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Trial ensued after both the petitioner and Dr.

Lina Ercillo pleaded not guilty to


Republic of the Philippines
SUPREME COURT the above-mentioned charge. On March 4, 1994, the Municipal Trial Court in
Manila Cities (MTCC) of San Pablo City rendered a decision, the dispositive portion
of which is hereunder quoted as follows:
THIRD DIVISION
WHEREFORE, the court finds the accused Dra. Lina Ercillo
not guilty of the offense charged for insufficiency of evidence
G.R. No. 122445 November 18, 1997 while her co-accused Dra. Ninevetch Cruz is hereby held
responsible for the death of Lydia Umali on March 24, 1991,
DR. NINEVETCH CRUZ, petitioner, and therefore guilty under Art. 365 of the Revised Penal
vs. Code, and she is hereby sentenced to suffer the penalty of 2
COURT OF APPEALS and LYDIA UMALI, respondents. months and 1 day imprisonment of arresto mayor with
costs. 6
FRANCISCO, J.: The petitioner appealed her conviction to the Regional Trial Court
(RTC) which affirmed in toto the decision of the MTCC 7 prompting
Doctors are protected by a special rule of law. They are not guarantors of the petitioner to file a petition for review with the Court of Appeals but
care. They do not even warrant a good result. They are not insurers against to no avail. Hence this petition for review on certiorari assailing the
mishaps or unusual consequences. Furthermore they are not liable for decision promulgated by the Court of Appeals on October 24, 1995
honest mistakes of judgment . . . 1 affirming petitioner's conviction with modification that she is further
The present case against petitioner is in the nature of a medical malpractice directed to pay the heirs of Lydia Umali P50,000.00 as indemnity for
suit, which in simplest terms is the type of claim which a victim has available her death. 8
to him or her to redress a wrong committed by a medical professional which In substance, the petition brought before this Court raises the issue
has caused bodily harm. 2 In this jurisdiction, however, such claims are most of whether or not petitioner's conviction of the crime of reckless
often brought as a civil action for damages under Article 2176 of the Civil imprudence resulting in homicide, arising from an alleged medical
Code, 3 and in some instances, as a criminal case under Article 365 of the malpractice, is supported by the evidence on record.
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 First the antecedent facts.
sought redress for the petitioner's alleged imprudence and negligence in On March 22, 1991, prosecution witness, Rowena Umali De Ocampo,
treating the deceased thereby causing her death. The petitioner and one Dr. accompanied her mother to the Perpetual Help Clinic and General Hospital
Lina Ercillo who was the attending anaesthesiologist during the operation of situated in Balagtas Street, San Pablo City, Laguna. They arrived at the said
the deceased were charged with "reckless imprudence and negligence hospital at around 4:30 in the afternoon of the same day. 9 Prior to
resulting to (sic) homicide" in an information which reads: March 22, 1991, Lydia was examined by the petitioner who found a
That on or about March 23, 1991, in the City of San Pablo, "myoma" 10 in her uterus, and scheduled her for a hysterectomy operation on
Republic of the Philippines and within the jurisdiction of this March 23,
Honorable Court, the accused above named, being then the 1991. 11 Rowena and her mother slept in the clinic on the evening of March
attending anaesthesiologist and surgeon, respectively, did 22, 1991 as the latter was to be operated on the next day at 1:00 o'clock in
then and there, in a negligence (sic), careless, imprudent, the afternoon. 12 According to Rowena, she noticed that the clinic was untidy
and incompetent manner, and failing to supply or store and the window and the floor were very dusty prompting her to ask the
sufficient provisions and facilities necessary to meet any and attendant for a rag to wipe the window and the floor with. 13 Because of the
all exigencies apt to arise before, during and/or after a untidy state of the clinic, Rowena tried to persuade her mother not to proceed
surgical operation causing by such negligence, with the operation. 14 The following day, before her mother was wheeled into
carelessness, imprudence, and incompetence, and causing the operating room, Rowena asked the petitioner if the operation could be
by such failure, including the lack of preparation and postponed. The petitioner called Lydia into her office and the two had a
foresight needed to avert a tragedy, the untimely death of conversation. Lydia then informed Rowena that the petitioner told her that
said Lydia Umali on the day following said surgical she must be operated on as scheduled. 15
operation. 5
Rowena and her other relatives, namely her husband, her sister and two happen during the operation. The manner and the fact that
aunts waited outside the operating room while Lydia underwent operation. the patient was brought to the San Pablo District Hospital for
While they were waiting, Dr. Ercillo went out of the operating room and reoperation indicates that there was something wrong in the
instructed them to buy tagamet ampules which Rowena's sister immediately manner in which Dra. Cruz conducted the operation. There
bought. About one hour had passed when Dr. Ercillo came out again this was no showing that before the operation, accused Dra.
time to ask them to buy blood for Lydia. They bought type "A" blood from the Cruz had conducted a cardio pulmonary clearance or any
St. Gerald Blood Bank and the same was brought by the attendant into the typing of the blood of the patient. It was (sic) said in medical
operating room. After the lapse of a few hours, the petitioner informed them parlance that the "the abdomen of the person is a temple of
that the operation was finished. The operating staff then went inside the surprises" because you do not know the whole thing the
petitioner's clinic to take their snacks. Some thirty minutes after, Lydia was moment it was open (sic) and surgeon must be prepared for
brought out of the operating room in a stretcher and the petitioner asked any eventuality thereof. The patient (sic) chart which is a
Rowena and the other relatives to buy additional blood for Lydia. public document was not presented because it is only there
Unfortunately, they were not able to comply with petitioner's order as there that we could determine the condition of the patient before
was no more type "A" blood available in the blood bank. Thereafter, a person the surgery. The court also noticed in Exh. "F-1" that the
arrived to donate blood which was later transfused to Lydia. Rowena then sister of the deceased wished to postpone the operation but
noticed her mother, who was attached to an oxygen tank, gasping for breath. the patient was prevailed upon by Dra. Cruz to proceed with
Apparently the oxygen supply had run out and Rowena's husband together the surgery. The court finds that Lydia Umali died because of
with the driver of the accused had to go to the San Pablo District Hospital to the negligence and carelessness of the surgeon Dra.
get oxygen. Lydia was given the fresh supply of oxygen as soon as it Ninevetch Cruz because of loss of blood during the
arrived. 16 But at around 10:00 o'clock P.M. she went into shock and her operation of the deceased for evident unpreparedness and
blood pressure dropped to 60/50. Lydia's unstable condition necessitated her for lack of skill, the reason why the patient was brought for
transfer to the San Pablo District Hospital so she could be connected to a operation at the San Pablo City District Hospital. As such,
respirator and further examined. 17 The transfer to the San Pablo District the surgeon should answer for such negligence. With
Hospital was without the prior consent of Rowena nor of the other relatives respect to Dra. Lina Ercillo, the anaesthesiologist, there is no
present who found out about the intended transfer only when an ambulance evidence to indicate that she should be held jointly liable with
arrived to take Lydia to the San Pablo District Hospital. Rowena and her Dra. Cruz who actually did the operation. 23
other relatives then boarded a tricycle and followed the ambulance. 18
The RTC reiterated the abovementioned findings of the MTCC and upheld
Upon Lydia's arrival at the San Pablo District Hospital, she was wheeled into the latter's declaration of "incompetency, negligence and lack of foresight
the operating room and the petitioner and Dr. Ercillo re-operated on her and skill of appellant (herein petitioner) in handling the subject patient before
because there was blood oozing from the abdominal incision. 19 The and after the operation." 24 And likewise affirming the petitioner's conviction,
attending physicians summoned Dr. Bartolome Angeles, head of the the Court of Appeals echoed similar observations, thus:
Obstetrics and Gynecology Department of the San Pablo District Hospital.
. . . While we may grant that the untidiness and filthiness of
However, when Dr. Angeles arrived, Lydia was already in shock and possibly
the clinic may not by itself indicate negligence, it
dead as her blood pressure was already 0/0. Dr. Angeles then informed
nevertheless shows the absence of due care and
petitioner and Dr. Ercillo that there was nothing he could do to help save the supervision over her subordinate employees. Did this
patient. 20 While the petitioner was closing the abdominal wall, the patient
unsanitary condition permeate the operating room? Were the
died. 21 Thus, on March 24, 1991, at 3:00 o'clock in the morning, Lydia Umali
surgical instruments properly sterilized? Could the conditions
was pronounced dead. Her death certificate states "shock" as the immediate
in the OR have contributed to the infection of the patient?
cause of death and "Disseminated Intravascular Coagulation (DIC)" as the
Only the petitioner could answer these, but she opted not to
antecedent cause. 22
testify. This could only give rise to the presumption that she
In convicting the petitioner, the MTCC found the following circumstances as has nothing good to testify on her defense. Anyway, the
sufficient basis to conclude that she was indeed negligent in the performance alleged "unverified statement of the prosecution witness"
of the operation: remains unchallenged and unrebutted.
. . . , the clinic was untidy, there was lack of provision like Likewise undisputed is the prosecution's version indicating
blood and oxygen to prepare for any contingency that might the following facts: that the accused asked the patient's
relatives to buy Tagamet capsules while the operation was et al., 27 this Court stated that in accepting a case, a doctor in effect
already in progress; that after an hour, they were also asked represents that, having the needed training and skill possessed by
to buy type "A" blood for the patient; that after the surgery, physicians and surgeons practicing in the same field, he will employ such
they were again asked to procure more type "A" blood, but training, care and skill in the treatment of his patients. He therefore has a
such was not anymore available from the source; that the duty to use at least the same level of care that any other reasonably
oxygen given to the patient was empty; and that the son-in- competent doctor would use to treat a condition under the same
law of the patient, together with a driver of the petitioner, had circumstances. It is in this aspect of medical malpractice that expert
to rush to the San Pablo City District Hospital to get the testimony is essential to establish not only the standard of care of the
much-needed oxygen. All these conclusively show that the profession but also that the physician's conduct in the treatment and care
petitioner had not prepared for any unforeseen falls below such standard. 28 Further, inasmuch as the causes of the injuries
circumstances before going into the first surgery, which was involved in malpractice actions are determinable only in the light of scientific
not emergency in nature, but was elective or pre-scheduled; knowledge, it has been recognized that expert testimony is usually necessary
she had no ready antibiotics, no prepared blood, properly to support the conclusion as to causation. 29
typed and cross-matched, and no sufficient oxygen supply. Immediately apparent from a review of the records of this case is the
Moreover, there are a lot of questions that keep nagging Us. absence of any expert testimony on the matter of the standard of care
Was the patient given any cardio-pulmonary clearance, or at employed by other physicians of good standing in the conduct of similar
least a clearance by an internist, which are standard operations. The prosecution's expert witnesses in the persons of Dr. Floresto
requirements before a patient is subjected to surgery. Did Arizala and Dr. Nieto Salvador, Jr. of the National Bureau of Investigation
the petitioner determine as part of the pre-operative (NBI) only testified as to the possible cause of death but did not venture to
evaluation, the bleeding parameters of the patient, such as illuminate the court on the matter of the standard of care that petitioner
bleeding time and clotting time? There is no showing that should have exercised.
these were done. The petitioner just appears to have been in
All three courts below bewail the inadequacy of the facilities of the clinic and
a hurry to perform the operation, even as the family wanted its untidiness; the lack of provisions such as blood, oxygen, and certain
a postponement to April 6, 1991. Obviously, she did not medicines; the failure to subject the patient to a cardio-pulmonary test prior to
prepare the patient; neither did she get the family's consent
the operation; the omission of any form of blood typing before transfusion;
to the operation. Moreover, she did not prepare a medical
and even the subsequent transfer of Lydia to the San Pablo Hospital and the
chart with instructions for the patient's care. If she did all
reoperation performed on her by the petitioner. But while it may be true that
these, proof thereof should have been offered. But there is
the circumstances pointed out by the courts below seemed beyond cavil to
none. Indeed, these are overwhelming evidence of constitute reckless imprudence on the part of the surgeon, this conclusion is
recklessness and imprudence. 25
still best arrived at not through the educated surmises nor conjectures of
This Court, however, holds differently and finds the foregoing circumstances laymen, including judges, but by the unquestionable knowledge of expert
insufficient to sustain a judgment of conviction against the petitioner for the witnesses. For whether a physician or surgeon has exercised the requisite
crime of reckless imprudence resulting in homicide. The elements of reckless degree of skill and care in the treatment of his patient is, in the generality of
imprudence are: (1) that the offender does or fails to do an act; (2) that the cases, a matter of expert opinion. 30 The deference of courts to the expert
doing or the failure to do that act is voluntary; (3) that it be without malice; (4) opinion of qualified physicians stems from its realization that the latter
that material damage results from the reckless imprudence; and (5) that possess unusual technical skills which laymen in most instances are
there is inexcusable lack of precaution on the part of the offender, taking into incapable of intelligently evaluating. 31 Expert testimony should have been
consideration his employment or occupation, degree of intelligence, physical offered to prove that the circumstances cited by the courts below are
condition, and other circumstances regarding persons, time and place. constitutive of conduct falling below the standard of care employed by other
Whether or not a physician has committed an "inexcusable lack of physicians in good standing when performing the same operation. It must be
remembered that when the qualifications of a physician are admitted, as in
precaution" in the treatment of his patient is to be determined according to
the instant case, there is an inevitable presumption that in proper cases he
the standard of care observed by other members of the profession in good
takes the necessary precaution and employs the best of his knowledge and
standing under similar circumstances bearing in mind the advanced state of
the profession at the time of treatment or the present state of medical skill in attending to his clients, unless the contrary is sufficiently
science. 26 In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pascasio, established. 32 This presumption is rebuttable by expert opinion which is so
sadly lacking in the case at bench.
