuries.
Q: And as far as you can recall, Doctor, what was the history of that injury that was told to
you?
A: The patient was sideswiped, I dont know if it is a car, but it is a vehicular accident.
Q: Who did you interview?
A: The mother.
Q: How about the child himself, Alfonso Santiago, Jr.?
A: Normally, we do not interview the child because, usually, at his age, the answers are not
accurate. So, it was the mother that I interviewed.
Q: And were you informed also of his early medication that was administered on Alfonso
Santiago, Jr.?
A: No, not actually medication. I was informed that this patient was seen initially at the
emergency room by the two (2) physicians that you just mentioned, Dr. Jarcia and Dra.
Bastan, that time who happened to be my residents who were [on] duty at the emergency
room.
xxxx
A: At the emergency room, at the Manila Doctors Hospital, the supervisor there is a
consultant that usually comes from a family medicine. They see where a certain patient have
to go and then if they cannot manage it, they refer it to the consultant on duty. Now at that
time, I dont why they dont Because at that time, I think, it is the decision. Since the x-rays
xxx
Q: You also said, Doctor, that Dr. Jarcia and Dra. Bastan are not even an orthopedic specialist.
A: They are general surgeon residents. You have to man[x] the emergency room, including
neurology, orthopedic, general surgery, they see everything at the emergency room.
xxxx
Q: But if initially, Alfonso Santiago, Jr. and his case was presented to you at the emergency room,
you would have subjected the entire foot to x-ray even if the history that was given to Dr. Jarcia
and Dra. Bastan is the same?
A: I could not directly say yes, because it would still depend on my examination, we cannot
subject the whole body for x-ray if we think that the damaged was only the leg.
Q: Not the entire body but the entire leg?
A: I think, if my examination requires it, I would.
Q: So, you would conduct first an examination?
A: Yes, sir.
Q: And do you think that with that examination that you would have conducted you would
discover the necessity subjecting the entire foot for x-ray?
A: It is also possible but according to them, the foot and the ankle were swollen and not the leg,
which sometimes normally happens that the actual fractured bone do not get swollen.
xxxx
Q: Doctor, if you know that the patient sustained a fracture on the ankle and on the foot and the
history that was told to you is the region that was hit is the region of the foot, will the doctor
subject the entire leg for x-ray?
A: I am an orthopedic surgeon, you have to subject an x-ray of the leg. Because you have to
consider the kind of fracture that the patient sustained would you say the exact mechanism of
injury. For example spiral, paikot yung bale nya, so it was possible that the leg was run over, the
patient fell, and it got twisted. Thats why the leg seems to be fractured.[17] [Emphases supplied]
It can be gleaned from the testimony of Dr. Tacata that a thorough examination was not
performed on Roy Jr. As residents on duty at the emergency room, Dr. Jarcia and Dr.
Bastan were expected to know the medical protocol in treating leg fractures and in
attending to victims of car accidents. There was, however, no precise evidence and
scientific explanation pointing to the fact that the delay in the application of the cast to
the patients fractured leg because of failure to immediately diagnose the specific injury
of the patient, prolonged the pain of the child or aggravated his condition or even caused
further complications. Any person may opine that had patient Roy Jr. been treated
properly and given the extensive X-ray examination, the extent and severity of the
injury, spiral fracture of the mid-tibial part or the bigger bone of the leg, could have been
detected early on and the prolonged pain and suffering of Roy Jr. could have been
prevented. But still, that opinion, even how logical it may seem would not, and could
not, be enough basis to hold one criminally liable; thus, a reasonable doubt as to the
petitioners guilt.
Although the Court sympathizes with the plight of the mother and the child in this case,
the Court is bound by the dictates of justice which hold inviolable the right of the
accused to be presumed innocent until proven guilty beyond reasonable doubt. The
Court, nevertheless, finds the petitioners civilly liable for their failure to sufficiently
attend to Roy Jr.s medical needs when the latter was rushed to the ER, for while a
criminal conviction requires proof beyond reasonable doubt, only a preponderance of
evidence is required to establish civil liability. Taken into account also was the fact that
there was no bad faith on their part.
Dr. Jarcia and Dr. Bastan cannot pass on the liability to the taxi driver who hit the
victim. It may be true that the actual, direct, immediate, and proximate cause of the
injury (fracture of the leg bone or tibia) of Roy Jr. was the vehicular accident when he
was hit by a taxi. The petitioners, however, cannot simply invoke such fact alone to
excuse themselves from any liability. If this would be so, doctors would have a ready
defense should they fail to do their job in attending to victims of hit-and-run,
maltreatment, and other crimes of violence in which the actual, direct, immediate, and
proximate cause of the injury is indubitably the act of the perpetrator/s.
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.
This Court cannot also stamp its imprimatur on the petitioners contention that no
physician-patient relationship existed between them and patient Roy Jr., since they were
not his attending physicians at that time. They claim that they were merely requested by
the ER nurse to see the patient while they were passing by the ER for their lunch.
Firstly, this issue was never raised during the trial at the RTC or even before the CA.
The petitioners, therefore, raise the want of doctor-patient relationship for the first time
on appeal with this Court. It has been settled that issues raised for the first time on
appeal cannot be considered because a party is not permitted to change his theory on
appeal. To allow him to do so is unfair to the other party and offensive to the rules of fair
play, justice and due process.[18] Stated differently, basic considerations of due process
dictate that theories, issues and arguments not brought to the attention of the trial court
need not be, and ordinarily will not be, considered by a reviewing court.[19]
Assuming again for the sake of argument that the petitioners may still raise this issue of
no physicianpatient relationship, the Court finds and so holds that there was a
physicianpatient relationship in this case.
In the case of Lucas v. Tuao,[20] the Court wrote that [w]hen a patient engages the
services of a physician, a physician-patient relationship is generated. And in accepting a
case, the physician, for all intents and purposes, represents that he has the needed
training and skill possessed by physicians and surgeons practicing in the same field; and
that he will employ such training, care, and skill in the treatment of the patient. Thus, in
treating his patient, a physician is under a duty to exercise that degree of care, skill and
diligence which physicians in the same general neighborhood and in the same general
line of practice ordinarily possess and exercise in like cases. Stated otherwise, the
physician has the obligation to use at least the same level of care that any other
reasonably competent physician would use to treat the condition under similar
circumstances.
To repeat for clarity and emphasis, if these doctors knew from the start that they were
not in the position to attend to Roy Jr., a vehicular accident victim, with the degree of
diligence and commitment expected of every doctor in a case like this, they should have
not made a baseless assurance that everything was all right. By doing so, they deprived
Roy Jr. of adequate medical attention that placed him in a more dangerous situation than
he was already in. What petitioners should have done, and could have done, was to refer
Roy Jr. to another doctor who could competently and thoroughly examine his injuries.
All told, the petitioners were, indeed, negligent but only civilly, and not criminally,
liable as the facts show.
Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in the
states:
A physician should attend to his patients faithfully and conscientiously. He should secure for
them all possible benefits that may depend upon his professional skill and care. As the sole
tribunal to adjudge the physicians failure to fulfill his obligation to his patients is, in most
cases, his own conscience, violation of this rule on his part is discreditable and inexcusable.
[22]
Established medical procedures and practices, though in constant instability, are devised for the
purpose of preventing complications. In this case, the petitioners failed to observe the most prudent
medical procedure under the circumstances to prevent the complications suffered by a child of tender
age.
As to the Award of
Damages
While no criminal negligence was found in the petitioners failure to administer the
necessary medical attention to Roy Jr., the Court holds them civilly liable for the
resulting damages to their patient. While it was the taxi driver who ran over the foot or
leg of Roy Jr., their negligence was doubtless contributory.
It appears undisputed that the amount of ₱3,850.00, as expenses incurred by patient Roy
Jr., was adequately supported by receipts. The Court, therefore, finds the petitioners
liable to pay this amount by way of actual damages.
The Court is aware that no amount of compassion can suffice to ease the sorrow felt by
the family of the child at that time. Certainly, the award of moral and exemplary
damages in favor of Roy Jr. in the amount of ₱100,000.00 and ₱50,000.00, respectively,
is proper in this case.
It is settled that moral damages are not punitive in nature, but are designed to
compensate and alleviate in some way the physical suffering, mental anguish, fright,
serious anxiety, besmirched reputation, wounded feelings, moral shock, social
humiliation, and similar injury unjustly inflicted on a person. Intended for the restoration
of the psychological or emotional status quo ante, the award of moral damages is
designed to compensate emotional injury suffered, not to impose a penalty on the
wrongdoer.[23]
The Court, likewise, finds the petitioners also liable for exemplary damages in the said amount. Article
2229 of the Civil Code provides that exemplary damages may be imposed by way of example or
correction for the public good.
WHEREFORE, the petition is PARTLY GRANTED. The Decision of the Court of
Appeals dated is REVERSED and SET ASIDE. A new judgment is entered
ACQUITTING Dr. Emmanuel Jarcia, Jr. and Dr. Marilou Bastan of the crime of
reckless imprudence resulting to serious physical injuries but declaring them civilly
liable in the amounts of:
with interest at the rate of 6% per annum from the date of the filing of the Information.
The rate shall be 12% interest per annum from the finality of judgment until fully paid.
SO ORDERED.
Petitioner, Present:
- versus - , C.J.,
CARPIO,
CARPIO MORALES,
VELASCO, JR.,
NACHURA,
LEONARDO-DE CASTRO,
BRION,
PERALTA,
BERSAMIN,
CASTILLO,*
ABAD,
VILLARAMA, JR.,
PEREZ,
, and
SERENO, JJ.
Respondents.
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
DECISION
VILLARAMA, JR., J.:
Challenged in this petition for review on certiorari is the Decision[1] dated as well as the
Resolution[2] dated of the Court of Appeals (CA) in CA-G.R. CV No. 58013 which
modified the Decision[3] dated of the , Branch 8 in Civil Case No. 8904.
On , Angelica was admitted to SLMC. However, she died on , just eleven (11) days after
the (intravenous) administration of the first cycle of the chemotherapy regimen. Because
SLMC refused to release a death certificate without full payment of their hospital bill,
respondents brought the cadaver of Angelica to the Philippine National Police (PNP)
Crime Laboratory at for post-mortem examination. The Medico-Legal Report issued by
said institution indicated the cause of death as Hypovolemic shock secondary to multiple
organ hemorrhages and Disseminated Intravascular Coagulation.[5]
On the other hand, the Certificate of Death[6] issued by SLMC stated the cause of death
as follows:
On , respondents filed a damage suit[7] against petitioner, Dr. Leo Marbella, Mr. Jose
Ledesma, a certain Dr. Arriete and SLMC. Respondents charged them with negligence
and disregard of Angelicas safety, health and welfare by their careless administration of
the chemotherapy drugs, their failure to observe the essential precautions in detecting
early the symptoms of fatal blood platelet decrease and stopping early on the
chemotherapy, which bleeding led to hypovolemic shock that caused Angelicas untimely
demise. Further, it was specifically averred that petitioner assured the respondents that
Angelica would recover in view of 95% chance of healing with chemotherapy
(Magiging normal na ang anak nyo basta ma-chemo. 95% ang healing) and when asked
regarding the side effects, petitioner mentioned only slight vomiting, hair loss and
weakness (Magsusuka ng kaunti. Malulugas ang buhok. Manghihina). Respondents thus
claimed that they would not have given their consent to chemotherapy had petitioner not
falsely assured them of its side effects.
Since the medical records of Angelica were not produced in court, the trial and appellate
courts had to rely on testimonial evidence, principally the declarations of petitioner and
respondents themselves. The following chronology of events was gathered:
On , petitioner saw the respondents at the hospital after Angelicas surgery and discussed
with them Angelicas condition. Petitioner told respondents that Angelica should be given
two to three weeks to recover from the operation before starting chemotherapy.
Respondents were apprehensive due to financial constraints as Reynaldo earns only
from P70,000.00 to P150,000.00 a year from his jewelry and watch repairing business.
[9] Petitioner, however, assured them not to worry about her professional fee and told
them to just save up for the medicines to be used.
Petitioner claimed that she explained to respondents that even when a tumor is removed,
there are still small lesions undetectable to the naked eye, and that adjuvant
chemotherapy is needed to clean out the small lesions in order to lessen the chance of
the cancer to recur. She did not give the respondents any assurance that chemotherapy
will cure Angelicas cancer. During these consultations with respondents, she explained
the following side effects of chemotherapy treatment to respondents: (1) falling hair; (2)
nausea and vomiting; (3) loss of appetite; (4) low count of white blood cells [WBC], red
blood cells [RBC] and platelets; (5) possible sterility due to the effects on Angelicas
ovary; (6) damage to the heart and kidneys; and (7) darkening of the skin especially
when exposed to sunlight. She actually talked with respondents four times, once at the
hospital after the surgery, twice at her clinic and the fourth time when Angelicas mother
called her through long distance.[10] This was disputed by respondents who countered
that petitioner gave them assurance that there is 95% chance of healing for Angelica if
she undergoes chemotherapy and that the only side effects were nausea, vomiting and
hair loss.[11] Those were the only side-effects of chemotherapy treatment mentioned by
petitioner.[12]
On , SLMC discharged Angelica, with instruction from petitioner that she be readmitted
after two or three weeks for the chemotherapy.
On , respondents brought Angelica to SLMC for chemotherapy, bringing with them the
results of the laboratory tests requested by petitioner: Angelicas chest x-ray, ultrasound
of the liver, creatinine and complete liver function tests.[13] Petitioner proceeded with
the chemotherapy by first administering hydration fluids to Angelica.[14]
The following day, August 19, petitioner began administering three chemotherapy drugs
Cisplatin,[15] Doxorubicin[16] and Cosmegen[17] intravenously. Petitioner was
supposedly assisted by her trainees Dr. Leo Marbella[18] and Dr. Grace Arriete.[19] In
his testimony, Dr. Marbella denied having any participation in administering the said
chemotherapy drugs.[20]
On the third day of chemotherapy, August 21, Angelica had difficulty breathing and was
thus provided with oxygen inhalation apparatus. This time, the reddish discoloration on
Angelicas face had extended to her neck, but petitioner dismissed it again as merely the
effect of medicines.[24] Petitioner testified that she did not see any discoloration on
Angelicas face, nor did she notice any difficulty in the childs breathing. She claimed that
Angelica merely complained of nausea and was given ice chips.[25]
On , at around in the morning, upon seeing that their child could not anymore bear the
pain, respondents pleaded with petitioner to stop the chemotherapy. Petitioner
supposedly replied: Dapat 15 Cosmegen pa iyan. Okay, lets observe. If pwede na,
bigyan uli ng chemo. At this point, respondents asked petitioners permission to bring
their child home. Later in the evening, Angelica passed black stool and reddish urine.
[26] Petitioner countered that there was no record of blackening of stools but only an
episode of loose bowel movement (LBM). Petitioner also testified that what Angelica
complained of was carpo-pedal spasm, not convulsion or epileptic attack, as respondents
call it (petitioner described it in the vernacular as naninigas ang kamay at paa). She then
requested for a serum calcium determination and stopped the chemotherapy. When
Angelica was given calcium gluconate, the spasm and numbness subsided.[27]
The following day, August 23, petitioner yielded to respondents request to take Angelica
home. But prior to discharging Angelica, petitioner requested for a repeat serum calcium
determination and explained to respondents that the chemotherapy will be temporarily
stopped while she observes Angelicas muscle twitching and serum calcium level. Take-
home medicines were also prescribed for Angelica, with instructions to respondents that
the serum calcium test will have to be repeated after seven days. Petitioner told
respondents that she will see Angelica again after two weeks, but respondents can see
her anytime if any immediate problem arises.[28]
The next day, August 24, respondents claimed that Angelica still suffered from
convulsions. They also noticed that she had a fever and had difficulty breathing.[30]
Petitioner insisted it was carpo-pedal spasm, not convulsions. She verified that at around
that afternoon, Angelica developed difficulty in breathing and had fever. She then
requested for an electrocardiogram analysis, and infused calcium gluconate on the
patient at a stat dose. She further ordered that Angelica be given Bactrim,[31] a synthetic
antibacterial combination drug,[32] to combat any infection on the childs body.[33]
By August 26, Angelica was bleeding through the mouth. Respondents also saw blood
on her anus and urine. When Lina asked petitioner what was happening to her daughter,
petitioner replied, Bagsak ang platelets ng anak mo. Four units of platelet concentrates
were then transfused to Angelica. Petitioner prescribed Solucortef. Considering that
Angelicas fever was high and her white blood cell count was low, petitioner prescribed
Leucomax. About four to eight bags of blood, consisting of packed red blood cells, fresh
whole blood, or platelet concentrate, were transfused to Angelica. For two days (August
27 to 28), Angelica continued bleeding, but petitioner claimed it was lesser in amount
and in frequency. Petitioner also denied that there were gadgets attached to Angelica at
that time.[34]
On August 29, Angelica developed ulcers in her mouth, which petitioner said were blood
clots that should not be removed. Respondents claimed that Angelica passed about half a
liter of blood through her anus at around that evening, which petitioner likewise denied.
On August 30, Angelica continued bleeding. She was restless as endotracheal and
nasogastric tubes were inserted into her weakened body. An aspiration of the nasogastric
tube inserted to Angelica also revealed a bloody content. Angelica was given more
platelet concentrate and fresh whole blood, which petitioner claimed improved her
condition. Petitioner told Angelica not to remove the endotracheal tube because this may
induce further bleeding.[35] She was also transferred to the intensive care unit to avoid
infection.
The next day, respondents claimed that Angelica became hysterical, vomited blood and
her body turned black. Part of Angelicas skin was also noted to be shredding by just
rubbing cotton on it. Angelica was so restless she removed those gadgets attached to her,
saying Ayaw ko na; there were tears in her eyes and she kept turning her head.
Observing her daughter to be at the point of death, Lina asked for a doctor but the latter
could not answer her anymore.[36] At this time, the attending physician was Dr.
Marbella who was shaking his head saying that Angelicas platelets were down and
respondents should pray for their daughter. Reynaldo claimed that he was introduced to
a pediatrician who took over his daughters case, Dr. Abesamis who also told him to pray
for his daughter. Angelica continued to have difficulty in her breathing and blood was
being suctioned from her stomach. A nurse was posted inside Angelicas room to assist
her breathing and at one point they had to revive Angelica by pumping her chest.
Thereafter, Reynaldo claimed that Angelica already experienced difficulty in urinating
and her bowel consisted of blood-like fluid. Angelica requested for an electric fan as she
was in pain. Hospital staff attempted to take blood samples from Angelica but were
unsuccessful because they could not even locate her vein. Angelica asked for a fruit but
when it was given to her, she only smelled it. At this time, Reynaldo claimed he could
not find either petitioner or Dr. Marbella. That night, Angelica became hysterical and
started removing those gadgets attached to her. At in the morning of September priest
came and they prayed before Angelica expired. Petitioner finally came back and
supposedly told respondents that there was malfunction or bogged-down machine.[37]
By petitioners own account, Angelica was merely irritable that day (August 31).
Petitioner noted though that Angelicas skin was indeed sloughing off.[38] She stressed
that at in the evening, Angelica pulled out her endotracheal tube.[39] On September 1,
exactly two weeks after being admitted at SLMC for chemotherapy, Angelica died.[40]
The cause of death, according to petitioner, was septicemia, or overwhelming infection,
which caused Angelicas other organs to fail.[41] Petitioner attributed this to the patients
poor defense mechanism brought about by the cancer itself.[42]
While he was seeking the release of Angelicas cadaver from SLMC, Reynaldo claimed
that petitioner acted arrogantly and called him names. He was asked to sign a
promissory note as he did not have cash to pay the hospital bill.[43]
Testifying on the findings stated in her medico-legal report, Dr. Vergara noted the
following: (1) there were fluids recovered from the abdominal cavity, which is not
normal, and was due to hemorrhagic shock secondary to bleeding; (2) there was
hemorrhage at the left side of the heart; (3) bleeding at the upper portion of and areas
adjacent to, the esophagus; (4) lungs were heavy with bleeding at the back and lower
portion, due to accumulation of fluids; (4) yellowish discoloration of the liver; (5)
kidneys showed appearance of facial shock on account of hemorrhages; and (6)
reddishness on external surface of the spleen. All these were the end result of
hypovolemic shock secondary to multiple organ hemorrhages and disseminated
intravascular coagulation. Dr. Vergara opined that this can be attributed to the chemical
agents in the drugs given to the victim, which caused platelet reduction resulting to
bleeding sufficient to cause the victims death. The time lapse for the production of DIC
in the case of Angelica (from the time of diagnosis of sarcoma) was too short,
considering the survival rate of about 3 years. The witness conceded that the victim will
also die of osteosarcoma even with amputation or chemotherapy, but in this case
Angelicas death was not caused by osteosarcoma. Dr. Vergara admitted that she is not a
pathologist but her statements were based on the opinion of an oncologist whom she had
interviewed. This oncologist supposedly said that if the victim already had DIC prior to
the chemotherapy, the hospital staff could have detected it.[44]
On her part, Dr. Balmaceda declared that it is the physicians duty to inform and explain
to the patient or his relatives every known side effect of the procedure or therapeutic
agents to be administered, before securing the consent of the patient or his relatives to
such procedure or therapy. The physician thus bases his assurance to the patient on his
personal assessment of the patients condition and his knowledge of the general effects of
the agents or procedure that will be allowed on the patient. Dr. Balmaceda stressed that
the patient or relatives must be informed of all known side effects based on studies and
observations, even if such will aggravate the patients condition.[45]
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelicas lower extremity,
testified for the defendants. He explained that in case of malignant tumors, there is no
guarantee that the ablation or removal of the amputated part will completely cure the
cancer. Thus, surgery is not enough. The mortality rate of osteosarcoma at the time of
modern chemotherapy and early diagnosis still remains at 80% to 90%. Usually, deaths
occur from metastasis, or spread of the cancer to other vital organs like the liver, causing
systemic complications. The modes of therapy available are the removal of the primary
source of the cancerous growth and then the residual cancer cells or metastasis should be
treated with chemotherapy. Dr. Tamayo further explained that patients with
osteosarcoma have poor defense mechanism due to the cancer cells in the blood stream.
