DUMAUAL, JEANNE PAULINE J.
2019-2020
G.R. No. 86890 January 21, 1994
LEANDRO CARILLO, petitioner,
vs.
PEOPLE OF THE PHILIPPINES, respondent.
Balane, Tamase, Alampay Law Office for petitioner.
The Solicitor General for the people.
FELICIANO, J.:
Petitioner Dr. Leandro Carillo, an anesthetist, seeks review of the Decision of
the Court of Appeals dated 28 November 1988, which affirmed his conviction
by the Regional Trial Court of the crime of simple negligence resulting in
homicide, for the death of his thirteen (13) year old patient
Catherine Acosta. The trial court had sentenced him to suffer the penalty
of arresto mayor in its medium period (four [4] months' imprisonment), as
well as to pay the heirs of his patient an indemnity of P30,000.00 for her
death, P10,000.00 as reimbursement for actual expenses incurred,
P50,000.00 as moral damages and to pay the costs of the suit. 1
The information filed against petitioner and his co-accused, the surgeon Dr.
Emilio Madrid, alleged the following:
That on or about the 31st of May 1981, in the municipality
of Parañaque, Metro Manila, Philippines and within the
jurisdiction of this Honorable Court, the above-named
accused, conspiring and confederating together and
mutually helping and aiding with one another, without
taking the necessary care and precaution to avoid injury to
person, did then and there willfully, unlawfully and
feloniously operate, in a reckless, careless and imprudent
manner and neglected to exercise their respective medical
knowhow and tasks and/or departed from the recognized
standard in their treatment, diagnosis of the condition, and
operation of the patient, one Catherine Acosta, 13 years old,
Atty. Yulo, Legal Medicine and Medical Jurisprudence
which negligence caused the death of the said Catherine
Acosta.2
Petitioner and Dr. Emilio Madrid entered pleas of not guilty at arraignment
and the case proceeded to trail with Judge Job B. Madayag presiding. 3
The prosecution presented as its principal evidence the testimony of four (4)
witnesses, namely: 1) Yolanda Acosta, Catherine's mother, who was able to
observe the conduct of the accused outside the operating theater before,
during and after the appendectomy procedure carried out on her
daughter;4 2) Domingo Acosta, Catherine's father, who corroborated some
parts of his wife's
testimony;5 3) Dr. Horacio Buendia, an expert witness who described before
the trial court the relationship between a surgeon and an anesthetist in the
course of a surgical operation, as well as define the likelihood of cardiac
arrest as a post operative complication; 6 and 4) Dr. Nieto Salvador, an expert
witness who analyzed and explained the significance of the results of the
pathological study and autopsy conducted on Catherine's body by one Dr.
Alberto Reyes.7
After the prosecution had rested its case, the defense was granted leave to
file a demurrer to the evidence.8 After failing to file the demurrer within the
reglementary period, Judge Manuel Yuzon, who had in the meantime taken
over as presiding judge of the sala where this case was pending, denied the
defense motion for extension of time to file demurrer and declared the case
submitted for decision.9
On 19 September 1985, the trial court promulgated its decision convicting
both the accused of the crime charged. 10
On appeal, the Court of Appeals affirmed the judgment of conviction, and
specified that the civil liability of the two (2) accused was solidary in
nature. 11
Petitioner Dr. Carillo alone filed the present Petition for Review with the
Court, seeking reversal of his conviction, or in the alternative, the grant of a
new trial. Dr. Madrid did not try to appeal further the Court of Appeals
Decision. Accordingly, the judgment of conviction became final insofar as the
accused surgeon Dr. Madrid is concerned.
Page 1

The facts of the case as established by the Court of Appeals are as follows:
The deceased, Catherine Acosta, a 13 year old girl, daughter
of spouses Domingo and Yolanda Acosta, complained to her
father at about 10:30 o'clock in the morning of May 31, 1981
of pains in the lower part of her abdomen. Catherine was
then brought to Dr. Elva Peña. Dra. Peña called for Dr.
Emilio 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, a nurse took blood sample
form the child. The findings became known at around 3:00
o'clock in the afternoon and 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.
When brought inside the operating room, the child was
feeling very well and they did not subject the child to ECG
(electrocardiogram) and
X-ray.
The appellant Dr. Emilio Madrid, a surgeon, operated on
Catherine. He was assisted by appellant, Dr. Leandro Carillo,
an anesthesiologists.
During the operation, while Yolanda Acosta, Catherine's
mother, was staying outside the operating room, she "noticed
something very unfamiliar." The three nurses who assisted
in the operation were going in and out of the operating room,
they were not carrying anything, but in going out of the
operating room, they were already holding something.
Yolanda asked one of the nurses if she could enter the
operating room but she was refused.
At around 6:30 p.m., Dr. Emilio Madrid went outside the
operating room and Yolanda Acosta was allowed to enter the
first door.
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The appendicitis (sic) was shown to them by Dr. Madrid,
because, according to Dr. Madrid, they might be wondering
because he was going to install drainage near the operating
(sic) portion of the child.
When asked, the doctor told them the child was already out
of danger but the operation was not yet finished.
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.
A portion of Yolanda Acosta's testimony on what happened
when she returned to the hospital are reproduced hereunder
as follows:
Q What happened afterward?
A When I arrived in the hospital, my child was being transferred
to her bed.
Q What else happened?
Q I noticed that the heartbeat of my daughter was not normal.
And I noticed that her hospital gown is rising up and down.
Q What transpired after that?
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A I asked Dr. Madrid why it was like that, that the heartbeat of
my daughter is not normal.
Q And did the doctor make any reply?
A The doctor said because of the lesion of the child.
Q What else happened?
A After they have revived the heartbeat of the child, Dr. Carillo and
Dr. Madrid left.
Q Now do you remember what time was it when Dr. Carillo
stepped out?
A Only a minute after they have transferred the child to the bed.
Q What happened later on after Dr. Carillo and Dr. Madrid stepped
out of the hospital?
A After 15 or 30 minutes has lapsed at about 7:15 or 7:30, the
child had developed convulsion and stiffening of the body.
Q When you observed convulsion and stiffening of the body, did
you do anything?
A We requested the nurse who was attending to her to call for a
doctor.
Q And the nurse who was attending to the patient called for a
doctor?
A They called for Dra. Peña, their family physician.
Q What transpired afterwards?
A What Dra. Peña did was call for Dr. Madrid and the cardiologist.
Q Did this doctor arrived?
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A Yes.
Q What transpired after the doctor arrived?
A They examined the child.
Q After they examined the child, did they inform you of the result
of the examination?
A The cardiologist was the one whom informed us after he
stepped out of the room when we followed him. The doctor told us
that she suffered severe infection which went up to her head.
Q After you were informed of the result of his examination, what
transpired next?
A According to them, they will do their best for the child and that
they will call for Dr. Carillo.
Q Did Dr. Carillo arrived?
A At around 10:30 in the evening.
Q Did Dr. Carillo do anything when he arrived on 31 May 1981?
A When he arrived, he noticed that there were two small bottles
and big bottles of dextrose which were hanging above the bed of
the child. Then he said, "What is this? Christmas tree or what?"
He told us that one bottle of dextrose be removed. And the big one
will remain.
Q What happened after that?
A After that we talked to Dr. Carillo and asked him how did this
happen to the child.
Q What did Dr. Carillo reply (sic) to you?
Page 3

A He answered "that is nothing, the child will regain consciousness
and if the child will not regain consciousness, I will resign (sic) as a
doctor."12
(Emphasis supplied)
When Catherine remained unconscious until noontime the next day, a
neurologist examined her and she was diagnosed as comatose. 13 Three (3)
days later, Catherine died without regaining consciousness. 14
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. 15 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. 16 The Court of Appeals identified such cardiac arrest as the
immediate cause of Catherine's death. 17
The Court of Appeals found criminal negligence on the part of petitioner Dr.
Carillo and his co-accused Dr. Madrid, holding that both had failed to
observe the required standard of diligence in the examination of Catherine
prior to the actual administration of anesthesia; 18 that it was "a bit rash" on
the part of the accused Dr. Carillo "to have administered Nubain without first
weighing Catherine"; 19 and that it was an act of negligence on the part of
both doctors when, (a) they failed to monitor Catherine's heartbeat after the
operation and
(b) they left the hospital immediately after reviving Catherine's heartbeat,
depriving the latter of immediate and expert medical assistance when she
suffered a heart attack approximately fifteen (15) to thirty (30) minutes
later. 20
Since neither petitioner nor his co-accused presented evidence in their own
behalf, the present Petition seeks to question the soundness of the factual
conclusions drawn by the Court of Appeals, upon which the affirmance of
petitioner's conviction was based.
Close examination of the instant Petition for Review shows that petitioner's
main arguments are two-fold: (1) the Court of Appeals "completely brushed
aside" and "misapprehended" Catherine's death certificate and biopsy report
which allegedly showed that the cause of death was a ruptured appendix,
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which led to blood poisoning, 21 rather than faulty anesthetic treatment;
and (2) there was no direct evidence of record showing that Nubain was
administered to Catherine either during the appendectomy procedure or after
such operation. 22
Two (2) related issues are thus posed for the Court's consideration. The first
is whether the Court of Appeals so drastically "misapprehended" the relevant,
operative facts in this case as to compel this Court to examine and resolve
question(s) of fact which would have a decisive significance for the
disposition of the case. The rule is too firmly settled to require much
documentation that only questions of law may be raised before this Court in
a petition for review on certiorari, subject to certain well-known
exceptions. 23 After careful scrutiny of petitioner's contentions before us and
the record of this case, we do not believe that petitioner has shown
"misapprehension of facts" on the part of the Court of Appeals which would
require this Court to overturn the judgment reached by the former.
The second issue is whether or not the findings of fact of the Court of
Appeals adequately support the conclusion that petitioner Dr. Carillo was,
along with Dr. Madrid, guilty of simple negligence which resulted in
homicide. Our review of the record leads us to an affirmative answer.
Petitioner contends that the Court of Appeals seriously erred in finding that
an overdose of, or an allergic reaction to, the anesthetic drug Nubain had led
to the death of Catherine Acosta and that the true cause of Catherine's death
was that set out in the death certificate of Catherine: "Septicemia (or blood
poisoning) due to perforated appendix with peritonitis." 24 The concept of
causation in general, and the cause of death in human beings in particular,
are complex and difficult notions. What is fairly clear is that death,
understood as a physical condition involving cessation of vital signs in the
brain and heart, is preceded by a series of physiological events, any one of
which events can, with equal cogency, be described as a "cause of death".
The Court of Appeals found that an overdose of, or an adverse reaction to,
Nubain, an anesthetic or
pain-killing drug the appropriate dose of which depends on the body weight
or mass of the patient, had generated or triggered off cardiac arrest, which in
turn led to lack of oxygen in Catherine's brain, which then brought about
hemorrhaging in the brain. Vital activity in the brain thereupon ceased. The
medical evidence presented at the trial was quite consistent with the findings
of the Court of Appeals which concluded that cardiac arrest was the cause of
Catherine's death. 25
Page 4

For his part, petitioner insists that cardiac arrest is not the only cause of
oxygen-starvation of the brain, that septicemia with peritonitis or severe
infection which had "gone up to the head" of Catherine was an equally
efficient cause of deprivation of the brain of oxygen and hence of brain
hemorrhage. The medical testimony of the expert witnesses for the
prosecution on which petitioner relies is also consistent with petitioner's
theory that septicemia with peritonitis was, or at least could have been, the
cause of Catherine's death. 26
Indeed, it appears to the Court that there was no medical proof submitted to
the trial court to show that one or the other "cause"
was necessarily an exclusive cause of death in the case of Catherine Acosta;
that an overdose or allergic reaction to Nubain could not have combined with
septicemia and peritonitis in bringing about Catherine's death.
What is of critical importance for present purposes is not so much the
identification of the "true cause" or "real cause" of Catherine's death but
rather the set of circumstances which both the trial court and the Court of
Appeals found constituted simple (as distinguished from reckless) negligence
on the part of the two accused Dr. Madrid and Dr. Carillo leading to the
death of Catherine.
When the patient was wheeled out of the operating room after completion of
surgery, she manifested signs of medical instability (i.e., shivering, paleness,
irregular breathing and weak heart beat). 27 She was not brought to a
properly equipped recovery room, or intensive care until which the hospital
lacked. 28 Such facilities and their professional staffs, of which an anesthetist
is commonly a part, are essential for providing close observation and patient
care while a post-surgery patient is recovering from the effects of anesthesia
and while the normal protective mechanisms are still dull or
obtunded. 29 Instead, the patient was merely brought to her assigned hospital
bed and was provided oxygen on the instructions of Dr. Madrid then "revived"
her heartbeat. 30 Both doctors then left their patient and the hospital;
approximately fifteen minutes later, she suffered convulsions and cardiac
arrest. 31
The conduct of Dr. Madrid and of the petitioner constituted inadequate care
of their patient in view of her vulnerable condition. Both doctors failed to
appreciate the serious condition of their patient whose adverse physical signs
were quite manifest right after surgery. And after reviving her heartbeat, both
doctors failed to monitor their patient closely or extend further medical care
to her; such conduct was especially necessary in view of the inadequate,
post-operative facilities of the hospital. We do not, of course, seek to hold
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petitioner responsible for the inadequate facilities of the Baclaran General
Hospital. We consider, however, that the inadequate nature of those facilities
did impose a somewhat higher standard of professional diligence upon the
accused surgeon and anesthetist personally than would have been called for
in a modern fully-equipped hospital.
While Dr. Madrid and a cardiologist were containing the patient's
convulsions, and after the latter had diagnosed that infection had reached
the patient's head, these two (2) apparently after consultation, decided to
call-in the petitioner. 32 There is here a strong implication that the patient's
post-operative condition must have been considered by the two (2) doctors as
in some way related to the anesthetic treatment she had received from the
petitioner either during or after the surgical procedure.
Once summoned, petitioner anesthesiologist could not be readily found.
When he finally appeared at 10:30 in the evening, he was evidently in a bad
temper, commenting critically on the dextrose bottles before ordering their
removal. 33 This circumstance indicated he was not disposed to attend to this
unexpected call, in violation of the canons of his profession that as a
physician, he should serve the interest of his patient "with the greatest of
solicitude, giving them always his best talent and skill." 34 Indeed, when
petitioner finally saw his patient, he offered the unprofessional bluster to the
parents of Catherine that he would resign if the patient will not regain
consciousness. 35 The canons of medical ethics require a physician to "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 physician's failure to fulfill his obligation to
his patient is, in most cases, his own conscience, violation of this rule on his
part is "discreditable and inexcusable". 36
Nubain was an experimental drug for anesthesia and post-operative pain and
the medical literature required that a patient be weighed first before it is
administered and warned that there was no (or inadequate) experience
relating to the administration thereof to a patient less that eighteen (18) ears
of age. 37 Yet, the doctor's order sheet (Exhibit "C") did not contain this
precaution but instead directed a reader to apply the drug only when
warranted by the circumstances. 38 During the offer of Exhibit "C" by the
prosecution, Dr. Madrid admitted that this prescription, which was
unsigned, was made in his own handwriting. 39 It must be observed that the
instruction was open-ended in that some other individual still had to
determine if circumstances existed warranting administration of the drug to
the patient. The document thus indicated the abdication of medical
responsibility on an extremely critical matter.
Page 5

Since petitioner anesthesiologist entered subsequent prescriptions or orders
in the same order sheet, which were signed by him, at 7:15 p.m. on the same
evening of 31 May 1981, he was in a position to appreciate the dangers
inherent in the prior prescription, which was within his (petitioner's) area of
specialization, and to order measures to correct this anomaly and protect his
patient's well-being. So far as the condition of the evidence shows, he failed
to do so. In sum, only a low level of diligence was exhibited by petitioner and
Dr. Madrid in the prescription of medication for their patient.
As noted earlier, petitioner relied heavily in this proceeding on the testimony
on cross-examination of the expert witnesses for the prosecution to show
that blood poisoning resulting from a ruptured appendix could also be
responsible for the patient's death.
No suggestion has been made that the rupture of the patient's occurred prior
to surgery. After her blood sample was examined, the patient was merely
diagnosed as a case of appendicitis, without further
elaboration. 40 No intensive preoperative preparations, like the immediate
administration of antibiotics, was thereafter undertaken on the patient. This
is a standard procedure for patients who are, after being diagnosed,
suspected of suffering from a perforated appendix and consequent
peritonitis. 41 The mother also testified that petitioner anesthesiologist merely
injected a drug, "pre-anesthesia" intended to put the patient to sleep, into the
container of fluids being administered to her daughter intravenously at her
room, prior to surgery. 42 We note further that the surgeon Dr. Madrid was
forty-five minutes late in arriving at the operating theater. 43 Considering that
delay in treatment of appendicitis increases the morbidity of the
patient, 44 Dr. Madrid's conduct can only be explained by a pre-operative
diagnosis on his part that the condition of appendicitis was not yet attended
by complications (i.e., a ruptured appendix and peritonitis).
The above circumstances do strongly indicate that the rupture of the
patient's appendix occurred during the appendectomy procedure, that is, at a
time and place — the operating room — where the two (2) accused were in
full control of the situation and could determine decisively what needed to be
done in respect of the patient. 45 This circumstance must be considered in
conjunction with other related circumstances which the prosecution had
proven: that the patient was ambulatory when brought to the operating
room; 46 that she left the operating room two (2) hours later in obviously
serious condition; and that an appendectomy accompanied or followed by
sustained antibiotic treatment is a fairly common and generally accepted
medical procedure for dealing with ruptured appendix and peritonitis, 47 a
fact of which judicial note may be taken.
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As early as in People v. Vistan, 48 the Court defined simple negligence,
penalized under what is now Article 365 of the Revised Penal Code, as "a
mere lack of prevision in a situation where either the threatened harm is
not immediate or the danger not openly visible." Put in a slightly different way,
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. 49 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. 50 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. 51 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
Page 6

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.
In addition to the main arguments raised by petitioner earlier, he also raised
an ancillary, constitutional claim of denial of due process. He contends that
he was deprived of his right to have competent representation at trial, and to
have his cause adequately heard, because his counsel of record, Atty. Jose B.
Puerto, was "incompetent" and exhibited "gross negligence" by manifesting an
intent to file a demurrer to the evidence, in failing to present evidence in his
behalf and in omitting to file a defense memorandum for the benefit of
Judge Yuzon, after the latter took over the case at the end of trial and before
the Judge rendered his decision. 52 Petitioner submits he is entitled to a new
trial. 53
These contentions do not persuade. An examination of the record indicates
that Atty. Puerto represented petitioner during trial with reasonable
competence. Except for the two hearing sessions when witnesses Domingo
Acosta was cross-examined and recross-examined by Atty. Puerto, petitioner
was present during all the sessions when the other prosecution witnesses
were presented and during which Atty. Puerto extensively cross-examined
them in behalf of petitioner and Dr. Madrid. This counsel elicited from the
two (2) expert witnesses for the prosecution testimony favorable to petitioner
and which was relied upon by the latter in this proceeding. 54 The record
further indicates that if petitioner indeed entertained substantial doubts
about the capability of Atty. Puerto, he could have easily terminated the
services of that counsel and retained a new one, or sought from the trial
court the appointment of counsel
de oficio, during the ample opportunity given from the time Atty. Puerto
manifested his intent to file a demurrer on 16 October 1985, to the
submission of the case for decision on 25 June 1986 and before the
promulgation of judgment on 19 September 1986. 55 During all this time,
petitioner could have obtained leave of court to present evidence in his behalf
in lieu of a demurrer, or to submit a memorandum for the defense. After
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promulgation of the judgment of conviction, petitioner did not seek a new
trial, but permitted Atty. Puerto to obtain leave from the trial court to
continue on bail during the pendency of the proceedings before the Court of
Appeals. 56 Indeed, petitioner replaced
Atty. Puerto as counsel only upon institution of the present petition. 57
Petitioner's constitutional objection is plainly an afterthought.
WHEREFORE, the Decision of the Court of Appeals dated 28 November 1988
is hereby AFFIRMED, subject only to the modification that the indemnity for
the death of Catherine Acosta is hereby increased to P50,000.00, in line with
current jurisprudence. 58
SO ORDERED.
LEANDRO CARILLO vs PEOPLE OF THE PHILIPPINES G.R. No. 86890,
January 21, 1994
Facts:
Petitioner Dr. Leandro Carillo, an anesthesiologists, seeks review of the
Decision of the Court of Appeals dated 28 November 1988, which affirmed
his conviction by the Regional Trial Court of the crime of simple negligence
resulting in homicide, for the death of his thirteen (13) year old patient
Catherine Acosta.
The deceased, 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 Dr. Elva Peña. Dra. Peña called for Dr. Emilio
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, a nurse took blood sample form the child.
The findings became known in the afternoon and the child was scheduled for
operation. When brought inside the operating room, the child was feeling
very well and they did not subject the child to ECG (electrocardiogram) and
X-ray.The appellant Dr. Emilio Madrid, a surgeon, operated on Catherine. He
was assisted by appellant, Dr. Leandro Carillo, an anesthesiologists.
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 DUMAUAL, JEANNE PAULINE J. 2019-2020

It has been established that the deceased was not weighed before the
administration of anesthesia on her.
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.
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

The Court of Appeals held that Catherine had suffered from an overdose of,
or an adverse reaction to, anaesthesia, leading to her death.

The Court of Appeals found criminal negligence on the part of petitioner

Dr.Carillo and his co-accused Dr. Madrid, holding that both had failed to
observe the required standard of diligence in the examination of Catherine
prior to the actual administration of anaesthesia.

Issue:
Whether or not Dr.Carillo is guilty of the crime of simple negligence resulting
in homicide.

Held:
Yes. Simple negligence, penalized under what is now Article 365 of the
Revised Penal Code,is defined as “a mere lack of prevision in a situation
where either the threatened harm is not immediate or the danger not openly
visible.” Put in a slightly different way, 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.

In the case at bar, the Court considered 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

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G.R. No. 118231 July 5, 1996
DR. VICTORIA L. BATIQUIN and ALLAN BATIQUIN, petitioners,
vs.
COURT OF APPEALS, SPOUSES QUEDO D. ACOGIDO and FLOTILDE G.
VILLEGAS, respondents.
DAVIDE, JR., J.:p
Throughout history, patients have consigned their fates and lives to the skill
of their doctors. For a breach of this trust, men have been quick to demand
retribution. Some 4,000 years ago, the Code of Hammurabi 1 then already
provided: "If a physician make a deep incision upon a man with his bronze
lancet and cause the man's death, or operate on the eye socket of a man with
his bronze lancet and destroy the man's eyes, they shall cut off his
hand." 2 Subsequently, Hippocrates3 wrote what was to become part of the
healer's oath: "I will follow that method of treatment which according to my
ability and judgment, I consider for the benefit of my patients, and abstain
from whatever is deleterious and mischievous. . . . While I continue to keep
this oath unviolated may it be granted me to enjoy life and practice the art,
respected by all men at all times but should I trespass and violate this oath,
may the reverse be my lot." At present, the primary objective of the medical
profession if the preservation of life and maintenance of the health of the
people.4
Needless to say then, when a physician strays from his sacred duty and
endangers instead the life of his patient, he must be made to answer
therefor. Although society today cannot and will not tolerate the punishment
meted out by the ancients, neither will it and this Court, as this case would
show, let the act go uncondemned.
The petitioners appeal from the decision 5 of the Court of Appeals of 11 May
1994 in CA-G.R. CV No. 30851, which reversed the decision 6 of 21 December
1990 of Branch 30 of the Regional Trial Court (RTC) of Negros Oriental in
Civil Case No. 9492.
The facts, as found by the trial court, are as follows:
Dr. Batiquin was a Resident Physician at the Negros Oriental
Provincial Hospital, Dumaguete City from January 9, 1978
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to September 1989. Between 1987 and September, 1989 she
was also the Actg. Head of the Department of Obstetrics and
Gynecology at the said Hospital.
Mrs. Villegas is a married woman who submitted to Dr.
Batiquin for prenatal care as the latter's private patient
sometime before September 21, 1988.
In the morning of September 21, 1988 Dr. Batiquin, 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
Page 9

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 [sic] 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 [sic] 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. 7
The piece of rubber allegedly found near private respondent Flotilde Villegas's
uterus was not presented in court, and although Dr. Ma. Salud Kho Testified
that she sent it to a pathologist in Cebu City for examination, 8 it was not
mentioned in the pathologist's Surgical Pathology Report. 9
Aside from Dr. Kho's testimony, the evidence which mentioned the piece of
rubber are a Medical Certificate, 10 a Progress Record,11 an Anesthesia
Record,12 a Nurse's Record,13 and a Physician's Discharge Summary. 14 The
trial court, however, regarded these documentary evidence as mere hearsay,
"there being no showing that the person or persons who prepared them are
deceased or unable to testify on the facts therein stated. . . . Except for the
Medical Certificate (Exhibit "F"), all the above documents were allegedly
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DUMAUAL, JEANNE PAULINE J. 2019-2020
prepared by persons other than Dr. Kho, and she merely affixed her
signature on some of them to express her agreement thereto. . . ." 15 The trial
court also refused to give weight to Dr. Kho's testimony regarding the subject
piece of rubber as Dr. Kho "may not have had first-hand knowledge"
thereof,16 as could be gleaned from her statement, thus:
A . . . I have heard somebody that [sic] says
[sic] there is [sic] a foreign body that goes
with the tissues but unluckily I don't know
where the rubber was. 17
The trial court deemed vital Dr. Victoria Batiquin's testimony that when she
confronted Dr. Kho regarding the piece of rubber, "Dr. Kho answered that
there was rubber indeed but that she threw it away." 18 This statement, the
trial court noted, was never denied nor disputed by Dr. Kho, leading it to
conclude:
There are now two different versions on the whereabouts of
that offending "rubber" — (1) that it was sent to the
Pathologist in Cebu as testified to in Court by Dr. Kho and
(2) that Dr. Kho threw it away as told by her to Defendant.
The failure of the Plaintiffs to reconcile these two different
versions serve only to weaken their claim against Defendant
Batiquin.19
All told, the trial court held in favor of the petitioners herein.
The Court of Appeals reviewed the entirety of Dr. Kho's testimony and, even
without admitting the private respondents' documentary evidence, deemed
Dr. Kho's positive testimony to definitely establish that a piece of rubber was
found near private respondent Villegas's uterus. Thus, the Court of Appeals
reversed the decision of the trial court, holding:
4. The fault or negligence of appellee Dr. Batiquin is
established by preponderance of evidence. The trial court
itself had narrated what happened to appellant Flotilde after
the caesarean operation made by appellee doctor. . . . After
the second operation, appellant Flotilde became well and
healthy. Appellant Flotilde's troubles were caused by the
infection due to the "rubber" that was left inside her
abdomen. Both appellant; testified that after the operation
made by appellee doctor, they did not go to any other doctor
Page 10

until they finally decided to see another doctor in January,
1989 when she was not getting any better under the care of
appellee Dr. Batiquin. . . . Appellee Dr. Batiquin admitted on
the witness stand that she alone decided when to close the
operating area; that she examined the portion she operated
on before closing the same. . . Had she exercised due
diligence, appellee Dr. Batiquin would have found the rubber
and removed it before closing the operating area. 20
The appellate court then ruled:
Appellants' evidence show[s] that they paid a total of
P17,000.00 [deposit of P7,100.00 (Exh. G-1-A) plus hospital
and medical expenses together with doctor's fees in the total
amount P9,900.00 (Exhs. G and G-2)] for the second
operation that saved her life.
For the miseries appellants endured for more than three (3)
months, due to the negligence of appellee Dr. Batiquin they
are entitled to moral damages in the amount of P100,000.00;
exemplary damages in the amount of P20,000.00 and
attorney's fees in the amount of P25,000.00.
The fact that appellant Flotilde can no longer bear children
because her uterus and ovaries were removed by Dr. Kho is
not taken into consideration as it is not shown that the
removal of said organs were the direct result of the rubber
left by appellee Dr. Batiquin near the uterus. What is
established is that the rubber left by appellee caused
infection, placed the life of appellant Flotilde in jeopardy and
caused appellant fear, worry and anxiety. . . .
WHEREFORE, the appealed judgment, dismissing the
complaint for damages is REVERSED and SET ASIDE.
Another judgment is hereby entered ordering defendants-
appellees to pay plaintiffs-appellants the amounts of
P17,000.00 as and for actual damages; P100,000.00 as and
for moral damages; P20,000.00 as and for exemplary
damages; and P25,000.00 as and for attorney's fees plus the
costs of litigation.
SO ORDERED.21
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DUMAUAL, JEANNE PAULINE J. 2019-2020
From the above judgment, the petitioners appealed to this Court claiming
that the appellate court: (1) committed grave abuse of discretion by resorting
to findings of fact not supported by the evidence on record, and (2) exceeded
its discretion, amounting to lack or excess of jurisdiction, when it gave
credence to testimonies punctured with contradictions and falsities.
The private respondents commented that the petition raised only questions of
fact, which were not proper for review by this Court.
While the rule is that only questions of law may be raised in a petition for
review on certiorari, there are exceptions, among which are when the factual
findings of the trial court and the appellate court conflict, when the appealed
decision is clearly contradicted by the evidence on record, or when the
appellate court misapprehended the facts. 22
After deciphering the cryptic petition, we find that the focal point of the
instant appeal is the appreciation of Dr. Kho's testimony. The petitioners
contend that the Court of Appeals misappreciated the following portion of Dr.
Kho's testimony:
Q What is the purpose of the examination?
A Just in case, I was just thinking at the
back of my mind, just in case this would
turn out to be a medico-legal
case, I have heard somebody that [sic] says [
sic] there is [sic] a
foreign body that goes with the tissues but u
nluckily I don't know where the rubber was.
It was not in the Lab, it was not in
Cebu. 23 (emphasis supplied)
The petitioners prefer the trial court's interpretation of the above
testimony, i.e., that Dr. Kho's knowledge of the piece of rubber was
based on hearsay. The Court of Appeals, on the other hand,
concluded that the underscored phrase was taken out of context by
the trial court. According to the Court of Appeals, the trial court
should have likewise considered the other portions of Dr. Kho's
testimony, especially the following:
Q So you did actually conduct the operation on her?
Page 11

A Yes, I did.
Q And what was the result?
A Opening up her abdomen, there was whitish-yellow
discharge inside the abdomen, there was an ovarian cyst
on the left and side and there was also an ovarian cyst on
the right which, on opening up or freeing it up from the
uterus, turned out to be pus. Both ovaries turned out. . .
to have pus. And then, cleaning up the uterus, at the
back of the uterus it was very dirty, it was full of pus. And
there was a [piece of] rubber, we found a [piece of] rubber
on the right
side. 24
We agree with the Court of Appeals. The phrase relied
upon by the trial court does not negate the fact that Dr.
Kho saw a piece of rubber in private respondent Villegas's
abdomen, and that she sent it to a laboratory and then to
Cebu City for examination by a pathologist. 25 Not even the
Pathologist's Report, although devoid of any mention of a
piece of rubber, could alter what Dr. Kho saw.
Furthermore, Dr. Kho's knowledge of the piece of rubber
could not be based on other than first-hand knowledge
for, as she asserted before the trial court:
Q But you are sure you have seen [the piece of rubber]?
26
A Oh yes. I was not the only one who saw it.
The petitioners emphasize that the private respondents never reconciled Dr.
Kho's testimony with Dr. Batiquin's claim on the witness stand that when Dr.
Batiquin confronted Dr. Kho about the foreign body, the latter said that there
was a piece of rubber but that she threw it away. Although hearsay, Dr.
Batiquin's claim was not objected to, and hence, the same is
admissible27 but it carries no probative value.28 Nevertheless, assuming
otherwise, Dr. Batiquin's statement cannot belie the fact that Dr. Kho found
a piece of rubber near private respondent Villegas's uterus. And even if we
were to doubt Dr. Kho as to what she did to the piece of rubber, i.e., whether
she threw it away or sent it to Cebu City, we are not justified in distrusting
her as to her recovery of a piece of rubber from private respondent Villegas's
abdomen. On this score, it is perfectly reasonable to believe the testimony of
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DUMAUAL, JEANNE PAULINE J. 2019-2020
a witness with respect to some facts and disbelieve his testimony with
respect to other facts. And it has been aptly said that even when a witness is
found to have deliberately falsified in some material particulars, it is not
required that the whole of his uncorroborated testimony be rejected, but
such portions thereof deemed worthy of belief may be credited. 29
It is here worth noting that the trial court paid heed to the following portions
of Dr. Batiquin's testimony: that no rubber drain was used in the
operation,30 and that there was neither any tear on Dr. Batiquin's gloves after
the operation nor blood smears on her hands upon removing her
gloves.31 Moreover, the trial court pointed out that the absence of a rubber
drain was corroborated by Dr. Doris Sy, Dr. Batiquin's assistant during the
operation on private respondent Villegas. 32 But the trial court failed to
recognize that the assertions of Drs. Batiquin and Sy were denials or negative
testimonies. Well-settled is the rule that positive testimony is stronger than
negative testimony.33 Of course, as the petitioners advocate, such positive
testimony must come from a credible source, which leads us to the second
assigned error.
While the petitioners claim that contradictions and falsities punctured Dr.
Kho's testimony, a regarding of the said testimony reveals no such infirmity
and establishes Dr. Kho as a credible witness. Dr. Kho was frank throughout
her turn on the witness stand. Furthermore, no motive to state any untruth
was ever imputed against Dr. Kho, leaving her trustworthiness
unimpaired.34 The trial court's following declaration shows that while it was
critical of the lack of care with which Dr. Kho handled the piece of rubber, it
was not prepared to doubt Dr. Kho's credibility, thus only supporting our
appraisal of Dr. Kho's trustworthiness:
This is not to say that she was less than honest when she
testified about her findings, but it can also be said that she did not
take the most appropriate precaution to preserve that "piece of
rubber" as an eloquent evidence of what she would reveal should
there be a "legal problem" which she claim[s] to have anticipated. 35
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:
Page 12

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." Or
as Black's Law Dictionary puts it:
Res ipsa loquitur. The thing speaks for itself. Rebuctable 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 ordinary 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 [sic] was such that in the ordinary
course of things would not happen if reasonable care had been used.
xxx xxx xxx
The doctrine of [r]es 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. 36
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
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DUMAUAL, JEANNE PAULINE J. 2019-2020
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.
As a final word, this Court reiterates its recognition of the vital role the
medical profession plays in the lives of the people, 3 7 and the State's
compelling interest to enact measures to protect the public from "the
potentially deadly effects of incompetence and ignorance in those who would
undertake to treat our bodies and minds for disease or trauma." 38 Indeed, a
physician is bound to serve the interest of his patients "with the greatest of
solicitude, giving them always his best talent and skill." 39 Through her
tortious conduct, the petitioner endangered the life of Flotilde Villegas, in
violation of her profession's rigid ethical code and in contravention of the
legal standards set forth for professionals, in general, 40 and members of the
medical profession,41 in particular.
WHEREFORE, the challenged decision of 11 May 1994 of the Court of
Appeals in CA-G.R. CV No. 30851 is hereby AFFIRMED in toto.
Costs against the petitioners.
SO ORDERED.
BATIQUIN v CA
Facts: September 21, 1988 petitioner performed a simple cesarean section on
Mrs. Villegas, the private respondent. After leaving the hospital, respondent
began to suffer abdominal pains and complained of being feverish. She also
gradually lost her appetite, so she consulted the petitioner who prescribed for
her certain medicines which she took up for 3 months. When the pain
Page 13

became unbearable she consulted Dr. Ma. Salud Kho at the Holy Child’s
Hospital in Dumaguete City on January 20, 1989.
Dr. Ma. Salud Kho examined the respondentand found the latter 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.A blood count showed that respondent had an infection inside her
abdominal cavity. The result 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 the respondent 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
materials 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.
A case was filed against the petitioner but the piece of rubber allegedly found
near private respondent’s uterus was not presented in court. Dr. Ma. Salud
Kho testified that she sent it to a pathologist in Cebu City for examination,
but it was not mentioned in the pathologist’s Surgical
Pathology Report.Aside from Dr. Kho’s testimony, the evidence which
mentioned the piece of rubber are a Medical Certificate, a Progress Record,
an Anesthesia Record, a Nurse’s Record, and a Physician’s Discharge
Summary
RTC, however, regarded these documentary evidence as mere hearsay, “there
being no showing that the person or persons who prepared them are
deceased or unable to testify on the facts therein stated . . . . Except for the
Medical Certificate (Exhibit “F”), all the above documents were allegedly
prepared by persons other than Dr. Kho, and she merely affixed her
signature on some of them to express her agreement thereto . . . .” RTC also
refused to give weight to Dr. Kho’s testimony regarding the subject piece of
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DUMAUAL, JEANNE PAULINE J. 2019-2020
rubber as Dr. Kho “may not have had first-hand knowledge” thereof. Thus,
RTC held in favor of the petitioners but was subsequently reversed by CA.
Issue: WON
(1) CA committed grave abuse of discretion by resorting to findings of fact not
supported by the evidence on record, and
(2) CA exceeded its discretion, amounting to lack or excess of jurisdiction,
when it gave credence to testimonies punctured with contradictions and
falsities.
Held: NO. The CA was correct in giving credence to the testimony.
The petitioners emphasize that the private respondents never reconciled Dr.
Kho’s testimony with Dr. Batiquin’s claim on the witness stand that when Dr.
Batiquin confronted Dr. Kho about the foreign body, the latter said that there
was a piece of rubber but that she threw it away. Although hearsay, Dr.
Batiquin’s claim was not objected to, and hence, the same is admissible but
it carries no probative value. Nevertheless, assuming otherwise, Dr.
Batiquin’s statement cannot belie the fact that Dr. Kho found a piece of
rubber near private respondent Villegas’ uterus. And even if we were to doubt
Dr. Kho as to what she did to the piece of rubber, i.e., whether she threw it
away or sent it to Cebu City, we are not justified in distrusting her as to her
recovery of a piece of rubber from private respondent Villegas’ abdomen. On
this score, it is perfectly reasonable to believe the testimony of a witness with
respect to some facts and disbelieve his testimony with respect to other facts.
And it has been aptly said that even when a witness is found to have
deliberately falsified in some material particulars, it is not required that the
whole of his uncorroborated testimony be rejected, but such portions thereof
deemed worthy of belief may be credited.
While the petitioners claim that contradictions and falsities punctured Dr.
Kho’s testimony, a reading of the said testimony reveals no such infirmity
and establishes Dr. Kho as a credible witness. Dr. Kho was frank throughout
her turn on the witness stand. Furthermore, no motive to state any untruth
was ever imputed against Dr. Kho, leaving her
trustworthiness unimpaired.The trial court’s following declaration shows that
while it was critical of the lack of care with which Dr. Kho handled the piece
of rubber, it was not prepared to doubt Dr. Kho’s credibility, thus only
supporting out appraisal of Dr. Kho’s trustworthiness.
Page 14
 DUMAUAL, JEANNE PAULINE J. 2019-2020