Even granting arguendo that the inadequacy of the facilities and untidiness of Q. You mentioned on your "Post Mortem
the clinic; the lack of provisions; the failure to conduct pre-operation tests on Findings" about surgical incision, 14:0 cm.,
the patient; and the subsequent transfer of Lydia to the San Pablo Hospital infraumbilical area, anterior abdominal area,
and the reoperation performed on her by the petitioner do indicate, even midline, will you please explain that in your
without expert testimony, that petitioner was recklessly imprudent in the own language?
exercise of her duties as a surgeon, no cogent proof exists that any of these A. There was incision wound (sic) the area
circumstances caused petitioner's death. Thus, the absence of the fourth
just below the navel, sir.
element of reckless imprudence: that the injury to the person or property was
a consequence of the reckless imprudence. Q. And the last paragraph of the postmortem
findings which I read: Uterus, pear-shaped
In litigations involving medical negligence, the plaintiff has the burden of
and pale measuring 7.5 x 5.5 x 5.0 cm. with
establishing appellant's negligence and for a reasonable conclusion of
some surface nodulation of the fundic area
negligence, there must be proof of breach of duty on the part of the posteriorly. Cut-section shows diffusely pale
surgeon as well as a causal connection of such breach and the resulting
myometrium with areas of streak induration.
death of his patient. 33 In Chan Lugay v. St. Luke's Hospital, Inc., 34 where
The ovaries and adnexal structures are
the attending physician was absolved of liability for the death of the
missing with the raw surfaces patched with
complainant's wife and newborn baby, this Court held that:
clotted blood. Surgical sutures were noted
In order that there may be a recovery for an injury, however, on the operative site.
it must be shown that the "injury for which recovery is sought
Intestines and mesenteries are pale with
must be the legitimate consequence of the wrong done; the
blood clots noted between the mesentric
connection between the negligence and the injury must be a
folds.
direct and natural sequence of events, unbroken by
intervening efficient causes." In other words, the negligence Hemoperitoneum: 300 s.s.,
must be the proximate cause of the injury. For, "negligence, right paracolic gutter,
no matter in what it consists, cannot create a right of action 50 c.c., left paracolic gutter
unless it is the proximate cause of the injury complained of ." 200 c.c., mesentric area,
And "the proximate cause of an injury is that cause, which, in 100 c.c., right pelvic gutter
natural and continuous sequence, unbroken by any efficient stomach empty.
intervening cause, produces the injury, and without which Other visceral organs, pale.,
the result would not have occurred." 35 (Emphasis supplied.)
will you please explain that on (sic) your own language or in
Dr. Arizala who conducted an autopsy on the body of the deceased ordinary. . . . . . . . . . . .
summarized his findings as follows:
A. There was a uterus which was not
Atty. Cachero: attached to the adnexal structures namely
Q. You mentioned about your Autopsy ovaries which were not present and also
Report which has been marked as Exh. "A- sign of previous surgical operation and there
1-b". There appears here a signature above were (sic) clotted blood, sir.
the typewritten name Floresto Arizala, Jr., Q. How about the ovaries and adnexal
whose signature is that? structures?
A. That is my signature, sir. A. They are missing, sir.
Q. Do you affirm the truth of all the contents Q. You mean to say there are no ovaries?
of Exh. "A-1-b"?
A. During that time there are no ovaries, sir.
A. Only as to the autopsy report no. 91-09,
the time and place and everything after the Q. And there were likewise sign of surgical
post mortem findings, sir. sutures?
A. Yes, sir. Q. What could have caused the death of the
victim?
Q. How about the intestines and
mesenteries are place (sic) with blood clots A. This pathologic examination are (sic)
noted between the mesenteric folds, will you compatible with the person who died, sir.
please explain on (sic) this?
Q. Will you explain to us the meaning of
A. In the peritoneal cavity, they are mostly hemorrhagic compatible?
perritonial blood . . . . . . . . A. It means that a person died of blood
Q. And what could have caused this blood? loss. Meaning a person died of non-
replacement of blood and so the victim
A. Well, ordinarily blood is found inside the
before she died there was shock of diminish
blood vessel. Blood were (sic) outside as a
of blood of the circulation. She died most
result of the injuries which destroyed the
probably before the actual complete blood
integrity of the vessel allowing blood to sip
loss, sir.
(sic) out, sir.
Court: Is it possible doctor that the loss of
Q. By the nature of the postmortem findings
the blood was due on (sic) operation?
indicated in Exh. A-1-B, can you tell the
court the cause of death? A. Based on my pathologist finding, sir.
A. Yes, sir. The cause of death is: Gross Q. What could have caused this loss of
findings are compatible with hemorrhagic blood?
shock.
A. Many, sir. A patient who have undergone
Q. Can you tell the us what could have surgery. Another may be a blood vessel may
caused this hemorrhagic shock? be cut while on operation and this cause
(sic) bleeding, or may be set in the course of
A. Well hemorrhagic shock is the result of
blood loss. operation, or may be (sic) he died after the
operation. Of course there are other cause
Q. What could have the effect of that loss of (sic).
blood?
Atty. Cachero:
A. Unattended hemorrhage,
Q. Especially so doctor when there was no
sir. 36 (Emphasis supplied.)
blood replacement?
The foregoing was corroborated by Dr. Nieto Salvador:
A. Yes, sir. 37 (Emphasis supplied.)
Q. And were you able to determine the
The testimonies of both doctors establish hemorrhage or hemorrhagic shock
cause of death by virtue of the examination
as the cause of death. However, as likewise testified to by the expert
of the specimen submitted by Dr. Arizala?
witnesses in open court, hemorrhage or hemorrhagic shock during surgery
A. Without knowledge of the autopsy may be caused by several different factors. Thus, Dr. Salvador's elaboration
findings it would be difficult for me to on the matter:
determine the cause of death, sir.
Atty. Pascual:
Q. Have you also examined the post mortem
of Dr. Arizala? Q. Doctor, among the causes of hemorrhage
that you mentioned you said that it could be
A. Yes, sir, and by virtue of the autopsy at the moment of operation when one losses
report in connection with your pathology (sic) control of the presence, is that correct?
report. During the operation there is lost (sic) of
control of the cut vessel?
A. Yes, sir. vessel or any suture that become (sic) loose
Q. Or there is a failure to ligate a vessel of the cause of the bleeding could not be
considerable size? attributed to the fault of the subject?
A. Definitely, sir. 39 (Emphasis supplied.)
A. Yes, sir.
Q. Or even if the vessel were ligated the 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
knot may have slipped later on?
vessel; (2) allowing a cut blood vessel to get out of control; (3) the
A. Yes, sir. subsequent loosening of the tie or suture applied to a cut blood vessel; and
Q. And you also mentioned that it may be (4) and a clotting defect known as DIC. It is significant to state at this juncture
possible also to some clotting defect, is that that the autopsy conducted by Dr. Arizala on the body of Lydia did not reveal
correct? 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
A. May be (sic). 38 (Emphasis supplied). hemorrhage. 40 Hence the following pertinent portion of Dr. Arizala's
Defense witness, Dr. Bu C. Castro also gave the following expert opinion: testimony:
Q. Doctor even a patient after an operations Q: Doctor, in examining these structures did
(sic) would suffer hemorrage what would be you know whether these were sutured
the possible causes of such hemorrage ligature or plain ligature
(sic)? A: Ligature, sir.
A. Among those would be what we call Q: We will explain that later on. Did you
Intravascular Coagulation and this is the recall if the cut structures were tied by first
reason for the bleeding, sir, which cannot be suturing it and then tying a knot or the tie
prevented by anyone, it will happen to was merely placed around the cut structure
anyone, anytime and to any persons (sic), and tied?
sir.
A: I cannot recall, sir.
COURT:
Q: As a matter of fact, you cannot recall
What do you think of the cause of the because you did not even bothered (sic) to
bleeding, the cutting or the operations done examine, is that correct?
in the body?
A: Well, I bothered enough to know that they
A. Not related to this one, the bleeding here were sutured, sir.
is not related to any cutting or operation that
I (sic) have done. Q: So, therefore, Doctor, you would not
know whether any of the cut structures were
Q. Aside from the DIC what could another not sutured or tied neither were you able to
causes (sic) that could be the cause for the determine whether any loose suture was
hemorrhage or bleeding in a patient by an found in the peritoneal cavity?
operations (sic)?
A: I could not recall any loose sutured (sic),
A. In general sir, if there was an operations sir. 41
(sic) and it is possible that the ligature in the
suture was (sic) become (sic) loose, it is On the other hand, the findings of all three doctors do not preclude the
(sic) becomes loose if proven.. probability that DIC caused the hemorrhage and consequently, Lydia's death.
DIC which is a clotting defect creates a serious bleeding tendency and when
xxx xxx xxx massive DIC occurs as a complication of surgery leaving raw surface, major
Q. If the person who performed an autopsy hemorrhage occurs. 42 And as testified to by defense witness, Dr. Bu C.
does not find any untight (sic) clot (sic) blood Castro, hemorrhage due to DIC "cannot be prevented, it will happen to
anyone, ATTY. MALVEDA:
anytime." 43 He testified further:
Not finding, there was no finding made.
Q. Now, under that circumstance one of the
COURT:
possibility as you mentioned in (sic) DIC?
He is only reading the record.
A. Yes, sir.
ATTY. PASCUAL:
Q. And you mentioned that this cannot be
prevented? Yes, sir.
A. Yes, sir. A. No, sir, there is no fault on the part of the
surgeon, sir. 44
Q. Can you even predict if it really happen
(sic)? This Court has no recourse but to rely on the expert testimonies rendered by
both prosecution and defense witnesses that substantiate rather than
A. Possible, sir.
contradict petitioner's allegation that the cause of Lydia's death was DIC
Q. Are there any specific findings of autopsy which, as attested to by an expert witness, cannot be attributed to the
that will tell you whether this patient suffered petitioner's fault or negligence. The probability that Lydia's death was caused
among such things as DIC? 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
A. Well, I did reserve because of the
crime of reckless imprudence resulting in homicide. While we condole with
condition of the patient.
the family of Lydia Umali, our hands are bound by the dictates of justice and
Q. Now, Doctor you said that you went fair dealing which hold inviolable the right of an accused to be presumed
through the record of the deceased Lydia innocent until proven guilty beyond reasonable doubt. Nevertheless, this
Umali looking for the chart, the operated Court finds the petitioner civilly liable for the death of Lydia Umali, for while a
(sic) records, the post mortem findings on conviction of a crime requires proof beyond reasonable doubt, only a
the histophanic (sic) examination based on preponderance of evidence is required to establish civil liability. 45
your examination of record, doctor, can you
more or less says (sic) what part are (sic) The petitioner is a doctor in whose hands a patient puts his life and limb. For
concerned could have been the caused (sic) 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
of death of this Lydia Umali?
the petitioner carried out her duties. A precious life has been lost and the
A. As far as the medical record is concern circumstances leading thereto exacerbated the grief of those left behind. The
(sic) the caused (sic) of death is heirs of the deceased continue to feel the loss of their mother up to the
dessimulated (sic) Intra Vascular present time 46 and this Court is aware that no amount of compassion and
Coagulation or the DIC which resulted to commiseration nor words of bereavement can suffice to assuage the sorrow
hemorrhage or bleedings, sir. felt for the loss of a loved one. Certainly, the award of moral and exemplary
Q. Doctor based on your findings then there damages in favor of the heirs of Lydia Umali are proper in the instant case.
is knowing (sic) the doctor would say WHEREFORE, premises considered, petitioner DR. NINEVETCH CRUZ is
whether the doctor her (sic) has been (sic) hereby ACQUITTED of the crime of reckless imprudence resulting in
fault? homicide but is ordered to pay the heirs of the deceased Lydia Umali the
ATTY. MALVEDA: amount of FIFTY THOUSAND PESOS (P50,000.00) as civil liability, ONE
HUNDRED THOUSAND PESOS (P100,000.00) as moral damages, and
We will moved (sic) to strike out the (sic) FIFTY THOUSAND PESOS (P50,000.00) as exemplary damages.
based on finding they just read the chart as
Let a copy of this decision be furnished to the Professional Regulation Commission (PRC) for
well as the other record. appropriate action.
