UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS

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Medical Malpractice Physician-Patient Relationship

- No exact law, BASIS: Civil Code - contractual in nature
“Art. 2176. Whoever by act or omission causes - Implied consent
damage to another, there being fault or negligence, - contract may be oral or written
is obliged to pay for the damage done. Such fault or - inferred from the acts of the parties
negligence, if there is no pre-existing contractual
relation between the parties, is called a quasi-delict The Human Body
and is governed by the provisions of this Chapter.” Anatomic Position - palm face forward

“Art. 2179. When the plaintiff's own negligence was

the immediate and proximate cause of his injury, he
cannot recover damages. But if his negligence was
only contributory, the immediate and proximate
cause of the injury being the defendant's lack of due
care, the plaintiff may recover damages, but the
courts shall mitigate the damages to be awarded”

“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.
The father and, in case of his death or
incapacity, the mother, are responsible for the
damages caused by the minor children who live in
their company.
Guardians are liable for damages caused by
the minors or incapacitated persons who are under
their authority and live in their company.
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. Head
Employers shall be liable for the damages 1. Parietal - top
caused by their employees and household helpers 2. Frontal - forehead
acting within the scope of their assigned tasks, even 3. Orbit - eyeball
though the former are not engaged in any business 4. Temporal - sides
or industry. 5. Zygomatic area - cheeks
The State is responsible in like manner when 5.1. maxilla - upper teeth
it acts through a special agent; but not when the 5.2. mandible - lower teeth
damage has been caused by the official to whom the *occipital - back (batok)
task done properly pertains, in which case what is 6. Hands
provided in Article 2176 shall be applicable. Fingers = digits
Lastly, teachers or heads of establishments Digit #1 - thumb
of arts and trades shall be liable for damages caused Trunk
by their pupils and students or apprentices, so long 7. Chest Area
as they remain in their custody. 7.1. Anterior - front
The responsibility treated of in this article 7.2. Posterior - back
shall cease when the persons herein mentioned 7.3. Lateral - sides
prove that they observed all the diligence of a good *Number of Ribs - 12
father of a family to prevent damage. Rib #1 - underneath the clavicle
Rib #2 - start counting
Line at the center is your landmark

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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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8. Abdominal (umbilicus is the landmark) Teresita did not return the next week as
Quadrant advised. However, when her condition persisted, she
went to further consult Dr. Flores at his UDMC clinic.
When Dr. Fredelicto arrived, he did a routine check-
up and ordered Teresita's admission to the hospital.
In the admission slip, he directed the hospital staff to
prepare the patient for an "on call" D&C5 operation
to be performed by his wife, Dr. Felicisima Flores (Dr.
Felicisima). Teresita was brought to her hospital
Back room at around 12 noon; the hospital staff forthwith
Lumbar Area took her blood and urine samples for the laboratory
Upper back/ Lower back tests which Dr. Fredelicto ordered.
On the same day, Teresita was taken to the
Limbs operating room. It was only then that she met Dr.
9. Arm Felicisima, an obstetrician and gynecologist. The two
9.1 .anterior - front doctors - Dr. Felicisima and Dr. Fredelicto, conferred
9.2. posterior - back on the patient's medical condition, while the
9.3. medial - middle resident physician and the medical intern gave Dr.
10. Forearm Felicisima their own briefings. She also interviewed
10.1 .anterior - front and conducted an internal vaginal examination of
10.2. posterior - back the patient which lasted for about 15 minutes. Dr.
10.3. medial - middle Felicisima thereafter called up the laboratory for the
results of the tests. At that time, only the results for
11. Thigh (same as above) the blood sugar (BS), uric acid determination,
12. Leg (same as above) cholesterol determination, and complete blood
13. Foot count (CBC) were available. Teresita's BS count was
Toes = digits 10.67mmol/l7 and her CBC was 109g/l.8
Digit #1 - big toe Based on these preparations, Dr. Felicisima
proceeded with the D&C operation with Dr.
Vital Organs Fredelicto administering the general anesthesia. A
Brain day after the operation, Teresita was subjected to an
Heart ultrasound examination as a confirmatory
Lungs procedure. The results showed that she had an
enlarged uterus and myoma uteri. Dr. Felicisima,
however, advised Teresita that she could spend her
MEDICAL NEGLIGENCE CASES recovery period at home. Still feeling weak, Teresita
opted for hospital confinement. Teresita's complete
1. Sps. Flores vs. Sps. Pineda laboratory examination results came only on that
FACTS: day . Teresita's urinalysis showed a three plus sign
Teresita Pineda consulted Dr. Fredelicto (+++) indicating that the sugar in her urine was very
Flores, regarding her medical condition. She high. She was then placed under the care of Dr.
complained of general body weakness, loss of Amado Jorge, an internist.
appetite, frequent urination and thirst, and on-and- Teresita's condition had worsened. She
off vaginal bleeding. Dr. Fredelicto initially experienced difficulty in breathing and was rushed
interviewed the patient and asked for the history of to the intensive care unit. Further tests confirmed
her monthly period to analyze the probable cause of that she was suffering from Diabetes Mellitus Type
the vaginal bleeding. He advised her to return the II. Insulin was administered on the patient, but the
following week or to go to the United Doctors medication might have arrived too late. Due to
Medical Center (UDMC) in Quezon City for a general complications induced by diabetes, Teresita died.
check-up. As for her other symptoms, he suspected Believing that Teresita's death resulted
that Teresita might be suffering from diabetes and from the negligent handling of her medical needs,
told her to continue her medications. her family (respondents) instituted an action for
damages against Dr. Fredelicto Flores and Dr.

