10
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 Paraaque, 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, 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.
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.
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 Pea. Dra. Pea
called for Dr. Emilio Madrid and the latter examined Catherine Acosta. According to Dr. Madrid,
his findings might be appendicitis. Then Dr. Pea 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.
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.
1
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?
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. Pea, their family physician.
Q What transpired afterwards?
A What Dra. Pea did was call for Dr. Madrid and the
cardiologist.
Q Did this doctor arrived?
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?
2
 A At around 10:30 in the evening.
Q Did Dr. Carillo do anything when he arrived on 31 May
1981?
which allegedly showed that the cause of death was a ruptured appendix, which led to blood poisoning, 21rather
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

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.
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.

Q What did Dr. Carillo reply (sic) to you?
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
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
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
3
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 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.
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. 45This
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.
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 summons of petitioner by Dr. Madrid and the cardiologist
4
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. 52Petitioner 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 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.
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.
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, Hippocrates 3 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 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
5
 rapidly losing weight she consulted Dr. Ma. Salud Kho at the Holy Child's Hospital in Dumaguete
City on January 20, 1989.
The evidence of Plaintiffs show that when Dr. Ma. Salud Kho examined Mrs. Villegas at the Holy
Child's Hospital on January 20, 1989 she found Mrs. Villegas to be feverish, pale and was
breathing fast. Upon examination she felt an abdominal mass one finger below the umbilicus
which she suspected to be either a tumor of the uterus or an ovarian cyst, either of which could
be cancerous. She had an x-ray taken of Mrs. Villegas' chest, abdomen and kidney. She also
took blood tests of Plaintiff. A blood count showed that Mrs. Villegas had [an] infection inside her
abdominal cavity. The results of all those examinations impelled Dr. Kho to suggest that Mrs.
Villegas submit to another surgery to which the latter agreed.
When Dr. Kho opened the abdomen of Mrs. Villegas she found whitish-yellow discharge inside,
an ovarian cyst on each of the left and right ovaries which gave out pus, dirt and pus behind the
uterus, and a piece of rubber material on the right side of the uterus embedded on [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 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 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
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.
6
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 unluckily I don't know where the r
ubber 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?
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]?
A Oh yes. I was not the only one who saw it. 26
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 27 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 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:
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]
7
 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 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, 37 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.
G.R. No. 118141 September 5, 1997
LEONILA GARCIA-RUEDA, petitioner,
vs.
WILFRED L. PASCASIO, RAUL R. ARNAU, ABELARDO L. APORTADERA JR., Honorable CONRADO M.
VASQUEZ, all of the Office of the Ombudsman; JESUS F. GUERRERO, PORFIRIO MACARAEG, and
GREGORIO A. ARIZALA, all of the Office of the City Prosecutor, Manila, respondents.
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 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.
8
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 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 Ombudsmans 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 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.
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. 14Consequently, 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
9
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:
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:
Sec. 1. What May Be Appealed. Only resolutions of the Chief State Prosecutor/Regional
State Prosecutor/Provincial or City Prosecutor dismissing a criminal complaint may be the
subject of an appeal to the Secretary of Justice except as otherwise provided in Section 4
hereof.
What action may the Secretary of Justice take on the appeal? Section 9 of Order No. 223 states: "The Secretary of
Justice may reverse, affirm or modify the appealed resolution." On the other hand, "He may motu proprio or on
motion of the appellee, dismiss outright the appeal on specified grounds." 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
respondent City Prosecutors. No costs.
SO ORDERED.
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 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
10
 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 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 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
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.
11

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 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 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
32
sufficiently established. 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 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?
A. There was incision wound (sic) the area just below the navel, sir.
Q. And the last paragraph of the postmortem findings which I read: Uterus,
pear-shaped and pale measuring 7.5 x 5.5 x 5.0 cm. with some surface
12
 nodulation of the fundic area posteriorly. Cut-section shows diffusely pale
myometrium with areas of streak induration. The ovaries and adnexal
structures are missing with the raw surfaces patched with clotted blood.
Surgical sutures were noted on the operative site.
Intestines and mesenteries are pale with blood clots noted between the
mesentric folds.
Hemoperitoneum: 300 s.s.,
right paracolic gutter,
50 c.c., left paracolic gutter
200 c.c., mesentric area,
100 c.c., right pelvic gutter
stomach empty.
Other visceral organs, pale.,
will you please explain that on (sic) your own language or in ordinary. . . . . . . . . . . .
A. There was a uterus which was not attached to the adnexal structures
namely ovaries which were not present and also sign of previous surgical
operation and there were (sic) clotted blood, sir.
Q. How about the ovaries and adnexal structures?
A. They are missing, sir.
Q. You mean to say there are no ovaries?
A. During that time there are no ovaries, sir.
Q. And there were likewise sign of surgical sutures?
A. Yes, sir.
Q. How about the intestines and mesenteries are place (sic) with blood clots
noted between the mesenteric folds, will you please explain on (sic) this?
A. In the peritoneal cavity, they are mostly perritonial blood . . . . . . . .
Q. And what could have caused this blood?
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 the vessel
allowing blood to sip (sic) out, sir.
Q. By the nature of the postmortem findings indicated in Exh. A-1-B, can you
tell the court the cause of death?
A. Yes, sir. The cause of death is: Gross findings are compatible with
hemorrhagic shock.
Q. Can you tell the us what could have caused this hemorrhagic shock?
A. Well hemorrhagic shock is the result of blood loss.
Q. What could have the effect of that loss of blood?
A. Unattended hemorrhage, sir. 36 (Emphasis supplied.)
The foregoing was corroborated by Dr. Nieto Salvador:
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.
Q. Have you also examined the post mortem of Dr. Arizala?
A. Yes, sir, and by virtue of the autopsy report in connection with your
pathology report.
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?
13
 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?
A. Yes, sir. 37 (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 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.
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?
A. Definitely, sir. 39 (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.
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.
14
 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?
A: I could not recall any loose sutured (sic), sir. 41
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. 42And 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.
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.
A. No, sir, there is no fault on the part of the surgeon, sir. 44
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.
SO ORDERED.
15
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.
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 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 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).
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).
16
 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 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
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, 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
17
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.
8
SO ORDERED.
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. 9Meanwhile, 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 plaintiffs/appellees received a copy of the decision
as early as June 9, 1995. Computation wise, the period to file a Motion for Reconsideration
expired on June 24. The Motion for Reconsideration, in turn, was received by the Court of
Appeals already on July 4, necessarily, the 15-day period already passed. For that alone, the
latter should be denied.
Even assuming admissibility of the Motion for the Reconsideration, but after considering the
Comment/Opposition, the former, for lack of merit, is hereby DENIED.
SO ORDERED. 10
A copy of the above resolution was received by Atty. Sillano on 11 April 1996. The next day, or on 12 April 1996,
Atty. Sillano filed before this Court a motion for extension of time to file the present petition for certiorari under Rule
45. The Court granted the motion for extension of time and gave petitioners additional thirty (30) days after the
expiration of the fifteen-day (15) period counted from the receipt of the resolution of the Court of Appeals within
which to submit the petition. The due date fell on 27 May 1996. The petition was filed on 9 May 1996, well within
the extended period given by the Court.
Petitioners assail the decision of the Court of Appeals on the following grounds:
I from or was caused by the defendant's want of care. 14
IN PUTTING MUCH RELIANCE ON THE TESTIMONIES OF RESPONDENTS DRA.
GUTIERREZ, DRA. CALDERON AND DR. JAMORA;
II
IN FINDING THAT THE NEGLIGENCE OF THE RESPONDENTS DID NOT CAUSE THE
UNFORTUNATE COMATOSE CONDITION OF PETITIONER ERLINDA RAMOS;
III
IN NOT APPLYING THE DOCTRINE OF RES IPSA LOQUITUR. 11
Before we discuss the merits of the case, we shall first dispose of the procedural issue on the timeliness of the
petition in relation to the motion for reconsideration filed by petitioners with the Court of Appeals. In their
Comment, 12 private respondents contend that the petition should not be given due course since the motion for
reconsideration of the petitioners on the decision of the Court of Appeals was validly dismissed by the appellate
court for having been filed beyond the reglementary period. We do not agree.
A careful review of the records reveals that the reason behind the delay in 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 appellate court was instead sent to and
received by petitioner Rogelio Ramos on 9 June 1995 wherein he was mistakenly addressed as Atty. Rogelio
Ramos. Based on the other communications received by petitioner Rogelio Ramos, the appellate court apparently
mistook him for the counsel on record. Thus, no copy of the decision of the counsel on record. Petitioner, not being
a lawyer and unaware of the prescriptive period for filing a motion for reconsideration, referred the same to a legal
counsel only on 20 June 1995.
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 exceptions, notice to a litigant without notice to his counsel on record is no 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 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 of Appeals already issued a second
Resolution, dated 29 March 1996, which superseded the earlier resolution issued on 25 July 1995, and denied the
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.
After resolving the foregoing procedural issue, we shall now look into the merits of the case. For a more logical
presentation of the discussion we shall first consider the issue on the applicability of the doctrine of res ipsa
loquitur to the instant case. Thereafter, the first two assigned errors shall be tackled in relation to the res ipsa
loquitur doctrine.
Res ipsa loquitur is a Latin phrase which literally means "the thing or the transaction speaks for itself." The phrase
"res ipsa loquitur'' is a maxim for the rule that the fact of the occurrence of an injury, taken with the surrounding
circumstances, may permit an inference or raise a presumption of negligence, or make out a plaintiff's prima
facie case, and present a question of fact for defendant to meet with an explanation. 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
18
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
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. 22Such 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 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 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
19
 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
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.
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 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?
ATTY. ALCERA:
She will be incompetent Your Honor.
COURT:
Witness may answer if she knows.
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 remarks coming from
Dra. Perfecta Gutierrez herself. She was saying "Ang hirap ma-intubate nito,
mali yata ang pagkakapasok. O lumalaki ang tiyan.
xxx xxx xxx
ATTY. PAJARES:
20
 Q: From whom did you hear those words "lumalaki ang tiyan"? 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
A: From Dra. Perfecta Gutierrez. 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
xxx xxx xxx 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
Q: After hearing the phrase "lumalaki ang tiyan," what did you notice on the heart, lungs, and other organs. Thus, witness Cruz's categorical statements that appellant Dra.
person of the patient? 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
A: I notice (sic) some bluish discoloration on the nailbeds of the left hand
where I was at. 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.
Q: Where was Dr. Orlino Ho[s]aka then at that particular time?
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
A: I saw him approaching the patient during that time. 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
Q: When he approached the patient, what did he do, if any? 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 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
A: He made an order to call on the anesthesiologist in the person of Dr. procedures have become so common, that even an ordinary person can tell if it was administered properly. As
Calderon. 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.
Q: Did Dr. Calderon, upon being called, arrive inside the operating room?
At any rate, without doubt, petitioner's witness, an experienced clinical nurse whose long experience and
A: Yes sir. 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
Q: What did [s]he do, if any?
Laguna College of Nursing in San Pablo City; and then Dean of the Capitol Medical Center School of
Nursing. 50Reviewing witness Cruz' statements, we find that the same were delivered in a straightforward manner,
A: [S]he tried to intubate the patient. 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
Q: What happened to the patient? truly transpired on that fateful day.

A: When Dr. Calderon try (sic) to intubate the patient, after a while the
patient's nailbed became bluish and I saw the patient was placed in
trendelenburg position.
xxx xxx xxx
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
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.

xxx xxx xxx Q: Did you pull away the tube immediately?

The appellate court, however, disbelieved Dean Cruz's testimony in the trial court by declaring that: A: You do not pull the . . .
21
 Q: Did you or did you not?
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?
51
A: Yes, because of (sic) my first attempt, I did not see right away.
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
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 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 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:
22
 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.
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' 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 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
23
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 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 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 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:
24
 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.
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
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 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. 84The 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 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
25
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.
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 decision1 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 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 Jorges 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 Jorges temperature rose to 41C. 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 patients
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 complaint 6 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. 7Instead,
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 patients 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 findings9 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
patients 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 Jorges 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
26
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 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
Jorges 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 Jorges
death was due to the latters 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 DOCTORS NEGLIGENCE IN THE TREATMENT OF JORGE REYES.
Petitioners 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 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 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 patients 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 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
27
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 Jorges
illness as typhoid fever, and 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?
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 bronchospasms 24 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 Ricos 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, 27and if the
1:320 results of the Widal test on Jorge Reyes had been presented to him along with the patients 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?
28
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 41oC, and then about 40 minutes later the temperature rose to 100oF,
cardiac rate of 150 per minute who 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 deceaseds gastro-intestinal tract was normal, Dr.
Rico explained that, while hyperplasia31 in the payers 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. Gotiongs
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 be obtained from a higher ratio.35 He
also agreed with Dr. Gotiong that hyperplasia in the payers 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 patients 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 Harrisons 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 oclock 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) hours. (cf. Pediatric Drug Handbook, 1st Ed., Philippine
Pediatric Society, Committee on Therapeutics and Toxicology, 1996). The intravenous route is likewise correct.
(Mansser, ONick, 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
29
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:
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.1wphi1 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.
SO ORDERED.
A.M. No. 2005-08-SC December 9, 2005
SAMUEL R. RUEZ, JR., Complainant,
vs.
MARYBETH V. JURADO, Respondent.
AZCUNA, J.:
It is unfortunate that this administrative case involves co-workers in this Court. Complainant, Samuel R. Ruez, Jr.
(Ruez, Jr.), is Chief of the Clearance Section, Checks Disbursement Division of the FMO-OCA and is the son of
the aggrieved party, Samuel V. Ruez, Sr. (Ruez, 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., Ruez, Sr. arrived by himself at this 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, respectively. What transpired next is disputed. Ruez, Jr. alleged that
despite his fathers 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 Ruez, 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 patients blood pressure. She then 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, 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 Ruez, Sr. but he was unable to locate him.
According to Ruez, Jr., after being informed of his fathers condition, he rushed him to the Manila Doctors
Hospital. There, Ruez, 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, Ruez, Sr. began experiencing nausea, abnormal palpitation and uneasiness and had to be brought
back to the hospital.
Ruez, Sr. and Ruez, Jr.1 arrived at the emergency room of the Manila Doctors Hospital at around 10:00 p.m.
after which Ruez, 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,
Ruez Sr. never recovered from his ailment and, on September 12, 2005, he passed away due to medical
complications.2
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. 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. Ruez, 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 respondents witnesses. This
was followed by Ruez, Jr.s reply to the comment on April 12, 2005 and Dr. Jurados 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
Ruez, 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
clinics personnel, including the ambulance driver, who witnessed the events that happened between Ruez, 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 Ruez, Sr. proper treatment inside the
clinic. However, in her opinion, Dr. Jurados actions after Ruez, Sr. had left 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. Ruez, 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. Ruez, Sr. because of his
30
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. Ruez 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] didnt materialize and [she] put [the]
blame on Mr. Ruez, Sr. As admitted by complainant, Mr. Ruez, 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 courts 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.
Candelarias report cites the applicable yardstick: a physician or surgeon is expected to apply in his practice of
medicine that degree of care and skill which is ordinarily employed by the profession, generally, and under similar
conditions.7Therefore, 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 Ruez, 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 physicians failure
to fulfill his obligation to his patients is, in most cases, his own conscience, violation of this rule on his part is
discreditable and inexcusable."
A doctors 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 Ruez, Sr. inside the clinic. But what of Dr.
Jurados conduct after Ruez, 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 Ruez, Sr. to walk out of the clinic despite her earlier diagnosis of his condition. By
that time Ruez, 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 disease13 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 Ruez, Sr.s 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 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.
Some people may interpret Dr. Jurados inaction as indifference, while others may view the same as just proper.
Some would applaud Dr. Jurados 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 Ruez, 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, 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.
SO ORDERED.
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
The Case
This petition for review1 assails the 6 February 1998 Decision2 and 21 March 2000 Resolution3 of the Court of
Appeals in CA-G.R. CV No. 45641. The Court of Appeals affirmed in toto the 22 November 1993 Decision4 of the
31
Regional Trial Court of Manila, Branch 33, finding Dr. Oscar Estrada solely liable for damages for the death of his
patient, Corazon Nogales, while absolving the remaining respondents of any liability. The Court of Appeals denied
petitioners' motion for reconsideration.
The Facts
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 years old, was under the exclusive
prenatal care of Dr. Oscar Estrada ("Dr. Estrada") beginning on her fourth month of pregnancy or as early as
December 1975. While Corazon was on her last trimester of pregnancy, Dr. Estrada noted an increase in her blood
pressure and development of leg edema5 indicating preeclampsia,6 which is a dangerous complication of
pregnancy.7
Around midnight of 25 May 1976, Corazon started to experience mild labor pains prompting Corazon and Rogelio
Nogales ("Spouses Nogales") to see Dr. Estrada at his home. After examining Corazon, Dr. Estrada advised her
immediate admission to the Capitol Medical Center ("CMC").
On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the staff nurse noted the written admission
request8 of Dr. Estrada. Upon Corazon's admission at the CMC, Rogelio Nogales ("Rogelio") executed and signed
the "Consent on Admission and Agreement"9 and "Admission Agreement."10 Corazon was then brought to the labor
room of the CMC.
Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an internal examination of Corazon.
Dr. Uy then called up Dr. Estrada to notify him of her findings.
11
Based on the Doctor's Order Sheet, around 3:00 a.m., Dr. Estrada ordered for 10 mg. of valium to be
administered immediately by intramuscular injection. Dr. Estrada later ordered the start of intravenous
administration of syntocinon admixed with dextrose, 5%, in lactated Ringers' solution, at the rate of eight to ten
micro-drops per minute.
According to the Nurse's Observation Notes,12 Dr. Joel Enriquez ("Dr. Enriquez"), an anesthesiologist at CMC, was
notified at 4:15 a.m. of Corazon's admission. Subsequently, when asked if he needed the services of an
anesthesiologist, Dr. Estrada refused. Despite Dr. Estrada's refusal, Dr. Enriquez stayed to observe Corazon's
condition.
At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10 a.m., Corazon's bag of water
ruptured spontaneously. At 6:12 a.m., Corazon's cervix was fully dilated. At 6:13 a.m., Corazon started to
experience convulsions.
At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfate. However, Dr. Ely Villaflor ("Dr.
Villaflor"), who was assisting Dr. Estrada, administered only 2.5 grams of magnesium sulfate.
At 6:22 a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract Corazon's baby. In the process, a
1.0 x 2.5 cm. piece of cervical tissue was allegedly torn. The baby came out in an apnic, cyanotic, weak and injured
condition. Consequently, the baby had to be intubated and resuscitated by Dr. Enriquez and Dr. Payumo.
At 6:27 a.m., Corazon began to manifest moderate vaginal bleeding which rapidly became profuse. Corazon's
blood pressure dropped from 130/80 to 60/40 within five minutes. There was continuous profuse vaginal bleeding.
The assisting nurse administered hemacel through a gauge 19 needle as a side drip to the ongoing intravenous
injection of dextrose.
At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with bottled blood. It took approximately 30
minutes for the CMC laboratory, headed by Dr. Perpetua Lacson ("Dr. Lacson"), to comply with Dr. Estrada's order
and deliver the blood.
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-Gynecology Department of the CMC, was
apprised of Corazon's condition by telephone. Upon being informed that Corazon was bleeding profusely, Dr.
Espinola ordered immediate hysterectomy. Rogelio was made to sign a "Consent to Operation." 13
Due to the inclement weather then, Dr. Espinola, who was fetched from his residence by an ambulance, arrived at
the CMC about an hour later or at 9:00 a.m. He examined the patient and ordered some resuscitative measures to
be administered. Despite Dr. Espinola's efforts, Corazon died at 9:15 a.m. The cause of death was "hemorrhage,
post partum."14
On 14 May 1980, petitioners filed a complaint for damages 15 with the Regional Trial Court16 of Manila against CMC,
Dr. Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr. Lacson, Dr. Espinola, and a certain Nurse J. Dumlao for the
death of Corazon. Petitioners mainly contended that defendant physicians and CMC personnel were negligent in
the treatment and management of Corazon's condition. Petitioners charged CMC with negligence in the selection
and supervision of defendant physicians and hospital staff.
For failing to file their answer to the complaint despite service of summons, the trial court declared Dr. Estrada, Dr.
Enriquez, and Nurse Dumlao in default.17 CMC, Dr. Villaflor, Dr. Uy, Dr. Espinola, and Dr. Lacson filed their
respective answers denying and opposing the allegations in the complaint. Subsequently, trial ensued.
After more than 11 years of trial, the trial court rendered judgment on 22 November 1993 finding Dr. Estrada solely
liable for damages. The trial court ruled as follows:
The victim was under his pre-natal care, apparently, his fault began from his incorrect and inadequate
management and lack of treatment of the pre-eclamptic condition of his patient. It is not disputed that he
misapplied the forceps in causing the delivery because it resulted in a large cervical tear which had
caused the profuse bleeding which he also failed to control with the application of inadequate injection of
magnesium sulfate by his assistant Dra. Ely Villaflor. Dr. Estrada even failed to notice the erroneous
administration by nurse Dumlao of hemacel by way of side drip, instead of direct intravenous injection,
and his failure to consult a senior obstetrician at an early stage of the problem.
On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr. Joel Enriquez, Dr. Lacson, Dr. Espinola, nurse
J. Dumlao and CMC, the Court finds no legal justification to find them civilly liable.
On the part of Dra. Ely Villaflor, she was only taking orders from Dr. Estrada, the principal physician of
Corazon Nogales. She can only make suggestions in the manner the patient maybe treated but she
cannot impose her will as to do so would be to substitute her good judgment to that of Dr. Estrada. If she
failed to correctly diagnose the true cause of the bleeding which in this case appears to be a cervical
laceration, it cannot be safely concluded by the Court that Dra. Villaflor had the correct diagnosis and she
failed to inform Dr. Estrada. No evidence was introduced to show that indeed Dra. Villaflor had discovered
that there was laceration at the cervical area of the patient's internal organ.
On the part of nurse Dumlao, there is no showing that when she administered the hemacel as a side drip,
she did it on her own. If the correct procedure was directly thru the veins, it could only be because this
was what was probably the orders of Dr. Estrada.
32
While the evidence of the plaintiffs shows that Dr. Noe Espinola, who was the Chief of the Department of
Obstetrics and Gynecology who attended to the patient Mrs. Nogales, it was only at 9:00 a.m. That he
was able to reach the hospital because of typhoon Didang (Exhibit 2). While he was able to give
prescription in the manner Corazon Nogales may be treated, the prescription was based on the
information given to him by phone and he acted on the basis of facts as presented to him, believing in
good faith that such is the correct remedy. He was not with Dr. Estrada when the patient was brought to
the hospital at 2:30 o'clock a.m. So, whatever errors that Dr. Estrada committed on the patient before 9:00
o'clock a.m. are certainly the errors of Dr. Estrada and cannot be the mistake of Dr. Noe Espinola. His
failure to come to the hospital on time was due to fortuitous event.
On the part of Dr. Joel Enriquez, while he was present in the delivery room, it is not incumbent upon him
to call the attention of Dr. Estrada, Dra. Villaflor and also of Nurse Dumlao on the alleged errors
committed by them. Besides, as anesthesiologist, he has no authority to control the actuations of Dr.
Estrada and Dra. Villaflor. For the Court to assume that there were errors being committed in the
presence of Dr. Enriquez would be to dwell on conjectures and speculations.
On the civil liability of Dr. Perpetua Lacson, [s]he is a hematologist and in-charge of the blood bank of the
CMC. The Court cannot accept the theory of the plaintiffs that there was delay in delivering the blood
needed by the patient. It was testified, that in order that this blood will be made available, a laboratory test
has to be conducted to determine the type of blood, cross matching and other matters consistent with
medical science so, the lapse of 30 minutes maybe considered a reasonable time to do all of these
things, and not a delay as the plaintiffs would want the Court to believe.
Admittedly, Dra. Rosa Uy is a resident physician of the Capitol Medical Center. She was sued because of
her alleged failure to notice the incompetence and negligence of Dr. Estrada. However, there is no
evidence to support such theory. No evidence was adduced to show that Dra. Rosa Uy as a resident
physician of Capitol Medical Center, had knowledge of the mismanagement of the patient Corazon
Nogales, and that notwithstanding such knowledge, she tolerated the same to happen.
In the pre-trial order, plaintiffs and CMC agreed that defendant CMC did not have any hand or
participation in the selection or hiring of Dr. Estrada or his assistant Dra. Ely Villaflor as attending
physician[s] of the deceased. In other words, the two (2) doctors were not employees of the hospital and
therefore the hospital did not have control over their professional conduct. When Mrs. Nogales was
brought to the hospital, it was an emergency case and defendant CMC had no choice but to admit her.
Such being the case, there is therefore no legal ground to apply the provisions of Article 2176 and 2180 of
the New Civil Code referring to the vicarious liability of an employer for the negligence of its employees. If
ever in this case there is fault or negligence in the treatment of the deceased on the part of the attending
physicians who were employed by the family of the deceased, such civil liability should be borne by the
attending physicians under the principle of "respondeat superior".
WHEREFORE, premises considered, judgment is hereby rendered finding defendant Dr. Estrada of
Number 13 Pitimini St. San Francisco del Monte, Quezon City civilly liable to pay plaintiffs: 1) By way of
actual damages in the amount of P105,000.00; 2) By way of moral damages in the amount
of P700,000.00; 3) Attorney's fees in the amount of P100,000.00 and to pay the costs of suit.
For failure of the plaintiffs to adduce evidence to support its [sic] allegations against the other defendants,
the complaint is hereby ordered dismissed. While the Court looks with disfavor the filing of the present
complaint against the other defendants by the herein plaintiffs, as in a way it has caused them personal
inconvenience and slight damage on their name and reputation, the Court cannot accepts [sic] however,
the theory of the remaining defendants that plaintiffs were motivated in bad faith in the filing of this
complaint. For this reason defendants' counterclaims are hereby ordered dismissed.
SO ORDERED.18
Petitioners appealed the trial court's decision. Petitioners claimed that aside from Dr. Estrada, the remaining
respondents should be held equally liable for negligence. Petitioners pointed out the extent of each respondent's
alleged liability.
On 6 February 1998, the Court of Appeals affirmed the decision of the trial court.19 Petitioners filed a motion for
reconsideration which the Court of Appeals denied in its Resolution of 21 March 2000.20
Hence, this petition.
Meanwhile, petitioners filed a Manifestation dated 12 April 2002 21 stating that respondents Dr. Estrada, Dr.
Enriquez, Dr. Villaflor, and Nurse Dumlao "need no longer be notified of the petition because they are absolutely
not involved in the issue raised before the [Court], regarding the liability of [CMC]."22 Petitioners stressed that the
subject matter of this petition is the liability of CMC for the negligence of Dr. Estrada. 23
The Court issued a Resolution dated 9 September 200224 dispensing with the requirement to submit the correct
and present addresses of respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao. The Court stated
that with the filing of petitioners' Manifestation, it should be understood that they are claiming only against
respondents CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy who have filed their respective comments. Petitioners are
foregoing further claims against respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao.
The Court noted that Dr. Estrada did not appeal the decision of the Court of Appeals affirming the decision of the
Regional Trial Court. Accordingly, the decision of the Court of Appeals, affirming the trial court's judgment, is
already final as against Dr. Oscar Estrada.
Petitioners filed a motion for reconsideration25 of the Court's 9 September 2002 Resolution claiming that Dr.
Enriquez, Dr. Villaflor and Nurse Dumlao were notified of the petition at their counsels' last known addresses.
Petitioners reiterated their imputation of negligence on these respondents. The Court denied petitioners' Motion for
Reconsideration in its 18 February 2004 Resolution. 26
The Court of Appeals' Ruling
In its Decision of 6 February 1998, the Court of Appeals upheld the trial court's ruling. The Court of Appeals
rejected petitioners' view that the doctrine in Darling v. Charleston Community Memorial Hospital27 applies to this
case. According to the Court of Appeals, the present case differs from the Darling case since Dr. Estrada is an
independent contractor-physician whereas the Darling case involved a physician and a nurse who were employees
of the hospital.
Citing other American cases, the Court of Appeals further held that the mere fact that a hospital permitted a
physician to practice medicine and use its facilities is not sufficient to render the hospital liable for the physician's
negligence.28 A hospital is not responsible for the negligence of a physician who is an independent contractor. 29
The Court of Appeals found the cases of Davidson v. Conole30 and Campbell v. Emma Laing Stevens
Hospital31applicable 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.
33
On the liability of the other respondents, the Court of Appeals applied the "borrowed servant" doctrine considering
that Dr. Estrada was an independent contractor who was merely exercising hospital privileges. This doctrine
provides that once the surgeon enters the operating room and takes charge of the proceedings, the acts or
omissions of operating room personnel, and any negligence associated with such acts or omissions, are imputable
to the surgeon.32 While the assisting physicians and nurses may be employed by the hospital, or engaged by the
patient, they normally become the temporary servants or agents of the surgeon in charge while the operation is in
progress, and liability may be imposed upon the surgeon for their negligent acts under the doctrine of respondeat
superior.33
The Court of Appeals concluded that since Rogelio engaged Dr. Estrada as the attending physician of his wife, any
liability for malpractice must be Dr. Estrada's sole responsibility.
While it found the amount of damages fair and reasonable, the Court of Appeals held that no interest could be
imposed on unliquidated claims or damages.
The Issue
Basically, the issue in this case is whether CMC is vicariously liable for the negligence of Dr. Estrada. The
resolution of this issue rests, on the other hand, on the ascertainment of the relationship between Dr. Estrada and
CMC. The Court also believes that a determination of the extent of liability of the other respondents is inevitable to
finally and completely dispose of the present controversy.
The Ruling of the Court
The petition is partly meritorious.
On the Liability of CMC
Dr. Estrada's negligence in handling the treatment and management of Corazon's condition which ultimately
resulted in Corazon's death is no longer in issue. Dr. Estrada did not appeal the decision of the Court of Appeals
which affirmed the ruling of the trial court finding Dr. Estrada solely liable for damages. Accordingly, the finding of
the trial court on Dr. Estrada's negligence is already final.
Petitioners maintain that CMC is vicariously liable for Dr. Estrada's negligence based on Article 2180 in relation to
Article 2176 of the Civil Code. These provisions pertinently state:
Art. 2180. The obligation imposed by article 2176 is demandable not only for one's own acts or omissions,
but also for those of persons for whom one is responsible.
xxxx
Employers shall be liable for the damages caused by their employees and household helpers acting
within the scope of their assigned tasks, even though the former are not engaged in any business or
industry.
xxxx
The responsibility treated of in this article shall cease when the persons herein mentioned prove that they
observed all the diligence of a good father of a family to prevent damage.
Art. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is
obliged to pay for the damage done. Such fault or negligence, if there is no pre-existing contractual
relation between the parties, is called a quasi-delict and is governed by the provisions of this Chapter.
Similarly, in the United States, a hospital which is the employer, master, or principal of a physician employee,
servant, or agent, may be held liable for the physician's negligence under the doctrine of respondeat superior.34
In the present case, petitioners maintain that CMC, in allowing Dr. Estrada to practice and admit patients at CMC,
should be liable for Dr. Estrada's malpractice. Rogelio claims that he knew Dr. Estrada as an accredited physician
of CMC, though he discovered later that Dr. Estrada was not a salaried employee of the CMC. 35 Rogelio further
claims that he was dealing with CMC, whose primary concern was the treatment and management of his wife's
condition. Dr. Estrada just happened to be the specific person he talked to representing CMC. 36 Moreover, the fact
that CMC made Rogelio sign a Consent on Admission and Admission 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 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
34
 foregoing, we rule that for the purpose of allocating responsibility in medical negligence cases, an
employer-employee relationship in effect exists between hospitals and their attending and visiting
physicians. This being the case, the question now arises as to whether or not respondent hospital is
solidarily liable with respondent doctors for petitioner's condition.
The basis for holding an employer solidarily responsible for the negligence of its employee is found in
Article 2180 of the Civil Code which considers a person accountable not only for his own acts but also for
those of others based on the former's responsibility under a relationship of patria potestas. x x
x40(Emphasis supplied)
While the Court in Ramos did not expound on the control test, such test essentially determines whether an
employment relationship exists between a physician and a hospital based on the exercise of control over the
physician as to details. Specifically, the employer (or the hospital) must have the right to control both the means
and the details of the process by which the employee (or the physician) is to accomplish his task.41
After a thorough examination of the voluminous records of this case, the Court finds no single evidence pointing to
CMC's exercise of control over Dr. Estrada's treatment and management of Corazon's condition. It is undisputed
that throughout Corazon's pregnancy, she was under the exclusive prenatal care of Dr. Estrada. At the time of
Corazon's admission at CMC and during her delivery, it was Dr. Estrada, assisted by Dr. Villaflor, who attended to
Corazon. There was no showing that CMC had a part in diagnosing Corazon's condition. While Dr. Estrada enjoyed
staff privileges at CMC, such fact alone did not make him an employee of CMC. 42 CMC merely allowed Dr. Estrada
to use its facilities43 when Corazon was about to give birth, which CMC considered an emergency. Considering
these circumstances, Dr. Estrada is not an employee of CMC, but an independent contractor.
The question now is whether CMC is automatically exempt from liability considering that Dr. Estrada is an
independent contractor-physician.
In general, a hospital is not liable for the negligence of an independent contractor-physician. There is, however, an
exception to this principle. The hospital may be liable if the physician is the "ostensible" agent of the hospital.44This
exception is also known as the "doctrine of apparent authority." 45 In Gilbert v. Sycamore Municipal Hospital,46 the
Illinois Supreme Court explained the doctrine of apparent authority in this wise:
[U]nder the doctrine of apparent authority a hospital can be held vicariously liable for the negligent acts of
a physician providing care at the hospital, regardless of whether the physician is an independent
contractor, unless the patient knows, or should have known, that the physician is an independent
contractor. The elements of the action have been set out as follows:
"For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show that: (1) the
hospital, or its agent, acted in a manner that would lead a reasonable person to conclude that the
individual who was alleged to be negligent was an employee or agent of the hospital; (2) where the acts
of the agent create the appearance of authority, the plaintiff must also prove that the hospital had
knowledge of and acquiesced in them; and (3) the plaintiff acted in reliance upon the conduct of the
hospital or its agent, consistent with ordinary care and prudence."
The element of "holding out" on the part of the hospital does not require an express representation by the
hospital that the person alleged to be negligent is an employee. Rather, the element is satisfied if the
hospital holds itself out as a provider of emergency room care without informing the patient that the care
is provided by independent contractors.
The element of justifiable reliance on the part of the plaintiff is satisfied if the plaintiff relies upon the
hospital to provide complete emergency room care, rather than upon a specific physician.
The doctrine of apparent authority essentially involves two factors to determine the liability of an independent-
contractor physician.
The first factor focuses on the hospital's manifestations and is sometimes described as an inquiry whether the
hospital acted in a manner which would lead a reasonable person to conclude that the individual who was alleged
to be negligent was an employee or agent of the hospital. 47 In this regard, the hospital need not make express
representations to the patient that the treating physician is an employee of the hospital; rather a
representation may be general and implied.48
The doctrine of apparent authority is a species of the doctrine of estoppel. Article 1431 of the Civil Code provides
that "[t]hrough estoppel, an admission or representation is rendered conclusive upon the person making it, and
cannot be denied or disproved as against the person relying thereon." Estoppel rests on this rule: "Whenever a
party has, by his own declaration, act, or omission, intentionally and deliberately led another to believe a particular
thing true, and to act upon such belief, he cannot, in any litigation arising out of such declaration, act or omission,
be permitted to falsify it."49
In the instant case, CMC impliedly held out Dr. Estrada as a member of its medical staff. Through CMC's acts,
CMC clothed Dr. Estrada with apparent authority thereby leading the Spouses Nogales to believe that Dr. Estrada
was an employee or agent of CMC. CMC cannot now repudiate such authority.
First, CMC granted staff privileges to Dr. Estrada. CMC extended its medical staff and facilities to Dr. Estrada.
Upon Dr. Estrada's request for Corazon's admission, CMC, through its personnel, readily accommodated Corazon
and updated Dr. Estrada of her condition.
Second, CMC made Rogelio sign consent forms printed on CMC letterhead. Prior to Corazon's admission and
supposed hysterectomy, CMC asked Rogelio to sign release forms, the contents of which reinforced Rogelio's
belief that Dr. Estrada was a member of CMC's medical staff.50 The Consent on Admission and Agreement
explicitly provides:
KNOW ALL MEN BY THESE PRESENTS:
I, Rogelio Nogales, of legal age, a resident of 1974 M. H. Del Pilar St., Malate Mla., being the
father/mother/brother/sister/spouse/relative/ guardian/or person in custody of Ma. Corazon, and
representing his/her family, of my own volition and free will, do consent and submit said Ma. Corazon to
Dr. Oscar Estrada (hereinafter referred to as Physician) for cure, treatment, retreatment, or emergency
measures, that the Physician, personally or by and through the Capitol Medical Center and/or its
staff, may use, adapt, or employ such means, forms or methods of cure, treatment, retreatment, or
emergency measures as he may see best and most expedient; that Ma. Corazon and I will comply
with any and all rules, regulations, directions, and instructions of the Physician, the Capitol
Medical Center and/or its staff; and, that I will not hold liable or responsible and hereby waive and
forever discharge and hold free the Physician, the Capitol Medical Center and/or its staff, from any and all
claims of whatever kind of nature, arising from directly or indirectly, or by reason of said cure, treatment,
or retreatment, or emergency measures or intervention of said physician, the Capitol Medical Center
and/or its staff.
x x x x51 (Emphasis supplied)
35
While the Consent to Operation pertinently reads, thus:
I, ROGELIO NOGALES, x x x, of my own volition and free will, do consent and submit said CORAZON
NOGALES to Hysterectomy, by the Surgical Staff and Anesthesiologists of Capitol Medical
Center and/or whatever succeeding operations, treatment, or emergency measures as may be necessary
and most expedient; and, that I will not hold liable or responsible and hereby waive and forever discharge
and hold free the Surgeon, his assistants, anesthesiologists, the Capitol Medical Center and/or its staff,
from any and all claims of whatever kind of nature, arising from directly or indirectly, or by reason of said
operation or operations, treatment, or emergency measures, or intervention of the Surgeon, his
assistants, anesthesiologists, the Capitol Medical Center and/or its staff. 52 (Emphasis supplied)
Without any indication in these consent forms that Dr. Estrada was an independent contractor-physician, the
Spouses Nogales could not have known that Dr. Estrada was an independent contractor. Significantly, no one from
CMC informed the Spouses Nogales that Dr. Estrada was an independent contractor. On the contrary, Dr. Atencio,
who was then a member of CMC Board of Directors, testified that Dr. Estrada was part of CMC's surgical staff. 53
Third, Dr. Estrada's referral of Corazon's profuse vaginal bleeding to Dr. Espinola, who was then the Head of the
Obstetrics and Gynecology Department of CMC, gave the impression that Dr. Estrada as a member of CMC's
medical staff was collaborating with other CMC-employed specialists in treating Corazon.
The second factor focuses on the patient's reliance. It is sometimes characterized as an inquiry on whether the
plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care and
prudence.54
The records show that the Spouses Nogales relied upon a perceived employment relationship with CMC in
accepting Dr. Estrada's services. Rogelio testified that he and his wife specifically chose Dr. Estrada to handle
Corazon's delivery not only because of their friend's recommendation, but more importantly because of Dr.
Estrada's "connection with a reputable hospital, the [CMC]." 55 In other words, Dr. Estrada's relationship with CMC
played a significant role in the Spouses Nogales' decision in accepting Dr. Estrada's services as the obstetrician-
gynecologist for Corazon's delivery. Moreover, as earlier stated, there is no showing that before and during
Corazon's confinement at CMC, the Spouses Nogales knew or should have known that Dr. Estrada was not an
employee of CMC.
Further, the Spouses Nogales looked to CMC to provide the best medical care and support services for Corazon's
delivery. The Court notes that prior to Corazon's fourth pregnancy, she used to give birth inside a clinic.
Considering Corazon's age then, the Spouses Nogales decided to have their fourth child delivered at CMC, which
Rogelio regarded one of the best hospitals at the time. 56 This is precisely because the Spouses Nogales feared that
Corazon might experience complications during her delivery which would be better addressed and treated in a
modern and big hospital such as CMC. Moreover, Rogelio's consent in Corazon's hysterectomy to be performed by
a different physician, namely Dr. Espinola, is a clear indication of Rogelio's confidence in CMC's surgical staff.
CMC's defense that all it did was "to extend to [Corazon] its facilities" is untenable. The Court cannot close its eyes
to the reality that hospitals, such as CMC, are in the business of treatment. In this regard, the Court agrees with the
observation made by the Court of Appeals of North Carolina in Diggs v. Novant Health, Inc., 57 to wit:
"The conception that the hospital does not undertake to treat the patient, does not undertake to act
through its doctors and nurses, but undertakes instead simply to procure them to act upon their own
responsibility, no longer reflects the fact. Present day hospitals, as their manner of operation plainly
demonstrates, do far more than furnish facilities for treatment. They regularly employ on a salary
basis a large staff of physicians, nurses and internes [sic], as well as administrative and manual
workers, and they charge patients for medical care and treatment, collecting for such services, if
necessary, by legal action. Certainly, the person who avails himself of 'hospital facilities' expects
that the hospital will attempt to cure him, not that its nurses or other employees will act on their
own responsibility." x x x (Emphasis supplied)
Likewise unconvincing is CMC's argument that petitioners are estopped from claiming damages based on the
Consent on Admission and Consent to Operation. Both release forms consist of two parts. The first part gave CMC
permission to administer to Corazon any form of recognized medical treatment which the CMC medical staff
deemed advisable. The second part of the documents, which may properly be described as the releasing part,
releases CMC and its employees "from any and all claims" arising from or by reason of the treatment and
operation.
The documents do not expressly release CMC from liability for injury to Corazon due to negligence during her
treatment or operation. Neither do the consent forms expressly exempt CMC from liability for Corazon's death due
to negligence during such treatment or operation. Such release forms, being in the nature of contracts of adhesion,
are construed strictly against hospitals. Besides, a blanket release in favor of hospitals "from any and all claims,"
which includes claims due to bad faith or gross negligence, would be contrary to public policy and thus void.
Even simple negligence is not subject to blanket release in favor of establishments like hospitals but may only
mitigate liability depending on the circumstances. 58 When a person needing urgent medical attention rushes to a
hospital, he cannot bargain on equal footing with the hospital on the terms of admission and operation. Such a
person is literally at the mercy of the hospital. There can be no clearer example of a contract of adhesion than one
arising from such a dire situation. Thus, the release forms of CMC cannot relieve CMC from liability for the
negligent medical treatment of Corazon.
On the Liability of the Other Respondents
Despite this Court's pronouncement in its 9 September 200259 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.
36
The Court believes Dr. Uy's claim that as a second year resident physician then at CMC, she was merely
authorized to take the clinical history and physical examination of Corazon.62 However, that routine internal
examination did not ipso facto make Dr. Uy liable for the errors committed by Dr. Estrada. Further, petitioners'
imputation of negligence rests on their baseless assumption that Dr. Uy was present at the delivery room. Nothing
shows that Dr. Uy participated in delivering Corazon's baby. Further, it is unexpected from Dr. Uy, a mere resident
physician at that time, to call the attention of a more experienced specialist, if ever she was present at the delivery
room.
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

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
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.

Petitioners fault Dr. Perpetua Lacson for her purported delay in the delivery of blood Corazon needed. 64Petitioners
claim that Dr. Lacson was remiss in her duty of supervising the blood bank staff.
G.R. No. 126297 January 31, 2007

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 PROFESSIONAL SERVICES, INC., Petitioner,
the patient.65 Taking into account the bleeding time, clotting time and cross-matching, Dr. Lacson stated that it vs.
would take approximately 45-60 minutes before blood could be ready for transfusion. 66 Further, no evidence exists NATIVIDAD and ENRIQUE AGANA, Respondents.
that Dr. Lacson neglected her duties as head of the blood bank.
x-----------------------x
e) Dr. Noe Espinola
G.R. No. 126467 January 31, 2007
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, NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE AGANA, JR., EMMA AGANA
and advised a thorough examination of the cervix, instead of believing outright Dr. Estrada's diagnosis that the ANDAYA, JESUS AGANA, and RAYMUND AGANA) and ENRIQUE AGANA, Petitioners,
cause of bleeding was uterine atony. vs.
JUAN FUENTES, Respondent.
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 x- - - - - - - - - - - - - - - - - - - -- - - - x
about Corazon's condition, believed in good faith that hysterectomy was the correct remedy. At any rate, the
hysterectomy did not push through because upon Dr. Espinola's arrival, it was already too late. At the time,
G.R. No. 127590 January 31, 2007
Corazon was practically dead.

MIGUEL AMPIL, Petitioner,

f) Nurse J. Dumlao
vs.
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
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
DECISION
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.