Considering that we have assessed Dr. Kho to be a credible witness, her the duty of due care. The doctrine can be invoked when and only when,
positive testimony that a piece of rubber was indeed found in private under the circumstances involved, direct evidence is absent and not readily
respondent Villegas’ abdomenprevails over the negative testimony in favor of available.[36]
the petitioners. In the instant case, all the requisites for recourse to the doctrine are present.
First, the entire proceedings of the cesarean section were under the exclusive
control of Dr. Batiquin. In this light, the private respondents were bereft of
As such, the rule of res ipsa loquitur comes to fore. This Court has had direct evidence as to the actual culprit or the exact cause of the foreign object
occasion to delve into the nature and operation of this doctrine: finding its way into private respondent Villegas’ body, which, needless to say,
This doctrine [res ipsa loquitur] is stated thus: “Where the thing which does not occur unless through the intervention of negligence. Second, since
causes injury is shown to be under the management of the defendant, and aside from the cesarean section, private respondent Villegas underwent no
the accident is such as in the ordinary course of things does not happen if other operation which could have caused the offending piece of rubber to
those who have the management use proper care, it affords reasonable appear in her uterus, it stands to reason that such could only have been a
evidence, in the absence of an explanation by the defendant, that the by-product of the cesarean section performed by Dr. Batiquin. The
accident arose from want of care.” Or as Black’s Law Dictionary puts it: 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
Res ipsa loquitur. The thing speaks for itself. Rebuttable presumption or respondent Villegas’ abdomen and for all the adverse effects thereof.
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 ordinary 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 [sic] was
such that in the ordinary course of things would not happen if reasonable
care had been used.
xxx xxx xxx

The doctrine of [r]esipsa 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

Atty. Yulo, Legal Medicine and Medical Jurisprudence Page 15


344 Phil. 323
ROMERO, J.:
May this Court review the findings of the Office of the Ombudsman? The
general rule has been enunciated in Ocampo v. Ombudsman [1] 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."
Does the instant case warrant a departure from the foregoing general rule?
When a patient dies soon after surgery under circumstances which indicate
that the attending surgeon and anaesthesiologist may have been guilty of
negligence but upon their being charged, a series of nine prosecutors toss the
responsibility of conducting a preliminary investigation to each other with
contradictory recommendations, "ping-pong" style, perhaps the distraught
widow is not to be blamed if she finally decides to accuse the City
Prosecutors at the end of the line for partiality under the Anti-Graft and
Corrupt Practices Act. Nor may she be entirely faulted for finally filing a
petition before this Court against the Ombudsman for grave abuse of
discretion in dismissing her complaint against said City Prosecutors on the
ground of lack of evidence. Much as we sympathize with the bereaved widow,
however, this Court is of the opinion that the general rule still finds
application in instant case. In other words, the respondent Ombudsman did
not commit grave abuse of discretion in deciding against filing the necessary
information against public respondents of the Office of the City Prosecutor.
The following facts are borne out by the records.
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. [2]
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
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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.
During the preliminary investigation, what transpired was a confounding
series of events which we shall try to disentangle. The case was initially
assigned to Prosecutor Antonio M. Israel, who had to inhibit himself because
he was related to the counsel of one of the doctors. As a result, the case was
re-raffled to Prosecutor Norberto G. Leono who was, however, disqualified on
motion of the petitioner since he disregarded prevailing laws and
jurisprudence regarding preliminary investigation. The case was then
referred to Prosecutor Ramon O. Carisma, who issued a resolution
recommending that only Dr. Reyes be held criminally liable and that the
complaint against Dr. Antonio be dismissed.
The case took another perplexing turn when Assistant City Prosecutor
Josefina Santos Sioson, in the "interest of justice and peace of mind of the
parties," recommended that the case be re-raffled on the ground that
Prosecutor Carisma was partial to the petitioner. Thus, the case was
transferred to Prosecutor Leoncia R. Dimagiba, where a volte face occurred
again with the endorsement that the complaint against Dr. Reyes be
dismissed and instead, a corresponding information be filed against Dr.
Antonio. Petitioner filed a motion for reconsideration, questioning the
findings of Prosecutor Dimagiba.
Pending the resolution of petitioner's motion for reconsideration regarding
Prosecutor Dimagiba's resolution, the investigative "pingpong" continued
when the case was again assigned to another prosecutor, Eudoxia T.
Gualberto, who recommended that Dr. Reyes be included in the criminal
information of Homicide through Reckless Imprudence. While the
recommendation of Prosecutor Gualberto was pending, the case was
transferred to Senior State Prosecutor Gregorio A. Arizala, who resolved to
exonerate Dr. Reyes from any wrongdoing, a resolution which was approved
by both City Prosecutor Porfirio G. Macaraeg and City Prosecutor Jesus F.
Guerrero.
Aggrieved, petitioner filed graft charges specifically for violation of Section
3(e) of Republic Act No. 3019 [3] against Prosecutors Guerrero, Macaraeg, and
Arizala for manifest partiality in favor of Dr. Reyes before the Office of the
Ombudsman. However, on July 11, 1994, the Ombudsman issued the
assailed resolution dismissing the complaint for lack of evidence.
In fine, petitioner assails the exercise of the discretionary power of the
Page 16

Ombudsman to review the recommendations of the government prosecutors
and to approve and disapprove the same. Petitioner faults the Ombudsman
for, allegedly in grave abuse of discretion, refusing to find that there exists
probable cause to hold public respondent City Prosecutors liable for violation
of Section 3(e) of R.A. No. 3019.
Preliminarily, the powers and functions of the Ombudsman have generally
been categorized into the following: investigatory powers, prosecutory power,
public assistance function, authority to inquire and obtain information, and
function to adopt, institute and implement preventive measures. [4]
As protector of the people, the Office of the Ombudsman has the power,
function and duty "to act promptly on complaints filed in any form or manner
against public officials" and "to investigate any act or omission of any public
official when such act or omission appears to be illegal, unjust, improper or
inefficient." [5]
While the Ombudsman has the full discretion to determine whether or not a
criminal case should be filed, this Court is not precluded from reviewing the
Ombudsman's action when there is an abuse of discretion, in which case
Rule 65 of the Rules of Court may exceptionally be invoked pursuant to
Section I, Article VIII of the 1987 Constitution. [6]
In this regard, "grave abuse of discretion" has been defined as "where a power
is exercised in an arbitrary or despotic manner by reason of passion or
personal hostility so patent and gross as to amount to evasion of positive
duty or virtual refusal to perform a duty enjoined by, or in contemplation of
law. [7]
From a procedural standpoint, it is certainly odd why the successive
transfers from one prosecutor to another were not sufficiently explained in
the Resolution of the Ombudsman. Being the proper investigating authority
with respect to misfeasance, non-feasance and malfeasance of public
officials, the Ombudsman should have been more vigilant and assiduous in
determining the reasons behind the "buckpassing" to ensure that no
irregularity took place.
Whether such transfers were due to any outside pressure or ulterior motive
is a matter of evidence. One would have expected the Ombudsman, however,
to inquire into what could hardly qualify as "standard operating procedure,"
given the surrounding circumstances of the case.
While it is true that a preliminary investigation is essentially inquisitorial,
and is often the only means to discover who may be charged with a crime, its
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function is merely to determine the existence of probable cause. [8] Probable
cause has been defined as "the existence of such fact and circumstances as
would excite the belief, in a reasonable mind, acting on the facts within the
knowledge of the prosecution, that the person charged was guilty of the
crime for which he was prosecuted." [9]
"Probable cause is a reasonable ground of presumption that a matter is, or
may be, well founded, such a state of facts in the mind of the prosecutor as
would lead a person of ordinary caution and prudence to believe, or entertain
an honest or strong suspicion, that a thing is so." The term does not mean
actual and positive cause nor does it import absolute certainty. It is merely
based on opinion and reasonable belief. Thus, a finding of probable cause
does not require an inquiry into whether there is sufficient evidence to
procure a conviction. It is enough that it is believed that the act or omission
complained of constitutes the offense charged. Precisely, there is a trial for
the reception of evidence of the prosecution in support of the charge. [10]
In the instant case, no less than the NBI pronounced after conducting an
autopsy that there was indeed negligence on the part of the attending
physicians in administering the anaesthesia. [11] The fact of want of
competence or diligence is evidentiary in nature, the veracity of which can
best be passed upon after a full-blown trial for it is virtually impossible to
ascertain the merits of a medical negligence case without extensive
investigation, research, evaluation and consultations with medical experts.
Clearly, the City Prosecutors are not in a competent position to pass
judgment on such a technical matter, especially when there are conflicting
evidence and findings. The bases of a party's accusation and defenses are
better ventilated at the trial proper than at the preliminary investigation.
A word on medical malpractice or negligence cases.
In its simplest terms, 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." [12]
Hence, there are four elements involved in medical negligence cases: duty,
breach, injury and proximate causation.
Page 17

Evidently, when the victim employed the services of Dr. Antonio and Dr.
Reyes, a physician-patient relationship was created. In accepting the case,
Dr. Antonio and Dr. Reyes in effect represented that, having the needed
training and skill possessed by physicians and surgeons practicing in the
same field, they will employ such training, care and skill in the treatment of
their patients.[13] They have 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. 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.
[14]
Consequently, in the event that any injury results to the patient from want
of due care or skill during the operation, the surgeons may be held
answerable in damages for negligence. [15]
Moreover, in malpractice or negligence cases involving the administration of
anaesthesia, the necessity of expert testimony and the availability of the
charge of res ipsa loquitur to the plaintiff, have been applied in actions
against anaesthesiologists to hold the defendant liable for the death or injury
of a patient under excessive or improper anaesthesia. [16] Essentially, it
requires two-pronged evidence: evidence as to the recognized standards of
the medical community in the particular kind of case, and a showing that the
physician in question negligently departed from this standard in his
treatment.[17]
Another element in medical negligence cases is causation which is divided
into two inquiries: whether the doctor's actions in fact caused the harm to
the patient and whether these were the proximate cause of the patient's
injury.[18] Indeed here, a causal connection is discernible from the occurrence
of the victim's death after the negligent act of the anaesthesiologist in
administering the anesthesia, a fact which, if confirmed, should warrant the
filing of the appropriate criminal case. To be sure, the allegation of negligence
is not entirely baseless. Moreover, the NBI deduced that the attending
surgeons did not conduct the necessary interview of the patient prior to the
operation. It appears that the cause of the death of the victim could have
been averted had the proper drug been applied to cope with the symptoms of
malignant hyperthermia. Also, we cannot ignore the fact that an antidote was
readily available to counteract whatever deleterious effect the anaesthesia
might produce. [19] Why these precautionary measures were disregarded must
be sufficiently explained.
The City Prosecutors were charged with violating Section 3(e) of the Anti-
Graft and Corrupt Practices Act which requires the following facts:
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1. The accused is a public officer discharging administrative or official
functions or private persons charged in conspiracy with them;
2. The public officer committed the prohibited act during the
performance of his official duty or in relation to his public position;
3. The public officer acted with manifest partiality, evident bad faith or
gross, inexcusable negligence; and
4. His action caused undue injury to the Government or any private
party, or gave any party any unwarranted benefit, advantage or preference to
such parties." [20]
Why did the complainant, petitioner in instant case, elect to charge
respondents under the above law?
While a party who feels himself aggrieved is at liberty to choose the
appropriate "weapon from the armory," it is with no little surprise that this
Court views the choice made by the complainant widow.
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, [21] 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:
Section 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." [22]
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.
WHEREFORE, in view of the foregoing, the instant petition is DISMISSED,
without prejudice to the filing of an appeal by the petitioner with the
Secretary of Justice assailing the dismissal of her criminal complaint by the
Page 18
 DUMAUAL, JEANNE PAULINE J. 2019-2020

respondent City Prosecutors. No costs. Prosecutor Gregorio A. Arizala, who resolved to exonerate Dr. Reyes from any
SO ORDERED. wrongdoing, a resolution which was approved by both City Prosecutor
Porfirio G. Macaraeg and City Prosecutor Jesus F. Guerrero.

GARCIA-RUEDA vs. PASCASIO G.R. No. 118141. September 5, 1997

Aggrieved, petitioner filed graft charges specifically for violation of Section
3(e) of Republic Act No. 3019 against Prosecutors Guerrero, Macaraeg, and
FACTS:
Arizala for manifest partiality in favor of Dr. Reyes before the Office of the
Ombudsman. However, the Ombudsman issued the assailed resolution
dismissing the complaint for lack of evidence. In fine, petitioner assails the
Florencio V. Rueda, husband of petitioner Leonila Garcia-Rueda, underwent
exercise of the discretionary power of the Ombudsman to review the
surgical operation at the UST hospital for the removal of a stone blocking his
recommendations of the government prosecutors and to approve and
ureter. He was attended by Dr. Domingo Antonio, Jr. who was the surgeon,
disapprove the same. Petitioner faults the Ombudsman for, allegedly ingrave
while Dr. ErlindaBalatbat-Reyes was the anaesthesiologist. Six hours after
abuse of discretion, refusing to find that there exists probable cause to hold
the surgery, however, Florencio died of complications of “unknown cause,”
public respondent City Prosecutors liable for violation of Section 3(e) of R.A.
according to officials of the UST Hospital.
No. 3019.

Not satisfied with the findings of the hospital, petitioner requested the
ISSUE:
National Bureau of Investigation (NBI) to conduct an autopsy on her
Whether there was negligence on the part of the physicians which resulted to
husband’s body.Consequently, the NBI ruled that Florencio’s death was due
the death of Petitioner’s husband
to lack of care by the attending physician in administeringanaesthesia.
Pursuant to its findings, the NBI recommended that Dr. Domingo Antonio
and Dr. ErlindaBalatbat-Reyes be charged for Homicide through Reckless
HELD:
Imprudence. The case was initially assigned to Prosecutor Antonio M. Israel,
who had to inhibit himself because he was related to the counsel of one of
the doctors. The case was re-raffled to Prosecutor Norberto G. Leono who
Yes. No less than the NBI pronounced after conducting an autopsy that there
was, however, disqualified on motion of the petitioner. The case was then
was indeed negligence on the part of the attending physicians in
referred to Prosecutor Ramon O. Carisma, who issued a resolution
administering the anaesthesia
recommending that only Dr. Reyes be held criminally liable and that the
complaint against Dr. Antonio be dismissed.
RATIO:
Assistant City Prosecutor Josefina Santos Sioson, recommended that the
case be re-raffled on the ground that Prosecutor Carisma was partial to the
The fact of want of competence or diligence is evidentiary in nature, the
petitioner. Thus, the case was transferred to Prosecutor Leoncia R. Dimagiba,
veracity of which can best be passed upon after a full-blown trial for it is
who endorsed that the complaint against Dr. Reyes be dismissed and
virtually impossible to ascertain the merits of a medical negligence case
instead, a corresponding information be filed against Dr. Antonio. Petitioner
without extensive investigation, research, evaluation and consultations with
filed a motion for reconsideration, questioning the findings of Prosecutor
medical experts. Clearly, the City Prosecutors are not in a competent position
Dimagiba. Pending the resolution of petitioner’s motion for reconsideration
to pass judgment on such a technical matter, especially when there are
regarding Prosecutor Dimagiba’s resolution, the investigative “pingpong”
conflicting evidence and findings. The bases of a party’s accusation and
continued when the case was again assigned to another prosecutor, who
defenses are better ventilated at the trial proper than at the preliminary
recommended that Dr. Reyes be included in the criminal information of
investigation.
Homicide through Reckless Imprudence. While the recommendation of
Prosecutor Gualberto was pending, the case was transferred to Senior State

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 DUMAUAL, JEANNE PAULINE J. 2019-2020

There are four elements involved in medical negligence cases: duty, breach,
injury and proximate causation.

Evidently, when the victim employed the services of Dr. Antonio and Dr.
Reyes, a physician-patient relationship was created. In accepting the case,
Dr. Antonio and Dr. Reyes in effect represented that, having the needed
training and skill possessed by physicians and surgeons practicing in the
same field, they will employ such training, care and skill in the treatment of
their patients.

They have 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. 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.
Consequently, in the event that any injury results to the patient from want of
due care or skill during the operation, the surgeons may be held answerable
in damages for negligence.

Moreover, in malpractice or negligence cases involving the administration of

anaesthesia, the necessity of expert testimony and the availability of the
charge of res ipsa loquitur to the plaintiff, have been applied in actions
against anaesthesiologist to hold the defendant liable for the death or injury
of a patient under excessive or improper anaesthesia. Essentially, it requires
two-pronged evidence: evidence as to the recognized standards of the medical
community in the particular kind of case, and a showing that the physician
in question negligently departed from this standard in his treatment.

Causal connection is discernible from the occurrence of the victim’s death

after the negligent act of the anaesthesiologist in administering the
anesthesia, a fact which, if confirmed, should warrant the filing of the
appropriate criminal case. To be sure, the allegation of negligence is not
entirely baseless. Moreover, the NBI deduced that the attending surgeons did
not conduct the necessary interview of the patient prior to the operation. It
appears that the cause of the death of the victim could have been averted
had the proper drug been applied to cope with the symptoms of malignant
hyperthermia. Also, we cannot ignore the fact that an antidote was readily
available to counteract whatever deleterious effect the anaesthesia might
produce. Why these precautionary measures were disregarded must be
sufficiently explained.

Atty. Yulo, Legal Medicine and Medical Jurisprudence Page 20


G.R. No. 122445 November 18, 1997
DR. NINEVETCH CRUZ, petitioner,
vs.
COURT OF APPEALS and LYDIA UMALI, respondents.
FRANCISCO, J.:
Doctors are protected by a special rule of law. They are not guarantors of
care. They do not even warrant a good result. They are not insurers against
mishaps or unusual consequences. Furthermore they are not liable for
honest mistakes of judgment . . . 1
The present case against petitioner is in the nature of a medical malpractice
suit, which in simplest terms is the 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. 2 In this jurisdiction, however, such claims are most
often brought as a civil action for damages under Article 2176 of the Civil
Code, 3 and in some instances, as a criminal case under Article 365 of the
Revised Penal Code 4 with which the civil action for damages is impliedly
instituted. It is via the latter type of action that the heirs of the deceased
sought redress for the petitioner's alleged imprudence and negligence in
treating the deceased thereby causing her death. The petitioner and one Dr.
Lina Ercillo who was the attending anaesthesiologist during the operation of
the deceased were charged with "reckless imprudence and negligence
resulting to (sic) homicide" in an information which reads:
That on or about March 23, 1991, in the City of San Pablo,
Republic of the Philippines and within the jurisdiction of this
Honorable Court, the accused above named, being then the
attending anaesthesiologist and surgeon, respectively, did
then and there, in a negligence (sic), careless, imprudent,
and incompetent manner, and failing to supply or store
sufficient provisions and facilities necessary to meet any and
all exigencies apt to arise before, during and/or after a
surgical operation causing by such negligence, carelessness,
imprudence, and incompetence, and causing by such failure,
including the lack of preparation and foresight needed to
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avert a tragedy, the untimely death of said Lydia Umali on
the day following said surgical operation. 5
Trial ensued after both the petitioner and Dr. Lina Ercillo pleaded not guilty
to the above-mentioned charge. On March 4, 1994, the Municipal Trial Court
in Cities (MTCC) of San Pablo City rendered a decision, the dispositive
portion of which is hereunder quoted as follows:
WHEREFORE, the court finds the accused Dra. Lina Ercillo
not guilty of the offense charged for insufficiency of evidence
while her co-accused Dra. Ninevetch Cruz is hereby held
responsible for the death of Lydia Umali on March 24, 1991,
and therefore guilty under Art. 365 of the Revised Penal
Code, and she is hereby sentenced to suffer the penalty of 2
months and 1 day imprisonment of arresto mayor with
costs. 6
The petitioner appealed her conviction to the Regional Trial Court
(RTC) which affirmed in toto the decision of the MTCC 7 prompting
the petitioner to file a petition for review with the Court of Appeals
but to no avail. Hence this petition for review on certiorari assailing
the decision promulgated by the Court of Appeals on October 24,
1995 affirming petitioner's conviction with modification that she is
further directed to pay the heirs of Lydia Umali P50,000.00 as
indemnity for her death.8
In substance, the petition brought before this Court raises the issue
of whether or not 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.
First the antecedent facts.
On March 22, 1991, prosecution witness, Rowena Umali De Ocampo,
accompanied her mother to the Perpetual Help Clinic and General Hospital
situated in Balagtas Street, San Pablo City, Laguna. They arrived at the said
hospital at around 4:30 in the afternoon of the same day. 9 Prior to
March 22, 1991, Lydia was examined by the petitioner who found a
"myoma" 10 in her uterus, and scheduled her for a hysterectomy operation on
March 23,
1991. 11 Rowena and her mother slept in the clinic on the evening of March
Page 21

22, 1991 as the latter was to be operated on the next day at 1:00 o'clock in
the afternoon. 12 According to Rowena, 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. 13 Because of the
untidy state of the clinic, Rowena tried to persuade her mother not to
proceed with the operation. 14 The following day, before her mother was
wheeled into the operating room, Rowena asked the petitioner if the
operation could be postponed. The petitioner 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. 15
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 went out of the operating room and
instructed them to buy tagamet ampules which Rowena's sister immediately
bought. About one 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, the petitioner 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. 16 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. 17 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. 18
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. 19 The attending
physicians summoned Dr. Bartolome Angeles, head of the Obstetrics and
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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. 20 While the petitioner was closing the abdominal wall, the patient
died. 21 Thus, on March 24, 1991, at 3:00 o'clock in the morning, Lydia
Umali was pronounced dead. Her death certificate states "shock" as the
immediate cause of death and "Disseminated Intravascular Coagulation
(DIC)" as the antecedent cause. 22
In convicting the petitioner, the MTCC found the following circumstances as
sufficient basis to conclude that she was indeed negligent in the performance
of the operation:
. . . , the clinic was untidy, there was lack of provision like
blood and oxygen to prepare for any contingency that might
happen during the operation. The manner and the fact that
the patient was brought to the San Pablo District Hospital
for reoperation indicates that there was something wrong in
the manner in which Dra. Cruz conducted the operation.
There was no showing that before the operation, accused
Dra. Cruz had conducted a cardio pulmonary clearance or
any typing of the blood of the patient. It was (sic) said in
medical parlance that the "the abdomen of the person is a
temple of surprises" because you do not know the whole
thing the moment it was open (sic) and surgeon must be
prepared for any eventuality thereof. The patient (sic) chart
which is a public document was not presented because it is
only there that we could determine the condition of the
patient before the surgery. The court also noticed in Exh. "F-
1" that the sister of the deceased wished to postpone the
operation but the patient was prevailed upon by Dra. Cruz to
proceed with the surgery. The court finds that Lydia Umali
died because of the negligence and carelessness of the
surgeon Dra. Ninevetch Cruz because of loss of blood during
the operation of the deceased for evident unpreparedness
and for lack of skill, the reason why the patient was brought
for operation at the San Pablo City District Hospital. As
such, the surgeon should answer for such negligence. With
respect to Dra. Lina Ercillo, the anaesthesiologist, there is no
evidence to indicate that she should be held jointly liable
with Dra. Cruz who actually did the operation. 23
Page 22

The RTC reiterated the abovementioned findings of the MTCC and upheld the
latter's declaration of "incompetency, negligence and lack of foresight and
skill of appellant (herein petitioner) in handling the subject patient before
and after the operation." 24 And likewise affirming the petitioner's conviction,
the Court of Appeals echoed similar observations, thus:
. . . While we may grant that the untidiness and filthiness of
the clinic may not by itself indicate negligence, it
nevertheless shows the absence of due care and supervision
over her subordinate employees. Did this unsanitary
condition permeate the operating room? Were the surgical
instruments properly sterilized? Could the conditions in the
OR have contributed to the infection of the patient? Only the
petitioner could answer these, but she opted not to testify.
This could only give rise to the presumption that she has
nothing good to testify on her defense. Anyway, the alleged
"unverified statement of the prosecution witness" remains
unchallenged and unrebutted.
Likewise undisputed is the prosecution's version indicating
the following facts: that the accused asked the patient's
relatives to buy Tagamet capsules while the operation was
already in progress; that after an hour, they were also asked
to buy type "A" blood for the patient; that after the surgery,
they were again asked to procure more type "A" blood, but
such was not anymore available from the source; that the
oxygen given to the patient was empty; and that the son-in-
law of the patient, together with a driver of the petitioner,
had to rush to the San Pablo City District Hospital to get the
much-needed oxygen. All these conclusively show that the
petitioner had not prepared for any unforeseen
circumstances before going into the first surgery, which was
not emergency in nature, but was elective or pre-scheduled;
she had no ready antibiotics, no prepared blood, properly
typed and cross-matched, and no sufficient oxygen supply.
Moreover, there are a lot of questions that keep nagging Us.
Was the patient given any cardio-pulmonary clearance, or at
least a clearance by an internist, which are standard
requirements before a patient is subjected to surgery. Did
the petitioner determine as part of the pre-operative
evaluation, the bleeding parameters of the patient, such as
bleeding time and clotting time? There is no showing that
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DUMAUAL, JEANNE PAULINE J. 2019-2020
these were done. The petitioner just appears to have been in
a hurry to perform the operation, even as the family wanted
a postponement to April 6, 1991. Obviously, she did not
prepare the patient; neither did she get the family's consent
to the operation. Moreover, she did not prepare a medical
chart with instructions for the patient's care. If she did all
these, proof thereof should have been offered. But there is
none. Indeed, these are overwhelming evidence of
recklessness and imprudence. 25
This Court, however, holds differently and finds the foregoing circumstances
insufficient to sustain a judgment of conviction against the petitioner for the
crime of reckless imprudence resulting in homicide. 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. 26 In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pascasio,
et al., 27 this 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. It is in this aspect of medical malpractice that 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. 28 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. 29
Immediately apparent from a review of the records of this case is the absence
of any expert testimony on the matter of the standard of care employed by
other physicians of good standing in the conduct of similar operations. The
Page 23

prosecution's expert witnesses in the persons of Dr. Floresto Arizala and Dr.
Nieto Salvador, Jr. of the National Bureau of Investigation (NBI) only testified
as to the possible cause of death but did not venture to illuminate the court
on the matter of the standard of care that petitioner should have exercised.
All three courts below bewail the inadequacy of the facilities of the clinic and
its untidiness; the lack of provisions such as blood, oxygen, and certain
medicines; the failure to subject the patient to a cardio-pulmonary test prior
to the operation; the omission of any form of blood typing before transfusion;
and even the subsequent transfer of Lydia to the San Pablo Hospital and the
reoperation performed on her by the petitioner. But while it may be true that
the circumstances pointed out by the courts below seemed beyond cavil to
constitute reckless imprudence on the part of the surgeon, this conclusion is
still best arrived at not through the educated surmises nor conjectures of
laymen, including judges, but by the unquestionable knowledge of expert
witnesses. For whether a physician or surgeon has exercised the requisite
degree of skill and care in the treatment of his patient is, in the generality of
cases, a matter of expert opinion. 30 The deference of courts to the expert
opinion of qualified physicians stems from its realization that the latter
possess unusual technical skills which laymen in most instances are
incapable of intelligently evaluating. 31 Expert testimony should have been
offered to prove that the circumstances cited by the courts below are
constitutive of conduct falling below the standard of care employed by other
physicians in good standing when performing the same operation. It must be
remembered that when the qualifications of a physician are admitted, as in
the instant case, there is an inevitable presumption that in proper cases he
takes the necessary precaution and employs the best of his knowledge and
skill in attending to his clients, unless the contrary is sufficiently
established. 32 This presumption is rebuttable by expert opinion which is so
sadly lacking in the case at bench.
Even granting arguendo that the inadequacy of the facilities and untidiness
of the clinic; the lack of provisions; the failure to conduct pre-operation tests
on the patient; and the subsequent transfer of Lydia to the San Pablo
Hospital and the reoperation performed on her by the petitioner do indicate,
even without expert testimony, that petitioner was recklessly imprudent in
the exercise of her duties as a surgeon, no cogent proof exists that any of
these circumstances caused petitioner's death. Thus, the absence of the
fourth element of reckless imprudence: that the injury to the person or
property was a consequence of the reckless imprudence.
In litigations involving medical negligence, the plaintiff has the burden of
establishing appellant's negligence and for a reasonable conclusion of
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DUMAUAL, JEANNE PAULINE J. 2019-2020
negligence, there must be proof of breach of duty on the part of the
surgeon as well as a causal connection of such breach and the resulting death
of his patient. 33 In Chan Lugay v. St. Luke's Hospital, Inc., 34 where the
attending physician was absolved of liability for the death of the
complainant's wife and newborn baby, this Court held that:
In order that there may be a recovery for an injury, however,
it must be shown that the "injury for which recovery is
sought must be the legitimate consequence of the wrong
done; the connection between the negligence and the injury
must be a direct and natural sequence of events, unbroken
by intervening efficient causes." In other words, the
negligence must be the proximate cause of the injury. For,
"negligence, no matter in what it consists, cannot create a
right of action unless it is the proximate cause of the injury
complained of ." And "the proximate cause of an injury is
that cause, which, in natural and continuous sequence,
unbroken by any efficient intervening cause, produces the
injury, and without which the result would not have
occurred." 35 (Emphasis supplied.)
Dr. Arizala who conducted an autopsy on the body of the deceased
summarized his findings as follows:
Atty. Cachero:
Q. You mentioned about your Autopsy Report which has been marked
as Exh. "A-1-b". There appears here a signature above the typewritten
name Floresto Arizala, Jr., whose signature is that?
A. That is my signature, sir.
Q. Do you affirm the truth of all the contents of Exh. "A-1-b"?
A. Only as to the autopsy report no. 91-09, the time and place and
everything after the post mortem findings, sir.
Q. You mentioned on your "Post Mortem Findings" about surgical
incision, 14:0 cm., infraumbilical area, anterior abdominal area,
midline, will you please explain that in your own language?
Page 24
 DUMAUAL, JEANNE PAULINE J. 2019-2020

A. There was incision wound (sic) the area just below the navel, sir. Q. How about the intestines and mesenteries are place (sic) with blood
clots noted between the mesenteric folds, will you please explain on
Q. And the last paragraph of the postmortem findings which I read: (sic) this?
Uterus, pear-shaped and pale measuring 7.5 x 5.5 x 5.0 cm. with
some surface nodulation of the fundic area posteriorly. Cut-section A. In the peritoneal cavity, they are mostly perritonial blood . . . . . . . .
shows diffusely pale myometrium with areas of streak induration. The
ovaries and adnexal structures are missing with the raw surfaces Q. And what could have caused this blood?
patched with clotted blood. Surgical sutures were noted on the
operative site.
A. Well, ordinarily blood is found inside the blood vessel. Blood were
(sic) outside as a result of the injuries which destroyed the integrity of
Intestines and mesenteries are pale with blood clots noted between the vessel allowing blood to sip (sic) out, sir.
the mesentric folds.
Q. By the nature of the postmortem findings indicated in Exh. A-1-B,
Hemoperitoneum: 300 s.s., can you tell the court the cause of death?
right paracolic gutter,
50 c.c., left paracolic gutter
200 c.c., mesentric area, A. Yes, sir. The cause of death is: Gross findings are compatible with
100 c.c., right pelvic gutter hemorrhagic shock.
stomach empty.
Q. Can you tell the us what could have caused this hemorrhagic shock?
Other visceral organs, pale.,
A. Well hemorrhagic shock is the result of blood loss.
will you please explain that on (sic) your own language or in
ordinary. . . . . . . . . . . . Q. What could have the effect of that loss of blood?

36
A. There was a uterus which was not attached to the adnexal A. Unattended hemorrhage, sir. (Emphasis supplied.)
structures namely ovaries which were not present and also sign of
previous surgical operation and there were (sic) clotted blood, sir. The foregoing was corroborated by Dr. Nieto Salvador:

Q. How about the ovaries and adnexal structures?
A. They are missing, sir.
Q. You mean to say there are no ovaries?
Q. And were you able to determine the cause of death by virtue of the
examination of the specimen submitted by Dr. Arizala?
A. Without knowledge of the autopsy findings it would be difficult for
me to determine the cause of death, sir.

A. During that time there are no ovaries, sir. Q. Have you also examined the post mortem of Dr. Arizala?

Q. And there were likewise sign of surgical sutures? A. Yes, sir, and by virtue of the autopsy report in connection with
your pathology report.
A. Yes, sir.