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Felicisima Flores (collectively referred to as the
petitioner spouses) before the RTC of Nueva Ecija.
The RTC ruled in favor of Teresita's family
and awarded actual, moral, and exemplary damages,
plus attorney's fees and costs. The CA affirmed the
judgment, but modified the amount of damages
awarded and deleted the award for attorney's fees
and costs of suit.
ISSUE:
W/N the doctors were liable through
negligence for the death of the patient?
RULING: Yes. Decision of the RTC and CA affirmed.
RATIO
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
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.
As in any civil action, the burden to prove the
existence of the necessary elements rests with the
plaintiff. To successfully pursue a claim, the plaintiff
must prove by preponderance of evidence that
1. 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;
2. the failure or action caused injury to the patient.
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.
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 plaintiff's injuries;
the plaintiff must plead and prove not only that he
had been injured and defendant has been at fault,
but also that the defendant's 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.
In the present case, there was a duty on the part of
the Doctors to exercise the standard of care in
performing surgery on a patient with diabetes. There
was a breach of that duty when they decided to
proceed with the D&C operation (raspa),
notwithstanding Teresita's hyperglycemia and
without adequately preparing her for the procedure.
It 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.
2. Cruz vs. CA
FACTS
Lydia Umali was Diagnosed by Dr. Cruz to
have a myoma in her uterus and scheduled her for a
hysterectomy operation. According to Rowena
(Lydia’s daughter), she noticed that the clinic was
untidy and the window and the floor were very
dusty prompting her to ask the attendant for a rag to
wipe the window and the floor with. Because of the
untidy state of the clinic, Rowena tried to persuade
her mother not to proceed with the operation. The
following day, before her mother was wheeled into
the operating room, Rowena asked Dr. Cruz if the
operation could be postponed. Dr. Cruz called Lydia
into her office and the two had a conversation. Lydia
then informed Rowena that the petitioner told her
that she must be operated on as scheduled.
Rowena and her other relatives, namely her
husband, her sister and two aunts waited outside
the operating room while Lydia underwent
operation. While they were waiting, Dr. Ercillo
(anaesthesiologist) went out of the operating room
and instructed them to buy tagamet ampules which
Rowena's sister immediately bought. About one
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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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hour had passed when Dr. Ercillo came out again this
time to ask them to buy blood for Lydia. They bought
type "A" blood from the St. Gerald Blood Bank and
the same was brought by the attendant into the
operating room. After the lapse of a few hours, Dr.
Cruz informed them that the operation was finished.
The operating staff then went inside the petitioner's
clinic to take their snacks. Some thirty minutes after,
Lydia was brought out of the operating room in a
stretcher and the petitioner asked Rowena and the
other relatives to buy additional blood for Lydia.
Unfortunately, they were not able to comply with
petitioner's order as there was no more type "A"
blood available in the blood bank. Thereafter, a
person arrived to donate blood which was later
transfused to Lydia. Rowena then noticed her
mother, who was attached to an oxygen tank,
gasping for breath. Apparently the oxygen supply
had run out and Rowena's husband together with
the driver of the accused had to go to the San Pablo
District Hospital to get oxygen. Lydia was given the
fresh supply of oxygen as soon as it arrived. But at
around 10:00 o'clock P.M. she went into shock and
her blood pressure dropped to 60/50. Lydia's
unstable condition necessitated her transfer to the
San Pablo District Hospital so she could be
connected to a respirator and further examined. The
transfer to the San Pablo District Hospital was
without the prior consent of Rowena nor of the
other relatives present who found out about the
intended transfer only when an ambulance arrived
to take Lydia to the San Pablo District Hospital.
Rowena and her other relatives then boarded a
tricycle and followed the ambulance.
Upon Lydia's arrival at the San Pablo District
Hospital, she was wheeled into the operating room
and the petitioner and Dr. Ercillo re-operated on her
because there was blood oozing from the abdominal
incision. The attending physicians summoned Dr.
Bartolome Angeles, head of the Obstetrics and
Gynecology Department of the San Pablo District
Hospital. However, when Dr. Angeles arrived, Lydia
was already in shock and possibly dead as her blood
pressure was already 0/0. Dr. Angeles then informed
petitioner and Dr. Ercillo that there was nothing he
could do to help save the patient. While Dr. Cruz was
closing the abdominal wall, the patient died. Thus,
on March 24, 1991, at 3:00 o'clock in the morning,
Lydia Umali was pronounced dead.
Dr. Cruz was charged with reckless
imprudence and negligence resulting to homicide.
The MTC, RTC and CA found Dr. Cruz guilty. Hence
this petition.
ISSUE:
W/N petitioner's conviction of the crime of
reckless imprudence resulting in homicide, arising
from an alleged medical malpractice, is supported by
the evidence on record.
RULING:
Petitioner is hereby ACQUITTED of the
crime of reckless imprudence resulting in homicide
but is ordered to pay the heirs of the deceased Lydia
Umali the amount of P50,000.00 as civil liability,
P100,000.00 as moral damages, and P50,000.00 as
exemplary damages.
RATIO:
The elements of reckless imprudence are:
(1) that the offender does or fails to do an act; (2)
that the doing or the failure to do that act is
voluntary; (3) that it be without malice; (4) that
material damage results from the reckless
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 a physician has committed
an "inexcusable lack of precaution" in the treatment
of his patient is to be determined according to the
standard of care observed by other members of the
profession in good standing under similar
circumstances bearing in mind the advanced state of
the profession at the time of treatment or the
present state of medical science.
Expert testimony is essential to establish
not only the standard of care of the profession but
also that the physician's conduct in the treatment
and care falls below such standard. Further,
inasmuch as the causes of the injuries involved in
malpractice actions are determinable only in the
light of scientific knowledge, it has been recognized
that expert testimony is usually necessary to support
the conclusion as to causation.
In order that there may be a recovery for an
injury, however, it must be shown that the "injury
for which recovery is sought must be the legitimate
consequence of the wrong done; the connection
between the negligence and the injury must be a
direct and natural sequence of events, unbroken by
intervening efficient causes." In other words, the
negligence must be the proximate cause of the
injury. For, "negligence, no matter in what it
consists, cannot create a right of action unless it is
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the proximate cause of the injury complained of ."
And "the proximate cause of an injury is that cause,
which, in natural and continuous sequence,
unbroken by any efficient intervening cause,
produces the injury, and without which the result
would not have occurred."
This Court has no recourse but to rely on
the expert testimonies rendered by both
prosecution and defense witnesses that substantiate
rather than contradict petitioner's allegation that
the cause of Lydia's death was DIC which, as attested
to by an expert witness, cannot be attributed to the