37
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankinds 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 hospitals 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
Decision3 dated March 17, 1993 of the Regional Trial Court (RTC), Branch 96, Quezon City in Civil Case No. Q-
43322 and nullifying its Order dated September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital (Medical City Hospital) because
of difficulty of bowel movement and bloody anal discharge. After a series of medical examinations, Dr. Miguel
Ampil, petitioner in G.R. No. 127590, diagnosed her to be suffering from "cancer of the sigmoid."
On April 11, 1984, Dr. Ampil, assisted by the medical staff 4 of the Medical City Hospital, performed an anterior
resection surgery on Natividad. He found that the malignancy in her sigmoid area had spread on her left ovary,
necessitating the removal of certain portions of it. Thus, Dr. Ampil obtained the consent of Natividads husband,
Enrique Agana, to permit Dr. Juan Fuentes, respondent in G.R. No. 126467, to perform hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and closed the
incision.
However, the operation appeared to be flawed. In the corresponding Record of Operation dated April 11, 1984, the
attending nurses entered these remarks:
"sponge count lacking 2
"announced to surgeon searched (sic) done but to no avail continue for closure."
On April 24, 1984, Natividad was released from the hospital. Her hospital and medical bills, including the doctors
fees, amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating pain in her anal region. She consulted both Dr. Ampil
and Dr. Fuentes about it. They told her that the pain was the natural consequence of the surgery. Dr. Ampil then
recommended that she consult an oncologist to examine the cancerous nodes which were not removed during the
operation.
On May 9, 1984, Natividad, accompanied by her husband, went to the United States to seek further treatment. After
four months of consultations and laboratory examinations, Natividad was told she was free of cancer. Hence, she
was advised to return to the Philippines.
On August 31, 1984, Natividad flew back to the Philippines, still suffering from pains. Two weeks thereafter, her
daughter found a piece of gauze protruding from her vagina. Upon being informed about it, Dr. Ampil proceeded to
her house where he managed to extract by hand a piece of gauze measuring 1.5 inches in width. He then assured
her that the pains would soon vanish.
Dr. Ampils 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 Natividads body and malpractice for concealing their acts of negligence.
Meanwhile, Enrique Agana also filed with the Professional Regulation Commission (PRC) an administrative
complaint for gross negligence and malpractice against Dr. Ampil and Dr. Fuentes, docketed as Administrative
Case No. 1690. The PRC Board of Medicine heard the case only with respect to Dr. Fuentes because it failed to
acquire jurisdiction over Dr. Ampil who was then in the United States.
On February 16, 1986, pending the outcome of the above cases, Natividad died and was duly substituted by her
above-named children (the Aganas).
On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes
liable for negligence and malpractice, the decretal part of which reads:
WHEREFORE, judgment is hereby rendered for the plaintiffs ordering the defendants PROFESSIONAL
SERVICES, INC., DR. MIGUEL AMPIL and DR. JUAN FUENTES to pay to the plaintiffs, jointly and severally,
except in respect of the award for exemplary damages and the interest thereon which are the liabilities of
defendants Dr. Ampil and Dr. Fuentes only, as follows:
1. As actual damages, the following amounts:
a. The equivalent in Philippine Currency of the total of US$19,900.00 at the rate of P21.60-
US$1.00, as reimbursement of actual expenses incurred in the United States of America;
b. The sum of P4,800.00 as travel taxes of plaintiffs and their physician daughter;
c. The total sum of P45,802.50, representing the cost of hospitalization at Polymedic Hospital,
medical fees, and cost of the saline solution;
2. As moral damages, the sum of P2,000,000.00;
3. As exemplary damages, the sum of P300,000.00;
4. As attorneys fees, the sum of P250,000.00;
38
 5. Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove, from date of filing of the complaint until
full payment; and
6. Costs of suit.
SO ORDERED.
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals, docketed as CA-G.R. CV
No. 42062.
Incidentally, on April 3, 1993, the Aganas filed with the RTC a motion for a partial execution of its Decision, which
was granted in an Order dated May 11, 1993. Thereafter, the sheriff levied upon certain properties of Dr. Ampil and
sold them for P451,275.00 and delivered the amount to the Aganas.
Following their receipt of the money, the Aganas entered into an agreement with PSI and Dr. Fuentes to indefinitely
suspend any further execution of the RTC Decision. However, not long thereafter, the Aganas again filed a motion
for an alias writ of execution against the properties of PSI and Dr. Fuentes. On September 21, 1993, the RTC
granted the motion and issued the corresponding writ, prompting Dr. Fuentes to file with the Court of Appeals a
petition for certiorari and prohibition, with prayer for preliminary injunction, docketed as CA-G.R. SP No. 32198.
During its pendency, the Court of Appeals issued a Resolution 5 dated October 29, 1993 granting Dr. Fuentes
prayer for injunctive relief.
On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No. 42062.
Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision 6 in Administrative Case No.
1690 dismissing the case against Dr. Fuentes. The Board held that the prosecution failed to show that Dr. Fuentes
was the one who left the two pieces of gauze inside Natividads body; and that he concealed such fact from
Natividad.
On September 6, 1996, the Court of Appeals rendered its Decision jointly disposing of CA-G.R. CV No. 42062 and
CA-G.R. SP No. 32198, thus:
WHEREFORE, except for the modification that the case against defendant-appellant Dr. Juan Fuentes is hereby
DISMISSED, and with the pronouncement that defendant-appellant Dr. Miguel Ampil is liable to reimburse
defendant-appellant Professional Services, Inc., whatever amount the latter will pay or had paid to the plaintiffs-
appellees, the decision appealed from is hereby AFFIRMED and the instant appeal DISMISSED.
Concomitant with the above, the petition for certiorari and prohibition filed by herein defendant-appellant Dr. Juan
Fuentes in CA-G.R. SP No. 32198 is hereby GRANTED and the challenged order of the respondent judge dated
September 21, 1993, as well as the alias writ of execution issued pursuant thereto are hereby NULLIFIED and SET
ASIDE. The bond posted by the petitioner in connection with the writ of preliminary injunction issued by this Court
on November 29, 1993 is hereby cancelled.
Costs against defendants-appellants Dr. Miguel Ampil and Professional Services, Inc.
SO ORDERED.
Only Dr. Ampil filed a motion for reconsideration, but it was denied in a 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 Natividads 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 Courts attention to other possible causes of Natividads
detriment. He argues that the Court should not discount either of the following possibilities: first, Dr. Fuentes left the
gauzes in Natividads body after performing hysterectomy; second, the attending nurses erred in counting the
gauzes; and third, the American doctors were the ones who placed the gauzes in Natividads body.
Dr. Ampils 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 Natividads 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.
39
 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 patients 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 patients abdomen, because of the dangers attendant upon delay, still, it is his legal duty to
so inform his patient within a reasonable time thereafter by advising her of what he had been compelled to do. This
is in order that she might seek relief from the effects of the foreign object left in her body as her condition might
permit. The ruling in Smith v. Zeagler10 is explicit, thus:
The removal of all sponges used is part of a surgical operation, and when a physician or surgeon fails to remove a
sponge he has placed in his patients 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 patients 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 Natividads 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. Ampils negligence is the proximate
cause12 of Natividads 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 Natividads
vagina established the causal link between Dr. Ampils negligence and the injury. And what further aggravated such
injury was his deliberate concealment of the missing gauzes from the knowledge of Natividad and her family.
II - G.R. No. 126467
Whether the Court of Appeals Erred in Absolving
Dr. Fuentes of any Liability
The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes on the ground that it is contrary
to the doctrine of res ipsa loquitur. According to them, the fact that the two pieces of gauze were left inside
Natividads 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 plaintiffs 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 defendants want of care,
and the burden of proof is shifted to him to establish that he has observed due care and diligence. 14
From the foregoing statements of the rule, the requisites for the applicability of the doctrine of res ipsa loquitur are:
(1) the occurrence of an injury; (2) the thing which caused the injury was under the control and management of the
defendant; (3) the occurrence was such that in the ordinary course of things, would not have happened if those who
had control or management used proper care; and (4) the absence of explanation by the defendant. Of the
foregoing requisites, the most instrumental is the "control and management of the thing which caused the injury." 15
We find the element of "control and management of the thing which caused the injury" to be wanting. Hence, the
doctrine of res ipsa loquitur will not lie.
It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He requested the
assistance of Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil) found that the malignancy in her
sigmoid area had spread to her left ovary. Dr. Fuentes performed the surgery and thereafter reported and showed
his work to Dr. Ampil. The latter examined it and finding everything to be in order, allowed Dr. Fuentes to leave the
operating room. Dr. Ampil then resumed operating on Natividad. He was about to finish the procedure when the
attending nurses informed him that two pieces of gauze were missing. A "diligent search" was conducted, but the
misplaced gauzes were not found. Dr. Ampil then directed that the incision be closed. During this entire period, Dr.
Fuentes was no longer in the operating room and had, in fact, left the hospital.
Under the "Captain of the Ship" rule, the operating surgeon is the person in complete charge of the surgery room
and all personnel connected with the operation. Their duty is to obey his orders. 16 As stated before, Dr. Ampil was
the lead surgeon. In other words, he was the "Captain of the Ship." That he discharged such role is evident from his
following conduct: (1) calling Dr. Fuentes to perform a hysterectomy; (2) examining the work of Dr. Fuentes and
finding it in order; (3) granting Dr. Fuentes permission to leave; and (4) ordering the closure of the incision. To our
mind, it was this act of ordering the closure of the incision notwithstanding that two pieces of gauze remained
unaccounted for, that caused injury to Natividads 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
40
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 patients ability to pay. 18 Those who could afford medical treatment
were usually treated at home by their doctors.19 However, the days of house calls and philanthropic health care are
over. The modern health care industry continues to distance itself from its charitable past and has experienced a
significant conversion from a not-for-profit health care to for-profit hospital businesses. Consequently, significant
changes in health law have accompanied the business-related changes in the hospital industry. One important
legal change is an increase in hospital liability for medical malpractice. Many courts now allow claims for hospital
vicarious liability under the theories of respondeat superior, apparent authority, ostensible authority, or agency by
estoppel. 20
In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of the Civil Code, which reads:
Art. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is obliged to pay
for the damage done. Such fault or negligence, if there is no pre-existing contractual relation between the parties, is
called a quasi-delict and is governed by the provisions of this Chapter.
A derivative of this provision is Article 2180, the rule governing vicarious liability under the doctrine of respondeat
superior, thus:
ART. 2180. The obligation imposed by Article 2176 is demandable not only for ones 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 either accept or reject the application. x x x.
The responsibility treated of in this article shall cease when the persons herein mentioned prove that they observed
all the diligence of a good father of a family to prevent damage.
A prominent civilist commented that professionals engaged by an employer, such as physicians, dentists, and
pharmacists, are not "employees" under this article because the manner in which they perform their work is not
within the control of the latter (employer). In other words, professionals are considered personally liable for the fault
or negligence they commit in the discharge of their duties, and their employer cannot be held liable for such fault or
negligence. In the context of the present case, "a hospital cannot be held liable for the fault or negligence of a
physician or surgeon in the treatment or operation of patients." 21
The foregoing view is grounded on the traditional notion that the professional status and the very nature of the
physicians 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 hospitals functions limited to furnishing room, food, facilities for treatment and
operation, and attendants for its patients. Thus, in Bing v. Thunig, 27 the New York Court of Appeals deviated from
the Schloendorff doctrine, noting that modern hospitals actually do far more than provide facilities for treatment.
Rather, they regularly employ, on a salaried basis, a large staff of physicians, interns, nurses, administrative and
manual workers. They charge patients for medical care and treatment, even collecting for such services through
legal action, if necessary. The court then concluded that there is no reason to exempt hospitals from the universal
rule of respondeat superior.
In our shores, the nature of the relationship between the hospital and the physicians is rendered inconsequential in
view of our categorical pronouncement in Ramos v. Court of Appeals 28 that for purposes of apportioning
responsibility in medical negligence cases, an employer-employee relationship in effect exists between hospitals
and their attending and visiting physicians. This Court held:
"We now discuss the responsibility of the hospital in this particular incident. The unique practice (among private
hospitals) of filling up specialist staff with attending and visiting "consultants," who are allegedly not hospital
employees, presents problems in apportioning responsibility for negligence in medical malpractice cases. However,
the difficulty is more apparent than real.
In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the conduct of
their work within the hospital premises. Doctors who apply for consultant slots, visiting or attending, are required to
submit proof of completion of residency, their educational qualifications, generally, evidence of accreditation by the
appropriate board (diplomate), evidence of fellowship in most cases, and references. These requirements are
carefully scrutinized by members of the hospital administration or by a review committee set up by the hospital who
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 physicians
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
41
negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and
visiting physicians. "
But the Ramos pronouncement is not our only basis in sustaining PSIs 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 hospitals 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 physicians negligence.
Our jurisdiction recognizes the concept of an agency by implication or estoppel. Article 1869 of the Civil Code
reads:
ART. 1869. Agency may be express, or implied from the acts of the principal, from his silence or lack of action, or
his failure to repudiate the agency, knowing that another person is acting on his behalf without authority.
In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and specializations of the
physicians associated or accredited by it, including those of Dr. Ampil and Dr. Fuentes. We concur with the Court of
Appeals conclusion that it "is now estopped from passing all the blame to the physicians whose names it proudly
paraded in the public directory leading the public to believe that it vouched for their skill and competence." Indeed,
PSIs 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 hospitals act of listing him and his specialty in its
lobby directory, as in the case herein. The high costs of todays medical and health care should at least exact on
the hospital greater, if not broader, legal responsibility for the conduct of treatment and surgery within its facility by
its accredited physician or surgeon, regardless of whether he is independent or employed." 33
The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like PSI, are capable of acting only
through other individuals, such as physicians. If these accredited physicians do their job well, the hospital succeeds
in its mission of offering quality medical services and thus profits financially. Logically, where negligence mars the
quality of its services, the hospital should not be allowed to escape liability for the acts of its ostensible agents.
We now proceed to the doctrine of corporate negligence or corporate responsibility.
One allegation in the complaint in Civil Case No. Q-43332 for negligence and malpractice is that PSI as owner,
operator and manager of Medical City Hospital, "did not perform the necessary supervision nor exercise diligent
efforts in the supervision of Drs. Ampil and Fuentes and its nursing staff, resident doctors, and medical interns who
assisted Drs. Ampil and Fuentes in the performance of their duties as surgeons."34 Premised on the doctrine of
corporate negligence, the trial court held that PSI is directly liable for such breach of duty.
We agree with the trial court.
Recent years have seen the doctrine of corporate negligence as the judicial answer to the problem of allocating
hospitals 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 judiciarys 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
hospitals corporate negligence extends to permitting a physician known to be incompetent to practice at the
hospital.37 With the passage of time, more duties were expected from hospitals, among them: (1) the use of
reasonable care in the maintenance of safe and adequate facilities and equipment; (2) the selection and retention
of competent physicians; (3) the overseeing or supervision of all persons who practice medicine within its walls; and
(4) the formulation, adoption and enforcement of adequate rules and policies that ensure quality care for its
patients.38 Thus, in Tucson Medical Center, Inc. v. Misevich, 39 it was held that a hospital, following the doctrine of
corporate responsibility, has the duty to see that it meets the standards of responsibilities for the care of patients.
Such duty includes the proper supervision of the members of its medical staff. And in Bost v. Riley, 40 the court
concluded that a patient who enters a hospital does so with the reasonable expectation that it will attempt to cure
him. The hospital accordingly has the duty to make a reasonable effort to monitor and oversee the treatment
prescribed and administered by the physicians practicing in its premises.
In the present case, it was duly established that PSI operates the Medical City Hospital for the purpose and under
the concept of providing comprehensive medical services to the public. Accordingly, it has the duty to exercise
reasonable care to protect from harm all patients admitted into its facility for medical treatment. Unfortunately, PSI
failed to perform such duty. The findings of the trial court are convincing, thus:
x x x PSIs 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 PSIs 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
42
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 PSIs 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
Natividads case.
It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the assistance of the Medical City
Hospitals staff, composed of resident doctors, nurses, and interns. As such, it is reasonable to conclude that PSI,
as the operator of the hospital, has actual or constructive knowledge of the procedures carried out, particularly the
report of the attending nurses that the two pieces of gauze were missing. In Fridena v. Evans, 41 it was held that a
corporation is bound by the knowledge acquired by or notice given to its agents or officers within the scope of their
authority and in reference to a matter to which their authority extends. This means that the knowledge of any of the
staff of Medical City Hospital constitutes knowledge of PSI. Now, the failure of PSI, despite the attending nurses
report, to investigate and inform Natividad regarding the missing gauzes amounts to callous negligence. Not only
did PSI breach its duties to oversee or supervise all persons who practice medicine within its walls, it also failed to
take an active step in fixing the negligence committed. This renders PSI, not only vicariously liable for the
negligence of Dr. Ampil under Article 2180 of the Civil Code, but also directly liable for its own negligence under
Article 2176. In Fridena, the Supreme Court of Arizona held:
x x x In recent years, however, the duty of care owed to the patient by the hospital has expanded. The emerging
trend is to hold the hospital responsible where the hospital has failed to monitor and review medical services being
provided within its walls. See Kahn Hospital Malpractice Prevention, 27 De Paul . Rev. 23 (1977).
Among the cases indicative of the emerging trend is Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972).
In Purcell, the hospital argued that it could not be held liable for the malpractice of a medical practitioner because
he was an independent contractor within the hospital. The Court of Appeals pointed out that the hospital had
created a professional staff whose competence and performance was to be monitored and reviewed by the
governing body of the hospital, and the court held that a hospital would be negligent where it had knowledge or
reason to believe that a doctor using the facilities was employing a method of treatment or care which fell below the
recognized standard of care.
Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hospital has certain inherent
responsibilities regarding the quality of medical care furnished to patients within its walls and it must meet the
standards of responsibility commensurate with this undertaking. Beeck v. Tucson General Hospital, 18 Ariz. App.
165, 500 P. 2d 1153 (1972). This court has confirmed the rulings of the Court of Appeals that a hospital has the
duty of supervising the competence of the doctors on its staff. x x x.
x x x x x x
In the amended complaint, the plaintiffs did plead that the operation was performed at the hospital with its
knowledge, aid, and assistance, and that the negligence of the defendants was the proximate cause of the patients
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 hospitals liability based on the theory of negligent supervision."
Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for damages, let it be emphasized that
PSI, apart from a general denial of its responsibility, failed to adduce evidence showing that it exercised the
diligence of a good father of a family in the accreditation and supervision of the latter. In neglecting to offer such
proof, PSI failed to discharge its burden under the last paragraph of Article 2180 cited earlier, and, therefore, must
be adjudged solidarily liable with Dr. Ampil. Moreover, as we have discussed, PSI is also directly liable to the
Aganas.
One final word. Once a physician undertakes the treatment and care of a patient, the law imposes on him certain
obligations. In order to escape liability, he must possess that reasonable degree of learning, skill and experience
required by his profession. At the same time, he must apply reasonable care and diligence in the exercise of his
skill and the application of his knowledge, and exert his best judgment.
WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of the Court of Appeals in CA-G.R.
CV No. 42062 and CA-G.R. SP No. 32198.
Costs against petitioners PSI and Dr. Miguel Ampil.
SO ORDERED.
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 Decision1 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 Noras blood pressure. Her blood pressure was frequently monitored with the use
of a sphygmomanometer. While petitioner was massaging Noras uterus for it to contract and stop bleeding, she
ordered a droplight to warm Nora and her baby.4 Nora remained unconscious until she recovered.
While in the recovery room, her husband, respondent John David Z. Go noticed a fresh gaping wound two and a
half (2 ) by three and a half (3 ) inches in the inner portion of her left arm, close to the armpit. 5 He asked the
nurses what caused the injury. He was informed it was a burn. Forthwith, on April 22, 1992, John David filed a
request for investigation.6 In response, Dr. Rainerio S. Abad, the medical director of the hospital, called petitioner
and the assisting resident physician to explain what happened. Petitioner said the blood pressure cuff caused the
injury.
43
On May 7, 1992, John David brought Nora to the National Bureau of Investigation for a physical examination, which
was conducted by medico-legal officer Dr. Floresto Arizala, Jr.7 The medico-legal officer later testified that Noras
injury appeared to be a burn and that a droplight when placed near the skin for about 10 minutes could cause such
burn.8 He dismissed the likelihood that the wound was caused by a blood pressure cuff as the scar was not around
the arm, but just on one side of the arm.9
On May 22, 1992, Noras injury was referred to a plastic surgeon at the Dr. Jesus Delgado Memorial Hospital for
skin grafting.10 Her wound was covered with skin sourced from her abdomen, which consequently bore a scar as
well. About a year after, on April 30, 1993, scar revision had to be performed at the same hospital. 11 The surgical
operation left a healed linear scar in Noras left arm about three inches in length, the thickest portion rising about
one-fourth (1/4) of an inch from the surface of the skin. The costs of the skin grafting and the scar revision were
shouldered by the hospital.12
Unfortunately, Noras arm would never be the same.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;
(c) to pay the sum of Eighty Thousand Pesos (P80,000.00) nominal damages;
(d) to pay Fifty Thousand Pesos (P50,000.00) for and as attorneys fees; and
(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, attorneys fees and expenses of litigation;1awphi1.nt
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
Petitioners motion for reconsideration was denied by the Court of Appeals. Hence, the instant petition assigning
the following as errors and issues:
I.
WHETHER OR NOT, THE LOWER COURT, AND THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF
THEIR DISCRETION WHEN, NOTWITHSTANDING THAT BOTH PARTIES HAVE RESTED THEIR RESPECTIVE
CASES, THE LOWER COURT ADMITTED THE ADDITIONAL EXHIBITS FURTHER OFFERED BY
RESPONDENTS NOT TESTIFIED TO BY ANY WITNESS AND THIS DECISION OF THE LOWER COURT WAS
UPHELD BY THE COURT OF APPEALS LIKEWISE COMMITTING GRAVE ABUSE OF DISCRETION;
II.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION WHEN,
CONTRARY TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE PETITIONER, IT RULED THAT THE
PETITIONER HAS NOT AMPLY SHOWED THAT THE DROPLIGHT DID NOT TOUCH THE BODY OF MRS.
NORA GO, AND THIS DECISION OF THE LOWER COURT WAS UPHELD BY THE COURT OF APPEALS
LIKEWISE COMMITTING GRAVE ABUSE OF DISCRETION;
III.
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 RESPONDENTS 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 INTENDED TO INFLICT THE INJURY TO SAVE THE LIFE OF
RESPONDENT MRS. GO;
44
 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 Noras body. She maintains the injury was due to the constant taking of Noras
blood pressure. Petitioner also insinuates the Court of Appeals was misled by the testimony of the medico-legal
officer who never saw the original injury before plastic surgery was performed. Finally, petitioner stresses that
plastic surgery was not intended to restore respondents injury to its original state but rather to prevent further
complication.
Respondents, however, counter that the genuineness and due execution of the additional documentary exhibits
were duly admitted by petitioners counsel. Respondents point out that petitioners blood pressure cuff theory is
highly improbable, being unprecedented in medical history and that the injury was definitely caused by the
droplight. At any rate, they argue, even if the injury was brought about by the blood pressure cuff, petitioner was still
negligent in her duties as Noras attending physician.
Simply put, the threshold issues for resolution are: (1) Are the questioned additional exhibits admissible in
evidence? (2) Is petitioner liable for the injury suffered by respondent Nora Go? Thereafter, the inquiry is whether
the appellate court committed grave abuse of discretion in its assailed issuances.
As to the first issue, we agree with the Court of Appeals that said exhibits are admissible in evidence. We note that
the questioned exhibits consist mostly of Noras medical records, which were produced by the hospital during trial
pursuant to a subpoena duces tecum. Petitioners counsel admitted the existence of the same when they were
formally offered for admission by the trial court. In any case, given the particular circumstances of this case, a ruling
on the negligence of petitioner may be made based on the res ipsa loquitur doctrine even in the absence of such
additional exhibits.
Petitioners contention that the medico-legal officer who conducted Noras physical examination never saw her
original injury before plastic surgery was performed is without basis and contradicted by the records. Records show
that the medico-legal officer conducted the physical examination on May 7, 1992, while the skin grafting and the
scar revision were performed on Nora on May 22, 1992 and April 30, 1993, respectively.
Coming now to the substantive matter, is petitioner liable for the injury suffered by respondent Nora Go?
The Hippocratic Oath mandates physicians to give primordial consideration to the well-being of their patients. If a
doctor fails to live up to this precept, he is accountable for his acts. This notwithstanding, courts face a unique
restraint in adjudicating medical negligence cases because physicians are not guarantors of care and, they never
set out to intentionally cause injury to their patients. However, intent is immaterial in negligence cases because
where negligence exists and is proven, it automatically gives the injured a right to reparation for the damage
caused.17
In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere existence of an injury to
justify a presumption of negligence on the part of the person who controls the instrument causing the injury,
provided that the following requisites concur:
1. The accident is of a kind which ordinarily does not occur in the absence of someones negligence;
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 Noras arm is certainly not an ordinary occurrence in the act of
delivering a baby, far removed as the arm is from the organs involved in the process of giving birth. Such injury
could not have happened unless negligence had set in somewhere.
Second, whether the injury was caused by the droplight or by the blood pressure cuff is of no moment. Both
instruments are deemed within the exclusive control of the physician in charge under the "captain of the ship"
doctrine. This doctrine holds the surgeon in charge of an operation liable for the negligence of his assistants during
the time when those assistants are under the surgeons control.19 In this particular case, it can be logically inferred
that petitioner, the senior consultant in charge during the delivery of Noras baby, exercised control over the
assistants assigned to both the use of the droplight and the taking of Noras blood pressure. Hence, the use of the
droplight and the blood pressure cuff is also within petitioners exclusive control.
Third, the gaping wound on Noras left arm, by its very nature and considering her condition, could only be caused
by something external to her and outside her control as she was unconscious while in hypovolemic shock. Hence,
Nora could not, by any stretch of the imagination, have contributed to her own injury.
Petitioners defense that Noras wound was caused not by the droplight but by the constant taking of her blood
pressure, even if the latter was necessary given her condition, does not absolve her from liability. As testified to by
the medico-legal officer, Dr. Arizala, Jr., the medical practice is to deflate the blood pressure cuff immediately after
each use. Otherwise, the inflated band can cause injury to the patient similar to what could have happened in this
case. Thus, if Noras wound was caused by the blood pressure cuff, then the taking of Noras blood pressure must
have been done so negligently as to have inflicted a gaping wound on her arm, 20 for which petitioner cannot escape
liability under the "captain of the ship" doctrine.
Further, petitioners argument that the failed plastic surgery was not intended as a cosmetic procedure, but rather
as a measure to prevent complication does not help her case. It does not negate negligence on her part.
Based on the foregoing, the presumption that petitioner was negligent in the exercise of her profession stands
unrebutted. In this connection, the Civil Code provides:
45
ART. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is obliged to
pay for the damage done.
ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious anxiety, besmirched
reputation, wounded feelings, moral shock, social humiliation, and similar injury. Though incapable of pecuniary
computation, moral damages may be recovered if they are the proximate result of the defendants wrongful act or
omission.
Clearly, under the law, petitioner is obliged to pay Nora for moral damages suffered by the latter as a proximate
result of petitioners negligence.
We note, however, that petitioner has served well as Noras obstetrician for her past three successful deliveries.
This is the first time petitioner is being held liable for damages due to negligence in the practice of her profession.
The fact that petitioner promptly took care of Noras wound before infection and other complications set in is also
indicative of petitioners good intentions. We also take note of the fact that Nora was suffering from a critical
condition when the injury happened, such that saving her life became petitioners elemental concern. Nonetheless,
it should be stressed that all these could not justify negligence on the part of petitioner.
Hence, considering the specific circumstances in the instant case, we find no grave abuse of discretion in the
assailed decision and resolution of the Court of Appeals. Further, we rule that the Court of Appeals award of Two
Hundred Thousand Pesos (P200,000) as moral damages in favor of respondents and against petitioner is just and
equitable.21
WHEREFORE, the petition is DENIED. The Decision dated October 3, 2002 and Resolution dated November 19,
2003 of the Court of Appeals in CA-G.R. CV No. 58184 are AFFIRMED.
No pronouncement as to costs.
SO ORDERED.
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. Lukes
Medical Center where she was, at the time material to the case, the chief of the Reproductive Endocrinology and
Infertility Section.
Upon Dr. Ilao-Oretas advice, Eva Marie agreed to undergo a laparoscopic procedure whereby a laparascope
would be inserted through the patients 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. Lukes 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. Lukes 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, moral damages, exemplary damages, the costs of litigation, attorneys 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. Lukes 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 P9,939 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 Decision6 of April 21, 2006, finding Dr. Ilao-Oreta grossly
negligent,7 modified the trial courts decision as follows:
WHEREFORE, the trial Courts 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 attorneys fees.
SO ORDERED.8 (Underscoring supplied)
46
Hence, the present Petition for Review9 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 Attorneys 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. 14It 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 oclock 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 time and I can easily do the case at
2:00 oclock, 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 didnt 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 didnt want to talk to me, and
that she didnt want re-scheduling of the surgery . . .
ATTY LONTOK: May we move, your Honor, for the striking out of the answer, this is purely hearsay.
COURT: Remain on the record.
WITNESS [DR. ILAO-ORETA]: . . . and then Mr. Ronquillo told me "Im 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 doctors 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 doctors negligence not being gross, the spouses are not entitled to recover moral damages.
47
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 attorneys 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:
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 when the breach of contract complained of occurred. 24 The Court of Appeals
also included the alleged P300 spent on fuel consumption from the spouses residence at San Pascual, Batangas
to the St. Lukes Medical Center in Quezon City and the alleged P500 spent on food in the hospital canteen, both of
which are unsubstantiated by independent or competent proof. 25 The only 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 actual damages. So Premiere
Development Bank v. Court of Appeals27 instructs:

Q: Isnt 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 In the instant case, the actual damages were proven through the sole testimony of Themistocles Ruguero, the vice
operation? president for administration of Panacor. In his testimony, the witness affirmed that Panacor incurred losses,
specifically, in terms of training and seminars, leasehold acquisition, procurement of vehicles and office equipment
without, however, adducing receipts to substantiate the same. The documentary evidence marked as Exhibit "W,"
A [EVA MARIE]: I will tell the truth. Dr. Augusto Reyes of St. Lukes . . . 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 the lower
Q: But did you demand? 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
A: No, I did not demand because independent evidence. Premieres failure to prove actual expenditure consequently conduces to a failure of its
claim. In determining actual damages, the court cannot rely on mere assertions, speculations, conjectures or
ATTY. SINJIAN: That will be all, your Honor. guesswork but must depend on competent proof and on the best evidence obtainable regarding the actual amount
of loss.28 (Underscoring supplied)
ATTY. LONTOK: The witness is still explaining.
The list of expenses cannot replace receipts when they should have been issued as a matter of course in business
transactions29 as in the case of purchase of gasoline and of food.1wphi1
WITNESS: Im 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. The documented claim for hospital and medical expenses of the spouses is detailed in the Statement of Account
issued by the hospital, the pertinent entries of which read:
ATTY. SINJIAN:
xxxx
Q: So it was to Dr. Augusto Reyes that you talked?
GROSS HOSPITAL CHARGES 2,416.50
A: Yes.
4/5/1999 1699460 DEPOSITOFFICIAL
Q: But you did not demand anything or write to Dr. Oreta? RECEIPT (5,000.00)

A: No. (5,000.00)

Q: Before instituting this case?

4/5/1999 SECOND 0284893 UNUSED MED 0439534 (65.55)
FLOOR HINOX 500 MG CAP
A: No.23 (Underscoring supplied)
SECOND 0284894 UNUSED MED 0439893 (62.25)
FLOOR PHENERGAN 2 ML
Finally, Dr. Ilao-Oretas prayer for the reduction of actual damages is well-taken. Article 2201 of the Civil Code
provides:
50MG ________ (127.80)

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 consequences of the breach of the obligation, and which the parties have BALANCE DUE (2,711.30)30
foreseen or could have reasonably foreseen at the time the obligation was constituted. ==========