Atty. Yulo, Legal Medicine and Medical Jurisprudence Page 25


Q. What could have caused the death of the victim?
A. This pathologic examination are (sic) compatible with the person who
died, sir.
Q. Will you explain to us the meaning of hemorrhagic compatible?
A. It means that a person died of blood loss. Meaning a person died of
non-replacement of blood and so the victim before she died there was
shock of diminish of blood of the circulation. She died most probably
before the actual complete blood loss, sir.
Court: Is it possible doctor that the loss of the blood was due on (sic)
operation?
A. Based on my pathologist finding, sir.
Q. What could have caused this loss of blood?
A. Many, sir. A patient who have undergone surgery. Another may be a
blood vessel may be cut while on operation and this cause (sic)
bleeding, or may be set in the course of operation, or may be (sic) he
died after the operation. Of course there are other cause (sic).
Atty. Cachero:
Q. Especially so doctor when there was no blood replacement?
37
A. Yes, sir. (Emphasis supplied.)
The testimonies of both doctors establish hemorrhage or hemorrhagic shock
as the cause of death. However, as likewise testified to by the expert
witnesses in open court, hemorrhage or hemorrhagic shock during surgery
may be caused by several different factors. Thus, Dr. Salvador's elaboration
on the matter:
Atty. Pascual:
Q. Doctor, among the causes of hemorrhage that you mentioned
you said that it could be at the moment of operation when one
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DUMAUAL, JEANNE PAULINE J. 2019-2020
losses (sic) control of the presence, is that correct? During the
operation there is lost (sic) of control of the cut vessel?
A. Yes, sir.
Q. Or there is a failure to ligate a vessel of considerable size?
A. Yes, sir.
Q. Or even if the vessel were ligated the knot may have slipped
later on?
A. Yes, sir.
Q. And you also mentioned that it may be possible also to some
clotting defect, is that correct?
A. May be (sic). 38
(Emphasis supplied).
Defense witness, Dr. Bu C. Castro also gave the following expert
opinion:
Q. Doctor even a patient after an operations (sic) would suffer
hemorrage what would be the possible causes of such
hemorrage (sic)?
A. Among those would be what we call Intravascular
Coagulation and this is the reason for the bleeding, sir, which
cannot be prevented by anyone, it will happen to anyone,
anytime and to any persons (sic), sir.
COURT:
What do you think of the cause of the bleeding, the cutting or
the operations done in the body?
A. Not related to this one, the bleeding here is not related to
any cutting or operation that I (sic) have done.
Page 26

Q. Aside from the DIC what could another causes (sic) that
could be the cause for the hemorrhage or bleeding in a
patient by an operations (sic)?
A. In general sir, if there was an operations (sic) and it is
possible that the ligature in the suture was (sic) become (sic)
loose, it is (sic) becomes loose if proven..
xxx xxx xxx
Q. If the person who performed an autopsy does not find any
untight (sic) clot (sic) blood vessel or any suture that become
(sic) loose the cause of the bleeding could not be attributed to
the fault of the subject?
39
A. Definitely, sir. (Emphasis supplied.)
According to both doctors, the possible causes of hemorrhage during an
operation are: (1) the failure of the surgeon to tie or suture a cut blood vessel;
(2) allowing a cut blood vessel to get out of control; (3) the subsequent
loosening of the tie or suture applied to a cut blood vessel; and (4) and a
clotting defect known as DIC. It is significant to state at this juncture that
the autopsy conducted by Dr. Arizala on the body of Lydia did not reveal any
untied or unsutured cut blood vessel nor was there any indication that the
tie or suture of a cut blood vessel had become loose thereby causing the
hemorrhage. 40 Hence the following pertinent portion of Dr. Arizala's
testimony:
Q: Doctor, in examining these structures did you know
whether these were sutured ligature or plain ligature
A: Ligature, sir.
Q: We will explain that later on. Did you recall if the cut
structures were tied by first suturing it and then tying a knot
or the tie was merely placed around the cut structure and
tied?
A: I cannot recall, sir.
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DUMAUAL, JEANNE PAULINE J. 2019-2020
Q: As a matter of fact, you cannot recall because you did not
even bothered (sic) to examine, is that correct?
A: Well, I bothered enough to know that they were sutured, sir.
Q: So, therefore, Doctor, you would not know whether any of
the cut structures were not sutured or tied neither were you
able to determine whether any loose suture was found in the
peritoneal cavity?
41
A: I could not recall any loose sutured (sic), sir.
On the other hand, the findings of all three doctors do not preclude the
probability that DIC caused the hemorrhage and consequently, Lydia's death.
DIC which is a clotting defect creates a serious bleeding tendency and when
massive DIC occurs as a complication of surgery leaving raw surface, major
hemorrhage occurs. 42 And as testified to by defense witness, Dr. Bu C.
Castro, hemorrhage due to DIC "cannot be prevented, it will happen to
anyone,
anytime." 43 He testified further:
Q. Now, under that circumstance one of the possibility as
you mentioned in (sic) DIC?
A. Yes, sir.
Q. And you mentioned that this cannot be prevented?
A. Yes, sir.
Q. Can you even predict if it really happen (sic)?
A. Possible, sir.
Q. Are there any specific findings of autopsy that will tell
you whether this patient suffered among such things as
DIC?
A. Well, I did reserve because of the condition of the patient.
Page 27

Q. Now, Doctor you said that you went through the record
of the deceased Lydia Umali looking for the chart, the
operated (sic) records, the post mortem findings on the
histophanic (sic) examination based on your examination of
record, doctor, can you more or less says (sic) what part are
(sic) concerned could have been the caused (sic) of death of
this Lydia Umali?
A. As far as the medical record is concern (sic) the caused
(sic) of death is dessimulated (sic) Intra Vascular
Coagulation or the DIC which resulted to hemorrhage or
bleedings, sir.
Q. Doctor based on your findings then there is knowing (sic)
the doctor would say whether the doctor her (sic) has been
(sic) fault?
ATTY. MALVEDA:
We will moved (sic) to strike out the (sic) based on finding
they just read the chart as well as the other record.
ATTY. PASCUAL:
Precisely based on this examination.
ATTY. MALVEDA:
Not finding, there was no finding made.
COURT:
He is only reading the record.
ATTY. PASCUAL:
Yes, sir.
44
A. No, sir, there is no fault on the part of the surgeon, sir.
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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. 45
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 46 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.
WHEREFORE, premises considered, petitioner DR. NINEVETCH CRUZ 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 FIFTY THOUSAND PESOS (P50,000.00) as civil liability, ONE
HUNDRED THOUSAND PESOS (P100,000.00) as moral damages, and FIFTY
THOUSAND PESOS (P50,000.00) as exemplary damages.
Let a copy of this decision be furnished to the Professional Regulation
Commission (PRC) for appropriate action.
Cruz vs Court of Appeals
GR No. 122445 November 18, 1997
Page 28

Facts: On March 22, 1991, prosecution witness, Rowena Umali de Ocampo,
accompanied her mother to the Perpetual Help Clinic and General Hospital
situated in Balagtas Street, San Pablo City, Laguna. They arrived at the said
hospital at around 4:30 in the afternoon of the same day. Prior to March 22,
1991, Lydia was examined by the petitioner who found a “Myoma” in her
uterus, and scheduled her for a hysterectomy operation on March 23, 1991.
Rowena and her mother slept in the clinic on the evening of March 22, 1991
as the latter was to be operated on the next day at 1pm. According to
Rowena, she noticed that the clinic was untidy and the windows and the
floor were very dusty prompting her to ask the attendant fora rag to wipe the
window and floor with. Prior to the operation, Rowena tried to convince her
mother to not proceed with the operation and even asked petitioner for it to
be postponed, however it still pushed through after the petitioner told Lydia
that operation must be done as scheduled. During the operation, the
assisting doctor of the petitioner, Dr. Ercillo went out of the operating room
and asked that tagmet ampules be bought which was followed by another
instruction to buy a bag of blood. After the operation, when Lydia came out of
the OR, another bag of blood was requested to be bought, however, the same
was not bought due to unavailability of type A from the blood bank.
Thereafter a person arrived to donate blood which was later transferred to
Lydia. Rowena then noticed her mother, who was attached to an oxygen
tank, gasping for breathe apparently, the oxygen tank is empty, so her
husband and petitioner’s driver bought an oxygen. Later, without the
knowledge of Lydia’s relatives,she was decided by the doctors to be
transferred to San Pablo District Hospital were she was supposed to be re-
operated. After Lydia experienced shocks, she died.
Issue: Whether or not petitioner has been negligent which caused the death
of Lydia Umali.
Held: Yes. Whether or not a physician has committed an “inexcusable lack of
precaution” in the treatment of his patient 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. 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. It is in this aspect of medical malpractice that 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
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DUMAUAL, JEANNE PAULINE J. 2019-2020
falls below such standard. Further, in as much 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 the conclusion as to causation.
In litigations involving medical negligence, the plaintiff has the burden of
establishing appellant’s negligence and for a reasonable conclusion of
negligence, there must be proof of breach of duty on the part of the surgeon
as well as causal connection of such breach and the resulting death of his
patient.
In order that there may be recovery for an injury, however, it must be shown
that the injury for which recovery is sought must be legitimate consequence
of the wrong done; the connection between the negligence and the injury
must be a direct and natural reference of events, unbroken by intervening
efficient causes. In other words, the negligence must be the proximate cause
of the injury. For negligence, no matter what it consists, cannot create a right
of action unless it is the proximate cause of the injury complained of and the
proximate cause of an injury is that cause, which in natural and continuous
sequence, unbroken by any efficient intervening cause, produces the injury
and without which the result would have occurred.
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.
The possible causes of hemorrhage during an operation are: 1.) the failure of
the surgeon to tie or suture a cut blood vessel; 2.) allowing a cut blood vessel
to get out of control; 3.) the subsequent loosening of the tie or suture applied
to a cut blood vessel; and 4.)and a clotting defect known as DIC.
Page 29
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Atty. Yulo, Legal Medicine and Medical Jurisprudence Page 30


G.R. No. 124354 December 29, 1999
ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as
natural guardians of the minors, ROMMEL RAMOS, ROY RODERICK
RAMOS and RON RAYMOND RAMOS, petitioners,
vs.
COURT OF APPEALS, DELOS SANTOS MEDICAL CENTER, DR. ORLINO
HOSAKA and DRA. PERFECTA GUTIERREZ, respondents.
KAPUNAN, J.:
The Hippocratic Oath mandates physicians to give primordial consideration
to the health and welfare of their patients. If a doctor fails to live up to this
precept, he is made accountable for his acts. A mistake, through gross
negligence or incompetence or plain human error, may spell the difference
between life and death. In this sense, the doctor plays God on his patient's
fate. 1
In the case at bar, the Court is called upon to rule whether a surgeon, an
anesthesiologist and a hospital should be made liable for the unfortunate
comatose condition of a patient scheduled for cholecystectomy. 2
Petitioners seek the reversal of the decision 3 of the Court of Appeals, dated
29 May 1995, which overturned the decision 4 of the Regional Trial Court,
dated 30 January 1992, finding private respondents liable for damages
arising from negligence in the performance of their professional duties
towards petitioner Erlinda Ramos resulting in her comatose condition.
The antecedent facts as summarized by the trial court are reproduced
hereunder:
Plaintiff Erlinda Ramos was, until the afternoon of June 17,
1985, a 47-year old (Exh. "A") robust woman (TSN, October
19, 1989, p. 10). Except for occasional complaints of
discomfort due to pains allegedly caused by the presence of a
stone in her gall bladder (TSN, January 13, 1988, pp. 4-5),
she was as normal as any other woman. Married to Rogelio
E. Ramos, an executive of Philippine Long Distance
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Telephone Company, she has three children whose names
are Rommel Ramos, Roy Roderick Ramos and Ron Raymond
Ramos (TSN, October 19, 1989, pp. 5-6).
Because the discomforts somehow interfered with her
normal ways, she sought professional advice. She was
advised to undergo an operation for the removal of a stone in
her gall bladder (TSN, January 13, 1988, p. 5). She
underwent a series of examinations which included blood
and urine tests (Exhs. "A" and "C") which indicated she was
fit for surgery.
Through the intercession of a mutual friend, Dr. Buenviaje
(TSN, January 13, 1988, p. 7), she and her husband Rogelio
met for the first time Dr. Orlino Hozaka (should be
Hosaka; see TSN, February 20, 1990, p. 3), one of the
defendants in this case, on June 10, 1985. They agreed that
their date at the operating table at the DLSMC (another
defendant), would be on June 17, 1985 at 9:00 A.M.. Dr.
Hosaka decided that she should undergo a
"cholecystectomy" operation after examining the documents
(findings from the Capitol Medical Center, FEU Hospital and
DLSMC) presented to him. Rogelio E. Ramos, however, asked
Dr. Hosaka to look for a good anesthesiologist. Dr. Hosaka,
in turn, assured Rogelio that he will get a good
anesthesiologist. Dr. Hosaka charged a fee of P16,000.00,
which was to include the anesthesiologist's fee and which
was to be paid after the operation (TSN, October 19, 1989,
pp. 14-15, 22-23, 31-33; TSN, February 27, 1990, p. 13; and
TSN, November 9, 1989, pp. 3-4, 10, 17).
A day before the scheduled date of operation, she was
admitted at one of the rooms of the DLSMC, located along E.
Rodriguez Avenue, Quezon City (TSN, October 19,1989, p.
11).
At around 7:30 A.M. of June 17, 1985 and while still in her
room, she was prepared for the operation by the hospital
staff. Her sister-in-law, Herminda Cruz, who was the Dean of
the College of Nursing at the Capitol Medical Center, was
also there for moral support. She reiterated her previous
Page 31

request for Herminda to be with her even during the
operation. After praying, she was given injections. Her hands
were held by Herminda as they went down from her room to
the operating room (TSN, January 13, 1988, pp. 9-11). Her
husband, Rogelio, was also with her (TSN, October 19, 1989,
p. 18). At the operating room, Herminda saw about two or
three nurses and Dr. Perfecta Gutierrez, the other defendant,
who was to administer anesthesia. Although not a member
of the hospital staff, Herminda introduced herself as Dean of
the College of Nursing at the Capitol Medical Center who was
to provide moral support to the patient, to them. Herminda
was allowed to stay inside the operating room.
At around 9:30 A.M., Dr. Gutierrez reached a nearby phone
to look for Dr. Hosaka who was not yet in (TSN, January 13,
1988, pp. 11-12). Dr. Gutierrez thereafter informed
Herminda Cruz about the prospect of a delay in the arrival of
Dr. Hosaka. Herminda then went back to the patient who
asked, "Mindy, wala pa ba ang Doctor"? The former replied,
"Huwag kang mag-alaala, darating na iyon" (Ibid.).
Thereafter, Herminda went out of the operating room and
informed the patient's husband, Rogelio, that the doctor was
not yet around (id., p. 13). When she returned to the
operating room, the patient told her, "Mindy, inip na inip na
ako, ikuha mo ako ng ibang Doctor." So, she went out again
and told Rogelio about what the patient said (id., p. 15).
Thereafter, she returned to the operating room.
At around 10:00 A.M., Rogelio E. Ramos was "already dying
[and] waiting for the arrival of the doctor" even as he did his
best to find somebody who will allow him to pull out his wife
from the operating room (TSN, October 19, 1989, pp. 19-20).
He also thought of the feeling of his wife, who was inside the
operating room waiting for the doctor to arrive (ibid.). At
almost 12:00 noon, he met Dr. Garcia who remarked that he
(Dr. Garcia) was also tired of waiting for Dr. Hosaka to arrive
(id., p. 21). While talking to Dr. Garcia at around 12:10 P.M.,
he came to know that Dr. Hosaka arrived as a nurse
remarked, "Nandiyan na si Dr. Hosaka, dumating na raw."
Upon hearing those words, he went down to the lobby and
waited for the operation to be completed (id., pp. 16, 29-30).
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At about 12:15 P.M., Herminda Cruz, who was inside the
operating room with the patient, heard somebody say that
"Dr. Hosaka is already here." She then saw people inside the
operating room "moving, doing this and that, [and] preparing
the patient for the operation" (TSN, January 13, 1988, p. 16).
As she held the hand of Erlinda Ramos, she then saw Dr.
Gutierrez intubating the hapless patient. She thereafter
heard Dr. Gutierrez say, "ang hirap ma-intubate nito, mali
yata ang pagkakapasok. O lumalaki ang tiyan" (id., p. 17).
Because of the remarks of Dra. Gutierrez, she focused her
attention on what Dr. Gutierrez was doing. She thereafter
noticed bluish discoloration of the nailbeds of the left hand
of the hapless Erlinda even as Dr. Hosaka approached her.
She then heard Dr. Hosaka issue an order for someone to
call Dr. Calderon, another anesthesiologist (id., p. 19). After
Dr. Calderon arrived at the operating room, she saw this
anesthesiologist trying to intubate the patient. The patient's
nailbed became bluish and the patient was placed in a
trendelenburg position — a position where the head of the
patient is placed in a position lower than her feet which is an
indication that there is a decrease of blood supply to the
patient's brain (Id., pp. 19-20). Immediately thereafter, she
went out of the operating room, and she told Rogelio E.
Ramos "that something wrong was . . . happening" (Ibid.). Dr.
Calderon was then able to intubate the patient (TSN, July
25, 1991, p. 9).
Meanwhile, Rogelio, who was outside the operating room,
saw a respiratory machine being rushed towards the door of
the operating room. He also saw several doctors rushing
towards the operating room. When informed by Herminda
Cruz that something wrong was happening, he told her
(Herminda) to be back with the patient inside the operating
room (TSN, October 19, 1989, pp. 25-28).
Herminda Cruz immediately rushed back, and saw that the
patient was still in trendelenburg position (TSN, January 13,
1988, p. 20). At almost 3:00 P.M. of that fateful day, she saw
the patient taken to the Intensive Care Unit (ICU).
About two days thereafter, Rogelio E. Ramos was able to talk
to Dr. Hosaka. The latter informed the former that something
went wrong during the intubation. Reacting to what was told
Page 32

to him, Rogelio reminded the doctor that the condition of his
wife would not have happened, had he (Dr. Hosaka) looked
for a good anesthesiologist (TSN, October 19, 1989, p. 31).
Doctors Gutierrez and Hosaka were also asked by the
hospital to explain what happened to the patient. The
doctors explained that the patient had bronchospasm (TSN,
November 15, 1990, pp. 26-27).
Erlinda Ramos stayed at the ICU for a month. About four
months thereafter or on November 15, 1985, the patient was
released from the hospital.
During the whole period of her confinement, she incurred
hospital bills amounting to P93,542.25 which is the subject
of a promissory note and affidavit of undertaking executed
by Rogelio E. Ramos in favor of DLSMC. Since that fateful
afternoon of June 17, 1985, she has been in a comatose
condition. She cannot do anything. She cannot move any
part of her body. She cannot see or hear. She is living on
mechanical means. She suffered brain damage as a result of
the absence of oxygen in her brain for four to five minutes
(TSN, November 9, 1989, pp. 21-22). After being discharged
from the hospital, she has been staying in their residence,
still needing constant medical attention, with her husband
Rogelio incurring a monthly expense ranging from P8,000.00
to P10,000.00 (TSN, October 19, 1989, pp. 32-34). She was
also diagnosed to be suffering from "diffuse cerebral
parenchymal damage" (Exh. "G"; see also TSN, December 21,
1989,
p. 6). 5
Thus, on 8 January 1986, petitioners filed a civil case 6 for damages with the
Regional Trial Court of Quezon City against herein private respondents
alleging negligence in the management and care of Erlinda Ramos.
During the trial, both parties presented evidence as to the possible cause of
Erlinda's injury. Plaintiff presented the testimonies of Dean Herminda Cruz
and Dr. Mariano Gavino to prove that the sustained by Erlinda was due to
lack of oxygen in her brain caused by the faulty management of her airway
by private respondents during the anesthesia phase. On the other hand,
private respondents primarily relied on the expert testimony of Dr. Eduardo
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Jamora, a pulmonologist, to the effect that the cause of brain damage was
Erlinda's allergic reaction to the anesthetic agent, Thiopental Sodium
(Pentothal).
After considering the evidence from both sides, the Regional Trial Court
rendered judgment in favor of petitioners, to wit:
After evaluating the evidence as shown in the finding of facts
set forth earlier, and applying the aforecited provisions of law
and jurisprudence to the case at bar, this Court finds and so
holds that defendants are liable to plaintiffs for damages.
The defendants were guilty of, at the very least, negligence in
the performance of their duty to plaintiff-patient Erlinda
Ramos.
On the part of Dr. Perfecta Gutierrez, this Court finds that
she omitted to exercise reasonable care in not only
intubating the patient, but also in not repeating the
administration of atropine (TSN, August 20, 1991, pp. 5-10),
without due regard to the fact that the patient was inside the
operating room for almost three (3) hours. For after she
committed a mistake in intubating [the] patient, the patient's
nailbed became bluish and the patient, thereafter, was
placed in trendelenburg position, because of the decrease of
blood supply to the patient's brain. The evidence further
shows that the hapless patient suffered brain damage
because of the absence of oxygen in her (patient's) brain for
approximately four to five minutes which, in turn, caused
the patient to become comatose.
On the part of Dr. Orlino Hosaka, this Court finds that he is
liable for the acts of Dr. Perfecta Gutierrez whom he had
chosen to administer anesthesia on the patient as part of his
obligation to provide the patient a good anesthesiologist', and
for arriving for the scheduled operation almost three (3)
hours late.
On the part of DLSMC (the hospital), this Court finds that it
is liable for the acts of negligence of the doctors in their
"practice of medicine" in the operating room. Moreover, the
hospital is liable for failing through its responsible officials,
Page 33

to cancel the scheduled operation after Dr. Hosaka
inexcusably failed to arrive on time.
In having held thus, this Court rejects the defense raised by
defendants that they have acted with due care and prudence
in rendering medical services to plaintiff-patient. For if the
patient was properly intubated as claimed by them, the
patient would not have become comatose. And, the fact that
another anesthesiologist was called to try to intubate the
patient after her (the patient's) nailbed turned bluish, belie
their claim. Furthermore, the defendants should have
rescheduled the operation to a later date. This, they should
have done, if defendants acted with due care and prudence
as the patient's case was an elective, not an emergency case.
xxx xxx xxx
WHEREFORE, and in view of the foregoing, judgment is
rendered in favor of the plaintiffs and against the
defendants. Accordingly, the latter are ordered to pay, jointly
and severally, the former the following sums of money, to
wit:
1) the sum of P8,000.00 as actual monthly
expenses for the plaintiff Erlinda Ramos
reckoned from November 15, 1985 or in the
total sum of P632,000.00 as of April 15,
1992, subject to its being updated;
2) the sum of P100,000.00 as reasonable
attorney's fees;
3) the sum of P800,000.00 by way of moral
damages and the further sum of
P200,000,00 by way of exemplary damages;
and,
4) the costs of the suit.
SO ORDERED. 7 plaintiffs/appellees received a copy of the decision as early
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Private respondents seasonably interposed an appeal to the Court of Appeals.
The appellate court rendered a Decision, dated 29 May 1995, reversing the
findings of the trial court. The decretal portion of the decision of the appellate
court reads:
WHEREFORE, for the foregoing premises the appealed
decision is hereby REVERSED, and the complaint below
against the appellants is hereby ordered DISMISSED. The
counterclaim of appellant De Los Santos Medical Center is
GRANTED but only insofar as appellees are hereby ordered
to pay the unpaid hospital bills amounting to P93,542.25,
plus legal interest for justice must be tempered with mercy.
SO ORDERED. 8
The decision of the Court of Appeals was received on 9 June 1995 by
petitioner Rogelio Ramos who was mistakenly addressed as "Atty. Rogelio
Ramos." No copy of the decision, however, was sent nor received by the
Coronel Law Office, then counsel on record of petitioners. Rogelio referred the
decision of the appellate court to a new lawyer, Atty. Ligsay, only on 20 June
1995, or four (4) days before the expiration of the reglementary period for
filing a motion for reconsideration. On the same day, Atty. Ligsay, filed with
the appellate court a motion for extension of time to file a motion for
reconsideration. The motion for reconsideration was submitted on 4 July
1995. However, the appellate court denied the motion for extension of time in
its Resolution dated 25 July 1995. 9 Meanwhile, petitioners engaged the
services of another counsel, Atty. Sillano, to replace Atty. Ligsay. Atty. Sillano
filed on 7 August 1995 a motion to admit the motion for reconsideration
contending that the period to file the appropriate pleading on the assailed
decision had not yet commenced to run as the Division Clerk of Court of the
Court of Appeals had not yet served a copy thereof to the counsel on record.
Despite this explanation, the appellate court still denied the motion to admit
the motion for reconsideration of petitioners in its Resolution, dated 29
March 1996, primarily on the ground that the fifteen-day (15) period for filing
a motion for reconsideration had already expired, to wit:
We said in our Resolution on July 25, 1995, that the filing of
a Motion for Reconsideration cannot be extended; precisely,
the Motion for Extension (Rollo, p. 12) was denied. It is, on
the other hand, admitted in the latter Motion that
as June 9, 1995. Computation wise, the period to file a
Motion for Reconsideration expired on June 24. The Motion
Page 34
 DUMAUAL, JEANNE PAULINE J. 2019-2020

for Reconsideration, in turn, was received by the Court of Before we discuss the merits of the case, we shall first dispose of the
Appeals already on July 4, necessarily, the 15-day period procedural issue on the timeliness of the petition in relation to the motion for
already passed. For that alone, the latter should be denied. reconsideration filed by petitioners with the Court of Appeals. In their
Comment, 12 private respondents contend that the petition should not be
Even assuming admissibility of the Motion for the given due course since the motion for reconsideration of the petitioners on
Reconsideration, but after considering the the decision of the Court of Appeals was validly dismissed by the appellate
Comment/Opposition, the former, for lack of merit, is hereby court for having been filed beyond the reglementary period. We do not agree.
DENIED.
A careful review of the records reveals that the reason behind the delay in
SO ORDERED. 10 filing the motion for reconsideration is attributable to the fact that the
decision of the Court of Appeals was not sent to then counsel on record of
petitioners, the Coronel Law Office. In fact, a copy of the decision of the
A copy of the above resolution was received by Atty. Sillano on 11 April 1996. appellate court was instead sent to and received by petitioner Rogelio Ramos
The next day, or on 12 April 1996, Atty. Sillano filed before this Court a on 9 June 1995 wherein he was mistakenly addressed as Atty. Rogelio
motion for extension of time to file the present petition for certiorari under Ramos. Based on the other communications received by petitioner Rogelio
Rule 45. The Court granted the motion for extension of time and gave Ramos, the appellate court apparently mistook him for the counsel on
petitioners additional thirty (30) days after the expiration of the fifteen-day record. Thus, no copy of the decision of the counsel on record. Petitioner, not
(15) period counted from the receipt of the resolution of the Court of Appeals being a lawyer and unaware of the prescriptive period for filing a motion for
within which to submit the petition. The due date fell on 27 May 1996. The reconsideration, referred the same to a legal counsel only on 20 June 1995.
petition was filed on 9 May 1996, well within the extended period given by
the Court.
It is elementary that when a party is represented by counsel, all notices
should be sent to the party's lawyer at his given address. With a few
Petitioners assail the decision of the Court of Appeals on the following exceptions, notice to a litigant without notice to his counsel on record is no
grounds: notice at all. In the present case, since a copy of the decision of the appellate
court was not sent to the counsel on record of petitioner, there can be no
I sufficient notice to speak of. Hence, the delay in the filing of the motion for
reconsideration cannot be taken against petitioner. Moreover, since the Court
IN PUTTING MUCH RELIANCE ON THE TESTIMONIES OF of Appeals already issued a second Resolution, dated 29 March 1996, which
RESPONDENTS DRA. GUTIERREZ, DRA. CALDERON AND superseded the earlier resolution issued on 25 July 1995, and denied the
DR. JAMORA; motion for reconsideration of petitioner, we believed that the receipt of the
former should be considered in determining the timeliness of the filing of the
present petition. Based on this, the petition before us was submitted on time.
II
After resolving the foregoing procedural issue, we shall now look into the
IN FINDING THAT THE NEGLIGENCE OF THE merits of the case. For a more logical presentation of the discussion we shall
RESPONDENTS DID NOT CAUSE THE UNFORTUNATE first consider the issue on the applicability of the doctrine of res ipsa
COMATOSE CONDITION OF PETITIONER ERLINDA RAMOS; loquitur to the instant case. Thereafter, the first two assigned errors shall be
tackled in relation to the res ipsa loquitur doctrine.
III
Res ipsa loquitur is a Latin phrase which literally means "the thing or the
IN NOT APPLYING THE DOCTRINE OF RES IPSA transaction speaks for itself." The phrase "res ipsa loquitur'' is a maxim for
LOQUITUR. 11 the rule that the fact of the occurrence of an injury, taken with the
surrounding circumstances, may permit an inference or raise a presumption

Atty. Yulo, Legal Medicine and Medical Jurisprudence Page 35


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 Where the thing
which caused the injury complained of is shown to be under the
management of the defendant or his servants and the accident is such as in
ordinary course of things does not happen if those who have its management
or control use proper care, it affords reasonable evidence, in the absence of
explanation by the defendant, that the accident arose from or was caused by
the defendant's want of care. 14
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 defendant who is charged with negligence. 15 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. 16 Hence, res ipsa loquitur is
applied in conjunction with the doctrine of common knowledge.
However, much has been said that res ipsa loquitur is not a rule of
substantive law and, as such, does not create or constitute an independent
or separate ground of liability. 17 Instead, it is considered as merely
evidentiary or in the nature of a procedural rule. 18 It is regarded as a mode
of proof, or a mere procedural of convenience since it furnishes a substitute
for, and relieves a plaintiff of, the burden of producing specific proof of
negligence. 19 In other words, mere invocation and application of the doctrine
does not dispense with the requirement of proof of negligence. It is simply a
step in the process of such proof, permitting the plaintiff to present along
with the proof of the accident, enough of the attending circumstances to
invoke the doctrine, creating an inference or presumption of negligence, and
to thereby place on the defendant the burden of going forward with the
proof. 20 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 someone's
negligence;
2. It is caused by an instrumentality within
the exclusive control of the defendant or
defendants; and
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3. The possibility of contributing conduct
which would make the plaintiff responsible
is eliminated. 21
In the above requisites, the fundamental element is the "control of
instrumentality" which caused the damage. 22 Such element of control must
be shown to be within the dominion of the defendant. 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. 23
Medical malpractice 24 cases do not escape the application of this doctrine.
Thus, res ipsa loquitur has been applied when the circumstances attendant
upon the harm are themselves of such a character as to justify an inference
of negligence as the cause of that harm. 25 The application of res ipsa
loquitur in medical negligence cases presents a question of law since it is a
judicial function to determine whether a certain set of circumstances does,
as a matter of law, permit a given inference. 26
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. 27 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. 28 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 and surgeons, external appearances, and
manifest conditions which are observable by any one may be given by non-
expert witnesses. 29 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. 30 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. 31 When the doctrine is appropriate, all that the patient must do is
Page 36

prove a nexus between the particular act or omission complained of and the
injury sustained while under the custody and management of the defendant
without need to produce expert medical testimony to establish the standard
of care. Resort to res ipsa loquitur is allowed because there is no other way,
under usual and ordinary conditions, by which the patient can obtain
redress for injury suffered by him.
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, 32 injuries sustained on a healthy part of the body which was not
under, or in the area, of treatment, 33 removal of the wrong part of the body
when another part was intended, 34 knocking out a tooth while a patient's jaw
was under anesthetic for the removal of his tonsils, 35 and loss of an eye
while the patient plaintiff was under the influence of anesthetic, during or
following an operation for appendicitis, 36 among others.
Nevertheless, despite the fact that the scope of res ipsa loquitur has been
measurably enlarged, it does not automatically apply to all cases of medical
negligence as to mechanically shift the burden of proof to the defendant to
show that he is not guilty of the ascribed negligence. 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. 37 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. It must be conceded that the
doctrine of res ipsa loquitur can have no application in a suit against a
physician or surgeon which involves the merits of a diagnosis or of a
scientific treatment. 38 The physician or surgeon is not required at his peril to
explain why any particular diagnosis was not correct, or why any particular
scientific treatment did not produce the desired result. 39 Thus, res ipsa
loquitur is not available in a malpractice suit if the only showing is that the
desired result of an operation or treatment was not accomplished. 40 The real
question, therefore, is whether or not in the process of the operation any
extraordinary incident or unusual event outside of the routine performance
occurred which is beyond the regular scope of customary professional
activity in such operations, which, if unexplained would themselves
reasonably speak to the average man as the negligent cause or causes of the
untoward consequence. 41 If there was such extraneous interventions, the
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doctrine of res ipsa loquitur may be utilized and the defendant is called upon
to explain the matter, by evidence of exculpation, if he could. 42
We find the doctrine of res ipsa loquitur appropriate in the case at bar. As will
hereinafter be explained, the damage sustained by Erlinda in her brain prior
to a scheduled gall bladder operation presents a case for the application
of res ipsa loquitur.
A case strikingly similar to the one before us is Voss vs. Bridwell, 43
where
the Kansas Supreme Court in applying the res ipsa loquitur stated:
The plaintiff herein submitted himself for a mastoid
operation and delivered his person over to the care, custody
and control of his physician who had complete and exclusive
control over him, but the operation was never performed. At
the time of submission he was neurologically sound and
physically fit in mind and body, but he suffered irreparable
damage and injury rendering him decerebrate and totally
incapacitated. The injury was one which does not ordinarily
occur in the process of a mastoid operation or in the absence
of negligence in the administration of an anesthetic, and in
the use and employment of an endoctracheal tube.
Ordinarily a person being put under anesthesia is not
rendered decerebrate as a consequence of administering
such anesthesia in the absence of negligence. Upon these
facts and under these circumstances a layman would be able
to say, as a matter of common knowledge and observation,
that the consequences of professional treatment were not as
such as would ordinarily have followed if due care had been
exercised.
Here the plaintiff could not have been guilty of contributory
negligence because he was under the influence of
anesthetics and unconscious, and the circumstances are
such that the true explanation of event is more accessible to
the defendants than to the plaintiff for they had the exclusive
control of the instrumentalities of anesthesia.
Upon all the facts, conditions and circumstances alleged in
Count II it is held that a cause of action is stated under the
doctrine of res ipsa loquitur. 44
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Indeed, the principles enunciated in the aforequoted case apply with equal
force here. In the present case, Erlinda submitted herself for cholecystectomy
and expected a routine general surgery to be performed on her gall bladder.
On that fateful day she delivered her person over to the care, custody and
control of private respondents who exercised complete and exclusive control
over her. At the time of submission, Erlinda was neurologically sound and,
except for a few minor discomforts, was likewise physically fit in mind and
body. However, during the administration of anesthesia and prior to the
performance of cholecystectomy she suffered irreparable damage to her
brain. Thus, without undergoing surgery, she went out of the operating room
already decerebrate and totally incapacitated. Obviously, brain damage,
which Erlinda sustained, is an injury which does not normally occur in the
process of a gall bladder operation. In fact, this kind of situation does not in
the absence of negligence of someone in the administration of anesthesia and
in the use of endotracheal tube. Normally, a person being put under
anesthesia is not rendered decerebrate as a consequence of administering
such anesthesia if the proper procedure was followed. Furthermore, the
instruments used in the administration of anesthesia, including the
endotracheal tube, were all under the exclusive control of private
respondents, who are the physicians-in-charge. Likewise, petitioner Erlinda
could not have been guilty of contributory negligence because she was under
the influence of anesthetics which rendered her unconscious.
Considering that a sound and unaffected member of the body (the brain) is
injured or destroyed while the patient is unconscious and under the
immediate and exclusive control of the physicians, we hold that a practical
administration of justice dictates the application of res ipsa loquitur. Upon
these facts and under these circumstances the Court would be able to say,
as a matter of common knowledge and observation, if negligence attended the
management and care of the patient. Moreover, the liability of the physicians
and the hospital in this case is not predicated upon an alleged failure to
secure the desired results of an operation nor on an alleged lack of skill in
the diagnosis or treatment as in fact no operation or treatment was ever
performed on Erlinda. Thus, upon all these initial determination a case is
made out for the application of the doctrine of res ipsa loquitur.
Nonetheless, in holding that res ipsa loquitur is available to the present case
we are not saying that the doctrine is applicable in any and all cases where
injury occurs to a patient while under anesthesia, or to any and all
anesthesia cases. Each case must be viewed in its own light and scrutinized
in order to be within the res ipsa loquitur coverage.
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Having in mind the applicability of the res ipsa loquitur doctrine and the
presumption of negligence allowed therein, the Court now comes to the issue
of whether the Court of Appeals erred in finding that private respondents
were not negligent in the care of Erlinda during the anesthesia phase of the
operation and, if in the affirmative, whether the alleged negligence was the
proximate cause of Erlinda's comatose condition. Corollary thereto, we shall
also determine if the Court of Appeals erred in relying on the testimonies of
the witnesses for the private respondents.
In sustaining the position of private respondents, the Court of Appeals relied
on the testimonies of Dra. Gutierrez, Dra. Calderon and Dr. Jamora. In giving
weight to the testimony of Dra. Gutierrez, the Court of Appeals rationalized
that she was candid enough to admit that she experienced some difficulty in
the endotracheal intubation 45 of the patient and thus, cannot be said to be
covering her negligence with falsehood. The appellate court likewise opined
that private respondents were able to show that the brain damage sustained
by Erlinda was not caused by the alleged faulty intubation but was due to
the allergic reaction of the patient to the drug Thiopental Sodium (Pentothal),
a short-acting barbiturate, as testified on by their expert witness, Dr.
Jamora. On the other hand, the appellate court rejected the testimony of
Dean Herminda Cruz offered in favor of petitioners that the cause of the
brain injury was traceable to the wrongful insertion of the tube since the
latter, being a nurse, was allegedly not knowledgeable in the process of
intubation. In so holding, the appellate court returned a verdict in favor of
respondents physicians and hospital and absolved them of any liability
towards Erlinda and her family.
We disagree with the findings of the Court of Appeals. We hold that private
respondents were unable to disprove the presumption of negligence on their
part in the care of Erlinda and their negligence was the proximate cause of
her piteous condition.
In the instant case, the records are helpful in furnishing not only the logical
scientific evidence of the pathogenesis of the injury but also in providing the
Court the legal nexus upon which liability is based. As will be shown
hereinafter, private respondents' own testimonies which are reflected in the
transcript of stenographic notes are replete of signposts indicative of their
negligence in the care and management of Erlinda.
With regard to Dra. Gutierrez, we find her negligent in the care of Erlinda
during the anesthesia phase. As borne by the records, respondent Dra.
Gutierrez failed to properly intubate the patient. This fact was attested to by
Prof. Herminda Cruz, Dean of the Capitol Medical Center School of Nursing
Page 38
 DUMAUAL, JEANNE PAULINE J. 2019-2020

and petitioner's sister-in-law, who was in the operating room right beside the
patient when the tragic event occurred. Witness Cruz testified to this effect:
ATTY. PAJARES:
Q: In particular, what did Dra. Perfecta
Gutierrez do, if any on the patient?
A: In particular, I could see that she was
intubating the patient.
Q: Do you know what happened to that
intubation process administered by Dra.
Gutierrez?
xxx xxx xxx
Q: After hearing the phrase "lumalaki ang
tiyan," what did you notice on the person of
the patient?
A: I notice (sic) some bluish discoloration on
the nailbeds of the left hand where I was at.
Q: Where was Dr. Orlino Ho[s]aka then at
that particular time?
A: I saw him approaching the patient during
that time.

ATTY. ALCERA: Q: When he approached the patient, what

did he do, if any?
She will be incompetent Your Honor.
A: He made an order to call on the
COURT: anesthesiologist in the person of Dr.
Calderon.
Witness may answer if she knows.
Q: Did Dr. Calderon, upon being called,
arrive inside the operating room?
A: As have said, I was with the patient, I was
beside the stretcher holding the left hand of
the patient and all of a sudden heard some A: Yes sir.
remarks coming from Dra. Perfecta
Gutierrez herself. She was saying "Ang hirap Q: What did [s]he do, if any?
ma-intubate nito, mali yata ang
pagkakapasok. O lumalaki ang tiyan. A: [S]he tried to intubate the patient.

xxx xxx xxx Q: What happened to the patient?

ATTY. PAJARES: A: When Dr. Calderon try (sic) to intubate

the patient, after a while the patient's
Q: From whom did you hear those words nailbed became bluish and I saw the patient
"lumalaki ang tiyan"? was placed in trendelenburg position.