petitioner's fault or negligence. The probability that
Lydia's death was caused by DIC was unrebutted
during trial and has engendered in the mind of this
Court a reasonable doubt as to the petitioner's guilt.
Thus, her acquittal of the crime of reckless
imprudence resulting in homicide. While we condole
with the family of Lydia Umali, our hands are bound
by the dictates of justice and fair dealing which hold
inviolable the right of an accused to be presumed
innocent until proven guilty beyond reasonable
doubt. Nevertheless, this Court finds the petitioner
civilly liable for the death of Lydia Umali, for while a
conviction of a crime requires proof beyond
reasonable doubt, only a preponderance of evidence
is required to establish civil liability.
The petitioner is a doctor in whose hands a
patient puts his life and limb. For insufficiency of
evidence this Court was not able to render a
sentence of conviction but it is not blind to the
reckless and imprudent manner in which the
petitioner carried out her duties. A precious life has
been lost and the circumstances leading thereto
exacerbated the grief of those left behind. The heirs
of the deceased continue to feel the loss of their
mother up to the present time and this Court is
aware that no amount of compassion and
commiseration nor words of bereavement can
suffice to assuage the sorrow felt for the loss of a
loved one. Certainly, the award of moral and
exemplary damages in favor of the heirs of Lydia
Umali are proper in the instant case.
3. Carillo vs. Ppl
FACTS
The deceased, Catherine Acosta, a 13 year
old girl, daughter of spouses Domingo and Yolanda
Acosta, complained to her father of pains in the
lower part of her abdomen. Catherine was then
brought to Peña. Dra. Peña called for Dr. Madrid and
the latter examined Catherine Acosta. According to
Dr. Madrid, his findings might be appendicitis. Then
Dr. Peña told Catherine's parents to bring the child
to the hospital in Baclaran so that the child will be
observed.
At the Baclaran General Hospital, the child
was scheduled for operation at 5:00 o'clock in the
afternoon. The operation took place at 5:45 p.m.
because Dr. Madrid arrived only at that time.
It has also been established that the
deceased was not weighed before the
administration of anesthesia on her.
The operation was finished at 7:00 o'clock
in the evening and when the child was brought out
from the operating room, she was observed to be
shivering (nanginginig); her heart beat was not
normal; she was asleep and did not wake up; she
was pale; and as if she had difficulty in breathing and
Dr. Emilio Madrid suggested that she placed under
oxygen tank; that oxygen was administered to the
child when she was already in the room.
Witness Yolanda Acosta further testified
that shortly before the child was transferred from
the operating room to her room, she (witness) was
requested by the anesthesiologist to go home and
get a blanket.
When Catherine remained unconscious
until noontime the next day, a neurologist examined
her and she was diagnosed as comatose. Three (3)
days later, Catherine died without regaining
consciousness.
The Court of Appeals held that Catherine
had suffered from an overdose of, or an adverse
reaction to, anesthesia, particularly the arbitrary
administration of Nubain, a pain killer, without
benefit of prior weighing of the patient's body mass,
which weight determines the dosage of Nubain
which can safely be given to a patient. The Court of
Appeals held that this condition triggered off a heart
attack as a post-operative complication, depriving
Catherine's brain of oxygen, leading to the brain's
hemorrhage. The Court of Appeals identified such
cardiac arrest as the immediate cause of Catherine's
death.
The RTC and the CA found that there was criminal
negligence on the part of Dr. Carillo and Dr. Madrid.
ISSUE:
W/N the finding of facts of the CA
adequately support the conclusion that both doctors
are guilty of simple negligence which resulted in
homicide?
RULING:
Decision of the CA is affirmed.
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RATIO:
The gravamen of the offense of simple negligence is
the failure to exercise the diligence necessitated or
called for the situation which was not immediately
life-destructive but which culminated, in the present
case, in the death of a human being three (3) days
later. Such failure to exercise the necessary degree
of care and diligence is a negative ingredient of the
offense charged. The rule in such cases is that while
the prosecution must prove the negative ingredient
of the offense, it needs only to present the best
evidence procurable under the circumstances, in
order to shift the burden of disproving or countering
the proof of the negative ingredient to the accused,
provided that such initial evidence establishes at
least on a prima facie basis the guilt of the accused.
This rule is particularly applicable where the
negative ingredient of the offense is of such a nature
or character as, under the circumstances, to be
specially within the knowledge or control of the
accused. In the instant case, the Court is bound to
observe that the events which occurred during the
surgical procedure (including whether or not Nubain
had in fact been administered as an anesthesia
immediately before or during the surgery) were
peculiarly within the knowledge and control of Dr.
Carillo and Dr. Madrid. It was, therefore, incumbent
upon the two (2) accused to overturn the prima facie
case which the prosecution had established, by
reciting the measures which they had actually taken
to prevent or to counter the obviously serious
condition of Catherine Acosta which was evident
right after surgery. This they failed or refused to do
so.
Still another circumstance of which account
must be taken is that both petitioner and Dr. Madrid
failed to inform the parents of their minor patient of
the nature of her illness, or to explain to them either
during the surgery
(if feasible) or at any time after the surgery, the
events which comprised the dramatic deterioration
of her condition immediately after surgery as
compared with her pre-surgery condition. To give a
truthful explanation to the parents was a duty
imposed upon them by the canons of their
profession. Petitioner should have explained to
Catherine's parents the actual circumstances
surrounding Catherine's death, how, in other words,
a simple appendectomy procedure upon an
ambulatory patient could have led to such fatal
consequences.
By way of resume, in the case at bar, we
consider that the chain of circumstances above
noted, namely: (1) the failure of petitioner and Dr.
Madrid to appreciate the serious post-surgery
condition of their patient and to monitor her
condition and provide close patient care to her; (2)
the summons of petitioner by Dr. Madrid and the
cardiologist after the patient's heart attack on the
very evening that the surgery was completed; (3) the
low level of care and diligence exhibited by
petitioner in failing to correct Dr. Madrid's
prescription of Nubain for post-operative pain; (4)
the extraordinary failure or refusal of petitioner and
Dr. Madrid to inform the parents of Catherine Acosta
of her true condition after surgery, in disregard of
the requirements of the Code of Medical Ethics; and
(5) the failure of petitioner and Dr. Madrid to prove
that they had in fact exercised the necessary and
appropriate degree of care and diligence to prevent
the sudden decline in the condition of Catherine
Acosta and her death three (3) days later, leads the
Court to the conclusion, with moral certainty, that
petitioner and Dr. Madrid were guilty of simple
negligence resulting in homicide.
4. Dr. Cantre vs. Sps. Go
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 S. Go. Nora
gave birth to her fourth child, a baby boy. However,
after giving birth, 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 Nora’s blood pressure. Her blood pressure
was frequently monitored with the use of a
sphygmomanometer. While petitioner was
massaging Nora’s uterus for it to contract and stop