ATTY. PASCUAL: SO ORDERED.
Romero, Melo and Panganiban, JJ., concur.
Precisely based on this examination. Narvasa, C.J., is on leave.
Republic of the Philippines signed the "Consent on Admission and Agreement"9 and "Admission
SUPREME COURT Agreement."10 Corazon was then brought to the labor room of the CMC.
Manila Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC,
THIRD DIVISION conducted an internal examination of Corazon. Dr. Uy then called up Dr.
G.R. No. 142625 December 19, 2006 Estrada to notify him of her findings.

ROGELIO P. NOGALES, for himself and on behalf of the minors, Based on the Doctor's Order Sheet,11 around 3:00 a.m., Dr. Estrada ordered
ROGER ANTHONY, ANGELICA, NANCY, and MICHAEL CHRISTOPHER, for 10 mg. of valium to be administered immediately by intramuscular
all surnamed NOGALES, petitioners, injection. Dr. Estrada later ordered the start of intravenous administration of
syntocinon admixed with dextrose, 5%, in lactated Ringers' solution, at the
vs.
CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR. ELY rate of eight to ten micro-drops per minute.
VILLAFLOR, DR. ROSA UY, DR. JOEL ENRIQUEZ, DR. PERPETUA According to the Nurse's Observation Notes,12 Dr. Joel Enriquez ("Dr.
LACSON, DR. NOE ESPINOLA, and NURSE J. DUMLAO, respondents. 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.
DECISION
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
CARPIO, J.: experience convulsions.
The Case 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.
This petition for review1 assails the 6 February 1998 Decision2 and 21 March Estrada, administered only 2.5 grams of magnesium sulfate.
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 At 6:22 a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to
Regional Trial Court of Manila, Branch 33, finding Dr. Oscar Estrada solely extract Corazon's baby. In the process, a 1.0 x 2.5 cm. piece of cervical
liable for damages for the death of his patient, Corazon Nogales, while tissue was allegedly torn. The baby came out in an apnic, cyanotic, weak and
absolving the remaining respondents of any liability. The Court of Appeals injured condition. Consequently, the baby had to be intubated and
denied petitioners' motion for reconsideration. resuscitated by Dr. Enriquez and Dr. Payumo.
The Facts 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
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 60/40 within five minutes. There was continuous profuse vaginal bleeding.
37 years old, was under the exclusive prenatal care of Dr. Oscar Estrada The assisting nurse administered hemacel through a gauge 19 needle as a
("Dr. Estrada") beginning on her fourth month of pregnancy or as early as side drip to the ongoing intravenous injection of dextrose.
December 1975. While Corazon was on her last trimester of pregnancy, Dr.
Estrada noted an increase in her blood pressure and development of leg At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with
edema5 indicating preeclampsia,6 which is a dangerous complication of bottled blood. It took approximately 30 minutes for the CMC laboratory,
pregnancy.7 headed by Dr. Perpetua Lacson ("Dr. Lacson"), to comply with Dr. Estrada's
order and deliver the blood.
Around midnight of 25 May 1976, Corazon started to experience mild labor
pains prompting Corazon and Rogelio Nogales ("Spouses Nogales") to see At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-
Dr. Estrada at his home. After examining Corazon, Dr. Estrada advised her Gynecology Department of the CMC, was apprised of Corazon's condition by
immediate admission to the Capitol Medical Center ("CMC"). telephone. Upon being informed that Corazon was bleeding profusely, Dr.
Espinola ordered immediate hysterectomy. Rogelio was made to sign a
On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the "Consent to Operation."13
staff nurse noted the written admission request8 of Dr. Estrada. Upon
Corazon's admission at the CMC, Rogelio Nogales ("Rogelio") executed and
Due to the inclement weather then, Dr. Espinola, who was fetched from his Villaflor had discovered that there was laceration at the cervical area
residence by an ambulance, arrived at the CMC about an hour later or at of the patient's internal organ.
9:00 a.m. He examined the patient and ordered some resuscitative measures On the part of nurse Dumlao, there is no showing that when she
to be administered. Despite Dr. Espinola's efforts, Corazon died at 9:15 a.m.
administered the hemacel as a side drip, she did it on her own. If the
The cause of death was "hemorrhage, post partum."14
correct procedure was directly thru the veins, it could only be
On 14 May 1980, petitioners filed a complaint for damages15 with the because this was what was probably the orders of Dr. Estrada.
Regional Trial Court16 of Manila against CMC, Dr. Estrada, Dr. Villaflor, Dr. While the evidence of the plaintiffs shows that Dr. Noe Espinola, who
Uy, Dr. Enriquez, Dr. Lacson, Dr. Espinola, and a certain Nurse J. Dumlao
was the Chief of the Department of Obstetrics and Gynecology who
for the death of Corazon. Petitioners mainly contended that defendant
attended to the patient Mrs. Nogales, it was only at 9:00 a.m. That he
physicians and CMC personnel were negligent in the treatment and
was able to reach the hospital because of typhoon Didang (Exhibit
management of Corazon's condition. Petitioners charged CMC with
2). While he was able to give prescription in the manner Corazon
negligence in the selection and supervision of defendant physicians and Nogales may be treated, the prescription was based on the
hospital staff. information given to him by phone and he acted on the basis of facts
For failing to file their answer to the complaint despite service of summons, as presented to him, believing in good faith that such is the correct
the trial court declared Dr. Estrada, Dr. Enriquez, and Nurse Dumlao in remedy. He was not with Dr. Estrada when the patient was brought
default.17 CMC, Dr. Villaflor, Dr. Uy, Dr. Espinola, and Dr. Lacson filed their to the hospital at 2:30 o'clock a.m. So, whatever errors that Dr.
respective answers denying and opposing the allegations in the complaint. Estrada committed on the patient before 9:00 o'clock a.m. are
Subsequently, trial ensued. 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
After more than 11 years of trial, the trial court rendered judgment on 22
fortuitous event.
November 1993 finding Dr. Estrada solely liable for damages. The trial court
ruled as follows: 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.
The victim was under his pre-natal care, apparently, his fault began
Estrada, Dra. Villaflor and also of Nurse Dumlao on the alleged
from his incorrect and inadequate management and lack of treatment
errors committed by them. Besides, as anesthesiologist, he has no
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 authority to control the actuations of Dr. Estrada and Dra. Villaflor.
a large cervical tear which had caused the profuse bleeding which he For the Court to assume that there were errors being committed in
the presence of Dr. Enriquez would be to dwell on conjectures and
also failed to control with the application of inadequate injection of
speculations.
magnesium sulfate by his assistant Dra. Ely Villaflor. Dr. Estrada
even failed to notice the erroneous administration by nurse Dumlao On the civil liability of Dr. Perpetua Lacson, [s]he is a hematologist
of hemacel by way of side drip, instead of direct intravenous and in-charge of the blood bank of the CMC. The Court cannot
injection, and his failure to consult a senior obstetrician at an early accept the theory of the plaintiffs that there was delay in delivering
stage of the problem. 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
On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr. Joel
to determine the type of blood, cross matching and other matters
Enriquez, Dr. Lacson, Dr. Espinola, nurse J. Dumlao and CMC, the
Court finds no legal justification to find them civilly liable. consistent with medical science so, the lapse of 30 minutes maybe
considered a reasonable time to do all of these things, and not a
On the part of Dra. Ely Villaflor, she was only taking orders from Dr. delay as the plaintiffs would want the Court to believe.
Estrada, the principal physician of Corazon Nogales. She can only
Admittedly, Dra. Rosa Uy is a resident physician of the Capitol
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 Medical Center. She was sued because of her alleged failure to
judgment to that of Dr. Estrada. If she failed to correctly diagnose the notice the incompetence and negligence of Dr. Estrada. However,
there is no evidence to support such theory. No evidence was
true cause of the bleeding which in this case appears to be a cervical
adduced to show that Dra. Rosa Uy as a resident physician of
laceration, it cannot be safely concluded by the Court that Dra.
Capitol Medical Center, had knowledge of the mismanagement of
Villaflor had the correct diagnosis and she failed to inform Dr.
Estrada. No evidence was introduced to show that indeed Dra.
the patient Corazon Nogales, and that notwithstanding such no longer be notified of the petition because they are absolutely not involved
knowledge, she tolerated the same to happen. in the issue raised before the [Court], regarding the liability of
In the pre-trial order, plaintiffs and CMC agreed that defendant CMC [CMC]."22 Petitioners stressed that the subject matter of this petition is the
liability of CMC for the negligence of Dr. Estrada. 23
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 Court issued a Resolution dated 9 September 200224 dispensing with
the deceased. In other words, the two (2) doctors were not the requirement to submit the correct and present addresses of respondents
employees of the hospital and therefore the hospital did not have Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao. The Court stated
control over their professional conduct. When Mrs. Nogales was that with the filing of petitioners' Manifestation, it should be understood that
brought to the hospital, it was an emergency case and defendant they are claiming only against respondents CMC, Dr. Espinola, Dr. Lacson,
CMC had no choice but to admit her. Such being the case, there is and Dr. Uy who have filed their respective comments. Petitioners are
therefore no legal ground to apply the provisions of Article 2176 and foregoing further claims against respondents Dr. Estrada, Dr. Enriquez, Dr.
2180 of the New Civil Code referring to the vicarious liability of an Villaflor, and Nurse Dumlao.
employer for the negligence of its employees. If ever in this case The Court noted that Dr. Estrada did not appeal the decision of the Court of
there is fault or negligence in the treatment of the deceased on the
Appeals affirming the decision of the Regional Trial Court. Accordingly, the
part of the attending physicians who were employed by the family of
decision of the Court of Appeals, affirming the trial court's judgment, is
the deceased, such civil liability should be borne by the attending
already final as against Dr. Oscar Estrada.
physicians under the principle of "respondeat superior".
Petitioners filed a motion for reconsideration25 of the Court's 9 September
WHEREFORE, premises considered, judgment is hereby rendered
2002 Resolution claiming that Dr. Enriquez, Dr. Villaflor and Nurse Dumlao
finding defendant Dr. Estrada of Number 13 Pitimini St. San
were notified of the petition at their counsels' last known addresses.
Francisco del Monte, Quezon City civilly liable to pay plaintiffs: 1) By
Petitioners reiterated their imputation of negligence on these respondents.
way of actual damages in the amount of P105,000.00; 2) By way of
The Court denied petitioners' Motion for Reconsideration in its 18 February
moral damages in the amount of P700,000.00; 3) Attorney's fees in 2004 Resolution.26
the amount of P100,000.00 and to pay the costs of suit.
The Court of Appeals' Ruling
For failure of the plaintiffs to adduce evidence to support its [sic]
allegations against the other defendants, the complaint is hereby In its Decision of 6 February 1998, the Court of Appeals upheld the trial
ordered dismissed. While the Court looks with disfavor the filing of court's ruling. The Court of Appeals rejected petitioners' view that the
the present complaint against the other defendants by the herein doctrine in Darling v. Charleston Community Memorial Hospital27 applies to
plaintiffs, as in a way it has caused them personal inconvenience this case. According to the Court of Appeals, the present case differs from
and slight damage on their name and reputation, the Court cannot the Darling case since Dr. Estrada is an independent contractor-physician
accepts [sic] however, the theory of the remaining defendants that whereas the Darling case involved a physician and a nurse who were
plaintiffs were motivated in bad faith in the filing of this complaint. For employees of the hospital.
this reason defendants' counterclaims are hereby ordered dismissed. Citing other American cases, the Court of Appeals further held that the mere
SO ORDERED.18 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
Petitioners appealed the trial court's decision. Petitioners claimed that aside negligence.28 A hospital is not responsible for the negligence of a physician
from Dr. Estrada, the remaining respondents should be held equally liable for
who is an independent contractor.29
negligence. Petitioners pointed out the extent of each respondent's alleged
liability. The Court of Appeals found the cases of Davidson v. Conole30 and Campbell
v. Emma Laing Stevens Hospital31applicable to this case.