48
As extrapolated from the above-quoted entries in the Statement of Account, P2,288.70 (the gross hospital charges
of P2,416.50 less the unused medicine in the amount of P127.80) was debited from the P5,000 deposit31to thus
leave a balance of the deposit in the amount of P2,711.30, which the trial court erroneously denominated as
"confinement fee." The remaining balance of P2,711.30 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 P2,288.70, 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 attorneys fees is DELETED.
SO ORDERED.
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 Decision1 of the Court of Appeals (CA) in
CA G.R. CV No. 63234, which affirmed with modification the Decision 2 of the Regional Trial Court (RTC) of Nueva
Ecija, Branch 37 in Civil Case No. SD-1233. The dispositive portion of the assailed CA decision states:
WHEREFORE, premises considered, the assailed Decision of the Regional Trial Court of Baloc, Sto.
Domingo, Nueva Ecija, Branch 37 is hereby AFFIRMED but with modifications as follows:
1) Ordering defendant-appellants Dr. and Dra. Fredelicto A. Flores and the United Doctors
Medical Center, Inc. to jointly and severally pay the plaintiff-appellees - heirs of Teresita Pineda,
namely, Spouses Dominador Pineda and Virginia Saclolo and Florencio, Candida, Marta,
Godofredo, Baltazar and Lucena, all surnamed Pineda, the sum of P400,000.00 by way of moral
damages;
2) Ordering the above-named defendant-appellants to jointly and severally pay the above-
named plaintiff-appellees the sum of P100,000.00 by way of exemplary damages;
3) Ordering the above-named defendant-appellants to jointly and severally pay the above-
named plaintiff-appellees the sum of P36,000.00 by way of actual and compensatory damages;
and
4) Deleting the award of 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.
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.9Dr. Felicisima,
however, advised Teresita that she could spend her recovery period at home. Still feeling weak, Teresita opted for
hospital confinement.
49
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 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
15
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.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:
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?
50
 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 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.
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. Tan35 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 dysfunctionThe goal is to
uncover problem areas that may require further investigation or be amenable to preoperative
optimization.
If the preoperative evaluation uncovers significant comorbidity or evidence of poor control of an
underlying disease process, consultation with an internist or medical specialist may be required to
facilitate the work-up and direct management. In this process, communication between the surgeons and
the consultants is essential to define realistic goals for this optimization process and to expedite surgical
management.39 [Emphasis supplied.]
Significantly, the evidence strongly suggests that the pre-operative evaluation was less than complete as the
laboratory results were fully reported only on the day following the D&C operation. Dr. Felicisima only secured a
telephone report of the preliminary laboratory result prior to the D&C. This preliminary report did not include the 3+
status of sugar in the patient's urine40 - 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
The prudent move is to address the patient's hyperglycemic state immediately and promptly before any other
procedure is undertaken. In this case, there was no evidence that insulin was administered on Teresita prior to or
during the D&C operation. Insulin was only administered two days after the operation.
As Dr. Tan testified, the 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 patient; the concern, as the petitioner
spouses expressly admitted, was limited to the complaint of vaginal bleeding. Interestingly, while the ultrasound test
confirmed that Teresita had a myoma in her uterus, she was advised that she could be discharged a day after the
operation and that her recovery could take place at home. This advice implied that a day after the operation and
51
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.
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 death is a matter we shall next
determine.
Injury and Causation
As previously mentioned, the critical and clinching factor in a medical negligence case is proof of the causal
connection between the negligence which the evidence established and the 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:
Immediate cause: Cardiorespiratory arrest
Antecedent cause: Septicemic shock, ketoacidocis
Underlying cause: Diabetes Mellitus II
Other significant conditions
contributing to death: Renal Failure - Acute47
Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C operation is a form of
physical stress. Dr. Mendoza explained how surgical stress can aggravate the patient's hyperglycemia: when stress
occurs, the diabetic's body, especially the autonomic system, reacts by secreting hormones which are counter-
regulatory; she can have prolonged hyperglycemia which, if unchecked, could lead to death.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.
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 that a plaintiff is entitled to be compensated for
proven pecuniary loss.52 This proof the respondents successfully presented. Thus, we affirm the award of actual
damages of P36,000.00 representing the hospital expenses the patient incurred.
In addition to the award for actual damages, the respondent heirs of Teresita are likewise entitled to P50,000.00
as death indemnity pursuant to Article 2206 of the Civil Code, which states that "the amount of damages for death
52
caused by a xxx quasi-delict shall be at least three thousand pesos,53even though there may have been mitigating
circumstances xxx." This is a question of law that the CA missed in its decision and which we now decide in the
respondents' favor.
The same article allows the recovery of moral damages in case of death caused by a quasi-delict and enumerates
the spouse, legitimate or illegitimate ascendants or descendants as the persons entitled thereto. Moral damages
are designed to compensate the claimant for the injury suffered, that is, for the mental anguish, serious anxiety,
wounded feelings which the respondents herein must have surely felt with the unexpected loss of their daughter.
We affirm the appellate court's award of P400,000.00 by way of moral damages to the respondents.
We similarly affirm the grant of exemplary damages. Exemplary damages are imposed by way of example or
correction for the public good.54 Because of the petitioner spouses' negligence in subjecting Teresita to an
operation without first recognizing and addressing her diabetic condition, the appellate court awarded exemplary
damages to the respondents in the amount of P100,000.00. Public policy requires such imposition to suppress the
wanton acts of an offender.55 We therefore affirm the CA's award as an example to the medical profession and to
stress that the public good requires stricter measures to avoid the repetition of the type of medical malpractice that
happened in this case.
With the award of exemplary damages, the grant of attorney's fees is legally in order. 56 We therefore reverse the
CA decision deleting these awards, and grant the respondents the amount of P100,000.00 as attorney's
fees taking into consideration the legal route this case has taken.
WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003 in CA G.R. CV No. 63234 finding
petitioner spouses liable for negligent medical practice. We likewise AFFIRM the awards of actual and
compensatory damages of P36,000.00; moral damages of P400,000.00; and exemplary damages of P100,000.00.
We MODIFY the CA Decision by additionally granting an award of P50,000.00 as death indemnity and by reversing
the deletion of the award of attorney's fees and costs and restoring the award of P100,000.00 as attorney's fees.
Costs of litigation are adjudged against petitioner spouses.
To summarize, the following awards shall be paid to the family of the late Teresita Pineda:
1. The sum of P36,000.00 by way of actual and compensatory damages;
2. The sum of P50,000.00 by way of death indemnity;
3. The sum of P400,000.00 by way of moral damages;
4. The sum of P100,000.00 by way of exemplary damages;
5. The sum of P100,000.00 by way of attorney's fees; and
6. Costs.
SO ORDERED.
G.R. No. 159132 December 18, 2008
FE CAYAO-LASAM, petitioner,
vs.
SPOUSES CLARO and EDITHA RAMOLETE, respondents.*
DECISION
AUSTRIA-MARTINEZ, J.:
Before the Court is a Petition for Review on Certiorari under Rule 45 of the Rules of Court filed by Dr. Fe Cayao-
Lasam (petitioner) seeking to annul the Decision1 dated July 4, 2003 of the Court of Appeals (CA) in CA-G.R. SP
No. 62206.
The antecedent facts:
On July 28, 1994, respondent, three months pregnant Editha Ramolete (Editha) was brought to the Lorma Medical
Center (LMC) in San Fernando, La Union due to vaginal bleeding. Upon advice of petitioner relayed via telephone,
Editha was admitted to the LMC on the same day. A pelvic sonogram2 was then conducted on Editha revealing the
fetus weak cardiac pulsation.3 The following day, Edithas repeat pelvic sonogram 4 showed that aside from the
fetus weak cardiac pulsation, no fetal movement was also appreciated. Due to persistent and profuse vaginal
bleeding, petitioner advised Editha to undergo a Dilatation and Curettage Procedure (D&C) or "raspa."
On July 30, 1994, petitioner performed the D&C procedure. Editha was discharged from the hospital the following
day.
On September 16, 1994, Editha was once again brought at the LMC, as she was suffering from vomiting and
severe abdominal pains. Editha was attended by Dr. Beatriz de la Cruz, Dr. Victor B. Mayo and Dr. Juan V.
Komiya. Dr. Mayo allegedly informed Editha that there was a dead fetus in the latters womb. After, Editha
underwent laparotomy,5 she was found to have a massive intra-abdominal hemorrhage and a ruptured uterus.
Thus, Editha had to undergo a procedure for hysterectomy6 and as a result, she has no more chance to bear a
child.
On November 7, 1994, Editha and her husband Claro Ramolete (respondents) filed a Complaint 7 for Gross
Negligence and Malpractice against petitioner before the Professional Regulations Commission (PRC).
Respondents alleged that Edithas 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
Edithas womb.8 Among the alleged acts of negligence were: first, petitioners failure to check up, visit or administer
medication on Editha during her first day of confinement at the LMC;9 second, petitioner recommended that a D&C
procedure be performed on Editha without conducting any internal examination prior to the procedure;10 third,
petitioner immediately suggested a D&C procedure instead of closely monitoring the state of pregnancy of Editha. 11
In her Answer,12 petitioner denied the allegations of negligence and incompetence with the following explanations:
upon Edithas confirmation that she would seek admission at the LMC, petitioner immediately called the hospital to
anticipate the arrival of Editha and ordered through the telephone the medicines Editha needed to take, which the
nurses carried out; petitioner visited Editha on the morning of July 28, 1994 during her rounds; on July 29, 1994,
she performed an internal examination on Editha and she discovered that the latters cervix was already open, thus,
petitioner discussed the possible D&C procedure, should the bleeding become more profuse; on July 30 1994, she
53
conducted another internal examination on Editha, which revealed that the latters cervix was still open; Editha
persistently complained of her vaginal bleeding and her passing out of some 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 an abortus;13 taking the words of
Editha to mean that she was passing out 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 she wanted to be discharged;
petitioner agreed, but she advised Editha to return for check-up on August 5, 1994, which the latter failed to do.
Petitioner contended that it was Edithas gross negligence and/or omission in insisting to be discharged on July 31,
1994 against doctors advice and her unjustified failure to return for check-up as directed by petitioner that
contributed to her life-threatening condition on September 16, 1994; that Edithas hysterectomy was brought about
by her very abnormal pregnancy known as placenta increta, which was an extremely rare and very unusual 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
Decision16 reversing the findings of the Board and revoking petitioners 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 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. PRCS 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;
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 PETITIONERS LICENSE TO
PRACTICE MEDICINE WITHOUT AN EXPERT TESTIMONY TO SUPPORT ITS CONCLUSION AS TO
THE CAUSE OF RESPONDENT EDITHAT [SIC] RAMOLETES 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 EDITHAS 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:
54
 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 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)
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 appellants brief or memorandum on appeal, and
paying the appeal and legal research fees. x x x29
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.
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 that Batas Pambansa (B.P.) Blg. 12938 conferred upon
the CA exclusive appellate jurisdiction over appeals from decisions of the PRC. The Court held:
The law has since been changed, however, at least in the matter of the particular court to which appeals
from the Commission should be taken. On August 14, 1981, Batas Pambansa Bilang 129 became
effective and in its Section 29, conferred on the Court of Appeals "exclusive appellate jurisdiction over all
final judgments, decisions, resolutions, orders or awards of Regional Trial Courts and quasi-judicial
agencies, instrumentalities, boards or commissions except those falling under the appellate jurisdiction of
the Supreme Court. x x x." In virtue of BP 129, appeals from the Professional Regulations
Commission are now exclusively cognizable by the Court of Appeals. 39 (Emphasis supplied)
55
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 Edithas 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 Edithas
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.
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 Edithas 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 Edithas 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 dont think so, because it is the triggering factor for
the rupture, it could havethe 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 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 dont think so for the two reasons that I have just mentioned- that it would not be possible
for the instrument to 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 Edithas uterus.
During his cross-examination, Dr. Manalo testified on how he would have addressed Edithas 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 theres 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 rightscanty.
Q: And you would not mind checking those scant or those little parts that were removed?
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. Its 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
56
 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, thats 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 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 2176 54 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.
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 complainants 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 petitioners 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 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 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 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 Edithas own injury. Had Editha
returned, petitioner could have conducted the proper medical tests and procedure necessary to determine Edithas
health condition and applied the corresponding treatment which could have prevented the rupture of Edithas
uterus. The D&C procedure having been conducted in accordance with the standard medical practice, it is clear
that Edithas 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 defendants 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 plaintiffs 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 Edithas injury was her
own omission when she did not return for a follow-up check up, in defiance of petitioners orders. The
immediate cause of Edithas 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 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 petitioners 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.
57
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.
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. TUAO, 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. Tuao."
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. Tuao,"
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. Tuao, M.D. (Dr. Tuao), an
ophthalmologist at St. Lukes Medical Center, for an eye consult.
Upon consultation with Dr. Tuao, 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. Tuao, he
performed "ocular routine examination" on Peters eyes, wherein: (1) a gross examination of Peters eyes and their
surrounding area was made; (2) Peters visual acuity were taken; (3) Peters eyes were palpated to check the
intraocular pressure of each; (4) the motility of Peters eyes was observed; and (5) the ophthalmoscopy 4 on Peters
eyes was used. On that particular consultation, Dr. Tuao diagnosed that Peter was suffering from conjunctivitis 5 or
"sore eyes." Dr. Tuao then prescribed Spersacet-C6 eye drops for Peter and told the latter to return for follow-up
after one week.
As instructed, Peter went back to Dr. Tuao on 9 September 1988. Upon examination, Dr. Tuao told Peter that the
"sore eyes" in the latters 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
Peters right eye, Dr. Tuao 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. Tuao.
On 21 September 1988, Peter saw Dr. Tuao for a follow-up consultation. After examining both of Peters eyes, Dr.
Tuao instructed the former to taper down10 the dosage of Maxitrol, because the EKC in his right eye had already
resolved. Dr. Tuao 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. Tuao for another check-up on 6
October 1988. Dr. Tuao examined Peters eyes and found that the right eye had once more developed EKC. So,
Dr. Tuao 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. Tuao at his clinic, alleging severe eye pain, feeling
as if his eyes were about to "pop-out," a headache and blurred vision. Dr. Tuao examined Peters eyes and
discovered that the EKC was again present in his right eye. As a result, Dr. Tuao told Peter to resume the
maximum dosage of Blephamide.
Dr. Tuao saw Peter once more at the formers clinic on 4 November 1988. Dr. Tuaos examination showed that
only the periphery of Peters right eye was positive for EKC; hence, Dr. Tuao prescribed a lower dosage of
Blephamide.
It was also about this time that Fatima Gladys Lucas (Fatima), Peters 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:
58
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 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. Tuaos clinic, complaining of "feeling worse."14 It appeared that the
EKC had spread to the whole of Peters right eye yet again. Thus, Dr. Tuao instructed Peter to resume the use of
Maxitrol. Petitioners averred that Peter already made mention to Dr. Tuao during said visit of the above-quoted
warning against the prolonged use of steroids, but Dr. Tuao supposedly brushed aside Peters concern as mere
paranoia, even assuring him that the former was taking care of him (Peter).
Petitioners further alleged that after Peters 26 November 1988 visit to Dr. Tuao, 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
Peters right eye appeared to be bloody and swollen. 15 Thus, spouses Peter and Fatima rushed to the clinic of Dr.
Tuao. Peter reported to Dr. Tuao that he had been suffering from constant headache in the afternoon and
blurring of vision.
Upon examination, Dr. Tuao noted the hardness of Peters right eye. With the use of a tonometer to verify the
16
exact intraocular pressure17 (IOP) of Peters eyes, Dr. Tuao discovered that the tension in Peters right eye
was 39.0 Hg, while that of his left was 17.0 Hg.18 Since the tension in Peters right eye was way over the normal
IOP, which merely ranged from 10.0 Hg to 21.0 Hg,19 Dr. Tuao ordered20 him to immediately discontinue the use
of Maxitrol and prescribed to the latter Diamox21 and Normoglaucon, instead.22 Dr. Tuao also required Peter to go
for daily check-up in order for the former to closely monitor the pressure of the latters eyes.
On 15 December 1988, the tonometer reading of Peters right eye yielded a high normal level, i.e., 21.0 Hg.
Hence, Dr. Tuao told Peter to continue using Diamox and Normoglaucon. But upon Peters complaint of "stomach
pains and tingling sensation in his fingers,"23 Dr. Tuao discontinued Peters 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 Peters eyes. Dr. Batungbacals diagnosis
was Glaucoma25 O.D.26 He recommended Laser Trabeculoplasty27 for Peters right eye.
When Peter returned to Dr. Tuao on 23 December 1988, 28 the tonometer measured the IOP of Peters right eye to
be 41.0 Hg,29 again, way above normal. Dr. Tuao 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 Peters regular follow-ups with Dr. Tuao, the doctor conducted another
ocular routine examination of Peters eyes. Dr. Tuao noted the recurrence of EKC in Peters right eye.
Considering, however, that the IOP of Peters right eye was still quite high at 41.0 Hg, Dr. Tuao was at a loss as to
how to balance the treatment of Peters EKC vis--vis the presence of glaucoma in the same eye. Dr. Tuao, thus,
referred Peter to Dr. Manuel B. Agulto, M.D. (Dr. Agulto), another ophthalmologist specializing in the treatment of
glaucoma.31 Dr. Tuaos 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 Im in
a fix whether to resume the steroid or not considering that the IOP is still uncontrolled. 32
On 29 December 1988, Peter went to see Dr. Agulto at the latters clinic. Several tests were conducted thereat to
evaluate the extent of Peters condition. Dr. Agulto wrote Dr. Tuao 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 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 Depifrin 39 BID OD (despite
low PAS). Im 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. Tuao on 31 December 1988, bearing Dr. Agultos aforementioned letter. Though Peters
right and left eyes then had normal IOP of 21.0 Hg and 17.0 Hg, respectively, Dr. Tuao 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. Tuao instructed Peter to just continue using Diamox and Normoglaucon in the meantime.
59
Just two days later, on 2 January 1989, the IOP of Peters right eye remained elevated at 21.0 Hg,42 as he had
been without Diamox for the past three (3) days.
On 4 January 1989, Dr. Tuao conducted a visual field study43 of Peters eyes, which revealed that the latter had
tubular vision44 in his right eye, while that of his left eye remained normal. Dr. Tuao directed Peter to religiously
use the Diamox and Normoglaucon, as the tension of the latters 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 Depifrin were still not available in the market. Again,
Dr. Tuao advised Peter to come for regular check-up so his IOP could be monitored.
Obediently, Peter went to see Dr. Tuao 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 Peters eyes.
According to petitioners, after Dr. Aquino conducted an extensive evaluation of Peters 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. Tuaos diagnosis of tubular vision in Peters right eye. Petitioners
claimed that Dr. Aquino essentially told Peter that the latters 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. Tuao for the same, Peter, joined by: (1) Fatima, his
spouse46; (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. Tuao, 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 [Peters] 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 [Peters right eye] caused the impairment of his vision which impairment is
not curable and may even lead to total blindness."49
Petitioners additionally alleged that the visual impairment of Peters 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.; Peters 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. Tuaos grossly negligent conduct in prescribing to Peter the medicine Maxitrol for a period of three (3)
months, without monitoring Peters IOP, as required in cases of prolonged use of said medicine, and
notwithstanding Peters constant complaint of intense eye pain while using the same. Petitioners particularly prayed
that Dr. Tuao be adjudged liable for the following amounts:
1. The amount of P2,000,000.00 to plaintiff Peter Lucas as and by way of compensation for his impaired
vision.
2. The amount of P300,000.00 to spouses Lucas as and by way of actual damages plus such additional
amounts that may be proven during trial.
3. The amount of P1,000,000.00 as and by way of moral damages.
4. The amount of P500,000.00 as and by way of exemplary damages.
5. The amount of P200,000.00 as and by way of attorneys fees plus costs of suit.54
In rebutting petitioners complaint, Dr. Tuao asserted that the "treatment made by [him] more than three years ago
has no causal connection to [Peters] present glaucoma or condition."55 Dr. Tuao 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 Kerato Conjunctivitis or EKC which is an infiltration of the cornea as a result of
conjunctivitis or sore eyes."56 Dr. Tuao 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
[Peters 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 [Peters] EKC caused the steroid induced
glaucoma,"59 Dr. Tuao 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, [Peters] 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 latters 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."61The
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
60
The RTC opined that petitioners failed to prove by preponderance of evidence that Dr. Tuao was negligent in his
treatment of Peters condition. In particular, the record of the case was bereft of any evidence to establish that the
steroid medication and its dosage, as prescribed by Dr. Tuao, caused Peters 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 [Tuao] liable."63 According to the RTC:
[Petitioners] failed to establish the duty required of a medical practitioner against which Peter Pauls 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. Tuao of Peter Pauls 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 defendants 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 [Peters] eye." 65
Correspondingly, the RTC accepted Dr. Tuaos 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, plaintiffs 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
[D]id not present any medical expert to testify that Dr. Tuanos prescription of Maxitrol and Blephamide for the
treatment of EKC on Peters right eye was not proper and that his palpation of Peters 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 latters 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. Tuaos medical judgment, specifically the latters
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 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
ATTORNEYS 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. Tuao.
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. Tuaos negligence in his treatment of Peters eye condition.
This question clearly involves a factual inquiry, the determination of which is not within the ambit of this Courts
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+
61
Petitioners contend, that "[c]ontrary to the findings of the Honorable Court of Appeals, [they] were more than able to
establish that: Dr. Tuao ignored the standard medical procedure for ophthalmologists, administered medication
with recklessness, and exhibited an absence of competence and skills expected from him." 72Petitioners reject the
necessity of presenting expert and/or medical testimony to establish (1) the standard of care respecting the
treatment of the disorder affecting Peters eye; and (2) whether or not negligence attended Dr. Tuaos treatment of
Peter, because, in their words
That Dr. Tuao was grossly negligent in the treatment of Peters 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. Tuao] Dr. Tuao himself. [Emphasis supplied.]
They insist that Dr. Tuao himself gave sufficient evidence to establish his gross negligence that ultimately caused
the impairment of the vision of Peters right eye,73 i.e., that "[d]espite [Dr. Tuaos] 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 Peters glaucoma is the direct result of Dr. Tuaos 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 latters 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 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.
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 patients] 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 experts role is to present to the [court] a realistic assessment of the
likelihood that [the physicians] alleged negligence caused [the patients] 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 formers
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. Tuao 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. Tuao, 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 Peters 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
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 Peters under similar circumstances; (2) that, in his treatment of Peter, Dr. Tuao
failed in his duty to exercise said standard of care that any other competent physician would use in treating the
same condition as Peters under similar circumstances; and (3) that the injury or damage to Peters right eye, i.e.,
his glaucoma, was the result of his use of Maxitrol, as prescribed by Dr. Tuao. Petitioners failure to prove the first
element alone is already fatal to their cause.
Petitioners maintain that Dr. Tuao failed to follow in Peters 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
62
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. Tuao 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. Tuao 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. Tuao was able to clearly explain that what is only required of ophthalmologists, in cases such as
Peters, 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 patients eye and he did all those tests/procedures every time Peter went to see him for
follow-up consultation and/or check-up.
We cannot but agree with Dr. Tuaos 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. Tuao 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. Tuao on 2 September 1988 and had exhibited no
previous untoward reaction to that particular drug. 91
Also, Dr. Tuao categorically denied petitioners claim that he never monitored the tension of Peters eyes while the
latter was on Maxitrol. Dr. Tuao testified that he palpated Peters eyes every time the latter came for a check-up
as part of the doctors ocular routine examination, a fact which petitioners failed to rebut. Dr. Tuaos regular
conduct of examinations and tests to ascertain the state of Peters eyes negate the very basis of petitioners
complaint for damages. As to whether Dr. Tuaos 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. Tuao committed negligent acts in his treatment of Peters condition, the causal
connection between Dr. Tuaos supposed negligence and Peters 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 plaintiffs 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 defendants fault caused the injury. A verdict in a
malpractice action cannot be based on speculation or conjecture. Causation must be proven within a reasonable
medical probability based upon competent expert testimony. 93
The causation between the physicians negligence and the patients injury may only be established by the
presentation of proof that Peters glaucoma would not have occurred but for Dr. Tuaos supposed negligent
conduct. Once more, petitioners failed in this regard.
Dr. Tuao does not deny that the use of Maxitrol involves the risk of increasing a patients IOP. In fact, this was the
reason why he made it a point to palpate Peters eyes every time the latter went to see him -- so he could monitor
the tension of Peters eyes. But to say that said medication conclusively caused Peters 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. 95Visual acuity
remains good until late in the course of the disease. 96 Hence, Dr. Tuao claims that Peters 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. Tuao is in a better position to determine and evaluate the necessity of using
Maxitrol to cure Peters EKC vis--vis the attendant risks of using the same?
That Dr. Tuao has the necessary training and skill to practice his chosen field is beyond cavil. Petitioners do not
dispute Dr. Tuaos 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. Lukes 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 Peters EKC with Maxitrol, Dr. Tuao took the necessary precaution by palpating Peters
eyes to monitor their IOP every time the latter went for a check-up, and he 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. Tuaos
part, which resulted in Peters 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. Tuaos 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 plaintiffs 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
63
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 reasonable connection between Dr. Tuaos alleged breach of duty and the
damage sustained by Peters 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. Tuao 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. Tuao failed to exercise
reasonable care, diligence and skill generally required in medical practice. Dr. Tuaos 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.
SO ORDERED.
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
Resolution2dated September 1, 2004 of the Court of Appeals (CA) in CA-G.R. CV No. 58013 which modified the
Decision3dated 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. Lukes 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, Angelicas 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 patients 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 death as "Hypovolemic shock secondary to
multiple organ hemorrhages and Disseminated Intravascular Coagulation." 5
On the other hand, the Certificate of Death6 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 Angelicas safety,
health and welfare by their careless administration of the chemotherapy drugs, their failure to observe the essential
precautions in detecting early the symptoms of fatal blood platelet decrease and stopping early on the
chemotherapy, which bleeding led to hypovolemic shock that caused Angelicas untimely demise. Further, it was
specifically averred that petitioner assured the respondents that Angelica would recover in view of 95% chance of
healing with chemotherapy ("Magiging normal na ang anak nyo basta ma-chemo. 95% ang healing") and when
asked regarding the side effects, petitioner mentioned only slight vomiting, hair loss and weakness ("Magsusuka ng
kaunti. Malulugas ang buhok. Manghihina"). Respondents thus claimed that they would not have given their
consent to chemotherapy had petitioner not falsely assured them of its side effects.
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 patients 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.
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 Angelicas surgery and discussed with them
Angelicas condition. Petitioner told respondents that Angelica should be given two to three weeks to recover from
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the operation before starting chemotherapy. Respondents were apprehensive due to financial constraints as
Reynaldo earns only from P70,000.00 to P150,000.00 a year from his jewelry and watch repairing
business.9Petitioner, however, assured them not to worry about her professional fee and told them to just save up
for the medicines to be used.
Petitioner claimed that she explained to respondents that even when a tumor is removed, there are still small
lesions undetectable to the naked eye, and that adjuvant chemotherapy is needed to clean out the small lesions in
order to lessen the chance of the cancer to recur. She did not give the respondents any assurance that
chemotherapy will cure Angelicas cancer. During these consultations with respondents, she explained the following
side effects of chemotherapy treatment to respondents: (1) falling hair; (2) nausea and vomiting; (3) loss of
appetite; (4) low count of white blood cells [WBC], red blood cells [RBC] and platelets; (5) possible sterility due to
the effects on Angelicas ovary; (6) damage to the heart and kidneys; and (7) darkening of the skin especially when
exposed to sunlight. She actually talked with respondents four times, once at the hospital after the surgery, twice at
her clinic and the fourth time when Angelicas mother called her through long distance. 10 This was disputed by
respondents who countered that petitioner gave them assurance that there is 95% chance of healing for Angelica if
she undergoes chemotherapy and that the only side effects were nausea, vomiting and hair loss. 11Those 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: Angelicas chest x-ray, ultrasound of the liver, creatinine and complete
liver function tests.13 Petitioner proceeded with the chemotherapy by first administering hydration fluids to
Angelica.14
The following day, August 19, petitioner began administering three chemotherapy drugs
Cisplatin,15Doxorubicin16 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 Angelicas
face.21They 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 Angelicas face had extended to her neck, but
petitioner dismissed it again as merely the effect of medicines.24 Petitioner testified that she did not see any
discoloration on Angelicas face, nor did she notice any difficulty in the childs breathing. She claimed that Angelica
merely complained of nausea and was given ice chips. 251avvphi1
On August 22, 1993, at around ten oclock in the morning, upon seeing that their child could not anymore bear the
pain, respondents pleaded with petitioner to stop the chemotherapy. Petitioner supposedly replied: "Dapat 15
Cosmegen pa iyan. Okay, lets observe. If pwede na, bigyan uli ng chemo." At this point, respondents asked
petitioners permission to bring their child home. Later in the evening, Angelica passed black stool and reddish
urine.26 Petitioner countered that there was no record of blackening of stools but only an episode of loose bowel
movement (LBM). Petitioner also testified that what Angelica complained of was carpo-pedal spasm, not convulsion
or epileptic attack, as respondents call it (petitioner described it in the vernacular as "naninigas ang kamay at paa").
She then requested for a serum calcium determination and stopped the chemotherapy. When Angelica was given
calcium gluconate, the spasm and numbness subsided. 27
The following day, August 23, petitioner yielded to respondents request to take Angelica home. But prior to
discharging Angelica, petitioner requested for a repeat serum calcium determination and explained to respondents
that the chemotherapy will be temporarily stopped while she observes Angelicas muscle twitching and serum
calcium level. Take-home medicines were also prescribed for Angelica, with instructions to respondents that the
serum calcium test will have to be repeated after seven days. Petitioner told respondents that she will see Angelica
again after two weeks, but respondents can see her anytime if any immediate problem arises. 28
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 childs body.33
By August 26, Angelica was bleeding through the mouth. Respondents also saw blood on her anus and urine.
When Lina asked petitioner what was happening to her daughter, petitioner replied, "Bagsak ang platelets ng anak
mo." Four units of platelet concentrates were then transfused to Angelica. Petitioner prescribed Solucortef.
Considering that Angelicas fever was high and her white blood cell count was low, petitioner prescribed Leucomax.
About four to eight bags of blood, consisting of packed red blood cells, fresh whole blood, or platelet concentrate,
were transfused to Angelica. For two days (August 27 to 28), Angelica continued bleeding, but petitioner claimed it
was lesser in amount and in frequency. Petitioner also denied that there were gadgets attached to Angelica at that
time.34
On August 29, Angelica developed ulcers in her mouth, which petitioner said were blood clots that should not be
removed. Respondents claimed that Angelica passed about half a liter of blood through her anus at around seven
oclock that evening, which petitioner likewise denied.
On August 30, Angelica continued bleeding. She was restless as endotracheal and nasogastric tubes were inserted
into her weakened body. An aspiration of the nasogastric tube inserted to Angelica also revealed a bloody content.
Angelica was given more platelet concentrate and fresh whole blood, which petitioner claimed improved her
condition. Petitioner told Angelica not to remove the endotracheal tube because this may induce further
bleeding.35 She was also transferred to the intensive care unit to avoid infection.
The next day, respondents claimed that Angelica became hysterical, vomited blood and her body turned black. Part
of Angelicas skin was also noted to be shredding by just rubbing cotton on it. Angelica was so restless she
removed those gadgets attached to her, saying "Ayaw ko na"; there were tears in her eyes and she kept turning her
head. Observing her daughter to be at the point of death, Lina asked for a doctor but the latter could not answer her
anymore.36 At this time, the attending physician was Dr. Marbella who was shaking his head saying that Angelicas
platelets were down and respondents should pray for their daughter. Reynaldo claimed that he was introduced to a
pediatrician who took over his daughters case, Dr. Abesamis who also told him to pray for his daughter. Angelica
continued to have difficulty in her breathing and blood was being suctioned from her stomach. A nurse was posted
inside Angelicas room to assist her breathing and at one point they had to revive Angelica by pumping her chest.
Thereafter, Reynaldo claimed that Angelica already experienced difficulty in urinating and her bowel consisted of
blood-like fluid. Angelica requested for an electric fan as she was in pain. Hospital staff attempted to take blood
samples from Angelica but were unsuccessful because they could not even locate her vein. Angelica asked for a
fruit but when it was given to her, she only smelled it. At this time, Reynaldo claimed he could not find either
petitioner or Dr. Marbella. That night, Angelica became hysterical and started removing those gadgets attached to
her. At three oclock in the morning of September 1, a priest came and they prayed before Angelica expired.
65
Petitioner finally came back and supposedly told respondents that there was "malfunction" or bogged-down
machine.37
By petitioners own account, Angelica was merely irritable that day (August 31). Petitioner noted though that
Angelicas skin was indeed sloughing off. 38 She stressed that at 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
Angelicas other organs to fail.41 Petitioner attributed this to the patients poor defense mechanism brought about by
the cancer itself.42
While he was seeking the release of Angelicas cadaver from SLMC, Reynaldo claimed that petitioner acted
arrogantly and called him names. He was asked to sign a promissory note as he did not have cash to pay the
hospital bill.43
Respondents also presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-Legal Officer of the PNP-Crime
Laboratory who conducted the autopsy on Angelicas cadaver, and Dr. Melinda Vergara Balmaceda who is a
Medical 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 victims death. The time lapse for the production of DIC in the case of
Angelica (from the time of diagnosis of sarcoma) was too short, considering the survival rate of about 3 years. The
witness conceded that the victim will also die of osteosarcoma even with amputation or chemotherapy, but in this
case Angelicas death was not caused by osteosarcoma. Dr. Vergara admitted that she is not a pathologist but her
statements were based on the opinion of an oncologist whom she had interviewed. This oncologist supposedly said
that if the victim already had DIC prior to the chemotherapy, the hospital staff could have detected it. 44
On her part, Dr. Balmaceda declared that it is the physicians duty to inform and explain to the patient or his
relatives every known side effect of the procedure or therapeutic agents to be administered, before securing the
consent of the patient or his relatives to such procedure or therapy. The physician thus bases his assurance to the
patient on his personal assessment of the patients condition and his knowledge of the general effects of the agents
or procedure that will be allowed on the patient. Dr. Balmaceda stressed that the patient or relatives must be
informed of all known side effects based on studies and observations, even if such will aggravate the patients
condition.45
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelicas lower extremity, testified for the
defendants. He explained that in case of malignant tumors, there is no guarantee that the ablation or removal of the
amputated part will completely cure the cancer. Thus, surgery is not enough. The mortality rate of osteosarcoma at
the time of modern chemotherapy and early diagnosis still remains at 80% to 90%. Usually, deaths occur from
metastasis, or spread of the cancer to other vital organs like the liver, causing systemic complications. The modes
of therapy available are the removal of the primary source of the cancerous growth and then the residual cancer
cells or metastasis should be treated with chemotherapy. Dr. Tamayo further explained that patients with
osteosarcoma have poor defense mechanism due to the cancer cells in the blood stream. In the case of Angelica,
he had previously explained to her parents that after the surgical procedure, chemotherapy is imperative so that
metastasis of these cancer cells will hopefully be addressed. He referred the patient to petitioner because he felt
that petitioner is a competent oncologist. Considering that this type of cancer is very aggressive and will
metastasize early, it will cause the demise of the patient should there be no early intervention (in this case, the
patient developed sepsis which caused her death). Cancer cells in the blood cannot be seen by the naked eye nor
detected through bone scan. On cross-examination, Dr. Tamayo stated that of the more than 50 child patients who
had osteogenic sarcoma he had handled, he thought that probably all of them died within six months from
amputation because he did not see them anymore after follow-up; it is either they died or had seen another
doctor.46
In dismissing the complaint, the trial court held that petitioner was not liable for damages as she observed the best
known procedures and employed her highest skill and knowledge in the administration of chemotherapy drugs on
Angelica but despite all efforts said patient died. It cited the testimony of Dr. Tamayo who testified that he
considered petitioner one of the most proficient in the treatment of cancer and that the patient in this case was
afflicted with a very aggressive type of cancer necessitating chemotherapy as adjuvant treatment. Using the
standard of negligence laid down in Picart v. Smith, 47 the trial court declared that petitioner has taken the necessary
precaution against the adverse effect of chemotherapy on the patient, adding that a wrong decision is not by itself
negligence. Respondents were ordered to pay their unpaid hospital bill in the amount of P139,064.43.48
Respondents appealed to the CA which, while concurring with the trial courts finding that there was no negligence
committed by the petitioner in the administration of chemotherapy treatment to Angelica, found that petitioner as
her attending physician failed to fully explain to the respondents all the known side effects of chemotherapy. The
appellate court stressed that since the respondents have been told of only three side effects of chemotherapy, they
readily consented thereto. Had petitioner made known to respondents those other side effects which gravely
affected their child -- such as carpo-pedal spasm, sepsis, decrease in the blood platelet count, bleeding, infections
and eventual death -- respondents could have decided differently or adopted a different course of action which
could have delayed or prevented the early death of their child.
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 Lis representation that the deceased would have
a strong chance of survival after chemotherapy and also because of the representation of appellee Dr. Rubi Li that
there were only three possible side-effects of the treatment. However, all sorts of painful side-effects resulted from
the treatment including the premature death of Angelica. The appellants were clearly and totally unaware of these
other side-effects which manifested only during the chemotherapy treatment. This was shown by the fact that every
time a problem would take place regarding Angelicas condition (like an unexpected side-effect manifesting itself),
they would immediately seek explanation from Dr. Rubi Li. Surely, those unexpected side-effects culminating in the
loss of a love[d] one caused the appellants so much trouble, pain and suffering.
On this point therefore, [w]e find defendant-appellee Dr. Rubi Li negligent which would entitle plaintiffs-appellants to
their claim for damages.
xxxx
WHEREFORE, the instant appeal is hereby GRANTED. Accordingly, the assailed decision is hereby modified to
the extent that defendant-appellee Dr. Rubi Li is ordered to pay the plaintiffs-appellants the following amounts:
1. Actual damages of P139,064.43, plus P9,828.00 for funeral expenses;
2. Moral damages of P200,000.00;
66
 3. Exemplary damages of P50,000.00;
4. Attorneys fee of P30,000.00.
SO ORDERED.49 (Emphasis supplied.)
Petitioner filed a motion for partial reconsideration which the appellate court denied.
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
attorneys 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 patients 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. 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 formers realization
that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently
evaluating, hence the indispensability of expert testimonies. 52
In this case, both the trial and appellate courts concurred in finding that the alleged negligence of petitioner in the
administration of chemotherapy drugs to respondents child was not proven considering that Drs. Vergara and
Balmaceda, not being oncologists or cancer specialists, were not qualified to give expert opinion as to whether
petitioners lack of skill, knowledge and professional competence in failing to observe the standard of care in her
line of practice was the proximate cause of the patients death. Furthermore, respondents case was not at all
helped by the non-production of medical records by the hospital (only the biopsy result and medical bills were
submitted to the court). Nevertheless, the CA found petitioner liable for her failure to inform the respondents on all
possible side effects of chemotherapy before securing their consent to the said treatment.
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 Cardozos 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 patients 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. Spence56 the court observed that the duty to disclose should not be limited to
medical usage as to arrogate the decision on revelation to the physician alone. Thus, respect for the patients right
of self-determination on particular therapy demands a standard set by law for physicians rather than one which
physicians may or may not impose upon themselves. 57 The scope of disclosure is premised on the fact that patients
ordinarily are persons unlearned in the medical sciences. Proficiency in diagnosis and therapy is not the full
measure of a physicians responsibility. It is also his duty to warn of the dangers lurking in the proposed treatment
and to impart information which the patient has every right to expect. Indeed, the patients reliance upon the
physician is a trust of the kind which traditionally has exacted obligations beyond those associated with armslength
transactions.58 The physician is not expected to give the patient a short medical education, the disclosure rule only
requires of him a reasonable explanation, which means generally informing the patient in nontechnical terms as to
what is at stake; the therapy alternatives open to him, the goals expectably to be achieved, and the risks that may
ensue from particular treatment or no treatment.59 As to the issue of demonstrating what risks are considered
material necessitating disclosure, it was held that experts are unnecessary to a showing of the materiality of a risk
to a patients decision on treatment, or to the reasonably, expectable effect of risk disclosure on the decision. Such
unrevealed risk that should have been made known must further materialize, for otherwise the omission, however
unpardonable, is without legal consequence. And, as in malpractice actions generally, there must be a causal
relationship between the physicians failure to divulge and damage to the patient. 60
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Reiterating the foregoing considerations, Cobbs v. Grant 61 deemed it as integral part of physicians 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 patients 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 physicians communications to the patient, then must be measured by the patients 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 patients 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 physicians failure to inform and the injury to
patient and such connection arises only if it is established that, had revelation been made, consent to treatment
would not have been given.
There are four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed
consent: "(1) the physician had a duty to disclose material risks; (2) he failed to disclose or inadequately disclosed
those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to treatment she
otherwise would not have consented to; and (4) plaintiff was injured by the proposed treatment." The gravamen in
an informed consent case requires the plaintiff to "point to significant undisclosed information relating to the
treatment which would have altered her decision to undergo it. 64
Examining the evidence on record, we hold that there was adequate disclosure of material risks inherent in the
chemotherapy procedure performed with the consent of Angelicas parents. Respondents could not have been
unaware in the course of initial treatment and amputation of Angelicas lower extremity, that her immune system
was already weak on account of the malignant tumor in her knee. When petitioner informed the respondents
beforehand of the side effects of chemotherapy which includes lowered counts of white and red blood cells,
decrease in blood platelets, possible kidney or heart damage and skin darkening, there is reasonable expectation
on the part of the doctor that the respondents understood very well that the severity of these side effects will not be
the same for all patients undergoing the procedure. In other words, by the nature of the disease itself, each
patients reaction to the chemical agents even with pre-treatment laboratory tests cannot be precisely determined
by the physician. That death can possibly result from complications of the treatment or the underlying cancer itself,
immediately or sometime after the administration of chemotherapy drugs, is a risk that cannot be ruled out, as with
most other major medical procedures, but such conclusion can be reasonably drawn from the general side effects
of chemotherapy already disclosed.
As a physician, petitioner can reasonably expect the respondents to have considered the variables in the
recommended treatment for their daughter afflicted with a life-threatening illness. On the other hand, it is difficult to
give credence to respondents claim that petitioner told them of 95% chance of recovery for their daughter, as it
was unlikely for doctors like petitioner who were dealing with grave conditions such as cancer to have falsely
assured patients of chemotherapys success rate. Besides, informed consent laws in other countries generally
require only a reasonable explanation of potential harms, so specific disclosures such as statistical data, may not
be legally necessary.65
The element of ethical duty to disclose material risks in the proposed medical treatment cannot thus be reduced to
one simplistic formula applicable in all instances. Further, in a medical malpractice action based on lack of informed
consent, "the plaintiff must prove both the duty and the breach of that duty through expert testimony. 66Such expert
testimony must show the customary standard of care of physicians in the same practice as that of the defendant
doctor.67
In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medical Specialist of the DOHs
Operational and Management Services charged with receiving complaints against hospitals, does not qualify as
expert testimony to establish the standard of care in obtaining consent for chemotherapy treatment. In the absence
of expert testimony in this regard, the Court feels hesitant in defining the scope of mandatory disclosure in cases of
malpractice based on lack of informed consent, much less set a standard of disclosure that, even in foreign
jurisdictions, has been noted to be an evolving one.
As society has grappled with the juxtaposition between personal autonomy and the medical profession's intrinsic
impetus to cure, the law defining "adequate" disclosure has undergone a dynamic evolution. A standard once
guided solely by the ruminations of physicians is now dependent on what a reasonable person in the patients
position regards as significant. This change in perspective is especially important as medical breakthroughs move
practitioners to the cutting edge of technology, ever encountering new and heretofore unimagined treatments for
currently incurable diseases or ailments. An adaptable standard is needed to account for this constant progression.
Reasonableness analyses permeate our legal system for the very reason that they are determined by social norms,
expanding and contracting with the ebb and flow of societal evolution.
As we progress toward the twenty-first century, we now realize that the legal standard of disclosure is not subject to
construction as a categorical imperative. Whatever formulae or processes we adopt are only useful as a
foundational starting point; the particular quality or quantity of disclosure will remain inextricably bound by the facts
of each case. Nevertheless, juries that ultimately determine whether a physician properly informed a patient are
inevitably guided by what they perceive as the common expectation of the medical consumer"a reasonable
person in the patients 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.
No costs.
SO ORDERED.
G.R. No. 177407 February 9, 2011
RICO ROMMEL ATIENZA, Petitioner,
vs.
BOARD OF MEDICINE and EDITHA SIOSON, Respondents.
DECISION
NACHURA, J.:
Before us is a petition for review on certiorari under Rule 45 of the Rules of Court, assailing the Decision1 dated
September 22, 2006 of the Court of Appeals (CA) in CA-G.R. SP No. 87755. The CA dismissed the petition for
68
certiorari filed by petitioner Rico Rommel Atienza (Atienza), which, in turn, assailed the Orders 2 issued by public
respondent Board of Medicine (BOM) in Administrative Case No. 1882.
The facts, fairly summarized by the appellate court, follow.
Due to her lumbar pains, private respondent Editha Sioson went to Rizal Medical Center (RMC) for check-up on
February 4, 1995. Sometime in 1999, due to the same problem, she was referred to Dr. Pedro Lantin III of RMC
who, accordingly, ordered several diagnostic laboratory tests. The tests revealed that her right kidney is normal. It
was ascertained, however, that her left kidney is non-functioning and non-visualizing. Thus, she underwent kidney
operation in September, 1999.
On February 18, 2000, private respondents husband, Romeo Sioson (as complainant), filed a complaint for gross
negligence and/or incompetence before the [BOM] against the doctors who allegedly participated in the fateful
kidney operation, namely: Dr. Judd dela Vega, Dr. Pedro Lantin, III, Dr. Gerardo Antonio Florendo and petitioner
Rico Rommel Atienza.
It was alleged in the complaint that the gross negligence and/or incompetence committed by the said doctors,
including petitioner, consists of the removal of private respondents fully functional right kidney, instead of the left
non-functioning and non-visualizing kidney.
The complaint was heard by the [BOM]. After complainant Romeo Sioson presented his evidence, private
respondent Editha Sioson, also named as complainant there, filed her formal offer of documentary evidence.
Attached to the formal offer of documentary evidence are her Exhibits "A" to "D," which she offered for the purpose
of proving that her kidneys were both in their proper anatomical locations at the time she was operated. She
described her exhibits, as follows:
"EXHIBIT A the certified photocopy of the X-ray Request form dated December 12, 1996, which is also
marked as Annex 2 as it was actually originally the Annex to x x x Dr. Pedro Lantin, IIIs counter affidavit
filed with the City Prosecutor of Pasig City in connection with the criminal complaint filed by [Romeo
Sioson] with the said office, on which are handwritten entries which are the interpretation of the results of
the ultrasound examination. Incidentally, this exhibit happens to be the same as or identical to the
certified photocopy of the document marked as Annex 2 to the Counter-Affidavit dated March 15, 2000,
filed by x x x Dr. Pedro Lantin, III, on May 4, 2000, with this Honorable Board in answer to this complaint;
"EXHIBIT B the certified photo copy of the X-ray request form dated January 30, 1997, which is also
marked as Annex 3 as it was actually likewise originally an Annex to x x x Dr. Pedro Lantin, IIIs counter-
affidavit filed with the Office of the City Prosecutor of Pasig City in connection with the criminal complaint
filed by the herein complainant with the said office, on which are handwritten entries which are the
interpretation of the results of the examination. Incidentally, this exhibit happens to be also the same as or
identical to the certified photo copy of the document marked as Annex 3 which is likewise dated January
30, 1997, which is appended as such Annex 3 to the counter-affidavit dated March 15, 2000, filed by x x
x Dr. Pedro Lantin, III on May 4, 2000, with this Honorable Board in answer to this complaint.
"EXHIBIT C the certified photocopy of the X-ray request form dated March 16, 1996, which is also
marked as Annex 4, on which are handwritten entries which are the interpretation of the results of the
examination.
"EXHIBIT D the certified photocopy of the X-ray request form dated May 20, 1999, which is also
marked as Annex 16, on which are handwritten entries which are the interpretation of the results of the
examination. Incidentally, this exhibit appears to be the draft of the typewritten final report of the same
examination which is the document appended as Annexes 4 and 1 respectively to the counter-affidavits
filed by x x x Dr. Judd dela Vega and Dr. Pedro Lantin, III in answer to the complaint. In the case of Dr.
dela Vega however, the document which is marked as Annex 4 is not a certified photocopy, while in the
case of Dr. Lantin, the document marked as Annex 1 is a certified photocopy. Both documents are of the
same date and typewritten contents are the same as that which are written on Exhibit D.
Petitioner filed his comments/objections to private respondents [Editha Siosons] formal offer of exhibits. He
alleged that said exhibits are inadmissible because the same are mere photocopies, not properly identified and
authenticated, and intended to establish matters which are hearsay. He added that the exhibits are incompetent to
prove the purpose for which they are offered.
Dispositions of the Board of Medicine
The formal offer of documentary exhibits of private respondent [Editha Sioson] was admitted by the [BOM] per its
Order dated May 26, 2004. It reads:
"The Formal Offer of Documentary Evidence of [Romeo Sioson], the Comments/Objections of [herein petitioner]
Atienza, [therein respondents] De la Vega and Lantin, and the Manifestation of [therein] respondent Florendo are
hereby ADMITTED by the [BOM] for whatever purpose they may serve in the resolution of this case.
"Let the hearing be set on July 19, 2004 all at 1:30 p.m. for the reception of the evidence of the respondents.
"SO ORDERED."
Petitioner moved for reconsideration of the abovementioned Order basically on the same reasons stated in his
comment/objections to the formal offer of exhibits.
The [BOM] denied the motion for reconsideration of petitioner in its Order dated October 8, 2004. It concluded that
it should first admit the evidence being offered so that it can determine its probative value when it decides the case.
According to the Board, it can determine whether the evidence is relevant or not if it will take a look at it through the
process of admission. x x x.3
Disagreeing with the BOM, and as previously adverted to, Atienza filed a petition for certiorari with the CA, assailing
the BOMs Orders which admitted Editha Siosons (Edithas) Formal Offer of Documentary Evidence. The CA
dismissed the petition for certiorari for lack of merit.
Hence, this recourse positing the following issues:
I. PROCEDURAL ISSUE:
WHETHER PETITIONER ATIENZA AVAILED OF THE PROPER REMEDY WHEN HE FILED THE
PETITION FOR CERTIORARI DATED 06 DECEMBER 2004 WITH THE COURT OF APPEALS UNDER
RULE 65 OF THE RULES OF COURT TO ASSAIL THE ORDERS DATED 26 MAY 2004 AND 08
OCTOBER 2004 OF RESPONDENT BOARD.
II. SUBSTANTIVE ISSUE:
69
 WHETHER THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR AND DECIDED A
QUESTION OF SUBSTANCE IN A WAY NOT IN ACCORDANCE WITH LAW AND THE APPLICABLE
DECISIONS OF THE HONORABLE COURT WHEN IT UPHELD THE ADMISSION OF INCOMPETENT
AND INADMISSIBLE EVIDENCE BY RESPONDENT BOARD, WHICH CAN RESULT IN THE
DEPRIVATION OF PROFESSIONAL LICENSE A PROPERTY RIGHT OR ONES LIVELIHOOD.4
We find no reason to depart from the ruling of the CA.
Petitioner is correct when he asserts that a petition for certiorari is the proper remedy to assail the Orders of the
BOM, admitting in evidence the exhibits of Editha. As the assailed Orders were interlocutory, these cannot be the
subject of an appeal separate from the judgment that completely or finally disposes of the case.5 At that stage,
where there is no appeal, or any plain, speedy, and adequate remedy in the ordinary course of law, the only and
remaining remedy left to petitioner is a petition for certiorari under Rule 65 of the Rules of Court on the ground of
grave abuse of discretion amounting to lack or excess of jurisdiction.
However, the writ of certiorari will not issue absent a showing that the BOM has acted without or in excess of
jurisdiction or with grave abuse of discretion. Embedded in the CAs finding that the BOM did not exceed its
jurisdiction or act in grave abuse of discretion is the issue of whether the exhibits of Editha contained in her Formal
Offer of Documentary Evidence are inadmissible.
Petitioner argues that the exhibits formally offered in evidence by Editha: (1) violate the best evidence rule; (2) have
not been properly identified and authenticated; (3) are completely hearsay; and (4) are incompetent to prove their
purpose. Thus, petitioner contends that the exhibits are inadmissible evidence.
We disagree.
To begin with, it is well-settled that the rules of evidence are not strictly applied in proceedings before administrative
bodies such as the BOM.6 Although trial courts are enjoined to observe strict enforcement of the rules of
evidence,7 in connection with evidence which may appear to be of doubtful relevancy, incompetency, or
admissibility, we have held that:
[I]t is the safest policy to be liberal, not rejecting them on doubtful or technical grounds, but admitting them unless
plainly irrelevant, immaterial or incompetent, for the reason that their rejection places them beyond the
consideration of the court, if they are thereafter found relevant or competent; on the other hand, their admission, if
they turn out later to be irrelevant or incompetent, can easily be remedied by completely discarding them or
ignoring them.8
From the foregoing, we emphasize the distinction between the admissibility of evidence and the probative weight to
be accorded the same pieces of evidence. PNOC Shipping and Transport Corporation v. Court of Appeals 9teaches:
Admissibility of evidence refers to the question of whether or not the circumstance (or evidence) is to be considered
at all. On the other hand, the probative value of evidence refers to the question of whether or not it proves an issue.
Second, petitioners insistence that the admission of Edithas exhibits violated his substantive rights leading to the
loss of his medical license is misplaced. Petitioner mistakenly relies on Section 20, Article I of the Professional
Regulation Commission Rules of Procedure, which reads:
Section 20. Administrative investigation shall be conducted in accordance with these Rules. The Rules of Court
shall only apply in these proceedings by analogy or on a suppletory character and whenever practicable and
convenient. Technical errors in the admission of evidence which do not prejudice the substantive rights of either
party shall not vitiate the proceedings.10
As pointed out by the appellate court, the admission of the exhibits did not prejudice the substantive rights of
petitioner because, at any rate, the fact sought to be proved thereby, that the two kidneys of Editha were in their
proper anatomical locations at the time she was operated on, is presumed under Section 3, Rule 131 of the Rules
of Court:
Sec. 3. Disputable presumptions. The following presumptions are satisfactory if uncontradicted, but may be
contradicted and overcome by other evidence:
xxxx
(y) That things have happened according to the ordinary course of nature and the ordinary habits of life.
The exhibits are certified photocopies of X-ray Request Forms dated December 12, 1996, January 30, 1997, March
16, 1996, and May 20, 1999, filed in connection with Edithas medical case. The documents contain handwritten
entries interpreting the results of the examination. These exhibits were actually attached as annexes to Dr. Pedro
Lantin IIIs counter affidavit filed with the Office of the City Prosecutor of Pasig City, which was investigating the
criminal complaint for negligence filed by Editha against the doctors of Rizal Medical Center (RMC) who handled
her surgical procedure. To lay the predicate for her case, Editha offered the exhibits in evidence to prove that her
"kidneys were both in their proper anatomical locations at the time" of her operation.
The fact sought to be established by the admission of Edithas exhibits, that her "kidneys were both in their proper
anatomical locations at the time" of her operation, need not be proved as it is covered by mandatory judicial
notice.11
Unquestionably, the rules of evidence are merely the means for ascertaining the truth respecting a matter of
fact.12 Thus, they likewise provide for some facts which are established and need not be proved, such as those
covered by judicial notice, both mandatory and discretionary. 13 Laws of nature involving the physical sciences,
specifically biology,14 include the structural make-up and composition of living things such as human beings. In this
case, we may take judicial notice that Edithas kidneys before, and at the time of, her operation, as with most
human beings, were in their proper anatomical locations.
Third, contrary to the assertion of petitioner, the best evidence rule is inapplicable.1awphil Section 3 of Rule 130
provides:
1. Best Evidence Rule
Sec. 3. Original document must be produced; exceptions. When the subject of inquiry is the contents of a
document, no evidence shall be admissible other than the original document itself, except in the following cases:
(a) When the original has been lost or destroyed, or cannot be produced in court, without bad faith on the
part of the offeror;
(b) When the original is in the custody or under the control of the party against whom the evidence is
offered, and the latter fails to produce it after reasonable notice;
70
 (c) When the original consists of numerous accounts or other documents which cannot be examined in
court without great loss of time and the fact sought to be established from them is only the general result
of the whole; and
(d) When the original is a public record in the custody of a public officer or is recorded in a public office.
The subject of inquiry in this case is whether respondent doctors before the BOM are liable for gross negligence in
removing the right functioning kidney of Editha instead of the left non-functioning kidney, not the proper anatomical
locations of Edithas kidneys. As previously discussed, the proper anatomical locations of Edithas kidneys at the
time of her operation at the RMC may be established not only through the exhibits offered in evidence.
Finally, these exhibits do not constitute hearsay evidence of the anatomical locations of Edithas kidneys. To further
drive home the point, the anatomical positions, whether left or right, of Edithas kidneys, and the removal of one or
both, may still be established through a belated ultrasound or x-ray of her abdominal area.
In fact, the introduction of secondary evidence, such as copies of the exhibits, is allowed. 15 Witness Dr. Nancy
Aquino testified that the Records Office of RMC no longer had the originals of the exhibits "because [it] transferred
from the previous building, x x x to the new building." 16 Ultimately, since the originals cannot be produced, the BOM
properly admitted Edithas formal offer of evidence and, thereafter, the BOM shall determine the probative value
thereof when it decides the case.
WHEREFORE, the petition is DENIED. The Decision of the Court of Appeals in CA-G.R. SP No. 87755 is
AFFIRMED. Costs against petitioner.
SO ORDERED.
G.R. No. 187926 February 15, 2012
Dr. EMMANUEL JARCIA, Jr. and Dr. MARILOU BASTAN, Petitioners,
vs.
PEOPLE OF THE PHILIPPINES, Respondent.
DECISION
MENDOZA, J.:
Even early on, patients have consigned their lives to the skill of their doctors. Time and again, it can be said that the
most important goal of the medical profession is the preservation of life and health of the people. Corollarily, when a
physician departs from his sacred duty and endangers instead the life of his patient, he must be made liable for the
resulting injury. This Court, as this case would show, cannot and will not let the act go unpunished. 1
This is a petition for review under Rule 45 of the Rules of Court challenging the August 29, 2008 Decision 2 of the
Court of Appeals (CA), and its May 19, 2009 Resolution3 in CA-G.R. CR No. 29559, dismissing the appeal and
affirming in toto the June 14, 2005 Decision4 of the Regional Trial Court, Branch 43, Manila (RTC), finding the
accused guilty beyond reasonable doubt of simple imprudence resulting to serious physical injuries.
THE FACTS
Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of Investigation (NBI) against the
petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou Bastan (Dr. Bastan), for their alleged neglect of
professional duty which caused her son, Roy Alfonso Santiago (Roy Jr.), to suffer serious physical injuries. Upon
investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was rushed to the Manila Doctors Hospital for
an emergency medical treatment; that an X-ray of the victims ankle was ordered; that the X-ray result showed no
fracture as read by Dr. Jarcia; that Dr. Bastan entered the emergency room (ER) and, after conducting her own
examination of the victim, informed Mrs. Santiago that since it was only the ankle that was hit, there was no need to
examine the upper leg; that eleven (11) days later, Roy Jr. developed fever, swelling of the right leg and
misalignment of the right foot; that Mrs. Santiago brought him back to the hospital; and that the X-ray revealed a
right mid-tibial fracture and a linear hairline fracture in the shaft of the bone.
The NBI indorsed the matter to the Office of the City Prosecutor of Manila for preliminary investigation. Probable
cause was found and a criminal case for reckless imprudence resulting to serious physical injuries, was filed
against Dr. Jarcia, Dr. Bastan and Dr. Pamittan,5 before the RTC, docketed as Criminal Case No. 01-196646.
On June 14, 2005, the RTC found the petitioners guilty beyond reasonable doubt of the crime of Simple
Imprudence Resulting to Serious Physical Injuries. The decretal portion of the RTC decision reads:
WHEREFORE, premises considered, the Court finds accused DR. EMMANUEL JARCIA, JR. and DR. MARILOU
BASTAN GUILTY beyond reasonable doubt of the crime of SIMPLE IMPRUDENCE RESULTING TO SERIOUS
PHYSICAL INJURIES and are hereby sentenced to suffer the penalty of ONE (1) MONTH and ONE (1) DAY to
TWO (2) MONTHS and to indemnify MRS. BELINDA SANTIAGO the amount of P 3,850.00 representing medical
expenses without subsidiary imprisonment in case of insolvency and to pay the costs.
It appearing that Dr. Pamittan has not been apprehended nor voluntarily surrendered despite warrant issued for her
arrest, let warrant be issued for her arrest and the case against her be ARCHIVED, to be reinstated upon her
apprehension.
SO ORDERED.6
The RTC explained:
After a thorough and in depth evaluation of the evidence adduced by the prosecution and the defense, this court
finds that the evidence of the prosecution is the more credible, concrete and sufficient to create that moral certainty
in the mind of the Court that accused herein [are] criminally responsible. The Court believes that accused are
negligent when both failed to exercise the necessary and reasonable prudence in ascertaining the extent of injury
of Alfonso Santiago, Jr.
However, the negligence exhibited by the two doctors does not approximate negligence of a reckless nature but
merely amounts to simple imprudence. Simple imprudence consists in the lack of precaution displayed in those
cases in which the damage impending to be caused is not the immediate nor the danger clearly manifest. The
elements of simple imprudence are as follows.
1. that there is lack of precaution on the part of the offender; and
2. that the damage impending to be caused is not immediate of the danger is not clearly manifest.
71
Considering all the evidence on record, The Court finds the accused guilty for simple imprudence resulting to
physical injuries. Under Article 365 of the Revised Penal Code, the penalty provided for is arresto mayor in its
minimum period.7
Dissatisfied, the petitioners appealed to the CA.
deduced from the mere occurrence of the accident itself. Hence, res ipsa loquitur is applied in conjunction with the
doctrine of common knowledge.
The specific acts of negligence was narrated by Mrs. Santiago who accompanied her son during the latters ordeal
at the hospital. She testified as follows:

As earlier stated, the CA affirmed the RTC decision in toto. The August 29, 2008 Decision of the CA pertinently Fiscal Formoso:
reads:
Q: Now, he is an intern did you not consult the doctors, Dr. Jarcia or Dra. Pamittan to confirm whether you should
This Court holds concurrently and finds the foregoing circumstances sufficient to sustain a judgment of conviction go home or not?
against the accused-appellants for the crime of simple imprudence resulting in serious physical injuries. The
elements of imprudence are: (1) that the offender does or fails to do an act; (2) that the doing or the failure to do A: Dra. Pamittan was inside the cubicle of the nurses and I asked her, you let us go home and you dont even clean
that act is voluntary; (3) that it be without malice; (4) that material damage results from the imprudence; and (5) that the wounds of my son.
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.
Q: And what did she [tell] you?
Whether or not Dr. Jarcia and Dr. Bastan had committed an "inexcusable lack of precaution" in the treatment of
their patient is to be determined according to the standard of care observed by other members of the profession in A: They told me they will call a resident doctor, sir.
good standing under similar circumstances, bearing in mind the advanced state of the profession at the time of
treatment or the present state of medical science. In the case of Leonila Garcia-Rueda v. Pascasio, the Supreme xxx xxx xxx
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 Q: Was there a resident doctor [who] came?
reasonably competent doctor would use to treat a condition under the same circumstances.
A: Yes, Sir. Dra. Bastan arrived.
In litigations involving medical negligence, the plaintiff has the burden of establishing accused-appellants
negligence, and for a reasonable conclusion of negligence, there must be proof of breach of duty on the part of the Q: Did you tell her what you want on you to be done?
physician as well as a causal connection of such breach and the resulting injury of his patient. The connection
between the negligence and the injury must be a direct and natural sequence of events, unbroken by intervening
efficient causes. In other words, the negligence must be the proximate cause of the injury. Negligence, no matter in A: Yes, sir.
what it consists, cannot create a right of action unless it is the proximate cause of the injury complained of. The
proximate cause of an injury is that cause which, in natural and continuous sequence, unbroken by any efficient Q: What did you [tell] her?
intervening cause, produces the injury and without which the result would not have occurred.
A: I told her, sir, while she was cleaning the wounds of my son, are you not going to x-ray up to the knee because
In the case at bench, the accused-appellants questioned the imputation against them and argued that there is no my son was complaining pain from his ankle up to the middle part of the right leg.
causal connection between their failure to diagnose the fracture and the injury sustained by Roy.
Q: And what did she tell you?
We are not convinced.
A: According to Dra. Bastan, there is no need to x-ray because it was the ankle part that was run over.
The prosecution is however after the cause which prolonged the pain and suffering of Roy and not on the failure of
the accused-appellants to correctly diagnose the extent of the injury sustained by Roy.
Q: What did you do or tell her?