bleeding, she ordered a droplight 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 gaping
wound two and a half (2 ½) by three and a half (3 ½)
inches in the inner portion of her left arm, close to
the armpit. He asked the nurses what caused the
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injury. He was informed it was a burn. John David
filed a request for investigation. 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.
After that, 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. The medico-legal
officer later testified that Nora’s injury appeared to
be a burn and that a droplight when placed near the
skin for about 10 minutes could cause such burn. 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.
Nora’s injury was referred to a plastic
surgeon at the Dr. Jesus Delgado Memorial Hospital
for skin grafting. Her wound was covered with skin
sourced from her abdomen, which consequently
bore a scar as well. About a year after, scar revision
had to be performed at the same hospital. The
surgical operation left a healed linear scar in Nora’s
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.
Unfortunately, Nora’s 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, respondent spouses filed a complaint
for damages in the RTC against petitioner, Dr. Abad,
and the hospital. The RTC ruled in favor of the
Spouses Go and on appeal, the CA affirmed the
decision of the RTC with modifications.
ISSUE
W/N petitioner is liable for the injury
suffered by respondent?
RULING:
Petition Denied. Ruling of the CA affirmed.
RATIO
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.
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 someone’s
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.
As to the first requirement, the gaping wound on
Nora’s 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 surgeon’s control. In
this particular case, it can be logically inferred that
petitioner, the senior consultant in charge during the
delivery of Nora’s baby, exercised control over the
assistants assigned to both the use of the droplight
and the taking of Nora’s blood pressure. Hence, the
use of the droplight and the blood pressure cuff is
also within petitioner’s exclusive control.
Third, the gaping wound on Nora’s 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.
Petitioner’s defense that Nora’s wound was
caused not by the droplight but by the constant
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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 Nora’s wound was
caused by the blood pressure cuff, then the taking of
Nora’s blood pressure must have been done so
negligently as to have inflicted a gaping wound on
her arm, for which petitioner cannot escape liability
under the "captain of the ship" doctrine.
Further, petitioner’s 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 defendant’s 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 petitioner’s negligence.
5. Batiquin vs. CA
FACTS
Mrs. Villegas is a married woman who
submitted to Dr. Batiquin for prenatal care as the
latter's private patient.
Dr. Batiquin, with the assistance of Dr. Doris
Teresita Sy who was also a Resident Physician at the
same Hospital, C.I. and O.R. Nurse Arlene Diones and
some student nurses performed a simple caesarean
section on Mrs. Villegas at the Negros Oriental
Provincial Hospital and after 45 minutes Mrs.
Villegas delivered her first child, Rachel Acogido, at
about 11:45 that morning. Thereafter, Plaintiff
remained confined at the Hospital until September
27, 1988 during which period of confinement she
was regularly visited by Dr. Batiquin. On September
28, 1988 Mrs. Villegas checked out of the Hospital. . .
and on that same day she paid Dr. Batiquin, thru the
latter's secretary, the amount of P1,500.00 as
"professional fee". . . .
Soon after leaving the Hospital Mrs. Villegas
began to suffer abdominal pains and complained of
being feverish. She also gradually lost her appetite,
so she consulted Dr. Batiquin at the latter's polyclinic
who prescribed for her certain medicines which she
had been taking up to December, 1988.
In the meantime, Mrs. Villegas was given a
Medical Certificate by Dr. Batiquin on October 31,
1988. . . certifying to her physical fitness to return to
her work on November 7, 1988. So, on the second
week of November, 1988 Mrs. Villegas returned to
her work at the Rural Bank of Ayungon, Negros
Oriental.
The abdominal pains and fever kept on
recurring and bothered Mrs. Villegas no end despite
the medications administered by Dr. Batiquin. When
the pains became unbearable and she was rapidly
losing weight she consulted Dr. Ma. Salud Kho at the
Holy Child's Hospital in Dumaguete City on January
20, 1989.
The evidence of Plaintiffs show that when
Dr. Ma. Salud Kho examined Mrs. Villegas at the Holy
Child's Hospital on January 20, 1989 she found Mrs.
Villegas to be feverish, pale and was breathing fast.
Upon examination she felt an abdominal mass one
finger below the umbilicus which she suspected to
be either a tumor of the uterus or an ovarian cyst,
either of which could be cancerous. She had an x-ray
taken of Mrs. Villegas' chest, abdomen and kidney.
She also took blood tests of Plaintiff. A blood count
showed that Mrs. Villegas had an infection inside her
abdominal cavity. The results of all those
examinations impelled Dr. Kho to suggest that Mrs.
Villegas submit to another surgery to which the
latter agreed.
When Dr. Kho opened the abdomen of Mrs.
Villegas she found whitish-yellow discharge inside,
an ovarian cyst on each of the left and right ovaries
which gave out pus, dirt and pus behind the uterus,
and a piece of rubber material on the right side of
the uterus embedded on the ovarian cyst, 2 inches
by 3/4 inch in size. This piece of rubber material
which Dr. Kho described as a "foreign body" looked
like a piece of a "rubber glove". . . and which is also
"rubber-drain like". . . . It could have been a torn
section of a surgeon's gloves or could have come
from other sources. And this foreign body was the
cause of the infection of the ovaries and
consequently of all the discomfort suffered by Mrs.
Villegas after her delivery on September 21, 1988.
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The trial court ruled in favor of Dr. Batiquin
dismissing the complaint, while the CA reversed this
decision holding Dr. Batiquin liable.
ISSUE
W/N the CA committed grave abuse of
discretion by resorting to findings of fact not
supported by the evidence on record?
RULING
Ruling of the CA is affirmed
RATIO:
Considering that we have assessed Dr. Kho
to be a credible witness, her positive testimony [that
a piece of rubber was indeed found in private
respondent Villega's abdomen] prevails over the
negative testimony in favor of the petitioners.
As such, the rule of res ipsa loquitur comes
to fore. This Court has had occasion to delve into the
nature and operation of this doctrine:
This doctrine [res ipsa loquitur] is
stated thus: "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 in 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 doctrine of res ipsa loquitur as a rule of
evidence is peculiar to the law of negligence which
recognizes that prima facie negligence may be
established without direct proof and furnishes a
substitute for specific proof of negligence. The
doctrine is not a rule of substantive law, but merely
a mode of proof or a mere procedural convenience.
The rule, when applicable to the facts and
circumstances of a particular case, is not intended to
and does not dispense with the requirement of
proof of culpable negligence on the party charged. It
merely determines and regulates what shall be
prima facie evidence thereof and facilitates the
burden of plaintiff of proving a breach of the duty of
due care. The doctrine can be invoked when and
only when, under the circumstances involved, direct
evidence is absent and not readily available.
In the instant case, all the requisites for
recourse to the doctrine are present. First, the entire
proceedings of the caesarean section were under
the exclusive control of Dr. Batiquin. In this light, the