In the case of Angelica, he had previously explained to her parents that after the surgical
procedure, chemotherapy is imperative so that metastasis of these cancer cells will
hopefully be addressed. He referred the patient to petitioner because he felt that
petitioner is a competent oncologist. Considering that this type of cancer is very
aggressive and will metastasize early, it will cause the demise of the patient should there
be no early intervention (in this case, the patient developed sepsis which caused her
death). Cancer cells in the blood cannot be seen by the naked eye nor detected through
bone scan. On cross-examination, Dr. Tamayo stated that of the more than 50 child
patients who had osteogenic sarcoma he had handled, he thought that probably all of
them died within six months from amputation because he did not see them anymore after
follow-up; it is either they died or had seen another doctor.[46]
In dismissing the complaint, the trial court held that petitioner was not liable for
damages as she observed the best known procedures and employed her highest skill and
knowledge in the administration of chemotherapy drugs on Angelica but despite all
efforts said patient died. It cited the testimony of Dr. Tamayo who testified that he
considered petitioner one of the most proficient in the treatment of cancer and that the
patient in this case was afflicted with a very aggressive type of cancer necessitating
chemotherapy as adjuvant treatment. Using the standard of negligence laid down in
Picart v. Smith,[47] the trial court declared that petitioner has taken the necessary
precaution against the adverse effect of chemotherapy on the patient, adding that a
wrong decision is not by itself negligence. Respondents were ordered to pay their unpaid
hospital bill in the amount of P139,064.43.[48]
Respondents appealed to the CA which, while concurring with the trial courts finding
that there was no negligence committed by the petitioner in the administration of
chemotherapy treatment to Angelica, found that petitioner as her attending physician
failed to fully explain to the respondents all the known side effects of chemotherapy. The
appellate court stressed that since the respondents have been told of only three side
effects of chemotherapy, they readily consented thereto. Had petitioner made known to
respondents those other side effects which gravely affected their child -- such as carpo-
pedal spasm, sepsis, decrease in the blood platelet count, bleeding, infections and
eventual death -- respondents could have decided differently or adopted a different
course of action which could have delayed or prevented the early death of their child.
Plaintiffs-appellants child was suffering from a malignant disease. The attending physician
recommended that she undergo chemotherapy treatment after surgery in order to increase her chances
of survival. Appellants consented to the chemotherapy treatment because they believed in Dr. Rubi Lis
representation that the deceased would have a strong chance of survival after chemotherapy and also
because of the representation of appellee Dr. Rubi Li that there were only three possible side-effects of
the treatment. However, all sorts of painful side-effects resulted from the treatment including the
premature death of Angelica. The appellants were clearly and totally unaware of these other side-
effects which manifested only during the chemotherapy treatment. This was shown by the fact
that every time a problem would take place regarding Angelicas condition (like an unexpected
side-effect manifesting itself), they would immediately seek explanation from Dr. Rubi Li. Surely,
those unexpected side-effects culminating in the loss of a love[d] one caused the appellants so much
trouble, pain and suffering.
On this point therefore, [w]e find defendant-appellee Dr. Rubi Li negligent which would entitle
plaintiffs-appellants to their claim for damages.
xxxx
WHEREFORE, the instant appeal is hereby GRANTED. Accordingly, the assailed decision is hereby
modified to the extent that defendant-appellee Dr. Rubi Li is ordered to pay the plaintiffs-appellants the
following amounts:
1. Actual damages of P139,064.43, plus P9,828.00 for funeral expenses;
Petitioner filed a motion for partial reconsideration which the appellate court denied.
Petitioner assails the CA in finding her guilty of negligence in not explaining to the
respondents all the possible side effects of the chemotherapy on their child, and in
holding her liable for actual, moral and exemplary damages and attorneys fees.
Petitioner emphasized that she was not negligent in the pre-chemotherapy procedures
and in the administration of chemotherapy treatment to Angelica.
Citing numerous trainings, distinctions and achievements in her field and her current
position as co-director for clinical affairs of the Medical Oncology, Department of
Medicine of SLMC, petitioner contends that in the absence of any clear showing or
proof, she cannot be charged with negligence in not informing the respondents all the
side effects of chemotherapy or in the pre-treatment procedures done on Angelica.
As to the cause of death, petitioner insists that Angelica did not die of platelet depletion
but of sepsis which is a complication of the cancer itself. Sepsis itself leads to bleeding
and death. She explains that the response rate to chemotherapy of patients with
osteosarcoma is high, so much so that survival rate is favorable to the patient. Petitioner
then points to some probable consequences if Angelica had not undergone
chemotherapy. Thus, without chemotherapy, other medicines and supportive treatment,
the patient might have died the next day because of massive infection, or the cancer cells
might have spread to the brain and brought the patient into a coma, or into the lungs that
the patient could have been hooked to a respirator, or into her kidneys that she would
have to undergo dialysis. Indeed, respondents could have spent as much because of these
complications. The patient would have been deprived of the chance to survive the
ailment, of any hope for life and her quality of life surely compromised. Since she had
not been shown to be at fault, petitioner maintains that the CA erred in holding her liable
for the damages suffered by the respondents.[50]
The issue to be resolved is whether the petitioner can be held liable for failure to fully
disclose serious side effects to the parents of the child patient who died while
undergoing chemotherapy, despite the absence of finding that petitioner was negligent in
administering the said treatment.
The type of lawsuit which has been called medical malpractice or, more appropriately,
medical negligence, is that type of claim which a victim has available to him or her to
redress a wrong committed by a medical professional which has caused bodily harm. In
order to successfully pursue such a claim, a patient must prove that a health care
provider, in most cases a physician, either failed to do something which a reasonably
prudent health care provider would have done, or that he or she did something that a
reasonably prudent provider would not have done; and that that failure or action caused
injury to the patient.[51]
This Court has recognized that medical negligence cases are best proved by opinions of
expert witnesses belonging in the same general neighborhood and in the same general
line of practice as defendant physician or surgeon. The deference of courts to the expert
opinion of qualified physicians stems from the formers realization that the latter possess
unusual technical skills which laymen in most instances are incapable of intelligently
evaluating, hence the indispensability of expert testimonies.[52]
In this case, both the trial and appellate courts concurred in finding that the alleged
negligence of petitioner in the administration of chemotherapy drugs to respondents
child was not proven considering that Drs. Vergara and Balmaceda, not being
oncologists or cancer specialists, were not qualified to give expert opinion as to whether
petitioners lack of skill, knowledge and professional competence in failing to observe
the standard of care in her line of practice was the proximate cause of the patients death.
Furthermore, respondents case was not at all helped by the non-production of medical
records by the hospital (only the biopsy result and medical bills were submitted to the
court). Nevertheless, the CA found petitioner liable for her failure to inform the
respondents on all possible side effects of chemotherapy before securing their consent to
the said treatment.
Subsequently, in Canterbury v. Spence[56] the court observed that the duty to disclose
should not be limited to medical usage as to arrogate the decision on revelation to the
physician alone. Thus, respect for the patients right of self-determination on particular
therapy demands a standard set by law for physicians rather than one which physicians
may or may not impose upon themselves.[57] The scope of disclosure is premised on the
fact that patients ordinarily are persons unlearned in the medical sciences. Proficiency in
diagnosis and therapy is not the full measure of a physicians responsibility. It is also his
duty to warn of the dangers lurking in the proposed treatment and to impart information
which the patient has every right to expect. Indeed, the patients reliance upon the
physician is a trust of the kind which traditionally has exacted obligations beyond those
associated with armslength transactions.[58] The physician is not expected to give the
patient a short medical education, the disclosure rule only requires of him a reasonable
explanation, which means generally informing the patient in nontechnical terms as to
what is at stake; the therapy alternatives open to him, the goals expectably to be
achieved, and the risks that may ensue from particular treatment or no treatment.[59] As
to the issue of demonstrating what risks are considered material necessitating disclosure,
it was held that experts are unnecessary to a showing of the materiality of a risk to a
patients decision on treatment, or to the reasonably, expectable effect of risk disclosure
on the decision. Such unrevealed risk that should have been made known must further
materialize, for otherwise the omission, however unpardonable, is without legal
consequence. And, as in malpractice actions generally, there must be a causal
relationship between the physicians failure to divulge and damage to the patient.[60]
Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that for
liability of the physician for failure to inform patient, there must be causal relationship
between physicians failure to inform and the injury to patient and such connection arises
only if it is established that, had revelation been made, consent to treatment would not
have been given.
There are four essential elements a plaintiff must prove in a malpractice action based
upon the doctrine of informed consent: (1) the physician had a duty to disclose material
risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and
proximate result of the failure to disclose, the patient consented to treatment she
otherwise would not have consented to; and (4) plaintiff was injured by the proposed
treatment. The gravamen in an informed consent case requires the plaintiff to point to
significant undisclosed information relating to the treatment which would have altered
her decision to undergo it.[64]
Examining the evidence on record, we hold that there was adequate disclosure of
material risks inherent in the chemotherapy procedure performed with the consent of
Angelicas parents. Respondents could not have been unaware in the course of initial
treatment and amputation of Angelicas lower extremity, that her immune system was
already weak on account of the malignant tumor in her knee. When petitioner informed
the respondents beforehand of the side effects of chemotherapy which includes lowered
counts of white and red blood cells, decrease in blood platelets, possible kidney or heart
damage and skin darkening, there is reasonable expectation on the part of the doctor that
the respondents understood very well that the severity of these side effects will not be
the same for all patients undergoing the procedure. In other words, by the nature of the
disease itself, each patients reaction to the chemical agents even with pre-treatment
laboratory tests cannot be precisely determined by the physician. That death can
possibly result from complications of the treatment or the underlying cancer itself,
immediately or sometime after the administration of chemotherapy drugs, is a risk that
cannot be ruled out, as with most other major medical procedures, but such conclusion
can be reasonably drawn from the general side effects of chemotherapy already
disclosed.
As a physician, petitioner can reasonably expect the respondents to have considered the
variables in the recommended treatment for their daughter afflicted with a life-
threatening illness. On the other hand, it is difficult to give credence to respondents
claim that petitioner told them of 95% chance of recovery for their daughter, as it was
unlikely for doctors like petitioner who were dealing with grave conditions such as
cancer to have falsely assured patients of chemotherapys success rate. Besides, informed
consent laws in other countries generally require only a reasonable explanation of
potential harms, so specific disclosures such as statistical data, may not be legally
necessary.[65]
The element of ethical duty to disclose material risks in the proposed medical treatment
cannot thus be reduced to one simplistic formula applicable in all instances. Further, in a
medical malpractice action based on lack of informed consent, the plaintiff must prove
both the duty and the breach of that duty through expert testimony.[66] Such expert
testimony must show the customary standard of care of physicians in the same practice
as that of the defendant doctor.[67]
In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medical
Specialist of the DOHs Operational and Management Services charged with receiving
complaints against hospitals, does not qualify as expert testimony to establish the
standard of care in obtaining consent for chemotherapy treatment. In the absence of
expert testimony in this regard, the Court feels hesitant in defining the scope of
mandatory disclosure in cases of malpractice based on lack of informed consent, much
less set a standard of disclosure that, even in foreign jurisdictions, has been noted to be
an evolving one.
As society has grappled with the juxtaposition between personal autonomy and the medical profession's
intrinsic impetus to cure, the law defining adequate disclosure has undergone a dynamic evolution. A
standard once guided solely by the ruminations of physicians is now dependent on what a reasonable
person in the patients position regards as significant. This change in perspective is especially important
as medical breakthroughs move practitioners to the cutting edge of technology, ever encountering new
and heretofore unimagined treatments for currently incurable diseases or ailments. An adaptable
standard is needed to account for this constant progression. Reasonableness analyses permeate our legal
system for the very reason that they are determined by social norms, expanding and contracting with
the ebb and flow of societal evolution.
As we progress toward the twenty-first century, we now realize that the legal standard of disclosure is
not subject to construction as a categorical imperative. Whatever formulae or processes we adopt
are only useful as a foundational starting point; the particular quality or quantity of disclosure will
remain inextricably bound by the facts of each case. Nevertheless, juries that ultimately determine
whether a physician properly informed a patient are inevitably guided by what they perceive as the
common expectation of the medical consumera reasonable person in the patients position when
deciding to accept or reject a recommended medical procedure.[68] (Emphasis supplied.)
No costs.
SO ORDERED.
Li vs Spouses Soliman
GR No. 165279 June 7, 2011
Facts: On July 7, 1993, respondents 11 year old daughter, Angelica Soliman underwent a biopsy of the
mass located in her lower extremity at the St. Lukes Medical Center (SLMC). Results showed that
Angelica was suffering from osteosaucoma, ostiobiostic type, a high-grade (highly malignant) cancer
of the bone which usually affects teenage children. Following this diagnosis, Angelica’s right leg was
amputated by Dr. Tamayo in order to remove the tumor. As a adjuvant treatment to eliminate any
remaining cancer cells, and hence minimizing the chances of recurrence and prevent the decease from
spreading to other parts of the patient’s body, chemotherapy was suggested by Dr. Tamayo and referred
Angelica to another doctor at SLMC, herein petitioner Dr. Rubi Li, a medical oncologist.
On July 23, 1993, petitioner saw the respondents at the hospital after Angelica’s surgery and discussed
with them Angelica’s condition. Petitioner told respondents that Angelica should be given 2-3 weeks to
recover from the operation before starting the chemotherapy. Respondents were apprehensive due to
financial constraints as Reynaldo earns only from P70,000-150,000 a year from his jewelry and
watching repair business. Petitioner, however, assured them not to worry about her professional fee and
told them to just save up for medicines to be used.
As the chemotherapy session started, day by day, Angelica experience worsening condition and other
physical effect on the body such as discoloration, nausea, and vomiting.
Petitioner claimed, that she explained to respondents that even when a tumor is removed, there are still
small lesions undetectable to the naked eye and that adjuvant chemotherapy is needed to clean out the
small lesions in order to lessen the chance of cancer to recur. She did not give the respondents any
assurance that chemotherapy will cure Angelica’s cancer. During these consultations with respondents,
she explained the following side effects of chemotherapy treatment to respondents: 1.) Falling hair; 2.)
nausea and vomiting; 3.) loss of appetite; 4.) low count of WBC, RBC, and platelets; 5.) possible
sterility due to the effects on Angelica’s ovary; 6.) Damage to kidney and heart; 7.) darkening of the
skin especially when exposed to sunlight. She actually talked to the respondents four times, once at the
hospital after the surgery, twice at her clinic and fourth when Angelica’s mother called her through long
distance. This was disputed by respondents who countered that petitioner gave them assurance that
there is 95% chance of healing for Angelica if she undergoes chemotherapy and that the only side
effects were nausea, vomiting and hair loss. Those were the only side effects of chemotherapy
mentioned by petitioner.
Issue: Whether or not petitioner committed medical malpractice.
Held: No. The type of lawsuit which has been called medical malpractice or more appropriately,
medical negligence, is that type of claim which a victim has available to him or her to redress a wrong
committed by a medical professional which has caused bodily harm. In order to successfully pursue
such claim, a patient must prove that a health care provider in most cases a physician, either failed to
do something which a reasonably prudent health care provider would have done or that he or she did
something that a reasonably health care provider would not have done; and that failure or action caused
injury to the patient.
Medical negligence cases are best proved by opinions of expert witnesses belonging in the same
general neighborhood and in the same general line of practice as defendant physician or surgeon. The
deference of courts to the expert opinion of qualified physicians stems from the former’s realization
that the latter possess unusual technical skills which layman in most instances are incapable of
intelligently evaluating, hence the indispensability of expert testimonies.
The doctrine of informed consent within the context of physician-patient relationships goes as far back
into english common law. As early as 1767, doctors were charged with the tort of battery if they have
not gained the consent of their patients prior to performing a surgery or procedure. In the United States,
the seminal case was Schoendorff vs Society of New York Hospital which involved unwanted
treatment performed by a doctor. Justice Bejamin Cardozo oft-quoted opinion upheld the basic right of
a patient to give consent to any medical procedure or treatment; every human being of adult year and
sound mind has a right to determine what shall be done with his own body; and a surgeon who
performs an operation without his patient’s consent commits an assault, for which he is liable in
damages. From a purely ethical norm, informed consent evolved into a general principle of law that a
physician has a duty to disclose what a reasonably prudent physician in the medical community in the
exercise of reasonable care would disclose to his patient as to whatever grave risk of injury might be
incurred from a proposed course of treatment, so that a patient, exercising ordinary care for her own
welfare and faced with a choice of undergoing the proposed treatment, as alternative treatment, or none
at all, may intelligently exercise his judgement by reasonably balancing the probable risk against the
probable benefits.
There are four essential elements a plaintiff must proved in a malpractice action based upon the
doctrine of informed consent: 1.) the physician had a duty to disclose material risks; 2.) he failed to
disclose or inadequately disclosed those risks; 3.) as a direct and proximate result of the failure to
disclose, the patient consented to treatment she otherwise would not have consented to; and 4.) plaintiff
was injured by the proposed treatment. The gravamen in an informed consent requires the plaintiff to
point to significant undisclosed information relating to the treatment which could have altered her
decision to undergo it.
Examining the evidence, we hold that there was adequate disclosure of material risks inherent in
chemotherapy procedure performed with the consent of Angelica’s parents. Respondents could not
have been unaware in the course of initial treatment and amputation of Angelica’s lower extremity that
her immune system was already weak on account of the malignant tumor in her knee. When petitioner
informed the respondents beforehand of the side effects of chemotherapy which includes lowered
counts of white and red blood cells, decrease in blood platelets, possible kidney or heart damage and
skin darkening, there is reasonable expectation on the part of the doctor that the respondents understood
very well that the severity of these side effects will not be the same for all patients undergoing the
procedure. In other words, by the nature of the disease itself, each patients reaction to the chemical
agents even with pre-treatment laboratory tests cannot be precisely determined by the physician. That
death can possibly result from complications of the treatment or the underlying cancer itself,
immediately or sometime after the administration of chemotherapy drugs, is a risk that cannot be ruled
out, as with most other major medical procedures, but such conclusion can be reasonably drawn from
the general side effects of chemotherapy already disclosed.
This is a petition filed under Rule 45 of the Rules of Court assailing the Decision and Resolution dated
January 22, 20131 and November 7, 2013,2 respectively, of the Court of Appeals, Cagayan De Oro City
(CA), in CA-G.R. CV No. 00911-MIN. The CA Decision reversed the Decision dated September 14,
20043 of the Regional Trial Court, Branch 33 in Davao City-(RTC) in Civil Case No. 27,354-99, a suit
for damages thereat which Nilo B. Rosit (Rosit) commenced against Dr. Rolando Gestuvo (Dr.
Gestuvo).
Factual Antecedents
On January 15, 1999, Rosit figured in a motorcycle accident. The X-ray soon taken the next day at the
Davao Doctors Hospital (DDH) showed that he fractured his jaw. Rosit was then referred to Dr.
Gestuvo, a specialist in mandibular injuries, 4 who, on January 19, 1999, operated on Rosit.
During the operation, Dr. Gestuvo used a metal plate fastened to the jaw with metal screws to
immobilize the mandible. As the operation required the smallest screws available, Dr. Gestuvo cut the
screws on hand to make them smaller. Dr. Gestuvo knew that there were smaller titanium screws
available in Manila, but did not so inform Rosit supposing that the latter would not be able to afford the
same.5
Following the procedure, Rosit could not properly open and close his mouth and was in pain. X-rays
done on Rosit two (2) days after the operation showed that the fracture in his jaw was aligned but the
screws used on him touched his molar. Given the X-ray results, Dr. Gestuvo referred Rosit to a dentist.
The dentist who checked Rosit, Dr. Pangan, opined that another operation is necessary and that it is to
be performed in Cebu.6
Alleging that the dentist told him that the operation conducted on his mandible was improperly done,
Rosit went back to Dr. Gestuvo to demand a loan to defray the cost of the additional operation as well
as the expenses of the trip to Cebu. Dr. Gestuvo gave Rosit P4,500.
Rosit went to Cebu on February 19, 1999, still suffering from pain and could hardly open his mouth.
In Cebu, Dr. Pangan removed the plate and screws thus installed by Dr. Gestuvo and replaced them
with smaller titanium plate and screws. Dr. Pangan also extracted Rosit's molar that was hit with a
screw and some bone fragments. Three days after the operation, Rosit was able to eat and speak well
and could open and close his mouth normally.7
On his return to Davao, Rosit demanded that Dr. Gestuvo reimburse him for the cost of the operation
and the expenses he incurred in Cebu amounting to P140,000, as well as for the P50,000 that Rosit
would have to spend for the removal of the plate and screws that Dr. Pangan installed. Dr. Gestuvo
refused to pay.8
Thus, Rosit filed a civil case for damages and attorney's fees with the RTC against Dr. Gestuvo and
DDH, the suit docketed as Civil Case No. 27,354-99.
The Ruling of the Regional Trial Court
The RTC freed DDH from liability on the ground that it exercised the proper diligence in the selection
and supervision of Dr. Gestuvo, but adjudged Dr. Gestuvo negligent and ruled, thus:
FOR ALL THE FOREGOING, finding the plaintiff Nilo B. Rosit to have preponderantly
established his cause of action in the complaint against defendant Dr. Rolando G. Gestuvo
only, judgment is hereby rendered for the plaintiff and against said defendant, ordering the
defendant DR. ROLANDO G. GESTUVO to pay unto plaintiff NILO B. ROSIT the
following: chanRoblesvirtualLawlibrary
For lack of merit, the complaint against defendant DAVAO DOCTORS HOSPITAL and the
defendants' counterclaims are hereby ordered DISMISSED.