For a more logical presentation of the discussion, we shall first consider the applicability of the doctrine of res ipsa
A: I told her, sir, why is it that they did not examine[x] the whole leg. They just lifted the pants of my son.
loquitur to the instant case. Res ipsa loquitur is a Latin phrase which literally means "the thing or the transaction
speaks for itself. The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a matter of
common knowledge and experience, the very nature of certain types of occurrences may justify an inference of Q: So you mean to say there was no treatment made at all?
negligence on the part of the person who controls the instrumentality causing the injury in the absence of some
explanation by the accused-appellant who is charged with negligence. It is grounded in the superior logic of A: None, sir.
ordinary human experience and, on the basis of such experience or common knowledge, negligence may be

72
 xxx xxx xxx
xxx xxx xxx
A: I just listened to them, sir. And I just asked if I will still return my son.
xxx xxx xxx
xxx xxx xxx
Q: And you were present when they were called?
A: Yes, sir.
Q: And what was discussed then by Sis. Retoria?
A: When they were there they admitted that they have mistakes, sir.
Still, before resort to the doctrine may be allowed, the following requisites must be satisfactorily shown:
1. The accident is of a kind which ordinarily does not occur in the absence of someones negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or defendants; and
3. The possibility of contributing conduct which would make the plaintiff responsible is eliminated.
In the above requisites, the fundamental element is the "control of the instrumentality" which caused the damage.
Such element of control must be shown to be within the dominion of the accused-appellants. In order to have the
benefit of the rule, a plaintiff, in addition to proving injury or damage, must show a situation where it is applicable
and must establish that the essential elements of the doctrine were present in a particular incident. The early
treatment of the leg of Roy would have lessen his suffering if not entirely relieve him from the fracture. A boy of
tender age whose leg was hit by a vehicle would engender a well-founded belief that his condition may worsen
without proper medical attention. As junior residents who only practice general surgery and without specialization
with the case consulted before them, they should have referred the matter to a specialist. This omission alone
constitutes simple imprudence on their part. When Mrs. Santiago insisted on having another x-ray of her child on
the upper part of his leg, they refused to do so. The mother would not have asked them if they had no exclusive
control or prerogative to request an x-ray test. Such is a fact because a radiologist would only conduct the x-ray test
upon request of a physician.
The testimony of Mrs. Santiago was corroborated by a bone specialist Dr. Tacata. He further testified based on his
personal knowledge, and not as an expert, as he examined himself the child Roy. He testified as follows:
Fiscal Macapagal:
Q: And was that the correct respon[se] to the medical problem that was presented to Dr. Jarcia and Dra. Bastan?
A: I would say at that stage, yes. Because they have presented the patient and the history. "At sabi nila, nadaanan
lang po ito." And then, considering their year of residency they are still junior residents, and they are not also
orthopedic residents but general surgery residents, its entirely different thing. Because if you are an orthopedic
resident, I am not trying to saybut if I were an orthopedic resident, there would be more precise and accurate
decision compare to a general surgery resident in so far as involved.
Q: You mean to say there is no supervisor attending the emergency room?
A: At the emergency room, at the Manila Doctors Hospital, the supervisor there is a consultant that usually comes
from a family medicine. They see where a certain patient have to go and then if they cannot manage it, they refer it
to the consultant on duty. Now at that time, I dont [know] why they dont.Because at that time, I think, it is the
decision. Since the x-rays.
Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to whether a patient has
been treated or operated upon with a reasonable degree of skill and care. However, testimony as to the statements
and acts of physicians, external appearances, and manifest conditions which are observable by any one may be
given by non-expert witnesses. Hence, in cases where the res ipsa loquitur is applicable, the court is permitted to
find a physician negligent upon proper proof of injury to the patient, without the aid of expert testimony, where the
court from its fund of common knowledge can determine the proper standard of care. Where common knowledge
and experience teach that a resulting injury would not have occurred to the patient if due care had been exercised,
an inference of negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur without
medical evidence, which is ordinarily required to show not only what occurred but how and why it occurred. In the
case at bench, we give credence to the testimony of Mrs. Santiago by applying the doctrine of res ipsa loquitur.
Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied,
depending upon the circumstances of each case. It is generally restricted to situations in malpractice cases where a
layman is able to say, as a matter of common knowledge and observation, that the consequences of professional
care were not as such as would ordinarily have followed if due care had been exercised. A distinction must be
made between the failure to secure results and the occurrence of something more unusual and not ordinarily found
if the service or treatment rendered followed the usual procedure of those skilled in that particular practice. The
latter circumstance is the primordial issue that confronted this Court and we find application of the doctrine of res
ipsa loquitur to be in order.
WHEREFORE, in view of the foregoing, the appeal in this case is hereby DISMISSED and the assailed decision of
the trial court finding accused-appellants guilty beyond reasonable doubt of simple imprudence resulting in serious
physical injuries is hereby AFFIRMED in toto.
SO ORDERED.8
The petitioners filed a motion for reconsideration, but it was denied by the CA in its May 19, 2009 Resolution.
Hence, this petition.
The petitioners pray for the reversal of the decision of both the RTC and the CA anchored on the following
GROUNDS-
1. IN AFFIRMING ACCUSED-PETITIONERS CONVICTION, THE COURT OF APPEALS ERRED IN
NOT HOLDING THAT THE ACTUAL, DIRECT, IMMEDIATE, AND PROXIMATE CAUSE OF THE
73
 PHYSICAL INJURY OF THE PATIENT (FRACTURE OF THE LEG BONE OR TIBIA), WHICH
REQUIRED MEDICAL ATTENDANCE FOR MORE THAN THIRTY (30) DAYS AND INCAPACITATED
HIM FROM PERFORMING HIS CUSTOMARY DUTY DURING THE SAME PERIOD OF TIME, WAS
THE VEHICULAR ACCIDENT WHERE THE PATIENTS RIGHT LEG WAS HIT BY A TAXI, NOT THE
FAILURE OF THE ACCUSED-PETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG TO AN X-
RAY EXAMINATION.
2. THE COURT OF APPEALS ERRED IN DISREGARDING ESTABLISHED FACTS CLEARLY
NEGATING PETITIONERS ALLEGED NEGLIGENCE OR IMPRUDENCE. SIGNIFICANTLY, THE
COURT OF APPEALS UNJUSTIFIABLY DISREGARDED THE OPINION OF THE PROSECUTIONS
EXPERT WITNESS, DR. CIRILO TACATA, THAT PETITIONERS WERE NOT GUILTY OF
NEGLIGENCE OR IMPRUDENCE COMPLAINED OF.
3. THE COURT OF APPEALS ERRED IN HOLDING THAT THE FAILURE OF PETITIONERS TO
SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY EXAMINATION PROLONGED THE PAIN
AND SUFFERING OF THE PATIENT, SUCH CONCLUSION BEING UNSUPPORTED BY, AND EVEN
CONTRARY TO, THE EVIDENCE ON RECORD.
4. ASSUMING ARGUENDO THAT THE PATIENT EXPERIENCED PROLONGED PAIN AND
SUFFERING, THE COURT OF APPEALS ERRED IN NOT HOLDING THAT THE ALLEGED PAIN AND
SUFFERING WERE DUE TO THE UNJUSTIFIED FAILURE OF THE PATIENTS MOTHER, A NURSE
HERSELF, TO IMMEDIATELY BRING THE PATIENT BACK TO THE HOSPITAL, AS ADVISED BY
THE PETITIONERS, AFTER HE COMPLAINED OF SEVERE PAIN IN HIS RIGHT LEG WHEN HE
REACHED HOME AFTER HE WAS SEEN BY PETITIONERS AT THE HOSPITAL. THUS, THE
PATIENTS ALLEGED INJURY (PROLONGED PAIN AND SUFFERING) WAS DUE TO HIS OWN
MOTHERS ACT OR OMISSION.
5. THE COURT OF APPEALS ERRED IN NOT HOLDING THAT NO PHYSICIAN-PATIENT
RELATIONSHIP EXISTED BETWEEN PETITIONERS AND PATIENT ALFONSO SANTIAGO, JR.,
PETITIONERS NOT BEING THE LATTERS ATTENDING PHYSICIAN AS THEY WERE MERELY
REQUESTED BY THE EMERGENCY ROOM (ER) NURSE TO SEE THE PATIENT WHILE THEY
WERE PASSING BY THE ER FOR THEIR LUNCH.
6. THE COURT OF APPEALS GRAVELY ERRED IN NOT ACQUITTING ACCUSED-PETITIONERS OF
THE CRIME CHARGED."9
The foregoing can be synthesized into two basic issues: [1] whether or not the doctrine of res ipsa loquitur is
applicable in this case; and [2] whether or not the petitioners are liable for criminal negligence.
THE COURTS RULING
The CA is correct in finding that there was negligence on the part of the petitioners. After a perusal of the records,
however, the Court is not convinced that the petitioners are guilty of criminal negligence complained of. The Court
is also of the view that the CA erred in applying the doctrine of res ipsa loquitur in this particular case.
As to the Application of The Doctrine of Res Ipsa Loquitur
This doctrine of res ipsa loquitur means "Where the thing which causes injury is shown to be under the
management of the defendant, and the accident is such as in the ordinary course of things does not happen if
those who have the management use proper care, it affords reasonable evidence, in the absence of an explanation
by the defendant, that the accident arose from want of care." The Black's Law Dictionary defines the said doctrine.
Thus:
The thing speaks for itself. Rebuttable presumption or inference that defendant was negligent, which arises upon
proof that the instrumentality causing injury was in defendant's exclusive control, and that the accident was one
which ordinarily does not happen in absence of negligence. Res ipsa loquitur is a rule of evidence whereby
negligence of the alleged wrongdoer may be inferred from the mere fact that the accident happened provided the
character of the accident and circumstances attending it lead reasonably to belief that in the absence of negligence
it would not have occurred and that thing which caused injury is shown to have been under the management and
control of the alleged wrongdoer. Under this doctrine, the happening of an injury permits an inference of negligence
where plaintiff produces substantial evidence that the injury was caused by an agency or instrumentality under the
exclusive control and management of defendant, and that the occurrence was such that in the ordinary course of
things would not happen if reasonable care had been used. 10
The doctrine of res ipsa loquitur as a rule of evidence is unusual to the law of negligence which recognizes
that prima facie negligence may be established without direct proof and furnishes a substitute for specific proof of
negligence. The doctrine, however, is not a rule of substantive law, but merely a mode of proof or a mere
procedural convenience. The rule, when applicable to the facts and circumstances of a given case, is not meant to
and does not dispense with the requirement of proof of culpable negligence on the party charged. It merely
determines and regulates what shall be prima facie evidence thereof and helps the plaintiff in proving a breach of
the duty. The doctrine can be invoked when and only when, under the circumstances involved, direct evidence is
absent and not readily available. 11
The requisites for the application of the doctrine of res ipsa loquitur are: (1) the accident was of a kind which does
not ordinarily occur unless someone is negligent; (2) the instrumentality or agency which caused the injury was
under the exclusive control of the person in charge; and (3) the injury suffered must not have been due to any
voluntary action or contribution of the person injured. 12
In this case, the circumstances that caused patient Roy Jr.s injury and the series of tests that were supposed to be
undergone by him to determine the extent of the injury suffered were not under the exclusive control of Drs. Jarcia
and Bastan. It was established that they are mere residents of the Manila Doctors Hospital at that time who
attended to the victim at the emergency room.13 While it may be true that the circumstances pointed out by the
courts below seem doubtless to constitute reckless imprudence on the part of the petitioners, this conclusion is still
best achieved, not through the scholarly assumptions of a layman like the patients mother, but by the
unquestionable knowledge of expert witness/es. As to whether the petitioners have exercised the requisite degree
of skill and care in treating patient Roy, Jr. is generally a matter of expert opinion.
As to Dr. Jarcia and Dr. Bastans negligence
The totality of the evidence on record clearly points to the negligence of the petitioners. At the risk of being
repetitious, the Court, however, is not satisfied that Dr. Jarcia and Dr. Bastan are criminally negligent in this case.
Negligence is defined as the failure to observe for the protection of the interests of another person that degree of
care, precaution, and vigilance which the circumstances justly demand, whereby such other person suffers injury. 14
Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act from which material
damage results by reason of an inexcusable lack of precaution on the part of the person performing or failing to
perform such act.15
74
The elements of simple negligence are: (1) that there is lack of precaution on the part of the offender, and (2) that
the damage impending to be caused is not immediate or the danger is not clearly manifest. 16
In this case, the Court is not convinced with moral certainty that the petitioners are guilty of reckless imprudence or
simple negligence. The elements thereof were not proved by the prosecution beyond reasonable doubt.
The testimony of Dr. Cirilo R. Tacata (Dr. Tacata), a specialist in pediatric orthopedic, although pointing to some
medical procedures that could have been done by Dr. Jarcia and Dr. Bastan, as physicians on duty, was not clear
as to whether the injuries suffered by patient Roy Jr. were indeed aggravated by the petitioners judgment call and
their diagnosis or appreciation of the condition of the victim at the time they assessed him. Thus:
Q: Will you please tell us, for the record, doctor, what is your specialization?
A: At present I am the chairman department of orthopedic in UP-PGH and I had special training in pediatric
orthopedic for two (2) years.
Q: In June 1998, doctor, what was your position and what was your specialization at that time?
A: Since 1980, I have been specialist in pediatric orthopedic.
Q: When Alfonso Santiago, Jr. was brought to you by his mother, what did you do by way of physicians as first
step?
A: As usual, I examined the patient physically and, at that time as I have said, the patient could not walk so I
[began] to suspect that probably he sustained a fracture as a result of a vehicular accident. So I examined the
patient at that time, the involved leg, I dont know if that is left or right, the involved leg then was swollen and the
patient could not walk, so I requested for the x-ray of [the] lower leg.
Q: What part of the leg, doctor, did you request to be examined?
A: If we refer for an x-ray, usually, we suspect a fracture whether in approximal, middle or lebistal tinial, we usually
x-ray the entire extremity.
Q: And what was the result?
A: Well, I can say that it was a spiral fracture of the mid-tibial, it is the bigger bone of the leg.
Q: And when you say spiral, doctor, how long was this fracture?
A: When we say spiral, it is a sort of letter S, the length was about six (6) to eight (8) centimeters.
Q: Mid-tibial, will you please point to us, doctor, where the tibial is?
(Witness pointing to his lower leg)
A: The tibial is here, there are two bones here, the bigger one is the tibial and the smaller one is the fibula. The
bigger one is the one that get fractured.
Q: And in the course of your examination of Alfonso Santiago, Jr. did you ask for the history of such injury?
A: Yes, actually, that was a routine part of our examination that once a patient comes in, before we actually
examine the patient, we request for a detailed history. If it is an accident, then, we request for the exact mechanism
of injuries.
Q: And as far as you can recall, Doctor, what was the history of that injury that was told to you?
A: The patient was sideswiped, I dont know if it is a car, but it is a vehicular accident.
Q: Who did you interview?
A: The mother.
Q: How about the child himself, Alfonso Santiago, Jr.?
A: Normally, we do not interview the child because, usually, at his age, the answers are not accurate. So, it was the
mother that I interviewed.
Q: And were you informed also of his early medication that was administered on Alfonso Santiago, Jr.?
A: No, not actually medication. I was informed that this patient was seen initially at the emergency room by the two
(2) physicians that you just mentioned, Dr. Jarcia and Dra. Bastan, that time who happened to be my residents who
were [on] duty at the emergency room.
xxxx
A: At the emergency room, at the Manila Doctors Hospital, the supervisor there is a consultant that usually comes
from a family medicine. They see where a certain patient have to go and then if they cannot manage it, they refer it
to the consultant on duty. Now at that time, I dont why they dont Because at that time, I think, it is the decision.
Since the x-rays
xxx
Q: You also said, Doctor, that Dr. Jarcia and Dra. Bastan are not even an orthopedic specialist.
A: They are general surgeon residents. You have to man[x] the emergency room, including neurology,
orthopedic, general surgery, they see everything at the emergency room.
xxxx
Q: But if initially, Alfonso Santiago, Jr. and his case was presented to you at the emergency room, you would have
subjected the entire foot to x-ray even if the history that was given to Dr. Jarcia and Dra. Bastan is the same?
75
A: I could not directly say yes, because it would still depend on my examination, we cannot subject the whole body
for x-ray if we think that the damaged was only the leg.
Q: Not the entire body but the entire leg?
A: I think, if my examination requires it, I would.
Q: So, you would conduct first an examination?
A: Yes, sir.
Q: And do you think that with that examination that you would have conducted you would discover the necessity
subjecting the entire foot for x-ray?
A: It is also possible but according to them, the foot and the ankle were swollen and not the leg, which sometimes
normally happens that the actual fractured bone do not get swollen.
xxxx
Q: Doctor, if you know that the patient sustained a fracture on the ankle and on the foot and the history that
was told to you is the region that was hit is the region of the foot, will the doctor subject the entire leg for x-
ray?
A: I am an orthopedic surgeon, you have to subject an x-ray of the leg. Because you have to consider the
kind of fracture that the patient sustained would you say the exact mechanism of injury. For example
spiral, "paikot yung bale nya," so it was possible that the leg was run over, the patient fell, and it got
twisted. Thats why the leg seems to be fractured.17 [Emphases supplied]
It can be gleaned from the testimony of Dr. Tacata that a thorough examination was not performed on Roy Jr. As
residents on duty at the emergency room, Dr. Jarcia and Dr. Bastan were expected to know the medical protocol in
treating leg fractures and in attending to victims of car accidents. There was, however, no precise evidence and
scientific explanation pointing to the fact that the delay in the application of the cast to the patients fractured leg
because of failure to immediately diagnose the specific injury of the patient, prolonged the pain of the child or
aggravated his condition or even caused further complications. Any person may opine that had patient Roy Jr. been
treated properly and given the extensive X-ray examination, the extent and severity of the injury, spiral fracture of
the mid-tibial part or the bigger bone of the leg, could have been detected early on and the prolonged pain and
suffering of Roy Jr. could have been prevented. But still, that opinion, even how logical it may seem would not, and
could not, be enough basis to hold one criminally liable; thus, a reasonable doubt as to the petitioners guilt.
Although the Court sympathizes with the plight of the mother and the child in this case, the Court is bound by the
dictates of justice which hold inviolable the right of the accused to be presumed innocent until proven guilty beyond
reasonable doubt. The Court, nevertheless, finds the petitioners civilly liable for their failure to sufficiently attend to
Roy Jr.s medical needs when the latter was rushed to the ER, for while a criminal conviction requires proof beyond
reasonable doubt, only a preponderance of evidence is required to establish civil liability. Taken into account also
was the fact that there was no bad faith on their part.
Dr. Jarcia and Dr. Bastan cannot pass on the liability to the taxi driver who hit the victim. It may be true that the
actual, direct, immediate, and proximate cause of the injury (fracture of the leg bone or tibia) of Roy Jr. was the
vehicular accident when he was hit by a taxi. The petitioners, however, cannot simply invoke such fact alone to
excuse themselves from any liability. If this would be so, doctors would have a ready defense should they fail to do
their job in attending to victims of hit-and-run, maltreatment, and other crimes of violence in which the actual, direct,
immediate, and proximate cause of the injury is indubitably the act of the perpetrator/s.
In failing to perform an extensive medical examination to determine the extent of Roy Jr.s injuries, Dr. Jarcia and
Dr. Bastan were remiss of their duties as members of the medical profession. Assuming for the sake of argument
that they did not have the capacity to make such thorough evaluation at that stage, they should have referred the
patient to another doctor with sufficient training and experience instead of assuring him and his mother that
everything was all right.
This Court cannot also stamp its imprimatur on the petitioners contention that no physician-patient relationship
existed between them and patient Roy Jr., since they were not his attending physicians at that time. They claim that
they were merely requested by the ER nurse to see the patient while they were passing by the ER for their
lunch. Firstly, this issue was never raised during the trial at the RTC or even before the CA. The petitioners,
therefore, raise the want of doctor-patient relationship for the first time on appeal with this Court. It has been settled
that "issues raised for the first time on appeal cannot be considered because a party is not permitted to change his
theory on appeal. To allow him to do so is unfair to the other party and offensive to the rules of fair play, justice and
due process."18 Stated differently, basic considerations of due process dictate that theories, issues and arguments
not brought to the attention of the trial court need not be, and ordinarily will not be, considered by a reviewing
court.19
Assuming again for the sake of argument that the petitioners may still raise this issue of "no physicianpatient
relationship," the Court finds and so holds that there was a "physicianpatient" relationship in this case.
In the case of Lucas v. Tuao,20 the Court wrote that "[w]hen a patient engages the services of a physician, a
physician-patient relationship is generated. And in accepting a case, the physician, for all intents and purposes,
represents that he has the needed training and skill possessed by physicians and surgeons practicing in the same
field; and that he will employ such training, care, and skill in the treatment of the patient. Thus, in treating his
patient, a physician is under a duty to exercise that degree of care, skill and diligence which physicians in the same
general neighborhood and in the same general line of practice ordinarily possess and exercise in like cases. Stated
otherwise, the physician has the obligation to use at least the same level of care that any other reasonably
competent physician would use to treat the condition under similar circumstances."
Indubitably, a physician-patient relationship exists between the petitioners and patient Roy Jr. Notably, the latter
and his mother went to the ER for an immediate medical attention. The petitioners allegedly passed by and were
requested to attend to the victim (contrary to the testimony of Dr. Tacata that they were, at that time, residents on
duty at the ER).21 They obliged and examined the victim, and later assured the mother that everything was fine and
that they could go home. Clearly, a physician-patient relationship was established between the petitioners and the
patient Roy Jr.
To repeat for clarity and emphasis, if these doctors knew from the start that they were not in the position to attend
to Roy Jr., a vehicular accident victim, with the degree of diligence and commitment expected of every doctor in a
case like this, they should have not made a baseless assurance that everything was all right. By doing so, they
deprived Roy Jr. of adequate medical attention that placed him in a more dangerous situation than he was already
in. What petitioners should have done, and could have done, was to refer Roy Jr. to another doctor who could
competently and thoroughly examine his injuries.
All told, the petitioners were, indeed, negligent but only civilly, and not criminally, liable as the facts show.
Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in the Philippines states:
76
A physician should attend to his patients faithfully and conscientiously. He should secure for them all possible
benefits that may depend upon his professional skill and care. As the sole tribunal to adjudge the physicians failure
to fulfill his obligation to his patients is, in most cases, his own conscience, violation of this rule on his part is
discreditable and inexcusable.22
Established medical procedures and practices, though in constant instability, are devised for the purpose of
preventing complications. In this case, the petitioners failed to observe the most prudent medical procedure under
the circumstances to prevent the complications suffered by a child of tender age.
As to the Award of Damages
While no criminal negligence was found in the petitioners failure to administer the necessary medical attention to
Roy Jr., the Court holds them civilly liable for the resulting damages to their patient. While it was the taxi driver who
ran over the foot or leg of Roy Jr., their negligence was doubtless contributory.
It appears undisputed that the amount of P 3,850.00, as expenses incurred by patient Roy Jr., was adequately
supported by receipts. The Court, therefore, finds the petitioners liable to pay this amount by way of actual
damages.
The Court is aware that no amount of compassion can suffice to ease the sorrow felt by the family of the child at
that time. Certainly, the award of moral and exemplary damages in favor of Roy Jr. in the amount of P 100,000.00
and P 50,000.00, respectively, is proper in this case.
It is settled that moral damages are not punitive in nature, but are designed to compensate and alleviate in some
way the physical suffering, mental anguish, fright, serious anxiety, besmirched reputation, wounded feelings, moral
shock, social humiliation, and similar injury unjustly inflicted on a person. Intended for the restoration of the
psychological or emotional status quo ante, the award of moral damages is designed to compensate emotional
injury suffered, not to impose a penalty on the wrongdoer. 23
The Court, likewise, finds the petitioners also liable for exemplary damages in the said amount.1wphi1 Article
2229 of the Civil Code provides that exemplary damages may be imposed by way of example or correction for the
public good.
WHEREFORE, the petition is PARTLY GRANTED. The Decision of the Court of Appeals dated August 29, 2008
is REVERSED and SET ASIDE. A new judgment is entered ACQUITTING Dr. Emmanuel Jarcia, Jr. and Dr.
Marilou Bastan of the crime of reckless imprudence resulting to serious physical injuries but declaring them civilly
liable in the amounts of:
(1) P 3,850.00 as actual damages;
(2) P 100,000.00 as moral damages;
(3) P 50,000.00 as exemplary damages; and
(4) Costs of the suit.
with interest at the rate of 6% per annum from the date of the filing of the Information. The rate shall be 12%
interest per annum from the finality of judgment until fully paid.
SO ORDERED.
G.R. No. 167366 September 26, 2012
DR. PEDRO DENNIS CERENO, and DR. SANTOS ZAFE, Petitioners,
vs.
COURT OF APPEALS, SPOUSES DIOGENES S. OLAVERE and FE R. SERRANO, Respondents.
DECISION
PEREZ, J.:
Before the Court is a Petition for Review on Certiorari 1 under Rule 45 of the Rules of Court seeking the annulment
and setting aside of the 21 February 2005 decision2 of the Court of Appeals (CA) in CA-G.R. CV No. 65800. In the
assailed decision, the CA affirmed in toto the decision of the Regional Trial Court (R TC), Branch 22, Nag a City
finding herein petitioners Dr. Pedro Dennis Cereno (Dr. Cereno) and Dr. Santos Zafe (Dr. Zafe) liable for damages.
Culled from the records are the following antecedent facts:
At about 9:15 in the evening of 16 September 1995, Raymond S. Olavere (Raymond), a victim of a stabbing
incident, was rushed to the emergency room of the Bicol Regional Medical Center (BRMC). There, Raymond was
attended to by Nurse Arlene Balares (Nurse Balares) and Dr. Ruel Levy Realuyo (Dr. Realuyo) the emergency
room resident physician.
Subsequently, the parents of Raymondthe spouses Deogenes Olavere (Deogenes) and Fe R. Serranoarrived
at the BRMC. They were accompanied by one Andrew Olavere, the uncle of Raymond.
After extending initial medical treatment to Raymond, Dr. Realuyo recommended that the patient undergo
"emergency exploratory laparotomy." Dr. Realuyo then requested the parents of Raymond to procure 500 cc of
type "O" blood needed for the operation. Complying with the request, Deogenes and Andrew Olavere went to the
Philippine National Red Cross to secure the required blood.
At 10:30 P.M., Raymond was wheeled inside the operating room. During that time, the hospital surgeons, Drs. Zafe
and Cereno, were busy operating on gunshot victim Charles Maluluy-on. Assisting them in the said operation was
Dr. Rosalina Tatad (Dr. Tatad), who was the only senior anesthesiologist on duty at BRMC that night. Dr. Tatad
also happened to be the head of Anesthesiology Department of the BRMC.
Just before the operation on Maluluy-on was finished, another emergency case involving Lilia Aguila, a woman who
was giving birth to triplets, was brought to the operating room.
At 10:59 P.M., the operation on Charles Maluluy-on was finished. By that time, however, Dr. Tatad was already
working with the obstetricians who will perform surgery on Lilia Aguila. There being no other available
anesthesiologist to assist them, Drs. Zafe and Cereno decided to defer the operation on Raymond.
77
Drs. Zafe and Cereno, in the meantime, proceeded to examine Raymond and they found that the latters blood
pressure was normal and "nothing in him was significant." 3 Dr. Cereno reported that based on the xray result he
interpreted, the fluid inside the thoracic cavity of Raymond was minimal at around 200-300 cc.
At 11:15 P.M., Deogenes and Andrew Olavere returned to the BRMC with a bag containing the requested 500 cc
type "O" blood. They handed over the bag of blood to Dr. Realuyo.
After Dr. Tatad finished her work with the Lilia Aguila operation, petitioners immediately started their operation on
Raymond at around 12:15 A.M. of 17 September 1995. Upon opening of Raymonds thoracic cavity, they found that
3,200 cc of blood was stocked therein. The blood was evacuated and petitioners found a puncture at the inferior
pole of the left lung.
In his testimony, Dr. Cereno stated that considering the loss of blood suffered by Raymond, he did not immediately
transfuse blood because he had to control the bleeders first. 4
Blood was finally transfused on Raymond at 1:40 A.M. At 1:45 A.M., while the operation was on-going, Raymond
suffered a cardiac arrest. The operation ended at 1:50 A.M. and Raymond was pronounced dead at 2:30 A.M.
Raymonds death certificate5 indicated that the immediate cause of death was "hypovolemic shock" or the
cessation of the functions of the organs of the body due to loss of blood. 6
Claiming that there was negligence on the part of those who attended to their son, the parents of Raymond, on 25
October 1995, filed before the RTC, Branch 22, Naga City a complaint for damages 7 against Nurse Balares, Dr.
Realuyo and attending surgeons Dr. Cereno and Dr. Zafe.
During trial, the parents of Raymond testified on their own behalf. They also presented the testimonies of Andrew
Olavere and one Loira Oira, the aunt of Raymond. On the other hand, Dr. Cereno, Dr. Realuyo, Nurse Balares and
Security Guard Diego Reposo testified for the defense. On rebuttal, the parents of Raymond presented Dr. Tatad,
among others.
On 15 October 1999, the trial court rendered a decision8 the dispositive portion of which reads:
WHEREFORE, premises considered, this Court hereby renders judgment:
1. Dismissing the case against Dr. Ruel Levy Realuyo and Arlene Balares for lack of merit;
2. Ordering defendants Dr. Santos Zafe and Dr. Dennis Cereno to pay the heirs of Raymond Olavere,
jointly and severally the following amounts:
1. P 50,000.00 for the death of the victim;
2. P 150,000.00 as moral damages;
3. P 100,000.00 as exemplary damages;
4. P 30,000.00 for attorneys fees; and
5. Cost of suit.9
x x x x.
The trial court found petitioners negligent in not immediately conducting surgery on Raymond. It noted that
petitioners have already finished operating on Charles Maluluy-on as early as 10:30 in the evening, and yet they
only started the operation on Raymond at around 12:15 early morning of the following day. The trial court held that
had the surgery been performed promptly, Raymond would not have lost so much blood and, therefore, could have
been saved.10
The trial court also held that the non-availability of Dr. Tatad after the operation on Maluluy-on was not a sufficient
excuse for the petitioners to not immediately operate on Raymond. It called attention to the testimony of Dr. Tatad
herself, which disclosed the possibility of calling a standby anesthesiologist in that situation. The trial court opined
that the petitioners could have just requested for the standby anesthesiologist from Dr. Tatad, but they did not.
Lastly, the trial court faulted petitioners for the delay in the transfusion of blood on Raymond.
On appeal, the CA in a decision dated 21 February 2005 affirmed in toto the judgment rendered by the RTC finding
herein petitioners guilty of gross negligence in the performance of their duties and awarding damages to private
respondents.
Hence, this petition for review on certiorari under Rule 45 of the Rules of Court assailing the CA decision on the
following grounds:
1. THAT THE CA ERRED IN RULING THAT PETITIONERS WERE GROSSLY NEGLIGENT IN THE
PERFORMANCE OF THEIR DUTIES;
2. THAT THE CA ERRED IN NOT CONSIDERING THE BICOL REGIONAL MEDICAL CENTER AS AN
INDISPENSABLE PARTY AND SUBSIDIARILY LIABLE SHOULD PETITIONERS BE FOUND LIABLE
FOR DAMAGES; and
3. THAT THE CA ERRED IN NOT FINDING THE AWARD OF MORAL AND EXEMPLARY DAMAGES
AS WELL AS ATTORNEYS FEES EXORBITANT OR EXCESSIVE.
We grant the petition
It is well-settled that under Rule 45 of the Rules of Court, only questions of law may be raised. The reason behind
this is that this Court is not a trier of facts and will not re-examine and re-evaluate the evidence on record.11Factual
findings of the CA, affirming that of the trial court, are therefore generally final and conclusive on this Court. This
rule is subject to the following exceptions: (1) the conclusion is grounded on speculations, surmises or conjectures;
(2) the inference is manifestly mistaken, absurd or impossible; (3) there is grave abuse of discretion; (4) the
judgment is based on a misapprehension of facts; (5) the findings of fact are conflicting; (6) there is no citation of
specific evidence on which the factual findings are based; (7) the findings of absence of fact are contradicted by the
presence of evidence on record; (8) the findings of the CA are contrary to those of the trial court; (9) the CA
manifestly overlooked certain relevant and undisputed facts that, if properly considered, would justify a different
conclusion; (10) the findings of the CA are beyond the issues of the case; and (11) such findings are contrary to the
admissions of both parties.12 In this case, We find exceptions (1) and (4) to be applicable.
78
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 the failure or action caused injury to the patient.13 Stated otherwise, the complainant
must prove: (1) that the health care provider, either by his act or omission, had been negligent, and (2) that such
act or omission proximately caused the injury complained of.
The best way to prove these is through the opinions of expert witnesses belonging in the same neighborhood and
in the same general line of practice as defendant physician or surgeon. The deference of courts to the expert
opinion of qualified physicians stems from the formers realization that the latter possess unusual technical skills
which laymen in most instances are incapable of intelligently evaluating, hence, the indispensability of expert
testimonies.14
Guided by the foregoing standards, We dissect the issues at hand.
Petitioners Not Negligent
The trial court first imputed negligence on the part of the petitioners by their failure to perform the operation on
Raymond immediately after finishing the Maluluy-on operation. It rejected as an excuse the nonavailability of Dr.
Tatad. The trial court relied on the testimony of Dr. Tatad about a "BRMC protocol" that introduces the possibility
that a standby anesthesiologist could have been called upon. The pertinent portions of the testimony of Dr. Tatad
provides:
Q: Aside from you and Dr. Rebancos, who was the standby anesthesiologist?
A: We have a protocol at the Bicol Medical Center to have a consultant who is on call.
Q: How many of them?
A: One.
Q: Who is she?
A: Dra. Flores.
Q: What is the first name?
A: Rosalina Flores.
Q: Is she residing in Naga City?
A: In Camaligan.
Q: She is on call anytime when there is an emergency case to be attended to in the Bicol Medical Center?
A: Yes sir.15
Dr. Tatad further testified:
Q: Alright (sic), considering that you said you could not attend to Raymond Olavere because another patient was
coming in the person of Lilia Aguila, did you not suggest to Dr. Cereno to call the standby anesthesiologist?
A: They are not ones to do that. They have no right to call for the standby anesthesiologist.
Q: Then, who should call for the standby anesthesiologist?
A: It is me if the surgeon requested.
Q: But in this case, the surgeon did not request you?
A: No. It is their prerogative.
Q: I just want to know that in this case the surgeon did not request you to call for the standby anesthesiologist?
A: No sir.16
From there, the trial court concluded that it was the duty of the petitioners to request Dr. Tatad to call on Dr.
Rosalina Flores, the standby anesthesiologist. Since petitioners failed to do so, their inability to promptly perform
the operation on Raymond becomes negligence on their part.
This Court does not agree with the aforesaid conclusion.
First. There is nothing in the testimony of Dr. Tatad, or in any evidence on the record for that matter, which shows
that the petitioners were aware of the "BRMC protocol" that the hospital keeps a standby anesthesiologist available
on call. Indeed, other than the testimony of Dr. Tatad, there is no evidence that proves that any such "BRMC
protocol" is being practiced by the hospitals surgeons at all.
Evidence to the effect that petitioners knew of the "BRMC protocol" is essential, especially in view of the contrary
assertion of the petitioners that the matter of assigning anesthesiologists rests within the full discretion of the BRMC
Anesthesiology Department. Without any prior knowledge of the "BRMC protocol," We find that it is quite
reasonable for the petitioners to assume that matters regarding the administration of anesthesia and the
assignment of anesthesiologists are concerns of the Anesthesiology Department, while matters pertaining to the
surgery itself fall under the concern of the surgeons. Certainly, We cannot hold petitioners accountable for not
complying with something that they, in the first place, do not know.
Second. Even assuming ex gratia argumenti that there is such "BRMC protocol" and that petitioners knew about it,
We find that their failure to request for the assistance of the standby anesthesiologist to be reasonable when taken
in the proper context. There is simply no competent evidence to the contrary.
From the testimony of Dr. Tatad herself, it is clear that the matter of requesting for a standby anaesthesiologist is
not within the full discretion of petitioners. The "BRMC protocol" described in the testimony requires the petitioners
79
to course such request to Dr. Tatad who, as head of the Department of Anesthesiology, has the final say of calling Q: Had this blood been given to you before the operation you could have transfused the blood to the patient?
the standby anesthesiologist.
A: Of course, yes.
As revealed by the facts, however, after the Maluluy-on operation, Dr. Tatad was already assisting in the Lilia
Aguila operation. Drs. Zafe and Cereno then proceeded to examine Raymond and they found that the latters blood Q: And the blood was transfused only after the operation?
pressure was normal and "nothing in him was significant." 17 Dr. Cereno even concluded that based on the x-ray
result he interpreted, the fluid inside the thoracic cavity of Raymond was minimal at around 200-300 cc. Such
findings of Drs. Cereno and Zafe were never challenged and were unrebutted. A: Because that was the time when the blood was given to us.

Given that Dr. Tatad was already engaged in another urgent operation and that Raymond was not showing any xxxx
symptom of suffering from major blood loss requiring an immediate operation, We find it reasonable that petitioners
decided to wait for Dr. Tatad to finish her surgery and not to call the standby anesthesiologist anymore. There is, Q: Have you monitored the condition of Raymond Olavere?
after all, no evidence that shows that a prudent surgeon faced with similar circumstances would decide otherwise.
A: I monitored the condition during the time when I would administer anesthesia.
Here, there were no expert witnesses presented to testify that the course of action taken by petitioners were not in
accord with those adopted by other reasonable surgeons in similar situations. Neither was there any testimony
given, except that of Dr. Tatads, on which it may be inferred that petitioners failed to exercise the standard of care, Q: What time was that?
diligence, learning and skill expected from practitioners of their profession. Dr. Tatad, however, is an expert neither
in the field of surgery nor of surgical practices and diagnoses. Her expertise is in the administration of anesthesia A: 11:45 already.
and not in the determination of whether surgery ought or not ought to be performed.
Q: What was the condition of the blood pressure at that time?
Another ground relied upon by the trial court in holding petitioners negligent was their failure to immediately
transfuse blood on Raymond. Such failure allegedly led to the eventual death of Raymond through "hypovolemic
shock." The trial court relied on the following testimony of Dr. Tatad: A: 60/40 initial.

Q: In this case of Raymond Olavere was blood transfused to him while he was inside the operating room? Q: With that kind of blood pressure the patient must have been in critical condition?

A: The blood arrived at 1:40 a.m. and that was the time when this blood was hooked to the patient. A: At the time when the blood pressure was 60/40 I again told Dr. Cereno that blood was already needed.

xxxx Q: With that condition, Doctor, that the patient had 60/40 blood pressure you did not decide on transfusing blood to
him?

Q: Prior to the arrival of the blood, you did not request for blood?
A: I was asking for blood but there was no blood available.

A: I requested for blood.

Q: From whom did you ask?

Q: From whom?
A: From the surgeon. According to Dr. Zafe there was only 500 cc but still for cross-matching.18

A: From the attending physician, Dr. Realuyo.