A: From Dra. Perfecta Gutierrez. xxx xxx xxx

Atty. Yulo, Legal Medicine and Medical Jurisprudence Page 39


Q: Do you know the reason why the patient
was placed in that trendelenburg position?
A: As far as I know, when a patient is in that
position, there is a decrease of blood supply
to the brain. 46
xxx xxx xxx
The appellate court, however, disbelieved Dean Cruz's testimony in the trial
court by declaring that:
A perusal of the standard nursing curriculum in our country
will show that intubation is not taught as part of nursing
procedures and techniques. Indeed, we take judicial notice of
the fact that nurses do not, and cannot, intubate. Even on
the assumption that she is fully capable of determining
whether or not a patient is properly intubated, witness
Herminda Cruz, admittedly, did not peep into the throat of
the patient. (TSN, July 25, 1991, p. 13). More importantly,
there is no evidence that she ever auscultated the patient or
that she conducted any type of examination to check if the
endotracheal tube was in its proper place, and to determine
the condition of the heart, lungs, and other organs. Thus,
witness Cruz's categorical statements that appellant Dra.
Gutierrez failed to intubate the appellee Erlinda Ramos and
that it was Dra. Calderon who succeeded in doing so clearly
suffer from lack of sufficient factual bases. 47
In other words, what the Court of Appeals is trying to impress is that being a
nurse, and considered a layman in the process of intubation, witness Cruz is
not competent to testify on whether or not the intubation was a success.
We do not agree with the above reasoning of the appellate court. Although
witness Cruz is not an anesthesiologist, she can very well testify upon
matters on which she is capable of observing such as, the statements and
acts of the physician and surgeon, external appearances, and manifest
conditions which are observable by any one. 48 This is precisely allowed
under the doctrine of res ipsa loquitur where the testimony of expert
witnesses is not required. It is the accepted rule that expert testimony is not
necessary for the proof of negligence in non-technical matters or those of
which an ordinary person may be expected to have knowledge, or where the
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lack of skill or want of care is so obvious as to render expert testimony
unnecessary. 49 We take judicial notice of the fact that anesthesia procedures
have become so common, that even an ordinary person can tell if it was
administered properly. As such, it would not be too difficult to tell if the tube
was properly inserted. This kind of observation, we believe, does not require a
medical degree to be acceptable.
At any rate, without doubt, petitioner's witness, an experienced clinical nurse
whose long experience and scholarship led to her appointment as Dean of the
Capitol Medical Center School at Nursing, was fully capable of determining
whether or not the intubation was a success. She had extensive clinical
experience starting as a staff nurse in Chicago, Illinois; staff nurse and
clinical instructor in a teaching hospital, the FEU-NRMF; Dean of the Laguna
College of Nursing in San Pablo City; and then Dean of the Capitol Medical
Center School of Nursing. 50 Reviewing witness Cruz' statements, we find that
the same were delivered in a straightforward manner, with the kind of detail,
clarity, consistency and spontaneity which would have been difficult to
fabricate. With her clinical background as a nurse, the Court is satisfied that
she was able to demonstrate through her testimony what truly transpired on
that fateful day.
Most of all, her testimony was affirmed by no less than respondent Dra.
Gutierrez who admitted that she experienced difficulty in inserting the tube
into Erlinda's trachea, to wit:
ATTY. LIGSAY:
Q: In this particular case, Doctora, while
you were intubating at your first attempt
(sic), you did not immediately see the
trachea?
DRA. GUTIERREZ:
A: Yes sir.
Q: Did you pull away the tube immediately?
A: You do not pull the . . .
Q: Did you or did you not?
Page 40

A: I did not pull the tube.
Q: When you said "mahirap yata ito," what
were you referring to?
A: "Mahirap yata itong i-intubate," that was
the patient.
Q: So, you found some difficulty in inserting
the tube?
A: Yes, because of (sic) my first attempt, I
did not see right away. 51
Curiously in the case at bar, respondent Dra. Gutierrez made the haphazard
defense that she encountered hardship in the insertion of the tube in the
trachea of Erlinda because it was positioned more anteriorly (slightly
deviated from the normal anatomy of a person) 52 making it harder to locate
and, since Erlinda is obese and has a short neck and protruding teeth, it
made intubation even more difficult.
The argument does not convince us. If this was indeed observed, private
respondents adduced no evidence demonstrating that they proceeded to
make a thorough assessment of Erlinda's airway, prior to the induction of
anesthesia, even if this would mean postponing the procedure. From their
testimonies, it appears that the observation was made only as an
afterthought, as a means of defense.
The pre-operative evaluation of a patient prior to the administration of
anesthesia is universally observed to lessen the possibility of anesthetic
accidents. Pre-operative evaluation and preparation for anesthesia begins
when the anesthesiologist reviews the patient's medical records and visits
with the patient, traditionally, the day before elective surgery. 53 It includes
taking the patient's medical history, review of current drug therapy, physical
examination and interpretation of laboratory data. 54 The physical
examination performed by the anesthesiologist is directed primarily toward
the central nervous system, cardiovascular system, lungs and upper
airway. 55 A thorough analysis of the patient's airway normally involves
investigating the following: cervical spine mobility, temporomandibular
mobility, prominent central incisors, diseased or artificial teeth, ability to
visualize uvula and the thyromental distance. 56 Thus, physical
characteristics of the patient's upper airway that could make tracheal
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intubation difficult should be studied. 57 Where the need arises, as when
initial assessment indicates possible problems (such as the alleged short
neck and protruding teeth of Erlinda) a thorough examination of the patient's
airway would go a long way towards decreasing patient morbidity and
mortality.
In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda
for the first time on the day of the operation itself, on 17 June 1985. Before
this date, no prior consultations with, or pre-operative evaluation of Erlinda
was done by her. Until the day of the operation, respondent Dra. Gutierrez
was unaware of the physiological make-up and needs of Erlinda. She was
likewise not properly informed of the possible difficulties she would face
during the administration of anesthesia to Erlinda. Respondent Dra.
Gutierrez' act of seeing her patient for the first time only an hour before the
scheduled operative procedure was, therefore, an act of exceptional
negligence and professional irresponsibility. The measures cautioning
prudence and vigilance in dealing with human lives lie at the core of the
physician's centuries-old Hippocratic Oath. Her failure to follow this medical
procedure is, therefore, a clear indicia of her negligence.
Respondent Dra. Gutierrez, however, attempts to gloss over this omission by
playing around with the trial court's ignorance of clinical procedure, hoping
that she could get away with it. Respondent Dra. Gutierrez tried to muddle
the difference between an elective surgery and an emergency surgery just so
her failure to perform the required pre-operative evaluation would escape
unnoticed. In her testimony she asserted:
ATTY. LIGSAY:
Q: Would you agree, Doctor, that it is good
medical practice to see the patient a day
before so you can introduce yourself to
establish good doctor-patient relationship
and gain the trust and confidence of the
patient?
DRA. GUTIERREZ:
A: As I said in my previous statement, it
depends on the operative procedure of the
anesthesiologist and in my case, with
elective cases and normal cardio-pulmonary
Page 41

clearance like that, I usually don't do it
except on emergency and on cases that have
an abnormalities (sic). 58
However, the exact opposite is true. In an emergency procedure, there is
hardly enough time available for the fastidious demands of pre-operative
procedure so that an anesthesiologist is able to see the patient only a few
minutes before surgery, if at all. Elective procedures, on the other hand, are
operative procedures that can wait for days, weeks or even months. Hence, in
these cases, the anesthesiologist possesses the luxury of time to be at the
patient's beside to do a proper interview and clinical evaluation. There is
ample time to explain the method of anesthesia, the drugs to be used, and
their possible hazards for purposes of informed consent. Usually, the pre-
operative assessment is conducted at least one day before the intended
surgery, when the patient is relaxed and cooperative.
Erlinda's case was elective and this was known to respondent Dra. Gutierrez.
Thus, she had all the time to make a thorough evaluation of Erlinda's case
prior to the operation and prepare her for anesthesia. However, she never
saw the patient at the bedside. She herself admitted that she had seen
petitioner only in the operating room, and only on the actual date of the
cholecystectomy. She negligently failed to take advantage of this important
opportunity. As such, her attempt to exculpate herself must fail.
Having established that respondent Dra. Gutierrez failed to perform pre-
operative evaluation of the patient which, in turn, resulted to a wrongful
intubation, we now determine if the faulty intubation is truly the proximate
cause of Erlinda's comatose condition.
Private respondents repeatedly hammered the view that the cerebral anoxia
which led to Erlinda's coma was due to bronchospasm 59 mediated by her
allergic response to the drug, Thiopental Sodium, introduced into her system.
Towards this end, they presented Dr. Jamora, a Fellow of the Philippine
College of Physicians and Diplomate of the Philippine Specialty Board of
Internal Medicine, who advanced private respondents' theory that the oxygen
deprivation which led to anoxic encephalopathy, 60 was due to an
unpredictable drug reaction to the short-acting barbiturate. We find the
theory of private respondents unacceptable.
First of all, Dr. Jamora cannot be considered an authority in the field of
anesthesiology simply because he is not an anesthesiologist. Since Dr.
Jamora is a pulmonologist, he could not have been capable of properly
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enlightening the court about anesthesia practice and procedure and their
complications. Dr. Jamora is likewise not an allergologist and could not
therefore properly advance expert opinion on allergic-mediated processes.
Moreover, he is not a pharmacologist and, as such, could not have been
capable, as an expert would, of explaining to the court the pharmacologic
and toxic effects of the supposed culprit, Thiopental Sodium (Pentothal).
The inappropriateness and absurdity of accepting Dr. Jamora's testimony as
an expert witness in the anesthetic practice of Pentothal administration is
further supported by his own admission that he formulated his opinions on
the drug not from the practical experience gained by a specialist or expert in
the administration and use of Sodium Pentothal on patients, but only from
reading certain references, to wit:
ATTY. LIGSAY:
Q: In your line of expertise on pulmonology,
did you have any occasion to use pentothal
as a method of management?
DR. JAMORA:
A: We do it in conjunction with the
anesthesiologist when they have to intubate
our patient.
Q: But not in particular when you practice
pulmonology?
A: No.
Q: In other words, your knowledge about
pentothal is based only on what you have
read from books and not by your own
personal application of the medicine
pentothal?
A: Based on my personal experience also on
pentothal.
Page 42

Q: How many times have you used
pentothal?
A: They used it on me. I went into
bronchospasm during my appendectomy.
Q: And because they have used it on you
and on account of your own personal
experience you feel that you can testify on
pentothal here with medical authority?
A: No. That is why I used references to
support my claims. 61
An anesthetic accident caused by a rare drug-induced bronchospasm
properly falls within the fields of anesthesia, internal medicine-allergy, and
clinical pharmacology. The resulting anoxic encephalopathy belongs to the
field of neurology. While admittedly, many bronchospastic-mediated
pulmonary diseases are within the expertise of pulmonary medicine, Dr.
Jamora's field, the anesthetic drug-induced, allergic mediated bronchospasm
alleged in this case is within the disciplines of anesthesiology, allergology and
pharmacology. On the basis of the foregoing transcript, in which the
pulmonologist himself admitted that he could not testify about the drug with
medical authority, it is clear that the appellate court erred in giving weight to
Dr. Jamora's testimony as an expert in the administration of Thiopental
Sodium.
The provision in the rules of evidence 62
regarding expert witnesses states:
Sec. 49. Opinion of expert witness. — The opinion of a
witness on a matter requiring special knowledge, skill,
experience or training which he is shown to possess, may be
received in evidence.
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. 63 Clearly, Dr. Jamora does not qualify as an expert witness
based on the above standard since he lacks the necessary knowledge, skill,
and training in the field of anesthesiology. Oddly, apart from submitting
testimony from a specialist in the wrong field, private respondents'
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intentionally avoided providing testimony by competent and independent
experts in the proper areas.
Moreover, private respondents' theory, that Thiopental Sodium may have
produced Erlinda's coma by triggering an allergic mediated response, has no
support in evidence. No evidence of stridor, skin reactions, or wheezing —
some of the more common accompanying signs of an allergic reaction —
appears on record. No laboratory data were ever presented to the court.
In any case, private respondents themselves admit that Thiopental induced,
allergic-mediated bronchospasm happens only very rarely. If courts were to
accept private respondents' hypothesis without supporting medical proof,
and against the weight of available evidence, then every anesthetic accident
would be an act of God. Evidently, the Thiopental-allergy theory vigorously
asserted by private respondents was a mere afterthought. Such an
explanation was advanced in order to advanced in order to absolve them of
any and all responsibility for the patient's condition.
In view of the evidence at hand, we are inclined to believe petitioners' stand
that it was the faulty intubation which was the proximate cause of Erlinda's
comatose condition.
Proximate cause has been defined as that which, in natural and continuous
sequence, unbroken by any efficient intervening cause, produces injury, and
without which the result would not have occurred. 64 An injury or damage is
proximately caused by an act or a failure to act, whenever it appears from the
evidence in the case, that the act or omission played a substantial part in
bringing about or actually causing the injury or damage; and that the injury
or damage was either a direct result or a reasonably probable consequence of
the act or omission. 65 It is the dominant, moving or producing cause.
Applying the above definition in relation to the evidence at hand, faulty
intubation is undeniably the proximate cause which triggered the chain of
events leading to Erlinda's brain damage and, ultimately, her comatosed
condition.
Private respondents themselves admitted in their testimony that the first
intubation was a failure. This fact was likewise observed by witness Cruz
when she heard respondent Dra. Gutierrez remarked, "Ang hirap ma-
intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan."
Thereafter, witness Cruz noticed abdominal distention on the body of
Erlinda. The development of abdominal distention, together with respiratory
Page 43

embarrassment indicates that the endotracheal tube entered the esophagus
instead of the respiratory tree. In other words, instead of the intended
endotracheal intubation what actually took place was an esophageal
intubation. During intubation, such distention indicates that air has entered
the gastrointestinal tract through the esophagus instead of the lungs through
the trachea. Entry into the esophagus would certainly cause some delay in
oxygen delivery into the lungs as the tube which carries oxygen is in the
wrong place. That abdominal distention had been observed during the first
intubation suggests that the length of time utilized in inserting the
endotracheal tube (up to the time the tube was withdrawn for the second
attempt) was fairly significant. Due to the delay in the delivery of oxygen in
her lungs Erlinda showed signs of cyanosis. 66 As stated in the testimony of
Dr. Hosaka, the lack of oxygen became apparent only after he noticed that
the nailbeds of Erlinda were already blue. 67 However, private respondents
contend that a second intubation was executed on Erlinda and this one was
successfully done. We do not think so. No evidence exists on record, beyond
private respondents' bare claims, which supports the contention that the
second intubation was successful. Assuming that the endotracheal tube
finally found its way into the proper orifice of the trachea, the same gave no
guarantee of oxygen delivery, the hallmark of a successful intubation. In fact,
cyanosis was again observed immediately after the second intubation.
Proceeding from this event (cyanosis), it could not be claimed, as private
respondents insist, that the second intubation was accomplished. Even
granting that the tube was successfully inserted during the second attempt,
it was obviously too late. As aptly explained by the trial court, Erlinda
already suffered brain damage as a result of the inadequate oxygenation of
her brain for about four to five minutes. 68
The above conclusion is not without basis. Scientific studies point out that
intubation problems are responsible for one-third (1/3) of deaths and serious
injuries associated with anesthesia. 69 Nevertheless, ninety-eight percent
(98%) or the vast majority of difficult intubations may be anticipated by
performing a thorough evaluation of the patient's airway prior to the
operation. 70 As stated beforehand, respondent Dra. Gutierrez failed to
observe the proper pre-operative protocol which could have prevented this
unfortunate incident. Had appropriate diligence and reasonable care been
used in the pre-operative evaluation, respondent physician could have been
much more prepared to meet the contingency brought about by the perceived
anatomic variations in the patient's neck and oral area, defects which would
have been easily overcome by a prior knowledge of those variations together
with a change in technique. 71 In other words, an experienced
anesthesiologist, adequately alerted by a thorough pre-operative evaluation,
would have had little difficulty going around the short neck and protruding
teeth. 72 Having failed to observe common medical standards in pre-operative
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management and intubation, respondent Dra. Gutierrez' negligence resulted
in cerebral anoxia and eventual coma of Erlinda.
We now determine the responsibility of respondent Dr. Orlino Hosaka as the
head of the surgical team. As the so-called "captain of the ship," 73 it is the
surgeon's responsibility to see to it that those under him perform their task
in the proper manner. Respondent Dr. Hosaka's negligence can be found in
his failure to exercise the proper authority (as the "captain" of the operative
team) in not determining if his anesthesiologist observed proper anesthesia
protocols. In fact, no evidence on record exists to show that respondent Dr.
Hosaka verified if respondent Dra. Gutierrez properly intubated the patient.
Furthermore, it does not escape us that respondent Dr. Hosaka had
scheduled another procedure in a different hospital at the same time as
Erlinda's cholecystectomy, and was in fact over three hours late for the
latter's operation. Because of this, he had little or no time to confer with his
anesthesiologist regarding the anesthesia delivery. This indicates that he was
remiss in his professional duties towards his patient. Thus, he shares equal
responsibility for the events which resulted in Erlinda's condition.
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," 74 who are allegedly not hospital
employees, presents problems in apportioning responsibility for negligence in
medical malpractice cases. However, the difficulty is only 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. 75 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
Page 44

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. 76
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. 77 Such responsibility ceases when the persons or entity concerned
prove that they have observed the diligence of a good father of the family to
prevent damage. 78 In other words, while the burden of proving negligence
rests on the plaintiffs, once negligence is shown, the burden shifts to the
respondents (parent, guardian, teacher or employer) who should prove that
they observed the diligence of a good father of a family to prevent damage.
In the instant case, respondent hospital, apart from a general denial of its
responsibility over respondent physicians, failed to adduce evidence showing
that it exercised the diligence of a good father of a family in the hiring and
supervision of the latter. It failed to adduce evidence with regard to the
degree of supervision which it exercised over its physicians. In neglecting to
offer such proof, or proof of a similar nature, respondent hospital thereby
failed to discharge its burden under the last paragraph of Article 2180.
Having failed to do this, respondent hospital is consequently solidarily
responsible with its physicians for Erlinda's condition.
Based on the foregoing, we hold that the Court of Appeals erred in accepting
and relying on the testimonies of the witnesses for the private respondents.
Indeed, as shown by the above discussions, private respondents were unable
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to rebut the presumption of negligence. Upon these disquisitions we hold
that private respondents are solidarily liable for damages under Article
2176 79 of the Civil Code.
We now come to the amount of damages due petitioners. The trial court
awarded a total of P632,000.00 pesos (should be P616,000.00) in
compensatory damages to the plaintiff, "subject to its being updated"
covering the period from 15 November 1985 up to 15 April 1992, based on
monthly expenses for the care of the patient estimated at P8,000.00.
At current levels, the P8000/monthly amount established by the trial court
at the time of its decision would be grossly inadequate to cover the actual
costs of home-based care for a comatose individual. The calculated amount
was not even arrived at by looking at the actual cost of proper hospice care
for the patient. What it reflected were the actual expenses incurred and
proved by the petitioners after they were forced to bring home the patient to
avoid mounting hospital bills.
And yet ideally, a comatose patient should remain in a hospital or be
transferred to a hospice specializing in the care of the chronically ill for the
purpose of providing a proper milieu adequate to meet minimum standards
of care. In the instant case for instance, Erlinda has to be constantly turned
from side to side to prevent bedsores and hypostatic pneumonia. Feeding is
done by nasogastric tube. Food preparation should be normally made by a
dietitian to provide her with the correct daily caloric requirements and
vitamin supplements. Furthermore, she has to be seen on a regular basis by
a physical therapist to avoid muscle atrophy, and by a pulmonary therapist
to prevent the accumulation of secretions which can lead to respiratory
complications.
Given these considerations, the amount of actual damages recoverable in
suits arising from negligence should at least reflect the correct minimum cost
of proper care, not the cost of the care the family is usually compelled to
undertake at home to avoid bankruptcy. However, the provisions of the Civil
Code on actual or compensatory damages present us with some difficulties.
Well-settled is the rule that actual damages which may be claimed by the
plaintiff are those suffered by him as he has duly proved. The Civil Code
provides:
Art. 2199. — Except as provided by law or by stipulation,
one is entitled to an adequate compensation only for such
Page 45

pecuniary loss suffered by him as he has duly proved. Such
compensation is referred to as actual or compensatory
damages.
Our rules on actual or compensatory damages generally assume that at the
time of litigation, the injury suffered as a consequence of an act of negligence
has been completed and that the cost can be liquidated. However, these
provisions neglect to take into account those situations, as in this case,
where the resulting injury might be continuing and possible future
complications directly arising from the injury, while certain to occur, are
difficult to predict.
In these cases, the amount of damages which should be awarded, if they are
to adequately and correctly respond to the injury caused, should be one
which compensates for pecuniary loss incurred and proved, up to the time of
trial; and one which would meet pecuniary loss certain to be suffered but
which could not, from the nature of the case, be made with certainty. 80 In
other words, temperate damages can and should be awarded on top of actual
or compensatory damages in instances where the injury is chronic and
continuing. And because of the unique nature of such cases, no
incompatibility arises when both actual and temperate damages are provided
for. The reason is that these damages cover two distinct phases.
As it would not be equitable — and certainly not in the best interests of the
administration of justice — for the victim in such cases to constantly come
before the courts and invoke their aid in seeking adjustments to the
compensatory damages previously awarded — temperate damages are
appropriate. The amount given as temperate damages, though to a certain
extent speculative, should take into account the cost of proper care.
In the instant case, petitioners were able to provide only home-based nursing
care for a comatose patient who has remained in that condition for over a
decade. Having premised our award for compensatory damages on the
amount provided by petitioners at the onset of litigation, it would be now
much more in step with the interests of justice if the value awarded for
temperate damages would allow petitioners to provide optimal care for their
loved one in a facility which generally specializes in such care. They should
not be compelled by dire circumstances to provide substandard care at home
without the aid of professionals, for anything less would be grossly
inadequate. Under the circumstances, an award of P1,500,000.00 in
temperate damages would therefore be reasonable. 81
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In Valenzuela vs. Court of Appeals, 82 this Court was confronted with a
situation where the injury suffered by the plaintiff would have led to
expenses which were difficult to estimate because while they would have
been a direct result of the injury (amputation), and were certain to be
incurred by the plaintiff, they were likely to arise only in the future. We
awarded P1,000,000.00 in moral damages in that case.
Describing the nature of the injury, the Court therein stated:
As a result of the accident, Ma. Lourdes Valenzuela
underwent a traumatic amputation of her left lower
extremity at the distal left thigh just above the knee.
Because of this, Valenzuela will forever be deprived of the full
ambulatory functions of her left extremity, even with the use
of state of the art prosthetic technology. Well beyond the
period of hospitalization (which was paid for by Li), she will
be required to undergo adjustments in her prosthetic devise
due to the shrinkage of the stump from the process of
healing.
These adjustments entail costs, prosthetic replacements and
months of physical and occupational rehabilitation and
therapy. During the lifetime, the prosthetic devise will have
to be replaced and readjusted to changes in the size of her
lower limb effected by the biological changes of middle-age,
menopause and aging. Assuming she reaches menopause,
for example, the prosthetic will have to be adjusted to
respond to the changes in bone resulting from a precipitate
decrease in calcium levels observed in the bones of all post-
menopausal women. In other words, the damage done to her
would not only be permanent and lasting, it would also be
permanently changing and adjusting to the physiologic
changes which her body would normally undergo through
the years. The replacements, changes, and adjustments will
require corresponding adjustive physical and occupational
therapy. All of these adjustments, it has been documented,
are painful.
xxx xxx xxx
A prosthetic devise, however technologically advanced, will
only allow a reasonable amount of functional restoration of
Page 46

the motor functions of the lower limb. The sensory functions
are forever lost. The resultant anxiety, sleeplessness,
psychological injury, mental and physical pain are
inestimable. 83
The injury suffered by Erlinda as a consequence of private respondents'
negligence is certainly much more serious than the amputation in the
Valenzuela case.
Petitioner Erlinda Ramos was in her mid-forties when the incident occurred.
She has been in a comatose state for over fourteen years now. The burden of
care has so far been heroically shouldered by her husband and children,
who, in the intervening years have been deprived of the love of a wife and a
mother.
Meanwhile, the actual physical, emotional and financial cost of the care of
petitioner would be virtually impossible to quantify. Even the temperate
damages herein awarded would be inadequate if petitioner's condition
remains unchanged for the next ten years.
We recognized, in Valenzuela that a discussion of the victim's actual injury
would not even scratch the surface of the resulting moral damage because it
would be highly speculative to estimate the amount of emotional and moral
pain, psychological damage and injury suffered by the victim or those
actually affected by the victim's condition. 84 The husband and the children,
all petitioners in this case, will have to live with the day to day uncertainty of
the patient's illness, knowing any hope of recovery is close to nil. They have
fashioned their daily lives around the nursing care of petitioner, altering their
long term goals to take into account their life with a comatose patient. They,
not the respondents, are charged with the moral responsibility of the care of
the victim. The family's moral injury and suffering in this case is clearly a
real one. For the foregoing reasons, an award of P2,000,000.00 in moral
damages would be appropriate.
Finally, by way of example, exemplary damages in the amount of
P100,000.00 are hereby awarded. Considering the length and nature of the
instant suit we are of the opinion that attorney's fees valued at P100,000.00
are likewise proper.
Our courts face unique difficulty in adjudicating medical negligence cases
because physicians are not insurers of life and, they rarely set out to
intentionally cause injury or death to their patients. However, intent is
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DUMAUAL, JEANNE PAULINE J. 2019-2020
immaterial in negligence cases because where negligence exists and is
proven, the same automatically gives the injured a right to reparation for the
damage caused.
Established medical procedures and practices, though in constant flux are
devised for the purpose of preventing complications. A physician's experience
with his patients would sometimes tempt him to deviate from established
community practices, and he may end a distinguished career using
unorthodox methods without incident. However, when failure to follow
established procedure results in the evil precisely sought to be averted by
observance of the procedure and a nexus is made between the deviation and
the injury or damage, the physician would necessarily be called to account
for it. In the case at bar, the failure to observe pre-operative assessment
protocol which would have influenced the intubation in a salutary way was
fatal to private respondents' case.
WHEREFORE, the decision and resolution of the appellate court appealed
from are hereby modified so as to award in favor of petitioners, and solidarily
against private respondents the following: 1) P1,352,000.00 as actual
damages computed as of the date of promulgation of this decision plus a
monthly payment of P8,000.00 up to the time that petitioner Erlinda Ramos
expires or miraculously survives; 2) P2,000,000.00 as moral damages, 3)
P1,500,000.00 as temperate damages; 4) P100,000.00 each as exemplary
damages and attorney's fees; and, 5) the costs of the suit.
SO ORDERED.
Ramos V. CA (1999)
G.R. No. 124354 December 29, 1999
Lessons Applicable: Personal Injury and Death (Torts and Damages)
Laws Applicable:
FACTS:
Page 47
 DUMAUAL, JEANNE PAULINE J. 2019-2020

June 17, 1985 afternoon: Erlinda Ramos, 47-year old robust woman RTC: favored the Ramos' awarding P8,000 as actual monthly expenses
underwent on an operation to the stone at her gall bladder removed after totalling to P632,000 as of April 15, 1992, P100,000 atty. fees, P800,000
being tested that she was fit for "cholecystectomy" operation performed moral damages,P200,000 exemplary damages and cost of suit
by Dr. Orlino Hozaka. Dr. Hosaka charged a fee of P16,000.00, which was to CA: reversed ordering the Ramos' to pay their unpaid bills of P93,542.25
include the anesthesiologist's fee and which was to be paid after the plus interest
operation. He assured Rogelio E. Ramos, husband that he will get a
good anesthesiologist who was Dra. Perfecta Gutierrez. Erlinda's hand was ISSUE: W/N the Ramos' are entitled to damages
held by Herminda Cruz, her sister -in-law who was the Dean of the College of
Nursing at the Capitol Medical Center together with her husband went down HELD: YES. CA modified in favor of petitioners, and solidarily against private
with her to the operating room. respondents the following: 1) P1,352,000 actual damages computed as of the
Instead of 9:30 am, Dr. Hosaka arrived at about 12:15 P.M. date of promulgation plus a monthly payment of P8,000.00 up to the time
Herminda noticing what Dra. Perfecta Gutierrez was doing, saw the nailbed that petitioner Erlinda Ramos expires or miraculously survives; 2)
of Erlinda becoming bluish and Dr. Hosaka called for P2,000,000 moral damages, 3) P1,500,000 temperate damages; 4) P100,000
another anesthesiologist Dr. Calderon. exemplary damages and P100,000 attorney's fees; and, 5) the costs of the
She went out of the operating room to tell Rogelio that something is wrong. suit.
When she went back she saw Erlinda in a trendelenburg position and at 3
 The application of res ipsa loquitur in medical negligence cases
p.m. she was taken to the Intensive Care Unit (ICU) where she stayed for a
presents a question of law since it is a judicial function to determine
month due to bronchospasm incurring P93,542.25 and she was since then
whether a certain set of circumstances does, as a matter of law, permit a
comatosed.
given inference.
She suffered brain damage as a result of the absence of oxygen in her brain
 doctrine of res ipsa loquitur is availed by the plaintiff, the need for
for four to five minutes.
expert medical testimony is dispensed with because the injury itself
She was also diagnosed to be suffering from "diffuse cerebral parenchymal
provides the proof of negligence - applicable in this case
damage"
 doctrine of res ipsa loquitur can have no application in a suit against
Monthly expenses ranged from P8,000 to P10,000
a physician or surgeon which involves the merits of a diagnosis or of a
Spouses Ramos and their minors filed against Dr. Hosaka and Dra. Perfecta
scientific treatment
Gutierrez
 As borne by the records, respondent Dra. Gutierrez failed to properly
intubate the patient according to witness Herminda

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 With her clinical background as a nurse, the Court is
satisfied with her testimony
 Dra. Gutierrez' act of seeing her patient for the first time only an
hour before the scheduled operative procedure was, therefore, an act of
exceptional negligence and professional irresponsibility
 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. Jamora, not an anesthesiologist, stated that oxygen
deprivation which led to anoxic encephalopathy was due to an
unpredictable drug reaction to the short-acting barbiturate was not
accepted as expert opinion
 Dr. Hosaka's negligence can be found in his failure to exercise the
proper authority in not determining if his anesthesiologist observed
proper anesthesia protocols
 Dr. Hosaka had scheduled another procedure in a different hospital
at the same time as Erlinda's cholecystectomy, and was in fact over three
hours late for the latter's operation. Because of this, he had little or no
time to confer with his anesthesiologist regarding the anesthesia
delivery. This indicates that he was remiss in his professional duties
towards his patient
 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
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DUMAUAL, JEANNE PAULINE J. 2019-2020
important hallmarks of an employer-employee relationship, with the
exception of the payment of wages.
 Art. 2199. — Except as provided by law or by stipulation, one is
entitled to an adequate compensation only for such pecuniary loss
suffered by him as he has duly proved. Such compensation is referred to
as actual or compensatory damages.
 temperate damages can and should be awarded on top of actual or
compensatory damages in instances where the injury is chronic and
continuing. And because of the unique nature of such cases, no
incompatibility arises when both actual and temperate damages are
provided for. The reason is that these damages cover two distinct phases.
 They should not be compelled by dire circumstances to provide
substandard care at home without the aid of professionals, for anything
less would be grossly inadequate. Under the circumstances, an award of
P1,500,000.00 in temperate damages would therefore be reasonable.
 the damage done to her would not only be permanent and lasting, it
would also be permanently changing and adjusting to the physiologic
changes which her body would normally undergo through the years.
 Erlinda Ramos was in her mid-forties when the incident occurred.
She has been in a comatose state for over fourteen years now
 Ramos' are charged with the moral responsibility of the care of the
victim. The family's moral injury and suffering in this case is clearly a
real one. Award of P2,000,000 in moral damages would be appropriate.
 Finally, by way of example, exemplary damages in the amount of
P100,000.00 are hereby awarded. Considering the length and nature of
the instant suit we are of the opinion that attorney's fees valued at
P100,000 are likewise proper.
Page 49

G.R. No. 130547 October 3, 2000
LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and minors LLOYD and
KRISTINE, all surnamed REYES, represented by their mother, LEAH
ALESNA REYES, petitioners,
vs.
SISTERS OF MERCY HOSPITAL, SISTER ROSE PALACIO, DR. MARVIE
BLANES, and DR. MARLYN RICO, respondents.
DECISION
MENDOZA, J.:
This is a petition for review of the decision 1 of the Court of Appeals in CA-G.R.
CV No. 36551 affirming the decision of the Regional Trial Court, Branch IX,
Cebu City which dismissed a complaint for damages filed by petitioners
against respondents.
The facts are as follows:
Petitioner Leah Alesna Reyes is the wife of the late Jorge Reyes. The other
petitioners, namely, Rose Nahdja, Johnny, Lloyd, and Kristine, all surnamed
Reyes, were their children. Five days before his death on January 8, 1987,
Jorge had been suffering from a recurring fever with chills. After he failed to
get relief from some home medication he was taking, which consisted of
analgesic, antipyretic, and antibiotics, he decided to see the doctor.
On January 8, 1987, he was taken to the Mercy Community Clinic by his
wife. He was attended to by respondent Dr. Marlyn Rico, resident physician
and admitting physician on duty, who gave Jorge a physical examination and
took his medical history. She noted that at the time of his admission, Jorge
was conscious, ambulatory, oriented, coherent, and with respiratory
distress.2 Typhoid fever was then prevalent in the locality, as the clinic had
been getting from 15 to 20 cases of typhoid per month. 3 Suspecting that
Jorge could be suffering from this disease, Dr. Rico ordered a Widal Test, a
standard test for typhoid fever, to be performed on Jorge. Blood count,
routine urinalysis, stool examination, and malarial smear were also
made.4 After about an hour, the medical technician submitted the results of
the test from which Dr. Rico concluded that Jorge was positive for typhoid
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DUMAUAL, JEANNE PAULINE J. 2019-2020
fever. As her shift was only up to 5:00 p.m., Dr. Rico indorsed Jorge to
respondent Dr. Marvie Blanes.
Dr. Marvie Blanes attended to Jorge at around six in the evening. She also
took Jorge’s history and gave him a physical examination. Like Dr. Rico, her
impression was that Jorge had typhoid fever. Antibiotics being the accepted
treatment for typhoid fever, she ordered that a compatibility test with the
antibiotic chloromycetin be done on Jorge. Said test was administered by
nurse Josephine Pagente who also gave the patient a dose of triglobe. As she
did not observe any adverse reaction by the patient to chloromycetin, Dr.
Blanes ordered the first five hundred milligrams of said antibiotic to be
administered on Jorge at around 9:00 p.m. A second dose was administered
on Jorge about three hours later just before midnight.
At around 1:00 a.m. of January 9, 1987, Dr. Blanes was called as Jorge’s
temperature rose to 41°C. The patient also experienced chills and exhibited
respiratory distress, nausea, vomiting, and convulsions. Dr. Blanes put him
under oxygen, used a suction machine, and administered hydrocortisone,
temporarily easing the patient’s convulsions. When he regained
consciousness, the patient was asked by Dr. Blanes whether he had a
previous heart ailment or had suffered from chest pains in the past. Jorge
replied he did not.5 After about 15 minutes, however, Jorge again started to
vomit, showed restlessness, and his convulsions returned. Dr. Blanes re-
applied the emergency measures taken before and, in addition, valium was
administered. Jorge, however, did not respond to the treatment and slipped
into cyanosis, a bluish or purplish discoloration of the skin or mucous
membrane due to deficient oxygenation of the blood. At around 2:00 a.m.,
Jorge died. He was forty years old. The cause of his death was "Ventricular
Arrythemia Secondary to Hyperpyrexia and typhoid fever."
On June 3, 1987, petitioners filed before the Regional Trial Court of Cebu
City a complaint6 for damages against respondents Sisters of Mercy, Sister
Rose Palacio, Dr. Marvie Blanes, Dr. Marlyn Rico, and nurse Josephine
Pagente. On September 24, 1987, petitioners amended their complaint to
implead respondent Mercy Community Clinic as additional defendant and to
drop the name of Josephine Pagente as defendant since she was no longer
connected with respondent hospital. Their principal contention was that
Jorge did not die of typhoid fever. 7 Instead, his death was due to the wrongful
administration of chloromycetin. They contended that had respondent
doctors exercised due care and diligence, they would not have recommended
and rushed the performance of the Widal Test, hastily concluded that Jorge
was suffering from typhoid fever, and administered chloromycetin without
Page 50