SO ORDERED.
In so ruling, the trial court applied the res ipsa loquitur principle holding that "the need for expert,
medical testimony may be dispensed with because the injury itself provides the proof of negligence."
SO ORDERED.
Unlike the RTC, the CA ruled that the res ipsa loquitur principle is not applicable and that the
testimony of an expert witness is necessary for a finding of negligence. The appellate court also gave
credence to Dr. Pangan's letter stating the opinion that Dr. Gestuvo did not commit gross negligence in
his emergency management of Rosit's fractured mandible.
Rosit's motion for reconsideration was denied in the CA's November 7, 2013 Resolution.
The ultimate issue for our resolution is whether the appellate court correctly absolved Dr. Gestuvo from
liability.
The Court's Ruling
In Flores v. Pineda,9 the Court explained the concept of a medical negligence case and the elements
required for its prosecution, viz: chanRoblesvirtualLawlibrary
A medical negligence case is a type of claim to redress a wrong committed by a medical professional,
that has caused bodily harm to or the death of a patient. There are four elements involved in a
medical negligence case, namely: duty, breach, injury, and proximate causation.
Duty refers to the standard of behavior which imposes restrictions on one's conduct. The standard in
turn refers to the amount of competence associated with the proper discharge of the profession. A
physician is expected to use at least the same level of care that any other reasonably competent doctor
would use under the same circumstances. Breach of duty occurs when the physician fails to comply
with these professional standards. If injury results to the patient as a result of this breach, the physician
is answerable for negligence. (Emphasis supplied)
An expert witness is not necessary as the res ipsa loquitur doctrine is applicable
To establish medical negligence, this Court has held that an expert testimony is generally required to
define the standard of behavior by which the court may determine whether the physician has properly
performed the requisite duty toward the patient. This is so considering that the requisite degree of skill
and care in the treatment of a patient is usually a matter of expert opinion. 10
Solidum v. People of the Philippines 11 provides an exception. There, the Court explained that where the
application of the principle of res ipsa loquitur is warranted, an expert testimony may be dispensed
with in medical negligence cases:
Although generally, expert medical testimony is relied upon in malpractice suits to
prove that a physician has done a negligent act or that he has deviated from the
standard medical procedure, when the doctrine of res ipsa loquitur is availed by the
plaintiff, the need for expert medical testimony is dispensed with because the injury
itself provides the proof of negligence. The reason is that the general rule on the necessity
of expert testimony applies only to such matters clearly within the domain of medical
science, and not to matters that are within the common knowledge of mankind which may
be testified to by anyone familiar with the facts. x x x
Thus, courts of other jurisdictions have applied the doctrine in the following situations:
leaving of a foreign object in the body of the patient after an operation, injuries sustained
on a healthy part of the body which was not under, or in the area, of treatment, removal of
the wrong part of the body when another part was intended, knocking out a tooth while a
patient's jaw was under anesthetic for the removal of his tonsils, and loss of an eye while
the patient plaintiff was under the influence of anesthetic, during or following an operation
for appendicitis, among others.
We have further held that resort to the doctrine of res ipsa loquitur as an exception to the requirement
of an expert testimony in medical negligence cases may be availed of if the following essential
requisites are satisfied: (1) the accident was of a kind that does not ordinarily occur unless someone is
negligent; (2) the instrumentality or agency that caused the injury was under the exclusive control of
the person charged; and (3) the injury suffered must not have been due to any voluntary action or
contribution of the person injured.12
In its assailed Decision, the CA refused to acknowledge the application of the res ipsa loquitur doctrine
on the ground that the foregoing elements are absent. In particular, the appellate court is of the position
that post-operative pain is not unusual after surgery and that there is no proof that the molar Dr. Pangan
removed is the same molar that was hit by the screw installed by Dr. Gestuvo in Rosit's mandible.
Further, a second operation was conducted within the 5-week usual healing period of the mandibular
fracture so that the second element cannot be considered present. Lastly, the CA pointed out that the X-
ray examination conducted on Rosit prior to his first surgery suggests that he had "chronic
inflammatory lung disease compatible," implying that the injury may have been due to Rosit's peculiar
condition, thus effectively negating the presence of the third element. 13
After careful consideration, this Court cannot accede to the CA's findings as it is at once apparent from
the records that the essential requisites for the application of the doctrine of res ipsa loquitur are
present.
The first element was sufficiently established when Rosit proved that one of the screws installed by Dr.
Gestuvo struck his molar. It was for this issue that Dr. Gestuvo himself referred Rosit to Dr. Pangan. In
fact, the affidavit of Dr. Pangan presented by Dr. Gestuvo himself before the trial court narrated that the
same molar struck with the screw installed by Dr. Gestuvo was examined and eventually operated on
by Dr. Pangan. Dr. Gestuvo cannot now go back and say that Dr. Pangan treated a molar different from
that which was affected by the first operation.
Clearly, had Dr. Gestuvo used the proper size and length of screws and placed the same in the proper
locations, these would not have struck Rosit's teeth causing him pain and requiring him to undergo a
corrective surgery.
Dr. Gestuvo knew that the screws he used on Rosit were too large as, in fact, he cut the same with a
saw.14 He also stated during trial that common sense dictated that the smallest screws available should
be used. More importantly, he also knew that these screws were available locally at the time of the
operation.15 Yet, he did not avail of such items and went ahead with the larger screws and merely
sawed them off. Even assuming that the screws were already at the proper length after Dr. Gestuvo cut
the same, it is apparent that he negligently placed one of the screws in the wrong area thereby striking
one of Rosit's teeth.
In any event, whether the screw hit Rosit's molar because it was too long or improperly placed, both
facts are the product of Dr. Gestuvo's negligence. An average man of common intelligence would know
that striking a tooth with any foreign object much less a screw would cause severe pain. Thus, the first
essential requisite is present in this case.
Anent the second element for the res ipsa loquitur doctrine application, it is sufficient that the operation
which resulted in the screw hitting Rosit's molar was, indeed, performed by Dr. Gestuvo. No other
doctor caused such fact.
The CA finds that Rosit is guilty of contributory negligence in having Dr. Pangan operate on him
during the healing period of his fractured mandible. What the CA overlooked is that it was Dr. Gestuvo
himself who referred Rosit to Dr. Pangan. Nevertheless, Dr. Pangan's participation could not have
contributed to the reality that the screw that Dr. Gestuvo installed hit Rosit's molar.
Lastly, the third element that the injury suffered must not have been due to any voluntary action or
contribution of the person injured was satisfied in this case. It was not shown that Rosit's lung disease
could have contributed to the pain. What is clear is that he suffered because one of the screws that Dr.
Gestuvo installed hit Rosit's molar.
Clearly then, the res ipsa loquitur doctrine finds application in the instant case and no expert
testimony is required to establish the negligence of defendant Dr. Gestuvo.
What is more damning for Dr. Gestuvo is his failure to inform Rosit that such smaller screws were
available in Manila, albeit at a higher price.16 As testified to by Dr. Gestuvo himself:
Court This titanium materials according to you were already available in the
Alright. Philippines since the time of Rosit's accident?
xxxx
Court Did you inform Rosit about the existence of titanium screws and plates
which according to you is the screws and plates of choice?
xxxx
Witness The reason I did not inform him anymore Judge because what I thought he
was already hard up with the down payment. And if I will further introduce
him this screws, the more he will not be able to afford the operation.
xxxx
Court This titanium screws and plates were available then it is up to Rosit to decide
whether to use it or not because after all the material you are using is paid by
the patient himscll, is it not?
x x x x
There are four essential elements a plaintiff must prove in a malpractice action based
upon the doctrine of informed consent: "(1) the physician had a duty to disclose
material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a
direct and proximate result of the failure to disclose, the patient consented to
treatment she otherwise would not have consented to; and (4) plaintiff was injured by
the proposed treatment." The gravamen in an informed consent case requires the plaintiff
to "point to significant undisclosed information relating to the treatment which would have
altered her decision to undergo it." (Emphasis supplied)
First, Dr. Gestuvo clearly had the duty of disclosing to Rosit the risks of using the larger screws for the
operation. This was his obligation as the physician undertaking the operation.
Second, Dr. Gestuvo failed to disclose these risks to Rosit, deciding by himself that Rosit could not
afford to get the more expensive titanium screws.
Third, had Rosit been informed that there was a risk that the larger screws are not appropriate for the
operation and that an additional operation replacing the screws might be required to replace the same,
as what happened in this case, Rosit would not have agreed to the operation. It bears pointing out that
Rosit was, in fact, able to afford the use of the smaller titanium screws that were later used by Dr.
Pangan to replace the screws that were used by Dr. Gestuvo.
Fourth, as a result of using the larger screws, Rosit experienced pain and could not heal properly
because one of the screws hit his molar. This was evident from the fact that just three (3) days after Dr.
Pangan repeated the operation conducted by Dr. Gestuvo, Rosit was pain-free and could already speak.
This is compared to the one (1) month that Rosit suffered pain and could not use his mouth after the
operation conducted by Dr. Gestuvo until the operation of Dr. Pangan.
Without a doubt, Dr. Gestuvo is guilty of withholding material information which would have been
vital in the decision of Rosit in going through with the operation with the materials at hand. Thus, Dr.
Gestuvo is also guilty of negligence on this ground.
The appellate court's Decision absolving Dr. Gestuvo of negligence was also anchored on a letter
signed by Dr. Pangan who stated the opinion that Dr. Gestuvo did not commit gross negligence in his
emergency management of Mr. Rosit's fractured mandible.18 Clearly, the appellate court overlooked the
elementary principle against hearsay evidence.
In Dantis v. Maghinang, Jr.,19 the Court reiterated the oft-repeated rule that "an affidavit is merely
hearsay evidence where its affiant/maker did not take the witness stand." Here, Dr. Pangan never took
the witness stand to affirm the contents of his affidavit. Thus, the affidavit is inadmissible and cannot
be given any weight. The CA, therefore, erred when it considered the affidavit of Dr. Pangan, mpreso
for considering the same as expert testimony.
Moreover, even if such affidavit is considered as admissible and the testimony of an expert witness, the
Court is not bound by such testimony. As ruled in Ilao-Quianay v. Mapile:20
Indeed, courts are not bound by expert testimonies. They may place whatever weight they
choose upon such testimonies in accordance with the facts of the case. The relative weight
and sufficiency of expert testimony is peculiarly within the province of the trial court to
decide, considering the ability and character of the witness, his actions upon the witness
stand, the weight and process of the reasoning by which he has supported his opinion, his
possible bias in favor of the side for whom he testifies, and any other matters which serve
to illuminate his statements. The opinion of an expert should be considered by the court in
view of all the facts and circumstances of the case. The problem of the evaluation of expert
testimony is left to the discretion of the trial court whose ruling thereupon is not revicwable
in the absence of an abuse of that discretion.
Thus, the belief of Dr. Pangan whether Dr. Gestuvo is guilty of negligence or not will not bind the
Court. The Court must weigh and examine such testimony and decide for itself the merits thereof.
As discussed above, Dr. Gestuvo's negligence is clearly demonstrable by the doctrines of res ipsa
loquitur and informed consent.
Damages
For the foregoing, the trial court properly awarded Rosit actual damages after he was able to prove the
actual expenses that he incurred due to the negligence of Dr. Gestuvo. In Mendoza v. Spouses Gomez,21
the Court explained that a claimant is entitled to actual damages when the damage he sustained is the
natural and probable consequences of the negligent act and he adequately proved the amount of such
damage.
Rosit is also entitled to moral damages as provided under Article 2217 of the Civil Code, 22 given the
unnecessary physical suffering he endured as a consequence of defendant's negligence.
To recall, from the time he was negligently operated upon by Dr. Gestuvo until three (3) days from the
corrective surgery performed by Dr. Pangan, or for a period of one (1) month, Rosit suffered pain and
could not properly use his jaw to speak or eat.
The trial court also properly awarded attorney's fees and costs of suit under Article 2208 of the Civil
Code,23 since Rosit was compelled to litigate due to Dr. Gestuvo's refusal to pay for Rosit's damages.
As to the award of exemplary damages, the same too has to be affirmed. In Mendoza,24 the Court
enumerated the requisites for the award of exemplary damages:
Our jurisprudence sets certain conditions when exemplary damages may be awarded: First,
they may be imposed by way of example or correction only in addition, among others, to
compensatory damages, and cannot be recovered as a matter of right, their determination
depending upon the amount of compensatory damages that may be awarded to the claimant.
Second, the claimant must first establish his right to moral, temperate, liquidated or
compensatory damages. Third, the wrongful act must be accompanied by bad faith, and the
award would be allowed only if the guilty party acted in a wanton, fraudulent, reckless,
oppressive or malevolent manner.
The three (3) requisites are met. Dr. Gestuvo's actions are clearly negligent. Likewise, Dr. Gestuvo
acted in bad faith or in a wanton, fraudulent, reckless, oppressive manner when he was in breach of the
doctrine of informed consent. Dr. Gestuvo had the duty to fully explain to Rosit the risks of using large
screws for the operation. More importantly, he concealed the correct medical procedure of using the
smaller titanium screws mainly because of his erroneous belief that Rosit cannot afford to buy the
expensive titanium screws. Such concealment is clearly a valid basis for an award of exemplary
damages.
WHEREFORE, the instant petition is GRANTED. The CA Decision dated January 22, 2013 and
Resolution dated November 7, 2013 in CA-G.R. CV No. 00911-MIN are hereby REVERSED and
SET ASIDE. Further, the Decision dated September 14, 2004 of the Regional Trial Court, Branch 33 in
Davao City in Civil Case No. 27,345-99 is hereby REINSTATED and AFFIRMED.
SO ORDERED.
SECOND DIVISION
x -------------------------------------------------------------------------------------------x
DECISION
BRION, J.:
This petition involves a medical negligence case that was elevated to this Court through
an appeal by certiorari under Rule 45 of the Rules of Court. The petition assails the
Decision[1] of the Court of Appeals (CA) in CA G.R. CV No. 63234, which affirmed
with modification the Decision[2] of the Regional Trial Court (RTC) of Nueva Ecija,
Branch 37 in Civil Case No. SD-1233. The dispositive portion of the assailed CA
decision states:
WHEREFORE, premises considered, the assailed Decision of the Regional Trial Court of Baloc, Sto.
Domingo, Nueva Ecija, Branch 37 is hereby AFFIRMED but with modifications as follows:
1) Ordering defendant-appellants Dr. and Dra. Fredelicto A. Flores and the United Doctors Medical
Center, Inc. to jointly and severally pay the plaintiff-appellees heirs of Teresita Pineda, namely, Spouses
Dominador Pineda and Virginia Saclolo and Florencio, Candida, Marta, Godofredo, Baltazar and
Lucena, all surnamed Pineda, the sum of P400,000.00 by way of moral damages;
2) Ordering the above-named defendant-appellants to jointly and severally pay the above-named
plaintiff-appellees the sum of P100,000.00 by way of exemplary damages;
3) Ordering the above-named defendant-appellants to jointly and severally pay
the above-named plaintiff-appellees the sum of P36,000.00 by way of actual and
compensatory damages; and
4) Deleting the award of attorneys fees and costs of suit.
SO ORDERED.
While this case essentially involves questions of facts, we opted for the requested review
in light of questions we have on the findings of negligence below, on the awarded
damages and costs, and on the importance of this type of ruling on medical practice.[3]
BACKGROUND FACTS
Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto. Domingo,
Nueva Ecija. She consulted on April 17, 1987 her townmate, Dr. Fredelicto Flores,
regarding her medical condition. She complained of general body weakness, loss of
appetite, frequent urination and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto
initially interviewed the patient and asked for the history of her monthly period to
analyze the probable cause of the vaginal bleeding. He advised her to return the
following week or to go to the United Doctors Medical Center (UDMC) in Quezon City
for a general check-up. As for her other symptoms, he suspected that Teresita might be
suffering from diabetes and told her to continue her medications.[4]
Teresita did not return the next week as advised. However, when her condition persisted,
she went to further consult Dr. Flores at his UDMC clinic on April 28, 1987, travelling
for at least two hours from Nueva Ecija to Quezon City with her sister, Lucena Pineda.
They arrived at UDMC at around 11:15 a.m.. Lucena later testified that her sister was
then so weak that she had to lie down on the couch of the clinic while they waited for
the doctor. When Dr. Fredelicto arrived, he did a routine check-up and ordered Teresitas
admission to the hospital. In the admission slip, he directed the hospital staff to prepare
the patient for an on call D&C[5] operation to be performed by his wife, Dr. Felicisima
Flores (Dr. Felicisima). Teresita was brought to her hospital room at around 12 noon; the
hospital staff forthwith took her blood and urine samples for the laboratory tests[6]
which Dr. Fredelicto ordered.
At 2:40 p.m. of that same day, Teresita was taken to the operating room. It was only then
that she met Dr. Felicisima, an obstetrician and gynecologist. The two doctors Dr.
Felicisima and Dr. Fredelicto, conferred on the patients medical condition, while the
resident physician and the medical intern gave Dr. Felicisima their own briefings. She
also interviewed and conducted an internal vaginal examination of the patient which
lasted for about 15 minutes. Dr. Felicisima thereafter called up the laboratory for the
results of the tests. At that time, only the results for the blood sugar (BS), uric acid
determination, cholesterol determination, and complete blood count (CBC) were
available. Teresitas BS count was 10.67mmol/l[7] and her CBC was 109g/l.[8]
Based on these preparations, Dr. Felicisima proceeded with the D&C operation with Dr.
Fredelicto administering the general anesthesia. The D&C operation lasted for about 10
to 15 minutes. By 3:40 p.m., Teresita was wheeled back to her room.
A day after the operation (or on April 29, 1987), Teresita was subjected to an ultrasound
examination as a confirmatory procedure. The results showed that she had an enlarged
uterus and myoma uteri.[9] Dr. Felicisima, however, advised Teresita that she could spend
her recovery period at home. Still feeling weak, Teresita opted for hospital confinement.
Teresitas complete laboratory examination results came only on that day (April 29,
1987). Teresitas urinalysis showed a three plus sign (+++) indicating that the sugar in
her urine was very high. She was then placed under the care of Dr. Amado Jorge, an
internist.
By April 30, 1987, Teresitas condition had worsened. She experienced difficulty in
breathing and was rushed to the intensive care unit. Further tests confirmed that she was
suffering from Diabetes Mellitus Type II.[10] Insulin was administered on the patient,
but the medication might have arrived too late. Due to complications induced by
diabetes, Teresita died in the morning of May 6, 1987.[11]
Believing that Teresitas death resulted from the negligent handling of her medical needs,
her family (respondents) instituted an action for damages against Dr. Fredelicto Flores
and Dr. Felicisima Flores (collectively referred to as the petitioner spouses) before the
RTC of Nueva Ecija.
The RTC ruled in favor of Teresitas family and awarded actual, moral, and exemplary
damages, plus attorneys fees and costs.[12] The CA affirmed the judgment, but modified
the amount of damages awarded and deleted the award for attorneys fees and costs of
suit.[13]
Through this petition for review on certiorari, the petitioner spouses Dr. Fredelicto (now
deceased) and Dr. Felicisima Flores allege that the RTC and CA committed a reversible
error in finding them liable through negligence for the death of Teresita Pineda.
ASSIGNMENT OF ERRORS
The petitioner spouses contend that they exercised due care and prudence in the
performance of their duties as medical professionals. They had attended to the patient to
the best of their abilities and undertook the management of her case based on her
complaint of an on-and-off vaginal bleeding. In addition, they claim that nothing on
record shows that the death of Teresita could have been averted had they employed
means other than what they had adopted in the ministration of the patient.
THE COURTS RULING
We do not find the petition meritorious.
The respondents claim for damages is predicated on their allegation that the decision of
the petitioner spouses to proceed with the D&C operation, notwithstanding Teresitas
condition and the laboratory test results, amounted to negligence. On the other hand, the
petitioner spouses contend that a D&C operation is the proper and accepted procedure to
address vaginal bleeding the medical problem presented to them. Given that the patient
died after the D&C, the core issue is whether the decision to proceed with the D&C
operation was an honest mistake of judgment or one amounting to negligence.
Elements of a Medical Negligence Case
A medical negligence case is a type of claim to redress a wrong committed by a medical
professional, that has caused bodily harm to or the death of a patient. There are four
elements involved in a medical negligence case, namely: duty, breach, injury, and
proximate causation.[14]
Duty refers to the standard of behavior which imposes restrictions on ones conduct.[15]
The standard in turn refers to the amount of competence associated with the proper
discharge of the profession. A physician is expected to use at least the same level of care
that any other reasonably competent doctor would use under the same circumstances.
Breach of duty occurs when the physician fails to comply with these professional
standards. If injury results to the patient as a result of this breach, the physician is
answerable for negligence.[16]
As in any civil action, the burden to prove the existence of the necessary elements rests
with the plaintiff.[17] To successfully pursue a claim, the plaintiff must prove by
preponderance of evidence that, one, the physician either failed to do something which a
reasonably prudent health care provider would have done, or that he did something that
a reasonably prudent provider would not have done; and two, the failure or action
caused injury to the patient.[18] Expert testimony is therefore essential since the factual
issue of whether a physician or surgeon has exercised the requisite degree of skill and
care in the treatment of his patient is generally a matter of expert opinion.[19]
Standard of Care and Breach of Duty
D&C is the classic gynecologic procedure for the evaluation and possible therapeutic
treatment for abnormal vaginal bleeding.[20] That this is the recognized procedure is
confirmed by Drs. Salvador Nieto (Dr. Nieto) and Joselito Mercado (Dr. Mercado), the
expert witnesses presented by the respondents:
DR. NIETO: [W]hat I know among obstetricians, if there is bleeding, they perform what we call D&C
for diagnostic purposes.
xxx xxx xxx
Q: So are you trying to tell the Court that D&C can be a diagnostic treatment?