private respondents were bereft of direct evidence
as to the actual culprit or the exact cause of the
foreign object finding its way into private
respondent Villegas's body, which, needless to say,
does not occur unless through the intersection of
negligence. Second, since aside from the caesarean
section, private respondent Villegas underwent no
other operation which could have caused the
offending piece of rubber to appear in her uterus, it
stands to reason that such could only have been a
by-product of the caesarean section performed by
Dr. Batiquin. The petitioners, in this regard, failed to
overcome the presumption of negligence arising
from resort to the doctrine of res ipsa loquitur. Dr.
Batiquin is therefore liable for negligently leaving
behind a piece of rubber in private respondent
Villegas's abdomen and for all the adverse effects
thereof.
6. Lasam v. Ramolete
FACTS
Three months pregnant Editha Ramolete
was brought to the Lorma Medical Center (LMC) in
San Fernando, La Union due to vaginal bleeding.
Upon advice of petitioner relayed via telephone,
Editha was admitted to the LMC on the same day. A
pelvic sonogram was then conducted on Editha
revealing the fetus’ weak cardiac pulsation. The
following day, Editha’s repeat pelvic sonogram
showed that aside from the fetus’ weak cardiac
pulsation, no fetal movement was also appreciated.
Due to persistent and profuse vaginal bleeding,
petitioner advised Editha to undergo a Dilatation and
Curettage Procedure (D&C) or "raspa."
Petitioner performed the D&C procedure.
Editha was discharged from the hospital the
following day.
After one month and a half, Editha was
once again brought at the LMC, as she was suffering
from vomiting and severe abdominal pains. Editha
was attended by Dr. Beatriz de la Cruz, Dr. Victor B.
Mayo and Dr. Juan V. Komiya. Dr. Mayo allegedly
informed Editha that there was a dead fetus in the
latter’s womb. After, Editha underwent laparotomy,
she was found to have a massive intra-abdominal
hemorrhage and a ruptured uterus. Thus, Editha had
to undergo a procedure for hysterectomy and as a
result, she has no more chance to bear a child.
Editha and her husband Claro Ramolete
(respondents) filed a Complaint for Gross Negligence
and Malpractice against petitioner before the
Professional Regulations Commission (PRC).
Respondents alleged that Editha’s
hysterectomy was caused by petitioner’s
unmitigated negligence and professional
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incompetence in conducting the D&C procedure and
the petitioner’s failure to remove the fetus inside
Editha’s womb. Among the alleged acts of
negligence were: first, petitioner’s failure to check
up, visit or administer medication on Editha during
her first day of confinement at the LMC; second,
petitioner recommended that a D&C procedure be
performed on Editha without conducting any
internal examination prior to the procedure; third,
petitioner immediately suggested a D&C procedure
instead of closely monitoring the state of pregnancy
of Editha.
The Board of Medicine of PRC exonerated
Dr. Lasam from the charges filed against her. On
appeal to the PRC, the decision of the Board of
Medicine was reversed and the license of Dr. Lasam
was revoked. Dr. Lasam then appealed the decision
of the PRC to the CA under Rule 43.
ISSUE:
1. W/N the petition to the CA was
erroneous, as PRC is not included in the list of the
quasi-judicial agencies whose decision can be
appealed to the CA?
2. W/N an expert witness is needed to
support and establish the medical negligence case
that was filed against Dr.Lasam?
RULING:
Petition is granted. The decision of the
Board of Medicine is reinstated.
RATIO:
1.Indeed, the PRC is not expressly
mentioned as one of the agencies which are
expressly enumerated under Section 1, Rule 43 of
the Rules of Court. However, its absence from the
enumeration does not, by this fact alone, imply its
exclusion from the coverage of said Rule. The Rule
expressly provides that it should be applied to
appeals from awards, judgments final orders or
resolutions of any quasi-judicial agency in the
exercise of its quasi-judicial functions. The phrase
"among these agencies" confirms that the
enumeration made in the Rule is not exclusive to the
agencies therein listed.
Specifically, the Court, in Yang v. Court of Appeals,
ruled that Batas Pambansa (B.P.) Blg. 129 conferred
upon the CA exclusive appellate jurisdiction over
appeals from decisions of the PRC. The Court held:
The law has since been changed, however,
at least in the matter of the particular court
to which appeals from the Commission
should be taken. On August 14, 1981, Batas
Pambansa Bilang 129 became effective and
in its Section 29, conferred on the Court of
Appeals "exclusive appellate jurisdiction
over all final judgments, decisions,
resolutions, orders or awards of Regional
Trial Courts and quasi-judicial agencies,
instrumentalities, boards or commissions
except those falling under the appellate
jurisdiction of the Supreme Court. x x x." In
virtue of BP 129, appeals from the
Professional Regulations Commission are
now exclusively cognizable by the Court of
Appeals.
Clearly, the enactment of B.P. Blg. 129, the
precursor of the present Rules of Civil Procedure,
lodged with the CA such jurisdiction over the appeals
of decisions made by the PRC.
2. Medical malpractice is a particular form
of negligence which consists in the failure of a
physician or surgeon to apply to his practice of
medicine that degree of care and skill which is
ordinarily employed by the profession generally,
under similar conditions, and in like surrounding
circumstances. In order to successfully pursue such a
claim, a patient must prove that the physician or
surgeon either failed to do something which a
reasonably prudent physician or surgeon would not
have done, and that the failure or action caused
injury to the patient.
There are four elements involved in medical
negligence cases: duty, breach, injury and proximate
causation.
A physician-patient relationship was
created when Editha employed the services of the
petitioner. As Editha’s physician, petitioner was
duty-bound to use at least the same level of care
that any reasonably competent doctor would use to
treat a condition under the same circumstances. The
breach of these professional duties of skill and care,
or their improper performance by a physician
surgeon, whereby the patient is injured in body or in
health, constitutes actionable malpractice. As to this
aspect of medical malpractice, the determination of
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the reasonable level of care and the breach thereof,
expert testimony is essential. Further, inasmuch as
the causes of the injuries involved in malpractice
actions are determinable only in the light of scientific
knowledge, it has been recognized that expert
testimony is usually necessary to support the
conclusion as to causation.
In the present case, respondents did not
present any expert testimony to support their claim
that petitioner failed to do something which a
reasonably prudent physician or surgeon would have
done.
Petitioner, on the other hand, presented
the testimony of Dr. Augusto M. Manalo, who was
clearly an expert on the subject.
Generally, to qualify as an expert witness,
one must have acquired special knowledge of the
subject matter about which he or she is to testify,
either by the study of recognized authorities on the
subject or by practical experience.
Dr. Manalo specializes in gynecology and
obstetrics, authored and co-authored various
publications on the subject, and is a professor at the
University of the Philippines. According to him, his
diagnosis of Editha’s case was "Ectopic Pregnancy
Interstitial (also referred to as Cornual), Ruptured."
In stating that the D&C procedure was not the
proximate cause of the rupture of Editha’s uterus
resulting in her hysterectomy,
From the foregoing testimony, it is clear
that the D&C procedure was conducted in
accordance with the standard practice, with the
same level of care that any reasonably competent