first conducting sufficient tests on the patient’s compatibility with said drug.
They charged respondent clinic and its directress, Sister Rose Palacio, with
negligence in failing to provide adequate facilities and in hiring negligent
doctors and nurses.8
Respondents denied the charges. During the pre-trial conference, the parties
agreed to limit the issues on the following: (1) whether the death of Jorge
Reyes was due to or caused by the negligence, carelessness, imprudence,
and lack of skill or foresight on the part of defendants; (2) whether
respondent Mercy Community Clinic was negligent in the hiring of its
employees; and (3) whether either party was entitled to damages. The case
was then heard by the trial court during which, in addition to the testimonies
of the parties, the testimonies of doctors as expert witnesses were presented.
Petitioners offered the testimony of Dr. Apolinar Vacalares, Chief Pathologist
at the Northern Mindanao Training Hospital, Cagayan de Oro City. On
January 9, 1987, Dr. Vacalares performed an autopsy on Jorge Reyes to
determine the cause of his death. However, he did not open the skull to
examine the brain. His findings 9 showed that the gastro-intestinal tract was
normal and without any ulceration or enlargement of the nodules. Dr.
Vacalares testified that Jorge did not die of typhoid fever. He also stated that
he had not seen a patient die of typhoid fever within five days from the onset
of the disease.
For their part, respondents offered the testimonies of Dr. Peter Gotiong and
Dr. Ibarra Panopio. Dr. Gotiong is a diplomate in internal medicine whose
expertise is microbiology and infectious diseases. He is also a consultant at
the Cebu City Medical Center and an associate professor of medicine at the
South Western University College of Medicine in Cebu City. He had treated
over a thousand cases of typhoid patients. According to Dr. Gotiong, the
patient’s history and positive Widal Test results ratio of 1:320 would make
him suspect that the patient had typhoid fever. As to Dr. Vacalares’
observation regarding the absence of ulceration in Jorge’s gastro-intestinal
tract, Dr. Gotiong said that such hyperplasia in the intestines of a typhoid
victim may be microscopic. He noted that since the toxic effect of typhoid
fever may lead to meningitis, Dr. Vacalares’ autopsy should have included an
examination of the brain.10
The other doctor presented was Dr. Ibarra Panopio, a member of the
American Board of Pathology, examiner of the Philippine Board of Pathology
from 1978 to 1991, fellow of the Philippine Society of Pathologist, associate
professor of the Cebu Institute of Medicine, and chief pathologist of the
Andres Soriano Jr. Memorial Hospital in Toledo City. Dr. Panopio stated that
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although he was partial to the use of the culture test for its greater reliability
in the diagnosis of typhoid fever, the Widal Test may also be used. Like Dr.
Gotiong, he agreed that the 1:320 ratio in Jorge’s case was already the
maximum by which a conclusion of typhoid fever may be made. No additional
information may be deduced from a higher dilution. 11 He said that Dr.
Vacalares’ autopsy on Jorge was incomplete and thus inconclusive.
On September 12, 1991, the trial court rendered its decision absolving
respondents from the charges of negligence and dismissing petitioners’ action
for damages. The trial court likewise dismissed respondents’ counterclaim,
holding that, in seeking damages from respondents, petitioners were impelled
by the honest belief that Jorge’s death was due to the latter’s negligence.
Petitioners brought the matter to the Court of Appeals. On July 31, 1997, the
Court of Appeals affirmed the decision of the trial court.
Hence this petition.
Petitioners raise the following assignment of errors:
I. THE HONORABLE COURT OF APPEALS COMMITTED A
REVERSIBLE ERROR WHEN IT RULED THAT THE DOCTRINE
OF RES IPSA LOQUITUR IS NOT APPLICABLE IN THE INSTANT
CASE.
II. THE HONORABLE COURT OF APPEALS COMMITTED
REVERSIBLE ERROR WHEN IT MADE AN UNFOUNDED
ASSUMPTION THAT THE LEVEL OF MEDICAL PRACTICE IS LOWER
IN ILIGAN CITY.
III. THE HONORABLE COURT OF APPEALS GRAVELY ERRED
WHEN IT RULED FOR A LESSER STANDARD OF CARE AND
DEGREE OF DILIGENCE FOR MEDICAL PRACTICE IN ILIGAN CITY
WHEN IT APPRECIATE[D] NO DOCTOR’S NEGLIGENCE IN THE
TREATMENT OF JORGE REYES.
Petitioner’s action is for medical malpractice. This 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.12 In order to successfully pursue such a claim, a
Page 51

patient must prove that the physician or surgeon either failed to do
something which a reasonably prudent physician or surgeon would have
done, or that he or she did something that a reasonably prudent physician or
surgeon would not have done, and that the failure or action caused injury to
the patient.13 There are thus four elements involved in medical negligence
cases, namely: duty, breach, injury, and proximate causation.
In the present case, there is no doubt that a physician-patient relationship
existed between respondent doctors and Jorge Reyes. Respondents were thus
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. It is breach of this duty which constitutes actionable
malpractice.14 As to this aspect of medical malpractice, the determination of
the reasonable level of care and the breach thereof, expert testimony is
essential. 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.15
Res Ipsa Loquitur
There is a case when expert testimony may be dispensed with, and that is
under the doctrine of res ipsa loquitur. As held in Ramos v. Court of
Appeals:16
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
loquitor 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. 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
and surgeons, 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
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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. When the doctrine is appropriate, all
that the patient must do is prove a nexus between the particular act or
omission complained of and the injury sustained while under the custody
and management of the defendant without need to produce expert medical
testimony to establish the standard of care. Resort to res ipsa loquitor is
allowed because there is no other way, under usual and ordinary conditions,
by which the patient can obtain redress for injury suffered by him.
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 was under the influence of anesthetic, during or following an
operation for appendicitis, among others.17
Petitioners asserted in the Court of Appeals that the doctrine of res ipsa
loquitur applies to the present case because Jorge Reyes was merely
experiencing fever and chills for five days and was fully conscious, coherent,
and ambulant when he went to the hospital. Yet, he died after only ten hours
from the time of his admission.
This contention was rejected by the appellate court.
Petitioners now contend that all requisites for the application of res ipsa
loquitur were present, namely: (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. 18
The contention is without merit. We agree with the ruling of the Court of
Appeals. In the Ramos case, the question was whether a surgeon, an
anesthesiologist, and a hospital should be made liable for the comatose
condition of a patient scheduled for cholecystectomy. 19 In that case, the
patient was given anesthesia prior to her operation. Noting that the patient
was neurologically sound at the time of her operation, the Court applied the
Page 52

doctrine of res ipsa loquitur as mental brain damage does not normally occur
in a gallblader operation in the absence of negligence of the anesthesiologist.
Taking judicial notice that anesthesia procedures had become so common
that even an ordinary person could tell if it was administered properly, we
allowed the testimony of a witness who was not an expert. In this case, while
it is true that the patient died just a few hours after professional medical
assistance was rendered, there is really nothing unusual or extraordinary
about his death. Prior to his admission, the patient already had recurring
fevers and chills for five days unrelieved by the analgesic, antipyretic, and
antibiotics given him by his wife. This shows that he had been suffering from
a serious illness and professional medical help came too late for him.
Respondents alleged failure to observe due care was not immediately
apparent to a layman so as to justify application of res ipsa loquitur. The
question required expert opinion on the alleged breach by respondents of the
standard of care required by the circumstances. Furthermore, on the issue of
the correctness of her diagnosis, no presumption of negligence can be applied
to Dr. Marlyn Rico.As held in Ramos:
. . . . 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. It must be conceded that the doctrine of res ipsa loquitur can have
no application in a suit against a physician or a surgeon which involves the
merits of a diagnosis or of a scientific treatment. The physician or surgeon is
not required at his peril to explain why any particular diagnosis was not
correct, or why any particular scientific treatment did not produce the
desired result.20
Specific Acts of Negligence
We turn to the question whether petitioners have established specific acts of
negligence allegedly committed by respondent doctors.
Petitioners contend that: (1) Dr. Marlyn Rico hastily and erroneously relied
upon the Widal test, diagnosed Jorge’s illness as typhoid fever, and
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immediately prescribed the administration of the antibiotic
chloromycetin;21 and (2) Dr. Marvie Blanes erred in ordering the
administration of the second dose of 500 milligrams of chloromycetin barely
three hours after the first was given.22 Petitioners presented the testimony of
Dr. Apolinar Vacalares, Chief Pathologist of the Northern Mindanao Training
Hospital, Cagayan de Oro City, who performed an autopsy on the body of
Jorge Reyes. Dr. Vacalares testified that, based on his findings during the
autopsy, Jorge Reyes did not die of typhoid fever but of shock undetermined,
which could be due to allergic reaction or chloromycetin overdose. We are not
persuaded.
First. While petitioners presented Dr. Apolinar Vacalares as an expert
witness, we do not find him to be so as he is not a specialist on infectious
diseases like typhoid fever. Furthermore, although he may have had
extensive experience in performing autopsies, he admitted that he had yet to
do one on the body of a typhoid victim at the time he conducted the
postmortem on Jorge Reyes. It is also plain from his testimony that he has
treated only about three cases of typhoid fever. Thus, he testified that: 23
ATTY. PASCUAL:
Q Why? Have you not testified earlier that you have never seen a patient who
died of typhoid fever?
A In autopsy. But, that was when I was a resident physician yet.
Q But you have not performed an autopsy of a patient who died of typhoid
fever?
A I have not seen one.
Q And you testified that you have never seen a patient who died of typhoid
fever within five days?
A I have not seen one.
Q How many typhoid fever cases had you seen while you were in the general
practice of medicine?
Page 53

A In our case we had no widal test that time so we cannot consider that the
typhoid fever is like this and like that. And the widal test does not specify the
time of the typhoid fever.
Q The question is: how many typhoid fever cases had you seen in your
general practice regardless of the cases now you practice?
A I had only seen three cases.
Q And that was way back in 1964?
A Way back after my training in UP.
Q Clinically?
A Way back before my training.
He is thus not qualified to prove that Dr. Marlyn Rico erred in her diagnosis.
Both lower courts were therefore correct in discarding his testimony, which is
really inadmissible.
In Ramos, the defendants presented the testimony of a pulmonologist to
prove that brain injury was due to oxygen deprivation after the patient had
bronchospasms24 triggered by her allergic response to a drug, 25 and not due
to faulty intubation by the anesthesiologist. As the issue was whether the
intubation was properly performed by an anesthesiologist, we rejected the
opinion of the pulmonologist on the ground that he was not: (1) an
anesthesiologist who could enlighten the court about anesthesia practice,
procedure, and their complications; nor (2) an allergologist who could
properly advance expert opinion on allergic mediated processes; nor (3) a
pharmacologist who could explain the pharmacologic and toxic effects of the
drug allegedly responsible for the bronchospasms.
Second. On the other hand, the two doctors presented by respondents
clearly were experts on the subject. They vouched for the correctness of Dr.
Marlyn Rico’s diagnosis. Dr. Peter Gotiong, a diplomate whose specialization
is infectious diseases and microbiology and an associate professor at the
Southwestern University College of Medicine and the Gullas College of
Medicine, testified that he has already treated over a thousand cases of
typhoid fever.26 According to him, when a case of typhoid fever is suspected,
the Widal test is normally used, 27 and if the 1:320 results of the Widal test on
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Jorge Reyes had been presented to him along with the patient’s history, his
impression would also be that the patient was suffering from typhoid
fever.28 As to the treatment of the disease, he stated that chloromycetin was
the drug of choice.29 He also explained that despite the measures taken by
respondent doctors and the intravenous administration of two doses of
chloromycetin, complications of the disease could not be discounted. His
testimony is as follows:30
ATTY. PASCUAL:
Q If with that count with the test of positive for 1 is to 320, what treatment if
any would be given?
A If those are the findings that would be presented to me, the first thing I
would consider would be typhoid fever.
Q And presently what are the treatments commonly used?
A Drug of choice of chloramphenical.
Q Doctor, if given the same patient and after you have administered
chloramphenical about 3 1/2 hours later, the patient associated with chills,
temperature - 41oC, what could possibly come to your mind?
A Well, when it is change in the clinical finding, you have to think of
complication.
Q And what will you consider on the complication of typhoid?
A One must first understand that typhoid fever is toximia. The problem is
complications are caused by toxins produced by the bacteria . . . whether you
have suffered complications to think of -- heart toxic myocardities; then you
can consider a toxic meningitis and other complications and perforations and
bleeding in the ilium.
Q Even that 40-year old married patient who received medication of
chloromycetin of 500 milligrams intravenous, after the skin test, and received
a second dose of chloromycetin of 500 miligrams, 3 hours later, the patient
developed chills . . . rise in temperature to 41 oC, and then about 40 minutes
later the temperature rose to 100 oF, cardiac rate of 150 per minute who
Page 54

appeared to be coherent, restless, nauseating, with seizures: what
significance could you attach to these clinical changes?
A I would then think of toxemia, which was toxic meningitis and probably a
toxic meningitis because of the high cardiac rate.
Q Even if the same patient who, after having given intramuscular valium,
became conscious and coherent about 20 minutes later, have seizure and
cyanosis and rolling of eyeballs and vomitting . . . and death: what
significance would you attach to this development?
A We are probably dealing with typhoid to meningitis.
Q In such case, Doctor, what finding if any could you expect on the post-
mortem examination?
A No, the finding would be more on the meninges or covering of the brain.
Q And in order to see those changes would it require opening the skull?
A Yes.
As regards Dr. Vacalares’ finding during the autopsy that the deceased’s
gastro-intestinal tract was normal, Dr. Rico explained that, while
hyperplasia31 in the payer’s patches or layers of the small intestines is
present in typhoid fever, the same may not always be grossly visible and a
microscope was needed to see the texture of the cells. 32
Respondents also presented the testimony of Dr. Ibarra T. Panopio who is a
member of the Philippine and American Board of Pathology, an examiner of
the Philippine Board of Pathology, and chief pathologist at the MetroCebu
Community Hospital, Perpetual Succor Hospital, and the Andres Soriano Jr.
Memorial Medical Center. He stated that, as a clinical pathologist, he
recognized that the Widal test is used for typhoid patients, although he did
not encourage its use because a single test would only give a presumption
necessitating that the test be repeated, becoming more conclusive at the
second and third weeks of the disease. 33 He corroborated Dr. Gotiong’s
testimony that the danger with typhoid fever is really the possible
complications which could develop like perforation, hemorrhage, as well as
liver and cerebral complications. 34 As regards the 1:320 results of the Widal
test on Jorge Reyes, Dr. Panopio stated that no additional information could
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be obtained from a higher ratio. 35 He also agreed with Dr. Gotiong that
hyperplasia in the payer’s patches may be microscopic. 36
Indeed, the standard contemplated is not what is actually the average merit
among all known practitioners from the best to the worst and from the most
to the least experienced, but the reasonable average merit among the
ordinarily good physicians. 37 Here, Dr. Marlyn Rico did not depart from the
reasonable standard recommended by the experts as she in fact observed the
due care required under the circumstances. Though the Widal test is not
conclusive, it remains a standard diagnostic test for typhoid fever and, in the
present case, greater accuracy through repeated testing was rendered
unobtainable by the early death of the patient. The results of the Widal test
and the patient’s history of fever with chills for five days, taken with the fact
that typhoid fever was then prevalent as indicated by the fact that the clinic
had been getting about 15 to 20 typhoid cases a month, were sufficient to
give upon any doctor of reasonable skill the impression that Jorge Reyes had
typhoid fever.
Dr. Rico was also justified in recommending the administration of the drug
chloromycetin, the drug of choice for typhoid fever. The burden of proving
that Jorge Reyes was suffering from any other illness rested with the
petitioners. As they failed to present expert opinion on this, preponderant
evidence to support their contention is clearly absent.
Third. Petitioners contend that respondent Dr. Marvie Blanes, who took over
from Dr. Rico, was negligent in ordering the intravenous administration of
two doses of 500 milligrams of chloromycetin at an interval of less than three
hours. Petitioners claim that Jorge Reyes died of anaphylactic shock 38 or
possibly from overdose as the second dose should have been administered
five to six hours after the first, per instruction of Dr. Marlyn Rico. As held by
the Court of Appeals, however:
That chloromycetin was likewise a proper prescription is best established by
medical authority. Wilson, et. al., in Harrison’s Principle of Internal Medicine,
12th ed. write that chlorampenicol (which is the generic of chloromycetin) is
the drug of choice for typhoid fever and that no drug has yet proven better in
promoting a favorable clinical response. "Chlorampenicol (Chloromycetin) is
specifically indicated for bacterial meningitis, typhoid fever, rickettsial
infections, bacteriodes infections, etc." (PIMS Annual, 1994, p. 211) The
dosage likewise including the first administration of five hundred milligrams
(500 mg.) at around nine o’clock in the evening and the second dose at around
11:30 the same night was still within medically acceptable limits, since the
recommended dose of chloromycetin is one (1) gram every six (6)
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hours. (cf. Pediatric Drug Handbook, 1st Ed., Philippine Pediatric Society,
Committee on Therapeutics and Toxicology, 1996). The intravenous route is
likewise correct. (Mansser, O’Nick, Pharmacology and Therapeutics) Even if
the test was not administered by the physician-on-duty, the evidence
introduced that it was Dra. Blanes who interpreted the results remain
uncontroverted. (Decision, pp. 16-17) Once more, this Court rejects any
claim of professional negligence in this regard.
....
As regards anaphylactic shock, the usual way of guarding against it prior to
the administration of a drug, is the skin test of which, however, it has been
observed: "Skin testing with haptenic drugs is generally not reliable. Certain
drugs cause nonspecific histamine release, producing a weal-and-flare
reaction in normal individuals. Immunologic activation of mast cells requires
a polyvalent allergen, so a negative skin test to a univalent haptenic drug
does not rule out anaphylactic sensitivity to that drug." (Terr, "Anaphylaxis
and Urticaria" in Basic and Clinical Immunology, p. 349) What all this means
legally is that even if the deceased suffered from an anaphylactic shock, this,
of itself, would not yet establish the negligence of the appellee-physicians for
all that the law requires of them is that they perform the standard tests and
perform standard procedures. The law cannot require them to predict every
possible reaction to all drugs administered. The onus probandi was on the
appellants to establish, before the trial court, that the appellee-physicians
ignored standard medical procedure, prescribed and administered
medication with recklessness and exhibited an absence of the competence
and skills expected of general practitioners similarly situated. 39
Fourth. Petitioners correctly observe that the medical profession is one
which, like the business of a common carrier, is affected with public interest.
Moreover, they assert that since the law imposes upon common carriers the
duty of observing extraordinary diligence in the vigilance over the goods and
for the safety of the passengers, 40 physicians and surgeons should have the
same duty toward their patients.41 They also contend that the Court of
Appeals erred when it allegedly assumed that the level of medical practice is
lower in Iligan City, thereby reducing the standard of care and degree of
diligence required from physicians and surgeons in Iligan City.
The standard of extraordinary diligence is peculiar to common carriers. The
Civil Code provides:
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DUMAUAL, JEANNE PAULINE J. 2019-2020
Art. 1733. Common carriers, from the nature of their business and for
reasons of public policy, are bound to observe extraordinary diligence in the
vigilance over the goods and for the safety of the passengers transported by
them, according to the circumstances of each case. . . .
The practice of medicine is a profession engaged in only by qualified
individuals.1âwphi1 It is a right earned through years of education, training,
and by first obtaining a license from the state through professional board
examinations. Such license may, at any time and for cause, be revoked by
the government. In addition to state regulation, the conduct of doctors is also
strictly governed by the Hippocratic Oath, an ancient code of discipline and
ethical rules which doctors have imposed upon themselves in recognition and
acceptance of their great responsibility to society. Given these safeguards,
there is no need to expressly require of doctors the observance of
"extraordinary" diligence. As it is now, the practice of medicine is already
conditioned upon the highest degree of diligence. And, as we have already
noted, the standard contemplated for doctors is simply the reasonable
average merit among ordinarily good physicians. That is reasonable diligence
for doctors or, as the Court of Appeals called it, the reasonable "skill and
competence . . . that a physician in the same or similar locality . . . should
apply."
WHEREFORE, the instant petition is DENIED and the decision of the Court
of Appeals is AFFIRMED.
Reyes vs. Sisters of Mercy Hospital
G.R No. 130547 (October 3, 2000)
A. Legal Issue
Whether or not Sisters of Mercy Hospital is liable for the death of
Jorge Reyes.
B. Facts
Petitioner, Leah Alesna Reyes, is the wife of the deceased patient,
Jorge Reyes. Five days before the latter’s death, Jorge has been suffering
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 DUMAUAL, JEANNE PAULINE J. 2019-2020

from recurring fever with chills. The doctors confirmed through the Widal test was shown to be properly done but did not work, they cannot be faulted for
that Jorge has typhoid fever. However, he did not respond to the treatment such result.
and died. The cause of his death was “Ventricular Arrythemia Secondary to
Hyperpyrexia and typhoid fever.” Consequently, petitioner filed the instant
case for damages before the Regional Trial Court of Cebu City, which
dismissed the case and was affirmed by the Court of Appeals.

The contention was that Jorge did not die of typhoid fever. Instead,
his death was due to the wrongful administration of chloromycetin. They
contended that had respondent doctors exercised due care and diligence,
they would not have recommended and rushed the performance of the Widal
Test, hastily concluded that Jorge was suffering from typhoid fever, and
administered chloromycetin without first conducting sufficient tests on the
patient’s compatibility with said drug.

C. Ruling

Sisters of Mercy Hospital is not liable for the death of Jorge Reyes.

D. Reasoning of the Court

There is no showing that the attending physician in this case

deviated from the usual course of treatment with respect to typhoid fever.
Jorge was given antibiotic choloromycetin and some dose of triglobe after
compatibility test was made by the doctor and found that no adverse
reactions manifested which would necessitate replacement of the medicines.
Indeed, the standard contemplated is not what is actually the average merit
among all known practitioners from the best to the worst and from the most
to the least experienced, but the reasonable average merit among the
ordinarily good physicians. Here, the doctors did not depart from the
reasonable standard recommended by the experts as they in fact observed
the due care required under the circumstances.

E. Policy

In Medical Negligence cases, it is incumbent upon the plaintiff to

establish that the usual procedure in treating the illness is not followed by
the doctor. Failure to prove this, the doctor is not liable. Physicians are not
insurers of the success of every procedure undertaken and if the procedure

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A.M. No. 2005-08-SC December 9, 2005
SAMUEL R. RUÑEZ, JR., Complainant,
vs.
MARYBETH V. JURADO, Respondent.
DECISION
AZCUNA, J.:
It is unfortunate that this administrative case involves co-workers in this
Court. Complainant, Samuel R. Ruñez, Jr. (Ruñez, Jr.), is Chief of the
Clearance Section, Checks Disbursement Division of the FMO-OCA and is
the son of the aggrieved party, Samuel V. Ruñez, Sr. (Ruñez, Sr.), Driver I for
the Motorpool, Property Division of the OCA. Respondent is Dr. Marybeth V.
Jurado (Dr. Jurado), Medical Officer IV of the Medical and Dental Services.
All three were working for the Court at the time of the incident in issue.
The parties agree that on January 12, 2005, at around 4:20 p.m., Ruñez, Sr.
arrived by himself at this Court’s clinic complaining of dizziness. His blood
pressure and pulse rate were taken by the reception nurse and were
registered at 210/100 mmHg and 112 beats a minute, respectively. What
transpired next is disputed. Ruñez, Jr. alleged that despite his father’s
medical condition, he was merely advised to go to a hospital and then
allowed to walk out of the clinic on his own. Dr. Jurado, on the other hand,
maintained that after being informed of Ruñez, Sr.’s blood pressure and
heart rate, she instructed the nurse to administer one tablet of Capoten
25mg, an emergency drug that quickly lowers a patient’s blood pressure. She
then informed Ruñez, Sr. that he will be taken to the hospital, after which
she immediately instructed the ambulance driver, Mr. Jacinto, to stand by
for hospital conduction. Minutes later, after having taken Capoten and being
given a chance to rest, Ruñez, Sr. stood up and walked out saying, " Doktora,
hanap lang ho ako ng kasama." Dr. Jurado said she waited for him to return
but he failed to show up. She asked Mr. Almarza, a nurse at the clinic, to
look for Ruñez, Sr. but he was unable to locate him.
According to Ruñez, Jr., after being informed of his father’s condition, he
rushed him to the Manila Doctors Hospital. There, Ruñez, Sr. was treated in
the emergency room for approximately four hours before he was discharged
at around 8:30 p.m. and allowed to go home. However, prior to reaching their
house in Balintawak, Caloocan City, Ruñez, Sr. began experiencing nausea,
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DUMAUAL, JEANNE PAULINE J. 2019-2020
abnormal palpitation and uneasiness and had to be brought back to the
hospital.
Ruñez, Sr. and Ruñez, Jr.1 arrived at the emergency room of the Manila
Doctors Hospital at around 10:00 p.m. after which Ruñez, Sr. underwent a
C.T. Scan. The C.T. Scan revealed a blood clot necessitating him to be
admitted for treatment and observation. The following morning he suffered a
stroke and for a moment was on flat line. The doctors were able to revive him
and thereafter he was transferred to the intensive care unit. Unfortunately,
Ruñez Sr. never recovered from his ailment and, on September 12, 2005, he
passed away due to medical complications.2
On February 15, 2005, Ruñez, Jr. filed a letter-complaint with the Office of
the Chief Justice regarding the alleged lack of attention given to his father by
Dr. Jurado. Specifically, he claims that Dr. Jurado merely advised his father
to go to the hospital and then allowed him to travel to Manila Doctors
Hospital despite the availability of an ambulance at the disposal of the clinic.
Ruñez, Jr. submits that his father would not have suffered a stroke if not for
the neglect of Dr. Jurado.
The letter-complaint was referred to Atty. Eden T. Candelaria, Deputy Clerk
of Court and Chief of Administrative Services, for investigation. Atty.
Candelaria required Dr. Jurado to submit her comment to the letter-
complaint. The comment was submitted on March 18, 2005, together with
supporting affidavits from respondent’s witnesses. This was followed by
Ruñez, Jr.’s reply to the comment on April 12, 2005 and Dr. Jurado’s
rejoinder on April 22, 2005.3
Atty. Candelaria submitted her report on June 17, 2005. The report gave
credence to the account of Dr. Jurado that Ruñez, Sr. was given Capoten,
informed that he should be hospitalized and that the ambulance was placed
on standby to take him there. These factual findings of Atty. Candelaria
appear to be supported by the affidavits of the clinic’s personnel, including
the ambulance driver, who witnessed the events that happened between
Ruñez, Sr. and Dr. Jurado.
The issue now for the Court to resolve is whether, given the accepted facts,
there is cause to hold Dr. Jurado administratively liable. Atty. Candelaria is
satisfied that Dr. Jurado provided Ruñez, Sr. proper treatment inside the
clinic. However, in her opinion, Dr. Jurado’s actions after Ruñez, Sr. had left
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were less than the required diligence of a good father of a family. We quote
below the analysis of Atty. Candelaria:
. . . Records will clearly show that minutes after Mr. Ruñez, Sr. left the clinic,
Dr. Jurado also left the clinic to go home. This is shown by her time out
registered in the Chronolog Machine on the said date which was 4:31 p.m.
and her inclusion in the list of passengers of Shuttle Bus No. 6. As an
efficient and intelligent doctor, Dr. Jurado should have at least personally
exerted all her efforts to determine the whereabouts of Mr. Ruñez, Sr.
because of his condition and again at the very least informed his relatives in
the Court in order that they too take the necessary action that very moment.
Or in the alternative, if indeed, Dr. Jurado may have been in a hurry at that
time to do some errands, she should have at least[,] again, turned Mr. Ruñez
over the a [d]octor who was willing to be left behind after office hours. These
however never happened. All that she relied on was the fact that there was
an emergency treatment and an order for hospital conduction but [the same]
didn’t materialize and [she] put [the] blame on Mr. Ruñez, Sr. As admitted by
complainant, Mr. Ruñez, Sr., is a mere "driver" and perhaps may have no
knowledge at all of the consequences of his 210/100 blood pressure and
since he sought refuge from the [c]linic, the clinic, particularly Dr. Jurado[,]
should have made him feel safe and secure in the said place. . . .
Atty. Candelaria recommends that Dr. Jurado be held liable for simple
neglect of duty and suspended for one (1) month and (1) day. She further
recommends that, in light of what happened, Dr. Prudencio Banzon, SC
Senior Staff Officer, Medical and Dental Services, be directed to prepare a
flexi-time schedule (until 5:30 p.m.) for all doctors and nurses in the clinic to
enable it to provide immediate and proper attention in case of any emergency
medical situation.
The Court does not agree that the acts or omission of Dr. Jurado amount to
simple neglect of duty. Simple neglect of duty is defined as failure to give
proper attention to a task expected of an employee resulting from either
carelessness or indifference4 or signifies a disregard of duty resulting from
carelessness or indifference.5 In Philippine Retirement Authority,6 it was stated,
"The Court has decided the following, inter alia, as constituting the less grave
offense of Simple Neglect of Duty: delay in the transmittal of court records,
delay in responding to written queries, and delay of more than one (1) year
and seven (7) months in furnishing a party with a copy of the court’s
decision." In all the instances cited by the Court, respondents had the duty
or were expected to do certain acts which they failed to do. How do we
determine what acts are expected of Dr. Jurado? Atty. Candelaria’s report
cites the applicable yardstick: a physician or surgeon is expected to apply in
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his practice of medicine that degree of care and skill which is ordinarily
employed by the profession, generally, and under similar
conditions.7 Therefore, to find Dr. Jurado liable for simple neglect of duty the
Court has to be convinced that those in the medical profession were also
expected to act in the manner illustrated by Atty. Candelaria, i.e., to exert all
efforts to determine the whereabouts of Ruñez, Sr., inform his relatives or
turn his case over to a doctor who was available after office hours.
Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in
the Philippines 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 physician’s
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."
A doctor’s duty to his patient is not required to be extraordinary. 8 The
standard contemplated for doctors is simply the reasonable average merit
among ordinarily good physicians, i.e. reasonable skill and competence.9 We
are persuaded that Dr. Jurado fulfilled such a standard when she treated
Ruñez, Sr. inside the clinic. But what of Dr. Jurado’s conduct after Ruñez,
Sr. left the clinic and failed to return?
It has been held that a patient cannot attribute to a physician damages
resulting from his own failure to follow his advice, even though he was
ignorant of the consequences which would result from his failure. 10 If a
patient leaves the hospital contrary to instructions, the physician is not liable
for subsequent events.11 There is no expectation from doctors that they track
down each patient who apparently missed their appointments or force them
to comply with their directives. After all, a person is still the master of his
own body.12
Dr. Jurado may have allowed Ruñez, Sr. to walk out of the clinic despite her
earlier diagnosis of his condition. By that time Ruñez, Sr.’s condition had
temporarily stabilized and she did not have the authority to stop him just as
other doctors have no power, save in certain instances (such as when the law
makes treatment compulsory due to some communicable disease 13 or when
consent is withheld by a minor but non-treatment would be detrimental or
when the court of competent jurisdiction orders the treatment), to force
patients into staying under their care. Dr. Jurado relied on Ruñez, Sr.’s
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representation that he would return in order to be brought to the hospital
but made no undertaking to wait for him beyond the clinic hours or to look
for him if he did not return. Thus, when Ruñez, Sr. failed to show up as of
closing time, and could not be found by the male nurse who looked for him
at her instructions, Dr. Jurado had reason to think that he had decided to
disregard her medical advice, which he in fact did when he and Ruñez, Jr.
decided to go to the hospital on their own. Ruñez, Sr., still of sound mind,
had the right to accept or ignore his doctor’s recommendation. Dr. Jurado
was obligated to care for Ruñez, Sr. when the latter asked for medical
treatment, which she did, but when he left on his own accord Dr. Jurado was
not expected, much less duty-bound, to seek out her patient and continue
being his doctor.
Some people may interpret Dr. Jurado’s inaction as indifference, while others
may view the same as just proper. Some would applaud Dr. Jurado’s
dedication had she done all the things mentioned by Atty. Candelaria and yet
others would see them as still insufficient. There will always be a divergence
of opinions as to how Dr. Jurado should have conducted herself but the
Court must distinguish between acts that deserve to be emulated or
disdained and those that deserve sanctions. The former is largely a matter of
opinion while the latter can only be imposed if there was a failure to perform
a clear duty, expectation or obligation. People may frown upon certain
behaviors and chastise others for having less compassion, but it does not
necessarily follow that those acts translate to neglect of duty, misconduct or
negligence.
Dr. Jurado could have exerted greater efforts by searching all over the
compound for Ruñez, Sr. but the fact remains that these were not part of her
duties nor were they expected from her. Simple neglect of duty presupposes a
task expected of an employee. Thus, it cannot be present if there was no
expected task on her part. That said, the Court wishes to exhort Dr. Jurado,
and all personnel in its clinic, not to be satisfied with merely fulfilling the
minimum, but to go for the magis, the best service they can render by way of
being exemplars for their fellow workers in the Court.
WHEREFORE, the Court finds no reason to hold Dr. Jurado liable for simple
neglect of duty, and, therefore, DISMISSES the complaint for lack of merit.
As recommended by Atty. Eden T. Candelaria, Deputy Clerk of Court and
Chief of Administrative Services, Dr. Prudencio Banzon, Senior Staff Officer,
Medical and Dental Services, is DIRECTED to prepare a flexi-time schedule
for all doctors and nurses in the clinic to further develop its capability to
provide immediate and proper attention in emergency medical situations,
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and to submit the same to Atty. Candelaria in 30 days from receipt of a copy
of this decision which should be served upon him forthwith.
Ruñez Jr. v. Dr. Jurado A.M. No. 2005-08-SC
Facts:
Ruñez, Sr. arrived by himself at the Courts clinic complaining of dizziness.
His blood pressure and pulse rate were taken by the reception nurse and
were registered at 210/100 mmHg and 112 beats a minute, Dr. Jurado then
instructed the nurse to administer one tablet of Capoten 25mg, an
emergency drug that quickly lowers a patients blood pressure. Dr Jurado
informed Ruez, Sr. that he will be taken to the hospital, after which she
immediately instructed the ambulance driver, Mr. Jacinto, to stand by for
hospital conduction. Minutes later, after having taken Capoten and being
given a chance to rest, Ruez, Sr. stood up and walked out saying, Doktora,
hanaplang ho ako ng kasama. Dr. Jurado said she waited for him to return
but he failed to show up.
According to Ruez, Jr (son of Ruez Sr.), after being informed of his father’s
condition, he rushed him to the Manila Doctors Hospital. The following
morning, he suffered a stroke and for a moment was on flat line.
On February 15, 2005, Ruez, Jr. filed a letter-complaint with the Office of the
Chief Justice regarding the alleged lack of attention given to his father by Dr.
Jurado, he claims that Dr. Jurado merely advised his father to go to the
hospital and then allowed him to travel to Manila Doctors Hospital despite
the availability of an ambulance at the disposal of the clinic.
Issue:
Whether or not Dr. Jurado be held liable for simple neglect of duty.
Held:
No. Simple neglect of duty is defined as failure to give proper attention to a
task expected of an employee resulting from either carelessness or
indifference or signifies a disregard of duty resulting from carelessness or
indifference.
Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in
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 DUMAUAL, JEANNE PAULINE J. 2019-2020

the Philippines 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 physician’s 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.

A doctors duty to his patient is not required to be extraordinary. The

standard contemplated for doctors is simply the reasonable average merit
among ordinarily good physicians, i.e. reasonable skill and competence.Dr.
Jurado fulfilled such a standard when she treated Ruez, Sr. inside the clinic.
Thus, when Ruez, Sr. failed to show up as of closing time, and could not be
found by the male nurse who looked for him at her instructions, Dr. Jurado
had reason to think that he had decided to disregard her medical advice,
which he in fact did when he and Ruez, Jr. decided to go to the hospital on
their own. Ruez, Sr., still of sound mind, had the right to accept or ignore his
doctors recommendation. Dr. Jurado was obligated to care for Ruez, Sr.
when the latter asked for medical treatment, which she did, but when he left
on his own accord Dr. Jurado was not expected, much less duty-bound, to
seek out her patient and continue being his doctor.

Simple neglect of duty presupposes a task expected of an employee. Thus, it

cannot be present if there was no expected task on her part.

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G.R. No. 142625 December 19, 2006
ROGELIO P. NOGALES, for himself and on behalf of the minors, ROGER
ANTHONY, ANGELICA, NANCY, and MICHAEL CHRISTOPHER, all
surnamed NOGALES, petitioners,
vs.
CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR. ELY
VILLAFLOR, DR. ROSA UY, DR. JOEL ENRIQUEZ, DR. PERPETUA
LACSON, DR. NOE ESPINOLA, and NURSE J. DUMLAO, respondents.
DECISION
CARPIO, J.:
The Case
This petition for review1 assails the 6 February 1998 Decision 2 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
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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 request 8 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
Page 62

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.
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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
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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
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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.
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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 2002 24 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 Hospital 27 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
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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 Hospital 31 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
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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
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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 Agreement 37 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
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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,
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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 facilities 43 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.
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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:
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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
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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
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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.
Page 69

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
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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
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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.
Atty. Yulo, Legal Medicine and Medical Jurisprudence
DUMAUAL, JEANNE PAULINE J. 2019-2020
OGELIO P. NOGALES, vs. CAPITOL MEDICAL CENTER, G.R. No. 142625,
December 19, 2006
FACTS:
Corazon Nogales (Corazon) was pregnant of her 4th child and was under the
exclusive prenatal care of Dr. Oscar Estrada (Dr. Estrada). On her last
trimester of pregnancy, Dr. Estrada noted an increase in Corazon’s blood
pressure and development of leg edema which may lead to a dangerous
complication of pregnancy. When Corazon started experiencing mild labor
pains, she and his husband Rogelio opted to see Dr. Estrada for examination,
and the latter advised them to admit Corazon to the Capitol Medical Center
(CMC). Short after Corazon’s bag of water ruptured, she started to experience
convulsions. Dr. Estrada and another physician in the name of Dr. Villaflor
began extracting the baby, which allegedly torn a piece of cervical tissue of
the patient. After the baby was taken out of the womb, Corazon began to
manifest moderate vaginal bleeding which rapidly became profuse. Despite
efforts to revive the patient, Corazon died. The cause of which was
“hemorrhage, post-partum.”
Rogelio Nogales, et al. (petitioners) filed a complaint for damages against
CMC, Dr. Estrada, and the other involved medical personnel of the hospital
(Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr. Lacson, Dr. Espinola, and a certain
Nurse J. Dumlao) for the death of Corazon, charging CMC with negligence in
the selection and supervision of defendant physicians and hospital staff.
The RTC (Manila) rendered judgment finding Dr. Estrada solely liable for
damages. In ruling the same, the Court finds no legal justification to find the
other impleaded physicians and hospital personnel civilly liable.
Upon appeal, petitioners claimed that aside from Dr. Estrada, the remaining
respondents should be held equally liable for negligence, pointing out the
extent of each respondent’s alleged liability.
The CA affirmed the decision of the trial court and on ruling the same, the
Court of Appeals applied the “borrowed servant” doctrine considering that Dr.
Estrada was an independent contractor who was merely exercising hospital
Page 71

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. 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. Hence, the
petition.
ISSUE:
Whether CMC is vicariously liable for the negligence of Dr. Estrada.
HELD:
YES. 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
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
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.
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 is 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,
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DUMAUAL, JEANNE PAULINE J. 2019-2020
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.”
x x x x
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 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.
Page 72
 DUMAUAL, JEANNE PAULINE J. 2019-2020

G.R. No. 126297 January 31, 2007 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
PROFESSIONAL SERVICES, INC., Petitioner, September 21, 1993.
vs.
NATIVIDAD and ENRIQUE AGANA, Respondents. The facts, as culled from the records, are:

x-----------------------x On April 4, 1984, Natividad Agana was rushed to the Medical City General
Hospital (Medical City Hospital) because of difficulty of bowel movement and
G.R. No. 126467 January 31, 2007 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."
NATIVIDAD (Substituted by her children MARCELINO AGANA III,
ENRIQUE AGANA, JR., EMMA AGANA ANDAYA, JESUS AGANA, and
RAYMUND AGANA) and ENRIQUE AGANA, Petitioners, On April 11, 1984, Dr. Ampil, assisted by the medical staff 4 of the Medical
vs. City Hospital, performed an anterior resection surgery on Natividad. He
JUAN FUENTES, Respondent. 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
x- - - - - - - - - - - - - - - - - - - -- - - - x Fuentes, respondent in G.R. No. 126467, to perform hysterectomy on her.