A: Yes, sir. Any doctor knows this.[21]
Dr. Mercado, however, objected with respect to the time the D&C operation should have
been conducted in Teresitas case. He opined that given the blood sugar level of Teresita,
her diabetic condition should have been
addressed first:
Q: Why do you consider the time of performance of the D&C not
appropriate?
A: Because I have read the record and I have seen the urinalysis, [there
is] spillage in the urine, and blood sugar was 10.67
Q: What is the significance of the spillage in the urine?
A: It is a sign that the blood sugar is very high.
Q: Does it indicate sickness?
A: 80 to 95% it means diabetes mellitus. The blood sugar was 10.67.
xxx xxx xxx
COURT: In other words, the operation conducted on the patient, your
opinion, that it is inappropriate?
A: The timing of [when] the D&C [was] done, based on the record, in
my personal opinion, that D&C should be postponed a day or two.[22]
The petitioner spouses countered that, at the time of the operation, there was nothing to
indicate that Teresita was afflicted with diabetes: a blood sugar level of 10.67mmol/l
did not necessarily mean that she was a diabetic considering that this was random
blood sugar;[23] there were other factors that might have caused Teresitas blood sugar
to rise such as the taking of blood samples during lunchtime and while patient was
being given intra-venous dextrose.[24] Furthermore, they claim that their principal
concern was to determine the cause of and to stop the vaginal bleeding.
The petitioner spouses contentions, in our view, miss several points. First, as early as
April 17, 1987, Teresita was already suspected to be suffering from diabetes.[25] This
suspicion again arose right before the D&C operation on April 28, 1987 when the
laboratory result revealed Teresitas increased blood sugar level.[26] Unfortunately, the
petitioner spouses did not wait for the full medical laboratory results before proceeding
with the D&C, a fact that was never considered in the courts below. Second, the
petitioner spouses were duly advised that the patient was experiencing general body
weakness, loss of appetite, frequent urination, and thirst all of which are classic
symptoms of diabetes.[27] 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:
[Expert testimony for the plaintiff showed that] tests should have been ordered immediately on
admission to the hospital in view of the symptoms presented, and that failure to recognize the existence
of diabetes constitutes negligence.[28]
Third, the petitioner spouses cannot claim that their principal concern was the vaginal
bleeding and should not therefore be held accountable for complications coming from
other sources. This is a very narrow and self-serving view that even reflects on their
competence.
Taken together, we find that reasonable prudence would have shown that diabetes and its
complications were foreseeable harm that should have been taken into consideration by
the petitioner spouses. If a patient suffers from some disability that increases the
magnitude of risk to him, that disability must be taken into account so long as it is
or should have been known to the physician.[29] And when the patient is exposed to
an increased risk, it is incumbent upon the physician to take commensurate and adequate
precautions.
Taking into account Teresitas high blood sugar,[30] Dr. Mendoza opined that the
attending physician should have postponed the D&C operation in order to conduct a
confirmatory test to make a conclusive diagnosis of diabetes and to refer the case to an
internist or diabetologist. This was corroborated by Dr. Delfin Tan (Dr. Tan), an
obstetrician and gynecologist, who stated that the patients diabetes should have been
managed by an internist prior to, during, and after the operation.[31]
Apart from bleeding as a complication of pregnancy, vaginal bleeding is only rarely so
heavy and life-threatening that urgent first-aid measures are required.[32] Indeed, the
expert witnesses declared that a D&C operation on a hyperglycemic patient may be
justified only when it is an emergency case when there is profuse vaginal bleeding. In
this case, we choose not to rely on the assertions of the petitioner spouses that there was
profuse bleeding, not only because the statements were self-serving, but also because the
petitioner spouses were inconsistent in their testimonies. Dr. Fredelicto testified earlier
that on April 28, he personally saw the bleeding,[33] but later on said that he did not see it
and relied only on Teresitas statement that she was bleeding.[34] He went on to state that
he scheduled the D&C operation without conducting any physical examination on the
patient.
The likely story is that although Teresita experienced vaginal bleeding on April 28, it
was not sufficiently profuse to necessitate an immediate emergency D&C operation. Dr.
Tan[35] and Dr. Mendoza[36] both testified that the medical records of Teresita failed to
indicate that there was profuse vaginal bleeding. The claim that there was profuse
vaginal bleeding although this was not reflected in the medical records strikes us as odd
since the main complaint is vaginal bleeding. A medical record is the only document that
maintains a long-term transcription of patient care and as such, its maintenance is
considered a priority in hospital practice. Optimal record-keeping includes all patient
inter-actions. The records should always be clear, objective, and up-to-date.[37] Thus, a
medical record that does not indicate profuse medical bleeding speaks loudly and clearly
of what it does not contain.
That the D&C operation was conducted principally to diagnose the cause of the vaginal
bleeding further leads us to conclude that it was merely an elective procedure, not an
emergency case. In an elective procedure, the physician must conduct a thorough pre-
operative evaluation of the patient in order to adequately prepare her for the operation
and minimize possible risks and complications. The internist is responsible for
generating a comprehensive evaluation of all medical problems during the pre-operative
evaluation.[38]
The aim of pre-operative evaluation is not to screen broadly for undiagnosed disease, but rather to
identify and quantify comorbidity that may impact on the operative outcome. This evaluation is driven
by findings on history and physical examination suggestive of organ system dysfunctionThe goal is to
uncover problem areas that may require further investigation or be amenable to preoperative
optimization.
If the preoperative evaluation uncovers significant comorbidity or evidence of poor control of an
underlying disease process, consultation with an internist or medical specialist may be required to
facilitate the work-up and direct management. In this process, communication between the surgeons
and the consultants is essential to define realistic goals for this optimization process and to expedite
surgical management.[39] [Emphasis supplied.]
Significantly, the evidence strongly suggests that the pre-operative evaluation was less
than complete as the laboratory results were fully reported only on the day following the
D&C operation. Dr. Felicisima only secured a telephone report of the preliminary
laboratory result prior to the D&C. This preliminary report did not include the 3+ status
of sugar in the patients urine[40] a result highly confirmatory of diabetes.
Because the D&C was merely an elective procedure, the patients uncontrolled
hyperglycemia presented a far greater risk than her on-and-off vaginal bleeding. The
presence of hyperglycemia in a surgical patient is associated with poor clinical
outcomes, and aggressive glycemic control positively impacts on morbidity and
mortality.[41] Elective surgery in people with uncontrolled diabetes should preferably be
scheduled after acceptable glycemic control has been achieved.[42] According to Dr.
Mercado, this is done by administering insulin on the patient.[43]
The management approach in this kind of patients always includes insulin therapy in combination with
dextrose and potassium infusion. Insulin xxx promotes glucose uptake by the muscle and fat cells while
decreasing glucose production by the liver xxx. The net effect is to lower blood glucose levels.[44]
The prudent move is to address the patients hyperglycemic state immediately and
promptly before any other procedure is undertaken. In this case, there was no evidence
that insulin was administered on Teresita prior to or during the D&C operation. Insulin
was only administered two days after the operation.
As Dr. Tan testified, the patients hyperglycemic condition should have been managed
not only before and during the operation, but also immediately after. Despite the
possibility that Teresita was afflicted with diabetes, the possibility was casually ignored
even in the post-operative evaluation of the patient; the concern, as the petitioner
spouses expressly admitted, was limited to the complaint of vaginal bleeding.
Interestingly, while the ultrasound test confirmed that Teresita had a myoma in her
uterus, she was advised that she could be discharged a day after the operation and that
her recovery could take place at home. This advice implied that a day after the operation
and even after the complete laboratory results were submitted, the petitioner spouses still
did not recognize any post-operative concern that would require the monitoring of
Teresitas condition in the hospital.
The above facts, point only to one conclusion that the petitioner spouses failed, as
medical professionals, to comply with their duty to observe the standard of care to be
given to hyperglycemic/diabetic patients undergoing surgery. Whether this breach of
duty was the proximate cause of Teresitas death is a matter we shall next determine.
Injury and Causation
As previously mentioned, the critical and clinching factor in a medical negligence case
is proof of the causal connection between the negligence which the evidence
established and the plaintiffs injuries;[45] the plaintiff must plead and prove not only
that he had been injured and defendant has been at fault, but also that the defendants
fault caused the injury. A verdict in a malpractice action cannot be based on speculation
or conjecture. Causation must be proven within a reasonable medical probability based
upon competent expert testimony.[46]
The respondents contend that unnecessarily subjecting Teresita to a D&C operation
without adequately preparing her, aggravated her hyperglycemic state and caused her
untimely demise. The death certificate of Teresita lists down the following causes of
death:
Immediate cause: Cardiorespiratory arrest
Antecedent cause: Septicemic shock, ketoacidocis
Underlying cause: Diabetes Mellitus II
Other significant conditions
contributing to death: Renal Failure Acute[47]
Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C
operation is a form of physical stress. Dr. Mendoza explained how surgical stress can
aggravate the patients hyperglycemia: when stress occurs, the diabetics body, especially
the autonomic system, reacts by secreting hormones which are counter-regulatory; she
can have prolonged hyperglycemia which, if unchecked, could lead to death.[48]
Medical literature further explains that if the blood sugar has become very high, the
patient becomes comatose (diabetic coma). When this happens over several days, the
body uses its own fat to produce energy, and the result is high levels of waste products
(called ketones) in the blood and urine (called diabetic ketoacidiosis, a medical
emergency with a significant mortality).[49] This was apparently what happened in
Teresitas case; in fact, after she had been referred to the internist Dr. Jorge, laboratory
test showed that her blood sugar level shot up to 14.0mmol/l, way above the normal
blood sugar range. Thus, between the D&C and death was the diabetic complication that
could have been prevented with the observance of standard medical precautions. The
D&C operation and Teresitas death due to aggravated diabetic condition is therefore
sufficiently established.
The trial court and the appellate court pinned the liability for Teresitas death on both the
petitioner spouses and this Court finds no reason to rule otherwise. However, we clarify
that Dr. Fredelictos negligence is not solely the act of ordering an on call D&C operation
when he was mainly an anaesthesiologist who had made a very cursory examination of
the patients vaginal bleeding complaint. Rather, it was his failure from the very start to
identify and confirm, despite the patients complaints and his own suspicions, that
diabetes was a risk factor that should be guarded against, and his participation in the
imprudent decision to proceed with the D&C operation despite his early suspicion and
the confirmatory early laboratory results. The latter point comes out clearly from the
following exchange during the trial:
Q: On what aspect did you and your wife consult [with] each other?
A: We discussed on the finding of the laboratory [results] because the hemoglobin was below normal,
the blood sugar was elevated, so that we have to evaluate these laboratory results what it means.
Q: So it was you and your wife who made the evaluation when it was phoned in?
A: Yes, sir.
Q: Did your wife, before performing D&C ask your opinion whether or not she can proceed?
A: Yes, anyway, she asked me whether we can do D&C based on my experience.
Q: And your answer was in the positive notwithstanding the elevation of blood sugar?
A: Yes, sir, it was both our disposition to do the D&C. [Emphasis supplied.][50]
If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not being an
internist or a diabetologist (for which reason he referred Teresita to Dr. Jorge),[51] he
should have likewise refrained from making a decision to proceed with the D&C
operation since he was niether an obstetrician nor a gynecologist.
These findings lead us to the conclusion that the decision to proceed with the D&C
operation, notwithstanding Teresitas hyperglycemia and without adequately preparing
her for the procedure, was contrary to the standards observed by the medical profession.
Deviation from this standard amounted to a breach of duty which resulted in the patients
death. Due to this negligent conduct, liability must attach to the petitioner spouses.
Liability of the Hospital
In the proceedings below, UDMC was the spouses Flores co-defendant. The RTC found
the hospital jointly and severally liable with the petitioner spouses, which decision the
CA affirmed. In a Resolution dated August 28, 2006, this Court however denied UDMCs
petition for review on certiorari. Since UDMCs appeal has been denied and they are not
parties to this case, we find it unnecessary to delve on the matter. Consequently, the
RTCs decision, as affirmed by the CA, stands.
Award of Damages
Both the trial and the appellate court awarded actual damages as compensation for the
pecuniary loss the respondents suffered. The loss was presented in terms of the hospital
bills and expenses the respondents incurred on account of Teresitas confinement and
death. The settled rule is that a plaintiff is entitled to be compensated for proven
pecuniary loss.[52] This proof the respondents successfully presented. Thus, we affirm
the award of actual damages of P36,000.00 representing the hospital expenses the
patient incurred.
In addition to the award for actual damages, the respondent heirs of Teresita are likewise
entitled to P50,000.00 as death indemnity pursuant to Article 2206 of the Civil Code,
which states that the amount of damages for death caused by a xxx quasi-delict shall be
at least three thousand pesos,[53] even though there may have been mitigating
circumstances xxx. This is a question of law that the CA missed in its decision and
which we now decide in the respondents favor.
The same article allows the recovery of moral damages in case of death caused by a
quasi-delict and enumerates the spouse, legitimate or illegitimate ascendants or
descendants as the persons entitled thereto. Moral damages are designed to compensate
the claimant for the injury suffered, that is, for the mental anguish, serious anxiety,
wounded feelings which the respondents herein must have surely felt with the
unexpected loss of their daughter. We affirm the appellate courts award of P400,000.00
by way of moral damages to the respondents.
We similarly affirm the grant of exemplary damages. Exemplary damages are imposed
by way of example or correction for the public good.[54] Because of the petitioner
spouses negligence in subjecting Teresita to an operation without first recognizing and
addressing her diabetic condition, the appellate court awarded exemplary damages to
the respondents in the amount of P100,000.00. Public policy requires such imposition to
suppress the wanton acts of an offender.[55] We therefore affirm the CAs award as an
example to the medical profession and to stress that the public good requires stricter
measures to avoid the repetition of the type of medical malpractice that happened in this
case.
With the award of exemplary damages, the grant of attorneys fees is legally in order.[56]
We therefore reverse the CA decision deleting these awards, and grant the respondents
the amount of P100,000.00 as attorneys fees taking into consideration the legal route
this case has taken.
WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003 in CA G.R.
CV No. 63234 finding petitioner spouses liable for negligent medical practice. We
likewise AFFIRM the awards of actual and compensatory damages of P36,000.00;
moral damages of P400,000.00; and exemplary damages of P100,000.00.
We MODIFY the CA Decision by additionally granting an award of P50,000.00 as
death indemnity and by reversing the deletion of the award of attorneys fees and costs
and restoring the award of P100,000.00 as attorneys fees. Costs of litigation are
adjudged against petitioner spouses.
To summarize, the following awards shall be paid to the family of the late Teresita
Pineda:
1. The sum of P36,000.00 by way of actual and compensatory damages;
2. The sum of P50,000.00 by way of death indemnity;
3. The sum of P400,000.00 by way of moral damages;
4. The sum of P100,000.00 by way of exemplary damages;
5. The sum of P100,000.00 by way of attorneys fees; and
6. Costs.
SO ORDERED.
Spouses Flores vs Spouses Pineda
GR No. 158996 November 14, 2008
Facts: Teresita Pineda consulted her townmate Dr. Fredelicto Flores regarding her medical condition,
complaining about general body weakness, loss of appetite, frequent urination and thirst, and on-and-
off vaginal bleeding. After interviewing Teresita, Dr. Fredelicto advised her to go to United Doctors
Medical Center (UDMC) in Quezon City for a general check-up the following week but the former did
not. As for her other symptoms, he suspected that Teresita might be suffering from diabetes and told her
to continue her medications. When her conditions persisted, she went to UDMC where Dr. Fredelictor
check-up her and ordered her admission and further indicate on call D&C operation to be performed by
his wife, Dra. Felicisima Flores, an Ob-Gyne. Laboratory tests were done on Teresita including internal
vaginal examination, however, only the blood sugar and CBC results came out prior to operation which
indicated of diabetes. D&C operations were still done and thereafter, Dra. Felicisima advised her that
she can go home and continue to rest at home but Teresita opted otherwise. Two days after the
operation, her condition worsened prompting further test to be done which resulted that Teresita have
diabetes melitus type II. Insulin was administered but it might arrived late, she died.
Issue: Whether or not spouses petitioners are liable for medical negligence.
Held: Yes. A medical negligence case is a type of claim to redress a wrong committed by a medical
professional, that caused a bodily harm to or the death of a patient. There are four elements involved in
a medical negligence case, namely: duty, breach, injury, and proximate cause.
Duty refers to the standard of behavior which imposes restrictions on one’s conduct. The standard in
turn refers to the amount of competence associated with the proper discharge of the profession. A
physician is expected to use at least the same level of case that any other reasonably competent doctor
would use under the same circumstances. Breach of duty occurs when the physician fails to comply
with those professional standards. If injury results to the patient as a result of this breach, the physician
is answerable for negligence.
If a patient suffers from some disability that increases the magnitude of risk to him, that disability must
be taken into account as long as it is or should have been known to the physician.
Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C operation is a
form of physical stress. Dr. Mendoza explained how surgical stress can aggravate the patient’s
hyperglycemia: when stress occurs, the diabetic’s body, especially the autonomic system, reacts by
secreting hormones which are counter-regulatory; she can have prolonged hyperglycemia which, if
unchecked, could lead to death. Medical lecture further explains that if the blood sugar has become
very high, the patient becomes comatose (diabetic coma). When this happens over several days, the
body uses its own fats to produce energy, and the result is high level of waste products in the blood and
urine.
These findings leads us to the conclusion that the decision to proceed with the D&C operation
notwithstanding Teresita’s hyperglycemia and without adequately preparing her for the procedure, was
contrary to the standards observed by the medical profession. Deviation from this standard amounted to
a breach of duty which resulted in the patient’s death. Due to this negligent conduct, liability must
attach to the petitioner spouses.
Petitioner,
G.R. No. 177407
Present:
- versus - NACHURA,
MENDOZA, JJ.
Promulgated:
February 9, 2011
x------------------------------------------------------------------------------------x
DECISION
NACHURA, J.:
Before us is a petition for review on certiorari under Rule 45 of the Rules of Court,
assailing the Decision[1] dated September 22, 2006 of the Court of Appeals (CA) in CA-
G.R. SP No. 87755. The CA dismissed the petition for certiorari filed by petitioner Rico
Rommel Atienza (Atienza), which, in turn, assailed the Orders[2] issued by public
respondent Board of Medicine (BOM) in Administrative Case No. 1882.
Due to her lumbar pains, private respondent Editha Sioson went to Rizal Medical Center (RMC) for
check-up on February 4, 1995. Sometime in 1999, due to the same problem, she was referred to Dr.
Pedro Lantin III of RMC who, accordingly, ordered several diagnostic laboratory tests. The tests
revealed that her right kidney is normal. It was ascertained, however, that her left kidney is non-
functioning and non-visualizing. Thus, she underwent kidney operation in September, 1999.
On February 18, 2000, private respondents husband, Romeo Sioson (as complainant), filed a complaint
for gross negligence and/or incompetence before the [BOM] against the doctors who allegedly
participated in the fateful kidney operation, namely: Dr. Judd dela Vega, Dr. Pedro Lantin, III, Dr.
Gerardo Antonio Florendo and petitioner Rico Rommel Atienza.
It was alleged in the complaint that the gross negligence and/or incompetence committed by the said
doctors, including petitioner, consists of the removal of private respondents fully functional right
kidney, instead of the left non-functioning and non-visualizing kidney.
The complaint was heard by the [BOM]. After complainant Romeo Sioson presented his evidence,
private respondent Editha Sioson, also named as complainant there, filed her formal offer of
documentary evidence. Attached to the formal offer of documentary evidence are her Exhibits A to D,
which she offered for the purpose of proving that her kidneys were both in their proper anatomical
locations at the time she was operated. She described her exhibits, as follows:
EXHIBIT A the certified photocopy of the X-ray Request form dated
December 12, 1996, which is also marked as Annex 2 as it was actually
originally the Annex to x x x Dr. Pedro Lantin, IIIs counter affidavit filed
with the City Prosecutor of Pasig City in connection with the criminal
complaint filed by [Romeo Sioson] with the said office, on which are
handwritten entries which are the interpretation of the results of the
ultrasound examination. Incidentally, this exhibit happens to be the same
as or identical to the certified photocopy of the document marked as
Annex 2 to the Counter-Affidavit dated March 15, 2000, filed by x x x
Dr. Pedro Lantin, III, on May 4, 2000, with this Honorable Board in
answer to this complaint;
EXHIBIT B the certified photo copy of the X-ray request form dated
January 30, 1997, which is also marked as Annex 3 as it was actually
likewise originally an Annex to x x x Dr. Pedro Lantin, IIIs counter-
affidavit filed with the Office of the City Prosecutor of Pasig City in
connection with the criminal complaint filed by the herein complainant
with the said office, on which are handwritten entries which are the
interpretation of the results of the examination. Incidentally, this exhibit
happens to be also the same as or identical to the certified photo copy of
the document marked as Annex 3 which is likewise dated January 30,
1997, which is appended as such Annex 3 to the counter-affidavit dated
March 15, 2000, filed by x x x Dr. Pedro Lantin, III on May 4, 2000, with
this Honorable Board in answer to this complaint.
EXHIBIT C the certified photocopy of the X-ray request form dated
March 16, 1996, which is also marked as Annex 4, on which are
handwritten entries which are the interpretation of the results of the
examination.
EXHIBIT D the certified photocopy of the X-ray request form dated May
20, 1999, which is also marked as Annex 16, on which are handwritten
entries which are the interpretation of the results of the examination.
Incidentally, this exhibit appears to be the draft of the typewritten final
report of the same examination which is the document appended as
Annexes 4 and 1 respectively to the counter-affidavits filed by x x x Dr.
Judd dela Vega and Dr. Pedro Lantin, III in answer to the complaint. In
the case of Dr. dela Vega however, the document which is marked as
Annex 4 is not a certified photocopy, while in the case of Dr. Lantin, the
document marked as Annex 1 is a certified photocopy. Both documents
are of the same date and typewritten contents are the same as that which
are written on Exhibit D.
