CARTICIANO VS.

NUVAL
FACTS: Plaintiff Zacarias Carticiano was on his
way home to Imus, Cavite. He was driving his
fathers Ford Laser car. On the same date and
time, defendant Nuvals owner-type Jeep, then
driven by defendant Darwin was traveling on the
opposite direction going to Paraaque. When the
two cars were about to pass one another, Darwin
veered his vehicle to his left going to the center
island of the highway an occupied the lane which
plaintiff Zacarias was traversing. Zacarias Ford
Laser collided head-on with Nuvals Jeep. Darwin
immediately fled from the scene. Zacarias
suffered multiple fracture. He underwent a leg
operation and physical therapy. Nuval offered
P100,000.00 as compensation for the injuries
caused. Plaintiffs refused to accept it. Plaintiffs
filed a criminal suit against Darwin and a civil suit
against defendants for damages. Trial court ruled
infavor of plaintiffs. CA reversed the decision.
ISSUE: W/N employer Nuval can be held liable.

Homicide was filed against the driver; before the

trial could end, he committed suicide.
Subsequently, , the spouses Vallejera filed a
complaint for damages against the petitioners as
employers of the deceased driver, basically
alleging that as such employers, they failed to
exercise due diligence in the selection and
supervision of their employees. Naturally,
defendants denied liability principally contending
that since the driver died during the pendency of
the criminal action, the sine qua non condition
for their subsidiary liability was not fulfilled,
hence the of lack of cause of action on the part of
the plaintiffs. The RTC denied the motion to
dismiss prompting the petitioners to bring the
case to the CA which appellate court sustained
the lower court. Essentially, the CA opined that
that the complaint neither represents nor implies
that the responsibility charged was the
petitioners subsidiary liability under Art. 103,
Revised Penal Code; further, a civil action to
enforce subsidiary liability separate and distinct
from the criminal action is even unnecessary.

RULING: Petition granted.

RATIO: Article 2180 of the Civil Code provides that
employers shall be liable for damages caused by
their employees acting within the scope of their
assigned tasks. The facts established in the case
at bar show that Darwin was acting within the
scope of the authority given him when the
collision occurred. That he had been hired only to
bring respondents children to and from school
must be rejected. True, this may have been one
of his assigned tasks, but no convincing proof was
presented showing that it was his only task. His
authority was to drive Nuvals vehicle. Once a
driver is proven negligent in causing damages,
the law presumes the vehicle owner equally
negligent and imposes upon the latter the burden
of proving proper selection of employee as a
defense. Respondent failed to show that he had
satisfactorily discharged this burden.
L.G. FOODS v. Pagapong-Agraviador
FACTS:Charles Vallereja, a 7-year old son of the
spouses Florentino Vallejera and Theresa
Vallejera, was hit by a Ford Fiera van owned by
the petitioners and driven at the time by their
employee, Vincent Norman Yeneza y Ferrer.
Charles died as a result of the accident. An
Information for Reckless Imprudence Resulting to

ISSUE
Whether the civil action against petitioner
employer on the ground of vicarious liability is
proper.

HOLDING
YES. Under Article 2180 of the Civil Code,
the liability of the employer is direct or
immediate. It is not conditioned upon prior
recourse against the negligent employee and a
prior showing of insolvency of such employee.
Here, the complaint sufficiently alleged that the
death of the couples minor son was caused by
the negligent act of the petitioners driver; and
that the petitioners themselves were civilly liable
for the negligence of their driver for failing to
exercise the necessary diligence required of a
good father of the family in the selection and
supervision of [their] employee, the driver, which
diligence, if exercised, would have prevented said
accident. The victims of negligence or their heirs
have a choice between an action to enforce the
civil liability arising from culpa criminal under
Article 100 of the Revised Penal Code, and an
action for quasi-delict (culpa aquiliana) under