G.R. No. 127590 January 31, 2007 After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over,
completed the operation and closed the incision.
MIGUEL AMPIL, Petitioner,
vs. However, the operation appeared to be flawed. In the corresponding Record of
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents. Operation dated April 11, 1984, the attending nurses entered these remarks:

DECISION "sponge count lacking 2

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’ Decision2 dated September 6, 1996 in CA-G.R. CV No.
42062 and CA-G.R. SP No. 32198 affirming with modification the
"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.

Atty. Yulo, Legal Medicine and Medical Jurisprudence Page 73


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:
Atty. Yulo, Legal Medicine and Medical Jurisprudence
DUMAUAL, JEANNE PAULINE J. 2019-2020
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.
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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
Decision6 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.
Atty. Yulo, Legal Medicine and Medical Jurisprudence
DUMAUAL, JEANNE PAULINE J. 2019-2020
Only Dr. Ampil filed a motion for reconsideration, but it was denied in a
Resolution7 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
Page 75

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
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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. Zeagler 10 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 cause12 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
Page 76

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
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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
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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 regularly employ, on a salaried basis, a large staff of physicians, interns,
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
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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
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
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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-
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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:
Page 79

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.
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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
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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
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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.
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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.
PROFESSIONAL SERVICES, INC., vs. NATIVIDAD and ENRIQUE AGANA
G.R. No. 126297 January 31, 2007
Facts:
Natividad Agana was rushed to the Medical City Hospital because of difficulty
of bowel movement and bloody anal discharge. Dr. Miguel Ampil, diagnosed
her to be suffering from “cancer of the sigmoid.” 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, 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. 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.
Two weeks after Natividad returned from the United States to seek further
treatment, her daughter found a piece of gauze protruding from her vagina.
Upon being informed about it, Dr. Ampil proceeded to her house where he
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DUMAUAL, JEANNE PAULINE J. 2019-2020
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.
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.
Pending the outcome of the above cases, Natividad died and was duly
substituted by her children (the Aganas). The RTC rendered its Decision in
favor of the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable for
negligence and malpractice.
The Court of Appeals rendered its Decision dismissing the case against Dr.
Fuentes with Dr. Ampil liable to reimburse Professional Services, Inc.,
whatever amount the latter will pay or had paid to the plaintiffs.
Issues: Whether or not PSI may be held solidarily liable for the negligence of
Dr. Ampil.
Held: Yes, PSI is solidarily liable for the negligence of Dr. Ampil. In Ramos v.
Court of Appeals, the court held that private hospitals, hire, fire and exercise
real control over their attending and visiting ‘consultant’ staff. While
‘consultants’ are not, technically employees, 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. The court held 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.
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In addition to the pronouncement in Ramos vs CA, Its liability is also
anchored upon the agency principle of apparent authority or agency by
estoppel and the doctrine of corporate negligence.
Apparent authority, or what is sometimes referred to as the “holding out”
theory, or doctrine of ostensible agency or agency by estoppel, 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.
In this case, PSI publicly displays in the lobby of Hospital the names and
specializations of the physicians associated or accredited by it, including
those of Dr. Ampil and Dr. Fuentes. 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. 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.
Under the doctrine of corporate negligence or corporate responsibility, 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. Premised on the doctrine of corporate negligence, the
trial court held that PSI is directly liable for such breach of duty.
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.
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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, 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.
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 Dr. Ampil. In neglecting to offer such
proof, PSI failed to discharge its burden under the last paragraph of Article
2180 and, therefore, must be adjudged solidarily liable with Dr. Ampil.
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G.R. No. 160889 April 27, 2007
DR. MILAGROS L. CANTRE, Petitioner,
vs.
SPS. JOHN DAVID Z. GO and NORA S. GO, Respondents.
DECISION
QUISUMBING, J.:
For review on certiorari are the Decision 1 dated October 3, 2002 and
Resolution2 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.
The facts, culled from the records, are as follows:
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 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. 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 ½) by three and a half (3 ½)
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.
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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 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. 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, Nora’s 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
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. 12
Unfortunately, Nora’s arm would never be the same.1a\^/phi1.net 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;
Page 84

(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 attorney’s
fees; and
(e) to pay Six Thousand Pesos (P6,000.00) litigation expenses.
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 March 3, 1997 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, attorney’s fees and
expenses of litigation;1awphi1.nét
3. Dismissing the complaint with respect to defendants-appellants
Dr. Rainerio S. Abad and Delgado Clinic, Inc.;
4. Dismissing the counterclaims of defendants-appellants for lack of
merit; and
5. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay
the costs.
SO ORDERED.15
Petitioner’s motion for reconsideration was denied by the Court of Appeals.
Hence, the instant petition assigning the following as errors and issues:
I.
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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.
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 PETITIONER DRA.
CANTRE WAS NOT ABLE TO AMPLY EXPLAIN HOW THE INJURY
(BLISTERS) IN THE LEFT INNER ARM OF RESPONDENT MRS. GO CAME
ABOUT;
IV.
WHETHER OR NOT THE COURT OF APPEALS COMMITTED GRAVE ABUSE
OF ITS DISCRETION WHEN IT MADE A RULING ON THE RESPONDENT’S
INJURY QUOTING THE TESTIMONY OF SOMEONE WHO WAS NOT
PRESENT AND HAS NOT SEEN THE ORIGINAL, FRESH INJURY OF
RESPONDENT MRS. NORA GO;
V.
WHETHER OR NOT THE COURT OF APPEALS GRAVELY ABUSING ITS
DISCRETION RULED THAT PETITIONER DRA. CANTRE SHOULD HAVE
Page 85

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.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF
DISCRETION WHEN, CONTRARY TO THE MEDICAL PURPOSES OF
COSMETIC SURGERY, IT RULED THAT THE COSMETIC SURGERY MADE
THE SCARS EVEN MORE UGLY AND DECLARED THE COSMETIC
SURGERY A FAILURE;
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 Nora’s body. She maintains the injury
was due to the constant taking of Nora’s 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 respondent’s 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 petitioner’s
counsel. Respondents point out that petitioner’s blood pressure cuff theory is
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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 Nora’s 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 Nora’s medical records, which were produced by the hospital during trial
pursuant to a subpoena duces tecum. Petitioner’s 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.
Petitioner’s contention that the medico-legal officer who conducted Nora’s
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:
Page 86

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.18
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. 19 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 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, 20 for which petitioner cannot
escape liability under the "captain of the ship" doctrine.
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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.
We note, however, that petitioner has served well as Nora’s 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 Nora’s wound before infection
and other complications set in is also indicative of petitioner’s 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
petitioner’s 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 (₱200,000) 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.
Page 87
 DUMAUAL, JEANNE PAULINE J. 2019-2020

Cantre vs Go part of the person who controls the instrument causing the injury, provided
GR No. 160889 April 27, 2007 that the following requisites concur:

Facts: Petitioner Dr. Milagros L. Cantre is a specialist in obstetrics and 1. The accident is of a kind which ordinarily does not occur in the
gynecology at the Dr. Jesus Delgado memorial Hospital. She was the absence of someone’s negligence;
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 2. It is caused by an instrumentality within the exclusive control of the
her fourth child, a baby boy. However, at around 3:30am Nora suffered defendant or defendants;
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 3. The possibility of contributing conduct which would make the
40/0. Petitioner said the assisting resident physician performed various plaintiff responsible is eliminated.
medical procedures to stop the bleeding and to restore Nora’s blood pressure.
Her blood pressure was frequently monitored with the use of a All of these three requisites were present in the case at bar.
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 Under the the captain of the ship doctrine, the surgeon in charge of the
baby. Nora remained unconscious until she recovered. While in the recovery operation is liable for the negligence of his assistants during the time when
room, her husband, respondent John David Z. Go noticed a fresh gasping those are under the surgeons control.
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

Atty. Yulo, Legal Medicine and Medical Jurisprudence Page 88


G.R. No. 172406 October 11, 2007
CONCEPCION ILAO-ORETA, Petitioner,
vs.
SPOUSES EVA MARIE and BENEDICTO NOEL RONQUILLO, Respondents.
DECISION
CARPIO MORALES, J.:
Respondents, spouses Eva Marie Ronquillo (Eva Marie) and Noel Benedicto
(Noel) Ronquillo (the Ronquillo spouses or the spouses), had not been blessed
with a child despite several years of marriage. They thus consulted petitioner,
Dr. Concepcion Ilao-Oreta (Dr. Ilao-Oreta), an obstetrician-gynecologist-
consultant at the St. Luke’s Medical Center where she was, at the time
material to the case, the chief of the Reproductive Endocrinology and
Infertility Section.
Upon Dr. Ilao-Oreta’s advice, Eva Marie agreed to undergo a laparoscopic
procedure whereby a laparascope would be inserted through the patient’s
abdominal wall to get a direct view of her internal reproductive organ in order
to determine the real cause of her infertility.
The procedure was scheduled on April 5, 1999 at 2:00 p.m., to be performed
by Dr. Ilao-Oreta. At around 7:00 a.m. of said date, Eva Marie, accompanied
by her husband Noel, checked in at the St. Luke’s Medical Center and
underwent pre-operative procedures including the administration of
intravenous fluid and enema.
Dr. Ilao-Oreta did not arrive at the scheduled time for the procedure,
however, and no prior notice of its cancellation was received. It turned out
that the doctor was on a return flight from Hawaii to, and arrived at 10:00
p.m. of April 5, 1999 in, Manila.
On May 18, 1999, the Ronquillo spouses filed a complaint 1 against Dr. Ilao-
Oreta and the St. Luke’s Medical Center for breach of professional and
service contract and for damages before the Regional Trial Court (RTC) of
Batangas City. They prayed for the award of actual damages including
alleged loss of income of Noel while accompanying his wife to the hospital,
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moral damages, exemplary damages, the costs of litigation, attorney’s fees,
and other available reliefs and remedies. 2
In her Answer,3 Dr. Ilao-Oreta gave her side of the case as follows: She went
on a honeymoon to Hawaii and was scheduled to leave Hawaii at 3:00 p.m. of
April 4, 1999 for Manila. Aware that her trip from Hawaii to Manila would
take about 12 hours, inclusive of a stop-over at the Narita Airport in Japan,
she estimated that she would arrive in Manila in the early morning of April 5,
1999. She thus believed in utmost good faith that she would be back in
Manila in time for the scheduled conduct of the laparoscopic procedure. She
failed to consider the time difference between Hawaii and the Philippines,
however.
In its Answer,4 the St. Luke’s Medical Center contended that the spouses
have no cause of action against it since it performed the pre-operative
procedures without delay, and any cause of action they have would be
against Dr. Ilao-Oreta.
By Decision5 of March 9, 2001, Branch 84 of the Batangas RTC, finding that
the failure of the doctor to arrive on time was not intentional, awarded Eva
Marie only actual damages in the total amount of ₱9,939 and costs of suit. It
found no adequate proof that Noel had been deprived of any job contract
while attending to his wife in the hospital.
On appeal by the spouses, the Court of Appeals, by Decision 6 of April 21,
2006, finding Dr. Ilao-Oreta grossly negligent, 7 modified the trial court’s
decision as follows:
WHEREFORE, the trial Court’s decision dated March 9, 2001 is affirmed,
subject to the modification that the amount of actual damages, for which
both defendants-appellees are jointly and severally liable to plaintiffs-
appellants, is increased to P16,069.40. Furthermore, defendant-appellee Dr.
Ilao-Oreta is also held liable to pay plaintiff-appellants the following:
(a) P50,000.00 as moral damages;
(b) P25,000.00 as exemplary damages; and
(c) P20,000.00 as attorney’s fees.
Page 89

SO ORDERED.8 (Underscoring supplied)
Hence, the present Petition for Review 9 of Dr. Ilao-Oreta raising the following
arguments:
The court a quo erred in finding petitioner to have acted with gross
negligence and awarding moral damages to respondents. 10
The court a quo erred in awarding Exemplary Damages to respondents. 11
The court a quo [erred] in awarding Attorney’s Fees to respondents. 12
The court a quo erred in increasing the award of actual damages in favor of
respondents.13
"Gross negligence" implies a want or absence of or failure to exercise slight
care or diligence, or the entire absence of care. It evinces a thoughtless
disregard of consequences without exerting any effort to avoid them. 14 It is
characterized by want of even slight care, acting or omitting to act in a
situation where there is a duty to act, not inadvertently but willfully and
intentionally with a conscious indifference to consequences in so far as other
persons may be affected.15
The records show that before leaving for Hawaii, Dr. Ilao-Oreta left an
admitting order with her secretary for one of the spouses to pick up, apprised
Eva Marie of the necessary preparations for the procedure, and instructed
the hospital staff to perform pre-operative treatments. 16 These acts of the
doctor reflect an earnest intention to perform the procedure on the day and
time scheduled.
The records also show that on realizing that she missed the scheduled
procedure, Dr. Ilao-Oreta, upon arrival in Manila, immediately sought to
rectify the same, thus:
[ATTY SINJAN] Q: So, can you tell us the reason why you missed that
operation?
[DR. ILAO-ORETA] A: When I scheduled her for the surgery, I looked at my
ticket and so I was to leave Hawaii on April 4 at around 4:00 o’clock in the
afternoon, so I was computing 12 hours of travel including stop-over, then
probably I would be in Manila early morning of April 5, then I have so much
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time and I can easily do the case at 2:00 o’clock, you know it skipped my
mind the change in time.
Q: So when you arrived at 10:00 [PM] in Manila, what did you do?
A: I called immediately the hospital and I talked with the nurses, I asked
about the patient, Mrs. Ronquillo, and they told me that she has already left
at around 7:00.
Q: And after calling the hospital, what happened?
A: I wanted to call the plaintiffs, but I didn’t have their number at that time,
so in the morning I went to my office early at 8:00 and looked for her chart,
because her telephone number was written in the chart. So, I called them
right away.
Q: Were you able to contact them?
A: I was able to reach Mr. Ronquillo.
Q: In the course of your conversation, what did you tell Mr. Ronquillo?
A: I apologized to him, I said I was sorry about the time that I missed the
surgery, and I told him that I can do the case right that same day without
Mrs. Ronquillo having to undergo another [b]arium enema.
Q: What else did you tell him, if any?
A: I asked him whether I can talk with Mrs. Ronquillo because I wanted to
apologize to her personally.
Q: And what did he say?
A: I could hear on the background that Mrs. Ronquillo was shouting angrily
that she didn’t want to talk to me, and that she didn’t want re-scheduling of
the surgery . . .
ATTY LONTOK: May we move, your Honor, for the striking out of the answer,
this is purely hearsay.
Page 90

COURT: Remain on the record.
WITNESS [DR. ILAO-ORETA]: . . . and then Mr. Ronquillo told me "I’m sorry,
Dra., we cannot re-schedule the surgery." 17 (Underscoring supplied)
Noel admitted that indeed Dr. Ilao-Oreta called him up after she arrived in
Manila as related by her.18
The evidence then shows that Dr. Ilao-Oreta, who had traveled more than
twice to the United States where she obtained a fellowship in Reproductive
Endocrinology and Infertility was indeed negligent when she scheduled to
perform professional service at 2:00 p.m. on April 5, 1999 without
considering the time difference between the Philippines and Hawaii.
The doctor’s act did not, however, reflect gross negligence as defined above.
Her argument that
Although petitioner failed to take into consideration the time difference
between the Philippines and Hawaii, the situation then did not present any
clear and apparent harm or injury that even a careless person may perceive.
Unlike in situations where the Supreme Court had found gross negligence to
exist, petitioner could not have been conscious of any foreseeable danger that
may occur since she actually believed that she would make it to
the operation that was elective in nature, the only purpose of which was to
determine the real cause of infertility and not to treat and cure a life
threatening disease. Thus, in merely fixing the date of her appointment with
respondent Eva Marie Ronquillo, petitioner was not in the pursuit or
performance of conduct which any ordinary person may deem to probably
and naturally result in injury,19 (Underscoring in original)
thus persuades.
It bears noting that when she was scheduling the date of her performance of
the procedure, Dr. Ilao-Oreta had just gotten married and was preparing for
her honeymoon,20 and it is of common human knowledge that excitement
attends its preparations. Her negligence could then be partly attributed to
human frailty which rules out its characterization as gross.
The doctor’s negligence not being gross, the spouses are not entitled to
recover moral damages.
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Neither are the spouses entitled to recover exemplary damages in the
absence of a showing that Dr. Ilao-Oreta acted in a wanton, fraudulent,
reckless, oppressive or malevolent manner, 21 nor to award of attorney’s fees
as, contrary to the finding of the Court of Appeals that the spouses "were
compelled to litigate and incur expenses to protect their interest," 22 the
records show that they did not exert enough efforts to settle the matter before
going to court. Eva Marie herself testified:
ATTY. SINJIAN:
Q: Isn’t it true that before instituting this present case, you did not
make any demand on Dr. Ilao-Oreta regarding the claims which you
have allegedly incurred, because of the failed laparoscopic surgery
operation?
A [EVA MARIE]: I will tell the truth. Dr. Augusto Reyes of St.
Luke’s . . .
Q: But did you demand?
A: No, I did not demand because…
ATTY. SINJIAN: That will be all, your Honor.
ATTY. LONTOK: The witness is still explaining.
WITNESS: I’m explaining first. Dr. Augusto Reyes told me that he will
hold the meeting for me and Dr. Oreta to settle things and reimburse
all the money that I spent from the hospital, and he even suggested
Dr. Oreta to personally talk to me.
ATTY. SINJIAN:
Q: So it was to Dr. Augusto Reyes that you talked?
A: Yes.
Q: But you did not demand anything or write to Dr. Oreta?
A: No.
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 DUMAUAL, JEANNE PAULINE J. 2019-2020

Q: Before instituting this case? mere assertions, speculations, conjectures or guesswork but must depend
on competent proof and on the best evidence obtainable regarding the actual
A: No.23 (Underscoring supplied) amount of loss.28 (Underscoring supplied)

Finally, Dr. Ilao-Oreta’s prayer for the reduction of actual damages is well- The list of expenses cannot replace receipts when they should have been
taken. Article 2201 of the Civil Code provides: issued as a matter of course in business transactions 29 as in the case of
purchase of gasoline and of food.1âwphi1
In contracts and quasi-contracts, the damages for which the obligor who
acted in good faith is liable shall be those which are the natural and probable The documented claim for hospital and medical expenses of the spouses is
consequences of the breach of the obligation, and which the parties have detailed in the Statement of Account issued by the hospital, the pertinent
foreseen or could have reasonably foreseen at the time the obligation was entries of which read:
constituted.
xxxx
In fixing the amount of actual damages, the Court of Appeals and the trial
court included expenses which the spouses incurred prior to April 5, 1999 GROSS HOSPITAL CHARGES 2,416.50
when the breach of contract complained of occurred. 24 The Court of Appeals
also included the alleged ₱300 spent on fuel consumption from the spouses’ 4/5/1999 1699460 DEPOSIT–OFFICIAL
residence at San Pascual, Batangas to the St. Luke’s Medical Center in
Quezon City and the alleged ₱500 spent on food in the hospital canteen, both RECEIPT (5,000.00)
of which are unsubstantiated by independent or competent proof. 25 The only
(5,000.00)
piece of documentary evidence supporting the food and fuel expenses is an
unsigned listing.26 As the fuel and food expenses are not adequately
substantiated, they cannot be included in the computation of the amount of
4/5/199 SECON 028489 UNUSED 043953 (65.55)
actual damages. So Premiere Development Bank v. Court of
9 D 3 MED 4
Appeals27 instructs:
FLOOR HINOX 500
MG CAP
In the instant case, the actual damages were proven through the sole
testimony of Themistocles Ruguero, the vice president for administration of SECON 028489 UNUSED 043989 (62.25)
Panacor. In his testimony, the witness affirmed that Panacor incurred losses, D 4 MED 3
specifically, in terms of training and seminars, leasehold acquisition, FLOOR PHENERGA
procurement of vehicles and office equipment without, however, adducing N 2 ML
receipts to substantiate the same. The documentary evidence marked as
50MG ________ (127.80)
Exhibit "W," which was an ordinary private writing allegedly itemizing the
capital expenditures and losses from the failed operation of Panacor, was not
testified to by any witness to ascertain the veracity of its content. Although
BALANCE DUE (2,711.30)30
the lower court fixed the sum of P4,520,000.00 as the total expenditures
=========
incurred by Panacor, it failed to show how and in what manner the same
=
were substantiated by the claimant with reasonable certainty. Hence, the
claim for actual damages should be received with extreme caution since it is
only based on bare assertion without support from independent evidence. As extrapolated from the above-quoted entries in the Statement of Account,
Premiere’s failure to prove actual expenditure consequently conduces to a ₱2,288.70 (the gross hospital charges of ₱2,416.50 less the unused medicine
failure of its claim. In determining actual damages, the court cannot rely on in the amount of ₱127.80) was debited from the ₱5,000 deposit31 to thus

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leave a balance of the deposit in the amount of ₱2,711.30, which the trial
court erroneously denominated as "confinement fee." The remaining balance
of ₱2,711.30 was the amount refundable to the spouses.
Following Eastern Shipping Lines, Inc. v. Court of Appeals,32 this Court awards
interest on the actual damages to be paid by Dr. Ilao-Oreta at the rate of
6% per annum from the time of the filing of the complaint on May 18, 1999,
and at 12% per annum from the finality of this judgment until its
satisfaction.
WHEREFORE, the petition is GRANTED. The decision appealed from
is MODIFIED in that
1) the award to respondents-spouses Noel and Eva Marie Ronquillo
of actual damages is REDUCED to ₱2,288.70, to bear interest at a
rate of 6% per annum from the time of the filing of the complaint on
May 18, 1999 and, upon finality of this judgment, at the rate of
12% per annum until satisfaction; and
2) The award of moral and exemplary damages and attorney’s fees is
DELETED.
CONCEPCION ILAO-ORETA v. SPOUSES EVA MARIE and BENEDICTO
NOEL RONQUILLO, et al.
Respondent spouses Eva Marie Ronquillo and Noel Benedicto
Ronquillo had not been blessed with a child despite several years of
marriage. They thus consulted petitioner Dr. Concepcion Ilao-Oreta, an
obstetrician-gynecologist-consultant and chief of the Reproductive
Endocrinology and Infertility Section at the St. Luke‘s Medical Center. Dr.
Ilao-Oreta advised Eva Marie to undergo a laparoscopic procedure whereby a
laparascope would be inserted through the patient‘s abdominal wall to get a
direct view of her internal reproductive organ in order to determine the real
cause of her infertility.
The procedure was scheduled on April 5, 1999 at 2:00 p.m. to be
performed by Dr. Ilao-Oreta. Eva Marie, accompanied by Noel, checked in at
the St. Luke‘s Medical Center and underwent pre-operative procedures
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including the administration of intravenous fluid and enema. However, Dr.
Ilao-Oreta did not arrive at the scheduled time for the procedure and no prior
notice of its cancellation was received. It turned out that the doctor was on a
return flight from Hawaii to, and arrived at 10:00 p.m. of April 5, 1999 in,
Manila.
The Ronquillo spouses filed a complaint against Dr. Ilao-Oreta and
the St. Luke‘s Medical Center for breach of professional and
service contract and for damages before the Regional Trial Court of Batangas
City. They prayed for the award of actual damages including alleged loss of
income of Noel while accompanying his wife to the hospital, moral damages,
exemplary damages, costs of litigation, attorney‘s fees, and other available
reliefs and remedies. The RTC decided in favor of Ronquillo spouses and
awarded Eva Marie actual damages but ruled that the failure of the doctor
to arrive on time was not intentional. It found no adequate proof that Noel
had been deprived of any job contract while attending to his wife in the
hospital. The spouses appealed to the Court of Appeals and found that Dr.
Ilao-Oreta grossly negligent.
ISSUE:
Whether or not Dr. Ilao-Oreta is guilty of gross negligence for her failure
to arrive at the scheduled time for the procedure
HELD:
It bears noting that when she was scheduling the date of her performance of
the procedure, Dr. Ilao-Oreta had just gotten married and was preparing for
her honeymoon, and it is of common human knowledge that
excitement attends its preparations. Her negligence could then be
partly attributed to human frailty which rules out its characterization as
gross.
Dr. Ilao-Oreta‘s negligence not being gross, Ronquillo spouses are not
entitled to recover moral damages. Neither are the spouses entitled to recover
exemplary damages in the absence of a showing that Dr. Ilao-Oreta acted in
a wanton, fraudulent, reckless, oppressive or malevolent manner, nor to
award of attorney‘s fees as, contrary to the finding of the CA that the spouses
“were compelled to litigate and incur expenses to protect their interest,” the
records show that they did not exert enough efforts to settle the matter before
going to court.
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G.R. No. 158996 November 14, 2008
SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA
FLORES, petitioners,
vs.
SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO, and
FLORENCIO, CANDIDA, MARTA, GODOFREDO, BALTAZAR and LUCENA,
all surnamed PINEDA, as heirs of the deceased TERESITA S. PINEDA,
and UNITED DOCTORS MEDICAL CENTER, INC., respondents.
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
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DUMAUAL, JEANNE PAULINE J. 2019-2020
sum of P36,000.00 by way of actual and compensatory
damages; and
4) Deleting the award of attorney's 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
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 room at around 12 noon; the hospital staff forthwith
took her blood and urine samples for the laboratory tests 6 which Dr.
Fredelicto ordered.
Page 95

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 patient's
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. Teresita's 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.
Teresita's complete laboratory examination results came only on that day
(April 29, 1987). Teresita's 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, Teresita's 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 Teresita's 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 Teresita's family and awarded actual, moral, and
exemplary damages, plus attorney's fees and costs. 12 The CA affirmed the
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judgment, but modified the amount of damages awarded and deleted the
award for attorney's 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 COURT'S 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 Teresita's 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 one's
conduct.15 The standard in turn refers to the amount of competence
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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 Teresita's case. He opined that given the
blood sugar level of Teresita, her diabetic condition should have been
addressed first:
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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 Teresita's 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 Teresita's 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
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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 Teresita's 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 patient's 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 Teresita's 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.
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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. Mendoza36 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 dysfunction…The 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
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 DUMAUAL, JEANNE PAULINE J. 2019-2020

report did not include the 3+ status of sugar in the patient's urine 40 - a result
highly confirmatory of diabetes.
Because the D&C was merely an elective procedure, the patient's
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
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 plaintiff's 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 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.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:

The prudent move is to address the patient's hyperglycemic state Immediate cause: Cardiorespiratory arrest
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.
Antecedent cause: Septicemic shock, ketoacidocis

As Dr. Tan testified, the patient's 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 Underlying cause: Diabetes Mellitus II
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
Other significant conditions
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 Teresita's condition in the hospital.
contributing to death: Renal Failure - Acute47
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 Teresita's Stress, whether physical or emotional, is a factor that can aggravate
death is a matter we shall next determine. diabetes; a D&C operation is a form of physical stress. Dr. Mendoza

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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. 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 Teresita's 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 Teresita's death due to
aggravated diabetic condition is therefore sufficiently established.
The trial court and the appellate court pinned the liability for Teresita's death
on both the petitioner spouses and this Court finds no reason to rule
otherwise. However, we clarify that Dr. Fredelicto's 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
patient's vaginal bleeding complaint. Rather, it was his failure from the very
start to identify and confirm, despite the patient's 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.
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DUMAUAL, JEANNE PAULINE J. 2019-2020
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 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.
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 UDMC's petition for review on certiorari.
Since UDMC's appeal has been denied and they are not parties to this case,
we find it unnecessary to delve on the matter. Consequently, the RTC's
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 Teresita's confinement and death. The settled rule is
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 DUMAUAL, JEANNE PAULINE J. 2019-2020

that a plaintiff is entitled to be compensated for proven pecuniary loss. 52 This damages of P36,000.00; moral damages of P400,000.00; and exemplary
proof the respondents successfully presented. Thus, we affirm the award damages of P100,000.00.
of actual damages of P36,000.00 representing the hospital expenses the
patient incurred. 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
In addition to the award for actual damages, the respondent heirs of Teresita of attorney's fees and costs and restoring the award of P100,000.00 as
are likewise entitled to P50,000.00 as death indemnity pursuant to Article attorney's fees. Costs of litigation are adjudged against petitioner spouses.
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 To summarize, the following awards shall be paid to the family of the late
though there may have been mitigating circumstances xxx." This is a Teresita Pineda:
question of law that the CA missed in its decision and which we now decide in
the respondents' favor.
1. The sum of P36,000.00 by way of actual and compensatory damages;
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 2. The sum of P50,000.00 by way of death indemnity;
ascendants or descendants as the persons entitled thereto. Moral damages
are designed to compensate the claimant for the injury suffered, that is, for 3. The sum of P400,000.00 by way of moral damages;
the mental anguish, serious anxiety, wounded feelings which the
respondents herein must have surely felt with the unexpected loss of their 4. The sum of P100,000.00 by way of exemplary damages;
daughter. We affirm the appellate court's award of P400,000.00 by way
of moral damages to the respondents.
5. The sum of P100,000.00 by way of attorney's fees; and
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 6. Costs.
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 CA's award as an
example to the medical profession and to stress that the public good requires SPOUSES FLORES vs. SPOUSES PINEDA G.R. No. 158996, November
stricter measures to avoid the repetition of the type of medical malpractice 14, 2008
that happened in this case.
Facts:
With the award of exemplary damages, the grant of attorney's fees is legally Teresita, went to UDMC to get treatment with her vaginal bleeding. Petitioner
in order.56 We therefore reverse the CA decision deleting these awards, and arrived and checked up Teresita and admitted her in the hospital. She
grant the respondents the amount of P100,000.00 as attorney's fees taking scheduled the patient for a D&C operation to find out the cause of bleeding.
into consideration the legal route this case has taken. Before the operation, the patient was subjected to laboratory testing. Without
the complete laboratory test results, the petitioners proceeded with the
operation. After the operation, all the laboratory result arrived which
WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003 in
indicated that the patient has a very high blood sugar. The patient’s
CA G.R. CV No. 63234 finding petitioner spouses liable for negligent medical
condition worsen and dies. The respondent filed a medical negligence case
practice. We likewise AFFIRM the awards of actual and compensatory
against the petitioner which was granted by the RTC and affirmed by the CA.
Hence this case.

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 DUMAUAL, JEANNE PAULINE J. 2019-2020

Issue:
Whether the Petitioner spouses exercised due care and prudence in the
performance of their duties as medical professionals and did not commit
medical negligence.

Held:
No, 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.

Causal connection between the negligence which the evidence established

and the plaintiff’s injuries is the critical and clinching factor in a medical
negligence case; 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.

When the Petitioner proceeded with the operation without the comprehensive
pre-operative evaluation, constitute medical negligence.

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 DUMAUAL, JEANNE PAULINE J. 2019-2020

G.R. No. 159132 December 18, 2008 On November 7, 1994, Editha and her husband Claro Ramolete
(respondents) filed a Complaint 7 for Gross Negligence and Malpractice
FE CAYAO-LASAM, petitioner, against petitioner before the Professional Regulations Commission (PRC).
vs.
SPOUSES CLARO and EDITHA RAMOLETE, respondents.* Respondents alleged that Editha’s hysterectomy was caused by petitioner’s
unmitigated negligence and professional incompetence in conducting the
DECISION D&C procedure and the petitioner’s failure to remove the fetus inside
Editha’s womb.8 Among the alleged acts of negligence were: first, petitioner’s
failure to check up, visit or administer medication on Editha during her first
AUSTRIA-MARTINEZ, J.: day of confinement at the LMC;9 second, petitioner recommended that a D&C
procedure be performed on Editha without conducting any internal
Before the Court is a Petition for Review on Certiorari under Rule 45 of the examination prior to the procedure; 10 third, petitioner immediately suggested
Rules of Court filed by Dr. Fe Cayao-Lasam (petitioner) seeking to annul the a D&C procedure instead of closely monitoring the state of pregnancy of
Decision1 dated July 4, 2003 of the Court of Appeals (CA) in CA-G.R. SP No. Editha.11
62206.
In her Answer,12 petitioner denied the allegations of negligence and
The antecedent facts: incompetence with the following explanations: upon Editha’s confirmation
that she would seek admission at the LMC, petitioner immediately called the
On July 28, 1994, respondent, three months pregnant Editha Ramolete hospital to anticipate the arrival of Editha and ordered through the telephone
(Editha) was brought to the Lorma Medical Center (LMC) in San Fernando, La the medicines Editha needed to take, which the nurses carried out; petitioner
Union due to vaginal bleeding. Upon advice of petitioner visited Editha on the morning of July 28, 1994 during her rounds; on July
relayed via telephone, Editha was admitted to the LMC on the same day. A 29, 1994, she performed an internal examination on Editha and she
pelvic sonogram2 was then conducted on Editha revealing the fetus’ weak discovered that the latter’s cervix was already open, thus, petitioner
cardiac pulsation.3 The following day, Editha’s repeat pelvic discussed the possible D&C procedure, should the bleeding become more
4
sonogram showed that aside from the fetus’ weak cardiac pulsation, no fetal profuse; on July 30 1994, she conducted another internal examination on
movement was also appreciated. Due to persistent and profuse vaginal Editha, which revealed that the latter’s cervix was still open; Editha
bleeding, petitioner advised Editha to undergo a Dilatation and Curettage persistently complained of her vaginal bleeding and her passing out of some
Procedure (D&C) or "raspa." meaty mass in the process of urination and bowel movement; thus, petitioner
advised Editha to undergo D&C procedure which the respondents consented
to; petitioner was very vocal in the operating room about not being able to see
On July 30, 1994, petitioner performed the D&C procedure. Editha was an abortus;13 taking the words of Editha to mean that she was passing out
discharged from the hospital the following day. some meaty mass and clotted blood, she assumed that the abortus must
have been expelled in the process of bleeding; it was Editha who insisted that
On September 16, 1994, Editha was once again brought at the LMC, as she she wanted to be discharged; petitioner agreed, but she advised Editha to
was suffering from vomiting and severe abdominal pains. Editha was return for check-up on August 5, 1994, which the latter failed to do.
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 Petitioner contended that it was Editha’s gross negligence and/or omission in
the latter’s womb. After, Editha underwent laparotomy, 5 she was found to insisting to be discharged on July 31, 1994 against doctor’s advice and her
have a massive intra-abdominal hemorrhage and a ruptured uterus. Thus, unjustified failure to return for check-up as directed by petitioner that
Editha had to undergo a procedure for hysterectomy 6 and as a result, she contributed to her life-threatening condition on September 16, 1994; that
has no more chance to bear a child. Editha’s hysterectomy was brought about by her very abnormal pregnancy
known as placenta increta, which was an extremely rare and very unusual

