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 ma-intubate 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
thatres 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 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. 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 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.
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.