From the aforesaid testimony, the trial court ruled that there was negligence on the part of petitioners for their
failure to have the blood ready for transfusion. It was alleged that at 11:15 P.M., the 500 cc of blood was given to
Q: What time was that? Dr. Realuyo by Raymonds parents. At 11:45 P.M., when Dr. Tatad was asking for the blood, 30 minutes had
passed. Yet, the blood was not ready for transfusion as it was still being cross-matched.19 It took another two hours
xxxx before blood was finally transfused to Raymond at 1:40 A.M. of 17 September 1995.

A: 9:30. Again, such is a mistaken conclusion.

xxxx First, the alleged delay in the cross-matching of the blood, if there was any, cannot be attributed as the fault of the
petitioners. The petitioners were never shown to be responsible for such delay. It is highly unreasonable and the

80
height of injustice if petitioners were to be sanctioned for lapses in procedure that does not fall within their duties
and beyond their control.
Second, Dr. Cereno, in his unchallenged testimony, aptly explained the apparent delay in the transfusion of blood
on Raymond before and during the operation.
Before the operation, Dr. Cereno explained that the reason why no blood transfusion was made on Raymond was
because they did not then see the need to administer such transfusion, viz:
Q: Now, you stated in your affidavit that prior to the operation you were informed that there was 500 cc of blood
available and was still to be cross-matched. What time was that when you were informed that 500 cc of blood was
due for crossmatching?
A: I am not sure of the time.
Q: But certainly, you learned of that fact that there was 500 cc of blood, which was due for crossmatching
immediately prior to the operation?
A: Yes, sir.
Q: And the operation was done at 12:15 of September 17?
A: Yes, sir.
Q: And that was the reason why you could not use the blood because it was being crossmatched?
A: No, sir. That was done only for a few minutes. We did not transfuse at that time because there was no
need. There is a necessity to transfuse blood when we saw there is gross bleeding inside the
body. 20(Emphasis supplied)
During the operation, on the other hand, Dr. Cereno was already able to discover that 3,200 cc of blood was
stocked in the thoracic cavity of Raymond due to the puncture in the latters left lung. Even then, however,
immediate blood transfusion was not feasible because:
Q: Now considering the loss of blood suffered by Raymund Olavere, why did you not immediately transfuse blood
to the patient and you waited for 45 minutes to elapse before transfusing the blood?
A: I did not transfuse blood because I had to control the bleeders. If you will transfuse blood just the same
the blood that you transfuse will be lost. After evacuation of blood and there is no more bleeding
Q: It took you 45 minutes to evacuate the blood?
A: The evacuation did not take 45 minutes.
Q: So what was the cause of the delay why you only transfuse blood after 45 minutes?
A: We have to look for some other lesions. It does not mean that when you slice the chest you will see the
lesions already.21
(Emphasis supplied)
Again, the foregoing testimonies of Dr. Cereno went unchallenged or unrebutted. The parents of Raymond were not
able to present any expert witness to dispute the course of action taken by the petitioners.
Causation Not Proven
In medical negligence cases, it is settled that the complainant has the burden of establishing breach of duty on the
part of the doctors or surgeons. It must be proven that such breach of duty has a causal connection to the resulting
death of the patient.22 A verdict in malpractice action cannot be based on speculation or conjecture. Causation must
be proven within a reasonable medical probability based upon competent expert testimony.
The parents of Raymond failed in this respect. Aside from their failure to prove negligence on the part of the
petitioners, they also failed to prove that it was petitioners fault that caused the injury. Their cause stands on the
mere assumption that Raymonds life would have been saved had petitioner surgeons immediately operated on
him; had the blood been cross-matched immediately and had the blood been transfused immediately. There was,
however, no proof presented that Raymonds life would have been saved had those things been done. Those are
mere assumptions and cannot guarantee their desired result. Such cannot be made basis of a decision in this case,
especially considering that the name, reputation and career of petitioners are at stake.
The Court understands the parents grief over their sons death.1wphi1 That notwithstanding, it cannot hold
petitioners liable. It was noted that Raymond, who was a victim of a stabbing incident, had multiple wounds when
brought to the hospital. Upon opening of his thoracic cavity, it was discovered that there was gross bleeding inside
the body. Thus, the need for petitioners to control first what was causing the bleeding. Despite the situation that
evening i.e. numerous patients being brought to the hospital for emergency treatment considering that it was the
height of the Peafrancia Fiesta, it was evident that petitioners exerted earnest efforts to save the life of Raymond.
It was just unfortunate that the loss of his life was not prevented.
In the case of Dr. Cruz v. CA, it was held that "[d]octors are protected by a special law. They are not guarantors of
care. They do not even warrant a good result. They are not insurers against mishaps or unusual consequences.
Furthermore, they are not liable for honest mistake of judgment" 23
This Court affirms the ruling of the CA that the BRMC is not an indispensible party. The core issue as agreed upon
by the parties and stated in the pre-trial order is whether petitioners were negligent in the performance of their
duties. It pertains to acts/omissions of petitioners for which they could be held liable. The cause of action against
petitioners may be prosecuted fully and the determination of their liability may be arrived at without impleading the
hospital where they are employed. As such, the BRMC cannot be considered an indispensible party without whom
no final determination can be had of an action.24
IN THE LIGHT OF THE FOREGOING, the instant Petition for Review on Certiorari is hereby GRANTED. The Court
of Appeals decision dated 21 February 2005 in CA-G.R. CV No. 65800 is hereby REVERSED and SET ASIDE. No
costs.
SO ORDERED.
81
G.R. No. 163753 January 15, 2014
DR. ENCARNACION C. LUMANTAS, M.D., Petitioner,
vs.
HANZ CALAPIZ, REPRESENTED BY HIS PARENTS, HILARIO CALAPIZ, JR. and HERLITA
CALAPIZ, Respondent.
DECISION
BERSAMIN, J.:
The acquittal of the accused does not necessarily mean his absolution from civil liability.
The Case
In this appeal, an accused desires the reversal of the decision promulgated on February 20, 2003, 1 whereby the
Court of Appeals (CA) affirmed the judgment rendered on August 6, 1999 by the Regional Trial Court (RTC),
Branch 13, in Oroquieta City ordering him to pay moral damages despite his acquittal of the crime of reckless
imprudence resulting in serious physical injuries charged against him.2
Antecedents
On January 16, 1995, Spouses Hilario Calapiz, Jr. and Herlita Calapiz brought their 8-year-old son, Hanz Calapiz
(Hanz), to the Misamis Occidental Provincial Hospital, Oroquieta City, for an emergency appendectomy. Hanz was
attended to by the petitioner, who suggested to the parents that Hanz also undergo circumcision at no added cost
to spare him the pain. With the parents consent, the petitioner performed the coronal type of circumcision on Hanz
after his appendectomy. On the following day, Hanz complained of pain in his penis, which exhibited blisters. His
testicles were swollen. The parents noticed that the child urinated abnormally after the petitioner forcibly removed
the catheter, but the petitioner dismissed the abnormality as normal. On January 30, 1995, Hanz was discharged
from the hospital over his parents protestations, and was directed to continue taking antibiotics.
On February 8, 1995, Hanz was confined in a hospital because of the abscess formation between the base and the
shaft of his penis. Presuming that the ulceration was brought about by Hanzs appendicitis, the petitioner referred
him to Dr. Henry Go, an urologist, who diagnosed the boy to have a damaged urethra. Thus, Hanz underwent
cystostomy, and thereafter was operated on three times to repair his damaged urethra.
When his damaged urethra could not be fully repaired and reconstructed, Hanzs parents brought a criminal charge
against the petitioner for reckless imprudence resulting to serious physical injuries. On April 17, 1997, the
information3 was filed in the Municipal Trial Court in Cities of Oroquieta City (MTCC), to which the latter pleaded not
guilty on May 22, 1998.4 Under the order of April 30, 1999, the case was transferred to the RTC pursuant to
Supreme Court Circular No. 11-99.5
At the trial, the Prosecution presented several witnesses, including Dr. Rufino Agudera as an expert witness and as
the physician who had operated on Hanz twice to repair the damaged urethra. Dr. Agudera testified that Hanz had
been diagnosed to have urethral stricture and cavernosal injury left secondary to trauma that had necessitated the
conduct of two operations to strengthen and to lengthen the urethra. Although satisfactorily explaining that the
injury to the urethra had been caused by trauma, Dr. Agudera could not determine the kind of trauma that had
caused the injury.
In his defense, the petitioner denied the charge. He contended that at the time of his examination of Hanz on
January 16, 1995, he had found an accumulation of pus at the vicinity of the appendix two to three inches from the
penis that had required immediate surgical operation; that after performing the appendectomy, he had circumcised
Hanz with his parents consent by using a congo instrument, thereby debunking the parents claim that their child
had been cauterized; that he had then cleared Hanz on January 27, 1995 once his fever had subsided; that he had
found no complications when Hanz returned for his follow up check-up on February 2, 1995; and that the abscess
formation between the base and the shaft of the penis had been brought about by Hanzs burst appendicitis.
Ruling of the RTC
In its decision rendered on August 6, 1999,6 the RTC acquitted the petitioner of the crime charged for insufficiency
of the evidence. It held that the Prosecutions evidence did not show the required standard of care to be observed
by other members of the medical profession under similar circumstances. Nonetheless, the RTC ruled that the
petitioner was liable for moral damages because there was a preponderance of evidence showing that Hanz had
received the injurious trauma from his circumcision by the petitioner. The decision disposed as follows:
WHEREFORE, for insufficiency of evidence, this court renders judgment acquitting the accused, Dr. Encarnacion
Lumantas, of reckless imprudence resulting in serious physical injuries, but ordering him to pay Hanz
Calapiz P50,000.00 as moral damages. No costs.
SO ORDERED.
Ruling of the CA
On appeal, the CA affirmed the RTC,7 sustaining the award of moral damages. It opined that even if the petitioner
had been acquitted of the crime charged, the acquittal did not necessarily mean that he had not incurred civil
liability considering that the Prosecution had preponderantly established the sufferings of Hanz as the result of the
circumcision.
The petitioner moved for reconsideration, but the CA denied the motion on April 28, 2004. 8
Hence, this appeal.
Issue
Whether the CA erred in affirming the petitioners civil liability despite his acquittal of the crime of reckless
imprudence resulting in serious physical injuries.
Ruling
The petition for review lacks merit.
It is axiomatic that every person criminally liable for a felony is also civilly liable. 9 Nevertheless, the acquittal of an
accused of the crime charged does not necessarily extinguish his civil liability. In Manantan v. Court of
Appeals,10the Court elucidates on the two kinds of acquittal recognized by our law as well as on the different effects
of acquittal on the civil liability of the accused, viz:
82
Our law recognizes two kinds of acquittal, with different effects on the civil liability of the accused.1wphi1 First is WHEREFORE, the Court AFFIRMS the decision promulgated on February 20, 2003, with the modification that legal
an acquittal on the ground that the accused is not the author of the act or omission complained of. This instance interest of 6% per annum to start from April 17, 1997 is imposed on the award of:P50,000.00 as moral damages;
closes the door to civil liability, for a person who has been found to be not the perpetrator of any act or omission and ORDERS the petitioner to pay the costs of suit.
cannot and can never be held liable for such act or omission. There being no delict, civil liability ex delicto is out of
the question, and the civil action, if any, which may be instituted must be based on grounds other than the delict SO ORDERED.
complained of. This is the situation contemplated in Rule 111 of the Rules of Court. The second instance is an
acquittal based on reasonable doubt on the guilt of the accused. In this case, even if the guilt of the accused has
not been satisfactorily established, he is not exempt from civil liability which may be proved by preponderance of
evidence only.
G.R. No. 163879 July 30, 2014
The Rules of Court requires that in case of an acquittal, the judgment shall state "whether the evidence of the
prosecution absolutely failed to prove the guilt of the accused or merely failed to prove his guilt beyond reasonable
DR. ANTONIO P. CABUGAO, Petitioner,
doubt. In either case, the judgment shall determine if the act or omission from which the civil liability might arise did
vs.
not exist."11
PEOPLE OF THE PHILIPPINES and SPOUSES RODOLFO M. PALMA and ROSARIO F. PALMA, Respondents.

Conformably with the foregoing, therefore, the acquittal of an accused does not prevent a judgment from still being
x-----------------------x
rendered against him on the civil aspect of the criminal case unless the court finds and declares that the fact from
which the civil liability might arise did not exist.
G.R. No. 165805
Although it found the Prosecutions evidence insufficient to sustain a judgment of conviction against the petitioner
for the crime charged, the RTC did not err in determining and adjudging his civil liability for the same act DR. CLENIO YNZON, Petitioner,
complained of based on mere preponderance of evidence.12 In this connection, the Court reminds that the acquittal vs.
for insufficiency of the evidence did not require that the complainants recovery of civil liability should be through the PEOPLE OF THE PHILIPPINES and SPOUSES RODOLFO M. PALMA AND ROSARIO F.
institution of a separate civil action for that purpose. 13 PALMA, Respondents.

The petitioners contention that he could not be held civilly liable because there was no proof of his negligence
deserves scant consideration. The failure of the Prosecution to prove his criminal negligence with moral certainty
did not forbid a finding against him that there was preponderant evidence of his negligence to hold him civilly
liable.14 With the RTC and the CA both finding that Hanz had sustained the injurious trauma from the hands of the
petitioner on the occasion of or incidental to the circumcision, and that the trauma could have been avoided, the
Court must concur with their uniform findings. In that regard, the Court need not analyze and weigh again the
evidence considered in the proceedings a quo. The Court, by virtue of its not being a trier of facts, should now
accord the highest respect to the factual findings of the trial court as affirmed by the CA in the absence of a clear
showing by the petitioner that such findings were tainted with arbitrariness, capriciousness or palpable error.
DECISION
PERALTA, J.:
Before this Court are appeals via Rule 45 from the Decision 1 dated June 4, 2004 of the Court of Appeals in CA-
G.R. CR No. 27293, affirming the Decision2 dated February 28,2003 of the Regional Trial Court (RTC), convicting
appellant Dr. Antonio P. Cabugao (Dr. Cabugao) and Dr. Clenio Ynzon (Dr. Ynzon) of the crime of Reckless
Imprudence Resulting to Homicide.

Every person is entitled to the physical integrity of his body.1wphi1 Although we have long advocated the view
that any physical injury, like the loss or diminution of the use of any part of ones body, is not equatable to a
pecuniary loss, and is not susceptible of exact monetary estimation, civil damages should be assessed once that
integrity has been violated. The assessment is but an imperfect estimation of the true value of ones body. The
usual practice is to award moral damages for the physical injuries sustained. 15 In Hanzs case, the undesirable
outcome of the circumcision performed by the petitioner forced the young child to endure several other procedures
on his penis in order to repair his damaged urethra. Surely, his physical and moral sufferings properly warranted
the amount of P50,000.00 awarded as moral damages.
Many years have gone by since Hanz suffered the injury. Interest of 6% per annum should then be imposed on the
award as a sincere means of adjusting the value of the award to a level that is not only reasonable but just and
commensurate. Unless we make the adjustment in the permissible manner by prescribing legal interest on the
award, his sufferings would be unduly compounded. For that purpose, the reckoning of interest should be from the
filing of the criminal information on April 17, 1997, the making of the judicial demand for the liability of the petitioner.
The Information3 alleged
That on or about June 17, 2000in the City of Dagupan, Philippines, and within the jurisdiction of this Honorable
Court, the abovenamed accused, DR. ANTONIO P.CABUGAO and DR. CLENIO YNZON, being then the attending
physicians of one RODOLFO PALMA, JR., a minor 10 years old, confederating and acting jointly with one another,
did, then and there, willfully, unlawfully and feloniously fail through negligence, carelessness and imprudence to
perform immediate operation upon their patient, RODOLFO PALMA, JR. of acute appendicitis, when they, the said
physicians, should have been done so considering that examinations conducted upon their patient Rodolfo Palma,
Jr. seriously manifest todo so, causing by such negligence, carelessness, and imprudence the victim, RODOLFO
PALMA JR., to die due to:
"CARDIORESPIRATORY ARREST, METABOLIC ENCEPHALOPATHY, SEPTICEMIA (ACUTE APPENDICITIS),
CEREBRAL ANEURYSM RUPTURED (?)"
As per Certificate of Death issued by accused Dr. Antonio P. Cabugao, to the damage and prejudice of the legal
heirs of said deceased RODOLFO PALMA, JR. and other consequential damages relative thereto.
83
CONTRARY to Article 365, 1st par. of the Revised Penal Code.
Dagupan City, Philippines, January 29, 2001.
Arising from the same events, the Court resolved to consolidate these cases. 4 The facts, as culled from the
records, are as follows:
On June 14, 2000, at around 4 o'clock in the afternoon, ten (10)-year old Rodolfo F. Palma, Jr. (JR) complained of
abdominal pain to his mother, Rosario Palma. At 5 oclock that sameafternoon, Palma's mother and father, Atty.
Rodolfo Palma Sr., brought JR to the clinic of accused Dr. Cabugao. Dr. Cabugao, a general practitioner,
specializing in familymedicine gave medicines for the pain and told Palma's parents to call him up if his stomach
pains continue. Due to persistent abdominal pains, at 4:30 in the early morning of June 15, 2000, they returnedto
Dr. Cabugao, who advised them to bring JR to the Nazareth General Hospital in Dagupan City, for confinement. JR
was admitted at the said hospital at 5:30 in the morning. 5
Blood samples were taken from JR for laboratory testing. The complete blood count conveyed the following result:
wbc 27.80 x 10 9/L; lymphocytes 0.10 and neutrophils 0.90. Diagnostic ultrasound was likewise conducted on
the patient's lower abdomen by radiologist, Dr. Ricky V. Querubin, with the following findings:
Normal liver, bile ducts, gallbladder, pancreas, spleen, kidneys and urinary bladder.
There is no free peritoneal fluid.
There is localized tenderness in the paraumbilical region, more so in the supra and right paraumbilical areas.
There is a vague elongated hypoechoic focus in the right periumbilical region roughly about 47 x 18 mm
surrounded by undistended gas-filled bowels. This is suggestive of an inflammatory process wherein appendiceal
or periappendiceal pathology cannot be excluded. Clinical correlation is essential." 6
Dr. Cabugao did a rectal examination noting the following: "rectal: good sphincter, negative tenderness, negative
mass." The initial impression was Acute Appendicitis,7 and hence, he referred the case to his co-accused, Dr.
Ynzon, a surgeon.8 In the later part of the morning of June 15, 2000, Dr. Ynzon went to the hospital and readthe
CBC and ultrasound results. The administration of massive antibiotics and pain reliever to JRwere ordered.
Thereafter, JR was placed on observation for twenty-four (24) hours.
In the morning of June 16, 2000, JR complained again of abdominal pain and his parents noticeda swelling in his
scrotum. In the afternoon of the same day, JR vomitted out greenish stuff three (3) times and had watery bowels
also three (3) times. The nurses on-duty relayed JR's condition to Dr. Ynzon who merely gaveorders via
telephone.9 Accused continued medications to alleviate JR's abdominal spasms and diarrhea. By midnight, JR
again vomitted twice, had loose bowel movements and was unable to sleep. The following morning, June 17,2000,
JR's condition worsened, he had a running fever of 38C. JR's fever remained uncontrolled and he became
unconscious, he was given Aeknil (1 ampule) and Valium (1 ampule). JR's condition continued to deteriorate that
by 2 o'clock in the afternoon, JR's temperature soared to 42C, had convulsions and finally died.
The Death Certificate10 dated June 19, 2000 prepared by Dr. Cabugao indicated the following causes of death:
Immediate cause: CARDIORESPIRATORY ARREST
Antecedent cause: METABOLIC ENCEPHALOPATHY
Underlying cause: SEPTICEMIA (ACUTE APPENDICITIS)
Other significant conditionscontributing to death:
CEREBRAL ANEURYSM RUPTURED (?)
No post-mortem examination was conducted on JR. On February 1, 2001, an Information was filed against accused
for reckless imprudence resulting to homicide. At their arraignment, both accused, duly assisted by counsel,
pleaded not guilty to the charge.
On February 28, 2003, in convicting both the accused, the trial court found the following circumstances as sufficient
basis to conclude that accused were indeed negligent in the performance of their duties:
It is unquestionable that JR was under the medical care of the accused from the time of his admission for
confinement at the Nazareth General Hospital until his death. Upon his admission, the initial working diagnosis was
to consider acute appendicitis. To assist the accused in the consideration of acute appendicitis, Dr. Cabugao
requested for a complete blood count (CBC) and a diagnostic ultrasound on JR. The findings of the CBC and
ultrasound showed that an inflammatory process or infection was going on inside the body of JR. Said inflammatory
process was happening in the periumbilical region where the appendix could be located. The initial diagnosis of
acute appendicitis appears to be a distinct possibility. x x x.
Dr. Ynzon ordered medications to treat the symptoms being manifested by JR. Thereafter, he ordered that JR be
observed for 24 hours. However, the accused, as the attending physicians, did not personally monitor JR in order to
check on subtle changes that may occur. Rather, they left the monitoring and actual observation to resident
physicians who are just on residency training and in doing so, they substituted their own expertise, skill and
competence with those of physicians who are merely new doctors still on training. Not having personally observed
JR during this 24-hour critical period of observation, the accused relinquished their duty and thereby were unable to
give the proper and correct evaluation as to the real condition of JR. In situations where massive infection is going
on as shown by the aggressive medication of antibiotics, the condition of the patient is serious which necessitated
personal, not delegated, attention of attending physicians, namely JR and the accused in this case.
xxxx
Throughout the course of the hospitalization and treatment of JR, the accused failed to address the acute
appendicitis which was the initial diagnosis. They did not take steps to find out if indeed acute appendicitis was
what was causing the massive infection that was ongoing inside the body of JR even when the inflammatory
process was located at the paraumbilical region where the appendix can be located. x x x
There may have been other diseases but the records do not show that the accused took steps to find outwhat
disease exactly was plaguing JR. It was their duty to find out the disease causing the health problem of JR, but they
did not perform any process of elimination. Appendicitis, according to expert testimonies, could be eliminated only
by surgery but no surgery was done by the accused. But the accused could not have found out the real disease of
JR because they were treating merely and exclusively the symptoms by means of the different medications to
arrest the manifested symptoms. In fact, by treating the symptoms alone, the accused were recklessly and
wantonly ignoring the same as signs of the graver health problem of JR. This gross negligence on the part of the
accused allowed the infection to spread inside the body of JR unabated. The infection obviously spread so fastand
was so massive that within a period of only two and a half (2 ) days from the day of admission to the hospital on
June 15, 2000, JR who was otherwise healthy died [of] Septicemia (Acute Appendicitis) on June 17, 2000. 11
84
On June 4, 2004, in affirming the accused' conviction, the Court of Appeals gave similar observations, to wit: III

The foregoing expert testimony clearly revealed such want of reasonable skill and care on the part of JR's attending WHETHER PETITIONER DR. CABUGAO IS A GENERAL PRACTITIONER (NOT A SURGEON) AND HAVE
physicians, appellants Dr. Cabugao and Dr. Ynzon in neglecting to monitor effectively and sufficiently the EXCLUDED SURGERY FROM THE LIMITS OFHIS PRACTICE, AND IT WAS NOT AND NEVER HIS DUTY TO
developments/changes during the observation period and act upon the situation after said 24-hour period when his OPERATE THE PATIENT RODOLFO PALMA JR., THAT WAS WHY HE REFERRED SUBJECT PATIENT TO A
abdominal pain subsisted, his condition even worsened with the appearance of more serious symptoms of nausea, SURGEON, DR. CLENIO YNZON;
vomiting and diarrhea. Considering the brief visit only made on regular rounds, the records clearly show such gross
negligence in failing to take appropriate steps to determine the real cause of JR's abdominal pain so that the crucial
IV
decision to perform surgery (appendectomy) had even been ruled out precisely because of the inexcusable neglect
to undertake suchefficient diagnosis by process of elimination, as correctly pointed out by the trial court. As has
been succinctly emphasized by Dr. Mateo, acute appendicitis was the working diagnosis, and with the emergence WHETHER THE DEFENSE NEVER STATED THAT THERE IS GUARANTEE THAT DOING SURGERY WOULD
of symptoms after the 24-hour observation (high fever, vomiting, diarrhea) still, appellants ruled out surgery, not HAVE SAVED THE PATIENT;
even considering exploratory laparoscopy. Dr. Mateo also expressed the opinion that the decision to operate could
have been made after the result of the ultrasound test, considering that acute appendicitis was the initial diagnosis V
by Dr. Cabugao after he had conducted a rectal examination.
WHETHER THE WITNESSES FOR THE PROSECUTION INCLUDING PROSECUTION'S EXPERT WITNESSES
Medical records buttress the trial court's finding that in treating JR, appellants have demonstrated indifference and EVER DECLARED/TESTIFIED THAT PETITIONER DR. CABUGAO HAD THE DUTY TO PERFORM IMMEDIATE
neglect of the patient's condition as a serious case. Indeed, appendicitis remains a clinical emergencyand a OPERATION ON RODOLFO PALMA, JR., AND THEY FAILED TO STATE/SHOW THAT THE PROXIMATE
surgical disease, as correctly underscored by Dr. Mateo, a practicing surgeon who has already performed over a CAUSE OF DEATH OF JR WAS ACUTE APPENDICITIS;
thousand appendectomy. In fact, appendectomy is the only rational therapy for acute appendicitis; it avoids clinical
deterioration and may avoid chronic or recurrent appendicitis. Although difficult, prompt recognition and immediate
treatment of the disease prevent complications. Under the factual circumstances, the inaction, neglect and VI
indifference of appellants who, after the day of admission and after being apprised of the ongoing infection from the
CBC and initial diagnosis as acute appendicitis from rectal examination and ultrasound testand only briefly visited WHETHER THE EXPERT WITNESSES PRESENTED BY THE PROSECUTION EVER QUESTIONED THE
JR once during regular rounds and gave medication orders by telephone constitutes gross negligenceleading to MANAGEMENT AND CARE APPLIED BY PETITIONER DR. CABUGAO;
the continued deterioration of the patient, his infection having spread in sofast a pace that he died within just two
and a half (2 ) days stay inthe hospital. Authorities state that if the clinical picture is unclear a short period of 4 to
6 hours of watchful waiting and a CT scan may improve diagnostic accuracy and help to hasten diagnosis.Even VII
assuming that JR's case had an atypical presentation in view of the location of his appendix, laboratory tests could
have helped to confirm diagnosis, as Dr. Mateo opined thatthe possibility of JR having a retrocecal appendicitis WHETHER THE EXPERT WITNESSES PRESENTED BY THE DEFENSE ARE UNANIMOUS IN APPROVING
should have been a strong consideration. Lamentably, however, as found by the trial court, appellants had not THE METHOD OF TREATMENT APPLIED BY BOTH ACCUSED DOCTORS ON SUBJECT PATIENT, AND THEY
taken steps towards correct diagnosis and demonstrated laxity even when JR was already running a high fever in DECLARED/AFFIRMED THAT THEY WOULD FIRST PLACE SUBJECT THE PATIENT UNDER OBSERVATION,
the morning of June 17, 2000 and continued vomiting with diarrhea, his abdominal pain becoming more intense. AND WOULD NOT PERFORM IMMEDIATE OPERATION;
This is the reason why private complainants were not even apprised of the progress of appellants' diagnosis
appellants have nothing to report because they did nothing towards the end and merely gave medications to
VIII
address the symptoms.12

Thus, these appeals brought beforethis Court raising the following arguments:
I
WHETHER THE CAUSE OF ACCUSATION AS CONTAINED IN THE INFORMATION IS "FAILURE TO
PERFORM IMMEDIATE OPERATION UPON THE PATIENT ROFOLFO PALMA JR. OF ACUTE APPENDICITIS;
II
WHETHER THE SUBJECT INFORMATION APPEARS TO HAVE ACCUSED BOTH ACCUSED DOCTORS OF
CONSPIRACY AND THE APPEALED DECISION SEEMS TO HAVE TREATED BOTH ACCUSED DOCTORS TO
BE IN CONSPIRACY;
WHETHER THE CONVICTION OF PETITIONER DR. YNZON WAS ESTABLISHED WITH THE REQUIRED
QUANTUM OF PROOF BEYOND REASONABLE DOUBT THAT THE PATIENT WAS SPECIFICALLY
SUFFERING FROM AND DIED OF ACUTE APPENDICITIS; and
IX
WHETHER THE FAILURE TO CONDUCT THE SPECIFIC SURGICAL OPERATION KNOWN AS
APPENDECTOMY CONSTITUTED CRIMINAL NEGLIGENCE.
In a nutshell, the petition brought before this Court raises the issue of whether or not petitioners' conviction of the
crime of reckless imprudence resulting in homicide, arising from analleged medical malpractice, is supported by the
evidence on record.

85
Worth noting is that the assigned errors are actually factual in nature, which as a general rule, findings of factof the A That means that infection would spread throughout the body, sir.
trial court and the Court of Appeals are binding and conclusiveupon this Court, and we will not normally disturb
such factual findings unless the findings of the court are palpably unsupported by the evidence on record or unless Q If unchecked doctor, what will happen?
the judgment itself is based on misapprehension of facts. Inthe instant case, we find the need to make certain
exception.
A It will result to death.17
AS TO DR. YNZON'S LIABILITY:
xxxx
Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act from which material
damage results by reason of an inexcusable lack of precautionon the part of the person performing or failing to Q And what would have you doneif you entertain other considerations from the time the patient was admitted?
perform such act.13 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 bewithout malice; (4) that material damage results A From the time the patient was admitted until the report of the sonologist, I would have made a decision by then.
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. 14 Q And when to decide the surgery would it be a particular exact time, would it be the same for all surgeons?

With respect to Dr. Ynzon, all the requisites of the offense have been clearly established by the evidence on record. A If you are asking acute appendicitis, it would be about 24 hours because acute appendicitis is a 24-hour disease,
The court a quoand the appellate court were one in concluding that Dr. Ynzon failed to observe the required sir.
standard of care expected from doctors.
Q. And would it be correct to say that it depends on the changes on the condition of the patient?
In the instant case, it was sufficiently established that to prevent certain death, it was necessary to perform surgery
on JR immediately. Even the prosecutions own expert witness, Dr. Antonio Mateo, 15 testified during cross- A. Yes, sir.
examination that he would perform surgery on JR:
Q. So, are you saying more than 24 hours when there are changes?
ATTY. CASTRO:
A. If there are changes in the patient pointing towards appendicitis then you have to decide right there and then, sir.
Q. Given these data soft non-tender abdomen, ambulatory, watery diarrhea, Exhibit C which is the ultrasound
result, with that laboratory would you operate the patient?
Q. So if there are changes in the patient pointing to appendicitis?

A Yes, I would do surgery.

A. It depends now on what you are trying to wait for in the observation period, sir.

Q And you should have done surgery with this particular case?"
Q. So precisely if the change is a condition which bring you in doubt that there is something else other than
appendicitis, would you extend over a period of 24 hours?
16
A Yes, sir.
A. It depends on the emergent development, sir.
xxxx
Q. That is the point, if you are the attending physician and there is a change not pointing to appendicitis, would you
COURT: extend over a period of 24 hours?

Q You stated a while ago doctor thatyou are going to [do] surgery to the patient, why doctor, if you are notgoing to A. In 24 hours you have to decide, sir.
do surgery, what will happen?
xxxx
A If this would be appendicitis, the usual progress would be that it would be ruptured and generalized peritonitis
and eventually septicemia, sir.
Q. And that is based on the assessment of the attending physician?

Q What do you mean by that doctor?

A. Yes, sir.18

86
Dr. Mateo further testified on cross-examination:
ATTY. CASTRO:
Q: So you will know yourself, as far as the record is concerned, because if you will agree with me, you did not even
touch the patient?
A. Yes, I based my opinion on what is put on record, sir. The records show that after the observation period, the
abdominal pain is still there plus there are already other signs and symptoms which are not seen or noted.
Q. But insofar as you yourself not having touched the abdomen of the patient, would you give a comment on that?
A. Yes, based on the record, after 24 hours of observation, the pain apparently was still there and there was more
vomiting and there was diarrhea. In my personal opinion, I think the condition of the patient was deteriorating.
Q. Even though you have not touched the patient?
A. I based on what was on the record, sir.19
From the foregoing, it is clear that if JRs condition remained unchecked it would ultimately result in his death, as
what actually happened in the present case. Another expert witness for the defense, Dr. Vivencio Villaflor, Jr.
testified on direct examination that he would perform a personal and thorough physical examination of the patient
as frequent as every 4 to 6 hours, to wit:
ATTY. CASTRO:
Q. As an expert doctor, if you were faced with a history of abdominal pain with nausea, vomiting, fever, anurecia
(sic), elevated white blood cell count, physical examination of a positive psoas sign, observation of the sonologist of
abdominal tenderness and the ultrasound findings of the probability of appendiceal (sic) pathology, what will you do
if you have faced these problems, Doctor?
A. I will examine the patient thoroughly and it will depend on my physical examination and that isprobably every 4 to
6 hours, sir.20
On cross-examination, Dr. Villaflor affirmed:
Cross Exam. By Atty. Marteja:
Q. x x x However, there are corrections and admissions made at that time, your Honor, do I understand thatT/C
does not mean ruled out but rather to consider the matter?
A. Yes, now that I have seen the records of the patient, it says here, impression and T/C means to consider the
appendicitis.
Q. Isn't it that it is worth then to say that the initial working diagnosis on Rodolfo Palma, Jr., otherwise known as JR,
to whom I shall now refer to as JR, the primary consideration then is acute appendicitis, is that correct to say
Doctor?
A. I think so, that is the impression.
Q. x x x Now if it is to be considered as the primary consideration in the initial working diagnosis, isn't it a fact that it
has tobe ruled out in order to consider it as not the disease of JR?
A. Yes. Sir.
Q. Isn't it a fact thatto rule out acute appendicitis as not the disease of JR, surgery or operation must be done, isn't
it Doctor?
A. You have to correlate all the findings.
Q. Is it yes or no, Doctor?
A. Yes.
Q. So, you are saying then that in order to rule out acute appendicitis there must be an operation, that is right
Doctor?
A. No, sir. If your diagnosis is toreally determine if it is an acute appendicitis, you have to operate. 21
xxxx
Q. Now Doctor, considering the infection, considering that there was a [symptom] that causes pain, considering that
JR likewise was feverish and that he was vomiting, does that not show a disease of acute appendicitis Doctor?
A. Its possible.
Q. So that if that is possible, are we getting the impression then Doctor what you have earlier mentioned that the
only way to rule out the suspect which is acute appendicitis is by surgery, you have said that earlier Doctor, I just
want any confirmation of it?
A. Yes, sir.22
Verily, 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. The deference of courts to the expert opinions of
qualified physicians stems from its realization that the latter possess unusual technical skills which laymen in most
instances are incapable of intelligently evaluating. 23 From the testimonies of the expert witnesses presented, it was
irrefutably proven that Dr. Ynzon failed to practice that degree of skill and care required in the treatment of his
patient.
As correctly observed by the appellate court, Dr. Ynzon revealed want of reasonable skill and care in attending to
the needs of JR by neglecting to monitor effectively the developmentsand changes on JR's condition during the
observation period, and to act upon the situation after the 24-hour period when his abdominal pain persisted and
his condition worsened. Lamentable, Dr. Ynzon appeared to have visited JRbriefly only during regular rounds in the
mornings. He was not there during the crucial times on June 16, 2000 when JR's condition started to deteriorate
until JR's death. As the attending surgeon, he should be primarily responsible in monitoring the condition of JR, as
87
he is in the best position considering his skills and experience to know if the patient's condition had deteriorated. A. If there is a lingering doubt, inshort period of observation of 18-24 hours can be allowed provided that there
While the resident-doctors-onduty could likewise monitor the patientscondition, he is the one directly responsible would be close monitoring of the patient, sir.
for the patient as the attending surgeon. Indeed, it is reckless and gross negligence of duty to relegate his personal
responsibility to observe the condition of the patient. Again, acute appendicitis was the working diagnosis, and with
Q. Would you please tell us who would be doing the monitoring doctor?
the emergence of graver symptoms after the 24-hour observation, Dr. Ynzon ruled out surgery for no apparent
reason. We, likewise, note that the records are devoid of showing of any reasonable cause which would lead Dr.
Ynzon tooverrule appendectomy despite the initial diagnosis of appendicitis. Neitherwas there any showing that he A. The best person should be the first examiner, the best surgeon, sir.
was entertaining another diagnosis nor he took appropriate steps towards another diagnosis.
Q. So that would you say that it is incumbent on the surgeon attending to the case to have been the one to observe
Among the elements constitutive of reckless imprudence, what perhaps is most central to a finding of guilt is the within the period of observation?
conclusive determination that the accused has exhibited, by his voluntary act without malice, an inexcusable lack of
precaution. It is that which supplies the criminal intent so indispensable as tobring an act of mere negligence and A. Yes, because he will be in the best position to observe the sudden changes in the condition of the patient, sir.
imprudence under the operation of the penal law. This is because a conscious indifference to the consequences of
the conduct is all that is required from the standpoint of the frame of mind of the accused.24Quasioffenses penalize
the mental attitudeor condition behind the act, the dangerous recklessness, the lack of care or foresight, the Q. And how often would in your experience doctor, how often would the surgeon re-assist (sic) the condition of the
"imprudencia punible," unlike willful offenses which punish the intentional criminal act. 25 This is precisely where this patient during the period of observation?
Court found Dr. Ynzon to be guilty of - his seemingly indifference to the deteriorating condition of JR that he as a
consequence, failed to exercise lack of precaution which eventually led to JR's death. A. Most foreign authors would recommend every four (4) hours, some centers will recommend hourly or every two
hours but here in the Philippines, would recommend for 4 to 6 hours, sir. 28
To be sure, 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 Dr. Cabugaos supervision does not cease upon his endorsement of his patient to the surgeon. Here, Dr. Cabugao
standing under similar circumstances bearing in mind the advanced state of the profession at the time of treatment has shown to have exerted all efforts to monitor his patient and under these circumstances he did not have any
or the present state of medical science. In accepting a case, a doctor in effect represents that, having the needed cause to doubt Dr. Ynzons competence and diligence. Expert testimonies have been offered to prove the
training and skill possessed by physicians and surgeons practicing in the same field, he will employ such training, circumstances surrounding the case of JR and the need to perform an operation. Defense witness, Dr. Villaflor, on
care and skill in the treatment of his patients. He, therefore, has a duty to use at least the same level of care that cross examination testified, to wit:
any other reasonably competent doctor would use to treat a condition under the same circumstances. 26 Sadly, Dr.
Ynzon did not display that degree of care and precaution demanded by the circumstances.
Q. Isn't it a fact that torule out acute appendicitis as notthe disease of JR, surgery or operation mustbe done, isn't it
Doctor?
AS TO DR. CABUGAO'S LIABILITY:
A. You have to [correlate] all the findings.
Every criminal conviction requires of the prosecution to prove two things the fact of the crime, i.e., the presence
of all the elements of the crime for which the accused stands charged, and the fact that the accused is the
perpetrator of the crime. Based on the above disquisitions, however, the prosecution failed to prove these two Q. Is it yes or no, Doctor?
things. The Court is not convinced with moral certainty that Dr. Cabugao isguilty of reckless imprudence as the
elements thereof were not proven by the prosecution beyond a reasonable doubt. A. Yes.

Both the trial court and the appellate court bewail the failure to perform appendectomy on JR, or the failure to Q. So, you are saying then that in order to rule out acute appendicitis there must be an operation, that is right
determine the source of infection which caused the deterioration of JR's condition. However, a review of the Doctor?
records fail to show that Dr. Cabugao is in any position to perform the required appendectomy.
A. No, sir. If your diagnosis is to really determine if it is an acute appendicitis, you have to operate. 29
Immediately apparent from a review of the records of this case is the fact that Dr. Cabugao is not a surgeon,but a
general practitioner specializing in family medicine; 27 thus, even if he wanted to, he cannot do an operation, much
xxxx
less an appendectomy on JR. It is precisely for this reason why he referred JR to Dr. Ynzon after he suspected
appendicitis. Dr. Mateo, the prosecutions expert witness, emphasized the role of the surgeon during direct
examination, to wit: Q. Now Doctor, considering the infection, considering that there was a [symptom] that causes pain, considering that
JR likewise was feverish and that he was vomitting, does that not show a disease of acute appendicitis Doctor?
ATTY. MARTEJA:
A. Its possible.
Q. You had mentioned that under this circumstances and condition, you have mentioned that surgery is the
solution, would you have allowed then a 24 hour observation?

88
Q. So that if that is possible, are we getting the impression then Doctor what you have earlier mentioned that the
only way to rule out the suspect which is acute appendicitis is by surgery, you have said that earlier Doctor, I just
want any confirmation of it?
A. Yes, sir.30
Neither do we find evidence that Dr. Cabugao has been negligent or lacked the necessary precaution in his
performance of his duty as a family doctor. On the contrary, a perusal ofthe medical records would show that during
the 24-hour monitoring on JR, it was Dr. Cabugao who frequently made orders on the administration of antibiotics
and pain relievers. There was also repetitive instructions from Dr. Cabugao to refer JR to Dr. Ynzon as it appeared
that he is suspecting appendicitis. The referral of JR to Dr. Ynzon, a surgeon, is actually an exercise of precaution
as he knew that appendicitis is not within his scope of expertise. This clearly showed that he employed the best of
his knowledge and skill in attending to JR's condition, even after the referral of JR to Dr. Ynzon. To be sure, the
calculated assessment of Dr. Cabugao to refer JRto a surgeon who has sufficient training and experience to handle
JRs case belies the finding that he displayed inexcusable lack of precaution in handling his patient.31
We likewise note that Dr. Cabugao was out of town when JR's condition began to deteriorate. Even so, before he
left, he made endorsement and notified the resident-doctor and nurses-on-duty that he will be on leave.
Moreover, while both appeared to be the attending physicians of JR during his hospital confinement, it cannot be
said that the finding of guilt on Dr. Ynzon necessitates the same finding on the co-accused Dr. Cabugao.
Conspiracy is inconsistent with the idea of a felony committed by means of culpa. 32 Thus, the accused-doctors to
be found guilty of reckless imprudence resulting in homicide, it must be shown that both accused-doctors
demonstratedan act executed without malice or criminal intent but with lack of foresight, carelessness, or
negligence. Noteworthy, the evidence on record clearly points to the reckless imprudence of Dr. Ynzon; however,
the same cannot be said in Dr. Cabugao's case.
AS TO CIVIL LIABILITY
While this case is pending appeal, counsel for petitioner Dr. Ynzon informed the Court that the latter died on
December 23, 2011 due to "multiorgan failure" as evidenced by a copy of death certificate. 33 Thus, the effect of
death, pending appeal of his conviction of petitioner Dr. Ynzon with regard to his criminal and pecuniary liabilities
should be in accordance to People v. Bayotas, 34 wherein the Court laid down the rules in case the accused dies
prior to final judgment:
1. Death of the accused pending appeal of his conviction extinguishes his criminal liability as well as the
civil liability based solely thereon. As opined by Justice Regalado, in this regard, "the death of the
accused prior to final judgment terminates his criminal liability and only the civil liability directly arising
from and based solely on the offense committed, i.e.,civil liability ex delictoin senso strictiore."
2. Corollarily, the claim for civil liability survives notwithstanding the death of accused, if the same may
also be predicated on a source of obligation other than delict. Article 1157 of the Civil Code enumerates
these other sources of obligation fromwhich the civil liability may arise as a result of the same act or
omission:
a) Law
b) Contracts
c) Quasi-contracts
d) x x x x x x x x x
e) Quasi-delicts
3. Where the civil liability survives, as explained in Number 2 above, an action for recovery therefor may
be pursued but only by way of filing a separate civil action and subject to Section 1, Rule 111 of the 1985
Rules on Criminal Procedure as amended. This separate civil action may be enforced either againstthe
executor/administrator or the estate of the accused, depending on the source of obligation upon which the
same is based as explained above.
4. Finally, the private offended party need not fear a forfeiture of his right to file this separate civil action
by prescription, in cases where during the prosecution of the criminal action and prior to its extinction, the
private-offended party instituted together therewith the civil action. In such case, the statute of
limitationson the civil liability is deemed interrupted during the pendency of the criminal case, conformably
with provisions of Article 1155 of the Civil Code, that should thereby avoid any apprehension on a
possible privation of right by prescription. 35
In view of the foregoing, it is clear that the death of the accused Dr. Ynzon pending appeal of his conviction
extinguishes his criminal liability. However, the recovery of civil liability subsists as the same is not based on
delictbut by contract and the reckless imprudence he was guilty of under Article 365 of the Revised Penal
Code.1wphi1 For this reason, a separate civil action may be enforced either against the executor/administrator or
the estate of the accused, depending on the source of obligation upon which the same is based, 36 and in
accordance with Section 4, Rule 111 of the Rules on Criminal Procedure, we quote:
Sec. 4. Effect of death on civil actions. The death of the accused after arraignment and during the pendency of
the criminal action shall extinguish the civil liability arising from the delict. However, the independent civil action
instituted under section 3 of this Rule or which thereafter is instituted to enforce liability arising from other sources
of obligation may be continued against the estate or legal representative of the accused after proper substitution or
against said estate, as the case may be. The heirs of the accused may besubstituted for the deceased without
requiring the appointment of an executor or administrator and the court may appoint a guardian ad litem for the
minor heirs.
The court shall forthwith order said legal representative or representatives to appear and be substituted within a
period of thirty (30) days from notice.
A final judgment entered in favor of the offended party shall be enforced in the manner especially provided in these
rules for prosecuting claims against the estate of the deceased.
If the accused dies before arraignment, the case shall be dismissed without prejudice to any civil action the
offended party may file against the estate of the deceased. (Emphases ours)
In sum, upon the extinction of the criminal liability and the offended party desires to recover damages from the
same act or omission complained of, the party may file a separate civil action based on the other sources of
obligation in accordance with Section 4, Rule 111. 37 If the same act or omission complained of arises from quasi-
delict,as in this case, a separate civil action must be filed against the executor or administrator of the estate of the
accused, pursuant to Section 1, Rule 87 of the Rules of Court: 38
89
Section 1. Actions which may and which may not be brought against executor or administrator. No action upon a DRA. RUBY SANGA-MIRANDA, Petitioner,
claim for the recovery of money or debtor interest thereon shall be commenced against the executor or vs.
administrator; but to recover real or personal property, or an interest therein, from the estate, or to enforce a lien NELSON CORTEJO, Respondent.
thereon, and actions to recover damages for an injury to person or property, real or personal, may be commenced
against him. (Emphases ours) x-----------------------x

Conversely, if the offended party desires to recover damages from the same act or omission complained of arising G.R. No. 171228
from contract, the filing of a separate civil action must be filed against the estate, pursuant to Section 5, Rule 86 of
the Rules of Court, to wit:
SAN JUAN DEDIOS HOSPITAL, Petitioner,
vs.
Section 5. Claims which must be filed under the notice. If not filed, barred; exceptions. All claims for money NELSON CORTEJO, Respondent.
against the decent, arising from contract, express or implied, whether the same be due, not due, or contingent, all
claims for funeral expenses and expense for the last sickness of the decedent, and judgment for money against the
decent, must be filed within the time limited in the notice; otherwise they are barred forever, except that they may DECISION
be set forth as counterclaims in any action that the executor or administrator may bring against the claimants.
Where an executor or administrator commencesan action, or prosecutes an action already commenced by the BRION, J.:
deceased in his lifetime, the debtor may set forth by answer the claims he has against the decedent, instead of
presenting them independently to the court as herein provided, and mutual claims may be set off against each
other in such action; and if final judgment is rendered in favor of the defendant, the amount so determined shall be We resolve the three (3) consolidated petitions for review on Certiorari 1 involving medical negligence, commonly
considered the true balance against the estate, as though the claim had been presented directly beforethe court in assailing the October 29, 2004 decision2 and the January 12, 2006 resolution3 of the Court of Appeals (CA) in CA-
the administration proceedings. Claims not yet due, or contingent, may be approved at their present value. G.R. CV No. 56400. This CA decision affirmed en totothe ruling of the Regional Trial Court (RTC), Branch 134,
Makati City.
As a final note, we reiterate thatthe policy against double recovery requires that only one action be maintained for
the same act or omission whether the action is brought against the executor or administrator, or the estate. 39 The The RTC awarded Nelson Cortejo (respondent) damages in the total amount of P595,000.00, for the wrongful
heirs of JR must choose which of the available causes of action for damages they will bring. death of his son allegedly due to the medical negligence of the petitioning doctors and the hospital.