On 6 February 1998, the Court of Appeals affirmed the decision of the trial Quoting Campbell, the Court of Appeals stated that where there is no proof
court.19 Petitioners filed a motion for reconsideration which the Court of
that defendant physician was an employee of defendant hospital or that
Appeals denied in its Resolution of 21 March 2000.20
defendant hospital had reason to know that any acts of malpractice would
Hence, this petition. take place, defendant hospital could not be held liable for its failure to
intervene in the relationship of physician-patient between defendant
Meanwhile, petitioners filed a Manifestation dated 12 April 200221 stating that
physician and plaintiff.
respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao "need
On the liability of the other respondents, the Court of Appeals applied the Employers shall be liable for the damages caused by their
"borrowed servant" doctrine considering that Dr. Estrada was an independent employees and household helpers acting within the scope of their
contractor who was merely exercising hospital privileges. This doctrine assigned tasks, even though the former are not engaged in any
provides that once the surgeon enters the operating room and takes charge business or industry.
of the proceedings, the acts or omissions of operating room personnel, and
xxxx
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 responsibility treated of in this article shall cease when the
the hospital, or engaged by the patient, they normally become the temporary persons herein mentioned prove that they observed all the diligence
servants or agents of the surgeon in charge while the operation is in of a good father of a family to prevent damage.
progress, and liability may be imposed upon the surgeon for their negligent Art. 2176. Whoever by act or omission causes damage to another,
acts under the doctrine of respondeat superior.33 there being fault or negligence, is obliged to pay for the damage
The Court of Appeals concluded that since Rogelio engaged Dr. Estrada as done. Such fault or negligence, if there is no pre-existing contractual
the attending physician of his wife, any liability for malpractice must be Dr. relation between the parties, is called a quasi-delict and is governed
Estrada's sole responsibility. by the provisions of this Chapter.
While it found the amount of damages fair and reasonable, the Court of Similarly, in the United States, a hospital which is the employer, master, or
Appeals held that no interest could be imposed on unliquidated claims or principal of a physician employee, servant, or agent, may be held liable for
damages. the physician's negligence under the doctrine of respondeat superior.34
The Issue 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
Basically, the issue in this case is whether CMC is vicariously liable for the malpractice. Rogelio claims that he knew Dr. Estrada as an accredited
negligence of Dr. Estrada. The resolution of this issue rests, on the other
physician of CMC, though he discovered later that Dr. Estrada was not a
hand, on the ascertainment of the relationship between Dr. Estrada and
salaried employee of the CMC.35 Rogelio further claims that he was dealing
CMC. The Court also believes that a determination of the extent of liability of
with CMC, whose primary concern was the treatment and management of his
the other respondents is inevitable to finally and completely dispose of the wife's condition. Dr. Estrada just happened to be the specific person he
present controversy. talked to representing CMC.36 Moreover, the fact that CMC made Rogelio
The Ruling of the Court sign a Consent on Admission and Admission Agreement37 and a Consent to
Operation printed on the letterhead of CMC indicates that CMC considered
The petition is partly meritorious.
Dr. Estrada as a member of its medical staff.
On the Liability of CMC
On the other hand, CMC disclaims liability by asserting that Dr. Estrada was
Dr. Estrada's negligence in handling the treatment and management of a mere visiting physician and that it admitted Corazon because her physical
Corazon's condition which ultimately resulted in Corazon's death is no longer condition then was classified an emergency obstetrics case.38
in issue. Dr. Estrada did not appeal the decision of the Court of Appeals
CMC alleges that Dr. Estrada is an independent contractor "for whose
which affirmed the ruling of the trial court finding Dr. Estrada solely liable for
actuations CMC would be a total stranger." CMC maintains that it had no
damages. Accordingly, the finding of the trial court on Dr. Estrada's
control or supervision over Dr. Estrada in the exercise of his medical
negligence is already final.
profession.
Petitioners maintain that CMC is vicariously liable for Dr. Estrada's
The Court had the occasion to determine the relationship between a hospital
negligence based on Article 2180 in relation to Article 2176 of the Civil Code.
and a consultant or visiting physician and the liability of such hospital for that
These provisions pertinently state:
physician's negligence in Ramos v. Court of Appeals,39 to wit:
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 In the first place, hospitals exercise significant control in the hiring
and firing of consultants and in the conduct of their work within the
for whom one is responsible.
hospital premises. Doctors who apply for "consultant" slots, visiting
xxxx 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 After a thorough examination of the voluminous records of this case, the
by members of the hospital administration or by a review committee Court finds no single evidence pointing to CMC's exercise of control over Dr.
set up by the hospital who either accept or reject the application. Estrada's treatment and management of Corazon's condition. It is undisputed
This is particularly true with respondent hospital. 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
After a physician is accepted, either as a visiting or attending
her delivery, it was Dr. Estrada, assisted by Dr. Villaflor, who attended to
consultant, he is normally required to attend clinico-pathological
Corazon. There was no showing that CMC had a part in diagnosing
conferences, conduct bedside rounds for clerks, interns and
residents, moderate grand rounds and patient audits and perform Corazon's condition. While Dr. Estrada enjoyed staff privileges at CMC, such
other tasks and responsibilities, for the privilege of being able to 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
maintain a clinic in the hospital, and/or for the privilege of admitting
CMC considered an emergency. Considering these circumstances, Dr.
patients into the hospital. In addition to these, the physician's
Estrada is not an employee of CMC, but an independent contractor.
performance as a specialist is generally evaluated by a peer review
committee on the basis of mortality and morbidity statistics, and The question now is whether CMC is automatically exempt from liability
feedback from patients, nurses, interns and residents. A consultant considering that Dr. Estrada is an independent contractor-physician.
remiss in his duties, or a consultant who regularly falls short of the
In general, a hospital is not liable for the negligence of an independent
minimum standards acceptable to the hospital or its peer review
contractor-physician. There is, however, an exception to this principle. The
committee, is normally politely terminated.
hospital may be liable if the physician is the "ostensible" agent of the
In other words, private hospitals, hire, fire and exercise real control hospital.44 This exception is also known as the "doctrine of apparent
over their attending and visiting "consultant" staff. While authority."45 In Gilbert v. Sycamore Municipal Hospital,46 the Illinois Supreme
"consultants" are not, technically employees, a point which Court explained the doctrine of apparent authority in this wise:
respondent hospital asserts in denying all responsibility for the
[U]nder the doctrine of apparent authority a hospital can be held
patient's condition, the control exercised, the hiring, and the
vicariously liable for the negligent acts of a physician providing care
right to terminate consultants all fulfill the important hallmarks
at the hospital, regardless of whether the physician is an
of an employer-employee relationship, with the exception of the
independent contractor, unless the patient knows, or should have
payment of wages. In assessing whether such a relationship in
known, that the physician is an independent contractor. The
fact exists, the control test is determining. Accordingly, on the
elements of the action have been set out as follows:
basis of the foregoing, we rule that for the purpose of allocating
responsibility in medical negligence cases, an employer- "For a hospital to be liable under the doctrine of apparent authority, a
employee relationship in effect exists between hospitals and plaintiff must show that: (1) the hospital, or its agent, acted in a
their attending and visiting physicians.This being the case, the manner that would lead a reasonable person to conclude that the
question now arises as to whether or not respondent hospital is individual who was alleged to be negligent was an employee or
solidarily liable with respondent doctors for petitioner's condition. agent of the hospital; (2) where the acts of the agent create the
appearance of authority, the plaintiff must also prove that the hospital
The basis for holding an employer solidarily responsible for the
had knowledge of and acquiesced in them; and (3) the plaintiff acted
negligence of its employee is found in Article 2180 of the Civil Code
in reliance upon the conduct of the hospital or its agent, consistent
which considers a person accountable not only for his own acts but
with ordinary care and prudence."
also for those of others based on the former's responsibility under a
relationship of patria potestas. x x x40 (Emphasis supplied) The element of "holding out" on the part of the hospital does not
require an express representation by the hospital that the person
While the Court in Ramos did not expound on the control test, such test
alleged to be negligent is an employee. Rather, the element is
essentially determines whether an employment relationship exists between a
satisfied if the hospital holds itself out as a provider of emergency
physician and a hospital based on the exercise of control over the physician
room care without informing the patient that the care is provided by
as to details. Specifically, the employer (or the hospital) must have the right independent contractors.
to control both the means and the details of the process by which the
employee (or the physician) is to accomplish his task.41 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 Corazon and I will comply with any and all rules, regulations,
determine the liability of an independent-contractor physician. directions, and instructions of the Physician, the Capitol
Medical Center and/or its staff; and, that I will not hold liable or
The first factor focuses on the hospital's manifestations and is sometimes
responsible and hereby waive and forever discharge and hold free
described as an inquiry whether the hospital acted in a manner which would
the Physician, the Capitol Medical Center and/or its staff, from any
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 and all claims of whatever kind of nature, arising from directly or
hospital need not make express representations to the patient that the indirectly, or by reason of said cure, treatment, or retreatment, or
treating physician is an employee of the hospital; rather a emergency measures or intervention of said physician, the Capitol
representation may be general and implied.48 Medical Center and/or its staff.
x x x x51 (Emphasis supplied)
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 While the Consent to Operation pertinently reads, thus:
or representation is rendered conclusive upon the person making it, and
I, ROGELIO NOGALES, x x x, of my own volition and free will, do
cannot be denied or disproved as against the person relying thereon."
consent and submit said CORAZON NOGALES to Hysterectomy, by
Estoppel rests on this rule: "Whenever a party has, by his own declaration, the Surgical Staff and Anesthesiologists of Capitol Medical
act, or omission, intentionally and deliberately led another to believe a Center and/or whatever succeeding operations, treatment, or
particular thing true, and to act upon such belief, he cannot, in any litigation emergency measures as may be necessary and most expedient;
arising out of such declaration, act or omission, be permitted to falsify it."49 and, that I will not hold liable or responsible and hereby waive and
In the instant case, CMC impliedly held out Dr. Estrada as a member of its forever discharge and hold free the Surgeon, his assistants,
medical staff. Through CMC's acts, CMC clothed Dr. Estrada with apparent anesthesiologists, the Capitol Medical Center and/or its staff, from
authority thereby leading the Spouses Nogales to believe that Dr. Estrada any and all claims of whatever kind of nature, arising from directly or
was an employee or agent of CMC. CMC cannot now repudiate such indirectly, or by reason of said operation or operations, treatment, or
authority. emergency measures, or intervention of the Surgeon, his assistants,
anesthesiologists, the Capitol Medical Center and/or its
First, CMC granted staff privileges to Dr. Estrada. CMC extended its medical
staff.52 (Emphasis supplied)
staff and facilities to Dr. Estrada. Upon Dr. Estrada's request for Corazon's
admission, CMC, through its personnel, readily accommodated Corazon and Without any indication in these consent forms that Dr. Estrada was an
updated Dr. Estrada of her condition. independent contractor-physician, the Spouses Nogales could not have
known that Dr. Estrada was an independent contractor. Significantly, no one
Second, CMC made Rogelio sign consent forms printed on CMC letterhead.
from CMC informed the Spouses Nogales that Dr. Estrada was an
Prior to Corazon's admission and supposed hysterectomy, CMC asked
Rogelio to sign release forms, the contents of which reinforced Rogelio's independent contractor. On the contrary, Dr. Atencio, who was then a
belief that Dr. Estrada was a member of CMC's medical staff. 50 The Consent member of CMC Board of Directors, testified that Dr. Estrada was part of
CMC's surgical staff.53
on Admission and Agreement explicitly provides:
Third, Dr. Estrada's referral of Corazon's profuse vaginal bleeding to Dr.
KNOW ALL MEN BY THESE PRESENTS:
Espinola, who was then the Head of the Obstetrics and Gynecology
I, Rogelio Nogales, of legal age, a resident of 1974 M. H. Del Pilar Department of CMC, gave the impression that Dr. Estrada as a member of
St., Malate Mla., being the CMC's medical staff was collaborating with other CMC-employed specialists
father/mother/brother/sister/spouse/relative/ guardian/or person in in treating Corazon.
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. The second factor focuses on the patient's reliance. It is sometimes
Oscar Estrada (hereinafter referred to as Physician) for cure, 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
treatment, retreatment, or emergency measures, that the
Physician, personally or by and through the Capitol Medical prudence.54
Center and/or its staff, may use, adapt, or employ such means, The records show that the Spouses Nogales relied upon a perceived
forms or methods of cure, treatment, retreatment, or emergency employment relationship with CMC in accepting Dr. Estrada's services.
measures as he may see best and most expedient; that Ma. 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 releases CMC and its employees "from any and all claims" arising from or by
more importantly because of Dr. Estrada's "connection with a reputable reason of the treatment and operation.
hospital, the [CMC]."55 In other words, Dr. Estrada's relationship with CMC The documents do not expressly release CMC from liability for injury to
played a significant role in the Spouses Nogales' decision in accepting Dr.