Articles 2176 to 2194 of the Civil Code. If, as

here, the action chosen is for quasi-delict, the
plaintiff may hold the employer liable for the
negligent act of its employee, subject to the
employers defense of exercise of the diligence of
a good father of the family. On the other hand, if
the action chosen is for culpa criminal, the
plaintiff can hold the employer subsidiarily liable
only upon proof of prior conviction of its
employee
It is worthy to note that the petitioners, in
their answer repeatedly made mention of Article
2180 of the Civil Code and anchored their
defense on their allegation that they had
exercised due diligence in the selection and
supervision of [their] employees. The Court
views this defense as an admission that indeed
the petitioners acknowledged the private
respondents cause of action as one for quasidelict under Article 2180 of the Civil Code.
RAMOS vs. COURT OF APPEALS
G.R. No. 124354. December 29, 1999.
FACTS: Erlinda Ramos underwent a surgical
procedure to remove stone from her gall bladder
(cholecystectomy). They hired Dr. Hosaka, a
surgeon, to conduct the surgery at the De Los
Santos Medical Center (DLSMC). Hosaka assured
them that he would find a good anesthesiologist.
But the operation did not go as planned, Dr.
Hosaka arrived 3 hours late for the operation,
Dra. Gutierrez, the anesthesiologist botched the
administration of the anesthesia causing Erlinda
to go into a coma and suffer brain damage. The
botched operation was witnessed by Herminda
Cruz, sister in law of Erlinda and Dean of College
of Nursing of Capitol Medical Center.
The family of Ramos (petitioners) sued the
hospital, the surgeon and the anesthesiologist for
damages. The petitioners showed expert
testimony showing that Erlinda's condition was
caused by the anesthesiologist in not exercising
reasonable care in intubating Erlinda.
Eyewitnesses heard the anesthesiologist saying
Ang hirap ma-intubate nito, mali yata ang
pagkakapasok. O lumalaki ang tiyan.
Diagnostic tests prior to surgery showed that
Erlinda was robust and fit to undergo surgery.

The RTC held that the anesthesiologist omitted to

exercise due care in intubating the patient, the
surgeon was remiss in his obligation to provide a
good anesthesiologist and for arriving 3 hours
late and the hospital is liable for the negligence
of the doctors and for not cancelling the
operation after the surgeon failed to arrive on
time. The surgeon, anesthesiologist and the
DLSMC were all held jointly and severally liable
for damages to petitioners. The CA reversed the
decision of the Trial Court.
ISSUES: Whether or not the private respondents
were negligent and thereby caused the comatose
condition of Ramos.
HELD: Yes, private respondents were all
negligent and are solidarily liable for the
damages.
RATIO: Res ipsa loquitur a procedural or
evidentiary rule which means the thing or the
transaction speaks for itself. It is a maxim for the
rule that the fact of the occurrence of an injury,
taken with the surrounding circumstances, may
permit an inference or raise a presumption of
negligence, or make out a plaintiffs prima facie
case, and present a question of fact for defendant
to meet with an explanation, where ordinarily in a
medical malpractice case, the complaining party
must present expert testimony to prove that the
attending physician was negligent.
This doctrine finds application in this case. On the
day of the operation, Erlinda Ramos already
surrendered her person to the private
respondents who had complete and exclusive
control over her. Apart from the gallstone
problem, she was neurologically sound and fit.
Then, after the procedure, she was comatose and
brain damagedres ipsa loquitur!the thing
speaks for itself!
Negligence Private respondents were not able
to disprove the presumption of negligence on
their part in the care of Erlinda and their
negligence was the proximate cause of her
condition. One need not be an anesthesiologist in
order to tell whether or not the intubation was a
success. [res ipsa loquitur applies here]. The
Supreme Court also found that the
anesthesiologist only saw Erlinda for the first time
on the day of the operation which indicates
unfamiliarity with the patient and which is an act
of negligence and irresponsibility.

The head surgeon, Dr. Hosaka was also negligent.