WHEREFORE, premises considered, petitioner DR. ANTONIO P. CABUGAO is hereby ACQUITTEDof the crime of Factual Antecedents
reckless imprudence resulting to homicide.
The common factual antecedents are briefly summarized below.
Due to the death of accused Dr. Clenio Ynzon prior to the disposition of this case, his criminal liability is
extinguished; however, his civil liability subsists. A separate civil action may be filed either against the On April 22, 1988, at about 11:30 in the morning, Mrs. Jesusa Cortejo brought her 11-year old son, Edmer Cortejo
executor/administrator, or the estateof Dr. Ynzon, depending on the source of obligation upon which the same are (Edmer), to the Emergency Room of the San Juan de Dios Hospital (SJDH) because of difficulty in breathing, chest
based. pain, stomach pain, and fever.4

SO ORDERED. Dr. Ramoncito Livelo (Dr. Livelo) initially attended to and examined Edmer. In her testimony, Mrs. Cortejo narrated
that in the morning of April 20, 1988, Edmer had developed a slight fever that lasted for one day; a few hours upon
discovery, she brought Edmer to their family doctor; and two hours after administering medications, Edmers fever
had subsided.5

G.R. No. 171127 March 11, 2015

After taking Edmers medical history, Dr. Livelo took his vital signs, body temperature, and blood pressure. 6 Based
on these initial examinations and the chest x-ray test that followed, Dr. Livelo diagnosed Edmer with
NOEL CASUMPANG, RUBY SANGA-MIRANDA and SAN JUAN DEDIOS HOSPITAL, Petitioners, "bronchopneumonia.7 " Edmers blood was also taken for testing, typing, and for purposes of administering
vs. antibiotics. Afterwards, Dr. Livelo gave Edmer an antibiotic medication to lessen his fever and to loosen his phlegm.
NELSON CORTEJO, Respondent.
Mrs. Cortejo did not know any doctor at SJDH. She used her Fortune Care card and was referred to an accredited
x-----------------------x Fortune Care coordinator, who was then out of town. She was thereafter assigned to Dr. Noel Casumpang (Dr.
Casumpang), a pediatrician also accredited with Fortune Care.8
G.R. No. 171217
At 5:30 in the afternoon of the same day, Dr. Casumpang for the first time examined Edmer in his room. Using only
a stethoscope, he confirmed the initial diagnosis of "Bronchopneumonia."9
90
At that moment, Mrs. Cortejo recalled entertaining doubts on the doctors diagnosis. She immediately advised Dr.
Casumpang that Edmer had a high fever, and had no colds or cough10 but Dr. Casumpang merely told her that her
sons "blood pressure is just being active,"11 and remarked that "thats the usual bronchopneumonia, no colds, no
phlegm."12 Dr. Casumpang next visited and examined Edmer at 9:00 in the morning the following day. 13 Still
suspicious about his sons illness, Mrs. Cortejo again called Dr. Casumpangs attention and stated that Edmer had
a fever, throat irritation, as well as chest and stomach pain. Mrs. Cortejo also alerted Dr. Casumpang about the
traces of blood in Edmers sputum. Despite these pieces of information, however, Dr. Casumpang simply nodded,
inquired if Edmer has an asthma, and reassured Mrs. Cortejo that Edmers illness is bronchopneumonia. 14
At around 11:30 in the morning of April 23, 1988, Edmer vomited "phlegm with blood streak" 15 prompting the
respondent (Edmers father) to request for a doctor at the nurses station. 16 Forty-five minutes later, Dr. Ruby
Miranda-Sanga (Dr. Sanga), one of the resident physicians of SJDH, arrived. She claimed that although aware that
Edmer had vomited "phlegm with blood streak," she failed to examine the blood specimen because the respondent
washed it away. She then advised the respondent to preserve the specimen for examination.
Thereafter, Dr. Sanga conducted a physical check-up covering Edmers head, eyes, nose, throat, lungs, skin and
abdomen; and found that Edmer had a low-grade non-continuing fever, and rashes that were not typical of dengue
fever.17 Her medical findings state:
the patients rapid breathing and then the lung showed sibilant and the patients nose is flaring which is a sign that
the patient is in respiratory distress; the abdomen has negative finding; the patient has low grade fever and not
continuing; and the rashes in the patients skin were not
"Hermans Rash" and not typical of dengue fever. 18
At 3:00 in the afternoon, Edmer once again vomited blood. Upon seeing Dr. Sanga, the respondent showed her
Edmers blood specimen, and reported that Edmer had complained of severe stomach pain and difficulty in moving
his right leg.19
Dr. Sanga then examined Edmers "sputum with blood" and noted that he was bleeding. Suspecting that he could
be afflicted with dengue, she inserted a plastic tube in his nose, drained the liquid from his stomach with ice cold
normal saline solution, and gave an instruction not to pull out the tube, or give the patient any oral medication.
Dr. Sanga thereafter conducted a tourniquet test, which turned out to be negative. 20 She likewise ordered the
monitoring of the patients blood pressure and some blood tests. Edmers blood pressure was later found to be
normal.21
At 4:40 in the afternoon, Dr. Sanga called up Dr. Casumpang at his clinic and told him about Edmers
condition.22Upon being informed, Dr. Casumpang ordered several procedures done including: hematocrit,
hemoglobin, blood typing, blood transfusion and tourniquet tests.
The blood test results came at about 6:00 in the evening.
Dr. Sanga advised Edmers parents that the blood test results showed that Edmer was suffering from "Dengue
Hemorrhagic Fever." One hour later, Dr. Casumpang arrived at Edmers room and he recommended his transfer to
the Intensive Care Unit (ICU), to which the respondent consented. Since the ICU was then full, Dr. Casumpang
suggested to the respondent that they hire a private nurse. The respondent, however, insisted on transferring his
son to Makati Medical Center.
After the respondent had signed the waiver, Dr. Casumpang, for the last time, checked Edmers condition, found
that his blood pressure was stable, and noted that he was "comfortable." The respondent requested for an
ambulance but he was informed that the driver was nowhere to be found. This prompted him to hire a private
ambulance that cost him P600.00.23
At 12:00 midnight, Edmer, accompanied by his parents and by Dr. Casumpang, was transferred to Makati Medical
Center.
Dr. Casumpang immediately gave the attending physician the patients clinical history and laboratory exam results.
Upon examination, the attending physician diagnosed "Dengue Fever Stage IV" that was already in its irreversible
stage.
Edmer died at 4:00 in the morning of April 24, 1988. 24 His Death Certificate indicated the cause of death as
"Hypovolemic Shock/hemorrhagic shock;" "Dengue Hemorrhagic Fever Stage IV."
Believing that Edmers death was caused by the negligent and erroneous diagnosis of his doctors, the respondent
instituted an action for damages against SJDH, and its attending physicians: Dr. Casumpang and Dr. Sanga
(collectively referred to as the "petitioners") before the RTC of Makati City.
The Ruling of the Regional Trial Court
In a decision25 dated May 30, 1997, the RTC ruled in favor of the respondent, and awarded actual and moral
damages, plus attorney's fees and costs.
In ruling that the petitioning doctors were negligent, the RTC found untenable the petitioning doctors contention
that Edmers initial symptoms did not indicate dengue fever. It faulted them for heavily relying on the chest x-ray
result and for not considering the other manifestations that Edmers parents had relayed. It held that in diagnosing
and treating an illness, the physicians conduct should be judged not only by what he/she saw and knew, but also
by what he/she could have reasonably seen and known. It also observed that based on Edmers signs and
symptoms, his medical history and physical examination, and also the information that the petitioning doctors
gathered from his family members, dengue fever was a reasonably foreseeable illness; yet, the petitioning doctors
failed to take a second look, much less, consider these indicators of dengue.
The trial court also found that aside from their self-serving testimonies, the petitioning doctors did not present other
evidence to prove that they exercised the proper medical attention in diagnosing and treating the patient, leading it
to conclude that they were guilty of negligence. The RTC also held SJDH solidarily liable with the petitioning
doctors for damages based on the following findings of facts: first, Dr. Casumpang, as consultant, is an ostensible
agent of SJDH because before the hospital engaged his medical services, it scrutinized and determined his fitness,
qualifications, and competence as a medical practitioner; and second, Dr. Sanga, as resident physician, is an
employee of SJDH because like Dr. Casumpang, the hospital, through its screening committee, scrutinized and
determined her qualifications, fitness,and competence before engaging her services; the hospital also exercised
control over her work.
The dispositive portion of the decision reads:
WHEREFORE, judgment is hereby rendered in favor of the plaintiff and against the defendants, ordering the latter
to pay solidarily and severally plaintiff the following:
(1) Moral damages in the amount of P500,000.00;
91
 (2) Costs of burial and funeral in the amount of P45,000.00;
(3) Attorneys fees of P50,000.00; and
(4) Cost of this suit.
SO ORDERED.
The petitioners appealed the decision to the CA.
The Ruling of the Court of Appeals
In its decision dated October 29, 2004, the CA affirmed en toto the RTCs ruling, finding that SJDH and its attending
physicians failed to exercise the minimum medical care, attention, and treatment expected of an ordinary doctor
under like circumstances.
The CA found the petitioning doctors failure to read even the most basic signs of "dengue fever" expected of an
ordinary doctor as medical negligence. The CA also considered the petitioning doctors testimonies as self-serving,
noting that they presented no other evidence to prove that they exercised due diligence in diagnosing Edmers
illness.
The CA likewise found Dr. Rodolfo Jaudians (Dr. Jaudian) testimony admissible. It gave credence to his
opinion26that: (1) given the exhibited symptoms of the patient, dengue fever should definitely be considered, and
bronchopneumonia could be reasonably ruled out; and (2) dengue fever could have been detected earlier than 7:30
in the evening of April 23, 1988 because the symptoms were already evident; and agreed with the RTC that the
petitioning doctors should not have solely relied on the chest-x-ray result, as it was not conclusive.
On SJDHs solidary liability, the CA ruled that the hospitals liability is based on Article 2180 of the Civil Code. The
CA opined that the control which the hospital exercises over its consultants, the hospitals power to hire and
terminate their services, all fulfill the employer-employee relationship requirement under Article 2180.
Lastly, the CA held that SJDH failed to adduce evidence showing that it exercised the diligence of a good father of
a family in the hiring and the supervision of its physicians.
The petitioners separately moved to reconsider the CA decision, but the CA denied their motion in its resolution of
January 12, 2006; hence, the present consolidated petitions pursuant to Rule 45 of the Rules of Court.
The Petitions
I. Dr. Casumpangs Position (G.R. No. 171127)
Dr. Casumpang contends that he gave his patient medical treatment and care to the best of his abilities, and within
the proper standard of care required from physicians under similar circumstances. He claims that his initial
diagnosis of bronchopneumonia was supported by the chest x-ray result.
Dr. Casumpang also contends that dengue fever occurs only after several days of confinement. He alleged that
when he had suspected that Edmer might be suffering from dengue fever, he immediately attended and treated
him.
Dr. Casumpang likewise raised serious doubts on Dr. Jaudians credibility, arguing that the CA erred in appreciating
his testimony as an expert witness since he lacked the necessary training, skills, and experience as a specialist in
dengue fever cases.
II. Dr. Sangas Position (G.R. No. 171217)
In her petition, Dr. Sanga faults the CA for holding her responsible for Edmers wrong diagnosis, stressing that the
function of making the diagnosis and undertaking the medical treatment devolved upon Dr. Casumpang, the doctor
assigned to Edmer, and who confirmed "bronchopneumonia."
Dr. Sanga also alleged that she exercised prudence in performing her duties as a physician, underscoring that it
was her professional intervention that led to the correct diagnosis of "Dengue Hemorrhagic Fever." Furthermore,
Edmers Complete Blood Count (CBC) showed leukopenia and an increase in balance as shown by the differential
count, demonstrating that Edmers infection, more or less, is of bacterial and not viral in nature.
Dr. Sanga as well argued that there is no causal relation between the alleged erroneous diagnosis and medication
for "Bronchopneumonia," and Edmers death due to "Dengue Hemorrhagic Fever."
Lastly, she claimed that Dr. Jaudianis not a qualified expert witness since he never presented any evidence of
formal residency training and fellowship status in Pediatrics.
III. SJDHs Position (G.R. No. 171228)
SJDH, on the other hand, disclaims liability by asserting that Dr. Casumpang and Dr. Sanga are mere independent
contractors and "consultants" (not employees) of the hospital. SJDH alleges that since it did not exercise control or
supervision over the consultants exercise of medical profession, there is no employer-employee relationship
between them, and consequently, Article 2180 of the Civil Code does not apply.
SJDH likewise anchored the absence of employer-employee relationship on the following circumstances: (1) SJDH
does not hire consultants; it only grants them privileges to admit patients in the hospital through accreditation; (2)
SJDH does not pay the consultants wages similar to an ordinary employee; (3) the consultants earn their own
professional fees directly from their patients; SJDH does not fire or terminate their services; and (4) SJDH does not
control or interfere with the manner and the means the consultants use in the treatment of their patients. It merely
provides them with adequate space in exchange for rental payment.
Furthermore, SJDH claims that the CA erroneously applied the control test when it treated the hospitals practice of
accrediting consultants as an exercise of control. It explained that the control contemplated by law is that which the
employer exercises over the: (i) end result; and the (ii) manner and means to be used to reach this end, and not
any kind of control, however significant, in accrediting the consultants.
SJDH moreover contends that even if the petitioning doctors are considered employees and not merely consultants
of the hospital, SJDH cannot still be held solidarily liable under Article 2180 of the Civil Code because it observed
the diligence of a good father of a family in their selection and supervision as shown by the following: (1) the
adequate measures that the hospital undertakes to ascertain the petitioning doctors qualifications and medical
92
competence; and (2) the documentary evidence that the petitioning doctors presented to prove their competence in
the field of pediatrics.27
SJDH likewise faults the CA for ruling that the petitioning doctors are its agents, claiming that this theory, aside
from being inconsistent with the CAs finding of employment relationship, is unfounded because: first, the
petitioning doctors are independent contractors, not agents of SJDH; and second, as a medical institution, SJDH
cannot practice medicine, much more, extend its personality to physicians to practice medicine on its behalf.
Lastly, SJDH maintains that the petitioning doctors arrived at an intelligently deduced and correct diagnosis. It
claimed that based on Edmer's signs and symptoms at the time of admission (i.e., one day fever, 28 bacterial
infection,29 and lack of hemorrhagic manifestations30), there was no reasonable indication yet that he was suffering
from dengue fever, and accordingly, their failure to diagnose dengue fever, does not constitute negligence on their
part.
The Case for the Respondent
In his comment, the respondent submits that the issues the petitioners raised are mainly factual in nature, which a
petition for review on certiorari under Rule 45 of the Rules of Courts does not allow.
In any case, he contends that the petitioning doctors were negligent in conducting their medical examination and
diagnosis based on the following: (1) the petitioning doctors failed to timely diagnose Edmers correct illness due to
their non-observance of the proper and acceptable standard of medical examination; (2) the petitioning doctors
medical examination was not comprehensive, as they were always in a rush; and (3) the petitioning doctors
employed a guessing game in diagnosing bronchopneumonia.
The respondent also alleges that there is a causal connection between the petitioning doctors negligence and
Edmers untimely death, warranting the claim for damages.
The respondent, too, asserted that SJDH is also negligent because it was not equipped with proper paging system,
has no bronchoscope, and its doctors are not proportionate to the number of its patients. He also pointed out that
out of the seven resident physicians in the hospital, only two resident physicians were doing rounds at the time of
his sons confinement.
The Issues
The case presents to us the following issues:
1. Whether or not the petitioning doctors had committed "inexcusable lack of precaution" in diagnosing
and in treating the patient;
2. Whether or not the petitioner hospital is solidarily liable with the petitioning doctors;
3. Whether or not there is a causal connection between the petitioners negligent act/omission and the
patients resulting death; and
4. Whether or not the lower courts erred in considering Dr. Rodolfo Tabangcora Jaudian as an expert
witness.
Our Ruling
We find the petition partly meritorious.
A Petition for Review on Certiorari
under Rule 45 of the Rules of Court
is Limited to Questions of Law.
The settled rule is that the Courts jurisdiction in a petition for review on certiorari under Rule 45 of the Rules of
Court is limited only to the review of pure questions of law. It is not the Courts function to inquire on the veracity of
the appellate courts factual findings and conclusions; this Court is not a trier of facts. 31
A question of law arises when there is doubt as to what the law is on a certain state of facts, while there is a
question of fact when the doubt arises as to the truth or falsity of the alleged facts. 32
These consolidated petitions before us involve mixed questions of fact and law. As a rule, we do not resolve
questions of fact. However, in determining the legal question of whether the respondent is entitled to claim
damages under Article 2176 of the Civil Code for the petitioners alleged medical malpractice, the determination of
the factual issues i.e., whether the petitioning doctors were grossly negligent in diagnosing the patients illness,
whether there is causal relation between the petitioners act/omission and the patients resulting death, and whether
Dr. Jaudian is qualified as an expert witness must necessarily be resolved. We resolve these factual questions
solely for the purpose of determining the legal issues raised.
Medical Malpractice Suit as a
Specialized Area of Tort Law
The claim for damages is based on the petitioning doctors negligence in diagnosing and treating the deceased
Edmer, the child of the respondent. It is a medical malpractice suit, an action available to victims to redress a wrong
committed by medical professionals who caused bodily harm to, or the death of, a patient. 33 As the term is used,
the suit is brought whenever a medical practitioner or health care provider fails to meet the standards demanded by
his profession, or deviates from this standard, and causes injury to the patient.
To successfully pursue a medical malpractice suit, the plaintiff (in this case, the deceased patients heir) must prove
that the doctor either failed to do what a reasonably prudent doctor would have done, or did what a reasonably
prudent doctor would not have done; and the act or omission had caused injury to the patient. 34 The patients heir/s
bears the burden of proving his/her cause of action.
The Elements of a Medical Malpractice Suit
The elements of medical negligence are: (1) duty; (2) breach; (3) injury; and (4) proximate causation.
Duty refers to the standard of behavior that imposes restrictions on one's conduct. 35 It requires proof of professional
relationship between the physician and the patient. Without the professional relationship, a physician owes no duty
to the patient, and cannot therefore incur any liability.
A physician-patient relationship is created when a patient engages the services of a physician, 36 and the latter
accepts or agrees to provide care to the patient.37 The establishment of this relationship is consensual, 38 and the
acceptance by the physician essential. The mere fact that an individual approaches a physician and seeks
diagnosis, advice or treatment does not create the duty of care unless the physician agrees. 39
93
The consent needed to create the relationship does not always need to be express. 40 In the absence of an express
agreement, a physician-patient relationship may be implied from the physicians affirmative action to diagnose
and/or treat a patient, or in his participation in such diagnosis and/or treatment. 41 The usual illustration would be the
case of a patient who goes to a hospital or a clinic, and is examined and treated by the doctor. In this case, we can
infer, based on the established and customary practice in the medical community that a patient-physician
relationship exists.
Once a physician-patient relationship is established, the legal duty of care follows. The doctor accordingly becomes
duty-bound to use at least the same standard of care that a reasonably competent doctor would use to treat a
medical condition under similar circumstances.
Breach of duty occurs when the doctor fails to comply with, or improperly performs his duties under professional
standards. This determination is both factual and legal, and is specific to each individual case. 42
If the patient, as a result of the breach of duty, is injured in body or in health, actionable malpractice is committed,
entitling the patient to damages.43
To successfully claim damages, the patient must lastly prove the causal relation between the negligence and the
injury. This connection must be direct, natural, and should be unbroken by any intervening efficient causes. In other
words, the negligence must be the proximate cause of the injury. 44 The injury or damage is proximately caused by
the physicians negligence when it appears, based on the evidence and the expert testimony, that the negligence
played an integral part in causing the injury or damage, and that the injury or damage was either a direct result, or a
reasonably probable consequence of the physicians negligence. 45
a. The Relationship Between Dr. Casumpang and Edmer
In the present case, the physician-patient relationship between Dr. Casumpang and Edmer was created when the
latters parents sought the medical services of Dr. Casumpang, and the latter knowingly accepted Edmer as a
patient. Dr. Casumpangs acceptance is implied from his affirmative examination, diagnosis and treatment of
Edmer. On the other hand, Edmers parents, on their sons behalf, manifested their consent by availing of the
benefits of their health care plan, and by accepting the hospitals assigned doctor without objections.
b. The Relationship Between Dr. Sanga and Edmer
With respect to Dr. Sanga, her professional relationship with Edmer arose when she assumed the obligation to
provide resident supervision over the latter. As second year resident doctor tasked to do rounds and assist other
physicians, Dr. Sanga is deemed to have agreed to the creation of physician-patient relationship with the hospitals
patients when she participated in the diagnosis and prescribed a course of treatment for Edmer.
The undisputed evidence shows that Dr. Sanga examined Edmer twice (at around 12:00 and 3:30 in the afternoon
of April 23, 1988),and in both instances, she prescribed treatment and participated in the diagnosis of Edmers
medical condition. Her affirmative acts amounted to her acceptance of the physician-patient relationship, and
incidentally, the legal duty of care that went with it.
In Jarcia, Jr. v. People of the Philippines, 46 the Court found the doctors who merely passed by and were requested
to attend to the patient, liable for medical malpractice. It held that a physician-patient relationship was established
when they examined the patient, and later assured the mother that everything was fine.
In the US case of Mead v. Legacy Health System,47 the Court also considered the rendering of an opinion in the
course of the patients care as the doctors assent to the physician-patient relationship. It ruled that the relationship
was formed because of the doctors affirmative action. Likewise, in Wax v. Johnson, 48 the court found that a
physician patient relationship was formed between a physician who "contracts, agrees, undertakes, or otherwise
assumes" the obligation to provide resident supervision at a teaching hospital, and the patient with whom the doctor
had no direct or indirect contract.
Standard of Care and Breach of Duty
A determination of whether or not the petitioning doctors met the required standard of care involves a question of
mixed fact and law; it is factual as medical negligence cases are highly technical in nature, requiring the
presentation of expert witnesses to provide guidance to the court on matters clearly falling within the domain of
medical science, and legal, insofar as the Court, after evaluating the expert testimonies, and guided by medical
literature, learned treatises, and its fund of common knowledge, ultimately determines whether breach of duty took
place. Whether or not Dr. Casumpang and Dr. Sanga committed a breach of duty is to be measured by the
yardstick of professional standards observed by the other members of the medical profession in good standing
under similar circumstances.49 It is in this aspect of medical malpractice that expert testimony is essential to
establish not only the professional standards observed in the medical community, but also that the physicians
conduct in the treatment of care falls below such standard. 50
In the present case, expert testimony is crucial in determining first, the standard medical examinations, tests, and
procedures that the attending physicians should have undertaken in the diagnosis and treatment of dengue fever;
and second, the dengue fever signs and symptoms that the attending physicians should have noticed and
considered.
Both the RTC and the CA relied largely on Dr. Jaudians expert testimony on dengue diagnosis and management to
support their finding that the petitioning doctors were guilty of breach of duty of care.
Dr. Jaudian testified that Edmers rapid breathing, chest and stomach pain, fever, and the presence of blood in his
saliva are classic symptoms of dengue fever. According to him, if the patient was admitted for chest pain,
abdominal pain, and difficulty in breathing coupled with fever, dengue fever should definitely be considered; 51 if the
patient spits coffee ground with the presence of blood, and the patients platelet count drops to 47,000, it becomes
a clear case of dengue fever, and bronchopneumonia can be reasonably ruled out. 52
Furthermore, the standard of care according to Dr. Jaudian is to administer oxygen inhalation, analgesic, and fluid
infusion or dextrose.53 If the patient had twice vomited fresh blood and thrombocytopenia has already occurred, the
doctor should order blood transfusion, monitoring of the patient every 30 minutes, hemostatic to stop bleeding, and
oxygen if there is difficulty in breathing. 54
We find that Dr. Casumpang, as Edmers attending physician, did not act according to these standards and, hence,
was guilty of breach of duty. We do not find Dr. Sanga liable for the reasons discussed below.
Dr. Casumpangs Negligence
a. Negligence in the Diagnosis
At the trial, Dr. Casumpang declared that a doctors impression regarding a patients illness is 90% based on the
physical examination, the information given by the patient or the latters parents, and the patients medical
history.55 He testified that he did not consider either dengue fever or dengue hemorrhagic fever because the
patients history showed that Edmer had low breath and voluntary submission, and that he was up and about
94
playing basketball.56 He based his diagnosis of bronchopneumonia on the following observations: "difficulty in
breathing, clearing run nostril, harsh breath sound, tight air, and sivilant sound." 57
It will be recalled that during Dr. Casumpangs first and second visits to Edmer, he already had knowledge of
Edmers laboratory test result (CBC), medical history, and symptoms (i.e., fever, rashes, rapid breathing, chest and
stomach pain, throat irritation, difficulty in breathing, and traces of blood in the sputum). However, these information
did not lead Dr. Casumpang to the possibility that Edmer could be suffering from either dengue fever, or dengue
hemorrhagic fever, as he clung to his diagnosis of broncho pneumonia. This means that given the symptoms
exhibited, Dr. Casumpang already ruled out the possibility of other diseases like dengue.
In other words, it was lost on Dr. Casumpang that the characteristic symptoms of dengue (as Dr. Jaudian testified)
are: patients rapid breathing; chest and stomach pain; fever; and the presence of blood in his saliva. All these
manifestations were present and known to Dr. Casumpang at the time of his first and second visits to Edmer. While
he noted some of these symptoms in confirming bronchopneumonia, he did not seem to have considered the
patients other manifestations in ruling out dengue fever or dengue hemorrhagic fever. 58 To our mind, Dr.
Casumpang selectively appreciated some, and not all of the symptoms; worse, he casually ignored the pieces of
information that could have been material in detecting dengue fever. This is evident from the testimony of Mrs.
Cortejo:
TSN, Mrs. Cortejo, November 27, 1990
Q: Now, when Dr. Casumpang visited your son for the first time at 5:30 p.m., what did he do, if any?
A: He examined my son by using stethoscope and after that, he confirmed to me that my son was suffering from
broncho pneumonia.
Q: After he confirmed that your son was suffering broncho pneumonia, what did you say if any?
A: Again, I told Dr. Casumpang, how come it was broncho pneumonia when my son has no cough or colds.
Q: What was the answer of Dr. Casumpang to your statement?
xxxx
A: And then, Dr. Casumpang answered "THATS THE USUAL BRONCHO PNEUMONIA, NO COLDS, NO
PHLEGM."
Q: How long did Dr. Casumpang stay in your sons room?
A: He stayed for a minute or 2.
xxxx
Q: When Dr. Casumpang arrived at 9:00 oclock a.m. on April 23, what did you tell him, if any?
xxxx
A: I told Dr. Casumpang After examining my son using stethoscope and nothing more, I told Dr. Casumpang
about the traces of blood in my sons sputum and I told him what is all about and he has throat irritation.
Q: What did he tell you?
A: He just nodded his head but he did not take the initiative of looking at the throat of my son.
Q: So what happened after that?
A: I also told Dr. Casumpang about his chest pain and also stomach pain.
Q: So what did Dr. Casumpang do after you have narrated all these complaints of your son?
A: Nothing. He also noticed the rapid breathing of my son and my son was almost moving because of rapid
breathing and he is swaying in the bed.
Q: Do you know what action was taken by Dr. Casumpang when you told him that your son is experiencing a rapid
breathing?
A: No action. He just asked me if my son has an asthma but I said none.
Q: So how long did Dr. Casumpang stay and attended your son on April 23?
A: More or less two (2) minutes then I followed him up to the door and I repeated about the fever of my son.
Q: What did he tell you, if any, regarding that information you gave him that your son had a fever?
A: He said, that is broncho pneumonia, Its only being active now. [Emphasis supplied]
We also find it strange why Dr. Casumpang did not even bother to check Edmers throat despite knowing that as
early as 9:00 in the morning of April 23, 1988, Edmer had blood streaks in his sputum. Neither did Dr. Casumpang
order confirmatory tests to confirm the source of bleeding. The Physicians Progress Notes59 stated: "Blood streaks
on phlegm can be due to bronchial irritation or congestion," which clearly showed that Dr. Casumpang merely
assumed, without confirmatory physical examination, that bronchopneumonia caused the bleeding.
Dr. Jaudian likewise opined that Dr. Casumpangs medical examination was not comprehensive enough to
reasonably lead to a correct diagnosis.60 Dr. Casumpang only used a stethoscope in coming up with the diagnosis
that Edmer was suffering from bronchopneumonia; he never confirmed this finding with the use of a bronchoscope.
Furthermore, Dr. Casumpang based his diagnosis largely on the chest x-ray result that is generally inconclusive. 61
Significantly, it was only at around 5:00 in the afternoon of April 23, 1988 (after Edmers third episode of bleeding)
that Dr. Casumpang ordered the conduct of hematocrit, hemoglobin, blood typing, blood transfusion and tourniquet
tests. These tests came too late, as proven by: (1) the blood test results that came at about 6:00 in the evening,
confirming that Edmers illness had developed to "Dengue Hemorrhagic Fever;" and (2) Dr. Jaudians testimony
that "dengue fever could have been detected earlier than 7:30 in the evening of April 23, 1988 because the
symptoms were already evident."62
95
In Spouses Flores v. Spouses Pineda,63 a case involving a medical malpractice suit, the Court ruled that the
petitioner doctors were negligent because they failed to immediately order tests to confirm the patients illness.
Despite the doctors suspicion that the patient could be suffering from diabetes, the former still proceeded to the
D&C operation. In that case, expert testimony showed that tests should have been ordered immediately on
admission to the hospital in view of the symptoms presented. The Court held:
When a patient exhibits symptoms typical of a particular disease, these symptoms should, at the very least, alert
the physician of the possibility that the patient may be afflicted with the suspected disease.
The Court also ruled that reasonable prudence would have shown that diabetes and its complications were
foreseeable harm. However, the petitioner doctors failed to take this into consideration and proceeded with the
D&C operation. Thus, the Court ruled that they failed to comply with their duty to observe the standard of care to be
given to hyperglycemic/diabetic patients.
Similarly, in Jarcia,64 involving the negligence of the doctors in failing to exercise reasonable prudence in
ascertaining the extent of the patients injuries, this Court declared that:
In failing to perform an extensive medical examination to determine the extent of Roy Jr.s injuries, Dr. Jarcia and
Dr. Bastan were remiss of their duties as members of the medical profession. Assuming for the sake of argument
that they did not have the capacity to make such thorough evaluation at that stage, they should have referred the
patient to another doctor with sufficient training and experience instead of assuring him and his mother that
everything was all right. [Emphasis supplied]
Apart from failing to promptly detect dengue fever, Dr. Casumpang also failed to promptly undertake the proper
medical management needed for this disease.
As Dr. Jaudian opined, the standard medical procedure once the patient had exhibited the classic symptoms of
dengue fever should have been: oxygen inhalation, use of analgesic, and infusion of fluids or dextrose;67 and once
the patient had twice vomited fresh blood, the doctor should have ordered: blood transfusion, monitoring of the
patient every 30 minutes, hemostatic to stop bleeding, and oxygen if there is difficulty in breathing. 68
Dr. Casumpang failed to measure up to these standards. The evidence strongly suggests that he ordered a
transfusion of platelet concentrate instead of blood transfusion. The tourniquet test was only conducted after
Edmers second episode of bleeding, and the medical management (as reflected in the records) did not include
antibiotic therapy and complete physical examination. Dr. Casumpangs testimony states:
Q: Now, after entertaining After considering that the patient Edmer Cortero was already suffering from dengue
hemorrhagic fever, what did you do, if any?
A: We ordered close monitoring of the blood pressure, the cardiac rate and respiratory rate of the patient.
Q: Now, was your instructions carried on?
A: Yes, sir.

Even assuming that Edmers symptoms completely coincided with the diagnosis of bronchopneumonia (so that this Q: What was the blood pressure of the patient?
diagnosis could not be considered "wrong"), we still find Dr. Casumpang guilty of negligence.
A: During those times, the blood pressure of the patient was even normal during those times.
First, we emphasize that we do not decide the correctness of a doctors diagnosis, or the accuracy of the medical
findings and treatment. Our duty in medical malpractice cases is to decide based on the evidence adduced and Q: How about the respiratory rate?
expert opinion presented whether a breach of duty took place.
A: The respiratory rate was fast because the patient in the beginning since admission had difficulty in breathing.
Second, we clarify that a wrong diagnosis is not by itself medical malpractice. 65 Physicians are generally not liable
for damages resulting from a bona fide error of judgment. Nonetheless, when the physicians erroneous diagnosis
was the result of negligent conduct (e.g., neglect of medical history, failure to order the appropriate tests, failure to Q: Then, after that, what did you do with the patient? Doctor?
recognize symptoms), it becomes an evidence of medical malpractice.
A: We transfused platelet concentrate and at the same time, we monitor [sic] the patient.
Third, we also note that medicine is not an exact science; 66 and doctors, or even specialists, are not expected to
give a 100% accurate diagnosis in treating patients who come to their clinic for consultations. Error is possible as Q: Then, who monitor [sic] the patient?
the exercise of judgment is called for in considering and reading the exhibited symptoms, the results of tests, and in
arriving at definitive conclusions. But in doing all these, the doctor must have acted according to acceptable
medical practice standards. A: The pediatric resident on duty at that time.

In the present case, evidence on record established that in confirming the diagnosis of bronchopneumonia, Dr. Q: Now, what happened after that?
Casumpang selectively appreciated some and not all of the symptoms presented, and failed to promptly conduct
the appropriate tests to confirm his findings. In sum, Dr. Casumpang failed to timely detect dengue fever, which Q: While monitoring the patient, all his vital signs were _____; his blood pressure was normal so we continued with
failure, especially when reasonable prudence would have shown that indications of dengue were evident and/or the supportive management at that time.
foreseeable, constitutes negligence.
Q: Now, after that?
a. Negligence in the Treatment and Management of Dengue