Corazon due to negligence during her treatment or operation. Neither do the
Estrada's services as the obstetrician-gynecologist for Corazon's delivery.
consent forms expressly exempt CMC from liability for Corazon's death due
Moreover, as earlier stated, there is no showing that before and during
to negligence during such treatment or operation. Such release forms, being
Corazon's confinement at CMC, the Spouses Nogales knew or should have
in the nature of contracts of adhesion, are construed strictly against
known that Dr. Estrada was not an employee of CMC. hospitals. Besides, a blanket release in favor of hospitals "from any and all
Further, the Spouses Nogales looked to CMC to provide the best medical claims," which includes claims due to bad faith or gross negligence, would be
care and support services for Corazon's delivery. The Court notes that prior contrary to public policy and thus void.
to Corazon's fourth pregnancy, she used to give birth inside a clinic.
Even simple negligence is not subject to blanket release in favor of
Considering Corazon's age then, the Spouses Nogales decided to have their establishments like hospitals but may only mitigate liability depending on the
fourth child delivered at CMC, which Rogelio regarded one of the best circumstances.58 When a person needing urgent medical attention rushes to
hospitals at the time.56 This is precisely because the Spouses Nogales
a hospital, he cannot bargain on equal footing with the hospital on the terms
feared that Corazon might experience complications during her delivery
of admission and operation. Such a person is literally at the mercy of the
which would be better addressed and treated in a modern and big hospital
hospital. There can be no clearer example of a contract of adhesion than one
such as CMC. Moreover, Rogelio's consent in Corazon's hysterectomy to be
arising from such a dire situation. Thus, the release forms of CMC cannot
performed by a different physician, namely Dr. Espinola, is a clear indication relieve CMC from liability for the negligent medical treatment of Corazon.
of Rogelio's confidence in CMC's surgical staff.
On the Liability of the Other Respondents
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 Despite this Court's pronouncement in its 9 September 200259 Resolution
as CMC, are in the business of treatment. In this regard, the Court agrees that the filing of petitioners' Manifestation confined petitioners' claim only
with the observation made by the Court of Appeals of North Carolina in Diggs against CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy, who have filed their
v. Novant Health, Inc.,57 to wit: 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
"The conception that the hospital does not undertake to treat the controversy.
patient, does not undertake to act through its doctors and nurses, but
undertakes instead simply to procure them to act upon their own a) Dr. Ely Villaflor
responsibility, no longer reflects the fact. Present day hospitals, as Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause of
their manner of operation plainly demonstrates, do far more Corazon's bleeding and to suggest the correct remedy to Dr.
than furnish facilities for treatment. They regularly employ on a Estrada.60 Petitioners assert that it was Dr. Villaflor's duty to correct the error
salary basis a large staff of physicians, nurses and internes of Nurse Dumlao in the administration of hemacel.
[sic], as well as administrative and manual workers, and they
charge patients for medical care and treatment, collecting for The Court is not persuaded. Dr. Villaflor admitted administering a lower
such services, if necessary, by legal action. Certainly, the dosage of magnesium sulfate. However, this was after informing Dr. Estrada
person who avails himself of 'hospital facilities' expects that the that Corazon was no longer in convulsion and that her blood pressure went
hospital will attempt to cure him, not that its nurses or other down to a dangerous level.61 At that moment, Dr. Estrada instructed Dr.
employees will act on their own responsibility." x x x (Emphasis Villaflor to reduce the dosage of magnesium sulfate from 10 to 2.5 grams.
supplied) Since petitioners did not dispute Dr. Villaflor's allegation, Dr. Villaflor's
defense remains uncontroverted. Dr. Villaflor's act of administering a lower
Likewise unconvincing is CMC's argument that petitioners are estopped from dosage of magnesium sulfate was not out of her own volition or was in
claiming damages based on the Consent on Admission and Consent to contravention of Dr. Estrada's order.
Operation. Both release forms consist of two parts. The first part gave CMC
permission to administer to Corazon any form of recognized medical b) Dr. Rosa Uy
treatment which the CMC medical staff deemed advisable. The second part Dr. Rosa Uy's alleged negligence consisted of her failure (1) to call the
of the documents, which may properly be described as the releasing part, attention of Dr. Estrada on the incorrect dosage of magnesium sulfate
administered by Dr. Villaflor; (2) to take corrective measures; and (3) to Corazon's condition, believed in good faith that hysterectomy was the correct
correct Nurse Dumlao's wrong method of hemacel administration. remedy. At any rate, the hysterectomy did not push through because upon
The Court believes Dr. Uy's claim that as a second year resident physician Dr. Espinola's arrival, it was already too late. At the time, Corazon was
practically dead.
then at CMC, she was merely authorized to take the clinical history and
physical examination of Corazon.62 However, that routine internal f) Nurse J. Dumlao
examination did not ipso facto make Dr. Uy liable for the errors committed by In Moore v. Guthrie Hospital Inc.,67 the US Court of Appeals, Fourth Circuit,
Dr. Estrada. Further, petitioners' imputation of negligence rests on their held that to recover, a patient complaining of injuries allegedly resulting when
baseless assumption that Dr. Uy was present at the delivery room. Nothing
the nurse negligently injected medicine to him intravenously instead of
shows that Dr. Uy participated in delivering Corazon's baby. Further, it is
intramuscularly had to show that (1) an intravenous injection constituted a
unexpected from Dr. Uy, a mere resident physician at that time, to call the
lack of reasonable and ordinary care; (2) the nurse injected medicine
attention of a more experienced specialist, if ever she was present at the
intravenously; and (3) such injection was the proximate cause of his injury.
delivery room.
In the present case, there is no evidence of Nurse Dumlao's alleged failure to
c) Dr. Joel Enriquez
follow Dr. Estrada's specific instructions. Even assuming Nurse Dumlao
Petitioners fault Dr. Joel Enriquez also for not calling the attention of Dr. defied Dr. Estrada's order, there is no showing that side-drip administration
Estrada, Dr. Villaflor, and Nurse Dumlao about their errors.63 Petitioners of hemacel proximately caused Corazon's death. No evidence linking
insist that Dr. Enriquez should have taken, or at least suggested, corrective Corazon's death and the alleged wrongful hemacel administration was
measures to rectify such errors. introduced. Therefore, there is no basis to hold Nurse Dumlao liable for
negligence.
The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field
of expertise is definitely not obstetrics and gynecology. As such, Dr. Enriquez On the Award of Interest on Damages
was not expected to correct Dr. Estrada's errors. Besides, there was no
The award of interest on damages is proper and allowed under Article 2211
evidence of Dr. Enriquez's knowledge of any error committed by Dr. Estrada
of the Civil Code, which states that in crimes and quasi-delicts, interest as a
and his failure to act upon such observation.
part of the damages may, in a proper case, be adjudicated in the discretion
d) Dr. Perpetua Lacson of the court.68
Petitioners fault Dr. Perpetua Lacson for her purported delay in the delivery WHEREFORE, the Court PARTLY GRANTS the petition. The Court finds
of blood Corazon needed.64 Petitioners claim that Dr. Lacson was remiss in respondent Capitol Medical Center vicariously liable for the negligence of Dr.
her duty of supervising the blood bank staff. 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
As found by the trial court, there was no unreasonable delay in the delivery of
(6%) per annum computed from the date of the judgment of the trial court.
blood from the time of the request until the transfusion to Corazon. Dr.
The Court affirms the rest of the Decision dated 6 February 1998 and
Lacson competently explained the procedure before blood could be given to
Resolution dated 21 March 2000 of the Court of Appeals in CA-G.R. CV No.
the patient.65 Taking into account the bleeding time, clotting time and cross-
matching, Dr. Lacson stated that it would take approximately 45-60 minutes 45641.
before blood could be ready for transfusion.66 Further, no evidence exists SO ORDERED.
that Dr. Lacson neglected her duties as head of the blood bank. Quisumbing, J., Chairperson, Carpio Morales, Tinga, and Velasco, Jr.,
e) Dr. Noe Espinola JJ., concur.
Petitioners argue that Dr. Espinola should not have ordered immediate
hysterectomy without determining the underlying cause of Corazon's
bleeding. Dr. Espinola should have first considered the possibility of cervical
injury, and advised a thorough examination of the cervix, instead of believing
outright Dr. Estrada's diagnosis that the cause of bleeding was uterine atony.
Dr. Espinola's order to do hysterectomy which was based on the information
he received by phone is not negligence. The Court agrees with the trial
court's observation that Dr. Espinola, upon hearing such information about
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
Republic of the Philippines below, on the awarded damages and costs, and on the importance of this
SUPREME COURT type of ruling on medical practice.3
Manila
BACKGROUND FACTS
SECOND DIVISION
Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto.
G.R. No. 158996 November 14, 2008 Domingo, Nueva Ecija. She consulted on April 17, 1987 her townmate, Dr.
SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA Fredelicto Flores, regarding her medical condition. She complained of
FLORES, petitioners, general body weakness, loss of appetite, frequent urination and thirst, and
vs. on-and-off vaginal bleeding. Dr. Fredelicto initially interviewed the patient and
SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO, and asked for the history of her monthly period to analyze the probable cause of
FLORENCIO, CANDIDA, MARTA, GODOFREDO, BALTAZAR and the vaginal bleeding. He advised her to return the following week or to go to
LUCENA, all surnamed PINEDA, as heirs of the deceased TERESITA S. the United Doctors Medical Center (UDMC) in Quezon City for a general
PINEDA, and UNITED DOCTORS MEDICAL CENTER, INC., respondents. check-up. As for her other symptoms, he suspected that Teresita might be
suffering from diabetes and told her to continue her medications.4
DECISION
Teresita did not return the next week as advised. However, when her
BRION, J.:
condition persisted, she went to further consult Dr. Flores at his UDMC clinic
This petition involves a medical negligence case that was elevated to this on April 28, 1987, travelling for at least two hours from Nueva Ecija to
Court through an appeal by certiorari under Rule 45 of the Rules of Court. Quezon City with her sister, Lucena Pineda. They arrived at UDMC at around
The petition assails the Decision1 of the Court of Appeals (CA) in CA G.R. 11:15 a.m.. Lucena later testified that her sister was then so weak that she
CV No. 63234, which affirmed with modification the Decision2 of the Regional had to lie down on the couch of the clinic while they waited for the doctor.
Trial Court (RTC) of Nueva Ecija, Branch 37 in Civil Case No. SD-1233. The When Dr. Fredelicto arrived, he did a routine check-up and ordered
dispositive portion of the assailed CA decision states: Teresita's admission to the hospital. In the admission slip, he directed the
WHEREFORE, premises considered, the assailed Decision of the hospital staff to prepare the patient for an "on call" D&C5 operation to be
Regional Trial Court of Baloc, Sto. Domingo, Nueva Ecija, Branch 37 performed by his wife, Dr. Felicisima Flores (Dr. Felicisima). Teresita was
is hereby AFFIRMED but with modifications as follows: brought to her hospital room at around 12 noon; the hospital staff forthwith
took her blood and urine samples for the laboratory tests6 which Dr.
1) Ordering defendant-appellants Dr. and Dra. Fredelicto A. Fredelicto ordered.
Flores and the United Doctors Medical Center, Inc. to jointly
and severally pay the plaintiff-appellees - heirs of Teresita At 2:40 p.m. of that same day, Teresita was taken to the operating room. It
Pineda, namely, Spouses Dominador Pineda and Virginia was only then that she met Dr. Felicisima, an obstetrician and gynecologist.
Saclolo and Florencio, Candida, Marta, Godofredo, Baltazar The two doctors - Dr. Felicisima and Dr. Fredelicto, conferred on the patient's
and Lucena, all surnamed Pineda, the sum of P400,000.00 medical condition, while the resident physician and the medical intern gave
by way of moral damages; Dr. Felicisima their own briefings. She also interviewed and conducted an
internal vaginal examination of the patient which lasted for about 15 minutes.
2) Ordering the above-named defendant-appellants to jointly Dr. Felicisima thereafter called up the laboratory for the results of the tests.
and severally pay the above-named plaintiff-appellees the At that time, only the results for the blood sugar (BS), uric acid determination,
sum of P100,000.00 by way of exemplary damages; cholesterol determination, and complete blood count (CBC) were available.