doctor would use to treat a condition under the
same circumstances, and that there was nothing
irregular in the way the petitioner dealt with Editha.
It is undisputed that Editha did not return
for a follow-up evaluation, in defiance of the
petitioner’s advise. Editha omitted the diligence
required by the circumstances which could have
avoided the injury. The omission in not returning for
a follow-up evaluation played a substantial part in
bringing about Editha’s own injury. Had Editha
returned, petitioner could have conducted the
proper medical tests and procedure necessary to
determine Editha’s health condition and applied the
corresponding treatment which could have
prevented the rupture of Editha’s uterus. The D&C
procedure having been conducted in accordance
with the standard medical practice, it is clear that
Editha’s omission was the proximate cause of her
own injury and not merely a contributory negligence
on her part.
Contributory negligence is the act or
omission amounting to want of ordinary care on the
part of the person injured, which, concurring with
the defendant’s negligence, is the proximate cause
of the injury. Difficulty seems to be apprehended in
deciding which acts of the injured party shall be
considered immediate causes of the accident. Where
the immediate cause of an accident resulting in an
injury is the plaintiff’s own act, which contributed to
the principal occurrence as one of its determining
factors, he cannot recover damages for the injury.
Again, based on the evidence presented in the
present case under review, in which no negligence
can be attributed to the petitioner, the immediate
cause of the accident resulting in Editha’s injury
was her own omission when she did not return for
a follow-up check up, in defiance of petitioner’s
orders. The immediate cause of Editha’s injury was
her own act; thus, she cannot recover damages
from the injury.
7. Nogales vs. Capitol Medical Center
FACTS
Pregnant with her fourth child, Corazon
Nogales was under the exclusive prenatal care of Dr.
Estrada beginning on her fourth month of
pregnancy. While Corazon was on her last trimester
of pregnancy, Dr. Estrada noted an increase in her
blood pressure and development of leg edema
indicating preeclampsia, which is a dangerous
complication of pregnancy.
Around midnight of 25 May 1976, Corazon
started to experience mild labor pains prompting
Spouses Nogales to see Dr. Estrada at his home.
After examining Corazon, Dr. Estrada advised her
immediate admission to the Capitol Medical Center.
Corazon was admitted at 2:30 a.m. at the
CMC after the staff nurse noted the written
admission request of Dr. Estrada. Upon Corazon's
admission at the CMC, Rogelio Nogales executed and
signed the "Consent on Admission and Agreement"
and "Admission Agreement." Corazon was then
brought to the labor room of the CMC.
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, 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
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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, 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. 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. Lacson, to comply with Dr. Estrada's
order and deliver the blood.
At 8:00 a.m., 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."
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."
Petitioners filed a complaint for damages
with the RTC against all the doctors including Capitol
Medical Center. The Trial court ruled that Dr. Estrada
was the one solely liable. The petitioners (Nogales)
appealed the decision of the RTC, contending that all
the physicians should be equally liable for
negligence. The CA affirmed the decision of the RTC.
Hence this petition.
ISSUE:
W/N CMC is vicariously liable for the
negligence of Dr. Estrada?
HELD:
Petition partly granted. CMC is held
vicariously liable with Dr. Estrada.
RATIO:
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."
In Gilbert v. Sycamore Municipal Hospital, 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
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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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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. 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.
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."
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.
8. Garcia-Rueda vs. Pascasio
FACTS:
Florencio V. Rueda, husband of petitioner
Leonila Garcia-Rueda, underwent surgical operation
at the UST hospital for the removal of a stone
blocking his ureter. He was attended by Dr. Domingo
Antonio, Jr. who was the surgeon, while Dr. Erlinda
Balatbat-Reyes was the anaesthesiologist. Six hours
after the surgery, however, Florencio died of
complications of "unknown cause," according to
officials of the UST Hospital.
Not satisfied with the findings of the
hospital, petitioner requested the National Bureau
of Investigation (NBI) to conduct an autopsy on her
husband's body. Consequently, the NBI ruled that
Florencio's death was due to lack of care by the
attending physician in administering anaesthesia.
Pursuant to its findings, the NBI recommended that
Dr. Domingo Antonio and Dr. Erlinda Balatbat-Reyes
be charged for Homicide through Reckless
Imprudence before the Office of the City Prosecutor.
(Here comes the Ping-Pong Match which
included 9 prosecutors.)
After the Ping-Pong, the City Prosecutor
exonerated the doctors from any wrongdoing.
Leonila was so badtrip she decided to file Graft
charges against all the prosecutors who took part in
the Ping-Pong match. The Ombudsman dismissed
the complaint for lack of evidence. So, because
Leonila was badtrip again, she filed a petition in the
SC under Rule 65.
ISSUE:
May the SC review the findings of the
Ombudsman?
HELD:
They do not have the GALACTIC POWER.
RATIO:
The general rule has been enunciated in
Ocampo v. Ombudsman which states:
In the exercise of its investigative
power, this Court has consistently
held that courts will not interfere
with the discretion of the fiscal or
the Ombudsman to determine the
specificity and adequacy of the
averments of the offense charged.
He may dismiss the complaint
forthwith if he finds it to be
insufficient in form and substance
or if he otherwise finds no ground
to continue with the inquiry; or he
may proceed with the investigation
of the complaint if, in his view, it is
in due and proper form.
To our mind, the better and more logical remedy
under the circumstances would have been to appeal
the resolution of the City Prosecutors dismissing the
criminal complaint to the Secretary of Justice under
the Department of Justice's Order No. 223,
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otherwise known as the "1993 Revised Rules on
Appeals From Resolutions In Preliminary
Investigations/Reinvestigations," as amended by
Department Order No. 359, Section 1 of which
provides:
Sec. 1. What May Be Appealed. —
Only resolutions of the Chief State
Prosecutor/Regional State
Prosecutor/Provincial or City
Prosecutor dismissing a criminal
complaint may be the subject of an
appeal to the Secretary of Justice
except as otherwise provided in
Section 4 hereof.
What action may the Secretary of Justice take on the
appeal? Section 9 of Order No. 223 states: "The
Secretary of Justice may reverse, affirm or modify
the appealed resolution." On the other hand, "He
may motu proprio or on motion of the appellee,
dismiss outright the appeal on specified grounds."
In exercising his discretion under the circumstances,
the Ombudsman acted within his power and
authority in dismissing the complaint against the
Prosecutors and this Court will not interfere with the
same.
9. Professional Services Inc. vs. Agana
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, 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 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 a complaint for damages
against the Professional Services, Inc. (PSI), owner of
the Medical City Hospital, Dr. Ampil, and Dr.
Fuentes. 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.