96
A: In the evening of April 23, 1988, I stayed in the hospital and I was informed by the pediatric resident on duty at
around 11:15 in the evening that the blood pressure of the patient went down to .60 palpatory.
Q: What did you do upon receipt of that information?
A: I immediately went up to the room of the patient and we changed the IV fluid from the present fluid which was D5
0.3 sodium chloride to lactated ringers solution.
Q: You mean to say you increased the dengue [sic] of the intervenus [sic] fluid?
A: We changed the IV fluid because lactated ringers was necessary to resume the volume and to bring back the
blood pressure, to increase the blood pressure. [Emphasis supplied]
Although Dr. Casumpang presented the testimonies of Dr. Rodolfo Jagonap and Dr. Ellewelyn Pasion (Dr. Pasion),
Personnel Officer and Medical Director of SJDH, respectively as well as the testimonies of Dr. Livelo and Dr. Reyes
(the radiologist who read Edmers chest x-ray result), these witnesses failed to dispute the standard of action that
Dr. Jaudian established in his expert opinion. We cannot consider them expert witnesses either for the sole reason
that they did not testify on the standard of care in dengue cases.69
On the whole, after examining the totality of the adduced evidence, we find that the lower courts correctly did not
rely on Dr. Casumpangs claim that he exercised prudence and due diligence in handling Edmers case. Aside from
being self-serving, his claim is not supported by competent evidence. As the lower courts did, we rely on the
uncontroverted fact that he failed, as a medical professional, to observe the most prudent medical procedure under
the circumstances in diagnosing and treating Edmer.
Dr. Sanga is Not Liable for Negligence
In considering the case of Dr. Sanga, the junior resident physician who was on-duty at the time of Edmers
confinement, we see the need to draw distinctions between the responsibilities and corresponding liability of Dr.
Casumpang, as the attending physician, and that of Dr. Sanga.
In his testimony, Dr. Pasion declared that resident applicants are generally doctors of medicine licensed to practice
in the Philippines and who would like to pursue a particular specialty. 70 They are usually the front line doctors
responsible for the first contact with the patient. During the scope of the residency program, 71 resident physicians
(or "residents")72 function under the supervision of attending physicians 73 or of the hospitals teaching staff. Under
this arrangement, residents operate merely as subordinates who usually defer to the attending physician on the
decision to be made and on the action to be taken.
The attending physician, on the other hand, is primarily responsible for managing the residents exercise of duties.
While attending and resident physicians share the collective responsibility to deliver safe and appropriate care to
the patients,74 it is the attending physician who assumes the principal responsibility of patient care. 75Because
he/she exercises a supervisory role over the resident, and is ultimately responsible for the diagnosis and treatment
of the patient, the standards applicable to and the liability of the resident for medical malpractice is theoretically less
than that of the attending physician. These relative burdens and distinctions, however, do not translate to immunity
from the legal duty of care for residents, 76 or from the responsibility arising from their own negligent act.
77
In Jenkins v. Clark, the Ohio Court of Appeals held that the applicable standard of care in medical malpractice
cases involving first-year residents was that of a reasonably prudent physician and not that of interns. According to
Jenkins:
It is clear that the standard of care required of physicians is not an individualized one but of physicians in general in
the community. In order to establish medical malpractice, it must be shown by a preponderance of the evidence
that a physician did some particular thing or things that a physician or surgeon of ordinary skill, care and diligence
would not have done under like or similar conditions or circumstances, or that he failed or omitted to do some
particular thing or things that a physician or surgeon of ordinary skill, care and diligence would have done under like
or similar conditions or circumstances, and that the inquiry complained of was the direct result of such doing or
failing to do such thing or things.
We note that the standard of instruction given by the court was indeed a proper one. It clearly informed the jury that
the medical care required is that of reasonably careful physicians or hospital emergency room operators, not of
interns or residents. [Emphasis supplied]
A decade later, Centman v. Cobb,78 affirmed the Jenkins ruling and held that interns and first-year residents are
"practitioners of medicine required to exercise the same standard of care applicable to physicians with unlimited
licenses to practice." The Indiana Court held that although a first-year resident practices under a temporary medical
permit, he/she impliedly contracts that he/she has the reasonable and ordinary qualifications of her profession and
that he/she will exercise reasonable skill, diligence, and care in treating the patient.
We find that Dr. Sanga was not independently negligent. Although she had greater patient exposure, and was
subject to the same standard of care applicable to attending physicians, we believe that a finding of negligence
should also depend on several competing factors, among them, her authority to make her own diagnosis, the
degree of supervision of the attending physician over her, and the shared responsibility between her and the
attending physicians.
In this case, before Dr. Sanga attended to Edmer, both Dr. Livelo and Dr. Casumpang had diagnosed Edmer with
bronchopneumonia. In her testimony, Dr. Sanga admitted that she had been briefed about Edmers condition, his
medical history, and initial diagnosis;79 and based on these pieces of information, she confirmed the finding of
bronchopneumonia.
Dr. Sanga likewise duly reported to Dr. Casumpang, who admitted receiving updates regarding Edmers
condition.80 There is also evidence supporting Dr. Sangas claim that she extended diligent care to Edmer. In fact,
when she suspected during Edmers second episode of bleeding that Edmer could be suffering from dengue
fever, she wasted no time in conducting the necessary tests, and promptly notified Dr. Casumpang about the
incident. Indubitably, her medical assistance led to the finding of dengue fever.
We note however, that during Edmers second episode of bleeding, 81 Dr. Sanga failed to immediately examine and
note the cause of the blood specimen. Like Dr. Casumpang, she merely assumed that the blood in Edmers phlegm
was caused by bronchopneumonia. Her testimony states:
TSN, June 8, 1993:
Q: Let us get this clear, you said that the father told you the patient cocked [sic] out phlegm.
A: With blood streak.
Q: Now, you stated specimen, were you not able to examine the specimen?
A: No, sir, I did not because according to the father he wash [sic] his hands.
97
 xxxx
Q: Now, from you knowledge, what does that indicate if the patient expels a phlegm and blood streak?
A: If a patient cocked [sic] out phlegm then the specimen could have come from the lung alone. 82
[Emphasis
supplied]
xxxx
TSN, June 17, 1993:
Q: Now, in the first meeting you had, when that was relayed to you by the father that Edmer Cortejo had coughed
out blood, what medical action did you take?
A: I examined the patient and I thought that, that coughed out phlegm was a product of broncho pneumonia.
xxxx
Q: So what examination did you specifically conduct to see that there was no internal bleeding? A: At that time I did
not do anything to determine the cause of coughing of the blood because I presumed that it was a mucous (sic)
produced by broncho pneumonia, And besides the patient did not even show any signs of any other illness at that
time.83
Based on her statements we find that Dr. Sanga was not entirely faultless. Nevertheless, her failure to discern the
import of Edmers second bleeding does not necessarily amount to negligence as the respondent himself admitted
that Dr. Sanga failed to examine the blood specimen because he wash edit away. In addition, considering the
diagnosis previously made by two doctors, and the uncontroverted fact that the burden of final diagnosis pertains to
the attending physician (in this case, Dr. Casumpang), we believe that Dr. Sangas error was merely an honest
mistake of judgment influenced in no small measure by her status in the hospital hierarchy; hence, she should not
be held liable for medical negligence.
Dr. Jaudians Professional Competence and Credibility
One of the critical issues the petitioners raised in the proceedings before the lower court and before this Court was
Dr. Jaudians competence and credibility as an expert witness. The petitioners tried to discredit his expert testimony
on the ground that he lacked the proper training and fellowship status in pediatrics.
Criteria in Qualifying as an Expert Witness
The competence of an expert witness is a matter for the trial court to decide upon in the exercise of its discretion.
The test of qualification is necessarily a relative one, depending upon the subject matter of the investigation, and
the fitness of the expert witness.84 In our jurisdiction, the criterion remains to be the expert witness special
knowledge experience and practical training that qualify him/her to explain highly technical medical matters to the
Court.
In Ramos v. Court of Appeals,85 the Court found the expert witness, who is a pulmonologist, not qualified to testify
on the field of anesthesiology. Similarly, in Cereno v. Court of Appeals, 86 a 2012 case involving medical negligence,
the Court excluded the testimony of an expert witness whose specialty was anesthesiology, and concluded that an
anesthesiologist cannot be considered an expert in the field of surgery or even in surgical practices and diagnosis.
Interestingly in this case, Dr. Jaudian, the expert witness was admittedly not a pediatrician but a practicing
physician who specializes in pathology.87 He likewise does not possess any formal residency training in pediatrics.
Nonetheless, both the lower courts found his knowledge acquired through study and practical experience sufficient
to advance an expert opinion on dengue-related cases.
We agree with the lower courts.
A close scrutiny of Ramos and Cereno reveals that the Court primarily based the witnesses disqualification to
testify as an expert on their incapacity to shed light on the standard of care that must be observed by the
defendant-physicians. That the expert witnesses specialties do not match the physicians practice area only
constituted, at most, one of the considerations that should not be taken out of context. After all, the sole function of
a medical expert witness, regardless of his/her specialty, is to afford assistance to the courts on medical matters,
and to explain the medical facts in issue.
Furthermore, there was no reasonable indication in Ramos and Cereno that the expert witnesses possess a
sufficient familiarity with the standard of care applicable to the physicians specialties. US jurisprudence on medical
malpractice demonstrated the trial courts wide latitude of discretion in allowing a specialist from another field to
testify against a defendant specialist.
In Brown v. Sims,88 a neurosurgeon was found competent to give expert testimony regarding a gynecologist's
standard of pre-surgical care. In that case, the court held that since negligence was not predicated on the
gynecologists negligent performance of the operation, but primarily on the claim that the pre-operative histories
and physicals were inadequate, the neurosurgeon was competent to testify as an expert.
Frost v. Mayo Clinic89 also allowed an orthopedic surgeon to testify against a neurologist in a medical malpractice
action. The court considered that the orthopedic surgeons opinion on the "immediate need for decompression"
need not come from a specialist in neurosurgery. The court held that:
It is well established that "the testimony of a qualified medical doctor cannot be excluded simply because he is not
a specialist x x x." The matter of "x x x training and specialization of the witness goes to the weight rather than
admissibility x x x."
xxxx
It did not appear to the court that a medical doctor had to be a specialist in neurosurgery to express the opinions
permitted to be expressed by plaintiffs doctors, e.g., the immediate need for a decompression in the light of certain
neurological deficits in a post-laminectomy patient. As stated above, there was no issue as to the proper execution
of the neurosurgery. The medical testimony supported plaintiffs theory of negligence and causation. (Citations
omitted)
In another case,90 the court declared that it is the specialists knowledge of the requisite subject matter, rather than
his/her specialty that determines his/her qualification to testify.
Also in Evans v. Ohanesian,91 the court set a guideline in qualifying an expert witness:
98
To qualify a witness as a medical expert, it must be shown that the witness (1) has the required professional
knowledge, learning and skill of the subject under inquiry sufficient to qualify him to speak with authority on the
subject; and (2) is familiar with the standard required of a physician under similar circumstances; where a witness
has disclosed sufficient knowledge of the subject to entitle his opinion to go to the jury, the question of the degree
of his knowledge goes more to the weight of the evidence than to its admissibility.
xxxx
Nor is it critical whether a medical expert is a general practitioner or a specialist so long as he exhibits knowledge of
the subject. Where a duly licensed and practicing physician has gained knowledge of the standard of care
applicable to a specialty in which he is not directly engaged but as to which he has an opinion based on education,
experience, observation, or association wit that specialty, his opinion is competent.(Emphasis supplied)
Finally, Brown v. Mladineo92 adhered to the principle that the witness familiarity, and not the classification by title or
specialty, which should control issues regarding the expert witness qualifications:
The general rule as to expert testimony in medical malpractice actions is that "a specialist in a particular branch
within a profession will not be required." Most courts allow a doctor to testify if they are satisfied of his familiarity
with the standards of a specialty, though he may not practice the specialty himself. One court explained that "it is
the scope of the witness knowledge and not the artificial classification by title that should govern the threshold
question of admissibility. (Citations omitted)
Application to the Present Case
In the case and the facts before us, we find that Dr. Jaudian is competent to testify on the standard of care in
dengue fever cases.1avvphi1
Although he specializes in pathology, it was established during trial that he had attended not less than 30 seminars
held by the Pediatric Society, had exposure in pediatrics, had been practicing medicine for 16 years, and had
handled not less than 50 dengue related cases.
As a licensed medical practitioner specializing in pathology, who had practical and relevant exposure in pediatrics
and dengue related cases, we are convinced that Dr. Jaudian demonstrated sufficient familiarity with the standard
of care to be applied in dengue fever cases. Furthermore, we agree that he possesses knowledge and experience
sufficient to qualify him to speak with authority on the subject.
The Causation Between Dr. Casumpangs
Negligent Act/Omission, and the Patients
Resulting Death was Adequately Proven
Dr. Jaudians testimony strongly suggests that due to Dr. Casumpangs failure to timely diagnose Edmer with
dengue, the latter was not immediately given the proper treatment. In fact, even after Dr. Casumpang had
discovered Edmers real illness, he still failed to promptly perform the standard medical procedure. We agree with
these findings.
As the respondent had pointed out, dengue fever, if left untreated, could be a life threatening disease. As in any
fatal diseases, it requires immediate medical attention. 93 With the correct and timely diagnosis, coupled with the
proper medical management, dengue fever is not a life threatening disease and could easily be cured. 94
Furthermore, as Dr. Jaudian testified, with adequate intensive care, the mortality rate of dengue fever should fall to
less than 2%. Hence, the survival of the patient is directly related to early and proper management of the illness.95
To reiterate, Dr. Casumpang failed to timely diagnose Edmer with dengue fever despite the presence of its
characteristic symptoms; and as a consequence of the delayed diagnosis, he also failed to promptly manage
Edmers illness. Had he immediately conducted confirmatory tests, (i.e., tourniquet tests and series of blood
tests)and promptly administered the proper care and management needed for dengue fever, the risk of
complications or even death, could have been substantially reduced.
Furthermore, medical literature on dengue shows that early diagnosis and management of dengue is critical in
reducing the risk of complications and avoiding further spread of the virus. 96 That Edmer later died of "Hypovolemic
Shock/hemorrhagic shock," "Dengue Hemorrhagic Fever Stage IV," a severe and fatal form of dengue fever,
established the causal link between Dr. Casumpangs negligence and the injury.
Based on these considerations, we rule that the respondent successfully proved the element of causation.
Liability of SJDH
We now discuss the liability of the hospital.
The respondent submits that SJDH should not only be held vicariously liable for the petitioning doctors negligence
but also for its own negligence. He claims that SJDH fell short of its duty of providing its patients with the necessary
facilities and equipment as shown by the following circumstances:
(a) SJDH was not equipped with proper paging system;
(b) the number of its doctors is not proportionate to the number of patients;
(c) SJDH was not equipped with a bronchoscope;
(d) when Edmers oxygen was removed, the medical staff did not immediately provide him with portable
oxygen;
(e) when Edmer was about to be transferred to another hospital, SJDHs was not ready and had no driver;
and
(f) despite Edmers critical condition, there was no doctor attending to him from 5:30 p.m. of April 22, to
9:00 a.m. of April 23, 1988.
SJDH on the other hand disclaims liability by claiming that the petitioning doctors are not its employees but are
mere consultants and independent contractors.
We affirm the hospitals liability not on the basis of Article 2180 of the Civil Code, but on the basis of the doctrine of
apparent authority or agency by estoppel.
There is No Employer-Employee Relationship
99
Between SJDH and the Petitioning Doctors
In determining whether an employer-employee relationship exists between the parties, the following elements must
be present: (1) selection and engagement of services; (2) payment of wages; (3) the power to hire and fire; and (4)
the power to control not only the end to be achieved, but the means to be used in reaching such an end. 97
Control, which is the most crucial among the elements, is not present in this case.
Based on the records, no evidence exists showing that SJDH exercised any degree of control over the means,
methods of procedure and manner by which the petitioning doctors conducted and performed their medical
profession. SJDH did not control their diagnosis and treatment. Likewise, no evidence was presented to show that
SJDH monitored, supervised, or directed the petitioning doctors in the treatment and management of Edmers case.
In these lights, the petitioning doctors were not employees of SJDH, but were mere independent contractors.
SJDH is Solidarily Liable Based
on The Principle of Agency or Doctrine
of Apparent Authority
Despite the absence of employer-employee relationship between SJDH and the petitioning doctors, SJDH is not
free from liability.98
As a rule, hospitals are not liable for the negligence of its independent contractors. However, it may be found liable
if the physician or independent contractor acts as an ostensible agent of the hospital. This exception is also known
as the "doctrine of apparent authority."99
The US case of Gilbert v. Sycamore Municipal Hospital100 abrogated the hospitals immunity to vicarious liability of
independent contractor physicians. In that case, the Illinois Supreme Court held that under the doctrine of apparent
authority, hospitals could be found vicariously liable for the negligence of an independent contractor:
Therefore, we hold that, under the doctrine of apparent authority, a hospital can be held vicariously liable for the
negligent acts of a physician providing care at the hospital, regardless of whether the physician is an independent
contractor, unless the patient knows, or should have known, that the physician is an independent contractor. 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.
(Emphasis supplied)
The doctrine was applied in Nogales v. Capitol Medical Center 101 where this Court, through the ponencia of
Associate Justice Antonio T. Carpio, discussed the two factors in determining hospital liability as follows:
The first factor focuses on the hospitals manifestations and is sometimes described as an inquiry whether the
hospital acted in a manner which would lead a reasonable person to conclude that the individual who was alleged
to be negligent was an employee or agent of the hospital. In this regard, the hospital need not make express
representations to the patient that the treating physician is an employee of the hospital; rather a representation may
be general and implied.
xxxx
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.
(Citation omitted)
In sum, a hospital can be held vicariously liable for the negligent acts of a physician (or an independent contractor)
providing care at the hospital if the plaintiff can prove these two factors: first, the hospitals manifestations; and
second, the patients reliance.
a. Hospitals manifestations
It involves an inquiry on whether the hospital acted in a manner that would lead a reasonable person to conclude
that the individual alleged to be negligent was an employee or agent of the hospital. As pointed out in Nogales, the
hospital need not make express representations to the patient that the physician or independent contractor is an
employee of the hospital; representation may be general and implied. 102
In Pamperin v. Trinity Memorial Hospital,103 questions were raised on "what acts by the hospital or its agent are
sufficient to lead a reasonable person to conclude that the individual was an agent of the hospital." In ruling that the
hospitals manifestations can be proven without the express representation by the hospital, the court relied on
several cases from other jurisdictions, and held that:
(1) the hospital, by providing emergency room care and by failing to advise patients that they were being
treated by the hospitals agent and not its employee, has created the appearance of agency; and
(2) patients entering the hospital through the emergency room, could properly assume that the treating
doctors and staff of the hospital were acting on its behalf.1wphi1
In this case, the court considered the act of the hospital of holding itself out as provider of complete medical care,
and considered the hospital to have impliedly created the appearance of authority.
b. Patients reliance
It involves an inquiry on whether the plaintiff acted in reliance on the conduct of the hospital or its agent, consistent
with ordinary care and prudence.104
In Pamperin, the court held that the important consideration in determining the patients reliance is: whether the
plaintiff is seeking care from the hospital itself or whether the plaintiff is looking to the hospital merely as a place for
his/her personal physician to provide medical care.105 Thus, this requirement is deemed satisfied if the plaintiff can
prove that he/she relied upon the hospital to provide care and treatment, rather than upon a specific physician. In
this case, we shall limit the determination of the hospitals apparent authority to Dr. Casumpang, in view of our
finding that Dr. Sanga is not liable for negligence.
SJDH Clothed Dr. Casumpang With Apparent Authority
SJDH impliedly held out and clothed Dr. Casumpang with apparent authority leading the respondent to believe that
he is an employee or agent of the hospital.
100
Based on the records, the respondent relied on SJDH rather than upon Dr. Casumpang, to care and treat his son
Edmer. His testimony during trial showed that he and his wife did not know any doctors at SJDH; they also did not
know that Dr. Casumpang was an independent contractor. They brought their son to SJDH for diagnosis because
of their family doctors referral. The referral did not specifically point to Dr. Casumpang or even to Dr. Sanga, but to
SJDH. Significantly, the respondent had relied on SJDHs representation of Dr. Casumpangs authority. To recall,
when Mrs. Cortejo presented her Fortune Care card, she was initially referred to the Fortune Care coordinator, who
was then out of town. She was thereafter referred to Dr. Casumpang, who is also accredited with Fortune Care. In
both instances, SJDH through its agent failed to advise Mrs. Cortejo that Dr. Casumpang is an independent
contractor.
Mrs. Cortejo accepted Dr. Casumpangs services on the reasonable belief that such were being provided by SJDH
or its employees, agents, or servants. By referring Dr. Casumpang to care and treat for Edmer, SJDH impliedly held
out Dr. Casumpang, not only as an accredited member of Fortune Care, but also as a member of its medical staff.
SJDH cannot now disclaim liability since there is no showing that Mrs. Cortejo or the respondent knew, or should
have known, that Dr. Casumpang is only an independent contractor of the hospital. In this case, estoppel has
already set in.
We also stress that Mrs. Cortejos use of health care plan (Fortune Care) did not affect SJDHs liability. The only
effect of the availment of her Fortune Care card benefits is that her choice of physician is limited only to physicians
who are accredited with Fortune Care. Thus, her use of health care plan in this case only limited the choice of
doctors (or coverage of services, amount etc.) and not the liability of doctors or the hospital.
WHEREFORE, premises considered, this Court PARTLY GRANTS the consolidated petitions. The Court finds Dr.
Noel Casumpang and San Juan de Dios Hospital solidarily liable for negligent medical practice. We SET ASIDE the
finding of liability as to Dr. Ruby Miranda-Sanga. The amounts of P45,000.00 as actual damages and P500,000.00
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 October 29, 2004 and the
Resolution dated January 12, 2006 in CA-G.R. CV No. 56400.
SO ORDERED.
G.R. No. 204095 June 15, 2015
DR. JAIME T. CRUZ, Petitioner,
vs.
FELICISIMO V. AGAS, JR., Respondent.
DECISION
MENDOZA, J.:
This petition for review on certiorari under Rule 45 of the Rules of Court assails the May 22, 2012 Decision 1 and
October 18, 2012 Resolution2 of the Court of Appeals (CA), in CA-G.R. SP No. 111910, which affirmed the March
2, 20073 and September 23, 20094 Resolutions of the Secretary of Justice. The said resolutions let stand the
February 16, 2004 Resolution of the Office of the Prosecutor of Quezon City, dismissing the complaint of petitioner
Dr. Jaime T. Cruz (Dr. Cruz) for Serious Physical Injuries through Reckless Imprudence and Medical Malpractice
against respondent, Dr. Felicisimo V. Agas, Jr. (Dr. Agas).
The Antecedents
In his Complaint-Affidavit5 for Serious Physical Injuries through Reckless Imprudence and Medical Malpractice
against Dr. Agas, Dr. Cruz alleged, among others, that sometime in May 2003, he engaged the services of St.
Lukes Medical Center (SLMC)for a medical check-up; that after being admitted in SLMC on May 28, 2003,he
underwent stool, urine, blood, and other body fluid tests conducted by the employees and doctors of the said
hospital; that on May 29, 2003, he was sent to the Gastro-Enterology Department for a scheduled gastroscopy and
colonoscopy; that because the specialist assigned to perform the procedure was nowhere to be found, he gave the
colonoscopy results to the attending female anesthesiologist for the information and consideration of the assigned
specialist; that, thereafter, he was sedated and the endoscopic examination was carried out; that when he regained
consciousness, he felt that something went wrong during the procedure because he felt dizzy, had cold clammy
perspiration and experienced breathing difficulty; that he could not stand or sit upright because he felt so exhausted
and so much pain in his abdomen; that when he was about to urinate in the comfort room, he collapsed; that he
tried to consult the specialist who performed the colonoscopy but he was nowhere to be found; and that his
cardiologist, Dra. Agnes Del Rosario, was able to observe his critical condition and immediately referred him to the
surgical department which suspected that he had hemorrhage in his abdomen and advised him to undergo an
emergency surgical operation.
Dr. Cruz further averred that he agreed to the operation and upon waking up at the ICU on May 30, 2003, he found
out that the doctors did an exploratory laparatomy because of the internal bleeding; that he learned that the doctors
cut a portion of the left side of his colon measuring 6-8 inches because it had a partial tear of the colonic wall which
caused the internal bleeding; that despite the painkillers, he was under tremendous pain in the incision area during
his recovery period in the ICU and had fever; and that he had intravenous tubes attached to his arms, subclavian
artery on the left part of his chest and a nasogastric tube through his nose.
Dr. Cruz claimed that Dr. Agas admitted that he was the one who performed the colonoscopy procedure but the
latter insisted that nothing went wrong. On June 7, 2003,he was discharged from SLMC. Nevertheless, he
complained that he had a hard time digesting his food; that he was frequently fed every two hours because he
easily got full; that he had fresh blood stools every time he moved his bowel; that he had lost his appetite and had
gastric acidity; that he slept most of the day; and that he was in good physical condition before the colonoscopy
procedure. He asserted that at the time of the filing of the complaint, he was still weak, tired and in pain.
Defense of Dr. Agas
Dr. Agas, on the other hand, countered that Dr. Cruz failed to prove the basic elements of reckless imprudence or
negligence. He averred that Dr. Cruz unfairly made it appear that he did not know that he would perform the
procedure. He explained that before the start of the colonoscopy procedure, he was able to confer with Dr. Cruz
and review his medical history which was taken earlier by a fellow gastrointestinal physician. He claimed that the
gastroscopy and colonoscopy procedures conducted on Dr. Cruz were completely successful considering that the
latter did not manifest any significant adverse reaction or body resistance during the procedures and that his vital
signs were normal throughout the procedure.6
Dr. Agas added that certifications and sworn statements were submitted by the Assistant Medical Director for
Professional Services, the Director of the Institute of Digestive Diseases, the anesthesiologist, and the hospital
nurse attesting to the fact that the intraperitonial bleeding which developed after the colonoscopy procedure, was
immediately recognized, evaluated, carefully managed, and corrected; that he provided an adequate and
reasonable standard of care to Dr. Cruz; that the endoscopist followed all precautionary measures; that the
colonoscopy procedure was done properly; that he was not negligent or reckless in conducting the colonoscopy
procedure; that he did not deviate from any standard medical norm, practice or procedure; and that he exercised
competence and diligence in rendering medical services to Dr. Cruz. 7
101
 Antecedents at the Prosecution Level
On February 16, 2004, the Office of the City Prosecutor (OCP) issued a resolution dismissing the complaint for
Serious Physical Injuries through Reckless Imprudence and Medical Malpractice. Aggrieved, Dr. Cruz filed a
petition for review with the Department of Justice (DOJ)but the same was dismissed in its March 2, 2007
Resolution. Dr. Cruz filed a motion for reconsideration but it was denied by the DOJ in its September 23, 2009
Resolution.8
At the Court of Appeals
Not satisfied, Dr. Cruz filed a petition for certiorari before the CA questioning the unfavorable DOJ resolutions. On
May 22, 2012, the CA rendered a decision affirming the said DOJ resolutions. The CA explained that, as a matter
of sound judicial policy, courts would not interfere with the public prosecutors wide discretion of determining
probable cause in a preliminary investigation unless such executive determination was tainted with manifest error
or grave abuse of discretion. It stated that the public prosecutors finding of lack of probable cause against Dr. Agas
was in accordance with law and that his alleged negligence was not adequately established by Dr. Cruz.
The CA also declared that Dr. Cruz failed to state in his Complaint-Affidavit the specific procedures that Dr. Agas
failed to do which a reasonable prudent doctor would have done, or specific norms he failed to observe which a
reasonably prudent doctor would have complied with. The CA pointed out that Dr. Agas was able to satisfactorily
explain in his Counter-Affidavit that the complications suffered by Dr. Cruz was not caused by his negligence or
was the result of medical malpractice. Dr. Agas explained as follows:
That the complication was due to the abnormal condition and configuration of the digestive system, colon in
particular, of the complainant and not from any negligent act in connection with the conduct of colonoscopy. The
surgical findings (xxx) revealed marked adhesions in the sigmoid colon which is not and never within my control.
That the tear in the serosa (the outermost layer of the colonic wall which has 4 layers) happened likely because of
the marked interloop adhesions and tortuousity of the sigmoid segment of the colon. These adhesions that connect
the serosa to the peritoneal lining of each loop detached from the serosa during the procedure. It is not possible to
detect the presence of marked adhesions prior to the endoscopic procedure because no clinical findings, laboratory
tests or diagnostic imaging such as x-ray, ultrasound or computed tomography (CT scan) of the abdomen can
diagnose these conditions. This can only be detected by surgically opening up the abdomen. Moreover, marked
adhesions and serosal tear, in particular, cannot likewise be detected by colonoscopy because they are in the outer
wall of the colon and only the inner lining of the colon is within the view of the colonoscope (camera). 9
The CA further wrote that the counter-affidavit of Dr. Agas was supported by the sworn affidavit of Dr. Jennifel S.
Bustos, an anesthesiologist at the SLMC and the affidavit of Evelyn E. Daulat, a nurse at SLMC, both swearing
under oath that Dr. Agas was not negligent in conducting a gastroscopy and colonoscopy procedure on Dr. Cruz
and the certification issued by the Hospital Ethics Committee which stated that Dr. Cruz was given an adequate
and reasonable standard of care; that Dr. Agas followed all precautionary measures in safeguarding Dr. Cruz from
any possible complications; and that the colonoscopy was done properly.
Hence, this petition.
ISSUE
WHETHER OR NOT THE CA WAS CORRECT IN AFFIRMING THE DECISION OF THE DOJ THAT NO
PROBABLE CAUSE EXISTS FOR FILING AN INFORMATION AGAINST THE RESPONDENT, THAT THE
RESPONDENT WAS NOT NEGLIGENT AND THAT THERE WAS NO DENIAL OF DUE PROCESS.
Non-interference with Executive
Determination of Probable Cause
in Preliminary Investigations
Under the doctrine of separation of powers, courts have no right to directly decide on matters over which full
discretionary authority has been delegated to the Executive Branch of the Government, or to substitute their own
judgment for that of the Executive Branch, represented in this case by the Department of Justice. The settled policy
is that the courts will not interfere with the executive determination of probable cause for the purpose of filing an
Information, in the absence of grave abuse of discretion. That abuse of discretion must be so patent and gross as
to amount to an evasion of a positive duty or a virtual refusal to perform a duty enjoined by law or to act at all in
contemplation of law, such as where the power is exercised in an arbitrary and despotic manner by reason of
passion or hostility.
Medical Negligence and
Malpractice Not Established
In the case at bench, Dr. Cruz failed to show that the DOJ gravely abused its discretion in finding that there was
lack of probable cause and dismissing the complaint against Dr. Agas for Serious Physical Injuries through
Reckless Imprudence and Medical Malpractice.
A medical negligence case can prosper if the patient can present solid proof that the doctor, like in this case, either
failed to do something which a reasonably prudent doctor would have done, or that he did something that a
reasonably prudent doctor would not have done, and such failure or action caused injury to the patient.
To successfully pursue this kind of case, a patient must only prove that a health care provider either failed to do
something which a reasonably prudent health care provider would have done, or that he did something that a
reasonably prudent provider would not have done; and that failure or action caused injury to the patient. Simply put,
the elements are duty, breach, injury and proximate causation. 10
In this case, Dr. Cruz has the burden of showing the negligence or recklessness of Dr. Agas. Although there is no
dispute that Dr. Cruz sustained internal hemorrhage due to a tear in the serosa of his sigmoid colon, he failed to
show that it was caused by Dr. Agass negligent and reckless conduct of the colonoscopy procedure. In other
words, Dr. Cruz failed to show and explain that particular negligent or reckless act or omission committed by Dr.
Agas. Stated differently, Dr. Cruz did not demonstrate that there was "inexcusable lack of precaution" on the part of
Dr. Agas.
Res Ipsa Loquitur Doctrine
Not Applicable Against Respondent
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 plaintiffs prima facie case, and present a question of fact for defendant to meet with an explanation. 11
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. 12
102
In this case, the Court agrees with Dr. Agas that his purported negligence in performing the colonoscopy on Dr.
Cruz was not immediately apparent to a layman to justify the application of res ipsa loquitur doctrine.
Dr. Agas was able to establish that the internal bleeding sustained by Dr. Cruz was due to the abnormal condition
and configuration of his sigmoid colon which was beyond his control considering that the said condition could not
be detected before a colonoscopic procedure. Dr. Agas adequately explained that no clinical findings, laboratory
tests, or diagnostic imaging, such as x-rays, ultrasound or computed tomography (CT) scan of the abdomen, could
have detected this condition prior to an endoscopic procedure. Specifically, Dr. Agas wrote:
On the other hand, in the present case, the correlation between petitioners injury, i.e., tear in the serosa of sigmoid
colon, and the colonoscopy conducted by respondent to the petitioner clearly requires the presentation of an expert
opinion considering that no perforation of the sigmoid colon was ever noted during the laparotomy. It cannot be
overemphasized that the colonoscope inserted by the respondent only passed through the inside of petitioners
sigmoid colon while the damaged tissue, i.e., serosa, which caused the bleeding, is located in the outermost layer
of the colon. It is therefore impossible for the colonoscope to touch, scratch, or even tear the serosa since the said
membrane is beyond reach of the colonoscope in the absence of perforation on the colon. 13
Dr. Cruz failed to rebut this.
WHEREFORE, the petition is DENIED.
G.R. No. 192973 September 29, 2014
PEDRITO DELA TORRE, Petitioner,
vs.
DR. ARTURO IMBUIDO, DRA. NORMA IMBUIDO in their capacity as owners and operators of DIVINE SPIRIT
GENERAL HOSPITAL and/or DR. NESTOR PASAMBA, Respondents.
RESOLUTION
REYES, J.:
This resolves the petition for review on certiorari 1 filed by petitioner Pedrito Dela Torre (Pedrito) assailing the
Decision2 dated December 15, 2009 and Resolution3 dated July 27, 2010 of the Court of Appeals (CA) in CA-G.R.
CV No. 78534.
The case stemmed from a complaint4 for damages filed by Pedrito against herein respondents Dr. ArturoImbuido
and Dr. Norma Imbuido (Dr. Norma), in their capacity as the ownersand operators of the Divine Spirit General
Hospital in Olongapo City, and Dr. Nestor Pasamba (Dr. Nestor) (respondents). Pedrito alleged in his complaint
that he was married to one Carmen Castillo Dela Torre(Carmen), who died while admitted at the Divine Spirit
General Hospital on February 13, 1992. Carmen was due to give birth on February 2,1992 and was brought at
around 11:30 p.m. on that day by Pedrito to the Divine Spirit General Hospital. When Carmen still had not delivered
her baby at the expected time, Dr. Norma discussed with Pedrito the possibility of a caesarean section operation. 5
At around 3:00 p.m. on February 3, 1992, Carmen was brought to the hospitals operating room for her caesarian
section operation, which was to be performed by Dr. Nestor. By 5:30 p.m. of the same day, Pedrito was informed of
his wifes delivery of a baby boy. In the early morning of February 4, 1992, Carmen experienced abdominal pain
and difficulty in urinating. She was diagnosed to be suffering from urinary tract infection (UTI), and was prescribed
medications by Dr. Norma. On February 10, 1992, Pedrito noticed that Carmens stomach was getting bigger, but
Dr. Norma dismissed the patients condition as mere flatulence (kabag). 6
When Carmens stomach still grewbigger despite medications, Dr. Norma advised Pedrito of the possibility of a
second operation on Carmen. Dr. Norma, however, provided no detailson its purpose and the doctor who would
perform it. At around 3:00 p.m. on February 12, 1992, Carmen had her second operation. Later in the evening, Dr.
Norma informed Pedrito that "everything was going on fine with [his] wife." 7
The condition of Carmen, however, did not improve. It instead worsened that on February 13, 1992, she vomited
dark red blood. At 9:30 p.m. on the same day, Carmen died. 8 Per her certificate of death upon information provided
by the hospital,the immediate cause of Carmens death was "cardio-respiratory arrest secondary to cerebro
vascular accident, hypertension and chronic nephritis induced by pregnancy." 9 An autopsy Report10prepared by Dr.
Richard Patilano(Dr. Patilano), Medico-Legal Officer-Designate of Olongapo City, however, provided that the cause
of Carmens death was "shock due to peritonitis, severe, with multiple intestinal adhesions; Status post C[a]esarian
Section and Exploratory Laparotomy."
Pedrito claimed in his complaint that the respondents "failed to exercise the degree of diligence required of them"
as members of the medical profession, and were "negligent for practicing surgery on [Carmen] in the most
unskilled, ignorant and cruel manner, x x x[.]"11
In their answer12 to the complaint, the respondents argued that they "observed the required standard of medical
care in attending to the needs of Carmen."13 The respondents explained that Carmen was admitted in Divine Spirit
General Hospital for "pregnancy in labor and pre-eclampsia." Her condition was closely monitored during her
confinement. A caesarian section operation became necessary, as she manifested no significant progress for the
spontaneous delivery of her baby.14 No unusual events were observed during the course of Carmens caesarian
section operation. The second surgery, however, became necessary due to suspected intestinal obstruction and
adhesions. This procedure was fully explained to Carmen and Pedrito prior to its conduct. During the second
operation, the diagnosis of intestinal obstruction and adhesion was confirmed but resolved by her doctors. Despite
the observance of due care by the doctors, however, Carmen died on February 13, 1992.15
The respondents included in their answer a counterclaim for P48,515.58 as unpaid hospital charges, professional
fees and medicines, P3,000,000.00 for moral damages, P1,500,000.00 for exemplary damages, and attorneys
fees.16
After the pre-trial conference, trial proper ensued. To support his claim, Pedrito presented the testimony of Dr.
Patilano, the medicolegal officer who conducted an autopsy on the body of Carmen upon a telephone request
made by the City Health Officer of Olongapo City, Dr. Generoso Espinosa. Among Dr. Patilanos observations, as
narrated in the lower courts decision, were as follows:
In the intestines, [Dr. Patilano] found outthat it was more reddish than the normal condition which is supposed to
bepinkish. There was presence of adhesions, meaning, it sticks to each other and these areas were dilated. There
were constricted areas. He concluded that there might have been foreign organic matters in the intestines. He did
not see any swelling but assuming that there was, it would be concomitant to the enlargement. x x x He came to the
conclusion that the cause of death was peritonitis, with the multiple adhesions status in the post caesarian section.
In connection with peritonitis, this is the inflammation of the abdomen. This peritonitis in the abdominal cavity may
be caused by several conditions which are supposed to be infections, entrance of foreign bodies in the intestines in
connection with ruptured peptic ulcer or [may be] somewhere in the spleen. The entrance of foreign object in the
abdominal cavities may cause severe infections of the intra-abdominal cavities resulting [in] multiple adhesions of
the intestines. In cases of surgical operation, it [may be] due to the conditions of the instruments used, the materials
used in the operating room being not aseptic and the ladies assisting the operation were not in uniform. x x x.17
103
Dr. Patilano claimed that peritonitis could have been prevented through proper medical procedures and medicines.
He also stated that if the cause of Carmens death was actually cerebro-vascular accident, there would have been
ruptured blood vessels and blood clot in her head; but there were none in Carmens case. 18
Among those who testified to refutePedritos claim was Dr. Nestor. He claimed that when Carmen was referred to
him on February 3, 1992, she was in full term uterine pregnancy, with pre-eclampsia, fetal distress and active labor
pains. A caesarian section operation became necessary to terminate the pregnancy for her safety. Carmen was
ready to go home four days after giving birth, but was advised by the doctors to stay more because of her
persistent hypertension.19
The second surgery performed on Carmen was necessary after she showed symptoms of intestinal obstruction,
which happens as the intestines get twisted due to adhesions and the normal flow of intestinal contents are
obstructed. For Dr. Nestor, this occurrence was not preventable since any interference of the abdominal cavity
would irritate the serosa of the intestines, inviting adhesions that could cause obstruction. Surgery could remedy
the adhesions and obstruction.20 Both Carmen and Pedrito gave their written consent to this second procedure. 21
Dr. Bienvenido G. Torres (Dr. Torres), Chief of the Medico-Legal Division of the Philippine National Police (PNP)
Crime Laboratory Service,22 also testified for the respondents.He claimed that based on Dr. Patilanos report, vital
internal organs of Carmen, such as her brain, lungs, kidneys, liver and adrenal glands, were not examined during
the autopsy.23
On January 28, 2003, the Regional Trial Court (RTC) of Olongapo City, Branch 75, rendered its Decision 24 in favor
of Pedrito. The trial court gave greater weight to the testimony of Dr. Patilano and thus disposed of the case as
follows:
WHEREFORE, premises considered, judgment is hereby rendered in favor of the plaintiff and against the
defendants, ordering the latter to pay jointly and severally, the former, the following sums of money, to wit:
1.) the sum of Php 28,759.46 as actual damages;
2.) the sum of Fifty Thousand (Php 50,000.00) Pesos as indemnity for the death of Carmen dela Torre;
3.) the sum of Fifty Thousand (Php 50,000.00) Pesos as moral damages and the further sum of Twenty
Thousand (Php 20,000.00) Pesos as exemplary damages;
4.) the sum of Twenty Thousand (Php 20,000.00) Pesos as attorneys fees; and
5.) the costs of [suit].
SO ORDERED.25
Dissatisfied with the RTC ruling, the respondents appealed to the CA. On December 15, 2009, the CA rendered its
Decision reversing and setting aside the decision of the RTC. For the appellate court, it was not established that the
respondents failed to exercisethe degree of diligence required of them by their profession as doctors. The CA also
granted the respondents counterclaim for the amount of P48,515.58, as it held:
WHEREFORE, the Decision of the Regional Trial Court of Olongapo City dated January 28, 2003 in Civil Case No.
165-0-92 is hereby REVERSED AND SET ASIDE.
Plaintiff-appellee is directed to pay the unpaid balance for hospital bills, professional fees and other expenses in the
amount of [P]48,515.58.
SO ORDERED.26
Hence, this petition for review on certiorariin which Pedrito insists that the respondents should be held liable for the
death of Carmen.
The petition is denied.
"[M]edical 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 professionalwhich has caused bodily harm." In order to
successfully pursue such a claim, a patient, or his or her family as in this case, "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 failure or action caused injury to the patient."27
The Court emphasized in Lucas, et al. v. Tuao28 that in medical negligence cases, there is a physician-patient
relationship between the doctor and the victim, but just like in any other proceeding for damages, four essential
elements must be established by the plaintiff, namely: (1) duty; (2) breach; (3) injury; and (4) proximate causation.
All four elements must be present in order to find the physician negligent and, thus, liable for damages. 29
It is settled that a physicians duty tohis patient relates to his exercise of the 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. There is breach of this duty when the patient is injured in body or in health. Proof of this
breach rests 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. To justify an award of damages, the negligence of the doctor must be
established to be the proximate cause of the injury. 30
Through the instant petition, Pedritoseeks the reinstatement of the decision of the RTC whose finding of the
respondents medical negligence depended mainly on the testimony of Dr. Patilano. Upon review, however, the
Court agrees with the CA that the report and testimony of Dr. Patilano failed to justify Pedritos entitlement to the
damages awarded by the RTC.
For the trial court to give weightto Dr. Patilanos report, it was necessary to show first Dr. Patilanos specialization
and competence to testify on the degree of care, skill and diligence needed for the treatment of Carmens case.
Considering that it was not duly established that Dr. Patilano practiced and was an expert inthe fields that involved
Carmens condition, he could not have accurately identified the said degree of care, skill, diligence and the medical
procedures that should have been applied by her attending physicians.
Similarly, such duty, degree of care, skill and diligence were not sufficiently established in this case because the
testimony of Dr. Patilano was based solely on the results of his autopsy on the cadaver of Carmen. His study and
assessment were restrictedby limitations that denied his full evaluation of Carmens case. He could have only
deduced from the injuries apparent in Carmens body, and in the condition when the body was examined. Judging
from his testimony, Dr. Patilano did not even take full consideration of the medical history of Carmen, her actual
health condition at the time of hospital admission, and her condition as it progressed while she was being
monitored and treated by the respondents. There was also no reference to the respondents defense that the
emergency caesarian section operation had to be performed in order to protect the lives and safety of Carmen and
her then unborn child. For lack of sufficient information on Carmens health condition while still alive, Dr. Patilano
104
could not have fully evaluated the suitability of the respondents decisions in handling Carmens medical condition
as it turned critical.
On the other hand, the CA pointed out that Dr. Nestor, a surgeon, possessed the reasonable degree of learning,
skill and experience required by his profession for the treatment ofCarmen. The respondents also emphasized in
their pleadings beforethe RTC that Dr. Nestor had his training and experience in surgery and obstetrics since
1970.1wphi1 Without sufficient proof from the claimant on a different degree of care, skill and diligence that should
be expected from the respondents, it could not be said with certainty that a breachwas actually committed.
Moreover, while Dr. Patilano opined that Carmen died of peritonitis which could be due to the poor state of the
hospital equipment and medical supplies used during her operation, there was no sufficient proof that any such
fault actually attended the surgery of Carmen, caused her illness and resulted in her death. It is also significant that
the Chief of the Medico-Legal Division of the PNP Crime Laboratory Service, Dr. Torres, testified before the trial
court that based on the autopsy report issued by Dr. Patilano, the latter did not comply with the basic autopsy
procedure when he examined the cadaver of Carmen. Dr. Patilano did not appear to have thoroughly examined
Carmens vital organs such as her heart, lungs, uterus and brain during the autopsy. His findings were then
inconclusive on the issue of the actual cause of Carmen's death, and the claim of negligence allegedly committed
by the respondents.
As the Court held in Spouses Flores v. Spouses Pineda, et al., 31 the critical and clinching factor in a medical
negligence case is proof of the causal connection between the negligence and the injuries. The claimant must
prove not only the injury but also the defendant's fault, and that such 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, 32 which the Court finds absent in the case at bar. As
regards the respondents' counterclaim, the CA's award of P48,515.58 is sustained, considering that among the
parties' stipulations during the pre-trial indicated:
5. That at the time of the death of the patient Carmen C. dela Torrell there was an unpaid balance for hospital bills,
professional fees and other expenses in the amount of P48,515.58, incurred by plaintiff when the patient was
confined at said hospital from February 3 to 13, 1992. 33
WHEREFORE, the petition is DENIED. The Decision dated December 15, 2009 and Resolution dated July 27,
2010 of the Court of Appeals in CA-G.R. CV No. 78534 are AFFIRMED.
SO ORDERED.
G.R. No. 210445, December 07, 2015
NILO B. ROSIT, Petitioner, v. DAVAO DOCTORS HOSPITAL AND DR. ROLANDO G. GESTUVO, Respondent.
DECISION
VELASCO JR., J.:
The Case
This is a petition filed under Rule 45 of the Rules of Court assailing the Decision and Resolution dated January 22,
20131 and November 7, 2013,2 respectively, of the Court of Appeals, Cagayan De Oro City (CA), in CA-G.R. CV
No. 00911-MIN. The CA Decision reversed the Decision dated September 14, 20043 of the Regional Trial Court,
Branch 33 in Davao City-(RTC) in Civil Case No. 27,354-99, a suit for damages thereat which Nilo B. Rosit (Rosit)
commenced against Dr. Rolando Gestuvo (Dr. Gestuvo).
Factual Antecedents
On January 15, 1999, Rosit figured in a motorcycle accident. The X-ray soon taken the next day at the Davao
Doctors Hospital (DDH) showed that he fractured his jaw. Rosit was then referred to Dr. Gestuvo, a specialist in
mandibular injuries,4 who, on January 19, 1999, operated on Rosit.
During the operation, Dr. Gestuvo used a metal plate fastened to the jaw with metal screws to immobilize the
mandible. As the operation required the smallest screws available, Dr. Gestuvo cut the screws on hand to make
them smaller. Dr. Gestuvo knew that there were smaller titanium screws available in Manila, but did not so inform
Rosit supposing that the latter would not be able to afford the same. 5
Following the procedure, Rosit could not properly open and close his mouth and was in pain. X-rays done on Rosit
two (2) days after the operation showed that the fracture in his jaw was aligned but the screws used on him touched
his molar. Given the X-ray results, Dr. Gestuvo referred Rosit to a dentist. The dentist who checked Rosit, Dr.
Pangan, opined that another operation is necessary and that it is to be performed in Cebu. 6
Alleging that the dentist told him that the operation conducted on his mandible was improperly done, Rosit went
back to Dr. Gestuvo to demand a loan to defray the cost of the additional operation as well as the expenses of the
trip to Cebu. Dr. Gestuvo gave Rosit P4,500.
Rosit went to Cebu on February 19, 1999, still suffering from pain and could hardly open his mouth.
In Cebu, Dr. Pangan removed the plate and screws thus installed by Dr. Gestuvo and replaced them with smaller
titanium plate and screws. Dr. Pangan also extracted Rosit's molar that was hit with a screw and some bone
fragments. Three days after the operation, Rosit was able to eat and speak well and could open and close his
mouth normally.7
On his return to Davao, Rosit demanded that Dr. Gestuvo reimburse him for the cost of the operation and the
expenses he incurred in Cebu amounting to P140,000, as well as for the P50,000 that Rosit would have to spend
for the removal of the plate and screws that Dr. Pangan installed. Dr. Gestuvo refused to pay. 8
Thus, Rosit filed a civil case for damages and attorney's fees with the RTC against Dr. Gestuvo and DDH, the suit
docketed as Civil Case No. 27,354-99.
The Ruling of the Regional Trial Court
The RTC freed DDH from liability on the ground that it exercised the proper diligence in the selection and
supervision of Dr. Gestuvo, but adjudged Dr. Gestuvo negligent and ruled, thus:
FOR ALL THE FOREGOING, finding the plaintiff Nilo B. Rosit to have preponderantly established his cause of
action in the complaint against defendant Dr. Rolando G. Gestuvo only, judgment is hereby rendered for the plaintiff
and against said defendant, ordering the defendant DR. ROLANDO G. GESTUVO to pay unto plaintiff NILO B.
ROSIT the following:chanRoblesvirtualLawlibrary
a) the sum of ONE HUNDRED FORTY THOUSAND ONE HUNDRED NINETY NINE PESOS and 13/100
(P140,199.13) representing reimbursement of actual expenses incurred by plaintiff in the operation and re-
105
 The Court's Ruling
operation of his mandible;
The petition is impressed with merit.

b) the sum of TWENTY NINE THOUSAND AND SIXTY EIGHT PESOS (P29,068.00) representing In Flores v. Pineda,9 the Court explained the concept of a medical negligence case and the elements required for
reimbursement of the filing fees and appearance fees; its prosecution, viz:chanRoblesvirtualLawlibrary

A medical negligence case is a type of claim to redress a wrong committed by a medical professional, that has
c) the sum of ONE HUNDRED FIFTY THOUSAND PESOS (P150,000.00) as and for attorney's fees; 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
d) the amount of FIFTY THOUSAND PESOS (P50,000.00) as moral damages; 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
e) the amount of TEN THOUSAND PESOS (P10,000.00) as exemplary damages; and results to the patient as a result of this breach, the physician is answerable for negligence. (Emphasis supplied)

f) the costs of the suit. An expert witness is not necessary as the res ipsa loquitur doctrine is applicable

For lack of merit, the complaint against defendant DAVAO DOCTORS HOSPITAL and the defendants'
counterclaims are hereby ordered DISMISSED.
Cost against Dr. Rolando G. Gestuvo.
SO ORDERED.
In so ruling, the trial court applied the res ipsa loquitur principle holding that "the need for expert, medical testimony
may be dispensed with because the injury itself provides the proof of negligence."
Therefrom, both parties appealed to the CA.
The Ruling of the Court of Appeals
In its January 22, 2013 Decision, the CA modified the appealed judgment by deleting the awards made by the trial
court, disposing as follows:
WHEREFORE, the appeal filed by Gestuvo is GRANTED. The Decision dated September 14, 2004 of the Regional
Trial Court, Branch 33, Davao City, rendered in Civil Case No. 27,354-99 is hereby MODIFIED. The monetary
awards adjudged in favor of Nilo B. Rosit are hereby DELETED for lack of basis.
SO ORDERED.
Unlike the RTC, the CA ruled that the res ipsa loquitur principle is not applicable and that the testimony of an expert
witness is necessary for a finding of negligence. The appellate court also gave credence to Dr. Pangan's letter
stating the opinion that Dr. Gestuvo did not commit gross negligence in his emergency management of Rosit's
fractured mandible.
To establish medical negligence, this Court has held that an expert testimony is generally required to define the
standard of behavior by which the court may determine whether the physician has properly performed the requisite
duty toward the patient. This is so considering that the requisite degree of skill and care in the treatment of a patient
is usually a matter of expert opinion.10
Solidum v. People of the Philippines11 provides an exception. There, the Court explained that where the application
of the principle of res ipsa loquitur is warranted, an expert testimony may be dispensed with in medical negligence
cases:
Although generally, expert medical testimony is relied upon in malpractice suits to prove that a physician
has done a negligent act or that he has deviated from the standard medical procedure, when the doctrine
of res ipsa loquitur is availed by the plaintiff, the need for expert medical testimony is dispensed with
because the injury itself provides the proof of negligence. The reason is that the general rule on the necessity
of expert testimony applies only to such matters clearly within the domain of medical science, and not to matters
that are within the common knowledge of mankind which may be testified to by anyone familiar with the facts. x x x
Thus, courts of other jurisdictions have applied the doctrine in the following situations: leaving of a foreign object in
the body of the patient after an operation, injuries sustained on a healthy part of the body which was not under, or
in the area, of treatment, removal of the wrong part of the body when another part was intended, knocking out a
tooth while a patient's jaw was under anesthetic for the removal of his tonsils, and loss of an eye while the patient
plaintiff was under the influence of anesthetic, during or following an operation for appendicitis, among others.
We have further held that resort to the doctrine of res ipsa loquitur as an exception to the requirement of an expert
testimony in medical negligence cases may be availed of if the following essential requisites are satisfied: (1) the
accident was of a kind that does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency
that caused the injury was under the exclusive control of the person charged; and (3) the injury suffered must not
have been due to any voluntary action or contribution of the person injured. 12