3) Ordering the above-named defendant-appellants to jointly Teresita's BS count was 10.67mmol/l7 and her CBC was 109g/l.8
and severally pay the above-named plaintiff-appellees the Based on these preparations, Dr. Felicisima proceeded with the D&C
sum of P36,000.00 by way of actual and compensatory operation with Dr. Fredelicto administering the general anesthesia. The D&C
damages; and operation lasted for about 10 to 15 minutes. By 3:40 p.m., Teresita was
4) Deleting the award of attorney's fees and costs of suit. wheeled back to her room.
SO ORDERED. 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, with the D&C operation was an honest mistake of judgment or one
advised Teresita that she could spend her recovery period at home. Still amounting to negligence.
feeling weak, Teresita opted for hospital confinement. Elements of a Medical Negligence Case
Teresita's complete laboratory examination results came only on that day A medical negligence case is a type of claim to redress a wrong committed
(April 29, 1987). Teresita's urinalysis showed a three plus sign (+++)
by a medical professional, that has caused bodily harm to or the death of a
indicating that the sugar in her urine was very high. She was then placed patient. There are four elements involved in a medical negligence case,
under the care of Dr. Amado Jorge, an internist. namely: duty, breach, injury, and proximate causation. 14
By April 30, 1987, Teresita's condition had worsened. She experienced
Duty refers to the standard of behavior which imposes restrictions on one's
difficulty in breathing and was rushed to the intensive care unit. Further tests
conduct.15 The standard in turn refers to the amount of competence
confirmed that she was suffering from Diabetes Mellitus Type II.10 Insulin
associated with the proper discharge of the profession. A physician is
was administered on the patient, but the medication might have arrived too expected to use at least the same level of care that any other reasonably
late. Due to complications induced by diabetes, Teresita died in the morning
competent doctor would use under the same circumstances. Breach of duty
of May 6, 1987.11
occurs when the physician fails to comply with these professional standards.
Believing that Teresita's death resulted from the negligent handling of her If injury results to the patient as a result of this breach, the physician is
medical needs, her family (respondents) instituted an action for damages answerable for negligence.16
against Dr. Fredelicto Flores and Dr. Felicisima Flores (collectively referred
As in any civil action, the burden to prove the existence of the necessary
to as the petitioner spouses) before the RTC of Nueva Ecija.
elements rests with the plaintiff.17 To successfully pursue a claim, the plaintiff
The RTC ruled in favor of Teresita's family and awarded actual, moral, and must prove by preponderance of evidence that, one, the physician either
exemplary damages, plus attorney's fees and costs.12 The CA affirmed the failed to do something which a reasonably prudent health care provider
judgment, but modified the amount of damages awarded and deleted the would have done, or that he did something that a reasonably prudent
award for attorney's fees and costs of suit.13 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
Through this petition for review on certiorari, the petitioner spouses -Dr.
Fredelicto (now deceased) and Dr. Felicisima Flores - allege that the RTC whether a physician or surgeon has exercised the requisite degree of skill
and CA committed a reversible error in finding them liable through and care in the treatment of his patient is generally a matter of expert
opinion.19
negligence for the death of Teresita Pineda.
ASSIGNMENT OF ERRORS Standard of Care and Breach of Duty
D&C is the classic gynecologic procedure for the evaluation and possible
The petitioner spouses contend that they exercised due care and prudence
therapeutic treatment for abnormal vaginal bleeding.20 That this is the
in the performance of their duties as medical professionals. They had
recognized procedure is confirmed by Drs. Salvador Nieto (Dr. Nieto) and
attended to the patient to the best of their abilities and undertook the
Joselito Mercado (Dr. Mercado), the expert witnesses presented by 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 respondents:
of Teresita could have been averted had they employed means other than DR. NIETO: [W]hat I know among obstetricians, if there is bleeding,
what they had adopted in the ministration of the patient. they perform what we call D&C for diagnostic purposes.
THE COURT'S RULING xxx xxx xxx
We do not find the petition meritorious. Q: So are you trying to tell the Court that D&C can be a diagnostic
treatment?
The respondents' claim for damages is predicated on their allegation that the
decision of the petitioner spouses to proceed with the D&C operation, A: Yes, sir. Any doctor knows this.21
notwithstanding Teresita's condition and the laboratory test results,
Dr. Mercado, however, objected with respect to the time the D&C operation
amounted to negligence. On the other hand, the petitioner spouses contend
should have been conducted in Teresita's case. He opined that given the
that a D&C operation is the proper and accepted procedure to address
blood sugar level of Teresita, her diabetic condition should have been
vaginal bleeding - the medical problem presented to them. Given that the addressed first:
patient died after the D&C, the core issue is whether the decision to proceed
Q: Why do you consider the time of performance of the D&C not Taken together, we find that reasonable prudence would have shown that
appropriate? diabetes and its complications were foreseeable harm that should have been
taken into consideration by the petitioner spouses. If a patient suffers from
A: Because I have read the record and I have seen the urinalysis,
some disability that increases the magnitude of risk to him, that
[there is] spillage in the urine, and blood sugar was 10.67
disability must be taken into account so long as it is or should have
Q: What is the significance of the spillage in the urine? been known to the physician.29 And when the patient is exposed to an
A: It is a sign that the blood sugar is very high. increased risk, it is incumbent upon the physician to take commensurate and
adequate precautions.
Q: Does it indicate sickness?
Taking into account Teresita's high blood sugar,30 Dr. Mendoza opined that
A: 80 to 95% it means diabetes mellitus. The blood sugar was 10.67. the attending physician should have postponed the D&C operation in order to
xxx xxx xxx 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.
COURT: In other words, the operation conducted on the patient, your Delfin Tan (Dr. Tan), an obstetrician and gynecologist, who stated that the
opinion, that it is inappropriate? patient's diabetes should have been managed by an internist prior to, during,
A: The timing of [when] the D&C [was] done, based on the record, in and after the operation.31
my personal opinion, that D&C should be postponed a day or two. 22 Apart from bleeding as a complication of pregnancy, vaginal bleeding is only
The petitioner spouses countered that, at the time of the operation, there was rarely so heavy and life-threatening that urgent first-aid measures are
nothing to indicate that Teresita was afflicted with diabetes: a blood sugar required.32 Indeed, the expert witnesses declared that a D&C operation on a
level of 10.67mmol/l did not necessarily mean that she was a diabetic hyperglycemic patient may be justified only when it is an emergency case -
considering that this was random blood sugar;23 there were other factors when there is profuse vaginal bleeding. In this case, we choose not to rely on
that might have caused Teresita's blood sugar to rise such as the taking of the assertions of the petitioner spouses that there was profuse bleeding, not
blood samples during lunchtime and while patient was being given intra- only because the statements were self-serving, but also because the
venous dextrose.24 Furthermore, they claim that their principal concern was petitioner spouses were inconsistent in their testimonies. Dr. Fredelicto
to determine the cause of and to stop the vaginal bleeding. 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
The petitioner spouses' contentions, in our view, miss several
was bleeding.34 He went on to state that he scheduled the D&C operation
points. First, as early as April 17, 1987, Teresita was already suspected to be
without conducting any physical examination on the patient.
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 The likely story is that although Teresita experienced vaginal bleeding on
increased blood sugar level.26 Unfortunately, the petitioner spouses did not April 28, it was not sufficiently profuse to necessitate an immediate
wait for the full medical laboratory results before proceeding with the D&C, a emergency D&C operation. Dr. Tan35 and Dr. Mendoza36 both testified that
fact that was never considered in the courts below. Second, the petitioner the medical records of Teresita failed to indicate that there was profuse
spouses were duly advised that the patient was experiencing general body vaginal bleeding. The claim that there was profuse vaginal bleeding although
weakness, loss of appetite, frequent urination, and thirst - all of which are this was not reflected in the medical records strikes us as odd since the main
classic symptoms of diabetes.27 When a patient exhibits symptoms typical of complaint is vaginal bleeding. A medical record is the only document that
a particular disease, these symptoms should, at the very least, alert the maintains a long-term transcription of patient care and as such, its
physician of the possibility that the patient may be afflicted with the maintenance is considered a priority in hospital practice. Optimal record-
suspected disease: keeping includes all patient inter-actions. The records should always be
Expert testimony for the plaintiff showed that] tests should have been ordered immediately on admission clear, objective, and up-to-date.37 Thus, a medical record that does not
to the hospital in view of the symptoms presented, and that failure to recognize the existence of diabetes indicate profuse medical bleeding speaks loudly and clearly of what it does
constitutes negligence.28 not contain.
That the D&C operation was conducted principally to diagnose the cause of
Third, the petitioner spouses cannot claim that their principal concern was
the vaginal bleeding further leads us to conclude that it was merely an
the vaginal bleeding and should not therefore be held accountable for
elective procedure, not an emergency case. In an elective procedure, the
complications coming from other sources. This is a very narrow and self-
physician must conduct a thorough pre-operative evaluation of the patient in
serving view that even reflects on their competence.
order to adequately prepare her for the operation and minimize possible risks
and complications. The internist is responsible for generating a after. Despite the possibility that Teresita was afflicted with diabetes, the
comprehensive evaluation of all medical problems during the pre-operative possibility was casually ignored even in the post-operative evaluation of the
evaluation.38 patient; the concern, as the petitioner spouses expressly admitted, was
limited to the complaint of vaginal bleeding. Interestingly, while the
The aim of pre-operative evaluation is not to screen broadly for
ultrasound test confirmed that Teresita had a myoma in her uterus, she was
undiagnosed disease, but rather to identify and quantify comorbidity
advised that she could be discharged a day after the operation and that her
that may impact on the operative outcome. This evaluation is driven
recovery could take place at home. This advice implied that a day after the
by findings on history and physical examination suggestive of organ
system dysfunctionThe goal is to uncover problem areas that operation and even after the complete laboratory results were submitted, the
may require further investigation or be amenable to petitioner spouses still did not recognize any post-operative concern that
preoperative optimization. would require the monitoring of Teresita's condition in the hospital.
The above facts, point only to one conclusion - that the petitioner spouses
If the preoperative evaluation uncovers significant comorbidity or
evidence of poor control of an underlying disease process, failed, as medical professionals, to comply with their duty to observe the
consultation with an internist or medical specialist may be required to standard of care to be given to hyperglycemic/diabetic patients undergoing
surgery. Whether this breach of duty was the proximate cause of Teresita's
facilitate the work-up and direct management. In this process,
death is a matter we shall next determine.
communication between the surgeons and the consultants is
essential to define realistic goals for this optimization process and to Injury and Causation
expedite surgical management.39 [Emphasis supplied.] As previously mentioned, the critical and clinching factor in a medical
Significantly, the evidence strongly suggests that the pre-operative negligence case is proof of the causal connection between the negligence
evaluation was less than complete as the laboratory results were fully which the evidence established and the plaintiff's injuries;45 the plaintiff must
reported only on the day following the D&C operation. Dr. Felicisima only plead and prove not only that he had been injured and defendant has been at
secured a telephone report of the preliminary laboratory result prior to the fault, but also that the defendant's fault caused the injury. A verdict in a
D&C. This preliminary report did not include the 3+ status of sugar in the malpractice action cannot be based on speculation or conjecture. Causation
patient's urine40 - a result highly confirmatory of diabetes. must be proven within a reasonable medical probability based upon
competent expert testimony.46
Because the D&C was merely an elective procedure, the patient's
uncontrolled hyperglycemia presented a far greater risk than her on-and-off The respondents contend that unnecessarily subjecting Teresita to a D&C
vaginal bleeding. The presence of hyperglycemia in a surgical patient is operation without adequately preparing her, aggravated her hyperglycemic
associated with poor clinical outcomes, and aggressive glycemic control state and caused her untimely demise. The death certificate of Teresita lists
positively impacts on morbidity and mortality.41 Elective surgery in people down the following causes of death:
with uncontrolled diabetes should preferably be scheduled after acceptable
glycemic control has been achieved.42 According to Dr. Mercado, this is done Immediate cause: Cardiorespiratory arrest
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. Antecedent cause: Septicemic shock, ketoacidocis
Insulin xxx promotes glucose uptake by the muscle and fat
cells while decreasing glucose production by the liver xxx. The net
Underlying cause: Diabetes Mellitus II
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 Other significant conditions
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. contributing to death: Renal Failure - Acute47

As Dr. Tan testified, the patient's hyperglycemic condition should have been
Stress, whether physical or emotional, is a factor that can aggravate
managed not only before and during the operation, but also immediately
diabetes; a D&C operation is a form of physical stress. Dr. Mendoza
explained how surgical stress can aggravate the patient's hyperglycemia: If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not
when stress occurs, the diabetic's body, especially the autonomic system, being an internist or a diabetologist (for which reason he referred Teresita to
reacts by secreting hormones which are counter-regulatory; she can have Dr. Jorge),51 he should have likewise refrained from making a decision to
prolonged hyperglycemia which, if unchecked, could lead to death.48 Medical proceed with the D&C operation since he was niether an obstetrician nor a
literature further explains that if the blood sugar has become very high, the gynecologist.
patient becomes comatose (diabetic coma). When this happens over several
These findings lead us to the conclusion that the decision to proceed with the
days, the body uses its own fat to produce energy, and the result is high
D&C operation, notwithstanding Teresita's hyperglycemia and without
levels of waste products (called ketones) in the blood and urine adequately preparing her for the procedure, was contrary to the standards
(called diabetic ketoacidiosis, a medical emergency with a significant
observed by the medical profession. Deviation from this standard amounted
mortality).49 This was apparently what happened in Teresita's case; in fact,
to a breach of duty which resulted in the patient's death. Due to this negligent
after she had been referred to the internist Dr. Jorge, laboratory test showed
conduct, liability must attach to the petitioner spouses.