He failed to exercise the proper authority as the
captain of the ship in determining if the
anesthesiologist observed the proper protocols.
Also, because he was late, he did not have time
to confer with the anesthesiologist regarding the
anesthesia delivery.
The hospital failed to adduce evidence showing
that it exercised the diligence of a good father of
the family in hiring and supervision of its doctors
(Art. 2180). The hospital was negligent since they
are the one in control of the hiring and firing of
their consultants. While these consultants are
not employees, hospitals still exert significant
controls on the selection and termination of
doctors who work there which is one of the
hallmarks of an employer-employee reationship.
Thus, the hospital was allocated a share in the
liability.
Damages temperate damages can and should
be awarded on top of actual or compensatory
damages in instances where the injury is chronic
and continuing.
Ramos v. CA
Facts:
Erlinda Ramos, a 47-year old robust woman, was
normal except for her experiencing occasional
pain due to the presence of stone in her gall
bladder. She was advised to undergo an operation
for its removal. The results in the examinations
she underwent indicate that she was fit for the
operation. She and her husband Rogelio met Dr.
Hosaka, one of the defendants, who advised that
she should undergo cholecystectomy. Dr. Hosaka
assured them that he will get a good
anaesthesiologist. At 7:30 a.m. on the day of the
operation at Delos Santos Medical Center,
Herminda Cruz, Erlindas sister-in-law and the
dean of the College of Nursing in Capitol Medical
Center, was there to provide moral support. Dr.
Perfecta Gutierrez was to administer the
anaesthesia. Dr. Hosaka arrived only at 12:15 p.
m. Herminda saw Dr. Gutierrez intubating the
patient, and heard the latter say Ang hirap maintubate nito, mali yata ang pagkakapasok. O,
lumalaki ang tiyan. Herminda saw bluish
discoloration of the nailbeds of the patient. She
heard Dr. Hosaka issue an order for someone to
call Dr. Calderon. The doctor arrived and placed
the patient in trendelenburg position, wherein the

head of the patient is positioned lower than the

feet, which indicates a decrease of blood supply
in the brain. Herminda knew and told Rogelio that
something wrong was happening. Dr. Calderon
was able to intubate the patient. Erlinda was
taken to the ICU and became comatose.
Rogelio filed a civil case for damages. The trial
court ruled in his favor, finding Dr. Gutierrez, Dr.
Hosaka, and the hospital, guilty of negligence,
but the Court of Appeals reversed the decision.
Hence, petitioner filed a Motion for
Reconsideration, which the Court of Appeals
denied for having been filed beyond the
reglementary period. However, it was found that
the notice of the decision was never sent to the
petitioners counsel. Rather, it was sent to the
petitioner, addressing him as Atty. Rogelio Ramos,
as if he was the legal counsel. The petitioner filed
the instant petition for certiorari. On the
procedural issue, the Supreme Court rules that
since the notice did not reach the petitioners
then legal counsel, the motion was filed on time.
Issue:
Whether a surgeon, an anaesthesiologist, and a
hospital, should be made liable for the
unfortunate comatose condition of a patient
scheduled for cholecystectomy
Held:
Res Ipsa Loquitor
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. Where
the thing which caused the injury complained of
is shown to be under the management of the
defendant or his servants and the accident is
such as in ordinary course of things does not
happen if those who have its management or
control use proper care, it affords reasonable
evidence, in the absence of explanation by the
defendant, that the accident arose from or was
caused by the defendant's want of care. 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. 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. 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. 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.
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. 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. 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. 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.
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. 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 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.
We find the doctrine of res ipsa
loquitur appropriate in the case at bar. 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.
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.
Negligence of the Anaesthesiologist
The pre-operative evaluation of a patient prior to
the administration of anesthesia is universally
observed to lessen the possibility of anesthetic
accidents. 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. Her failure to follow
this medical procedure is, therefore, a
clear indicia of her negligence. 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.
Opinion of Expert Witness
An anesthetic accident caused by a rare druginduced 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. 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. 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.
Proximate Cause
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. 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. 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.
Responsibility of the Surgeon
As the so-called "captain of the ship," 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 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.
Responsibility of the Hospital
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 employeremployee 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.
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. 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. 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.
Damages