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case of abdominal placental implantation. Petitioner argued that whether or
not a D&C procedure was done by her or any other doctor, there would be no
difference at all because at any stage of gestation before term, the uterus
would rupture just the same.
On March 4, 1999, the Board of Medicine (the Board) of the PRC rendered a
Decision,14 exonerating petitioner from the charges filed against her. The
Board held:
Based on the findings of the doctors who conducted the laparotomy
on Editha, hers is a case of Ectopic Pregnancy Interstitial. This type
of ectopic pregnancy is one that is being protected by the uterine
muscles and manifestations may take later than four (4) months and
only attributes to two percent (2%) of ectopic pregnancy cases.
When complainant Editha was admitted at Lorma Medical Center on
July 28, 1994 due to vaginal bleeding, an ultra-sound was performed
upon her and the result of the Sonogram Test reveals a morbid fetus
but did not specify where the fetus was located. Obstetricians will
assume that the pregnancy is within the uterus unless so specified
by the Sonologist who conducted the ultra-sound. Respondent (Dr.
Lasam) cannot be faulted if she was not able to determine that
complainant Editha is having an ectopic pregnancy interstitial. The
D&C conducted on Editha is necessary considering that her cervix is
already open and so as to stop the profuse bleeding. Simple
curettage cannot remove a fetus if the patient is having an ectopic
pregnancy, since ectopic pregnancy is pregnancy conceived outside
the uterus and curettage is done only within the uterus. Therefore, a
more extensive operation needed in this case of pregnancy in order to
remove the fetus.15
Feeling aggrieved, respondents went to the PRC on appeal. On November 22,
2000, the PRC rendered a Decision 16 reversing the findings of the Board and
revoking petitioner’s authority or license to practice her profession as a
physician.17
Petitioner brought the matter to the CA in a Petition for Review under Rule
43 of the Rules of Court. Petitioner also dubbed her petition as one
for certiorari18 under Rule 65 of the Rules of Court.
In the Decision dated July 4, 2003, the CA held that the Petition for Review
under Rule 43 of the Rules of Court was an improper remedy, as the
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DUMAUAL, JEANNE PAULINE J. 2019-2020
enumeration of the quasi-judicial agencies in Rule 43 is exclusive. 19 PRC is
not among the quasi-judicial bodies whose judgment or final orders are
subject of a petition for review to the CA, thus, the petition for review of the
PRC Decision, filed at the CA, was improper. The CA further held that should
the petition be treated as a petition for certiorari under Rule 65, the same
would still be dismissed for being improper and premature. Citing Section
2620 of Republic Act (R.A.) No. 2382 or the Medical Act of 1959, the CA held
that the plain, speedy and adequate remedy under the ordinary course of law
which petitioner should have availed herself of was to appeal to the Office of
the President.21
Hence, herein petition, assailing the decision of the CA on the following
grounds:
1. THE COURT OF APPEALS ERRED ON A QUESTION OF LAW IN
HOLDING THAT THE PROFESSIONAL REGULATION[S]
COMMISSION (PRC) WAS EXCLUDED AMONG THE QUASI-
JUDICIAL AGENCIES CONTEMPLATED UNDER RULE 43 OF THE
RULES OF CIVIL PROCEDURE;
2. EVEN ASSUMING, ARGUENDO, THAT PRC WAS EXCLUDED
FROM THE PURVIEW OF RULE 43 OF THE RULES OF CIVIL
PROCEDURE, THE PETITIONER WAS NOT PRECLUDED FROM
FILING A PETITION FOR CERTIORARI WHERE THE DECISION WAS
ALSO ISSUED IN EXCESS OF OR WITHOUT JURISDICTION, OR
WHERE THE DECISION WAS A PATENT NULLITY;
3. HEREIN RESPONDENTS-SPOUSES ARE NOT ALLOWED BY LAW
TO APPEAL FROM THE DECISION OF THE BOARD OF MEDICINE
TO THE PROFESSIONAL REGULATION[S] COMMISSION;
4. THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF
DISCRETION IN DENYING FOR IMPROPER FORUM THE PETITION
FOR REVIEW/PETITION FOR CERTIORARI WITHOUT GOING OVER
THE MERITS OF THE GROUNDS RELIED UPON BY THE
PETITIONER;
5. PRC’S GRAVE OMISSION TO AFFORD HEREIN PETITONER A
CHANCE TO BE HEARD ON APPEAL IS A CLEAR VIOLATION OF
HER CONSTITUTIONAL RIGHT TO DUE PROCESS AND HAS THE
EFFECT OF RENDERING THE JUDGMENT NULL AND VOID;
Page 104

6. COROLLARY TO THE FOURTH ASSIGNED ERROR, PRC
COMMITTED GRAVE ABUSE OF DISCRETION, AMOUNTING TO
LACK OF JURISDICTION, IN ACCEPTING AND CONSIDERING THE
MEMORANDUM ON APPEAL WITHOUT PROOF OF SERVICE TO
HEREIN PETITIONER, AND IN VIOLATION OF ART. IV, SEC. 35 OF
THE RULES AND REGULATIONS GOVERNING THE REGULATION
AND PRACTICE OF PROFESSIONALS;
7. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN REVOKING
PETITIONER’S LICENSE TO PRACTICE MEDICINE WITHOUT AN
EXPERT TESTIMONY TO SUPPORT ITS CONCLUSION AS TO THE
CAUSE OF RESPONDENT EDITHAT [SIC] RAMOLETE’S INJURY;
8. PRC COMMITTED AN EVEN GRAVER ABUSE OF DISCRETION IN
TOTALLY DISREGARDING THE FINDING OF THE BOARD OF
MEDICINE, WHICH HAD THE NECESSARY COMPETENCE AND
EXPERTISE TO ESTABLISH THE CAUSE OF RESPONDENT
EDITHA’S INJURY, AS WELL AS THE TESTIMONY OF THE EXPERT
WITNESS AUGUSTO MANALO, M.D. ;[and]
9. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN MAKING
CONCLUSIONS OF FACTS THAT WERE NOT ONLY UNSUPPORTED
BY EVIDENCE BUT WERE ACTUALLY CONTRARY TO EVIDENCE
ON RECORD.22
The Court will first deal with the procedural issues.
Petitioner claims that the law does not allow complainants to appeal to the
PRC from the decision of the Board. She invokes Article IV, Section 35 of the
Rules and Regulations Governing the Regulation and Practice of
Professionals, which provides:
Sec. 35. The respondent may appeal the decision of the Board within
thirty days from receipt thereof to the Commission whose decision
shall be final. Complainant, when allowed by law, may interpose
an appeal from the Decision of the Board within the same
period. (Emphasis supplied)
Petitioner asserts that a careful reading of the above law indicates that while
the respondent, as a matter of right, may appeal the Decision of the Board to
the Commission, the complainant may interpose an appeal from the decision
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DUMAUAL, JEANNE PAULINE J. 2019-2020
of the Board only when so allowed by law. 23 Petitioner cited Section 26 of
Republic Act No. 2382 or "The Medical Act of 1959," to wit:
Section 26. Appeal from judgment. The decision of the Board of
Medical Examiners (now Medical Board) shall automatically become
final thirty days after the date of its promulgation unless the
respondent, during the same period, has appealed to the
Commissioner of Civil Service (now Professional Regulations
Commission) and later to the Office of the President of the
Philippines. If the final decision is not satisfactory, the respondent
may ask for a review of the case, or may file in court a petition for
certiorari.
Petitioner posits that the reason why the Medical Act of 1959 allows only the
respondent in an administrative case to file an appeal with the Commission
while the complainant is not allowed to do so is double jeopardy. Petitioner is
of the belief that the revocation of license to practice a profession is penal in
nature.24
The Court does not agree.
For one, the principle of double jeopardy finds no application in
administrative cases. Double jeopardy attaches only: (1) upon a valid
indictment; (2) before a competent court; (3) after arraignment; (4) when a
valid plea has been entered; and (5) when the defendant was acquitted or
convicted, or the case was dismissed or otherwise terminated without the
express consent of the accused.25 These elements were not present in the
proceedings before the Board of Medicine, as the proceedings involved in the
instant case were administrative and not criminal in nature. The Court has
already held that double jeopardy does not lie in administrative cases. 26
Moreover, Section 35 of the Rules and Regulations Governing the Regulation
and Practice of Professionals cited by petitioner was subsequently amended
to read:
Sec. 35. The complainant/respondent may appeal the order, the
resolution or the decision of the Board within thirty (30) days from
receipt thereof to the Commission whose decision shall be final and
executory. Interlocutory order shall not be appealable to the
Commission. (Amended by Res. 174, Series of 1990). 27 (Emphasis
supplied)
Page 105

Whatever doubt was created by the previous provision was settled with said
amendment. It is axiomatic that the right to appeal is not a natural right or a
part of due process, but a mere statutory privilege that may be exercised only
in the manner prescribed by law. 28 In this case, the clear intent of the
amendment is to render the right to appeal from a decision of the Board
available to both complainants and respondents.
Such conclusion is bolstered by the fact that in 2006, the PRC issued
Resolution No. 06-342(A), or the New Rules of Procedure in Administrative
Investigations in the Professional Regulations Commission and the
Professional Regulatory Boards, which provides for the method of appeal, to
wit:
Sec. 1. Appeal; Period Non-Extendible.- The decision, order or
resolution of the Board shall be final and executory after the lapse of
fifteen (15) days from receipt of the decision, order or resolution
without an appeal being perfected or taken by either the respondent
or the complainant. A party aggrieved by the decision, order or
resolution may file a notice of appeal from the decision, order or
resolution of the Board to the Commission within fifteen (15)
days from receipt thereof, and serving upon the adverse party a
notice of appeal together with the appellant’s brief or memorandum
on appeal, and paying the appeal and legal research fees. x x x 29
The above-stated provision does not qualify whether only the complainant or
respondent may file an appeal; rather, the new rules provide that "a party
aggrieved" may file a notice of appeal. Thus, either the complainant or the
respondent who has been aggrieved by the decision, order or resolution of the
Board may appeal to the Commission. It is an elementary rule that when the
law speaks in clear and categorical language, there is no need, in the absence
of legislative intent to the contrary, for any interpretation. 30 Words and
phrases used in the statute should be given their plain, ordinary, and
common usage or meaning.31
Petitioner also submits that appeals from the decisions of the PRC should be
with the CA, as Rule 43 32 of the Rules of Court was precisely formulated and
adopted to provide for a uniform rule of appellate procedure for quasi-judicial
agencies.33 Petitioner further contends that a quasi-judicial body is not
excluded from the purview of Rule 43 just because it is not mentioned
therein.34
On this point, the Court agrees with the petitioner.
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DUMAUAL, JEANNE PAULINE J. 2019-2020
Sec. 1, Rule 43 of the Rules of Court provides:
Section 1. Scope. - This Rule shall apply to appeals from judgments
or final orders of the Court of Tax Appeals, and from awards,
judgments, final orders or resolutions of or authorized by any
quasi-judicial agency in the exercise of its quasi-judicial
functions. Among these agencies are the Civil Service Commission,
Central Board of Assessment Appeals, Securities and Exchange
Commission, Office of the President, Land Registration Authority,
Social Security Commission, Civil Aeronautics Board, Bureau of
Patents, Trademarks and Technology Transfer, National
Electrification Administration, Energy Regulatory Board, National
Telecommunications Commission, Department of Agrarian Reform
under Republic Act No. 6657, Government Service Insurance
System, Employees Compensation Commission, Agricultural
Inventions Board, Insurance Commission, Philippine Atomic Energy
Commission, Board of Investments, Construction Industry
Arbitration Commission, and voluntary arbitrators authorized by
law. (Emphasis supplied)
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. 35 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.36
Specifically, the Court, in Yang v. Court of Appeals,37 ruled
38
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
Page 106

Regulations Commission are now exclusively cognizable by the
Court of Appeals.39 (Emphasis supplied)
Clearly, the enactment of B.P. Blg. 129, the precursor of the present Rules of
Civil Procedure,40 lodged with the CA such jurisdiction over the appeals of
decisions made by the PRC.
Anent the substantive merits of the case, petitioner questions the PRC
decision for being without an expert testimony to support its conclusion and
to establish the cause of Editha’s injury. Petitioner avers that in cases of
medical malpractice, expert testimony is necessary to support the conclusion
as to the cause of the injury.41
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.42 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. 43
There are four elements involved in medical negligence cases: duty, breach,
injury and proximate causation.44
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. 45 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. 46 As to this aspect of medical malpractice,
the determination of the reasonable level of care and the breach thereof,
expert testimony is essential.47 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.48
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.
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DUMAUAL, JEANNE PAULINE J. 2019-2020
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.49
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. 50 According to him, his diagnosis of Editha’s
case was "Ectopic Pregnancy Interstitial (also referred to as Cornual),
Ruptured."51 In stating that the D&C procedure was not the proximate cause
of the rupture of Editha’s uterus resulting in her hysterectomy, Dr. Manalo
testified as follows:
Atty. Hidalgo:
Q: Doctor, we want to be clarified on this matter. The complainant
had testified here that the D&C was the proximate cause of the
rupture of the uterus. The condition which she found herself in on
the second admission. Will you please tell us whether that is true or
not?
A: Yah, I do not think so for two reasons. One, as I have said
earlier, the instrument cannot reach the site of the pregnancy, for it
to further push the pregnancy outside the uterus. And, No. 2, I was
thinking a while ago about another reason- well, why I don’t think
so, because it is the triggering factor for the rupture, it could have–
the rupture could have occurred much earlier, right after the D&C or
a few days after the D&C.
Q: In this particular case, doctor, the rupture occurred to have
happened minutes prior to the hysterectomy or right upon admission
on September 15, 1994 which is about 1 ½ months after the patient
was discharged, after the D&C was conducted. Would you tell us
whether there is any relation at all of the D&C and the rupture in
this particular instance?
A: I don’t think so for the two reasons that I have just
mentioned- that it would not be possible for the instrument to
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reach the site of pregnancy. And, No. 2, if it is because of the D&C
that rupture could have occurred earlier.52 (Emphases supplied)
Clearly, from the testimony of the expert witness and the reasons given by
him, it is evident that the D&C procedure was not the proximate cause of the
rupture of Editha’s uterus.
During his cross-examination, Dr. Manalo testified on how he would have
addressed Editha’s condition should he be placed in a similar circumstance
as the petitioner. He stated:
Atty. Ragonton:
Q: Doctor, as a practicing OB-Gyne, when do you consider that
you have done a good, correct and ideal dilatation and curettage
procedure?
A: Well, if the patient recovers. If the patient gets well. Because
even after the procedure, even after the procedure you may feel that
you have scraped everything, the patient stops bleeding, she feels
well, I think you should still have some reservations, and wait a little
more time.
Q: If you were the OB-Gyne who performed the procedure on
patient Editha Ramolete, would it be your standard practice to check
the fetal parts or fetal tissues that were allegedly removed?
A: From what I have removed, yes. But in this particular case, I
think it was assumed that it was part of the meaty mass which was
expelled at the time she was urinating and flushed in the toilet. So
there’s no way.
Q: There was [sic] some portions of the fetal parts that were
removed?
A: No, it was described as scanty scraping if I remember it right–
scanty.
Q: And you would not mind checking those scant or those little
parts that were removed?
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A: Well, the fact that it was described means, I assume that it
was checked, ‘no. It was described as scanty and the color also, I
think was described. Because it would be very unusual, even
improbable that it would not be examined, because when you
scrape, the specimens are right there before your eyes. It’s in
front of you. You can touch it. In fact, some of them will stick to
the instrument and therefore to peel it off from the instrument,
you have to touch them. So, automatically they are examined
closely.
Q: As a matter of fact, doctor, you also give telephone orders to
your patients through telephone?
A: Yes, yes, we do that, especially here in Manila because you
know, sometimes a doctor can also be tied-up somewhere and if you
have to wait until he arrive at a certain place before you give the
order, then it would be a lot of time wasted. Because if you know
your patient, if you have handled your patient, some of the
symptoms you can interpret that comes with practice. And, I see no
reason for not allowing telephone orders unless it is the first
time that you will be encountering the patient. That you have no
idea what the problem is.
Q: But, doctor, do you discharge patients without seeing them?
A: Sometimes yes, depending on how familiar I am with the
patient. We are on the question of telephone orders. I am not saying
that that is the idle [sic] thing to do, but I think the reality of
present day practice somehow justifies telephone orders. I have
patients whom I have justified and then all of a sudden, late in the
afternoon or late in the evening, would suddenly call they have
decided that they will go home inasmuch as they anticipated that I
will discharge them the following day. So, I just call and ask our
resident on duty or the nurse to allow them to go because I have
seen that patient and I think I have full grasp of her problems. So,
that’s when I make this telephone orders. And, of course before
giving that order I ask about how she feels. 53 (Emphases supplied)
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
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under the same circumstances, and that there was nothing irregular in the
way the petitioner dealt with Editha.
Medical malpractice, in our jurisdiction, is often brought as a civil action for
damages under Article 217654 of the Civil Code. The defenses in an action for
damages, provided for under Article 2179 of the Civil Code are:
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.
Proximate cause has been defined as that which, in natural and continuous
sequence, unbroken by any efficient intervening cause, produces injury, and
without which the result would not have occurred. 55 An injury or damage is
proximately caused by an act or a failure to act, whenever it appears from the
evidence in the case that the act or omission played a substantial part in
bringing about or actually causing the injury or damage; and that the injury
or damage was either a direct result or a reasonably probable consequence of
the act or omission.56
In the present case, the Court notes the findings of the Board of Medicine:
When complainant was discharged on July 31, 1994,
herein respondent advised her to return on August 4, 1994 or
four (4) days after the D&C. This advise was clear in
complainant’s Discharge Sheet. However, complainant failed to
do so. This being the case, the chain of continuity as required in
order that the doctrine of proximate cause can be validly invoked was
interrupted. Had she returned, the respondent could have
examined her thoroughly.57 x x x (Emphases supplied)
Also, in the testimony of Dr. Manalo, he stated further that assuming that
there was in fact a misdiagnosis, the same would have been rectified if
Editha followed the petitioner’s order to return for a check-up on August 4,
1994. Dr. Manalo stated:
Granting that the obstetrician-gynecologist has been misled
(justifiably) up to thus point that there would have been ample
opportunity to rectify the misdiagnosis, had the patient
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returned, as instructed for her follow-up evaluation. It was one
and a half months later that the patient sought consultation
with another doctor. The continued growth of an ectopic
pregnancy, until its eventual rupture, is a dynamic process. Much
change in physical findings could be expected in 1 ½ months,
including the emergence of suggestive ones. 58
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. 59 Difficulty
seems to be apprehended in deciding which acts of the injured party shall be
considered immediate causes of the accident. 60 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.61 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.
Lastly, petitioner asserts that her right to due process was violated because
she was never informed by either respondents or by the PRC that an appeal
was pending before the PRC. 62 Petitioner claims that a verification with the
records section of the PRC revealed that on April 15, 1999, respondents filed
a Memorandum on Appeal before the PRC, which did not attach the actual
registry receipt but was merely indicated therein. 63
Respondents, on the other hand avers that if the original registry receipt was
not attached to the Memorandum on Appeal, PRC would not have
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entertained the appeal or accepted such pleading for lack of notice or proof of
service on the other party.64 Also, the registry receipt could not be appended
to the copy furnished to petitioner’s former counsel, because the registry
receipt was already appended to the original copy of the Memorandum of
Appeal filed with PRC.65
It is a well-settled rule that when service of notice is an issue, the rule is that
the person alleging that the notice was served must prove the fact of service.
The burden of proving notice rests upon the party asserting its existence. 66 In
the present case, respondents did not present any proof that petitioner was
served a copy of the Memorandum on Appeal. Thus, respondents were not
able to satisfy the burden of proving that they had in fact informed the
petitioner of the appeal proceedings before the PRC.
In EDI-Staffbuilders International, Inc. v. National Labor Relations
Commission,67 in which the National Labor Relations Commission failed to
order the private respondent to furnish the petitioner a copy of the Appeal
Memorandum, the Court held that said failure deprived the petitioner of
procedural due process guaranteed by the Constitution, which could have
served as basis for the nullification of the proceedings in the appeal. The
same holds true in the case at bar. The Court finds that the failure of the
respondents to furnish the petitioner a copy of the Memorandum of Appeal
submitted to the PRC constitutes a violation of due process. Thus, the
proceedings before the PRC were null and void.
All told, doctors are protected by a special rule of law. They are not
guarantors of care. They are not insurers against mishaps or unusual
consequences68 specially so if the patient herself did not exercise the proper
diligence required to avoid the injury.
WHEREFORE, the petition is GRANTED. The assailed Decision of the Court
of Appeals dated July 4, 2003 in CA-GR SP No. 62206 is
hereby REVERSED and SET ASIDE. The Decision of the Board of Medicine
dated March 4, 1999 exonerating petitioner is AFFIRMED. No
pronouncement as to costs.
SO ORDERED.
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Lasam vs. Sps. Ramolete G.R. No. 159132 December 8, 2008
Facts:
On July 1994, respondent three months pregnant Editha Ramolete was
brought to the Lorma Medical Center (LMC) to vaginal bleeding. A pelvic
sonogram was then conducted on Editha revealing the fetus weak cardiac
pulsation. 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 Dr. Fe Cayao-Lasam
advised Editha to undergo a Dilatation and Curettage Procedure (D&C) or
raspa which the petitioner performed.
On September 1994, Editha was brought again to LMC due to vomiting and
severe abdominal pains. One of the attending physician, Dr. Mayo allegedly
informed Editha that there was a dead fetus in her womb. Editha underwent
laparotomy where she was found to have a massive intra-abdominal
hemorrhage and a ruptured uterus. Editha had to undergo a procedure for
hysterectomy and as a result, she has no more chance to bear a child.
On November 1994, Editha and her husband Claro Ramolete filed a
Complaint for Gross Negligence and Malpractice against petitioner before the
PRC.
Respondents alleged that Editha’s hysterectomy was caused by petitioners
unmitigated negligence and professional incompetence in conducting the
D&C procedure and the petitioners failure to remove the fetus inside Editha’s
womb. Petitioner denied the allegations of negligence and incompetence
On March 1999, Board of Medicine of the PRC exonerated petitioner from the
charges filed against her. Feeling aggrieved, respondents went to the PRC on
appeal. On November 2000, the PRC reversed the findings of the Board and
revoked petitioners authority or license to practice her profession as a
physician. Petitioner brought the matter to the CA but was dismissed on the
ground of being improper and premature.
Issue: WON there was medical malpractice in the case?
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 DUMAUAL, JEANNE PAULINE J. 2019-2020

Held: There was no medical malpractice in the case. 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
Medical malpractice is a particular form of negligence which consists in the is clear that Editha’s omission was the proximate cause of her own injury
failure of a physician or surgeon to apply to his practice of medicine that and not merely a contributory negligence on her part.
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.

From the testimony of the expert witness and the reasons given by him, it is
evident that the D&C procedure was not the proximate cause of the rupture
of Editha’s uterus. Further in the 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.

Medical malpractice is often brought as a civil action for damages under

Article 2176 of the Civil Code. The defenses in an action for damages,
provided for under Article 2179 of the Civil Code are:

Art. 2179. When the plaintiffs 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 defendants lack of due care, the plaintiff may recover
damages, but the courts shall mitigate the damages to be awarded.

It is also undisputed that Editha did not return for a follow-up evaluation, in
defiance of the petitioners 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