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 Liability of the Hospital
complication that could have been prevented with the observance of In the proceedings below, UDMC was the spouses Flores' co-defendant. The
standard medical precautions. The D&C operation and Teresita's death due RTC found the hospital jointly and severally liable with the petitioner
to aggravated diabetic condition is therefore sufficiently established. spouses, which decision the CA affirmed. In a Resolution dated August 28,
The trial court and the appellate court pinned the liability for Teresita's death 2006, this Court however denied UDMC's petition for review on certiorari.
on both the petitioner spouses and this Court finds no reason to rule Since UDMC's appeal has been denied and they are not parties to this case,
otherwise. However, we clarify that Dr. Fredelicto's negligence is not solely we find it unnecessary to delve on the matter. Consequently, the RTC's
the act of ordering an "on call" D&C operation when he was mainly decision, as affirmed by the CA, stands.
an anaesthesiologist who had made a very cursory examination of the Award of Damages
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 Both the trial and the appellate court awarded actual damages as
suspicions, that diabetes was a risk factor that should be guarded against, compensation for the pecuniary loss the respondents suffered. The loss was
and his participation in the imprudent decision to proceed with the D&C presented in terms of the hospital bills and expenses the respondents
operation despite his early suspicion and the confirmatory early laboratory incurred on account of Teresita's confinement and death. The settled rule is
results. The latter point comes out clearly from the following exchange during that a plaintiff is entitled to be compensated for proven pecuniary loss.52 This
the trial: proof the respondents successfully presented. Thus, we affirm the award
of actual damages of P36,000.00 representing the hospital expenses the
Q: On what aspect did you and your wife consult [with] each other? patient incurred.
A: We discussed on the finding of the laboratory [results] because In addition to the award for actual damages, the respondent heirs of Teresita
the hemoglobin was below normal, the blood sugar was elevated, so are likewise entitled to P50,000.00 as death indemnity pursuant to Article
that we have to evaluate these laboratory results - what it means. 2206 of the Civil Code, which states that "the amount of damages for death
Q: So it was you and your wife who made the evaluation when it was caused by a xxx quasi-delict shall be at least three thousand pesos,53even
phoned in? 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
A: Yes, sir. in the respondents' favor.
Q: Did your wife, before performing D&C ask your opinion whether or
The same article allows the recovery of moral damages in case of death
not she can proceed? caused by a quasi-delict and enumerates the spouse, legitimate or
A: Yes, anyway, she asked me whether we can do D&C based on illegitimate ascendants or descendants as the persons entitled thereto. Moral
my experience. damages are designed to compensate the claimant for the injury suffered,
Q: And your answer was in the positive notwithstanding the that is, for the mental anguish, serious anxiety, wounded feelings which the
elevation of blood sugar? 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
A: Yes, sir, it was both our disposition to do the D&C. [Emphasis of moral damages to the respondents.
supplied.]50
We similarly affirm the grant of exemplary damages. Exemplary damages are 5. The sum of P100,000.00 by way of attorney's fees; and
imposed by way of example or correction for the public good. 54 Because of 6. Costs.
the petitioner spouses' negligence in subjecting Teresita to an operation
without first recognizing and addressing her diabetic condition, the appellate SO ORDERED.
court awarded exemplary damages to the respondents in the amount ARTURO D. BRION
of P100,000.00. Public policy requires such imposition to suppress the Associate Justice
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. WE CONCUR:
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 LEONARDO A. QUISUMBING
grant the respondents the amount of P100,000.00 as attorney's fees taking Acting Chief Justice
into consideration the legal route this case has taken. Chairperson
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 CONCHITA CARPIO MORALES DANTE O. TINGA
practice. We likewise AFFIRM the awards of actual and compensatory Associate Justice Associate Justice
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 PRESBITERO J. VELASCO, JR.
of P50,000.00 as death indemnity and by reversing the deletion of the award Associate Justice
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 CERTIFICATION
Teresita Pineda:
Pursuant to Section 13, Article VIII of the Constitution, and the Division
1. The sum of P36,000.00 by way of actual and compensatory damages; Chairperson's Attestation, it is hereby certified that the conclusions in the
2. The sum of P50,000.00 by way of death indemnity; above Decision were reached in consultation before the case was assigned
to the writer of the opinion of the Court's Division.
3. The sum of P400,000.00 by way of moral damages;
LEONARDO A. QUISUMBING
4. The sum of P100,000.00 by way of exemplary damages; Acting Chief Justice
Republic of the Philippines the said office, on which are handwritten entries which are the
SUPREME COURT
Manila
interpretation of the results of the ultrasound examination.
SECOND DIVISION Incidentally, this exhibit happens to be the same as or identical to the
G.R. No. 177407 February 9, 2011 certified photocopy of the document marked as Annex 2 to the
RICO ROMMEL ATIENZA, Petitioner, Counter-Affidavit dated March 15, 2000, filed by x x x Dr. Pedro
vs.
BOARD OF MEDICINE and EDITHA SIOSON, Respondents.
Lantin, III, on May 4, 2000, with this Honorable Board in answer to
DECISION this complaint;
NACHURA, J.: "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
Before us is a petition for review on certiorari under Rule 45 of the Rules of actually likewise originally an Annex to x x x Dr. Pedro Lantin, IIIs
Court, assailing the Decision1 dated September 22, 2006 of the Court of counter-affidavit filed with the Office of the City Prosecutor of Pasig
Appeals (CA) in CA-G.R. SP No. 87755. The CA dismissed the petition for City in connection with the criminal complaint filed by the herein
certiorari filed by petitioner Rico Rommel Atienza (Atienza), which, in turn, complainant with the said office, on which are handwritten entries
assailed the Orders2 issued by public respondent Board of Medicine (BOM) which are the interpretation of the results of the examination.
in Administrative Case No. 1882. Incidentally, this exhibit happens to be also the same as or identical
The facts, fairly summarized by the appellate court, follow. to the certified photo copy of the document marked as Annex 3
which is likewise dated January 30, 1997, which is appended as
Due to her lumbar pains, private respondent Editha Sioson went to Rizal
such Annex 3 to the counter-affidavit dated March 15, 2000, filed by
Medical Center (RMC) for check-up on February 4, 1995. Sometime in 1999,
x x x Dr. Pedro Lantin, III on May 4, 2000, with this Honorable Board
due to the same problem, she was referred to Dr. Pedro Lantin III of RMC
in answer to this complaint.
who, accordingly, ordered several diagnostic laboratory tests. The tests
revealed that her right kidney is normal. It was ascertained, however, that her "EXHIBIT C the certified photocopy of the X-ray request form
left kidney is non-functioning and non-visualizing. Thus, she underwent dated March 16, 1996, which is also marked as Annex 4, on which
kidney operation in September, 1999. are handwritten entries which are the interpretation of the results of
the examination.
On February 18, 2000, private respondents husband, Romeo Sioson (as
complainant), filed a complaint for gross negligence and/or incompetence "EXHIBIT D the certified photocopy of the X-ray request form
before the [BOM] against the doctors who allegedly participated in the fateful dated May 20, 1999, which is also marked as Annex 16, on which
kidney operation, namely: Dr. Judd dela Vega, Dr. Pedro Lantin, III, Dr. are handwritten entries which are the interpretation of the results of
Gerardo Antonio Florendo and petitioner Rico Rommel Atienza. the examination. Incidentally, this exhibit appears to be the draft of
the typewritten final report of the same examination which is the
It was alleged in the complaint that the gross negligence and/or
document appended as Annexes 4 and 1 respectively to the
incompetence committed by the said doctors, including petitioner, consists of
counter-affidavits filed by x x x Dr. Judd dela Vega and Dr. Pedro
the removal of private respondents fully functional right kidney, instead of the
Lantin, III in answer to the complaint. In the case of Dr. dela Vega
left non-functioning and non-visualizing kidney.
however, the document which is marked as Annex 4 is not a
The complaint was heard by the [BOM]. After complainant Romeo Sioson certified photocopy, while in the case of Dr. Lantin, the document
presented his evidence, private respondent Editha Sioson, also named as marked as Annex 1 is a certified photocopy. Both documents are of
complainant there, filed her formal offer of documentary evidence. Attached the same date and typewritten contents are the same as that which
to the formal offer of documentary evidence are her Exhibits "A" to "D," which are written on Exhibit D.
she offered for the purpose of proving that her kidneys were both in their
Petitioner filed his comments/objections to private respondents [Editha
proper anatomical locations at the time she was operated. She described her
Siosons] formal offer of exhibits. He alleged that said exhibits are
exhibits, as follows:
inadmissible because the same are mere photocopies, not properly identified
"EXHIBIT A the certified photocopy of the X-ray Request form and authenticated, and intended to establish matters which are hearsay. He
dated December 12, 1996, which is also marked as Annex 2 as it added that the exhibits are incompetent to prove the purpose for which they
was actually originally the Annex to x x x Dr. Pedro Lantin, IIIs are offered.
counter affidavit filed with the City Prosecutor of Pasig City in
Dispositions of the Board of Medicine
connection with the criminal complaint filed by [Romeo Sioson] with
The formal offer of documentary exhibits of private respondent [Editha We find no reason to depart from the ruling of the CA.
Sioson] was admitted by the [BOM] per its Order dated May 26, 2004. It Petitioner is correct when he asserts that a petition for certiorari is the proper
reads: remedy to assail the Orders of the BOM, admitting in evidence the exhibits of
"The Formal Offer of Documentary Evidence of [Romeo Sioson], the Editha. As the assailed Orders were interlocutory, these cannot be the
Comments/Objections of [herein petitioner] Atienza, [therein respondents] De subject of an appeal separate from the judgment that completely or finally
la Vega and Lantin, and the Manifestation of [therein] respondent Florendo disposes of the case.5 At that stage, where there is no appeal, or any plain,
are hereby ADMITTED by the [BOM] for whatever purpose they may serve in speedy, and adequate remedy in the ordinary course of law, the only and
the resolution of this case. 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
"Let the hearing be set on July 19, 2004 all at 1:30 p.m. for the reception of
lack or excess of jurisdiction.
the evidence of the respondents.
"SO ORDERED." 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
Petitioner moved for reconsideration of the abovementioned Order basically discretion. Embedded in the CAs finding that the BOM did not exceed its
on the same reasons stated in his comment/objections to the formal offer of jurisdiction or act in grave abuse of discretion is the issue of whether the
exhibits. exhibits of Editha contained in her Formal Offer of Documentary Evidence
The [BOM] denied the motion for reconsideration of petitioner in its Order are inadmissible.
dated October 8, 2004. It concluded that it should first admit the evidence Petitioner argues that the exhibits formally offered in evidence by Editha: (1)
being offered so that it can determine its probative value when it decides the violate the best evidence rule; (2) have not been properly identified and
case. According to the Board, it can determine whether the evidence is authenticated; (3) are completely hearsay; and (4) are incompetent to prove
relevant or not if it will take a look at it through the process of admission. x x their purpose. Thus, petitioner contends that the exhibits are inadmissible
x.3 evidence.
Disagreeing with the BOM, and as previously adverted to, Atienza filed a We disagree.
petition for certiorari with the CA, assailing the BOMs Orders which admitted
To begin with, it is well-settled that the rules of evidence are not strictly
Editha Siosons (Edithas) Formal Offer of Documentary Evidence. The CA
applied in proceedings before administrative bodies such as the
dismissed the petition for certiorari for lack of merit.