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.
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.
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. 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.
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. The husband and the children, all
petitioners in this case, will have to live with the
day to day uncertainty of the patient's illness,
knowing any hope of recovery is close to nil. They
have fashioned their daily lives around the
nursing care of petitioner, altering their long term
goals to take into account their life with a
comatose patient. They, not the respondents, are
charged with the moral responsibility of the care
of the victim. The family's moral injury and
suffering in this case is clearly a real one. For the
foregoing reasons, an award of P2,000,000.00 in
moral damages would be appropriate.
Finally, by way of example, exemplary damages
in the amount of P100,000.00 are hereby
awarded. Considering the length and nature of
the instant suit we are of the opinion that
attorney's fees valued at P100,000.00 are
likewise proper.
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.
Nogales vs. Capitol Medical Center [GR. No.
142625, Dec. 19, 2006] Facts: Dr. Estrada applied
low forceps to extract Corazon's baby. In the
process, a cervical tissue was allegedly torn. The
baby came out in an apnic, cyanotic, weak and
injured condition. The baby survived, but the
mother died of profuse vaginal bleeding. The
husband sued CMC and the doctors. Issues: 1)
whether an employee-employer relationship
existedbetween CMC and Dr. Estrada 2) whether
CMC is vicariously liable for the negligence of Dr.
Estrada Held: In Ramos vs. CA, weheld: In other
words, private hospitals, hire, fire and exercise
real control over their attending and visiting
"consultant" staff. While "consultants" are not,
technically employees, the control exercised, the
hiring, and the right to terminate consultants all
fulfill the important hallmarks of an employeremployee 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. Dr. Estrada is
an independent contractor. Applying the control
test, SC did not find evidence pointing to CMC's
exercise of control over Dr. Estrada's treatment
and management of Corazon's condition. The
patient was under the exclusive prenatal care of
Dr. Estrada. CMC merely allowed Dr. Estrada to
use its facilitieswhen Corazon was about to give
birth, which CMC considered an emergency. But
while SC held that Dr. Estrada is not CMCs
employee, CMC is vicariously liable under the
doctrine of apparent authority. General Rule: A
hospital is not liable for the negligence of an
independent contractor-physician. Except: When
physician is the "ostensible" agent of the hospital
(doctrine of apparent authority) Requisites for the
doctrine to apply: (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.Two Factors to consider: 1) An
inquiry onwhether 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. 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. 2) An
inquiry on whether the plaintiff acted in reliance
upon the conduct of the hospital or its agent,
consistent with ordinary care and prudence.
Application of these factors to this case: 1) CMC
impliedly held out Estrada as a member of its
medical staff. a) CMC granted staff privileges to
Dr. Estrada. CMC extended its medical staff and
facilities to Dr. Estrada. b) CMC made Rogelio sign
consent forms printed on CMC letterhead. These
forms did not indicate that he was an
independent contractor-physician. No one from
CMC informed the Spouses c) 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 CMCemployed specialists in treating
Corazon. 2) 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." In other words, Dr. Estrada's
relationship with CMC played a significant role in
the Spouses Nogales' decision in accepting Dr.
Estrada's services
Professional Services VS CA and Natividad
G.R. No. 126297 February 11, 2008
PROFESSIONAL SERVICES, INC., petitioner, vs.
THE COURT OF APPEALS and NATIVIDAD and
ENRIQUE AGANA, respondents,
x- x
G.R. No. 126467 February 11, 2008
NATIVIDAD (Substituted by her children
MARCELINO AGANA III, ENRIQUE AGANA, JR.,