The RTC rendered its Decision in favor of
the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes
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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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liable for negligence and malpractice. Aggrieved, PSI,
Dr. Fuentes and Dr. Ampil interposed an appeal to
the Court of Appeals. The CA ruled that only Dr.
Ampil should be held liable and he should reimburse
PSI for whatever the latter had paid or is going to
pay the Aganas.
ISSUE:
1. W/N the CA erred in ruling that only Dr.
Ampil is liable.
2. W/N PSI as owner of the Hospital should
also be held liable.
HELD:
Petition Denied. Professional Services, Inc.
is ORDERED pro hac vice to pay and Enrique Agana
the total amount of P15 million, subject to 12% p.a.
interest from the finality of this resolution to full
satisfaction.
RATIO:
After gathering its thoughts on the issues,
this Court holds that PSI is liable to the Aganas, not
under the principle of respondeat superior for lack of
evidence of an employment relationship with Dr.
Ampil but under the principle of ostensible agency
for the negligence of Dr. Ampil and, pro hac vice,
under the principle of corporate negligence for its
failure to perform its duties as a hospital.
While in theory a hospital as a juridical
entity cannot practice medicine, in reality it utilizes
doctors, surgeons and medical practitioners in the
conduct of its business of facilitating medical and
surgical treatment. Within that reality, three legal
relationships crisscross: (1) between the hospital and
the doctor practicing within its premises; (2)
between the hospital and the patient being treated
or examined within its premises and (3) between the
patient and the doctor. The exact nature of each
relationship determines the basis and extent of the
liability of the hospital for the negligence of the
doctor.
Where an employment relationship exists,
the hospital may be held vicariously liable under
Article 2176 in relation to Article 2180 of the Civil
Code or the principle of respondeat superior. Even
when no employment relationship exists but it is
shown that the hospital holds out to the patient that
the doctor is its agent, the hospital may still be
vicariously liable under Article 2176 in relation to
Article 1431 and Article 1869 of the Civil Code or the
principle of apparent authority. Moreover,
regardless of its relationship with the doctor, the
hospital may be held directly liable to the patient for
its own negligence or failure to follow established
standard of conduct to which it should conform as a
corporation.
Nonetheless, to allay the anxiety of the
intervenors, the Court holds that, in this particular
instance, the concurrent finding of the RTC and the
CA that PSI was not the employer of Dr. Ampil is
correct. Control as a determinative factor in testing
the employer-employee relationship between doctor
and hospital under which the hospital could be held
vicariously liable to a patient in medical negligence
cases is a requisite fact to be established by
preponderance of evidence. Here, there was
insufficient evidence that PSI exercised the power of
control or wielded such power over the means and
the details of the specific process by which Dr. Ampil
applied his skills in the treatment of Natividad.
Consequently, PSI cannot be held vicariously liable
for the negligence of Dr. Ampil under the principle of
respondeat superior.
There is, however, ample evidence that the
hospital (PSI) held out to the patient (Natividad) that
the doctor (Dr. Ampil) was its agent. Present are the
two factors that determine apparent authority: first,
the hospital's implied manifestation to the patient
which led the latter to conclude that the doctor was
the hospital's agent; and second, the patient’s
reliance upon the conduct of the hospital and the
doctor, consistent with ordinary care and prudence.
To begin with, PSI could not simply wave off
the problem and nonchalantly delegate to Dr. Ampil
the duty to review what transpired during the
operation. The purpose of such review would have
been to pinpoint when, how and by whom two
surgical gauzes were mislaid so that necessary
remedial measures could be taken to avert any
jeopardy to Natividad’s recovery. Certainly, PSI could
not have expected that purpose to be achieved by
merely hoping that the person likely to have mislaid
the gauzes might be able to retrace his own steps. By
its own standard of corporate conduct, PSI's duty to
initiate the review was non-delegable.
While Dr. Ampil may have had the primary
responsibility of notifying Natividad about the
missing gauzes, PSI imposed upon itself the separate
and independent responsibility of initiating the
inquiry into the missing gauzes. The purpose of the
first would have been to apprise Natividad of what
transpired during her surgery, while the purpose of
the second would have been to pinpoint any lapse in
procedure that led to the gauze count discrepancy,
so as to prevent a recurrence thereof and to
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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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determine corrective measures that would ensure hemmed and hawed at every turn, disowning any
the safety of Natividad. That Dr. Ampil negligently such responsibility to its patient. Meanwhile, the
failed to notify Natividad did not release PSI from its options left to the Aganas have all but dwindled, for
self-imposed separate responsibility. the status of Dr. Ampil can no longer be ascertained.
Corollary to its non-delegable undertaking
to review potential incidents of negligence Disclaimer: Guys, sensha na… I cannot go on… last
committed within its premises, PSI had the duty to case na lang naman… Kayo na bahala… hehehe…
take notice of medical records prepared by its own GOD BLESS US!!! ;)
staff and submitted to its custody, especially when
these bear earmarks of a surgery gone awry. Thus,
the record taken during the operation of Natividad
which reported a gauze count discrepancy should
have given PSI sufficient reason to initiate a review.
It should not have waited for Natividad to complain.
As it happened, PSI took no heed of the
record of operation and consequently did not initiate
a review of what transpired during Natividad’s
operation. Rather, it shirked its responsibility and
passed it on to others – to Dr. Ampil whom it
expected to inform Natividad, and to Natividad
herself to complain before it took any meaningful
step. By its inaction, therefore, PSI failed its own
standard of hospital care. It committed corporate
negligence.
It should be borne in mind that the
corporate negligence ascribed to PSI is different
from the medical negligence attributed to Dr. Ampil.
The duties of the hospital are distinct from those of
the doctor-consultant practicing within its premises
in relation to the patient; hence, the failure of PSI to
fulfill its duties as a hospital corporation gave rise to
a direct liability to the Aganas distinct from that of
Dr. Ampil.
All this notwithstanding, we make it clear
that PSI’s hospital liability based on ostensible
agency and corporate negligence applies only to this
case, pro hac vice. It is not intended to set a
precedent and should not serve as a basis to hold
hospitals liable for every form of negligence of their
doctors-consultants under any and all circumstances.
The ruling is unique to this case, for the liability of
PSI arose from an implied agency with Dr. Ampil and
an admitted corporate duty to Natividad.
Other circumstances peculiar to this case
warrant this ruling, not the least of which being that
the agony wrought upon the Aganas has gone on for
26 long years, with Natividad coming to the end of
her days racked in pain and agony. Such
wretchedness could have been avoided had PSI
simply done what was logical: heed the report of a
guaze count discrepancy, initiate a review of what
went wrong and take corrective measures to ensure
the safety of Nativad. Rather, for 26 years, PSI