Petitioner filed his comments/objections to private respondents [Editha
Siosons] formal offer of exhibits. He alleged that said exhibits are
inadmissible because the same are mere photocopies, not properly
identified and authenticated, and intended to establish matters which are
hearsay. He added that the exhibits are incompetent to prove the purpose
for which they are offered.
Dispositions of the Board of Medicine
The formal offer of documentary exhibits of private respondent [Editha Sioson] was admitted by the
[BOM] per its Order dated May 26, 2004. It reads:
The Formal Offer of Documentary Evidence of [Romeo Sioson], the
Comments/Objections of [herein petitioner] Atienza, [therein
respondents] De la Vega and Lantin, and the Manifestation of [therein]
respondent Florendo are hereby ADMITTED by the [BOM] for whatever
purpose they may serve in the resolution of this case.
Let the hearing be set on July 19, 2004 all at 1:30 p.m. for the reception
of the evidence of the respondents.
SO ORDERED.
Petitioner moved for reconsideration of the abovementioned Order
basically on the same reasons stated in his comment/objections to the
formal offer of exhibits.
The [BOM] denied the motion for reconsideration of petitioner in its Order dated October 8, 2004. It
concluded that it should first admit the evidence being offered so that it can determine its probative
value when it decides the case. According to the Board, it can determine whether the evidence is
relevant or not if it will take a look at it through the process of admission. x x x.[3]
Disagreeing with the BOM, and as previously adverted to, Atienza filed a petition for
certiorari with the CA, assailing the BOMs Orders which admitted Editha Siosons
(Edithas) Formal Offer of Documentary Evidence. The CA dismissed the petition for
certiorari for lack of merit.
I. PROCEDURAL ISSUE:
WHETHER PETITIONER ATIENZA AVAILED OF THE PROPER REMEDY WHEN HE FILED
THE PETITION FOR CERTIORARI DATED 06 DECEMBER 2004 WITH THE COURT OF
APPEALS UNDER RULE 65 OF THE RULES OF COURT TO ASSAIL THE ORDERS DATED 26
MAY 2004 AND 08 OCTOBER 2004 OF RESPONDENT BOARD.
II. SUBSTANTIVE ISSUE:
WHETHER THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR AND
DECIDED A QUESTION OF SUBSTANCE IN A WAY NOT IN ACCORDANCE WITH LAW AND
THE APPLICABLE DECISIONS OF THE HONORABLE COURT WHEN IT UPHELD THE
ADMISSION OF INCOMPETENT AND INADMISSIBLE EVIDENCE BY RESPONDENT
BOARD, WHICH CAN RESULT IN THE DEPRIVATION OF PROFESSIONAL LICENSE A
PROPERTY RIGHT OR ONES LIVELIHOOD.[4]
We find no reason to depart from the ruling of the CA.
Petitioner is correct when he asserts that a petition for certiorari is the proper remedy to
assail the Orders of the BOM, admitting in evidence the exhibits of Editha. As the
assailed Orders were interlocutory, these cannot be the subject of an appeal separate
from the judgment that completely or finally disposes of the case.[5] At that stage, where
there is no appeal, or any plain, speedy, and adequate remedy in the ordinary course of
law, the only and remaining remedy left to petitioner is a petition for certiorari under
Rule 65 of the Rules of Court on the ground of grave abuse of discretion amounting to
lack or excess of jurisdiction.
However, the writ of certiorari will not issue absent a showing that the BOM has acted
without or in excess of jurisdiction or with grave abuse of discretion. Embedded in the
CAs finding that the BOM did not exceed its jurisdiction or act in grave abuse of
discretion is the issue of whether the exhibits of Editha contained in her Formal Offer of
Documentary Evidence are inadmissible.
Petitioner argues that the exhibits formally offered in evidence by Editha: (1) violate the
best evidence rule; (2) have not been properly identified and authenticated; (3) are
completely hearsay; and (4) are incompetent to prove their purpose. Thus, petitioner
contends that the exhibits are inadmissible evidence.
We disagree.
To begin with, it is well-settled that the rules of evidence are not strictly applied in
proceedings before administrative bodies such as the BOM.[6] Although trial courts are
enjoined to observe strict enforcement of the rules of evidence,[7] in connection with
evidence which may appear to be of doubtful relevancy, incompetency, or admissibility,
we have held that:
[I]t is the safest policy to be liberal, not rejecting them on doubtful or technical grounds, but admitting
them unless plainly irrelevant, immaterial or incompetent, for the reason that their rejection places them
beyond the consideration of the court, if they are thereafter found relevant or competent; on the other
hand, their admission, if they turn out later to be irrelevant or incompetent, can easily be remedied by
completely discarding them or ignoring them.[8]
From the foregoing, we emphasize the distinction between the admissibility of evidence
and the probative weight to be accorded the same pieces of evidence. PNOC Shipping
and Transport Corporation v. Court of Appeals[9] teaches:
Admissibility of evidence refers to the question of whether or not the circumstance (or evidence) is to
be considered at all. On the other hand, the probative value of evidence refers to the question of
whether or not it proves an issue.
Second, petitioners insistence that the admission of Edithas exhibits violated his
substantive rights leading to the loss of his medical license is misplaced. Petitioner
mistakenly relies on Section 20, Article I of the Professional Regulation Commission
Rules of Procedure, which reads:
Section 20. Administrative investigation shall be conducted in accordance with these Rules. The Rules
of Court shall only apply in these proceedings by analogy or on a suppletory character and whenever
practicable and convenient. Technical errors in the admission of evidence which do not prejudice the
substantive rights of either party shall not vitiate the proceedings.[10]
As pointed out by the appellate court, the admission of the exhibits did not prejudice the
substantive rights of petitioner because, at any rate, the fact sought to be proved thereby,
that the two kidneys of Editha were in their proper anatomical locations at the time she
was operated on, is presumed under Section 3, Rule 131 of the Rules of Court:
Sec. 3. Disputable presumptions. The following presumptions are satisfactory if uncontradicted, but
may be contradicted and overcome by other evidence:
xxxx
(y) That things have happened according to the ordinary course of nature and the ordinary habits of life.
The exhibits are certified photocopies of X-ray Request Forms dated December 12,
1996, January 30, 1997, March 16, 1996, and May 20, 1999, filed in connection with
Edithas medical case. The documents contain handwritten entries interpreting the results
of the examination. These exhibits were actually attached as annexes to Dr. Pedro Lantin
IIIs counter affidavit filed with the Office of the City Prosecutor of Pasig City, which
was investigating the criminal complaint for negligence filed by Editha against the
doctors of Rizal Medical Center (RMC) who handled her surgical procedure. To lay the
predicate for her case, Editha offered the exhibits in evidence to prove that her kidneys
were both in their proper anatomical locations at the time of her operation.
The fact sought to be established by the admission of Edithas exhibits, that her kidneys
were both in their proper anatomical locations at the time of her operation, need not be
proved as it is covered by mandatory judicial notice.[11]
Unquestionably, the rules of evidence are merely the means for ascertaining the truth
respecting a matter of fact.[12] Thus, they likewise provide for some facts which are
established and need not be proved, such as those covered by judicial notice, both
mandatory and discretionary.[13] Laws of nature involving the physical sciences,
specifically biology,[14] include the structural make-up and composition of living things
such as human beings. In this case, we may take judicial notice that Edithas kidneys
before, and at the time of, her operation, as with most human beings, were in their
proper anatomical locations.
Third, contrary to the assertion of petitioner, the best evidence rule is inapplicable.
Section 3 of Rule 130 provides:
Finally, these exhibits do not constitute hearsay evidence of the anatomical locations of
Edithas kidneys. To further drive home the point, the anatomical positions, whether left
or right, of Edithas kidneys, and the removal of one or both, may still be established
through a belated ultrasound or x-ray of her abdominal area.
WHEREFORE, the petition is DENIED. The Decision of the Court of Appeals in CA-
G.R. SP No. 87755 is AFFIRMED. Costs against petitioner.
SO ORDERED.
DECISION
CARPIO, J.:
The Case
This petition for review1 assails the 6 February 1998 Decision2 and 21 March 2000 Resolution3 of the
Court of Appeals in CA-G.R. CV No. 45641. The Court of Appeals affirmed in toto the 22 November
1993 Decision4 of the Regional Trial Court of Manila, Branch 33, finding Dr. Oscar Estrada solely
liable for damages for the death of his patient, Corazon Nogales, while absolving the remaining
respondents of any liability. The Court of Appeals denied petitioners' motion for reconsideration.
The 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 edema5 indicating
preeclampsia,6 which is a dangerous complication of pregnancy.7
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").
On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the staff nurse noted the written
admission request8 of Dr. Estrada. Upon Corazon's admission at the CMC, Rogelio Nogales
("Rogelio") executed and signed the "Consent on Admission and Agreement" 9 and "Admission
Agreement."10 Corazon was then brought to the labor room of the CMC.
Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an internal examination
of Corazon. Dr. Uy then called up Dr. Estrada to notify him of her findings.
Based on the Doctor's Order Sheet,11 around 3:00 a.m., Dr. Estrada ordered for 10 mg. of valium to be
administered immediately by intramuscular injection. Dr. Estrada later ordered the start of intravenous
administration of syntocinon admixed with dextrose, 5%, in lactated Ringers' solution, at the rate of
eight to ten micro-drops per minute.
According to the Nurse's Observation Notes,12 Dr. Joel Enriquez ("Dr. Enriquez"), an anesthesiologist
at CMC, was notified at 4:15 a.m. of Corazon's admission. Subsequently, when asked if he needed the
services of an anesthesiologist, Dr. Estrada refused. Despite Dr. Estrada's refusal, Dr. Enriquez stayed
to observe Corazon's condition.
At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10 a.m., Corazon's
bag of water ruptured spontaneously. At 6:12 a.m., Corazon's cervix was fully dilated. At 6:13 a.m.,
Corazon started to experience convulsions.
At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfate. However, Dr. Ely
Villaflor ("Dr. Villaflor"), who was assisting Dr. Estrada, administered only 2.5 grams of magnesium
sulfate.
At 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. The baby came out in an apnic,
cyanotic, weak and injured condition. Consequently, the baby had to be intubated and resuscitated by
Dr. Enriquez and Dr. Payumo.
At 6:27 a.m., Corazon began to manifest moderate vaginal bleeding which rapidly became profuse.
Corazon's blood pressure dropped from 130/80 to 60/40 within five minutes. There was continuous
profuse vaginal bleeding. The assisting nurse administered hemacel through a gauge 19 needle as a side
drip to the ongoing intravenous injection of dextrose.
At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with bottled blood. It took
approximately 30 minutes for the CMC laboratory, headed by Dr. Perpetua Lacson ("Dr. Lacson"), to
comply with Dr. Estrada's order and deliver the blood.
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-Gynecology Department of the
CMC, was apprised of Corazon's condition by telephone. Upon being informed that Corazon was
bleeding profusely, Dr. Espinola ordered immediate hysterectomy. Rogelio was made to sign a
"Consent to Operation."13
Due to the inclement weather then, Dr. Espinola, who was fetched from his residence by an ambulance,
arrived at the CMC about an hour later or at 9:00 a.m. He examined the patient and ordered some
resuscitative measures to be administered. Despite Dr. Espinola's efforts, Corazon died at 9:15 a.m. The
cause of death was "hemorrhage, post partum."14
On 14 May 1980, petitioners filed a complaint for damages 15 with the Regional Trial Court16 of Manila
against CMC, Dr. Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr. Lacson, Dr. Espinola, and a certain
Nurse J. Dumlao for the death of Corazon. Petitioners mainly contended that defendant physicians and
CMC personnel were negligent in the treatment and management of Corazon's condition. Petitioners
charged CMC with negligence in the selection and supervision of defendant physicians and hospital
staff.
For failing to file their answer to the complaint despite service of summons, the trial court declared Dr.
Estrada, Dr. Enriquez, and Nurse Dumlao in default.17 CMC, Dr. Villaflor, Dr. Uy, Dr. Espinola, and
Dr. Lacson filed their respective answers denying and opposing the allegations in the complaint.
Subsequently, trial ensued.
After more than 11 years of trial, the trial court rendered judgment on 22 November 1993 finding Dr.
Estrada solely liable for damages. The trial court ruled as follows:
The victim was under his pre-natal care, apparently, his fault began from his incorrect and
inadequate management and lack of treatment of the pre-eclamptic condition of his patient. It is
not disputed that he misapplied the forceps in causing the delivery because it resulted in a large
cervical tear which had caused the profuse bleeding which he also failed to control with the
application of inadequate injection of magnesium sulfate by his assistant Dra. Ely Villaflor. Dr.
Estrada even failed to notice the erroneous administration by nurse Dumlao of hemacel by way
of side drip, instead of direct intravenous injection, and his failure to consult a senior
obstetrician at an early stage of the problem.
On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr. Joel Enriquez, Dr. Lacson, Dr.
Espinola, nurse J. Dumlao and CMC, the Court finds no legal justification to find them civilly
liable.
On the part of Dra. Ely Villaflor, she was only taking orders from Dr. Estrada, the principal
physician of Corazon Nogales. She can only make suggestions in the manner the patient maybe
treated but she cannot impose her will as to do so would be to substitute her good judgment to
that of Dr. Estrada. If she failed to correctly diagnose the true cause of the bleeding which in
this case appears to be a cervical laceration, it cannot be safely concluded by the Court that Dra.
Villaflor had the correct diagnosis and she failed to inform Dr. Estrada. No evidence was
introduced to show that indeed Dra. Villaflor had discovered that there was laceration at the
cervical area of the patient's internal organ.
On the part of nurse Dumlao, there is no showing that when she administered the hemacel as a
side drip, she did it on her own. If the correct procedure was directly thru the veins, it could
only be because this was what was probably the orders of Dr. Estrada.
While the evidence of the plaintiffs shows that Dr. Noe Espinola, who was the Chief of the
Department of Obstetrics and Gynecology who attended to the patient Mrs. Nogales, it was only
at 9:00 a.m. That he was able to reach the hospital because of typhoon Didang (Exhibit 2).
While he was able to give prescription in the manner Corazon Nogales may be treated, the
prescription was based on the information given to him by phone and he acted on the basis of
facts as presented to him, believing in good faith that such is the correct remedy. He was not
with Dr. Estrada when the patient was brought to the hospital at 2:30 o'clock a.m. So, whatever
errors that Dr. Estrada committed on the patient before 9:00 o'clock a.m. are certainly the errors
of Dr. Estrada and cannot be the mistake of Dr. Noe Espinola. His failure to come to the hospital
on time was due to fortuitous event.
On the part of Dr. Joel Enriquez, while he was present in the delivery room, it is not incumbent
upon him to call the attention of Dr. Estrada, Dra. Villaflor and also of Nurse Dumlao on the
alleged errors committed by them. Besides, as anesthesiologist, he has no authority to control
the actuations of Dr. Estrada and Dra. Villaflor. For the Court to assume that there were errors
being committed in the presence of Dr. Enriquez would be to dwell on conjectures and
speculations.
On the civil liability of Dr. Perpetua Lacson, [s]he is a hematologist and in-charge of the blood
bank of the CMC. The Court cannot accept the theory of the plaintiffs that there was delay in
delivering the blood needed by the patient. It was testified, that in order that this blood will be
made available, a laboratory test has to be conducted to determine the type of blood, cross
matching and other matters consistent with medical science so, the lapse of 30 minutes maybe
considered a reasonable time to do all of these things, and not a delay as the plaintiffs would
want the Court to believe.
Admittedly, Dra. Rosa Uy is a resident physician of the Capitol Medical Center. She was sued
because of her alleged failure to notice the incompetence and negligence of Dr. Estrada.
However, there is no evidence to support such theory. No evidence was adduced to show that
Dra. Rosa Uy as a resident physician of Capitol Medical Center, had knowledge of the
mismanagement of the patient Corazon Nogales, and that notwithstanding such knowledge, she
tolerated the same to happen.
In the pre-trial order, plaintiffs and CMC agreed that defendant CMC did not have any hand or
participation in the selection or hiring of Dr. Estrada or his assistant Dra. Ely Villaflor as
attending physician[s] of the deceased. In other words, the two (2) doctors were not employees
of the hospital and therefore the hospital did not have control over their professional conduct.
When Mrs. Nogales was brought to the hospital, it was an emergency case and defendant CMC
had no choice but to admit her. Such being the case, there is therefore no legal ground to apply
the provisions of Article 2176 and 2180 of the New Civil Code referring to the vicarious
liability of an employer for the negligence of its employees. If ever in this case there is fault or
negligence in the treatment of the deceased on the part of the attending physicians who were
employed by the family of the deceased, such civil liability should be borne by the attending
physicians under the principle of "respondeat superior".
WHEREFORE, premises considered, judgment is hereby rendered finding defendant Dr.
Estrada of Number 13 Pitimini St. San Francisco del Monte, Quezon City civilly liable to pay
plaintiffs: 1) By way of actual damages in the amount of P105,000.00; 2) By way of moral
damages in the amount of P700,000.00; 3) Attorney's fees in the amount of P100,000.00 and to
pay the costs of suit.
For failure of the plaintiffs to adduce evidence to support its [sic] allegations against the other
defendants, the complaint is hereby ordered dismissed. While the Court looks with disfavor the
filing of the present complaint against the other defendants by the herein plaintiffs, as in a way
it has caused them personal inconvenience and slight damage on their name and reputation, the
Court cannot accepts [sic] however, the theory of the remaining defendants that plaintiffs were
motivated in bad faith in the filing of this complaint. For this reason defendants' counterclaims
are hereby ordered dismissed.
SO ORDERED.18
Petitioners appealed the trial court's 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 respondent's alleged liability.
On 6 February 1998, the Court of Appeals affirmed the decision of the trial court. 19 Petitioners filed a
motion for reconsideration which the Court of Appeals denied in its Resolution of 21 March 2000.20
Hence, this petition.
Meanwhile, petitioners filed a Manifestation dated 12 April 2002 21 stating that respondents Dr. Estrada,
Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao "need no longer be notified of the petition because they
are absolutely not involved in the issue raised before the [Court], regarding the liability of [CMC]." 22
Petitioners stressed that the subject matter of this petition is the liability of CMC for the negligence of
Dr. Estrada.23
The Court issued a Resolution dated 9 September 200224 dispensing with the requirement to submit the
correct and present addresses of respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse
Dumlao. The Court stated that with the filing of petitioners' Manifestation, it should be understood that
they are claiming only against respondents CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy who have filed
their respective comments. Petitioners are foregoing further claims against respondents Dr. Estrada, Dr.
Enriquez, Dr. Villaflor, and Nurse Dumlao.
The Court noted that Dr. Estrada did not appeal the decision of the Court of Appeals affirming the
decision of the Regional Trial Court. Accordingly, the decision of the Court of Appeals, affirming the
trial court's judgment, is already final as against Dr. Oscar Estrada.
Petitioners filed a motion for reconsideration 25 of the Court's 9 September 2002 Resolution claiming
that Dr. Enriquez, Dr. Villaflor and Nurse Dumlao were notified of the petition at their counsels' last
known addresses. Petitioners reiterated their imputation of negligence on these respondents. The Court
denied petitioners' Motion for Reconsideration in its 18 February 2004 Resolution.26
The Court of Appeals' Ruling
In its Decision of 6 February 1998, the Court of Appeals upheld the trial court's ruling. The Court of
Appeals rejected petitioners' view that the doctrine in Darling v. Charleston Community Memorial
Hospital27 applies to this case. According to the Court of Appeals, the present case differs from the
Darling case since Dr. Estrada is an independent contractor-physician whereas the Darling case
involved a physician and a nurse who were employees of the hospital.
Citing other American cases, the Court of Appeals further held that the mere fact that a hospital
permitted a physician to practice medicine and use its facilities is not sufficient to render the hospital
liable for the physician's negligence.28 A hospital is not responsible for the negligence of a physician
who is an independent contractor.29
The Court of Appeals found the cases of Davidson v. Conole30 and Campbell v. Emma Laing Stevens
Hospital31 applicable to this case. Quoting Campbell, the Court of Appeals stated that where there is no
proof that defendant physician was an employee of defendant hospital or that defendant hospital had
reason to know that any acts of malpractice would take place, defendant hospital could not be held
liable for its failure to intervene in the relationship of physician-patient between defendant physician
and plaintiff.
On the liability of the other respondents, the Court of Appeals applied the "borrowed servant" doctrine
considering that Dr. Estrada was an independent contractor who was merely exercising hospital
privileges. 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. 32 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.33
The Court of Appeals concluded that since Rogelio engaged Dr. Estrada as the attending physician of
his wife, any liability for malpractice must be Dr. Estrada's sole responsibility.
While it found the amount of damages fair and reasonable, the Court of Appeals held that no interest
could be imposed on unliquidated claims or damages.
The Issue
Basically, the issue in this case is whether CMC is vicariously liable for the negligence of Dr. Estrada.
The resolution of this issue rests, on the other hand, on the ascertainment of the relationship between
Dr. Estrada and CMC. The Court also believes that a determination of the extent of liability of the other
respondents is inevitable to finally and completely dispose of the present controversy.
The Ruling of the Court
The petition is partly meritorious.
On the Liability of CMC
Dr. Estrada's negligence in handling the treatment and management of Corazon's condition which
ultimately resulted in Corazon's death is no longer in issue. Dr. Estrada did not appeal the decision of
the Court of Appeals which affirmed the ruling of the trial court finding Dr. Estrada solely liable for
damages. Accordingly, the finding of the trial court on Dr. Estrada's negligence is already final.