EMMA AGANA ANDAYA, JESUS AGANA, and

RAYMUND AGANA) and ENRIQUE AGANA,
petitioners,
vs.
THE COURT OF APPEALS and JUAN FUENTES,
respondents,
x- x
G.R. No. 127590 February 11, 2008
MIGUEL AMPIL, petitioner, vs.
THE COURT OF APPEALS and NATIVIDAD AGANA
and ENRIQUE AGANA, respondents.
RESOLUTION
SANDOVAL-GUTIERREZ, J.:
FACTS:
Natividad Agana was admitted at the Medical City
General Hospital (Medical City) because of
difficulty of bowel movement and bloody anal
discharge. Dr. Ampil diagnosed her to be suffering
from cancer of the sigmoid. Thus, Dr.
Ampil performed an anterior resection surgery
upon her. During the surgery, he found that the
malignancy had spread to her left ovary,
necessitating the removal thus, Dr. Ampil
obtained the consent of Atty. Enrique Agana,
Natividads husband, to permit Dr. Juan Fuentes
to perform hysterectomy upon Natividad.
After a couple of days, Natividad complained of
excruciating pain in her anal region. Dr. Ampil and
Dr. Fuentes told her that the pain was the natural
consequence of the surgical operation. Natividad,
accompanied by her husband, went to the United
States to seek further treatment. After four (4)
months of consultations and laboratory
examinations, Natividad was told that she was
free of cancer. Natividad flew back to the
Philippines, still suffering from pains. Two (2)
weeks thereafter, her daughter found a piece of
gauze protruding from her vagina. Dr. Ampil
managed to extract by hand a piece of gauze
then assured Natividad that the pains would soon
vanish but it intensified which prompting
Natividad to seek treatment at the Polymedic
General Hospital. Dr. Gutierrez found that the
gauze had badly infected her vaginal vault.
Another surgical operation was needed to remedy
the situation.

On November 12, 1984, Natividad and her

husband filed with the RTC a complaint for
damages against PSI (owner of Medical City), Dr.
Ampil and Dr. Fuentes. On February 16, 1986,
pending the outcome of the above case,
Natividad died.
The trial court rendered judgment in favor of
spouses Agana finding PSI, Dr. Ampil and Dr.
Fuentes jointly and severally liable. On appeal,
the Court of Appeals, in its Decision dated
September 6, 1996, affirmed the assailed
judgment with modification in the sense that the
complaint against Dr. Fuentes was dismissed.
Issue:
Whether or not there exist an employer-employee
relationship.
Ruling:
The motion lacks merit.
The First Division ruled that an employeremployee relationship in effect exists between
the Medical City and Dr. Ampil. Consequently,
both are jointly and severally liable to the
Aganas. This ruling proceeds from the following
ratiocination in Ramos:
XXX
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 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, a point which
respondent hospital asserts in denying all
responsibility for the patients 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 petitioners 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 formers
responsibility under a relationship of partia
ptetas.
Clearly, in Ramos, the Court considered the
peculiar relationship between a hospital and its
consultants on the bases of certain factors. One
such factor is the control test wherein the
hospital exercises control in the hiring and firing
of consultants, like Dr. Ampil, and in the conduct
of their work.
Actually, contrary to PSIs contention, the Court
did not reverse its ruling in Ramos. What it
clarified was that the De Los Santos Medical Clinic

did not exercise control over its consultant,

hence, there is no employer-employee
relationship between them. Thus, despite the
granting of the said hospitals motion for
reconsideration, the doctrine in Ramos stays, i.e.,
for the purpose of allocating responsibility in
medical negligence cases, an employer-employee
relationship exists between hospitals and their
consultants.
In the instant cases, PSI merely offered a general
denial of responsibility, maintaining that
consultants, like Dr. Ampil, are independent
contractors, not employees of the hospital. Even
assuming that Dr. Ampil is not an employee of
Medical City, but an independent contractor, still
the said hospital is liable to the Aganas.
Professional Services Inc. v. Agana
Professional Services Inc. (PSI) v. Natividad
and Enrique Agana
Natividad and Enrique Agana v. Juan
Fuentes
Miguel Ampil v. Natividad and Enrique
Agana
2007 / Sandoval-Gutierrez / Petition for review on
certiorari of CA decisions
Standard of conduct > Experts > Medical
professionals