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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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Injuries Dead Body

Stab wound – caused by a knife; sharp/pointed edge *to document death in a hospital setting, ECG (flat
Puncture wound – caused by an icepick; pointed line) is always performed
object
Hack wound – caused by a “bolo” or “itak” Changes:
1. TEMPERATURE
INCISED WOUND LACERATED WOUND *will remain almost the same until about 3
Linear injury Not straight edge, hair hours after death when the body temp will
bulbs not removed start to drop
Clean cut Razed skin
Caused by a sharp edge Boxing match; hit by a 2. MUSCLES
ex. cutter bolo *flaccid
*after 3 hours, it will start to stiffen (Rigor
Gunshot wound- may be caused by bullet; there is Mortis)
an entry and an exit wound *12 hours after death galactic Rigor Mortis
*even number of gunshot wounds would *24-36 hours after death, flaccid again
give the presumption that there are no more bullets
left inside the body 3. BLOOD
*will go to the most dependent part of the
*odd number of gunshot wounds would
give rise to the presumption that there are still body
bullets left inside the body *post mortem lividity (blood will go down)
*points of entry are important because it *depends on the position of the body when
person died
will tell the distance and position of the assailant
*will start 3 hours after death
*if shot in close range, will leave marks on
the body SUICIDE V. HOMICIDE
-hair will be burned if shot 3 inches away  notes/ letters stating reasons therefor
-there will be smoke smudges if shot 6  taking up Civil Procedure
inches away  stiffening of the muscles in the hand
-there will be unburned gunpowder if shot  traumatic breath –cadaveric spasm;
12 inches away extreme tension at time of death

*presence of abrasion marks/abrasion collar means *if suicide, patient dies immediately, cadaveric
that the bullet rubbed the skin first before entering spasm in hand/arm; hand firmly clenched
the body, hence, victim was not shot in front *if drowned, hands are firmly clenched also
NOTE: NO Abrasion Collar = Frontal(?) Shot

Hematoma – pasa THROAT SLASHING

Abrasion – gasgas  homicide = below adam’s apple (also in
Contusion – bukol hanging)
 cut is diagonal in suicide (how the fuck
In rape, there are usually hymenal lacerations which can a person slit his own throat
are distinguished and determined by using the face vertically?)
of the clock
*there are usually multiple hymenal lacerations in
rape
*hematoma on legs/perineum area

Burns (Explosives) – measured by percentage

*1 hand = 1 percent

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