Petitioners maintain that CMC is vicariously liable for Dr. Estrada's negligence based on Article 2180
in relation to Article 2176 of the Civil Code. These provisions pertinently state:
Art. 2180. The obligation imposed by article 2176 is demandable not only for one's own acts or
omissions, but also for those of persons for whom one is responsible.
xxxx
Employers shall be liable for the damages caused by their employees and household helpers
acting within the scope of their assigned tasks, even though the former are not engaged in any
business or industry.
xxxx
The responsibility treated of in this article shall cease when the persons herein mentioned prove
that they observed all the diligence of a good father of a family to prevent damage.
Art. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done. Such fault or negligence, if there is no pre-
existing contractual relation between the parties, is called a quasi-delict and is governed by the
provisions of this Chapter.
Similarly, in the United States, a hospital which is the employer, master, or principal of a physician
employee, servant, or agent, may be held liable for the physician's negligence under the doctrine of
respondeat superior.34
In the present case, petitioners maintain that CMC, in allowing Dr. Estrada to practice and admit
patients at CMC, should be liable for Dr. Estrada's malpractice. Rogelio claims that he knew Dr.
Estrada as an accredited physician of CMC, though he discovered later that Dr. Estrada was not a
salaried employee of the CMC.35 Rogelio further claims that he was dealing with CMC, whose primary
concern was the treatment and management of his wife's condition. Dr. Estrada just happened to be the
specific person he talked to representing CMC.36 Moreover, the fact that CMC made Rogelio sign a
Consent on Admission and Admission Agreement37 and a Consent to Operation printed on the
letterhead of CMC indicates that CMC considered Dr. Estrada as a member of its medical staff.
On the other hand, CMC disclaims liability by asserting that Dr. Estrada was a mere visiting physician
and that it admitted Corazon because her physical condition then was classified an emergency
obstetrics case.38
CMC alleges that Dr. Estrada is an independent contractor "for whose actuations CMC would be a total
stranger." CMC maintains that it had no control or supervision over Dr. Estrada in the exercise of his
medical profession.
The Court had the occasion to determine the relationship between a hospital and a consultant or visiting
physician and the liability of such hospital for that physician's negligence in Ramos v. Court of
Appeals,39 to wit:
In the first place, hospitals exercise significant control in the hiring and firing of consultants and
in the conduct of their work within the hospital premises. Doctors who apply for "consultant"
slots, visiting or attending, are required to submit proof of completion of residency, their
educational qualifications; generally, evidence of accreditation by the appropriate board
(diplomate), evidence of fellowship in most cases, and references. These requirements are
carefully scrutinized by members of the hospital administration or by a review committee set up
by the hospital who either accept or reject the application. This is particularly true with
respondent hospital.
After a physician is accepted, either as a visiting or attending consultant, he is normally required
to attend clinico-pathological conferences, conduct bedside rounds for clerks, interns and
residents, moderate grand rounds and patient audits and perform other tasks and responsibilities,
for the privilege of being able to maintain a clinic in the hospital, and/or for the privilege of
admitting patients into the hospital. In addition to these, the physician's performance as a
specialist is generally evaluated by a peer review committee on the basis of mortality and
morbidity statistics, and feedback from patients, nurses, interns and residents. A consultant
remiss in his duties, or a consultant who regularly falls short of the minimum standards
acceptable to the hospital or its peer review committee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and
visiting "consultant" staff. While "consultants" are not, technically employees, a point
which respondent hospital asserts in denying all responsibility for the patient's condition,
the control exercised, the hiring, and the right to terminate consultants all fulfill the
important hallmarks of an employer-employee relationship, with the exception of the
payment of wages. In assessing whether such a relationship in fact exists, the control test is
determining. Accordingly, on the basis of the foregoing, we rule that for the purpose of
allocating responsibility in medical negligence cases, an employer-employee relationship in
effect exists between hospitals and their attending and visiting physicians. This being the
case, the question now arises as to whether or not respondent hospital is solidarily liable with
respondent doctors for petitioner's condition.
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. x x x40 (Emphasis supplied)
While the Court in Ramos did not expound on the control test, such test essentially determines whether
an employment relationship exists between a physician and a hospital based on the exercise of control
over the physician as to details. Specifically, the employer (or the hospital) must have the right to
control both the means and the details of the process by which the employee (or the physician) is to
accomplish his task.41
After a thorough examination of the voluminous records of this case, the Court finds no single evidence
pointing to CMC's exercise of control over Dr. Estrada's treatment and management of Corazon's
condition. It is undisputed that throughout Corazon's pregnancy, she was under the exclusive prenatal
care of Dr. Estrada. At the time of Corazon's admission at CMC and during her delivery, it was Dr.
Estrada, assisted by Dr. Villaflor, who attended to Corazon. There was no showing that CMC had a part
in diagnosing Corazon's condition. While Dr. Estrada enjoyed staff privileges at CMC, such fact alone
did not make him an employee of CMC.42 CMC merely allowed Dr. Estrada to use its facilities43 when
Corazon was about to give birth, which CMC considered an emergency. Considering these
circumstances, Dr. Estrada is not an employee of CMC, but an independent contractor.
The question now is whether CMC is automatically exempt from liability considering that Dr. Estrada
is an independent contractor-physician.
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.44 This exception is also known as the "doctrine of apparent authority." 45 In
Gilbert v. Sycamore Municipal Hospital,46 the Illinois Supreme Court explained the doctrine of
apparent authority in this wise:
[U]nder 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."
The element of "holding out" on the part of the hospital does not require an express
representation by the hospital that the person alleged to be negligent is an employee. Rather, the
element is satisfied if the hospital holds itself out as a provider of emergency room care without
informing the patient that the care is provided by independent contractors.
The element of justifiable reliance on the part of the plaintiff is satisfied if the plaintiff relies
upon the hospital to provide complete emergency room care, rather than upon a specific
physician.
The doctrine of apparent authority essentially involves two factors to determine the liability of an
independent-contractor physician.
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. 47 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.48
The doctrine of apparent authority is a species of the doctrine of estoppel. Article 1431 of the Civil
Code provides that "[t]hrough estoppel, an admission or representation is rendered conclusive upon the
person making it, and cannot be denied or disproved as against the person relying thereon." Estoppel
rests on this rule: "Whenever a party has, by his own declaration, act, or omission, intentionally and
deliberately led another to believe a particular thing true, and to act upon such belief, he cannot, in any
litigation arising out of such declaration, act or omission, be permitted to falsify it."49
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. CMC cannot now repudiate such authority.
First, CMC granted staff privileges to Dr. Estrada. CMC extended its medical staff and facilities to Dr.
Estrada. Upon Dr. Estrada's request for Corazon's admission, CMC, through its personnel, readily
accommodated Corazon and updated Dr. Estrada of her condition.
Second, CMC made Rogelio sign consent forms printed on CMC letterhead. Prior to Corazon's
admission and supposed hysterectomy, CMC asked Rogelio to sign release forms, the contents of
which reinforced Rogelio's belief that Dr. Estrada was a member of CMC's medical staff. 50 The
Consent on Admission and Agreement explicitly provides:
KNOW ALL MEN BY THESE PRESENTS:
I, Rogelio Nogales, of legal age, a resident of 1974 M. H. Del Pilar St., Malate Mla., being the
father/mother/brother/sister/spouse/relative/ guardian/or person in custody of Ma. Corazon, and
representing his/her family, of my own volition and free will, do consent and submit said Ma.
Corazon to Dr. Oscar Estrada (hereinafter referred to as Physician) for cure, treatment,
retreatment, or emergency measures, that the Physician, personally or by and through the
Capitol Medical Center and/or its staff, may use, adapt, or employ such means, forms or
methods of cure, treatment, retreatment, or emergency measures as he may see best and
most expedient; that Ma. Corazon and I will comply with any and all rules, regulations,
directions, and instructions of the Physician, the Capitol Medical Center and/or its staff;
and, that I will not hold liable or responsible and hereby waive and forever discharge and hold
free the Physician, the Capitol Medical Center and/or its staff, from any and all claims of
whatever kind of nature, arising from directly or indirectly, or by reason of said cure, treatment,
or retreatment, or emergency measures or intervention of said physician, the Capitol Medical
Center and/or its staff.
x x x x51 (Emphasis supplied)
While the Consent to Operation pertinently reads, thus:
I, ROGELIO NOGALES, x x x, of my own volition and free will, do consent and submit said
CORAZON NOGALES to Hysterectomy, by the Surgical Staff and Anesthesiologists of
Capitol Medical Center and/or whatever succeeding operations, treatment, or emergency
measures as may be necessary and most expedient; and, that I will not hold liable or responsible
and hereby waive and forever discharge and hold free the Surgeon, his assistants,
anesthesiologists, the Capitol Medical Center and/or its staff, from any and all claims of
whatever kind of nature, arising from directly or indirectly, or by reason of said operation or
operations, treatment, or emergency measures, or intervention of the Surgeon, his assistants,
anesthesiologists, the Capitol Medical Center and/or its staff.52 (Emphasis supplied)
Without any indication in these consent forms that Dr. Estrada was an independent contractor-
physician, the Spouses Nogales could not have known that Dr. Estrada was an independent contractor.
Significantly, no one from CMC informed the Spouses Nogales that Dr. Estrada was an independent
contractor. On the contrary, Dr. Atencio, who was then a member of CMC Board of Directors, testified
that Dr. Estrada was part of CMC's surgical staff.53
Third, Dr. Estrada's referral of Corazon's profuse vaginal bleeding to Dr. Espinola, who was then the
Head of the Obstetrics and Gynecology Department of CMC, gave the impression that Dr. Estrada as a
member of CMC's medical staff was collaborating with other CMC-employed specialists in treating
Corazon.
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.54
The records show that the Spouses Nogales relied upon a perceived employment relationship with
CMC in accepting Dr. Estrada's services. Rogelio testified that he and his wife specifically chose Dr.
Estrada to handle Corazon's delivery not only because of their friend's recommendation, but more
importantly because of Dr. Estrada's "connection with a reputable hospital, the [CMC]." 55 In other
words, Dr. Estrada's relationship with CMC played a significant role in the Spouses Nogales' decision
in accepting Dr. Estrada's services as the obstetrician-gynecologist for Corazon's delivery. Moreover, as
earlier stated, there is no showing that before and during Corazon's confinement at CMC, the Spouses
Nogales knew or should have known that Dr. Estrada was not an employee of CMC.
Further, the Spouses Nogales looked to CMC to provide the best medical care and support services for
Corazon's delivery. The Court notes that prior to Corazon's fourth pregnancy, she used to give birth
inside a clinic. Considering Corazon's age then, the Spouses Nogales decided to have their fourth child
delivered at CMC, which Rogelio regarded one of the best hospitals at the time.56 This is precisely
because the Spouses Nogales feared that Corazon might experience complications during her delivery
which would be better addressed and treated in a modern and big hospital such as CMC. Moreover,
Rogelio's consent in Corazon's hysterectomy to be performed by a different physician, namely Dr.
Espinola, is a clear indication of Rogelio's confidence in CMC's surgical staff.
CMC's 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. In this regard,
the Court agrees with the observation made by the Court of Appeals of North Carolina in Diggs v.
Novant Health, Inc.,57 to wit:
"The conception that the hospital does not undertake to treat the patient, does not undertake to
act through its doctors and nurses, but undertakes instead simply to procure them to act upon
their own responsibility, no longer reflects the fact. Present day hospitals, as their manner of
operation plainly demonstrates, do far more than furnish facilities for treatment. They
regularly employ on a salary basis a large staff of physicians, nurses and internes [sic], as
well as administrative and manual workers, and they charge patients for medical care and
treatment, collecting for such services, if necessary, by legal action. Certainly, the person
who avails himself of 'hospital facilities' expects that the hospital will attempt to cure him,
not that its nurses or other employees will act on their own responsibility." x x x (Emphasis
supplied)
Likewise unconvincing is CMC's argument that petitioners are estopped from claiming damages based
on the Consent on Admission and Consent to Operation. Both release forms consist of two parts. The
first part gave CMC permission to administer to Corazon any form of recognized medical treatment
which the CMC medical staff deemed advisable. The second part of the documents, which may
properly be described as the releasing part, releases CMC and its employees "from any and all claims"
arising from or by reason of the treatment and operation.
The documents do not expressly release CMC from liability for injury to Corazon due to negligence
during her treatment or operation. Neither do the consent forms expressly exempt CMC from liability
for Corazon's death due to negligence during such treatment or operation. Such release forms, being in
the nature of contracts of adhesion, are construed strictly against hospitals. Besides, a blanket release in
favor of hospitals "from any and all claims," which includes claims due to bad faith or gross
negligence, would be contrary to public policy and thus void.
Even simple negligence is not subject to blanket release in favor of establishments like hospitals but
may only mitigate liability depending on the circumstances. 58 When a person needing urgent medical
attention rushes to a hospital, he cannot bargain on equal footing with the hospital on the terms of
admission and operation. Such a person is literally at the mercy of the hospital. There can be no clearer
example of a contract of adhesion than one arising from such a dire situation. Thus, the release forms of
CMC cannot relieve CMC from liability for the negligent medical treatment of Corazon.
On the Liability of the Other Respondents
Despite this Court's pronouncement in its 9 September 2002 59 Resolution that the filing of petitioners'
Manifestation confined petitioners' claim only against CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy, who
have filed their comments, the Court deems it proper to resolve the individual liability of the remaining
respondents to put an end finally to this more than two-decade old controversy.
a) Dr. Ely Villaflor
Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause of Corazon's bleeding and to
suggest the correct remedy to Dr. Estrada.60 Petitioners assert that it was Dr. Villaflor's duty to correct
the error of Nurse Dumlao in the administration of hemacel.
The Court is not persuaded. Dr. Villaflor admitted administering a lower dosage of magnesium sulfate.
However, this was after informing Dr. Estrada that Corazon was no longer in convulsion and that her
blood pressure went down to a dangerous level. 61 At that moment, Dr. Estrada instructed Dr. Villaflor
to reduce the dosage of magnesium sulfate from 10 to 2.5 grams. Since petitioners did not dispute Dr.
Villaflor's allegation, Dr. Villaflor's defense remains uncontroverted. Dr. Villaflor's act of administering
a lower dosage of magnesium sulfate was not out of her own volition or was in contravention of Dr.
Estrada's order.
b) Dr. Rosa Uy
Dr. Rosa Uy's alleged negligence consisted of her failure (1) to call the attention of Dr. Estrada on the
incorrect dosage of magnesium sulfate administered by Dr. Villaflor; (2) to take corrective measures;
and (3) to correct Nurse Dumlao's wrong method of hemacel administration.
The Court believes Dr. Uy's claim that as a second year resident physician then at CMC, she was
merely authorized to take the clinical history and physical examination of Corazon. 62 However, that
routine internal examination did not ipso facto make Dr. Uy liable for the errors committed by Dr.
Estrada. Further, petitioners' imputation of negligence rests on their baseless assumption that Dr. Uy
was present at the delivery room. Nothing shows that Dr. Uy participated in delivering Corazon's baby.
Further, it is unexpected from Dr. Uy, a mere resident physician at that time, to call the attention of a
more experienced specialist, if ever she was present at the delivery room.
c) Dr. Joel Enriquez
Petitioners fault Dr. Joel Enriquez also for not calling the attention of Dr. Estrada, Dr. Villaflor, and
Nurse Dumlao about their errors.63 Petitioners insist that Dr. Enriquez should have taken, or at least
suggested, corrective measures to rectify such errors.
The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field of expertise is definitely
not obstetrics and gynecology. As such, Dr. Enriquez was not expected to correct Dr. Estrada's errors.
Besides, there was no evidence of Dr. Enriquez's knowledge of any error committed by Dr. Estrada and
his failure to act upon such observation.
d) Dr. Perpetua Lacson
Petitioners fault Dr. Perpetua Lacson for her purported delay in the delivery of blood Corazon
needed.64 Petitioners claim that Dr. Lacson was remiss in her duty of supervising the blood bank staff.
As found by the trial court, there was no unreasonable delay in the delivery of blood from the time of
the request until the transfusion to Corazon. Dr. Lacson competently explained the procedure before
blood could be given to the patient.65 Taking into account the bleeding time, clotting time and cross-
matching, Dr. Lacson stated that it would take approximately 45-60 minutes before blood could be
ready for transfusion.66 Further, no evidence exists that Dr. Lacson neglected her duties as head of the
blood bank.
e) Dr. Noe Espinola
Petitioners argue that Dr. Espinola should not have ordered immediate hysterectomy without
determining the underlying cause of Corazon's bleeding. Dr. Espinola should have first considered the
possibility of cervical injury, and advised a thorough examination of the cervix, instead of believing
outright Dr. Estrada's diagnosis that the cause of bleeding was uterine atony.
Dr. Espinola's order to do hysterectomy which was based on the information he received by phone is
not negligence. The Court agrees with the trial court's observation that Dr. Espinola, upon hearing such
information about Corazon's condition, believed in good faith that hysterectomy was the correct
remedy. At any rate, the hysterectomy did not push through because upon Dr. Espinola's arrival, it was
already too late. At the time, Corazon was practically dead.
f) Nurse J. Dumlao
In Moore v. Guthrie Hospital Inc.,67 the US Court of Appeals, Fourth Circuit, held that to recover, a
patient complaining of injuries allegedly resulting when the nurse negligently injected medicine to him
intravenously instead of intramuscularly had to show that (1) an intravenous injection constituted a lack
of reasonable and ordinary care; (2) the nurse injected medicine intravenously; and (3) such injection
was the proximate cause of his injury.
In the present case, there is no evidence of Nurse Dumlao's alleged failure to follow Dr. Estrada's
specific instructions. Even assuming Nurse Dumlao defied Dr. Estrada's order, there is no showing that
side-drip administration of hemacel proximately caused Corazon's death. No evidence linking
Corazon's death and the alleged wrongful hemacel administration was introduced. Therefore, there is
no basis to hold Nurse Dumlao liable for negligence.
On the Award of Interest on Damages
The award of interest on damages is proper and allowed under Article 2211 of the Civil Code, which
states that in crimes and quasi-delicts, interest as a part of the damages may, in a proper case, be
adjudicated in the discretion of the court.68
WHEREFORE, the Court PARTLY GRANTS the petition. 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.
SO ORDERED.
Nogales vs Capitol Medical Center
GR No. 142625 December 19, 2006
Facts: Pregnant with her fourth child, Corazon Nogales, who was then 37 y/o was under the exclusive
prenatal care of Dr. Oscar 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 edemas indicating preeclampsia which is a dangerous complication of
pregnancy. Around midnight of May 26, 1976, Corazon started to experience mild labor pains
prompting Corazon and Rogelio Nogales to see Dr. Estrada at his home. After examining Corazon, Dr.
Estrada advised her immediate admission to Capitol Medical Center (CMC). Upon her admission, an
internal examination was conducted upon her by a resident-physician. Based on the doctor’s sheet,
around 3am, Dr. Estrada advised for 10mg valium to be administered immediately by intramuscular
injection, he later ordered the start of intravenous administration of syntociron admixed with dextrose,
5% in lactated ringer’s solution, at the rate of 8-10 micro-drops per minute. When asked if he needed
the services of anesthesiologist, he refused. Corazon’s bag of water ruptured spontaneously and her
cervix was fully dilated and she experienced convulsions. Dr. Estrada ordered the injection of 10g of
magnesium sulfate but his assisting Doctor, Dr. Villaflor, only administered 2.5g. She also applied low
forceps to extract Corazon’s baby. In the process, a 10 x 2.5cm piece of cervical tissue was allegedly
torn. The baby came out in an apric, cyanatic weak and injured condition. Consequently the baby had
to be intubated and resuscitated. Corazon had professed vaginal bleeding where a blood typing was
ordered and she was supposed to undergo hysterectomy, however, upon the arrival of the doctor, she
was already pronounced dead due to hemorrhage.
Issue: Whether or not in the conduct of child delivery, the doctors and the respondent hospital is liable
for negligence.
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.
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.
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 acquired in them; and 3.) the plaintiff acted in reliance upon the conduct of the
hospital or its agent, consistent with ordinary care and prudence.
Borrowed servant doctrine provides that once a surgeon enters the operating room and takes charge of
the acts or omissions of operating room personnel and any negligence associated with each 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.
G.R. No. 126297 January 31, 2007
PROFESSIONAL SERVICES, INC., Petitioner,
vs.
NATIVIDAD and ENRIQUE AGANA, Respondents.
x-----------------------x
G.R. No. 126467 January 31, 2007
NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE AGANA, JR.,
EMMA AGANA ANDAYA, JESUS AGANA, and RAYMUND AGANA) and ENRIQUE AGANA,
Petitioners,
vs.
JUAN FUENTES, Respondent.
x- - - - - - - - - - - - - - - - - - - -- - - - x
G.R. No. 127590 January 31, 2007
MIGUEL AMPIL, Petitioner,
vs.
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
DECISION
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankind’s most important and delicate endeavors, must assume
the grave responsibility of pursuing it with appropriate care. The care and service dispensed through
this high trust, however technical, complex and esoteric its character may be, must meet standards of
responsibility commensurate with the undertaking to preserve and protect the health, and indeed, the
very lives of those placed in the hospital’s keeping.1
Assailed in these three consolidated petitions for review on certiorari is the Court of Appeals’ Decision 2
dated September 6, 1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198 affirming with
modification the Decision3 dated March 17, 1993 of the Regional Trial Court (RTC), Branch 96,
Quezon City in Civil Case No. Q-43322 and nullifying its Order dated September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital (Medical City
Hospital) because of difficulty of bowel movement and bloody anal discharge. After a series of medical
examinations, Dr. Miguel Ampil, petitioner in G.R. No. 127590, diagnosed her to be suffering from
"cancer of the sigmoid."
On April 11, 1984, Dr. Ampil, assisted by the medical staff 4 of the Medical City Hospital, performed an
anterior resection surgery on Natividad. He found that the malignancy in her sigmoid area had spread
on her left ovary, necessitating the removal of certain portions of it. Thus, Dr. Ampil obtained the
consent of Natividad’s husband, Enrique Agana, to permit Dr. Juan Fuentes, respondent in G.R. No.