FACTS
Natividad Agana was rushed to Medical City
because of difficulty of bowel movement and
bloody anal discharge. Dr. Ampil diagnosed her to
be suffering from cancer of the sigmoid. Dr.
Ampil performed an anterior resection
surgery on her, and finding that the malignancy
spread on her left ovary, he obtained the consent
of her husband, Enrique, to permit Dr. Fuentes to
perform hysterectomy on her. After the
hysterectomy, Dr. Fuentes showed his work to Dr.
Ampil, who examined it and found it in order, so
he allowed Dr. Fuentes to leave the operating
room. Dr. Ampil was about to complete the
procedure when the attending nurses made some
remarks on the Record of Operation: sponge
count lacking 2; announced to surgeon

search done but to no avail continue for

closure (two pieces of gauze were missing). A
diligent search was conducted but they could
not be found. Dr. Ampil then directed that the
incision be closed.
A couple of days after, she complained
of pain in her anal region, but the doctors told her
that it was just a natural consequence of the
surgery. Dr. Ampil recommended that she consult
an oncologist to examine the cancerous nodes
which were not removed during the operation.
After months of consultations and examinations
in the US, she was told that she was free of
cancer. Weeks after coming back, her daughter
found a piece of gauze (1.5 in) protruding from
her vagina, so Dr. Ampil manually extracted this,
assuring Natividad that the pains will go away.
However, the pain worsened, so she sought
treatment at a hospital, where another 1.5 in
piece of gauze was found in her vagina. She
underwent another surgery.
Sps. Agana filed a complaint for
damages against PSI (owner of Medical City), Dr.
Ampil, and Dr. Fuentes, alleging that the latter are
liable for negligence for leaving 2 pieces of
gauze in Natividads body, and malpractice for
concealing their acts of negligence. Enrique
Agana also filed an administrative
complaint for gross negligence and malpractice
against the two doctors with the PRC (although
only the case against Dr. Fuentes was heard since
Dr. Ampil was abroad). Pending the outcome of
the cases, Natividad died (now substituted by
her children). RTC found PSI and the two
doctors liable for negligence and
malpractice. PRC dismissed the case
against Dr. Fuentes. CA dismissed only the
case against Fuentes.

ISSUE AND HOLDING

1. WON CA erred in holding Dr. Ampil liable
for negligence and malpractice. NO; DR.
AMPIL IS GUILTY
2. WON CA erred in absolving Dr. Fuentes of
any liability. NO
3. WON PSI may be held solidarily liable for
Dr. Ampils negligence. YES

RATIO

pieces of gauze were still missing; what

established causal link: gauze pieces later
extracted from patients vagina

DR. AMPIL IS LIABLE FOR NEGLIGENCE AND

MALPRACTICE
His arguments are without basis [did not prove
that the American doctors were the ones who put
/ left the gauzes; did not submit evidence to rebut
the correctness of the operation record (re:
number of gauzes used); re: Dr. Fuentes alleged
negligence, Dr. Ampil examined his work and
found it in order].
Leaving foreign substances in the
wound after incision has been closed is at
least prima facie negligence by the
operating surgeon. Even if it has been shown
that a surgeon was required to leave a sponge in
his patients abdomen because of the dangers
attendant upon delay, still, it is his legal duty to
inform his patient within a reasonable time by
advising her of what he had been compelled to
do, so she can seek relief from the effects of the
foreign object left in her body as her condition
might permit. Whats worse in this case is that he
misled her by saying that the pain was an
ordinary consequence of her operation.