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G.R. No. 178763 April 21, 2009
PETER PAUL PATRICK LUCAS, FATIMA GLADYS LUCAS, ABBEYGAIL
LUCAS AND GILLIAN LUCAS, Petitioners,
vs.
DR. PROSPERO MA. C. TUAÑO, Respondent.
DECISION
CHICO-NAZARIO, J.:
In this petition for review on certiorari 1 under Rule 45 of the Revised Rules of
Court, petitioners Peter Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail
Lucas and Gillian Lucas seek the reversal of the 27 September 2006
Decision2 and 3 July 2007 Resolution,3 both of the Court of Appeals in CA-
G.R. CV No. 68666, entitled "Peter Paul Patrick Lucas, Fatima Gladys Lucas,
Abbeygail Lucas and Gillian Lucas v. Prospero Ma. C. Tuaño."
In the questioned decision and resolution, the Court of Appeals affirmed the
14 July 2000 Decision of the Regional Trial Court (RTC), Branch 150, Makati
City, dismissing the complaint filed by petitioners in a civil case entitled,
"Peter Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian
Lucas v. Prospero Ma. C. Tuaño," docketed as Civil Case No. 92-2482.
From the record of the case, the established factual antecedents of the
present petition are:
Sometime in August 1988, petitioner Peter Paul Patrick Lucas (Peter)
contracted "sore eyes" in his right eye.
On 2 September 1988, complaining of a red right eye and swollen eyelid,
Peter made use of his health care insurance issued by Philamcare Health
Systems, Inc. (Philamcare), for a possible consult. The Philamcare
Coordinator, Dr. Edwin Oca, M.D., referred Peter to respondent, Dr. Prospero
Ma. C. Tuaño, M.D. (Dr. Tuaño), an ophthalmologist at St. Luke’s Medical
Center, for an eye consult.
Upon consultation with Dr. Tuaño, Peter narrated that it had been nine (9)
days since the problem with his right eye began; and that he was already
taking Maxitrol to address the problem in his eye. According to Dr. Tuaño, he
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performed "ocular routine examination" on Peter’s eyes, wherein: (1) a gross
examination of Peter’s eyes and their surrounding area was made; (2) Peter’s
visual acuity were taken; (3) Peter’s eyes were palpated to check the
intraocular pressure of each; (4) the motility of Peter’s eyes was observed;
and (5) the ophthalmoscopy4 on Peter’s eyes was used. On that particular
consultation, Dr. Tuaño diagnosed that Peter was suffering from
conjunctivitis5 or "sore eyes." Dr. Tuaño then prescribed Spersacet-C 6 eye
drops for Peter and told the latter to return for follow-up after one week.
As instructed, Peter went back to Dr. Tuaño on 9 September 1988. Upon
examination, Dr. Tuaño told Peter that the "sore eyes" in the latter’s right eye
had already cleared up and he could discontinue the Spersacet-C. However,
the same eye developed Epidemic Kerato Conjunctivitis (EKC), 7 a viral
infection. To address the new problem with Peter’s right eye, Dr. Tuaño
prescribed to the former a steroid-based eye drop called Maxitrol, 8 a dosage
of six (6) drops per day.9 To recall, Peter had already been using Maxitrol
prior to his consult with Dr. Tuaño.
On 21 September 1988, Peter saw Dr. Tuaño for a follow-up consultation.
After examining both of Peter’s eyes, Dr. Tuaño instructed the former to taper
down10 the dosage of Maxitrol, because the EKC in his right eye had already
resolved. Dr. Tuaño specifically cautioned Peter that, being a steroid,
Maxitrol had to be withdrawn gradually; otherwise, the EKC might recur. 11
Complaining of feeling as if there was something in his eyes, Peter returned
to Dr. Tuaño for another check-up on 6 October 1988. Dr. Tuaño examined
Peter’s eyes and found that the right eye had once more developed EKC. So,
Dr. Tuaño instructed Peter to resume the use of Maxitrol at six (6) drops per
day.
On his way home, Peter was unable to get a hold of Maxitrol, as it was out of
stock. Consequently, Peter was told by Dr. Tuano to take, instead,
Blephamide12 another steroid-based medication, but with a lower
concentration, as substitute for the unavailable Maxitrol, to be used three (3)
times a day for five (5) days; two (2) times a day for five (5) days; and then
just once a day.13
Several days later, on 18 October 1988, Peter went to see Dr. Tuaño at his
clinic, alleging severe eye pain, feeling as if his eyes were about to "pop-out,"
a headache and blurred vision. Dr. Tuaño examined Peter’s eyes and
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discovered that the EKC was again present in his right eye. As a result, Dr.
Tuaño told Peter to resume the maximum dosage of Blephamide.
Dr. Tuaño saw Peter once more at the former’s clinic on 4 November 1988.
Dr. Tuaño’s examination showed that only the periphery of Peter’s right eye
was positive for EKC; hence, Dr. Tuaño prescribed a lower dosage of
Blephamide.
It was also about this time that Fatima Gladys Lucas (Fatima), Peter’s
spouse, read the accompanying literature of Maxitrol and found therein the
following warning against the prolonged use of such steroids:
WARNING:
Prolonged use may result in glaucoma, with damage to the optic nerve,
defects in visual acuity and fields of vision, and posterior, subcapsular
cataract formation. Prolonged use may suppress the host response and thus
increase the hazard of secondary ocular infractions, in those diseases
causing thinning of the cornea or sclera, perforations have been known to
occur with the use of topical steroids. In acute purulent conditions of the eye,
steroids may mask infection or enhance existing infection. If these products
are used for 10 days or longer, intraocular pressure should be routinely
monitored even though it may be difficult in children and uncooperative
patients.
Employment of steroid medication in the treatment of herpes simplex
requires great caution.
xxxx
ADVERSE REACTIONS:
Adverse reactions have occurred with steroid/anti-infective combination
drugs which can be attributed to the steroid component, the anti-infective
component, or the combination. Exact incidence figures are not available
since no denominator of treated patients is available.
Reactions occurring most often from the presence of the anti-infective
ingredients are allergic sensitizations. The reactions due to the steroid
component in decreasing order to frequency are elevation of intra-ocular
pressure (IOP) with possible development of glaucoma, infrequent optic nerve
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damage; posterior subcapsular cataract formation; and delayed wound
healing.
Secondary infection: The development of secondary has occurred after use of
combination containing steroids and antimicrobials. Fungal infections of the
correa are particularly prone to develop coincidentally with long-term
applications of steroid. The possibility of fungal invasion must be considered
in any persistent corneal ulceration where steroid treatment has been used.
Secondary bacterial ocular infection following suppression of host responses
also occurs.
On 26 November 1988, Peter returned to Dr. Tuaño’s clinic, complaining of
"feeling worse."14 It appeared that the EKC had spread to the whole of Peter’s
right eye yet again. Thus, Dr. Tuaño instructed Peter to resume the use of
Maxitrol. Petitioners averred that Peter already made mention to Dr. Tuaño
during said visit of the above-quoted warning against the prolonged use of
steroids, but Dr. Tuaño supposedly brushed aside Peter’s concern as mere
paranoia, even assuring him that the former was taking care of him (Peter).
Petitioners further alleged that after Peter’s 26 November 1988 visit to Dr.
Tuaño, Peter continued to suffer pain in his right eye, which seemed to
"progress," with the ache intensifying and becoming more frequent.
Upon waking in the morning of 13 December 1988, Peter had no vision in his
right eye. Fatima observed that Peter’s right eye appeared to be bloody and
swollen.15 Thus, spouses Peter and Fatima rushed to the clinic of Dr. Tuaño.
Peter reported to Dr. Tuaño that he had been suffering from constant
headache in the afternoon and blurring of vision.
Upon examination, Dr. Tuaño noted the hardness of Peter’s right eye. With
the use of a tonometer16 to verify the exact intraocular pressure17 (IOP) of
Peter’s eyes, Dr. Tuaño discovered that the tension in Peter’s right eye
was 39.0 Hg, while that of his left was 17.0 Hg. 18 Since the tension in Peter’s
right eye was way over the normal IOP, which merely ranged from 10.0 Hg
to 21.0 Hg,19 Dr. Tuaño ordered20 him to immediately discontinue the use of
Maxitrol and prescribed to the latter Diamox 21 and Normoglaucon,
instead.22 Dr. Tuaño also required Peter to go for daily check-up in order for
the former to closely monitor the pressure of the latter’s eyes.
On 15 December 1988, the tonometer reading of Peter’s right eye yielded
a high normal level, i.e., 21.0 Hg. Hence, Dr. Tuaño told Peter to continue
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using Diamox and Normoglaucon. But upon Peter’s complaint of "stomach
pains and tingling sensation in his fingers,"23 Dr. Tuaño discontinued Peter’s
use of Diamox.24
Peter went to see another ophthalmologist, Dr. Ramon T. Batungbacal (Dr.
Batungbacal), on 21 December 1988, who allegedly conducted a complete
ophthalmological examination of Peter’s eyes. Dr. Batungbacal’s diagnosis
was Glaucoma25 O.D.26 He recommended Laser Trabeculoplasty27 for Peter’s
right eye.
28
When Peter returned to Dr. Tuaño on 23 December 1988, the tonometer
measured the IOP of Peter’s right eye to be 41.0 Hg,29 again, way above
normal. Dr. Tuaño addressed the problem by advising Peter to resume taking
Diamox along with Normoglaucon.
During the Christmas holidays, Peter supposedly stayed in bed most of the
time and was not able to celebrate the season with his family because of the
debilitating effects of Diamox.30
On 28 December 1988, during one of Peter’s regular follow-ups with Dr.
Tuaño, the doctor conducted another ocular routine examination of Peter’s
eyes. Dr. Tuaño noted the recurrence of EKC in Peter’s right eye.
Considering, however, that the IOP of Peter’s right eye was still quite high
at 41.0 Hg, Dr. Tuaño was at a loss as to how to balance the treatment of
Peter’s EKC vis-à-vis the presence of glaucoma in the same eye. Dr. Tuaño,
thus, referred Peter to Dr. Manuel B. Agulto, M.D. (Dr. Agulto), another
ophthalmologist specializing in the treatment of glaucoma. 31 Dr. Tuaño’s
letter of referral to Dr. Agulto stated that:
Referring to you Mr. Peter Lucas for evaluation & possible management. I
initially saw him Sept. 2, 1988 because of conjunctivitis. The latter resolved
and he developed EKC for which I gave Maxitrol. The EKC was recurrent after
stopping steroid drops. Around 1 month of steroid treatment, he noted
blurring of vision & pain on the R. however, I continued the steroids for the
sake of the EKC. A month ago, I noted iris atrophy, so I took the IOP and it
was definitely elevated. I stopped the steroids immediately and has (sic) been
treating him medically.
It seems that the IOP can be controlled only with oral Diamox, and at the
moment, the EKC has recurred and I’m in a fix whether to resume the steroid
or not considering that the IOP is still uncontrolled. 32
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On 29 December 1988, Peter went to see Dr. Agulto at the latter’s clinic.
Several tests were conducted thereat to evaluate the extent of Peter’s
condition. Dr. Agulto wrote Dr. Tuaño a letter containing the following
findings and recommendations:
Thanks for sending Peter Lucas. On examination conducted vision was
20/25 R and 20/20L. Tension curve 19 R and 15 L at 1210 H while on
Normoglaucon BID OD & Diamox ½ tab every 6h po.
Slit lamp evaluation33 disclosed subepithelial corneal defect outer OD. There
was circumferential peripheral iris atrophy, OD. The lenses were clear.
Funduscopy34 showed vertical cup disc of 0.85 R and 0.6 L with temporal
slope R>L.
Zeiss gonioscopy35 revealed basically open angles both eyes with occasional
PAS,36 OD.
Rolly, I feel that Peter Lucas has really sustained significant glaucoma
damage. I suggest that we do a baseline visual fields and push medication to
lowest possible levels. If I may suggest further, I think we should prescribe
Timolol37 BID38 OD in lieu of Normoglaucon. If the IOP is still inadequate, we
may try D’epifrin39 BID OD (despite low PAS). I’m in favor of retaining Diamox
or similar CAI.40
If fields show further loss in say – 3 mos. then we should consider
trabeculoplasty.
I trust that this approach will prove reasonable for you and Peter. 41
Peter went to see Dr. Tuaño on 31 December 1988, bearing Dr. Agulto’s
aforementioned letter. Though Peter’s right and left eyes then had normal
IOP of 21.0 Hg and 17.0 Hg, respectively, Dr. Tuaño still gave him a
prescription for Timolol B.I.D. so Peter could immediately start using said
medication. Regrettably, Timolol B.I.D. was out of stock, so Dr. Tuaño
instructed Peter to just continue using Diamox and Normoglaucon in the
meantime.
Just two days later, on 2 January 1989, the IOP of Peter’s right eye remained
elevated at 21.0 Hg,42 as he had been without Diamox for the past three (3)
days.
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On 4 January 1989, Dr. Tuaño conducted a visual field study 43 of Peter’s
eyes, which revealed that the latter had tubular vision44 in his right eye,
while that of his left eye remained normal. Dr. Tuaño directed Peter to
religiously use the Diamox and Normoglaucon, as the tension of the latter’s
right eye went up even further to 41.0 Hg in just a matter of two (2) days, in
the meantime that Timolol B.I.D. and D’epifrin were still not available in the
market. Again, Dr. Tuaño advised Peter to come for regular check-up so his
IOP could be monitored.
Obediently, Peter went to see Dr. Tuaño on the 7th, 13th, 16th and 20th of
January 1989 for check-up and IOP monitoring.
In the interregnum, however, Peter was prodded by his friends to seek a
second medical opinion. On 13 January 1989, Peter consulted Dr. Jaime
Lapuz, M.D. (Dr. Lapuz), an ophthalmologist, who, in turn, referred Peter to
Dr. Mario V. Aquino, M.D. (Dr. Aquino), another ophthalmologist who
specializes in the treatment of glaucoma and who could undertake the long
term care of Peter’s eyes.
According to petitioners, after Dr. Aquino conducted an extensive evaluation
of Peter’s eyes, the said doctor informed Peter that his eyes were relatively
normal, though the right one sometimes manifested maximum borderline
tension. Dr. Aquino also confirmed Dr. Tuaño’s diagnosis of tubular vision in
Peter’s right eye. Petitioners claimed that Dr. Aquino essentially told Peter
that the latter’s condition would require lifetime medication and follow-ups.
In May 1990 and June 1991, Peter underwent two (2) procedures of laser
trabeculoplasty to attempt to control the high IOP of his right eye.
Claiming to have steroid-induced glaucoma45 and blaming Dr. Tuaño for the
same, Peter, joined by: (1) Fatima, his spouse 46; (2) Abbeygail, his natural
child47; and (3) Gillian, his legitimate child48 with Fatima, instituted on 1
September 1992, a civil complaint for damages against Dr. Tuaño, before the
RTC, Branch 150, Quezon City. The case was docketed as Civil Case No. 92-
2482.
In their Complaint, petitioners specifically averred that as the "direct
consequence of [Peter’s] prolonged use of Maxitrol, [he] suffered from steroid
induced glaucoma which caused the elevation of his intra-ocular pressure.
The elevation of the intra-ocular pressure of [Peter’s right eye] caused the
impairment of his vision which impairment is not curable and may even lead
to total blindness."49
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Petitioners additionally alleged that the visual impairment of Peter’s right eye
caused him and his family so much grief. Because of his present condition,
Peter now needed close medical supervision forever; he had already
undergone two (2) laser surgeries, with the possibility that more surgeries
were still needed in the future; his career in sports casting had suffered and
was continuing to suffer;50 his anticipated income had been greatly reduced
as a result of his "limited" capacity; he continually suffered from "headaches,
nausea, dizziness, heart palpitations, rashes, chronic rhinitis,
sinusitis,"51 etc.; Peter’s relationships with his spouse and children continued
to be strained, as his condition made him highly irritable and sensitive; his
mobility and social life had suffered; his spouse, Fatima, became the
breadwinner in the family;52 and his two children had been deprived of the
opportunity for a better life and educational prospects. Collectively,
petitioners lived in constant fear of Peter becoming completely blind. 53
In the end, petitioners sought pecuniary award for their supposed pain and
suffering, which were ultimately brought about by Dr. Tuaño’s grossly
negligent conduct in prescribing to Peter the medicine Maxitrol for a period of
three (3) months, without monitoring Peter’s IOP, as required in cases of
prolonged use of said medicine, and notwithstanding Peter’s constant
complaint of intense eye pain while using the same. Petitioners particularly
prayed that Dr. Tuaño be adjudged liable for the following amounts:
1. The amount of ₱2,000,000.00 to plaintiff Peter Lucas as and by
way of compensation for his impaired vision.
2. The amount of ₱300,000.00 to spouses Lucas as and by way of
actual damages plus such additional amounts that may be proven
during trial.
3. The amount of ₱1,000,000.00 as and by way of moral damages.
4. The amount of ₱500,000.00 as and by way of exemplary damages.
5. The amount of ₱200,000.00 as and by way of attorney’s fees plus
costs of suit.54
In rebutting petitioners’ complaint, Dr. Tuaño asserted that the "treatment
made by [him] more than three years ago has no causal connection to
[Peter’s] present glaucoma or condition." 55 Dr. Tuaño explained that "[d]rug-
induced glaucoma is temporary and curable, steroids have the side effect of
increasing intraocular pressure. Steroids are prescribed to treat Epidemic
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Kerato Conjunctivitis or EKC which is an infiltration of the cornea as a result
of conjunctivitis or sore eyes." 56 Dr. Tuaño also clarified that (1) "[c]ontrary to
[petitioners’] fallacious claim, [he] did NOT continually prescribe the drug
Maxitrol which contained steroids for any prolonged period" 57 and "[t]he truth
was the Maxitrol was discontinued x x x as soon as EKC disappeared and
was resumed only when EKC reappeared" 58; (2) the entire time he was
treating Peter, he "continually monitored the intraocular pressure of [Peter’s
eyes] by palpating the eyes and by putting pressure on the eyeballs," and no
hardening of the same could be detected, which meant that there was no
increase in the tension or IOP, a possible side reaction to the use of steroid
medications; and (3) it was only on 13 December 1988 that Peter complained
of a headache and blurred vision in his right eye, and upon measuring the
IOP of said eye, it was determined for the first time that the IOP of the right
eye had an elevated value.
But granting for the sake of argument that the "steroid treatment of [Peter’s]
EKC caused the steroid induced glaucoma,"59 Dr. Tuaño argued that:
[S]uch condition, i.e., elevated intraocular pressure, is temporary. As soon as
the intake of steroids is discontinued, the intraocular pressure automatically
is reduced. Thus, [Peter’s] glaucoma can only be due to other causes not
attributable to steroids, certainly not attributable to [his] treatment of more
than three years ago x x x.
From a medical point of view, as revealed by more current examination of
[Peter], the latter’s glaucoma can only be long standing glaucoma, open angle
glaucoma, because of the large C:D ratio. The steroids provoked the latest
glaucoma to be revealed earlier as [Peter] remained asymptomatic prior to
steroid application. Hence, the steroid treatment was in fact beneficial to
[Peter] as it revealed the incipient open angle glaucoma of [Peter] to allow
earlier treatment of the same.60
In a Decision dated 14 July 2000, the RTC dismissed Civil Case No. 92-2482
"for insufficiency of evidence."61 The decretal part of said Decision reads:
Wherefore, premises considered, the instant complaint is dismissed for
insufficiency of evidence. The counter claim (sic) is likewise dismissed in the
absence of bad faith or malice on the part of plaintiff in filing the suit. 62
The RTC opined that petitioners failed to prove by preponderance of evidence
that Dr. Tuaño was negligent in his treatment of Peter’s condition. In
particular, the record of the case was bereft of any evidence to establish that
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the steroid medication and its dosage, as prescribed by Dr. Tuaño, caused
Peter’s glaucoma. The trial court reasoned that the "recognized standards of
the medical community has not been established in this case, much less has
causation been established to render [Tuaño] liable." 63 According to the RTC:
[Petitioners] failed to establish the duty required of a medical practitioner
against which Peter Paul’s treatment by defendant can be compared with.
They did not present any medical expert or even a medical doctor to convince
and expertly explain to the court the established norm or duty required of a
physician treating a patient, or whether the non taking (sic) by Dr. Tuaño of
Peter Paul’s pressure a deviation from the norm or his non-discovery of the
glaucoma in the course of treatment constitutes negligence. It is important
and indispensable to establish such a standard because once it is
established, a medical practitioner who departed thereof breaches his duty
and commits negligence rendering him liable. Without such testimony or
enlightenment from an expert, the court is at a loss as to what is then the
established norm of duty of a physician against which defendant’s conduct
can be compared with to determine negligence. 64
The RTC added that in the absence of "any medical evidence to the contrary,
this court cannot accept [petitioners’] claim that the use of steroid is the
proximate cause of the damage sustained by [Peter’s] eye." 65
Correspondingly, the RTC accepted Dr. Tuaño’s medical opinion that "Peter
Paul must have been suffering from normal tension glaucoma, meaning,
optic nerve damage was happening but no elevation of the eye pressure is
manifested, that the steroid treatment actually unmasked the condition that
resulted in the earlier treatment of the glaucoma. There is nothing in the
record to contradict such testimony. In fact, plaintiff’s Exhibit ‘S’ even tends
to support them."
Undaunted, petitioners appealed the foregoing RTC decision to the Court of
Appeals. Their appeal was docketed as CA-G.R. CV No. 68666.
On 27 September 2006, the Court of Appeals rendered a decision in CA-G.R.
CV No. 68666 denying petitioners’ recourse and affirming the appealed RTC
Decision. The fallo of the judgment of the appellate court states:
WHEREFORE, the Decision appealed from is AFFIRMED. 66
The Court of Appeals faulted petitioners because they –
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[D]id not present any medical expert to testify that Dr. Tuano’s prescription
of Maxitrol and Blephamide for the treatment of EKC on Peter’s right eye was
not proper and that his palpation of Peter’s right eye was not enough to
detect adverse reaction to steroid. Peter testified that Dr. Manuel Agulto told
him that he should not have used steroid for the treatment of EKC or that he
should have used it only for two (2) weeks, as EKC is only a viral infection
which will cure by itself. However, Dr. Agulto was not presented by
[petitioners] as a witness to confirm what he allegedly told Peter and,
therefore, the latter’s testimony is hearsay. Under Rule 130, Section 36 of the
Rules of Court, a witness can testify only to those facts which he knows of
his own personal knowledge, x x x. Familiar and fundamental is the rule that
hearsay testimony is inadmissible as evidence. 67
Like the RTC, the Court of Appeals gave great weight to Dr. Tuaño’s medical
judgment, specifically the latter’s explanation that:
[W]hen a doctor sees a patient, he cannot determine whether or not the latter
would react adversely to the use of steroids, that it was only on December 13,
1989, when Peter complained for the first time of headache and blurred
vision that he observed that the pressure of the eye of Peter was elevated,
and it was only then that he suspected that Peter belongs to the 5% of the
population who reacts adversely to steroids.68
Petitioners’ Motion for Reconsideration was denied by the Court of Appeals in
a Resolution dated 3 July 2007.
Hence, this Petition for Review on Certiorari under Rule 45 of the Revised
Rules of Court premised on the following assignment of errors:
I.
THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN
AFFIRMING THE DECISION OF THE TRIAL COURT DISMISSING THE
PETITIONERS’ COMPLAINT FOR DAMAGES AGAINST THE RESPONDENT
ON THE GROUND OF INSUFFICIENCY OF EVIDENCE;
II.
THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN
DISMISSING THE PETITIONERS’ COMPLAINT FOR DAMAGES AGAINST THE
RESPONDENT ON THE GROUND THAT NO MEDICAL EXPERT WAS
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PRESENTED BY THE PETITIONERS TO PROVE THEIR CLAIM FOR
MEDICAL NEGLIGENCE AGAINST THE RESPONDENT; AND
III.
THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN
NOT FINDING THE RESPONDENT LIABLE TO THE PETITIONERS’ FOR
ACTUAL, MORAL AND EXEMPLARY DAMAGES, ASIDE FROM ATTORNEY’S
FEES, COSTS OF SUIT, AS A RESULT OF HIS GROSS NEGLIGENCE. 69
A reading of the afore-quoted reversible errors supposedly committed by the
Court of Appeals in its Decision and Resolution would reveal that petitioners
are fundamentally assailing the finding of the Court of Appeals that the
evidence on record is insufficient to establish petitioners’ entitlement to any
kind of damage. Therefore, it could be said that the sole issue for our
resolution in the Petition at bar is whether the Court of Appeals committed
reversible error in affirming the judgment of the RTC that petitioners failed to
prove, by preponderance of evidence, their claim for damages against Dr.
Tuaño.
Evidently, said issue constitutes a question of fact, as we are asked to revisit
anew the factual findings of the Court of Appeals, as well as of the RTC. In
effect, petitioners would have us sift through the evidence on record and pass
upon whether there is sufficient basis to establish Dr. Tuaño’s negligence in
his treatment of Peter’s eye condition. This question clearly involves a factual
inquiry, the determination of which is not within the ambit of this Court’s
power of review under Rule 45 of the 1997 Rules Civil Procedure, as
amended.70
Elementary is the principle that this Court is not a trier of facts; only errors
of law are generally reviewed in petitions for review on certiorari criticizing
decisions of the Court of Appeals. Questions of fact are not entertained. 71
Nonetheless, the general rule that only questions of law may be raised on
appeal in a petition for review under Rule 45 of the Rules of Court admits of
certain exceptions, including the circumstance when the finding of fact of the
Court of Appeals is premised on the supposed absence of evidence, but is
contradicted by the evidence on record. Although petitioners may not
explicitly invoke said exception, it may be gleaned from their allegations and
arguments in the instant Petition.1avvphi1.zw+
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Petitioners contend, that "[c]ontrary to the findings of the Honorable Court of
Appeals, [they] were more than able to establish that: Dr. Tuaño ignored the
standard medical procedure for ophthalmologists, administered medication
with recklessness, and exhibited an absence of competence and skills
expected from him."72 Petitioners reject the necessity of presenting expert
and/or medical testimony to establish (1) the standard of care respecting the
treatment of the disorder affecting Peter’s eye; and (2) whether or not
negligence attended Dr. Tuaño’s treatment of Peter, because, in their words –
That Dr. Tuaño was grossly negligent in the treatment of Peter’s simple eye
ailment is a simple case of cause and effect. With mere documentary
evidence and based on the facts presented by the petitioners, respondent can
readily be held liable for damages even without any expert testimony. In any
case, however, and contrary to the finding of the trial court and the Court of
Appeals, there was a medical expert presented by the petitioner showing the
recklessness committed by [Dr. Tuaño] – Dr. Tuaño himself. [Emphasis
supplied.]
They insist that Dr. Tuaño himself gave sufficient evidence to establish his
gross negligence that ultimately caused the impairment of the vision of
Peter’s right eye,73 i.e., that "[d]espite [Dr. Tuaño’s] knowledge that 5% of the
population reacts adversely to Maxitrol, [he] had no qualms whatsoever in
prescribing said steroid to Peter without first determining whether or not the
(sic) Peter belongs to the 5%." 74
We are not convinced. The judgments of both the Court of Appeals and the
RTC are in accord with the evidence on record, and we are accordingly bound
by the findings of fact made therein.
Petitioners’ position, in sum, is that Peter’s glaucoma is the direct result of
Dr. Tuaño’s negligence in his improper administration of the drug Maxitrol;
"thus, [the latter] should be liable for all the damages suffered and to be
suffered by [petitioners]."75 Clearly, the present controversy is a classic
illustration of a medical negligence case against a physician based on the
latter’s professional negligence. In this type of suit, the patient or his heirs, in
order to prevail, is required to prove by preponderance of evidence that the
physician failed to exercise that degree of skill, care, and learning possessed
by other persons in the same profession; and that as a proximate result of
such failure, the patient or his heirs suffered damages.
For lack of a specific law geared towards the type of negligence committed by
members of the medical profession, such claim for damages is almost always
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anchored on the alleged violation of Article 2176 of the Civil Code, which
states that:
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.
In medical negligence cases, also called medical malpractice suits, there exist
a physician-patient relationship between the doctor and the victim. But just
like any other proceeding for damages, four essential (4) elements i.e., (1)
duty; (2) breach; (3) injury; and (4) proximate causation, 76 must be
established by the plaintiff/s. All the four (4) elements must co-exist in order
to find the physician negligent and, thus, liable for damages.
When 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.77 Thus, in treating his patient, a physician is under a duty to [the
former] 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. 78 Stated otherwise, the
physician has the duty to use at least the same level of care that any other
reasonably competent physician would use to treat the condition under
similar circumstances.
This standard level of care, skill and diligence is a matter best addressed by
expert medical testimony, because the standard of care in a medical
malpractice case is a matter peculiarly within the knowledge of experts in the
field.79
There is breach of duty of care, skill and diligence, or the improper
performance of such duty, by the attending physician when the patient
is injured in body or in health [and this] constitutes the actionable
malpractice.80 Proof of such breach must likewise rest upon the testimony of
an expert witness that the treatment accorded to the patient failed to meet
the standard level 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.
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Even so, proof of breach of duty on the part of the attending physician is
insufficient, for there must be a causal connection between said breach and
the resulting injury sustained by the patient. Put in another way, in order
that there may be a recovery for an injury, 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";81 that is, the negligence must be the proximate cause of the injury.
And the proximate cause of an injury is that cause, which, in the natural and
continuous sequence, unbroken by any efficient intervening cause, produces
the injury, and without which the result would not have occurred. 82
Just as with the elements of duty and breach of the same, in order to
establish the proximate cause [of the injury] by a preponderance of the
evidence in a medical malpractice action, [the patient] must similarly use
expert testimony, because the question of whether the alleged professional
negligence caused [the patient’s] injury is generally one for specialized expert
knowledge beyond the ken of the average layperson; using the specialized
knowledge and training of his field, the expert’s role is to present to the
[court] a realistic assessment of the likelihood that [the physician’s] alleged
negligence caused [the patient’s] injury. 83
From the foregoing, it is apparent 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 [or surgeons] stems from the former’s realization that the latter
possess unusual technical skills which laymen in most instances are
incapable of intelligently evaluating;84 hence, the indispensability of expert
testimonies.
In the case at bar, there is no question that a physician-patient relationship
developed between Dr. Tuaño and Peter when Peter went to see the doctor on
2 September 1988, seeking a consult for the treatment of his sore eyes.
Admittedly, Dr. Tuaño, an ophthalmologist, prescribed Maxitrol when Peter
developed and had recurrent EKC. Maxitrol or neomycin/polymyxin B
sulfates/dexamethasone ophthalmic ointment is a multiple-dose anti-
infective steroid combination in sterile form for topical application. 85 It is the
drug which petitioners claim to have caused Peter’s glaucoma.
However, as correctly pointed out by the Court of Appeals, "[t]he onus
probandi was on the patient to establish before the trial court that the
physicians ignored standard medical procedure, prescribed and administered
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medication with recklessness and exhibited an absence of the competence
and skills expected of general practitioners similarly
situated."86 Unfortunately, in this case, there was absolute failure on the part
of petitioners to present any expert testimony to establish: (1) the standard of
care to be implemented by competent physicians in treating the same
condition as Peter’s under similar circumstances; (2) that, in his treatment of
Peter, Dr. Tuaño failed in his duty to exercise said standard of care that any
other competent physician would use in treating the same condition as
Peter’s under similar circumstances; and (3) that the injury or damage to
Peter’s right eye, i.e., his glaucoma, was the result of his use of Maxitrol, as
prescribed by Dr. Tuaño. Petitioners’ failure to prove the first element alone
is already fatal to their cause.
Petitioners maintain that Dr. Tuaño failed to follow in Peter’s case the
required procedure for the prolonged use of Maxitrol. But what is actually the
required procedure in situations such as in the case at bar? To be precise,
what is the standard operating procedure when ophthalmologists prescribe
steroid medications which, admittedly, carry some modicum of risk?
Absent a definitive standard of care or diligence required of Dr. Tuaño under
the circumstances, we have no means to determine whether he was able to
comply with the same in his diagnosis and treatment of Peter. This Court has
no yardstick upon which to evaluate or weigh the attendant facts of this case
to be able to state with confidence that the acts complained of, indeed,
constituted negligence and, thus, should be the subject of pecuniary
reparation.
Petitioners assert that prior to prescribing Maxitrol, Dr. Tuaño should have
determined first whether Peter was a "steroid responder." 87 Yet again,
petitioners did not present any convincing proof that such determination is
actually part of the standard operating procedure which ophthalmologists
should unerringly follow prior to prescribing steroid medications.
In contrast, Dr. Tuaño was able to clearly explain that what is only required
of ophthalmologists, in cases such as Peter’s, is the conduct of standard
tests/procedures known as "ocular routine examination," 88 composed of five
(5) tests/procedures – specifically, gross examination of the eyes and the
surrounding area; taking of the visual acuity of the patient; checking the
intraocular pressure of the patient; checking the motility of the eyes; and
using ophthalmoscopy on the patient’s eye – and he did all those
tests/procedures every time Peter went to see him for follow-up consultation
and/or check-up.
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We cannot but agree with Dr. Tuaño’s assertion that when a doctor sees a
patient, he cannot determine immediately whether the latter would react
adversely to the use of steroids; all the doctor can do is map out a course of
treatment recognized as correct by the standards of the medical profession. It
must be remembered that a physician is not an insurer of the good result of
treatment. The mere fact that the patient does not get well or that a bad
result occurs does not in itself indicate failure to exercise due care. 89 The
result is not determinative of the performance [of the physician] and he is not
required to be infallible.90
Moreover, that Dr. Tuaño saw it fit to prescribe Maxitrol to Peter was justified
by the fact that the latter was already using the same medication when he
first came to see Dr. Tuaño on 2 September 1988 and had exhibited no
previous untoward reaction to that particular drug. 91
Also, Dr. Tuaño categorically denied petitioners’ claim that he never
monitored the tension of Peter’s eyes while the latter was on Maxitrol. Dr.
Tuaño testified that he palpated Peter’s eyes every time the latter came for a
check-up as part of the doctor’s ocular routine examination, a fact which
petitioners failed to rebut. Dr. Tuaño’s regular conduct of examinations and
tests to ascertain the state of Peter’s eyes negate the very basis of petitioners’
complaint for damages. As to whether Dr. Tuaño’s actuations conformed to
the standard of care and diligence required in like circumstances, it is
presumed to have so conformed in the absence of evidence to the contrary.
Even if we are to assume that Dr. Tuaño committed negligent acts in his
treatment of Peter’s condition, the causal connection between Dr. Tuaño’s
supposed negligence and Peter’s injury still needed to be established. 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.92 The plaintiff must plead and prove not only that
he has 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. 93
The causation between the physician’s negligence and the patient’s injury
may only be established by the presentation of proof that Peter’s glaucoma
would not have occurred but for Dr. Tuaño’s supposed negligent conduct.
Once more, petitioners failed in this regard.
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Dr. Tuaño does not deny that the use of Maxitrol involves the risk of
increasing a patient’s IOP. In fact, this was the reason why he made it a point
to palpate Peter’s eyes every time the latter went to see him -- so he could
monitor the tension of Peter’s eyes. But to say that said medication
conclusively caused Peter’s glaucoma is purely speculative. Peter was
diagnosed with open-angle glaucoma. This kind of glaucoma is characterized
by an almost complete absence of symptoms and a chronic, insidious
course.94 In open-angle glaucoma, halos around lights and blurring of vision
do not occur unless there has been a sudden increase in the intraocular
vision.95 Visual acuity remains good until late in the course of the
disease.96 Hence, Dr. Tuaño claims that Peter’s glaucoma "can only be long
standing x x x because of the large C:D97 ratio," and that "[t]he steroids
provoked the latest glaucoma to be revealed earlier" was a blessing in
disguise "as [Peter] remained asymptomatic prior to steroid application."
Who between petitioners and Dr. Tuaño is in a better position to determine
and evaluate the necessity of using Maxitrol to cure Peter’s EKC vis-à-vis the
attendant risks of using the same?
That Dr. Tuaño has the necessary training and skill to practice his chosen
field is beyond cavil. Petitioners do not dispute Dr. Tuaño’s qualifications –
that he has been a physician for close to a decade and a half at the time
Peter first came to see him; that he has had various medical training; that he
has authored numerous papers in the field of ophthalmology, here and
abroad; that he is a Diplomate of the Philippine Board of Ophthalmology;
that he occupies various teaching posts (at the time of the filing of the
present complaint, he was the Chair of the Department of Ophthalmology
and an Associate Professor at the University of the Philippines-Philippine
General Hospital and St. Luke’s Medical Center, respectively); and that he
held an assortment of positions in numerous medical organizations like the
Philippine Medical Association, Philippine Academy of Ophthalmology,
Philippine Board of Ophthalmology, Philippine Society of Ophthalmic Plastic
and Reconstructive Surgery, Philippine Journal of Ophthalmology,
Association of Philippine Ophthalmology Professors, et al.
It must be remembered that when the qualifications of a physician are
admitted, as in the instant case, there is an inevitable presumption that in
proper cases, he takes the necessary precaution and employs the best of his
knowledge and skill in attending to his clients, unless the contrary is
sufficiently established.98 In making the judgment call of treating Peter’s EKC
with Maxitrol, Dr. Tuaño took the necessary precaution by palpating Peter’s
eyes to monitor their IOP every time the latter went for a check-up, and he
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employed the best of his knowledge and skill earned from years of training
and practice.
In contrast, without supporting expert medical opinions, petitioners’ bare
assertions of negligence on Dr. Tuaño’s part, which resulted in Peter’s
glaucoma, deserve scant credit.
Our disposition of the present controversy might have been vastly different
had petitioners presented a medical expert to establish their theory
respecting Dr. Tuaño’s so-called negligence. In fact, the record of the case
reveals that petitioners’ counsel recognized the necessity of presenting such
evidence. Petitioners even gave an undertaking to the RTC judge that Dr.
Agulto or Dr. Aquino would be presented. Alas, no follow-through on said
undertaking was made.1avvphi1
The plaintiff in a civil case has the burden of proof as he alleges the
affirmative of the issue. However, in the course of trial in a civil case, once
plaintiff makes out a prima facie case in his favor, the duty or the burden of
evidence shifts to defendant to controvert plaintiff’s prima facie case;
otherwise, a verdict must be returned in favor of plaintiff. 99 The party having
the burden of proof must establish his case by a preponderance of
evidence.100 The concept of "preponderance of evidence" refers to evidence
which is of greater weight or more convincing than that which is offered in
opposition to it;101 in the last analysis, it means probability of truth. It is
evidence which is more convincing to the court as worthy of belief than that
which is offered in opposition thereto. 102 Rule 133, Section 1 of the Revised
Rules of Court provides the guidelines for determining preponderance of
evidence, thus:
In civil cases, the party having the burden of proof must establish his case by
a preponderance of evidence. In determining where the preponderance or
superior weight of evidence on the issues involved lies the court may consider
all the facts and circumstances of the case, the witnesses’ manner of
testifying, their intelligence, their means and opportunity of knowing the
facts to which they are testifying, the nature of the facts to which they testify,
the probability or improbability of their testimony, their interest or want of
interest, and also their personal credibility so far as the same legitimately
appear upon the trial. The court may also consider the number of witnesses,
though the preponderance is not necessarily with the greater number.
Herein, the burden of proof was clearly upon petitioners, as plaintiffs in the
lower court, to establish their case by a preponderance of evidence showing a
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reasonable connection between Dr. Tuaño’s alleged breach of duty and the
damage sustained by Peter’s right eye. This, they did not do. In reality,
petitioners’ complaint for damages is merely anchored on a statement in the
literature of Maxitrol identifying the risks of its use, and the purported
comment of Dr. Agulto – another doctor not presented as witness before the
RTC – concerning the prolonged use of Maxitrol for the treatment of EKC.
It seems basic that what constitutes proper medical treatment is a medical
question that should have been presented to experts. If no standard is
established through expert medical witnesses, then courts have no standard
by which to gauge the basic issue of breach thereof by the physician or
surgeon. The RTC and Court of Appeals, and even this Court, could not be
expected to determine on its own what medical technique should have been
utilized for a certain disease or injury. Absent expert medical opinion, the
courts would be dangerously engaging in speculations.
All told, we are hard pressed to find Dr. Tuaño liable for any medical
negligence or malpractice where there is no evidence, in the nature of expert
testimony, to establish that in treating Peter, Dr. Tuaño failed to exercise
reasonable care, diligence and skill generally required in medical practice.
Dr. Tuaño’s testimony, that his treatment of Peter conformed in all respects
to standard medical practice in this locality, stands unrefuted. Consequently,
the RTC and the Court of Appeals correctly held that they had no basis at all
to rule that petitioners were deserving of the various damages prayed for in
their Complaint.
WHEREFORE, premises considered, the instant petition is DENIED for lack
of merit. The assailed Decision dated 27 September 2006
and Resolution dated 3 July 2007, both of the Court of Appeals in CA-G.R.
CV No. 68666, are hereby AFFIRMED. No cost.
PETER PAUL PATRICK LUCAS, et al. vs. DR. PROSPERO MA. C. TUAÑO
G.R. NO. 178763 21 April 2009
Chico-Nazario, J.
DOCTRINES:
Page 121

In a medical negligence suit, the patient or his heirs, in order to prevail, is
required to prove by preponderance of evidence that the physician failed to
exercise that degree of skill, care, and learning possessed by other persons in
the same profession; and that as a proximate result of such failure, the
patient or his heirs suffered damages.
There is breach of duty of care, skill and diligence, or the improper
performance of such duty, by the attending physician when the patient is
injured in body or in health constitutes the actionable malpractice.
FACTS:
Herein petitioner, Peter Lucas, first consulted respondent, Dr. Tuaño, on a
complaint of soreness and redness on his right eye. The respondent, after a
series of examinations, found that the former was suffering from
conjunctivitis or “sore eyes” and prescribed the use of the Spersacet-C.
However, after the petitioner’s condition seemed to have worsened, he sought
for the respondent’s second finding wherein the latter said that his condition
had progressed to Epidemic Kerato Conjunctivitis (EKC), a viral infection.
The respondent then prescribed the use of Maxitrol, a steroid-based eye
drop. The petitioner’s condition worsened overtime, yet he obediently
complied with all the prescriptions and orders of the respondent.
Four months later and after the petitioner suffered from significant swelling
of his right eyeball, headaches, nausea and blindness on this right eye, he
sought for the opinion of another doctor, Dr. Aquino. Dr. Aquino found that
the petitioner had been suffering from glaucoma and needed to undergo laser
surgery, lest he might suffer from total blindness.
After reading the literature on the use of the medicine Maxitrol, Fatima, one
of the petitioners herein and Peter Lucas’ wife, read that one of the adverse
effects of prolonged use of steroid-based eye drops could possibly be
glaucoma. Peter, Fatima, and their two children instituted a civil case for
damages against herein respondent for medical malpractice.
ISSUE:
Whether or not the petitioners amply proved that Dr. Tuaño failed to exercise
diligence in the performance of his duty as petitioner Peter Lucas’ physician.
RULING:
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No. Absent a definitive standard of care or diligence required of Dr. Tuaño
under the circumstances, the Court has no yardstick upon which to evaluate
the attendant facts of the case at hand to be able to state with confidence
that the acts complained of, indeed, constituted negligence and, thus, should
be the subject of pecuniary reparation.
In medical negligence cases, also called medical malpractice suits, there exist
a physician-patient relationship between the doctor and the victim. But just
like any other proceeding for damages, four essential (4) elements i.e., (1)
duty; (2) breach; (3) injury; and (4) proximate causation, must be established
by the plaintiff/s. All the four (4) elements must co-exist in order to find the
physician negligent and, thus, liable for damages.
As the physician has the duty to use at least the same level of care as that of
any other reasonably competent physician would use in the treatment of his
patient, said standard level of care, skill and diligence must likewise be
proven by expert medical testimony, because the standard of care in a
medical malpractice case is a matter peculiarly within the knowledge of
experts in the field. The same is outside the ken of the average layperson.
There is breach of duty of care, skill and diligence, or the improper
performance of such duty, by the attending physician when the patient is
injured in body or in health [and this] constitutes the actionable malpractice.
Hence, proof of breach of duty on the part of the attending physician is
insufficient. Rather, the negligence of the physician must be the proximate
cause of the injury.
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G.R. No. 165279 June 7, 2011
DR. RUBI LI, Petitioner,
vs.
SPOUSES REYNALDO and LINA SOLIMAN, as parents/heirs of deceased
Angelica Soliman, Respondents.
DECISION
VILLARAMA, JR., J.:
Challenged in this petition for review on certiorari is the Decision 1 dated
June 15, 2004 as well as the Resolution 2 dated September 1, 2004 of the
Court of Appeals (CA) in CA-G.R. CV No. 58013 which modified the
Decision3 dated September 5, 1997 of the Regional Trial Court of Legazpi
City, Branch 8 in Civil Case No. 8904.
The factual antecedents:
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.
Luke’s Medical Center (SLMC). Results showed that Angelica was suffering
from osteosarcoma, osteoblastic type, 4 a high-grade (highly malignant) cancer
of the bone which usually afflicts teenage children. Following this diagnosis
and as primary intervention, Angelica’s right leg was amputated by Dr. Jaime
Tamayo in order to remove the tumor. As adjuvant treatment to eliminate
any remaining cancer cells, and hence minimize the chances of recurrence
and prevent the disease from spreading to other parts of the patient’s body
(metastasis), chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo
referred Angelica to another doctor at SLMC, herein petitioner Dr. Rubi Li, a
medical oncologist.
On August 18, 1993, Angelica was admitted to SLMC. However, she died on
September 1, 1993, 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 Camp Crame for post-mortem examination.
The Medico-Legal Report issued by said institution indicated the cause of
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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:
Immediate cause : a. Osteosarcoma, Status Post AKA
Antecedent cause : b. (above knee amputation)
Underlying cause : c. Status Post Chemotherapy
On February 21, 1994, 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 Angelica’s
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 Angelica’s 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.
In her answer,8 petitioner denied having been negligent in administering the
chemotherapy drugs to Angelica and asserted that she had fully explained to
respondents how the chemotherapy will affect not only the cancer cells but
also the patient’s normal body parts, including the lowering of white and red
blood cells and platelets. She claimed that what happened to Angelica can be
attributed to malignant tumor cells possibly left behind after surgery. Few as
they may be, these have the capacity to compete for nutrients such that the
body becomes so weak structurally (cachexia) and functionally in the form of
lower resistance of the body to combat infection. Such infection becomes
uncontrollable and triggers a chain of events (sepsis or septicemia) that may
lead to bleeding in the form of Disseminated Intravascular Coagulation (DIC),
as what the autopsy report showed in the case of Angelica.
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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 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 two to three weeks to recover
from the operation before starting chemotherapy. Respondents were
apprehensive due to financial constraints as Reynaldo earns only from
₱70,000.00 to ₱150,000.00 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 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 white blood cells [WBC], red
blood cells [RBC] and platelets; (5) possible sterility due to the effects on
Angelica’s 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 Angelica’s 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 July 27, 1993, SLMC discharged Angelica, with instruction from
petitioner that she be readmitted after two or three weeks for the
chemotherapy.
On August 18, 1993, respondents brought Angelica to SLMC for
chemotherapy, bringing with them the results of the laboratory tests
requested by petitioner: Angelica’s 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
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The following day, August 19, petitioner began administering three
chemotherapy drugs – Cisplatin, 15 Doxorubicin16 and Cosmegen17 –
intravenously. Petitioner was supposedly assisted by her trainees Dr. Leo
Marbella18 and Dr. Grace Arriete.19 In his testimony, Dr. Marbella denied
having any participation in administering the said chemotherapy drugs. 20
On the second day of chemotherapy, August 20, respondents noticed reddish
discoloration on Angelica’s face. 21 They asked petitioner about it, but she
merely quipped, "Wala yan. Epekto ng gamot." 22 Petitioner recalled noticing
the skin rashes on the nose and cheek area of Angelica. At that moment, she
entertained the possibility that Angelica also had systemic lupus and
consulted Dr. Victoria Abesamis on the matter.23
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 Angelica’s 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
Angelica’s face, nor did she notice any difficulty in the child’s breathing. She
claimed that Angelica merely complained of nausea and was given ice
chips.251avvphi1
On August 22, 1993, at around ten o’clock 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, let’s observe. If pwede na, bigyan uli ng chemo." At
this point, respondents asked petitioner’s 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 Angelica’s
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
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respondents that she will see Angelica again after two weeks, but
respondents can see her anytime if any immediate problem arises. 28
However, Angelica remained in confinement because while still in the
premises of SLMC, her "convulsions" returned and she also had LBM.
Angelica was given oxygen and administration of calcium continued. 29
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 4:50 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 child’s 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 Angelica’s 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 seven
o’clock 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.
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The next day, respondents claimed that Angelica became hysterical, vomited
blood and her body turned black. Part of Angelica’s 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 Angelica’s platelets were down and respondents
should pray for their daughter. Reynaldo claimed that he was introduced to a
pediatrician who took over his daughter’s 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 Angelica’s 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 three o’clock in the morning of September 1, a 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 petitioner’s own account, Angelica was merely irritable that day (August
31). Petitioner noted though that Angelica’s skin was indeed sloughing
off.38 She stressed that at 9:30 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
Angelica’s other organs to fail.41 Petitioner attributed this to the patient’s poor
defense mechanism brought about by the cancer itself. 42
While he was seeking the release of Angelica’s 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
Respondents also presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-
Legal Officer of the PNP-Crime Laboratory who conducted the autopsy on
Angelica’s cadaver, and Dr. Melinda Vergara Balmaceda who is a Medical
Page 125

Specialist employed at the Department of Health (DOH) Operations and
Management Services.
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 victim’s 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 Angelica’s 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 physician’s 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 patient’s 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
patient’s condition.45
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelica’s 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,
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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 ₱139,064.43.48
Respondents appealed to the CA which, while concurring with the trial
court’s 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.
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The CA thus declared:
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
Li’s 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 Angelica’s 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;
2. Moral damages of P200,000.00;
3. Exemplary damages of P50,000.00;
4. Attorney’s fee of P30,000.00.
SO ORDERED.49 (Emphasis supplied.)
Petitioner filed a motion for partial reconsideration which the appellate court
denied.
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Hence, this petition.
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
attorney’s fees. Petitioner emphasized that she was not negligent in the pre-
chemotherapy procedures and in the administration of chemotherapy
treatment to Angelica.
On her supposed non-disclosure of all possible side effects of chemotherapy,
including death, petitioner argues that it was foolhardy to imagine her to be
all-knowing/omnipotent. While the theoretical side effects of chemotherapy
were explained by her to the respondents, as these should be known to a
competent doctor, petitioner cannot possibly predict how a particular
patient’s genetic make-up, state of mind, general health and body
constitution would respond to the treatment. These are obviously dependent
on too many known, unknown and immeasurable variables, thus requiring
that Angelica be, as she was, constantly and closely monitored during the
treatment. Petitioner asserts that she did everything within her professional
competence to attend to the medical needs of 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.
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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 petition is meritorious.
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 former’s 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 petitioner’s 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 patient’s 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.
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The doctrine of informed consent within the context of physician-patient
relationships goes far back into English common law. As early as 1767,
doctors were charged with the tort of "battery" (i.e., an unauthorized physical
contact with a patient) if they had not gained the consent of their patients
prior to performing a surgery or procedure. In the United States, the seminal
case was Schoendorff v. Society of New York Hospital 53 which involved
unwanted treatment performed by a doctor. Justice Benjamin Cardozo’s oft-
quoted opinion upheld the basic right of a patient to give consent to any
medical procedure or treatment: "Every human being of adult years 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." 54 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 risks of injury might be incurred from a
proposed course of treatment, so that a patient, exercising ordinary care for
his own welfare, and faced with a choice of undergoing the proposed
treatment, or alternative treatment, or none at all, may intelligently exercise
his judgment by reasonably balancing the probable risks against the
probable benefits.55
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 patient’s 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 physician’s 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 patient’s 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
patient’s decision on treatment, or to the reasonably, expectable effect of risk
disclosure on the decision. Such unrevealed risk that should have been made
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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 physician’s failure
to divulge and damage to the patient. 60
Reiterating the foregoing considerations, Cobbs v. Grant 61 deemed it as
integral part of physician’s overall obligation to patient, the duty of
reasonable disclosure of available choices with respect to proposed therapy
and of dangers inherently and potentially involved in each. However, the
physician is not obliged to discuss relatively minor risks inherent in common
procedures when it is common knowledge that such risks inherent in
procedure of very low incidence. Cited as exceptions to the rule that the
patient should not be denied the opportunity to weigh the risks of surgery or
treatment are emergency cases where it is evident he cannot evaluate data,
and where the patient is a child or incompetent.62 The court thus concluded
that the patient’s right of self-decision can only be effectively exercised if the
patient possesses adequate information to enable him in making an
intelligent choice. The scope of the physician’s communications to the
patient, then must be measured by the patient’s need, and that need is
whatever information is material to the decision. The test therefore for
determining whether a potential peril must be divulged is its materiality to
the patient’s decision.63
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 physician’s 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 Angelica’s parents. Respondents could not
have been unaware in the course of initial treatment and amputation of
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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 patient’s 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 chemotherapy’s 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 DOH’s 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
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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 patient’s 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 consumer—"a reasonable person in the patient’s position when
deciding to accept or reject a recommended medical procedure." 68 (Emphasis
supplied.)
WHEREFORE, the petition for review on certiorari is GRANTED. The Decision
dated June 15, 2004 and the Resolution dated September 1, 2004 of the
Court of Appeals in CA-G.R. CV No. 58013 are SET ASIDE.
The Decision dated September 5, 1997 of the Regional Trial Court of Legazpi
City, Branch 8, in Civil Case No. 8904 is REINSTATED and UPHELD.
Li vs Spouses Soliman
GR No. 165279 June 7, 2011
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DUMAUAL, JEANNE PAULINE J. 2019-2020
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.
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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
Atty. Yulo, Legal Medicine and Medical Jurisprudence
DUMAUAL, JEANNE PAULINE J. 2019-2020
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.
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