126467, to perform hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and
closed the incision.
However, the operation appeared to be flawed. In the corresponding Record of Operation dated April
11, 1984, the attending nurses entered these remarks:
"sponge count lacking 2
"announced to surgeon searched (sic) done but to no avail continue for closure."
On April 24, 1984, Natividad was released from the hospital. Her hospital and medical bills, including
the doctors’ fees, amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating pain in her anal region. She consulted
both Dr. Ampil and Dr. Fuentes about it. They told her that the pain was the natural consequence of the
surgery. Dr. Ampil then recommended that she consult an oncologist to examine the cancerous nodes
which were not removed during the operation.
On May 9, 1984, Natividad, accompanied by her husband, went to the United States to seek further
treatment. After four months of consultations and laboratory examinations, Natividad was told she was
free of cancer. Hence, she was advised to return to the Philippines.
On August 31, 1984, Natividad flew back to the Philippines, still suffering from pains. Two weeks
thereafter, her daughter found a piece of gauze protruding from her vagina. Upon being informed about
it, Dr. Ampil proceeded to her house where he managed to extract by hand a piece of gauze measuring
1.5 inches in width. He then assured her that the pains would soon vanish.
Dr. Ampil’s assurance did not come true. Instead, the pains intensified, prompting Natividad to seek
treatment at the Polymedic General Hospital. While confined there, Dr. Ramon Gutierrez detected the
presence of another foreign object in her vagina -- a foul-smelling gauze measuring 1.5 inches in width
which badly infected her vaginal vault. A recto-vaginal fistula had formed in her reproductive organs
which forced stool to excrete through the vagina. Another surgical operation was needed to remedy the
damage. Thus, in October 1984, Natividad underwent another surgery.
On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, Quezon City a
complaint for damages against the Professional Services, Inc. (PSI), owner of the Medical City
Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil Case No. Q-43322. They alleged that the latter
are liable for negligence for leaving two pieces of gauze inside Natividad’s body and malpractice for
concealing their acts of negligence.
Meanwhile, Enrique Agana also filed with the Professional Regulation Commission (PRC) an
administrative complaint for gross negligence and malpractice against Dr. Ampil and Dr. Fuentes,
docketed as Administrative Case No. 1690. The PRC Board of Medicine heard the case only with
respect to Dr. Fuentes because it failed to acquire jurisdiction over Dr. Ampil who was then in the
United States.
On February 16, 1986, pending the outcome of the above cases, Natividad died and was duly
substituted by her above-named children (the Aganas).
On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and
Dr. Fuentes liable for negligence and malpractice, the decretal part of which reads:
WHEREFORE, judgment is hereby rendered for the plaintiffs ordering the defendants
PROFESSIONAL SERVICES, INC., DR. MIGUEL AMPIL and DR. JUAN FUENTES to pay to the
plaintiffs, jointly and severally, except in respect of the award for exemplary damages and the interest
thereon which are the liabilities of defendants Dr. Ampil and Dr. Fuentes only, as follows:
1. As actual damages, the following amounts:
a. The equivalent in Philippine Currency of the total of US$19,900.00 at the rate of
P21.60-US$1.00, as reimbursement of actual expenses incurred in the United States of
America;
b. The sum of P4,800.00 as travel taxes of plaintiffs and their physician daughter;
c. The total sum of P45,802.50, representing the cost of hospitalization at Polymedic
Hospital, medical fees, and cost of the saline solution;
2. As moral damages, the sum of P2,000,000.00;
3. As exemplary damages, the sum of P300,000.00;
4. As attorney’s fees, the sum of P250,000.00;
5. Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove, from date of filing of the
complaint until full payment; and
6. Costs of suit.
SO ORDERED.
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals, docketed as
CA-G.R. CV No. 42062.
Incidentally, on April 3, 1993, the Aganas filed with the RTC a motion for a partial execution of its
Decision, which was granted in an Order dated May 11, 1993. Thereafter, the sheriff levied upon
certain properties of Dr. Ampil and sold them for P451,275.00 and delivered the amount to the Aganas.
Following their receipt of the money, the Aganas entered into an agreement with PSI and Dr. Fuentes to
indefinitely suspend any further execution of the RTC Decision. However, not long thereafter, the
Aganas again filed a motion for an alias writ of execution against the properties of PSI and Dr. Fuentes.
On September 21, 1993, the RTC granted the motion and issued the corresponding writ, prompting Dr.
Fuentes to file with the Court of Appeals a petition for certiorari and prohibition, with prayer for
preliminary injunction, docketed as CA-G.R. SP No. 32198. During its pendency, the Court of Appeals
issued a Resolution5 dated October 29, 1993 granting Dr. Fuentes’ prayer for injunctive relief.
On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No. 42062.
Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision 6 in Administrative
Case No. 1690 dismissing the case against Dr. Fuentes. The Board held that the prosecution failed to
show that Dr. Fuentes was the one who left the two pieces of gauze inside Natividad’s body; and that he
concealed such fact from Natividad.
On September 6, 1996, the Court of Appeals rendered its Decision jointly disposing of CA-G.R. CV
No. 42062 and CA-G.R. SP No. 32198, thus:
WHEREFORE, except for the modification that the case against defendant-appellant Dr. Juan Fuentes
is hereby DISMISSED, and with the pronouncement that defendant-appellant Dr. Miguel Ampil is
liable to reimburse defendant-appellant Professional Services, Inc., whatever amount the latter will pay
or had paid to the plaintiffs-appellees, the decision appealed from is hereby AFFIRMED and the instant
appeal DISMISSED.
Concomitant with the above, the petition for certiorari and prohibition filed by herein defendant-
appellant Dr. Juan Fuentes in CA-G.R. SP No. 32198 is hereby GRANTED and the challenged order of
the respondent judge dated September 21, 1993, as well as the alias writ of execution issued pursuant
thereto are hereby NULLIFIED and SET ASIDE. The bond posted by the petitioner in connection with
the writ of preliminary injunction issued by this Court on November 29, 1993 is hereby cancelled.
Costs against defendants-appellants Dr. Miguel Ampil and Professional Services, Inc.
SO ORDERED.
Only Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolution 7 dated December
19, 1996.
Hence, the instant consolidated petitions.
In G.R. No. 126297, PSI alleged in its petition that the Court of Appeals erred in holding that: (1) it is
estopped from raising the defense that Dr. Ampil is not its employee; (2) it is solidarily liable with Dr.
Ampil; and (3) it is not entitled to its counterclaim against the Aganas. PSI contends that Dr. Ampil is
not its employee, but a mere consultant or independent contractor. As such, he alone should answer for
his negligence.
In G.R. No. 126467, the Aganas maintain that the Court of Appeals erred in finding that Dr. Fuentes is
not guilty of negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. They
contend that the pieces of gauze are prima facie proofs that the operating surgeons have been negligent.
Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of Appeals erred in finding him liable for
negligence and malpractice sans evidence that he left the two pieces of gauze in Natividad’s vagina. He
pointed to other probable causes, such as: (1) it was Dr. Fuentes who used gauzes in performing the
hysterectomy; (2) the attending nurses’ failure to properly count the gauzes used during surgery; and
(3) the medical intervention of the American doctors who examined Natividad in the United States of
America.
For our resolution are these three vital issues: first, whether the Court of Appeals erred in holding Dr.
Ampil liable for negligence and malpractice; second, whether the Court of Appeals erred in absolving
Dr. Fuentes of any liability; and third, whether PSI may be held solidarily liable for the negligence of
Dr. Ampil.
I - G.R. No. 127590
Whether the Court of Appeals Erred in Holding Dr. Ampil
Liable for Negligence and Malpractice.
Dr. Ampil, in an attempt to absolve himself, gears the Court’s attention to other possible causes of
Natividad’s detriment. He argues that the Court should not discount either of the following
possibilities: first, Dr. Fuentes left the gauzes in Natividad’s body after performing hysterectomy;
second, the attending nurses erred in counting the gauzes; and third, the American doctors were the
ones who placed the gauzes in Natividad’s body.
Dr. Ampil’s arguments are purely conjectural and without basis. Records show that he did not present
any evidence to prove that the American doctors were the ones who put or left the gauzes in
Natividad’s body. Neither did he submit evidence to rebut the correctness of the record of operation,
particularly the number of gauzes used. As to the alleged negligence of Dr. Fuentes, we are mindful that
Dr. Ampil examined his (Dr. Fuentes’) work and found it in order.
The glaring truth is that all the major circumstances, taken together, as specified by the Court of
Appeals, directly point to Dr. Ampil as the negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges to control the bleeding of the
patient during the surgical operation.
Second, immediately after the operation, the nurses who assisted in the surgery noted in their
report that the ‘sponge count (was) lacking 2’; that such anomaly was ‘announced to surgeon’
and that a ‘search was done but to no avail’ prompting Dr. Ampil to ‘continue for closure’ x x x.
Third, after the operation, two (2) gauzes were extracted from the same spot of the body of Mrs.
Agana where the surgery was performed.
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. 8 To put it
simply, such act is considered so inconsistent with due care as to raise an inference of negligence.
There are even legions of authorities to the effect that such act is negligence per se.9
Of course, the Court is not blind to the reality that there are times when danger to a patient’s life
precludes a surgeon from further searching missing sponges or foreign objects left in the body. But this
does not leave him free from any obligation. Even if it has been shown that a surgeon was required by
the urgent necessities of the case to leave a sponge in his patient’s abdomen, because of the dangers
attendant upon delay, still, it is his legal duty to so inform his patient within a reasonable time thereafter
by advising her of what he had been compelled to do. This is in order that she might seek relief from
the effects of the foreign object left in her body as her condition might permit. The ruling in Smith v.
Zeagler10 is explicit, thus:
The removal of all sponges used is part of a surgical operation, and when a physician or surgeon fails to
remove a sponge he has placed in his patient’s body that should be removed as part of the operation, he
thereby leaves his operation uncompleted and creates a new condition which imposes upon him the
legal duty of calling the new condition to his patient’s attention, and endeavoring with the means he has
at hand to minimize and avoid untoward results likely to ensue therefrom.
Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even
misled her that the pain she was experiencing was the ordinary consequence of her operation. Had he
been more candid, Natividad could have taken the immediate and appropriate medical remedy to
remove the gauzes from her body. To our mind, what was initially an act of negligence by Dr. Ampil
has ripened into a deliberate wrongful act of deceiving his patient.
This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully
pursue this kind of case, a patient must only prove that a health care provider either failed to do
something which a reasonably prudent health care provider would have done, or that he did something
that a reasonably prudent provider would not have done; and that failure or action caused injury to the
patient.11 Simply put, 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 12 of
Natividad’s injury could be traced from his act of closing the incision despite the information given by
the attending nurses that two 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 the missing gauzes from the
knowledge of Natividad and her family.
II - G.R. No. 126467
Whether the Court of Appeals Erred in Absolving
Dr. Fuentes of any Liability
The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes on the ground that it
is contrary to the doctrine of res ipsa loquitur. According to them, the fact that the two pieces of gauze
were left inside Natividad’s body is a prima facie evidence of Dr. Fuentes’ negligence.
We are not convinced.
Literally, res ipsa loquitur means "the thing speaks for itself." It is 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.13 Stated differently, where the thing which caused the injury,
without the fault of the injured, is under the exclusive control of the defendant and the injury is such
that it should not have occurred if he, having such control used proper care, it affords reasonable
evidence, in the absence of explanation that the injury arose from the defendant’s want of care, and the
burden of proof is shifted to him to establish that he has observed due care and diligence.14
From the foregoing statements of the rule, the requisites for the applicability of the doctrine of res ipsa
loquitur are: (1) the 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 requisites, the most instrumental is the
"control and management of the thing which caused the injury."15
We find the element of "control and management of the thing which caused the injury" to be wanting.
Hence, the doctrine of res ipsa loquitur will not lie.
It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He
requested the assistance of Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil) found that
the malignancy in her sigmoid area had spread to her left ovary. Dr. Fuentes performed the surgery and
thereafter reported and showed his work to Dr. Ampil. The latter examined it and finding everything to
be in order, allowed Dr. Fuentes to leave the operating room. Dr. Ampil then resumed operating on
Natividad. He was about to finish the procedure when the attending nurses informed him that two
pieces of gauze were missing. A "diligent search" was conducted, but the misplaced gauzes were not
found. Dr. Ampil then directed that the incision be closed. During this entire period, Dr. Fuentes was no
longer in the operating room and had, in fact, left the hospital.
Under the "Captain of the Ship" rule, the operating surgeon is the person in complete charge of the
surgery room and all personnel connected with the operation. Their duty is to obey his orders. 16 As
stated before, Dr. Ampil was the lead surgeon. In other words, he was the "Captain of the Ship." That
he discharged such role is evident from his following conduct: (1) calling Dr. Fuentes to perform a
hysterectomy; (2) examining the work of Dr. Fuentes and finding it in order; (3) granting Dr. Fuentes’
permission to leave; and (4) ordering the closure of the incision. To our mind, it was this act of ordering
the closure of the incision notwithstanding that two pieces of gauze remained unaccounted for, that
caused injury to Natividad’s body. Clearly, the control and management of the thing which caused the
injury was in the hands of Dr. Ampil, not Dr. Fuentes.
In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not per se create or
constitute an independent or separate ground of liability, being a mere evidentiary rule. 17 In other
words, mere invocation and application of the doctrine does not dispense with the requirement of proof
of negligence. Here, the negligence was proven to have been committed by Dr. Ampil and not by Dr.
Fuentes.
III - G.R. No. 126297
Whether PSI Is Liable for the Negligence of Dr. Ampil
The third issue necessitates a glimpse at the historical development of hospitals and the resulting
theories concerning their liability for the negligence of physicians.
Until the mid-nineteenth century, hospitals were generally charitable institutions, providing medical
services to the lowest classes of society, without regard for a patient’s ability to pay. 18 Those who could
afford medical treatment were usually treated at home by their doctors. 19 However, the days of house
calls and philanthropic health care are over. The modern health care industry continues to distance itself
from its charitable past and has experienced a significant conversion from a not-for-profit health care to
for-profit hospital businesses. Consequently, significant changes in health law have accompanied the
business-related changes in the hospital industry. One important legal change is an increase in hospital
liability for medical malpractice. Many courts now allow claims for hospital vicarious liability under
the theories of respondeat superior, apparent authority, ostensible authority, or agency by estoppel. 20
In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of the Civil Code,
which reads:
Art. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is
obliged to pay for the damage done. Such fault or negligence, if there is no pre-existing contractual
relation between the parties, is called a quasi-delict and is governed by the provisions of this Chapter.
A derivative of this provision is Article 2180, the rule governing vicarious liability under the doctrine
of respondeat superior, thus:
ART. 2180. The obligation imposed by Article 2176 is demandable not only for one’s own acts or
omissions, but also for those of persons for whom one is responsible.
x x x x
x x
The owners and managers of an establishment or enterprise are likewise responsible for damages
caused by their employees in the service of the branches in which the latter are employed or on the
occasion of their functions.
Employers shall be liable for the damages caused by their employees and household helpers acting
within the scope of their assigned tasks even though the former are not engaged in any business or
industry.
x x x
x x x
The responsibility treated of in this article shall cease when the persons herein mentioned prove that
they observed all the diligence of a good father of a family to prevent damage.
A prominent civilist commented that professionals engaged by an employer, such as physicians,
dentists, and pharmacists, are not "employees" under this article because the manner in which they
perform their work is not within the control of the latter (employer). In other words, professionals are
considered personally liable for the fault or negligence they commit in the discharge of their duties, and
their employer cannot be held liable for such fault or negligence. In the context of the present case, "a
hospital cannot be held liable for the fault or negligence of a physician or surgeon in the treatment or
operation of patients."21
The foregoing view is grounded on the traditional notion that the professional status and the very nature
of the physician’s calling preclude him from being classed as an agent or employee of a hospital,
whenever he acts in a professional capacity.22 It has been said that medical practice strictly involves
highly developed and specialized knowledge,23 such that physicians are generally free to exercise their
own skill and judgment in rendering medical services sans interference. 24 Hence, when a doctor
practices medicine in a hospital setting, the hospital and its employees are deemed to subserve him in
his ministrations to the patient and his actions are of his own responsibility.25
The case of Schloendorff v. Society of New York Hospital 26 was then considered an authority for this
view. The "Schloendorff doctrine" regards a physician, even if employed by a hospital, as an
independent contractor because of the skill he exercises and the lack of control exerted over his work.
Under this doctrine, hospitals are exempt from the application of the respondeat superior principle for
fault or negligence committed by physicians in the discharge of their profession.
However, the efficacy of the foregoing doctrine has weakened with the significant developments in
medical care. Courts came to realize that modern hospitals are increasingly taking active role in
supplying and regulating medical care to patients. No longer were a hospital’s functions limited to
furnishing room, food, facilities for treatment and operation, and attendants for its patients. Thus, in
Bing v. Thunig,27 the New York Court of Appeals deviated from the Schloendorff doctrine, noting that
modern hospitals actually do far more than provide facilities for treatment. Rather, they regularly
employ, on a salaried basis, a large staff of physicians, interns, nurses, administrative and manual
workers. They charge patients for medical care and treatment, even collecting for such services through
legal action, if necessary. The court then concluded that there is no reason to exempt hospitals from the
universal rule of respondeat superior.
In our shores, the nature of the relationship between the hospital and the physicians is rendered
inconsequential in view of our categorical pronouncement in Ramos v. Court of Appeals 28 that for
purposes of apportioning responsibility in medical negligence cases, an employer-employee
relationship in effect exists between hospitals and their attending and visiting physicians. This Court
held:
"We now discuss the responsibility of the hospital in this particular incident. The unique practice
(among private hospitals) of filling up specialist staff with attending and visiting "consultants," who are
allegedly not hospital employees, presents problems in apportioning responsibility for negligence in
medical malpractice cases. However, the difficulty is more apparent than real.
In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the
conduct of their work within the hospital premises. Doctors who apply for ‘consultant’ slots, visiting or
attending, are required to submit proof of completion of residency, their educational qualifications,
generally, evidence of accreditation by the appropriate board (diplomate), evidence of fellowship in
most cases, and references. These requirements are carefully scrutinized by members of the hospital
administration or by a review committee set up by the hospital who either accept or reject the
application. x x x.
After a physician is accepted, either as a visiting or attending consultant, he is normally required to
attend clinico-pathological conferences, conduct bedside rounds for clerks, interns and residents,
moderate grand rounds and patient audits and perform other tasks and responsibilities, for the privilege
of being able to maintain a clinic in the hospital, and/or for the privilege of admitting patients into the
hospital. In addition to these, the physician’s performance as a specialist is generally evaluated by a
peer review committee on the basis of mortality and morbidity statistics, and feedback from patients,
nurses, interns and residents. A consultant remiss in his duties, or a consultant who regularly falls short
of the minimum standards acceptable to the hospital or its peer review committee, is normally politely
terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and visiting
‘consultant’ staff. While ‘consultants’ are not, technically employees, x x x, the control exercised, the
hiring, and the right to terminate consultants all fulfill the important hallmarks of an employer-
employee relationship, with the exception of the payment of wages. In assessing whether such a
relationship in fact exists, the control test is determining. Accordingly, on the basis of the foregoing, we
rule that for the purpose of allocating responsibility in medical negligence cases, an employer-
employee relationship in effect exists between hospitals and their attending and visiting physicians. "
But the Ramos pronouncement is not our only basis in sustaining PSI’s liability. Its liability is also
anchored upon the agency principle of apparent authority or agency by estoppel and the doctrine of
corporate negligence which have gained acceptance in the determination of a hospital’s liability for
negligent acts of health professionals. The present case serves as a perfect platform to test the
applicability of these doctrines, thus, enriching our jurisprudence.
Apparent authority, or what is sometimes referred to as the "holding
out" theory, or doctrine of ostensible agency or agency by estoppel, 29 has its origin from the law of
agency. It imposes liability, not as the result of the reality of a contractual relationship, but rather
because of the actions of a principal or an employer in somehow misleading the public into believing
that the relationship or the authority exists.30 The concept is essentially one of estoppel and has been
explained in this manner:
"The principal is bound by the acts of his agent with the apparent authority which he knowingly
permits the agent to assume, or which he holds the agent out to the public as possessing. The question
in every case is whether the principal has by his voluntary act placed the agent in such a situation that a
person of ordinary prudence, conversant with business usages and the nature of the particular business,
is justified in presuming that such agent has authority to perform the particular act in question.31
The applicability of apparent authority in the field of hospital liability was upheld long time ago in
Irving v. Doctor Hospital of Lake Worth, Inc. 32 There, it was explicitly stated that "there does not
appear to be any rational basis for excluding the concept of apparent authority from the field of hospital
liability." Thus, in cases where it can be shown that a hospital, by its actions, has held out a particular
physician as its agent and/or employee and that a patient has accepted treatment from that physician in
the reasonable belief that it is being rendered in behalf of the hospital, then the hospital will be liable
for the physician’s negligence.
Our jurisdiction recognizes the concept of an agency by implication or estoppel. Article 1869 of the
Civil Code reads:
ART. 1869. Agency may be express, or implied from the acts of the principal, from his silence or lack
of action, or his failure to repudiate the agency, knowing that another person is acting on his behalf
without authority.
In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and
specializations of the physicians associated or accredited by it, including those of Dr. Ampil and Dr.