Rosit's motion for reconsideration was denied in the CA's November 7, 2013 Resolution. In its assailed Decision, the CA refused to acknowledge the application of the res ipsa loquitur doctrine on the
ground that the foregoing elements are absent. In particular, the appellate court is of the position that post-
Hence, the instant appeal. operative pain is not unusual after surgery and that there is no proof that the molar Dr. Pangan removed is the
same molar that was hit by the screw installed by Dr. Gestuvo in Rosit's mandible. Further, a second operation was
The Issue conducted within the 5-week usual healing period of the mandibular fracture so that the second element cannot be
considered present. Lastly, the CA pointed out that the X-ray examination conducted on Rosit prior to his first
surgery suggests that he had "chronic inflammatory lung disease compatible," implying that the injury may have
The ultimate issue for our resolution is whether the appellate court correctly absolved Dr. Gestuvo from liability.
been due to Rosit's peculiar condition, thus effectively negating the presence of the third element. 13
106
After careful consideration, this Court cannot accede to the CA's findings as it is at once apparent from the records
that the essential requisites for the application of the doctrine of res ipsa loquitur are present.
The first element was sufficiently established when Rosit proved that one of the screws installed by Dr. Gestuvo
struck his molar. It was for this issue that Dr. Gestuvo himself referred Rosit to Dr. Pangan. In fact, the affidavit of
Dr. Pangan presented by Dr. Gestuvo himself before the trial court narrated that the same molar struck with the
screw installed by Dr. Gestuvo was examined and eventually operated on by Dr. Pangan. Dr. Gestuvo cannot now
go back and say that Dr. Pangan treated a molar different from that which was affected by the first operation.
Clearly, had Dr. Gestuvo used the proper size and length of screws and placed the same in the proper locations,
these would not have struck Rosit's teeth causing him pain and requiring him to undergo a corrective surgery.
14
Dr. Gestuvo knew that the screws he used on Rosit were too large as, in fact, he cut the same with a saw. He
also stated during trial that common sense dictated that the smallest screws available should be used. More
importantly, he also knew that these screws were available locally at the time of the operation. 15 Yet, he did not
avail of such items and went ahead with the larger screws and merely sawed them off. Even assuming that the
screws were already at the proper length after Dr. Gestuvo cut the same, it is apparent that he negligently placed
one of the screws in the wrong area thereby striking one of Rosit's teeth.
In any event, whether the screw hit Rosit's molar because it was too long or improperly placed, both facts are the
product of Dr. Gestuvo's negligence. An average man of common intelligence would know that striking a tooth with
any foreign object much less a screw would cause severe pain. Thus, the first essential requisite is present in this
case.
Anent the second element for the res ipsa loquitur doctrine application, it is sufficient that the operation which
resulted in the screw hitting Rosit's molar was, indeed, performed by Dr. Gestuvo. No other doctor caused such
fact.
The CA finds that Rosit is guilty of contributory negligence in having Dr. Pangan operate on him during the healing
period of his fractured mandible. What the CA overlooked is that it was Dr. Gestuvo himself who referred Rosit to
Dr. Pangan. Nevertheless, Dr. Pangan's participation could not have contributed to the reality that the screw that
Dr. Gestuvo installed hit Rosit's molar.
Lastly, the third element that the injury suffered must not have been due to any voluntary action or contribution of
the person injured was satisfied in this case. It was not shown that Rosit's lung disease could have contributed to
the pain. What is clear is that he suffered because one of the screws that Dr. Gestuvo installed hit Rosit's molar.
Clearly then, the res ipsa loquitur doctrine finds application in the instant case and no expert testimony is
required to establish the negligence of defendant Dr. Gestuvo.
Petitioner was deprived of the opportunity to make an "informed consent"
What is more damning for Dr. Gestuvo is his failure to inform Rosit that such smaller screws were available in
Manila, albeit at a higher price.16 As testified to by Dr. Gestuvo himself:
Court This titanium materials according to you were already available in the Philippines since the time of
Alright. Rosit's accident?
Witness Yes, your Honor.
xxxx
Court Did you inform Rosit about the existence of titanium screws and plates which according to you is the
screws and plates of choice?
Witness No, your Honor.
xxxx
Witness The reason I did not inform him anymore Judge because what I thought he was already hard up with the
down payment. And if I will further introduce him this screws, the more he will not be able to afford the
operation.
xxxx
Court This titanium screws and plates were available then it is up to Rosit to decide whether to use it or not
because after all the material you are using is paid by the patient himscll, is it not?
Witness Yes, that is true.
Li v. Soliman17 made the following disquisition on the relevant Doctrine of Informed Consent in relation to medical
negligence cases, to wit:
The doctrine of informed consent within the context of physician-patient relationships goes far back into English
common law. x x x 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.
xxxx
There are four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of
informed consent: "(1) the physician had a duty to disclose material risks; (2) he failed to disclose or
inadequately disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the
patient consented to treatment she otherwise would not have consented to; and (4) plaintiff was injured by
the proposed treatment." The gravamen in an informed consent case requires the plaintiff to "point to significant
undisclosed information relating to the treatment which would have altered her decision to undergo it." (Emphasis
supplied)
The four adverted essential elements above are present here.
First, Dr. Gestuvo clearly had the duty of disclosing to Rosit the risks of using the larger screws for the operation.
This was his obligation as the physician undertaking the operation.
107
Second, Dr. Gestuvo failed to disclose these risks to Rosit, deciding by himself that Rosit could not afford to get the
more expensive titanium screws.
Third, had Rosit been informed that there was a risk that the larger screws are not appropriate for the operation and
that an additional operation replacing the screws might be required to replace the same, as what happened in this
case, Rosit would not have agreed to the operation. It bears pointing out that Rosit was, in fact, able to afford the
use of the smaller titanium screws that were later used by Dr. Pangan to replace the screws that were used by Dr.
Gestuvo.
Fourth, as a result of using the larger screws, Rosit experienced pain and could not heal properly because one of
the screws hit his molar. This was evident from the fact that just three (3) days after Dr. Pangan repeated the
operation conducted by Dr. Gestuvo, Rosit was pain-free and could already speak. This is compared to the one (1)
month that Rosit suffered pain and could not use his mouth after the operation conducted by Dr. Gestuvo until the
operation of Dr. Pangan.
Without a doubt, Dr. Gestuvo is guilty of withholding material information which would have been vital in the
decision of Rosit in going through with the operation with the materials at hand. Thus, Dr. Gestuvo is also guilty of
negligence on this ground.
Dr. Pangan's Affidavit is not admissible
The appellate court's Decision absolving Dr. Gestuvo of negligence was also anchored on a letter signed by Dr.
Pangan who stated the opinion that Dr. Gestuvo did not commit gross negligence in his emergency management of
Mr. Rosit's fractured mandible.18 Clearly, the appellate court overlooked the elementary principle against hearsay
evidence.
In Dantis v. Maghinang, Jr.,19 the Court reiterated the oft-repeated rule that "an affidavit is merely hearsay evidence
where its affiant/maker did not take the witness stand." Here, Dr. Pangan never took the witness stand to affirm the
contents of his affidavit. Thus, the affidavit is inadmissible and cannot be given any weight. The CA, therefore,
erred when it considered the affidavit of Dr. Pangan, mpreso for considering the same as expert testimony.
Moreover, even if such affidavit is considered as admissible and the testimony of an expert witness, the Court is not
bound by such testimony. As ruled in Ilao-Quianay v. Mapile:20
Indeed, courts are not bound by expert testimonies. They may place whatever weight they choose upon such
testimonies in accordance with the facts of the case. The relative weight and sufficiency of expert testimony is
peculiarly within the province of the trial court to decide, considering the ability and character of the witness, his
actions upon the witness stand, the weight and process of the reasoning by which he has supported his opinion, his
possible bias in favor of the side for whom he testifies, and any other matters which serve to illuminate his
statements. The opinion of an expert should be considered by the court in view of all the facts and circumstances of
the case. The problem of the evaluation of expert testimony is left to the discretion of the trial court whose ruling
thereupon is not revicwable in the absence of an abuse of that discretion.
Thus, the belief of Dr. Pangan whether Dr. Gestuvo is guilty of negligence or not will not bind the Court. The Court
must weigh and examine such testimony and decide for itself the merits thereof.
As discussed above, Dr. Gestuvo's negligence is clearly demonstrable by the doctrines of res ipsa loquitur and
informed consent.
Damages
For the foregoing, the trial court properly awarded Rosit actual damages after he was able to prove the actual
expenses that he incurred due to the negligence of Dr. Gestuvo. In Mendoza v. Spouses Gomez,21 the Court
explained that a claimant is entitled to actual damages when the damage he sustained is the natural and probable
consequences of the negligent act and he adequately proved the amount of such damage.
Rosit is also entitled to moral damages as provided under Article 2217 of the Civil Code,22 given the unnecessary
physical suffering he endured as a consequence of defendant's negligence.
To recall, from the time he was negligently operated upon by Dr. Gestuvo until three (3) days from the corrective
surgery performed by Dr. Pangan, or for a period of one (1) month, Rosit suffered pain and could not properly use
his jaw to speak or eat.
The trial court also properly awarded attorney's fees and costs of suit under Article 2208 of the Civil Code, 23 since
Rosit was compelled to litigate due to Dr. Gestuvo's refusal to pay for Rosit's damages.
As to the award of exemplary damages, the same too has to be affirmed. In Mendoza,24 the Court enumerated the
requisites for the award of exemplary damages:
Our jurisprudence sets certain conditions when exemplary damages may be awarded: First, they may be imposed
by way of example or correction only in addition, among others, to compensatory damages, and cannot be
recovered as a matter of right, their determination depending upon the amount of compensatory damages that may
be awarded to the claimant. Second, the claimant must first establish his right to moral, temperate, liquidated or
compensatory damages. Third, the wrongful act must be accompanied by bad faith, and the award would be
allowed only if the guilty party acted in a wanton, fraudulent, reckless, oppressive or malevolent manner.
The three (3) requisites are met. Dr. Gestuvo's actions are clearly negligent. Likewise, Dr. Gestuvo acted in bad
faith or in a wanton, fraudulent, reckless, oppressive manner when he was in breach of the doctrine of informed
consent. Dr. Gestuvo had the duty to fully explain to Rosit the risks of using large screws for the operation. More
importantly, he concealed the correct medical procedure of using the smaller titanium screws mainly because of his
erroneous belief that Rosit cannot afford to buy the expensive titanium screws. Such concealment is clearly a valid
basis for an award of exemplary damages.
WHEREFORE, the instant petition is GRANTED. The CA Decision dated January 22, 2013 and Resolution dated
November 7, 2013 in CA-G.R. CV No. 00911-MIN are hereby REVERSED and SET ASIDE. Further, the Decision
dated September 14, 2004 of the Regional Trial Court, Branch 33 in Davao City in Civil Case No. 27,345-99 is
hereby REINSTATED and AFFIRMED.
SO ORDERED.chanroblesvirtuallawlibrary
G.R. No. 192123 March 10, 2014
DR. FERNANDO P. SOLIDUM, Petitioner,
vs.
PEOPLE OF THE PHILIPPINES, Respondent.
DECISION
BERSAMIN, J.:
This appeal is taken by a physician-anesthesiologist who has been pronounced guilty of reckless imprudence
resulting in serious physical injuries by the Regional Trial Court (RTC) and the Court of Appeals (CA). He had been
part of the team of anesthesiologists during the surgical pull-through operation conducted on a three-year old
patient born with an imperforate anus.1
The antecedents are as follows:
108
Gerald Albert Gercayo (Gerald) was born on June 2, 19922 with an imperforate anus. Two days after his birth,
Gerald underwent colostomy, a surgical procedure to bring one end of the large intestine out through the abdominal
wall,3 enabling him to excrete through a colostomy bag attached to the side of his body. 4
On May 17, 1995, Gerald, then three years old, was admitted at the Ospital ng Maynila for a pull-through
operation.5 Dr. Leandro Resurreccion headed the surgical team, and was assisted by Dr. Joselito Luceo, Dr.
Donatella Valea and Dr. Joseph Tibio. The anesthesiologists included Dr. Marichu Abella, Dr. Arnel Razon and
petitioner Dr. Fernando Solidum (Dr. Solidum).6 During the operation, Gerald experienced bradycardia, 7 and went
into a coma.8 His coma lasted for two weeks,9 but he regained consciousness only after a month.10 He could no
longer see, hear or move.11
Agitated by her sons helpless and unexpected condition, Ma. Luz Gercayo (Luz) lodged a complaint for reckless
imprudence resulting in serious physical injuries with the City Prosecutors Office of Manila against the attending
physicians.12
Upon a finding of probable cause, the City Prosecutors Office filed an information solely against Dr.
Solidum,13alleging:
That on or about May 17, 1995, in the City of Manila, Philippines, the said accused, being then an anesthesiologist
at the Ospital ng Maynila, Malate, this City, and as such was tasked to administer the anesthesia on three-year old
baby boy GERALD ALBERT GERCAYO, represented by his mother, MA. LUZ GERCAYO, the former having been
born with an imperforate anus [no anal opening] and was to undergo an operation for anal opening [pull through
operation], did then and there willfully, unlawfully and feloniously fail and neglect to use the care and diligence as
the best of his judgment would dictate under said circumstance, by failing to monitor and regulate properly the
levels of anesthesia administered to said GERALD ALBERT GERCAYO and using 100% halothane and other
anesthetic medications, causing as a consequence of his said carelessness and negligence, said GERALD
ALBERT GERCAYO suffered a cardiac arrest and consequently a defect called hypoxic encephalopathy meaning
insufficient oxygen supply in the brain, thereby rendering said GERALD ALBERT GERCAYO incapable of moving
his body, seeing, speaking or hearing, to his damage and prejudice.
Contrary to law.14
The case was initially filed in the Metropolitan Trial Court of Manila, but was transferred to the RTC pursuant to
Section 5 of Republic Act No. 8369 (The Family Courts Act of 1997),15 where it was docketed as Criminal Case No.
01-190889.
Judgment of the RTC
On July 19, 2004, the RTC rendered its judgment finding Dr. Solidum guilty beyond reasonable doubt of reckless
imprudence resulting to serious physical injuries, 16 decreeing:
WHEREFORE, premises considered, the Court finds accused DR. FERNANDO P. SOLIDUM GUILTY beyond
reasonable doubt as principal of the crime charged and is hereby sentenced to suffer the indeterminate penalty of
TWO (2) MONTHS and ONE (1) DAY of arresto mayor as minimum to ONE (1) YEAR, ONE (1) MONTH and TEN
(10) DAYS of prision correccional as maximum and to indemnify, jointly and severally with the Ospital ng Maynila,
Dr. Anita So and Dr. Marichu Abella, private complainant Luz Gercayo, the amount of P500,000.00 as moral
damages and P100,000.00 as exemplary damages and to pay the costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby CANCELLED.
SO ORDERED.17
Upon motion of Dr. Anita So and Dr. Marichu Abella to reconsider their solidary liability, 18 the RTC excluded them
from solidary liability as to the damages, modifying its decision as follows:
WHEREFORE, premises considered, the Court finds accused Dr. Fernando Solidum, guilty beyond reasonable
doubt as principal of the crime charged and is hereby sentenced to suffer the indeterminate penalty of two (2)
months and one (1) day of arresto mayor as minimum to one (1) year, one (1) month and ten (10) days of prision
correccional as maximum and to indemnify jointly and severally with Ospital ng Maynila, private complainant Luz
Gercayo the amount of P500,000.00 as moral damages and P100,000 as exemplary damages and to pay the
costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby cancelled. 19
Decision of the CA
On January 20, 2010, the CA affirmed the conviction of Dr. Solidum, 20 pertinently stating and ruling:
The case appears to be a textbook example of res ipsa loquitur.
xxxx
x x x [P]rior to the operation, the child was evaluated and found fit to undergo a major operation. As noted by the
OSG, the accused himself testified that pre-operation tests were conducted to ensure that the child could withstand
the surgery. Except for his imperforate anus, the child was healthy. The tests and other procedures failed to reveal
that he was suffering from any known ailment or disability that could turn into a significant risk. There was not a hint
that the nature of the operation itself was a causative factor in the events that finally led to hypoxia.
In short, the lower court has been left with no reasonable hypothesis except to attribute the accident to a failure in
the proper administration of anesthesia, the gravamen of the charge in this case. The High Court elucidates in
Ramos vs. Court of Appeals 321 SCRA 584
In cases where the res ipsa loquitur is applicable, the court is permitted to find a physician negligent upon proper
proof of injury to the patient, without the aid of expert testimony, where the court from its fund of common
knowledge can determine the proper standard of care.
Where common knowledge and experience teach that a resulting injury would not have occurred to the patient if
due care had been exercised, an inference of negligence may be drawn giving rise to an application of the doctrine
of res ipsa loquitur without medical evidence, which is ordinarily required to show not only what occurred but how
and why it occurred. 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
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.
The lower court has found that such a nexus exists between the act complained of and the injury sustained, and in
line with the hornbook rules on evidence, we will afford the factual findings of a trial court the respect they deserve
in the absence of a showing of arbitrariness or disregard of material facts that might affect the disposition of the
case. People v. Paraiso 349 SCRA 335.
109
The res ipsa loquitur test has been known to be applied in criminal cases. Although it creates a presumption of
negligence, it need not offend due process, as long as the accused is afforded the opportunity to go forward with
his own evidence and prove that he has no criminal intent. It is in this light not inconsistent with the constitutional
presumption of innocence of an accused.
IN VIEW OF THE FOREGOING, the modified decision of the lower court is affirmed.
SO ORDERED.21
Dr. Solidum filed a motion for reconsideration, but the CA denied his motion on May 7, 2010. 22
Hence, this appeal.
Issues
Dr. Solidum avers that:
I.
THE HONORABLE COURT OF APPEALS ERRED IN AFFIRMING THE DECISION OF THE LOWER
COURT IN UPHOLDING THE PETITIONERS CONVICTION FOR THE CRIME CHARGED BASED ON
THE TRIAL COURTS OPINION, AND NOT ON THE BASIS OF THE FACTS ESTABLISHED DURING
THE TRIAL. ALSO, THERE IS A CLEAR MISAPPREHENSION OF FACTS WHICH IF CORRECTED,
WILL RESULT TO THE ACQUITTAL OF THE PETITIONER. FURTHER, THE HONORABLE COURT
ERRED IN AFFIRMING THE SAID DECISION OF THE LOWER COURT, AS THIS BREACHES THE
CRIMINAL LAW PRINCIPLE THAT THE PROSECUTION MUST PROVE THE ALLEGATIONS OF THE
INFORMATION BEYOND REASONABLE DOUBT, AND NOT ON THE BASIS OF ITS PRESUMPTIVE
CONCLUSION.
II.
THE HONORABLE COURT OF APPEALS ERRED IN APPLYING THE PRINCIPLE OF RES IPSA
LOQUITOR (sic) WHEN THE DEFENSE WAS ABLE TO PROVE THAT THERE IS NO NEGLIGENCE
ON THE PART OF THE PETITIONER, AND NO OVERDOSING IN THE APPLICATION OF THE
ANESTHETIC AGENT BECAUSE THERE WAS NO 100% HALOTHANE ADMINISTERED TO THE
CHILD, BUT ONLY ONE (1%) PERCENT AND THE APPLICATION THEREOF, WAS REGULATED BY
AN ANESTHESIA MACHINE. THUS, THE APPLICATION OF THE PRINCIPLE OF RES IPSA
LOQUITOR (sic) CONTRADICTED THE ESTABLISHED FACTS AND THE LAW APPLICABLE IN THE
CASE.
III.
THE AWARD OF MORAL DAMAGES AND EXEMPLARY DAMAGES IS NOT JUSTIFIED THERE BEING
NO NEGLIGENCE ON THE PART OF THE PETITIONER. ASSUMING THAT THE CHILD IS ENTITLED
TO FINANCIAL CONSIDERATION, IT SHOULD BE ONLY AS A FINANCIAL ASSISTANCE, BECAUSE
THERE WAS NO NEGLIGENCE, AND NO OVERDOSING OF ANESTHETIC AGENT AND AS SUCH,
THE AWARD IS SO EXCESSIVE, AND NO FACTUAL AND LEGAL BASIS.23
To simplify, the following are the issues for resolution, namely: (a) whether or not the doctrine of res ipsa loquitur
was applicable herein; and (b) whether or not Dr. Solidum was liable for criminal negligence.
Ruling
The appeal is meritorious.
Applicability of the Doctrine of Res Ipsa Loquitur
Res ipsa loquitur is literally translated as "the thing or the transaction speaks for itself." The doctrine res ipsa
loquitur means that "where the thing which causes injury is shown to be under the management of the defendant,
and the accident is such as in the ordinary course of things does not happen if those who have the management
use proper care, it affords reasonable evidence, in the absence of an explanation by the defendant, that the
accident arose from want of care."24 It 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. It is grounded in the superior logic of ordinary human experience
and on the basis of such experience or common knowledge, negligence may be deduced from the mere
occurrence of the accident itself.
Hence, res ipsa loquitur is applied in conjunction with the doctrine of common knowledge." 25
Jarcia, Jr. v. People26 has underscored that the doctrine is not a rule of substantive law, but merely a mode of proof
or a mere procedural convenience. The doctrine, when applicable to the facts and circumstances of a given case, is
not meant to and does not dispense with the requirement of proof of culpable negligence against the party charged.
It merely determines and regulates what shall be prima facie evidence thereof, and helps the plaintiff in proving a
breach of the duty. The doctrine can be invoked when and only when, under the circumstances involved, direct
evidence is absent and not readily available.27
The applicability of the doctrine of res ipsa loquitur in medical negligence cases was significantly and exhaustively
explained in Ramos v. Court of Appeals,28 where the Court said
Medical malpractice 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. 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.
Although generally, expert medical testimony is relied upon in malpractice suits to prove that a physician has done
a negligent act or that he has deviated from the standard medical procedure, when the doctrine of res ipsa loquitur
is availed by the plaintiff, the need for expert medical testimony is dispensed with because the injury itself provides
the proof of negligence. The reason is that the general rule on the necessity of expert testimony applies only to
such matters clearly within the domain of medical science, and not to matters that are within the common
knowledge of mankind which may be testified to by anyone familiar with the facts. 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 experience
110
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 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, 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 patients jaw was under anesthetic for the removal of his tonsils, and loss of an eye while the patient
plaintiff was under the influence of anesthetic, during or following an operation for appendicitis, among others.
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. 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. 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. 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. 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. If there was such extraneous
intervention, the 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.
In order to allow resort to the doctrine, therefore, the following essential requisites must first be satisfied, to wit: (1)
the accident was of a kind that does not ordinarily occur unless someone is negligent; (2) the instrumentality or
agency that caused the injury was under the exclusive control of the person charged; and (3) the injury suffered
must not have been due to any voluntary action or contribution of the person injured.29
The Court considers the application here of the doctrine of res ipsa loquitur inappropriate. Although it should be
conceded without difficulty that the second and third elements were present, considering that the anesthetic agent
and the instruments were exclusively within the control of Dr. Solidum, and that the patient, being then unconscious
during the operation, could not have been guilty of contributory negligence, the first element was undeniably
wanting. Luz delivered Gerald to the care, custody and control of his physicians for a pull-through operation. Except
for the imperforate anus, Gerald was then of sound body and mind at the time of his submission to the physicians.
Yet, he experienced bradycardia during the operation, causing loss of his senses and rendering him immobile.
Hypoxia, or the insufficiency of oxygen supply to the brain that caused the slowing of the heart rate, scientifically
termed as bradycardia, would not ordinarily occur in the process of a pull-through operation, or during the
administration of anesthesia to the patient, but such fact alone did not prove that the negligence of any of his
attending physicians, including the anesthesiologists, had caused the injury. In fact, the anesthesiologists attending
to him had sensed in the course of the operation that the lack of oxygen could have been triggered by the vago-
vagal reflex, prompting them to administer atropine to the patient.30
This conclusion is not unprecedented. It was similarly reached in Swanson v. Brigham, 31 relevant portions of the
decision therein being as follows:
On January 7, 1973, Dr. Brigham admitted 15-year-old Randall Swanson to a hospital for the treatment of infectious
mononucleosis. The patient's symptoms had included a swollen throat and some breathing difficulty. Early in the
morning of January 9 the patient was restless, and at 1:30 a.m. Dr. Brigham examined the patient. His inspection of
the patient's air passage revealed that it was in satisfactory condition. At 4:15 a.m. Dr. Brigham received a
telephone call from the hospital, advising him that the patient was having respiratory difficulty. The doctor ordered
that oxygen be administered and he prepared to leave for the hospital. Ten minutes later, 4:25 a.m., the hospital
called a second time to advise the doctor that the patient was not responding. The doctor ordered that a medicine
be administered, and he departed for the hospital. When he arrived, the physician who had been on call at the
hospital had begun attempts to revive the patient. Dr. Brigham joined him in the effort, but the patient died.
The doctor who performed the autopsy concluded that the patient died between 4:25 a.m. and 4:30 a.m. of
asphyxia, as a result of a sudden, acute closing of the air passage. He also found that the air passage had been
adequate to maintain life up to 2 or 3 minutes prior to death. He did not know what caused the air passage to
suddenly close.
xxxx
It is a rare occurrence when someone admitted to a hospital for the treatment of infectious mononucleosis dies of
asphyxiation. But that is not sufficient to invoke res ipsa loquitur. The fact that the injury rarely occurs does not in
itself prove that the injury was probably caused by someone's negligence. Mason v. Ellsworth, 3 Wn. App. 298, 474
P.2d 909 (1970). Nor is a bad result by itself enough to warrant the application of the doctrine. Nelson v. Murphy,
42 Wn.2d 737, 258 P.2d 472 (1953). See 2 S. Speiser, The Negligence Case Res Ipsa Loquitur 24:10 (1972).
The evidence presented is insufficient to establish the first element necessary for application of res ipsa loquitur
doctrine. The acute closing of the patients air passage and his resultant asphyxiation took place over a very short
period of time. Under these circumstances it would not be reasonable to infer that the physician was negligent.
There was no palpably negligent act. The common experience of mankind does not suggest that death would not
be expected without negligence. And there is no expert medical testimony to create an inference that negligence
caused the injury.
Negligence of Dr. Solidum
In view of the inapplicability of the doctrine of res ipsa loquitur, the Court next determines whether the CA correctly
affirmed the conviction of Dr. Solidum for criminal negligence.
Negligence is defined as the failure to observe for the protection of the interests of another person that degree of
care, precaution, and vigilance that the circumstances justly demand, whereby such other person suffers
injury.32Reckless imprudence, on the other hand, consists of voluntarily doing or failing to do, without malice, an act
from which material damage results by reason of an inexcusable lack of precaution on the part of the person
performing or failing to perform such act.33
Dr. Solidums conviction by the RTC was primarily based on his failure to monitor and properly regulate the level of
anesthetic agent administered on Gerald by overdosing at 100% halothane. In affirming the conviction, the CA
observed:
On the witness stand, Dr. Vertido made a significant turnaround. He affirmed the findings and conclusions in his
report except for an observation which, to all intents and purposes, has become the storm center of this dispute. He
wanted to correct one piece of information regarding the dosage of the anesthetic agent administered to the child.
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He declared that he made a mistake in reporting a 100% halothane and said that based on the records it should
have been 100% oxygen.
The records he was relying on, as he explains, are the following:
(a) the anesthesia record A portion of the chart in the record was marked as Exhibit 1-A and 1-B to
indicate the administration at intervals of the anesthetic agent.
(b) the clinical abstract A portion of this record that reads as follows was marked Exhibit 3A. 3B
Approximately 1 hour and 45 minutes through the operation, patient was noted to have bradycardia (CR =
70) and ATSO4 0.2 mg was immediately administered. However, the bradycardia persisted, the
inhalational agent was shut off, and the patient was ventilated with 100% oxygen and another dose of
ATSO4 0.2 mg was given. However, the patient did not respond until no cardiac rate can be auscultated
and the surgeons were immediately told to stop the operation. The patient was put on a supine position
and CPR was initiated. Patient was given 1 amp of epinephrine initially while continuously doing cardiac
massage still with no cardiac rate appreciated; another ampule of epinephrine was given and after 45
secs, patients vital signs returned to normal. The entire resuscitation lasted approximately 3-5 mins. The
surgeons were then told to proceed to the closure and the childs vital signs throughout and until the end
of surgery were: BP = 110/70; CR = 116/min and RR = 20-22 cycles/min (on assisted ventilation).
Dr. Vertido points to the crucial passage in the clinical abstract that the patient was ventilated with 100% oxygen
and another dose of ATSO4 when the bradycardia persisted, but for one reason or another, he read it as 100%
halothane. He was asked to read the anesthesia record on the percentage of the dosage indicated, but he could
only sheepishly note I cant understand the number. There are no clues in the clinical abstract on the quantity of the
anesthetic agent used. It only contains the information that the anesthetic plan was to put the patient under general
anesthesia using a nonrebreathing system with halothane as the sole anesthetic agent and that 1 hour and 45
minutes after the operation began, bradycardia occurred after which the inhalational agent was shut off and the
patient administered with 100% oxygen. It would be apparent that the 100% oxygen that Dr. Vertido said should be
read in lieu of 100% halothane was the pure oxygen introduced after something went amiss in the operation and
the halothane itself was reduced or shut off.
The key question remains what was the quantity of halothane used before bradycardia set in?
The implication of Dr. Vertidos admission is that there was no overdose of the anesthetic agent, and the accused
Dr. Solidum stakes his liberty and reputation on this conclusion. He made the assurance that he gave his patient
the utmost medical care, never leaving the operating room except for a few minutes to answer the call of nature but
leaving behind the other members of his team Drs. Abella and Razon to monitor the operation. He insisted that he
administered only a point 1% not 100% halothane, receiving corroboration from Dr. Abella whose initial MA in the
record should be enough to show that she assisted in the operation and was therefore conversant of the things that
happened. She revealed that they were using a machine that closely monitored the concentration of the agent
during the operation.
But most compelling is Dr. Solidums interpretation of the anesthesia record itself, as he takes the bull by the horns,
so to speak. In his affidavit, he says, reading from the record, that the quantity of halothane used in the operation is
one percent (1%) delivered at time intervals of 15 minutes. He studiedly mentions the concentration of halothane
as reflected in the anesthesia record (Annex D of the complaint-affidavit) is only one percent (1%) The numbers
indicated in 15 minute increments for halothane is an indication that only 1% halothane is being delivered to the
patient Gerard Gercayo for his entire operation; The amount of halothane delivered in this case which is only one
percent cannot be summated because halothane is constantly being rapidly eliminated by the body during the
entire operation.
xxxx
In finding the accused guilty, despite these explanations, the RTC argued that the volte-face of Dr. Vertido on the
question of the dosage of the anesthetic used on the child would not really validate the non-guilt of the
anesthesiologist. Led to agree that the halothane used was not 100% as initially believed, he was nonetheless
unaware of the implications of the change in his testimony. The court observed that Dr. Vertido had described the
condition of the child as hypoxia which is deprivation of oxygen, a diagnosis supported by the results of the CT
Scan. All the symptoms attributed to a failing central nervous system such as stupor, loss of consciousness,
decrease in heart rate, loss of usual acuity and abnormal motor function, are manifestations of this condition or
syndrome. But why would there be deprivation of oxygen if 100% oxygen to 1% halothane was used? Ultimately, to
the court, whether oxygen or halothane was the object of mistake, the detrimental effects of the operation are
incontestable, and they can only be led to one conclusion if the application of anesthesia was really closely
monitored, the event could not have happened.34
The Prosecution did not prove the elements of reckless imprudence beyond reasonable doubt because the
circumstances cited by the CA were insufficient to establish that Dr. Solidum had been guilty of inexcusable lack of
precaution in monitoring the administration of the anesthetic agent to Gerald. The Court aptly explained in Cruz v.
Court of Appeals35 that:
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. In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pacasio, et. al., 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. 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.
xxxx
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
a causal connection of such breach and the resulting death of his patient. In Chan Lugay v. St Luke's Hospital, Inc.,
where the attending physician was absolved of liability for the death of the complainants 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."
An action upon medical negligence whether criminal, civil or administrative calls for the plaintiff to prove by
competent evidence each of the following four elements, namely: (a) the duty owed by the physician to the patient,
as created by the physician-patient relationship, to act in accordance with the specific norms or standards
112
established by his profession; (b) the breach of the duty by the physicians failing to act in accordance with the
applicable standard of care; (3) the causation, i.e., there must be a reasonably close and causal connection
between the negligent act or omission and the resulting injury; and (4) the damages suffered by the patient. 36
In the medical profession, specific norms or standards to protect the patient against unreasonable risk, commonly
referred to as standards of care, set the duty of the physician to act in respect of the patient. Unfortunately, no clear
definition of the duty of a particular physician in a particular case exists. Because most medical malpractice cases
are highly technical, witnesses with special medical qualifications must provide guidance by giving the knowledge
necessary to render a fair and just verdict. As a result, the standard of medical care of a prudent physician must be
determined from expert testimony in most cases; and in the case of a specialist (like an anesthesiologist), the
standard of care by which the specialist is judged is the care and skill commonly possessed and exercised by
similar specialists under similar circumstances. The specialty standard of care may be higher than that required of
the general practitioner.37
The standard of care is an objective standard by which the conduct of a physician sued for negligence or
malpractice may be measured, and it does not depend, therefore, on any individual physicians own knowledge
either. In attempting to fix a standard by which a court may determine whether the physician has properly
performed the requisite duty toward the patient, expert medical testimony from both plaintiff and defense experts is
required. The judge, as the trier of fact, ultimately determines the standard of care, after listening to the testimony of
all medical experts.38
Here, the Prosecution presented no witnesses with special medical qualifications in anesthesia to provide guidance
to the trial court on what standard of care was applicable. It would consequently be truly difficult, if not impossible,
to determine whether the first three elements of a negligence and malpractice action were attendant.
Although the Prosecution presented Dr. Benigno Sulit, Jr., an anesthesiologist himself who served as the Chairman
of the Committee on Ethics and Malpractice of the Philippine Society of Anesthesiologists that investigated the
complaint against Dr. Solidum, his testimony mainly focused on how his Committee had conducted the
investigation.39 Even then, the report of his Committee was favorable to Dr. Solidum, 40 to wit:
Presented for review by this committee is the case of a 3 year old male who underwent a pull-thru operation and
was administered general anesthesia by a team of anesthesia residents. The patient, at the time when the
surgeons was manipulating the recto-sigmoid and pulling it down in preparation for the anastomosis, had
bradycardia. The anesthesiologists, sensing that the cause thereof was the triggering of the vago-vagal reflex,
administered atropine to block it but despite the administration of the drug in two doses, cardiac arrest ensued. As
the records show, prompt resuscitative measures were administered and spontaneous cardiac function re-
established in less than five (5) minutes and that oxygen was continuously being administered throughout,
unfortunately, as later become manifest, patient suffered permanent irreversible brain damage.
In view of the actuations of the anaesthesiologists and the administration of anaesthesia, the committee find that
the same were all in accordance with the universally accepted standards of medical care and there is no evidence
of any fault or negligence on the part of the anaesthesiologists.
Dr. Antonio Vertido, a Senior Medico-Legal Officer of the National Bureau of Investigation, was also presented as a
Prosecution witness, but his testimony concentrated on the results of the physical examination he had conducted
on Gerald, as borne out by the following portions of his direct examination, to wit:
FISCAL CABARON Doctor, what do you mean by General Anesthetic Agent?
WITNESS General Anesthetic Agent is a substance used in the conduction of Anesthesia and in this case,
halothane was used as a sole anesthetic agent.
xxxx
Q Now under paragraph two of page 1 of your report you mentioned that after one hour and 45 minutes after the
operation, the patient experienced a bradycardia or slowing of heart rate, now as a doctor, would you be able to tell
this Honorable Court as to what cause of the slowing of heart rate as to Gerald Gercayo?
WITNESS Well honestly sir, I cannot give you the reason why there was a bradycardia of time because is some
reason one way or another that might caused bradycardia.
FISCAL CABARON What could be the possible reason?
A Well bradycardia can be caused by anesthetic agent itself and that is a possibility, were talking about possibility
here.
Q What other possibility do you have in mind, doctor?
A Well, because it was an operation, anything can happen within that situation.
FISCAL CABARON Now, this representation would like to ask you about the slowing of heart rate, now what is the
immediate cause of the slowing of the heart rate of a person?
WITNESS Well, one of the more practical reason why there is slowing of the heart rate is when you do a vagal
reflex in the neck wherein the vagal receptors are located at the lateral part of the neck, when you press that, you
produce the slowing of the heart rate that produce bradycardia.
Q I am pro[p]ounding to you another question doctor, what about the deficiency in the supply of oxygen by the
patient, would that also cause the slowing of the heart rate?
A Well that is a possibility sir, I mean not as slowing of the heart rate, if there is a hypoxia or there is a low oxygen
level in the blood, the normal thing for the heart is to pump or to do not a bradycardia but a to counter act the
Hypoxia that is being experienced by the patient
(sic).
xxxx
Q Now, you made mention also doctor that the use of general anesthesia using 100% halothane and other
anesthetic medications probably were contributory to the production of hypoxia.
A Yes, sir in general sir.41
On cross-examination, Dr. Vertido expounded more specifically on his interpretation of the anesthesia record and
the factors that could have caused Gerald to experience bradycardia, viz:
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ATTY. COMIA I noticed in, may I see your report Doctor, page 3, will you kindly read to this Honorable court your
last paragraph and if you will affirm that as if it is correct?
A "The use of General Anesthesia, that is using 100% Halothane probably will be contributory to the production of
Hypoxia and - - - -"
ATTY COMIA And do you affirm the figure you mentioned in this Court Doctor?
WITNESS Based on the records, I know the - - -
Q 100%?
A 100% based on the records.
Q I will show you doctor a clinical record. I am a lawyer I am not a doctor but will you kindly look at this and tell me
where is 100%, the word "one hundred" or 1-0-0, will you kindly look at this Doctor, this Xerox copy if you can show
to this Honorable Court and even to this representation the word "one hundred" or 1-0-0 and then call me.
xxxx
ATTY. COMIA Doctor tell this Honorable Court where is that 100, 1-0-0 and if there is, you just call me and even
the attention of the Presiding Judge of this Court. Okay, you read one by one.
WITNESS Well, are you only asking 100%, sir?
ATTY. COMIA Im asking you, just answer my question, did you see there 100% and 100 figures, tell me, yes or
no?
WITNESS Im trying to look at the 100%, there is no 100% there sir.
ATTY. COMIA Okay, that was good, so you Honor please, may we request also temporarily, because this is just a
xerox copy presented by the fiscal, that the percentage here that the Halothane administered by Dr. Solidum to the
patient is 1% only so may we request that this portion, temporarily your Honor, we are marking this anesthesia
record as our Exhibit 1 and then this 1% Halothane also be bracketed and the same be marked as our Exhibit "1-
A".
xxxx
ATTY. COMIA Doctor, my attention was called also when you said that there are so many factors that contributed
to Hypoxia is that correct?
WITNESS Yes, sir.
Q I remember doctor, according to you there are so many factors that contributed to what you call hypoxia and
according to you, when this Gerald suffered hypoxia, there are other factors that might lead to this Hypoxia at the
time of this operation is that correct?
WITNESS The possibility is there, sir.
Q And according to you, it might also be the result of such other, some or it might be due to operations being
conducted by the doctor at the time when the operation is being done might also contribute to that hypoxia is that
correct?
A That is a possibility also.
xxxx
ATTY. COMIA How will you classify now the operation conducted to this Gerald, Doctor?
WITNESS Well, that is a major operation sir.
Q In other words, when you say major operation conducted to this Gerald, there is a possibility that this Gerald
might [be] exposed to some risk is that correct?
A That is a possibility sir.
Q And which according to you that Gerald suffered hypoxia is that correct?
A Yes, sir.
Q And that is one of the risk of that major operation is that correct?
A That is the risk sir.42
At the continuation of his cross-examination, Dr. Vertido maintained that Geralds operation for his imperforate
anus, considered a major operation, had exposed him to the risk of suffering the same condition.43 He then
corrected his earlier finding that 100% halothane had been administered on Gerald by saying that it should be
100% oxygen.44
Dr. Solidum was criminally charged for "failing to monitor and regulate properly the levels of anesthesia
administered to said Gerald Albert Gercayo and using 100% halothane and other anesthetic
medications."45However, the foregoing circumstances, taken together, did not prove beyond reasonable doubt that
Dr. Solidum had been recklessly imprudent in administering the anesthetic agent to Gerald. Indeed, Dr. Vertidos
findings did not preclude the probability that other factors related to Geralds major operation, which could or could
not necessarily be attributed to the administration of the anesthesia, had caused the hypoxia and had then led
Gerald to experience bradycardia. Dr. Vertido revealingly concluded in his report, instead, that "although the
anesthesiologist followed the normal routine and precautionary procedures, still hypoxia and its corresponding side
effects did occur."46
The existence of the probability about other factors causing the hypoxia has engendered in the mind of the Court a
reasonable doubt as to Dr. Solidums guilt, and moves us to acquit him of the crime of reckless imprudence
resulting to serious physical injuries. "A reasonable doubt of guilt," according to United States v. Youthsey: 47
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x x x is a doubt growing reasonably out of evidence or the lack of it. It is not a captious doubt; not a doubt WHEREFORE, the Court GRANTS the petition for review on certiorari; REVERSES AND SETS ASIDE the
engendered merely by sympathy for the unfortunate position of the defendant, or a dislike to accept the decision promulgated on January 20, 2010; ACQUITS Dr. Fernando P. Solidum of the crime of reckless
responsibility of convicting a fellow man. If, having weighed the evidence on both sides, you reach the conclusion imprudence resulting to serious physical injuries; and MAKES no pronouncement on costs of suit. SO ORDERED.
that the defendant is guilty, to that degree of certainty as would lead you to act on the faith of it in the most
important and crucial affairs of your life, you may properly convict him. Proof beyond reasonable doubt is not proof
to a mathematical demonstration. It is not proof beyond the possibility of mistake.

We have to clarify that the acquittal of Dr. Solidum would not immediately exempt him from civil liability.1wphi1 But
we cannot now find and declare him civilly liable because the circumstances that have been established here do
not present the factual and legal bases for validly doing so. His acquittal did not derive only from reasonable doubt.
There was really no firm and competent showing how the injury to Gerard had been caused. That meant that the
manner of administration of the anesthesia by Dr. Solidum was not necessarily the cause of the hypoxia that
caused the bradycardia experienced by Gerard. Consequently, to adjudge Dr. Solidum civilly liable would be to
speculate on the cause of the hypoxia. We are not allowed to do so, for civil liability must not rest on speculation
but on competent evidence.

Liability of Ospital ng Maynila

Although the result now reached has resolved the issue of civil liability, we have to address the unusual decree of
the RTC, as affirmed by the CA, of expressly holding Ospital ng Maynila civilly liable jointly and severally with Dr.
Solidum. The decree was flawed in logic and in law.

In criminal prosecutions, the civil action for the recovery of civil liability that is deemed instituted with the criminal
action refers only to that arising from the offense charged.48 It is puzzling, therefore, how the RTC and the CA could
have adjudged Ospital ng Maynila jointly and severally liable with Dr. Solidum for the damages despite the obvious
fact that Ospital ng Maynila, being an artificial entity, had not been charged along with Dr. Solidum. The lower
courts thereby acted capriciously and whimsically, which rendered their judgment against Ospital ng Maynila void
as the product of grave abuse of discretion amounting to lack of jurisdiction.

Not surprisingly, the flawed decree raises other material concerns that the RTC and the CA overlooked. We deem it
important, then, to express the following observations for the instruction of the Bench and Bar.

For one, Ospital ng Maynila was not at all a party in the proceedings. Hence, its fundamental right to be heard was
not respected from the outset. The R TC and the CA should have been alert to this fundamental defect. Verily, no
person can be prejudiced by a ruling rendered in an action or proceeding in which he was not made a party. Such a
rule would enforce the constitutional guarantee of due process of law.

Moreover, Ospital ng Maynila could be held civilly liable only when subsidiary liability would be properly enforceable
pursuant to Article 103 of the Revised Penal Code. But the subsidiary liability seems far-fetched here. The
conditions for subsidiary liability to attach to Ospital ng Maynila should first be complied with. Firstly, pursuant to
Article 103 of the Revised Penal Code, Ospital ng Maynila must be shown to be a corporation "engaged in any kind
of industry." The term industry means any department or branch of art, occupation or business, especially one that
employs labor and capital, and is engaged in industry. 49 However, Ospital ng Maynila, being a public hospital, was
not engaged in industry conducted for profit but purely in charitable and humanitarian work. 50Secondly, assuming
that Ospital ng Maynila was engaged in industry for profit, Dr. Solidum must be shown to be an employee of Ospital
ng Maynila acting in the discharge of his duties during the operation on Gerald. Yet, he definitely was not such
employee but a consultant of the hospital. And, thirdly, assuming that civil liability was adjudged against Dr.
Solidum as an employee (which did not happen here), the execution against him was unsatisfied due to his being
insolvent.

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