DR. FUENTES NOT LIABLE

The res ipsa loquitur [thing speaks for
itself] argument of the Aganas does not convince
the court. Mere invocation and application of this
doctrine does not dispense with the requirement
of proof of negligence.

Requisites for the applicability of res ipsa

loquitur
1. Occurrence of injury
2. Thing which caused injury was under
the control and management of the
defendant [DR. FUENTES] LACKING
SINCE CTRL+MGT WAS WITH DR. AMPIL
3. Occurrence was such that in the ordinary
course of things, would not have
happened if those who had control or
management used proper care
4. Absence of explanation by defendant

Medical negligence; standard of diligence

To successfully pursue this case of medical
negligence, a patient must only prove that a
health care provider either failed to do something
[or did something] which a reasonably prudent
health care provider would have done [or
wouldnt have done], and that the failure or
action caused injury to the patient.

Duty - to remove all foreign objects from

the body before closure of the incision; if
he fails to do so, it was his duty to inform
the patient about it
Breach failed to remove foreign objects;
failed to inform patient

Injury - suffered pain that necessitated

examination and another surgery

Proximate Causation - breach caused this

injury; could be traced from his act of
closing the incision despite information
given by the attendant nurses that 2

Under the Captain of the Ship rule,

the operating surgeon is the person in complete
charge of the surgery room and all personnel
connected with the operation. That Dr. Ampil
discharged such role is evident from the
following:

He called Dr. Fuentes to perform a

hysterectomy

He examined Dr. Fuentes work and found

it in order

He granted Dr. Fuentes permission to

leave

He ordered the closure of the incision

HOSPITAL OWNER PSI SOLIDARILY LIABLE

WITH DR. AMPIL [NCC 2180], AND DIRECTLY
LIABLE TO SPS. AGANAS [NCC 2176]
Previously, employers cannot be held liable for
the fault or negligence of its professionals.
However, this doctrine has weakened since courts

came to realize that modern hospitals are taking

a more active role in supplying and regulating
medical care to its patients, by employing staff of
physicians, among others. Hence, there is no
reason to exempt hospitals from the universal
rule of respondeat superior. Here are the Courts
bases for sustaining PSIs liability:

Doctrine of corporate negligence /

corporate responsibility

This is 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.

This provides for the duties

expected [from hospitals]. In this
case, PSI failed to perform the duty
of exercising reasonable care to
protect from harm all patients
admitted into its facility for medical
treatment. PSI failed to conduct
an investigation of the matter
reported in the note of the
count nurse, and this
established PSIs part in the
dark conspiracy of silence and
concealment about the gauzes.

Ramos v. CA doctrine on E-E relationship

For purposes of apportioning

responsibility in medical negligence
cases, an employer-employee
relationship in effect exists
between hospitals and their
attending and visiting physicians.
[LABOR LESSON: power to hire,
fire, power of control]

Agency principle of apparent authority /

agency by estoppel

Imposes liability because of the

actions of a principal or employer
in somehow misleading the public
into believing that the relationship
or the authority exists [see NCC
1869]

PSI publicly displays in the Medical

City lobby the names and
specializations of their physicians.
Hence, PSI is now estopped from
passing all the blame to the
physicians whose names it proudly
paraded in the public directory,
leading the public to believe that it
vouched for their skill and
competence.

If doctors do well, hospital

profits financially, so when
negligence mars the quality
of its services, the hospital
should not be allowed to
escape liability for its
agents acts.

PSI has actual / constructive

knowledge of the matter,
through the report of the
attending nurses + the fact
that the operation was
carried on with the
assistance of various
hospital staff

It also breached its duties

to oversee or supervise all persons
who practice medicine within its
walls and take an active step in
fixing the negligence committed

PSI also liable under NCC 2180

It failed to adduce evidence to

show that it exercised the diligence
of a good father of the family in the
accreditation and supervision of Dr.
Ampil