Fuentes. We concur with the Court of Appeals’ conclusion that it "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." Indeed, PSI’s act is tantamount to holding out to
the public that Medical City Hospital, through its accredited physicians, offers quality health care
services. By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications, the
hospital created the impression that they were its agents, authorized to perform medical or surgical
services for its patients. As expected, these patients, Natividad being one of them, accepted the services
on the reasonable belief that such were being rendered by the hospital or its employees, agents, or
servants. The trial court correctly pointed out:
x x x regardless of the education and status in life of the patient, he ought not be burdened with the
defense of absence of employer-employee relationship between the hospital and the independent
physician whose name and competence are certainly certified to the general public by the hospital’s act
of listing him and his specialty in its lobby directory, as in the case herein. The high costs of today’s
medical and health care should at least exact on the hospital greater, if not broader, legal responsibility
for the conduct of treatment and surgery within its facility by its accredited physician or surgeon,
regardless of whether he is independent or employed."33
The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like PSI, are capable of
acting only through other individuals, such as physicians. If these accredited physicians do their job
well, the hospital succeeds in its mission of offering quality medical services and thus profits
financially. Logically, where negligence mars the quality of its services, the hospital should not be
allowed to escape liability for the acts of its ostensible agents.
We now proceed to the doctrine of corporate negligence or corporate responsibility.
One allegation in the complaint in Civil Case No. Q-43332 for negligence and malpractice is that PSI
as owner, operator and manager of Medical City Hospital, "did not perform the necessary supervision
nor exercise diligent efforts in the supervision of Drs. Ampil and Fuentes and its nursing staff, resident
doctors, and medical interns who assisted Drs. Ampil and Fuentes in the performance of their duties as
surgeons."34 Premised on the doctrine of corporate negligence, the trial court held that PSI is directly
liable for such breach of duty.
We agree with the trial court.
Recent years have seen the doctrine of corporate negligence as the judicial answer to the problem of
allocating hospital’s liability for the negligent acts of health practitioners, absent facts to support the
application of respondeat superior or apparent authority. Its formulation proceeds from the judiciary’s
acknowledgment that in these modern times, the duty of providing quality medical service is no longer
the sole prerogative and responsibility of the physician. The modern hospitals have changed structure.
Hospitals now tend to organize a highly professional medical staff whose competence and performance
need to be monitored by the hospitals commensurate with their inherent responsibility to provide
quality medical care.35
The doctrine has its genesis in Darling v. Charleston Community Hospital. 36 There, the Supreme Court
of Illinois held that "the jury could have found a hospital negligent, inter alia, in failing to have a
sufficient number of trained nurses attending the patient; failing to require a consultation with or
examination by members of the hospital staff; and failing to review the treatment rendered to the
patient." On the basis of Darling, other jurisdictions held that a hospital’s corporate negligence extends
to permitting a physician known to be incompetent to practice at the hospital. 37 With the passage of
time, more duties were expected from hospitals, among them: (1) the use of reasonable care in the
maintenance of safe and adequate facilities and equipment; (2) the selection and retention of competent
physicians; (3) the overseeing or supervision of all persons who practice medicine within its walls; and
(4) the formulation, adoption and enforcement of adequate rules and policies that ensure quality care
for its patients.38 Thus, in Tucson Medical Center, Inc. v. Misevich, 39 it was held that a hospital,
following 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. And in Bost v. Riley,40 the court concluded that a patient who enters a hospital does so
with the reasonable expectation that it will attempt to cure him. The hospital accordingly has the duty
to make a reasonable effort to monitor and oversee the treatment prescribed and administered by the
physicians practicing in its premises.
In the present case, it was duly established that PSI operates the Medical City Hospital for the purpose
and under the concept of providing comprehensive medical services to the public. Accordingly, it has
the duty to exercise reasonable care to protect from harm all patients admitted into its facility for
medical treatment. Unfortunately, PSI failed to perform such duty. The findings of the trial court are
convincing, thus:
x x x PSI’s liability is traceable to its failure to conduct an investigation of the matter reported in the
nota bene of the count nurse. Such failure established PSI’s part in the dark conspiracy of silence and
concealment about the gauzes. Ethical considerations, if not also legal, dictated the holding of an
immediate inquiry into the events, if not for the benefit of the patient to whom the duty is primarily
owed, then in the interest of arriving at the truth. The Court cannot accept that the medical and the
healing professions, through their members like defendant surgeons, and their institutions like PSI’s
hospital facility, can callously turn their backs on and disregard even a mere probability of mistake or
negligence by refusing or failing to investigate a report of such seriousness as the one in Natividad’s
case.
It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the assistance of the
Medical City Hospital’s staff, composed of resident doctors, nurses, and interns. As such, it is
reasonable to conclude that PSI, as the operator of the hospital, has actual or constructive knowledge of
the procedures carried out, particularly the report of the attending nurses that the two pieces of gauze
were missing. In Fridena v. Evans,41 it was held that a corporation is bound by the knowledge acquired
by or notice given to its agents or officers within the scope of their authority and in reference to a
matter to which their authority extends. This means that the knowledge of any of the staff of Medical
City Hospital constitutes knowledge of PSI. Now, the failure of PSI, despite the attending nurses’
report, to investigate and inform Natividad regarding the missing gauzes amounts to callous
negligence. Not only did PSI breach its duties to oversee or supervise all persons who practice
medicine within its walls, it also failed to take an active step in fixing the negligence committed. This
renders PSI, not only vicariously liable for the negligence of Dr. Ampil under Article 2180 of the Civil
Code, but also directly liable for its own negligence under Article 2176. In Fridena, the Supreme Court
of Arizona held:
x x x In recent years, however, the duty of care owed to the patient by the hospital has expanded. The
emerging trend is to hold the hospital responsible where the hospital has failed to monitor and review
medical services being provided within its walls. See Kahn Hospital Malpractice Prevention, 27 De
Paul . Rev. 23 (1977).
Among the cases indicative of the ‘emerging trend’ is Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d
335 (1972). In Purcell, the hospital argued that it could not be held liable for the malpractice of a
medical practitioner because he was an independent contractor within the hospital. The Court of
Appeals pointed out that the hospital had created a professional staff whose competence and
performance was to be monitored and reviewed by the governing body of the hospital, and the court
held that a hospital would be negligent where it had knowledge or reason to believe that a doctor using
the facilities was employing a method of treatment or care which fell below the recognized standard of
care.
Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hospital has certain
inherent responsibilities regarding the quality of medical care furnished to patients within its walls and
it must meet the standards of responsibility commensurate with this undertaking. Beeck v. Tucson
General Hospital, 18 Ariz. App. 165, 500 P. 2d 1153 (1972). This court has confirmed the rulings of the
Court of Appeals that a hospital has the duty of supervising the competence of the doctors on its staff. x
x x.
x x x x x x
In the amended complaint, the plaintiffs did plead that the operation was performed at the hospital with
its knowledge, aid, and assistance, and that the negligence of the defendants was the proximate cause of
the patient’s injuries. We find that such general allegations of negligence, along with the evidence
produced at the trial of this case, are sufficient to support the hospital’s liability based on the theory of
negligent supervision."
Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for damages, let it be
emphasized that PSI, apart from a general denial of its responsibility, failed to adduce evidence
showing that it exercised the diligence of a good father of a family in the accreditation and supervision
of the latter. In neglecting to offer such proof, PSI failed to discharge its burden under the last
paragraph of Article 2180 cited earlier, and, therefore, must be adjudged solidarily liable with Dr.
Ampil. Moreover, as we have discussed, PSI is also directly liable to the Aganas.
One final word. Once a physician undertakes the treatment and care of a patient, the law imposes on
him certain obligations. In order to escape liability, he must possess that reasonable degree of learning,
skill and experience required by his profession. At the same time, he must apply reasonable care and
diligence in the exercise of his skill and the application of his knowledge, and exert his best judgment.
WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of the Court of
Appeals in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198.
Costs against petitioners PSI and Dr. Miguel Ampil.
SO ORDERED.
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.
- versus - Present:
CARPIO MORALES,
TINGA, and
x------------------------------------------------x
DECISION
QUISUMBING, J.:
For review on certiorari are the Decision[1] dated October 3, 2002 and Resolution[2]
dated November 19, 2003 of the Court of Appeals in CA-G.R. CV No. 58184, which
affirmed with modification the Decision[3] dated March 3, 1997 of the Regional Trial
Court of Quezon City, Branch 98, in Civil Case No. Q-93-16562.
Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and Gynecology at the Dr.
Jesus Delgado Memorial Hospital. She was the attending physician of respondent Nora
S. Go, who was admitted at the said hospital on April 19, 1992.
At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy. However,
at around 3:30 a.m., Nora suffered profuse bleeding inside her womb due to some parts
of the placenta which were not completely expelled from her womb after delivery.
Consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood
pressure to 40 over 0. Petitioner and the assisting resident physician performed various
medical procedures to stop the bleeding and to restore Noras blood pressure. Her blood
pressure was frequently monitored with the use of a sphygmomanometer. While
petitioner was massaging Noras uterus for it to contract and stop bleeding, she ordered a
droplight to warm Nora and her baby.[4] Nora remained unconscious until she
recovered.
While in the recovery room, her husband, respondent John David Z. Go noticed a fresh
gaping wound two and a half (2 ) by three and a half (3 ) inches in the inner portion of
her left arm, close to the armpit.[5] He asked the nurses what caused the injury. He was
informed it was a burn. Forthwith, on April 22, 1992, John David filed a request for
investigation.[6] In response, Dr. Rainerio S. Abad, the medical director of the hospital,
called petitioner and the assisting resident physician to explain what happened.
Petitioner said the blood pressure cuff caused the injury.
On May 7, 1992, John David brought Nora to the National Bureau of Investigation for a
physical examination, which was conducted by medico-legal officer Dr. Floresto
Arizala, Jr.[7] The medico-legal officer later testified that Noras injury appeared to be a
burn and that a droplight when placed near the skin for about 10 minutes could cause
such burn.[8] He dismissed the likelihood that the wound was caused by a blood
pressure cuff as the scar was not around the arm, but just on one side of the arm.[9]
On May 22, 1992, Noras injury was referred to a plastic surgeon at the Dr. Jesus
Delgado Memorial Hospital for skin grafting.[10] Her wound was covered with skin
sourced from her abdomen, which consequently bore a scar as well. About a year after,
on April 30, 1993, scar revision had to be performed at the same hospital.[11] The
surgical operation left a healed linear scar in Noras left arm about three inches in length,
the thickest portion rising about one-fourth (1/4) of an inch from the surface of the skin.
The costs of the skin grafting and the scar revision were shouldered by the hospital.[12]
Unfortunately, Noras arm would never be the same. Aside from the unsightly mark, the
pain in her left arm remains. When sleeping, she has to cradle her wounded arm. Her
movements now are also restricted. Her children cannot play with the left side of her
body as they might accidentally bump the injured arm, which aches at the slightest
touch.
Thus, on June 21, 1993, respondent spouses filed a complaint[13] for damages against
petitioner, Dr. Abad, and the hospital. Finding in favor of respondent spouses, the trial
court decreed:
In view of the foregoing consideration, judgment is hereby rendered in favor of the plaintiffs and
against the defendants, directing the latters, (sic) jointly and severally
(a) to pay the sum of Five Hundred Thousand Pesos (P500,000.00) in moral damages;
(b) to pay the sum of One Hundred Fifty Thousand Pesos (P150,000.00) exemplary damages;
(c) to pay the sum of Eighty Thousand Pesos (P80,000.00) nominal damages;
(d) to pay Fifty Thousand Pesos (P50,000.00) for and as attorneys fees; and
SO ORDERED.[14]
Petitioner, Dr. Abad, and the hospital all appealed to the Court of Appeals, which
affirmed with modification the trial court decision, thus:
WHEREFORE, in view of all the foregoing, and finding no reversible error in the appealed Decision
dated of Branch 98 of the Regional Trial Court of Quezon City in Civil Case No. Q-93-16562, the same
is hereby AFFIRMED, with the following MODIFICATIONS:
1. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay plaintiffs-appellees John
David Go and Nora S. Go the sum of P200,000.00 as moral damages;
2. Deleting the award [of] exemplary damages, attorneys fees and expenses of litigation;
3. Dismissing the complaint with respect to defendants-appellants Dr. Rainerio S. Abad and
Delgado Clinic, Inc.;
5. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay the costs.
SO ORDERED.[15]
Petitioners motion for reconsideration was denied by the Court of Appeals.
Hence, the instant petition assigning the following as errors and issues:
I.
WHETHER OR NOT, THE LOWER COURT, AND THE COURT OF APPEALS COMMITTED
GRAVE ABUSE OF THEIR DISCRETION WHEN, NOTWITHSTANDING THAT BOTH PARTIES
HAVE RESTED THEIR RESPECTIVE CASES, THE LOWER COURT ADMITTED THE
ADDITIONAL EXHIBITS FURTHER OFFERED BY RESPONDENTS NOT TESTIFIED TO BY
ANY WITNESS AND THIS DECISION OF THE LOWER COURT WAS UPHELD BY THE COURT
OF APPEALS LIKEWISE COMMITTING GRAVE ABUSE OF DISCRETION;
II.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION
WHEN, CONTRARY TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE
PETITIONER, IT RULED THAT THE PETITIONER HAS NOT AMPLY SHOWED THAT THE
DROPLIGHT DID NOT TOUCH THE BODY OF MRS. NORA GO, AND THIS DECISION OF THE
LOWER COURT WAS UPHELD BY THE COURT OF APPEALS LIKEWISE COMMITTING
GRAVE ABUSE OF DISCRETION;
III.
IV.
V.
WHETHER OR NOT THE COURT OF APPEALS GRAVELY ABUSING ITS DISCRETION RULED
THAT PETITIONER DRA. CANTRE SHOULD HAVE INTENDED TO INFLICT THE INJURY TO
SAVE THE LIFE OF RESPONDENT MRS. GO;
VI.
WHETHER OR NOT THE LOWER COURT AND THE COURT [OF] APPEALS COMMITTED
GRAVE ABUSE OF DISCRETION WHEN, CONTRARY TO THE DETAILED PROCEDURES
DONE BY PETITIONER, BOTH RULED THAT THE RESPONDENT WAS LEFT TO THE CARE
OF THE NURSING STAFF;
VII.
VIII.
WHETHER OR NOT THE LOWER COURT GRAVELY ABUSE OF (SIC) DISCRETION WHEN,
CONTRARY TO RESPONDENTS CONTRARY TESTIMONIES AND THE ABSENCE OF ANY
TESTIMONY, IT RULED THAT THEY ARE ENTITLED TO DAMAGES AND WHICH WAS
UPHELD, ALTHOUGH MODIFIED, BY THE COURT OF APPEALS LIKEWISE ABUSING ITS
DISCRETION.[16]
Petitioner contends that additional documentary exhibits not testified to by any witness
are inadmissible in evidence because they deprived her of her constitutional right to
confront the witnesses against her. Petitioner insists the droplight could not have touched
Noras body. She maintains the injury was due to the constant taking of Noras blood
pressure. Petitioner also insinuates the Court of Appeals was misled by the testimony of
the medico-legal officer who never saw the original injury before plastic surgery was
performed. Finally, petitioner stresses that plastic surgery was not intended to restore
respondents injury to its original state but rather to prevent further complication.
Respondents, however, counter that the genuineness and due execution of the additional
documentary exhibits were duly admitted by petitioners counsel. Respondents point out
that petitioners blood pressure cuff theory is highly improbable, being unprecedented in
medical history and that the injury was definitely caused by the droplight. At any rate,
they argue, even if the injury was brought about by the blood pressure cuff, petitioner
was still negligent in her duties as Noras attending physician.
Simply put, the threshold issues for resolution are: (1) Are the questioned additional
exhibits admissible in evidence? (2) Is petitioner liable for the injury suffered by
respondent Nora Go? Thereafter, the inquiry is whether the appellate court committed
grave abuse of discretion in its assailed issuances.
As to the first issue, we agree with the Court of Appeals that said exhibits are admissible
in evidence. We note that the questioned exhibits consist mostly of Noras medical
records, which were produced by the hospital during trial pursuant to a subpoena duces
tecum. Petitioners counsel admitted the existence of the same when they were formally
offered for admission by the trial court. In any case, given the particular circumstances
of this case, a ruling on the negligence of petitioner may be made based on the res ipsa
loquitur doctrine even in the absence of such additional exhibits.
Petitioners contention that the medico-legal officer who conducted Noras physical
examination never saw her original injury before plastic surgery was performed is
without basis and contradicted by the records. Records show that the medico-legal
officer conducted the physical examination on May 7, 1992, while the skin grafting and
the scar revision were performed on Nora on May 22, 1992 and April 30, 1993,
respectively.
Coming now to the substantive matter, is petitioner liable for the injury suffered by
respondent Nora Go?
The Hippocratic Oath mandates physicians to give primordial consideration to the well-
being of their patients. If a doctor fails to live up to this precept, he is accountable for his
acts. This notwithstanding, courts face a unique restraint in adjudicating medical
negligence cases because physicians are not guarantors of care and, they never set out to
intentionally cause injury to their patients. However, intent is immaterial in negligence
cases because where negligence exists and is proven, it automatically gives the injured a
right to reparation for the damage caused.[17]
In cases involving medical negligence, the doctrine of res ipsa loquitur 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;
3. The possibility of contributing conduct which would make the plaintiff responsible is
eliminated.[18]
As to the first requirement, the gaping wound on Noras arm is certainly not an ordinary
occurrence in the act of delivering a baby, far removed as the arm is from the organs
involved in the process of giving birth. Such injury could not have happened unless
negligence had set in somewhere.
Second, whether the injury was caused by the droplight or by the blood pressure cuff is
of no moment. Both instruments are deemed within the exclusive control of the
physician in charge under the captain of the ship doctrine. This doctrine holds the
surgeon in charge of an operation liable for the negligence of his assistants during the
time when those assistants are under the surgeons control.[19] In this particular case, it
can be logically inferred that petitioner, the senior consultant in charge during the
delivery of Noras baby, exercised control over the assistants assigned to both the use of
the droplight and the taking of Noras blood pressure. Hence, the use of the droplight and
the blood pressure cuff is also within petitioners exclusive control.
Third, the gaping wound on Noras left arm, by its very nature and considering her
condition, could only be caused by something external to her and outside her control as
she was unconscious while in hypovolemic shock. Hence, Nora could not, by any stretch
of the imagination, have contributed to her own injury.
Petitioners defense that Noras wound was caused not by the droplight but by the
constant taking of her blood pressure, even if the latter was necessary given her
condition, does not absolve her from liability. As testified to by the medico-legal officer,
Dr. Arizala, Jr., the medical practice is to deflate the blood pressure cuff immediately
after each use. Otherwise, the inflated band can cause injury to the patient similar to
what could have happened in this case. Thus, if Noras wound was caused by the blood
pressure cuff, then the taking of Noras blood pressure must have been done so
negligently as to have inflicted a gaping wound on her arm,[20] for which petitioner
cannot escape liability under the captain of the ship doctrine.
Further, petitioners argument that the failed plastic surgery was not intended as a
cosmetic procedure, but rather as a measure to prevent complication does not help her
case. It does not negate negligence on her part.
Based on the foregoing, the presumption that petitioner was negligent in the exercise of
her profession stands unrebutted. In this connection, the Civil Code provides:
ART. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is
obliged to pay for the damage done.
ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious anxiety,
besmirched reputation, wounded feelings, moral shock, social humiliation, and similar injury. Though
incapable of pecuniary computation, moral damages may be recovered if they are the proximate result
of the defendants wrongful act or omission.
Clearly, under the law, petitioner is obliged to pay Nora for moral damages suffered by
the latter as a proximate result of petitioners negligence.
We note, however, that petitioner has served well as Noras obstetrician for her past three
successful deliveries. This is the first time petitioner is being held liable for damages due
to negligence in the practice of her profession. The fact that petitioner promptly took
care of Noras wound before infection and other complications set in is also indicative of
petitioners good intentions. We also take note of the fact that Nora was suffering from a
critical condition when the injury happened, such that saving her life became petitioners
elemental concern. Nonetheless, it should be stressed that all these could not justify
negligence on the part of petitioner.
Hence, considering the specific circumstances in the instant case, we find no grave
abuse of discretion in the assailed decision and resolution of the Court of Appeals.
Further, we rule that the Court of Appeals award of Two Hundred Thousand Pesos
(P200,000) as moral damages in favor of respondents and against petitioner is just and
equitable.[21]
WHEREFORE, the petition is DENIED. The Decision dated October 3, 2002 and
Resolution dated November 19, 2003 of the Court of Appeals in CA-G.R. CV No. 58184
are AFFIRMED.
No pronouncement as to costs.
SO ORDERED.
Cantre vs Go
GR No. 160889 April 27, 2007
Facts: Petitioner Dr. Milagros L. Cantre is a specialist in obstetrics and gynecology at the Dr. Jesus
Delgado memorial Hospital. She was the attending physician of respondent Nora Go, who was
admitted at the said hospital on April 19, 1992. At 1:30am of April 20, 1992, Nora gave birth to her
fourth child, a baby boy. However, at around 3:30am Nora suffered profuse bleeding insider her womb
due to some parts of the placenta were not completely expelled from her womb after delivery
consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood pressure to 40/0.
Petitioner said the assisting resident physician performed various medical procedures to stop the
bleeding and to restore Nora’s blood pressure. Her blood pressure was frequently monitored with the
use of a sphygmamometer. While petitioner was massaging Nora’s uterus for it to contract and stop
bleeding, she ordered a drop light to warm Nora and her baby. 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 Nora’s
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 Nora’s arm compelling the respondent spouse to file a complaint for damages against
petitioner.
Issue: Whether or not petitioner is liable for the injury referred by Nora.
Held: Yes. The Hippocratic oath mandates physicians to give primordial consideration to the well-
being of their patients. If a doctor fails to live up to his precept, he is accountable for his acts. This is
notwithstanding, courts face a unique restraint in adjudicating medical negligence cases because
physicians are not guardians of care and they never set out to intentionally cause injury to their patients.
However, intent is immaterial in negligence cases because where negligence exist and is proven, it
automatically gives the injured a right to reparation for the damage caused.
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 someone’s
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.
All of these three requisites were present in the case at bar.
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.