BOM.6 Although trial courts are enjoined to observe strict enforcement of the
Hence, this recourse positing the following issues: rules of evidence,7in connection with evidence which may appear to be of
I. PROCEDURAL ISSUE: doubtful relevancy, incompetency, or admissibility, we have held that:

WHETHER PETITIONER ATIENZA AVAILED OF THE PROPER [I]t is the safest policy to be liberal, not rejecting them on doubtful or technical
REMEDY WHEN HE FILED THE PETITION FOR CERTIORARI grounds, but admitting them unless plainly irrelevant, immaterial or
DATED 06 DECEMBER 2004 WITH THE COURT OF APPEALS incompetent, for the reason that their rejection places them beyond the
UNDER RULE 65 OF THE RULES OF COURT TO ASSAIL THE consideration of the court, if they are thereafter found relevant or competent;
ORDERS DATED 26 MAY 2004 AND 08 OCTOBER 2004 OF on the other hand, their admission, if they turn out later to be irrelevant or
RESPONDENT BOARD. incompetent, can easily be remedied by completely discarding them or
ignoring them.8
II. SUBSTANTIVE ISSUE:
From the foregoing, we emphasize the distinction between the admissibility
WHETHER THE COURT OF APPEALS COMMITTED GRAVE of evidence and the probative weight to be accorded the same pieces of
REVERSIBLE ERROR AND DECIDED A QUESTION OF evidence. PNOC Shipping and Transport Corporation v. Court of
SUBSTANCE IN A WAY NOT IN ACCORDANCE WITH LAW AND Appeals9 teaches:
THE APPLICABLE DECISIONS OF THE HONORABLE COURT
WHEN IT UPHELD THE ADMISSION OF INCOMPETENT AND Admissibility of evidence refers to the question of whether or not the
INADMISSIBLE EVIDENCE BY RESPONDENT BOARD, WHICH circumstance (or evidence) is to be considered at all. On the other hand, the
CAN RESULT IN THE DEPRIVATION OF PROFESSIONAL probative value of evidence refers to the question of whether or not it proves
LICENSE A PROPERTY RIGHT OR ONES LIVELIHOOD.4 an issue.
Second, petitioners insistence that the admission of Edithas exhibits Sec. 3. Disputable presumptions. The following presumptions are
violated his substantive rights leading to the loss of his medical license is satisfactory if uncontradicted, but may be contradicted and overcome by
misplaced. Petitioner mistakenly relies on Section 20, Article I of the other evidence:
Professional Regulation Commission Rules of Procedure, which reads:
xxxx
Section 20. Administrative investigation shall be conducted in accordance
(y) That things have happened according to the ordinary course of nature
with these Rules. The Rules of Court shall only apply in these proceedings and the ordinary habits of life.
by analogy or on a suppletory character and whenever practicable and
convenient. Technical errors in the admission of evidence which do not The exhibits are certified photocopies of X-ray Request Forms dated
prejudice the substantive rights of either party shall not vitiate the December 12, 1996, January 30, 1997, March 16, 1996, and May 20, 1999,
proceedings.10 filed in connection with Edithas medical case. The documents contain
handwritten entries interpreting the results of the examination. These exhibits
As pointed out by the appellate court, the admission of the exhibits did not were actually attached as annexes to Dr. Pedro Lantin IIIs counter affidavit
prejudice the substantive rights of petitioner because, at any rate, the fact
filed with the Office of the City Prosecutor of Pasig City, which was
sought to be proved thereby, that the two kidneys of Editha were in their
investigating the criminal complaint for
proper anatomical locations at the time she was operated on, is presumed
under Section 3, Rule 131 of the Rules of Court:
negligence filed by Editha against the doctors of Rizal Medical Center (RMC) (b) When the original is in the custody or under the control of the
who handled her surgical procedure. To lay the predicate for her case, Editha party against whom the evidence is offered, and the latter fails to
offered the exhibits in evidence to prove that her "kidneys were both in their produce it after reasonable notice;
proper anatomical locations at the time" of her operation.
(c) When the original consists of numerous accounts or other
The fact sought to be established by the admission of Edithas exhibits, that documents which cannot be examined in court without great loss of
her "kidneys were both in their proper anatomical locations at the time" of her time and the fact sought to be established from them is only the
operation, need not be proved as it is covered by mandatory judicial notice.11 general result of the whole; and
Unquestionably, the rules of evidence are merely the means for ascertaining (d) When the original is a public record in the custody of a public
the truth respecting a matter of fact.12Thus, they likewise provide for some officer or is recorded in a public office.
facts which are established and need not be proved, such as those covered
The subject of inquiry in this case is whether respondent doctors before the
by judicial notice, both mandatory and discretionary. 13 Laws of nature
BOM are liable for gross negligence in removing the right functioning kidney
involving the physical sciences, specifically biology,14 include the structural of Editha instead of the left non-functioning kidney, not the proper anatomical
make-up and composition of living things such as human beings. In this locations of Edithas kidneys. As previously discussed, the proper anatomical
case, we may take judicial notice that Edithas kidneys before, and at the
locations of Edithas kidneys at the time of her operation at the RMC may be
time of, her operation, as with most human beings, were in their proper
established not only through the exhibits offered in evidence.
anatomical locations.
Finally, these exhibits do not constitute hearsay evidence of the anatomical
Third, contrary to the assertion of petitioner, the best evidence rule is locations of Edithas kidneys. To further drive home the point, the anatomical
inapplicable.1awphil Section 3 of Rule 130 provides:
positions, whether left or right, of Edithas kidneys, and the removal of one or
1. Best Evidence Rule both, may still be established through a belated ultrasound or x-ray of her
Sec. 3. Original document must be produced; exceptions. When the abdominal area.
subject of inquiry is the contents of a document, no evidence shall be In fact, the introduction of secondary evidence, such as copies of the
admissible other than the original document itself, except in the following exhibits, is allowed.15 Witness Dr. Nancy Aquino testified that the Records
cases: Office of RMC no longer had the originals of the exhibits "because [it]
(a) When the original has been lost or destroyed, or cannot be transferred from the previous building, x x x to the new building." 16 Ultimately,
produced in court, without bad faith on the part of the offeror; 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 SO ORDERED.ANTONIO EDUARDO B. NACHURA
in CA-G.R. SP No. 87755 is AFFIRMED. Costs against petitioner. Associate Justice
Acting Chairperson WE CONCUR:
DIOSDADO M. PERALTA
Associate Justice

MARIANO C. DEL CASTILLO* MARTIN S. VILLARAMA, JR.**


Associate Justice Associate Justice

JOSE CATRAL MENDOZA


Associate Justice
ATTESTATION
I attest that the conclusions in the above Decision had been reached in
consultation before the case was assigned to the writer of the opinion of the
Courts Division.
ANTONIO EDUARDO B. NACHURA
Associate Justice
Acting Chairperson, Second Division
CERTIFICATION
Pursuant to Section 13, Article VIII of the Constitution and the Division Acting
Chairperson's Attestation, I certify that the conclusions in the above Decision
had been reached in consultation before the case was assigned to the writer
of the opinion of the Courts Division.
RENATO C. CORONA
Chief Justice
Republic of the Philippines As per Certificate of Death issued by accused Dr. Antonio P. Cabugao, to the
SUPREME COURT damage and prejudice of the legal heirs of said deceased RODOLFO
Manila PALMA, JR. and other consequential damages relative thereto.
THIRD DIVISION CONTRARY to Article 365, 1st par. of the Revised Penal Code.
G.R. No. 163879 July 30, 2014 Dagupan City, Philippines, January 29, 2001.
DR. ANTONIO P. CABUGAO, Petitioner, Arising from the same events, the Court resolved to consolidate these
vs. cases.4 The facts, as culled from the records, are as follows:
PEOPLE OF THE PHILIPPINES and SPOUSES RODOLFO M. PALMA
On June 14, 2000, at around 4 o'clock in the afternoon, ten (10)-year old
and ROSARIO F. PALMA, Respondents.
Rodolfo F. Palma, Jr. (JR) complained of abdominal pain to his mother,
x-----------------------x Rosario Palma. At 5 oclock that sameafternoon, Palma's mother and father,
G.R. No. 165805 Atty. Rodolfo Palma Sr., brought JR to the clinic of accused Dr. Cabugao. Dr.
Cabugao, a general practitioner, specializing in familymedicine gave
DR. CLENIO YNZON, Petitioner, medicines for the pain and told Palma's parents to call him up if his stomach
vs. pains continue. Due to persistent abdominal pains, at 4:30 in the early
PEOPLE OF THE PHILIPPINES and SPOUSES RODOLFO M. PALMA morning of June 15, 2000, they returnedto Dr. Cabugao, who advised them
AND ROSARIO F. PALMA, Respondents. to bring JR to the Nazareth General Hospital in Dagupan City, for
DECISION confinement. JR was admitted at the said hospital at 5:30 in the morning.5

PERALTA, J.: 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
Before this Court are appeals via Rule 45 from the Decision1 dated June 4, 0.10 and neutrophils 0.90. Diagnostic ultrasound was likewise conducted
2004 of the Court of Appeals in CA-G.R. CR No. 27293, affirming the on the patient's lower abdomen by radiologist, Dr. Ricky V. Querubin, with
Decision2 dated February 28,2003 of the Regional Trial Court (RTC), the following findings:
convicting appellant Dr. Antonio P. Cabugao (Dr. Cabugao) and Dr. Clenio
Ynzon (Dr. Ynzon) of the crime of Reckless Imprudence Resulting to Normal liver, bile ducts, gallbladder, pancreas, spleen, kidneys and urinary
Homicide. bladder.

The Information3 alleged There is no free peritoneal fluid.

That on or about June 17, 2000in the City of Dagupan, Philippines, and There is localized tenderness in the paraumbilical region, more so in the
within the jurisdiction of this Honorable Court, the abovenamed accused, DR. supra and right paraumbilical areas.
ANTONIO P.CABUGAO and DR. CLENIO YNZON, being then the attending There is a vague elongated hypoechoic focus in the right periumbilical region
physicians of one RODOLFO PALMA, JR., a minor 10 years old, roughly about 47 x 18 mm surrounded by undistended gas-filled bowels. This
confederating and acting jointly with one another, did, then and there, is suggestive of an inflammatory process wherein appendiceal or
willfully, unlawfully and feloniously fail through negligence, carelessness and periappendiceal pathology cannot be excluded. Clinical correlation is
imprudence to perform immediate operation upon their patient, RODOLFO essential."6
PALMA, JR. of acute appendicitis, when they, the said physicians, should
Dr. Cabugao did a rectal examination noting the following: "rectal: good
have been done so considering that examinations conducted upon their
sphincter, negative tenderness, negative mass." The initial impression was
patient Rodolfo Palma, Jr. seriously manifest todo so, causing by such
negligence, carelessness, and imprudence the victim, RODOLFO PALMA Acute Appendicitis,7 and hence, he referred the case to his co-accused, Dr.
JR., to die due to: 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
"CARDIORESPIRATORY ARREST, METABOLIC ENCEPHALOPATHY, administration of massive antibiotics and pain reliever to JRwere ordered.
SEPTICEMIA (ACUTE APPENDICITIS), CEREBRAL ANEURYSM Thereafter, JR was placed on observation for twenty-four (24) hours.
RUPTURED (?)"
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 to give the proper and correct evaluation as to the real condition of JR. In
who merely gaveorders via telephone.9Accused continued medications to situations where massive infection is going on as shown by the aggressive
alleviate JR's abdominal spasms and diarrhea. By midnight, JR again medication of antibiotics, the condition of the patient is serious which
vomitted twice, had loose bowel movements and was unable to sleep. The necessitated personal, not delegated, attention of attending physicians,
following morning, June 17,2000, JR's condition worsened, he had a running namely JR and the accused in this case.
fever of 38C. JR's fever remained uncontrolled and he became
xxxx
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 Throughout the course of the hospitalization and treatment of JR, the
temperature soared to 42C, had convulsions and finally died. 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
The Death Certificate10 dated June 19, 2000 prepared by Dr. Cabugao
what was causing the massive infection that was ongoing inside the body of
indicated the following causes of death:
JR even when the inflammatory process was located at the paraumbilical
Immediate cause: CARDIORESPIRATORY ARREST region where the appendix can be located. x x x
Antecedent cause: METABOLIC ENCEPHALOPATHY There may have been other diseases but the records do not show that the
Underlying cause: SEPTICEMIA (ACUTE APPENDICITIS) 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
Other significant conditionscontributing to death: did not perform any process of elimination. Appendicitis, according to expert
CEREBRAL ANEURYSM RUPTURED (?) 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
No post-mortem examination was conducted on JR. On February 1, 2001, an JR because they were treating merely and exclusively the symptoms by
Information was filed against accused for reckless imprudence resulting to means of the different medications to arrest the manifested symptoms. In
homicide. At their arraignment, both accused, duly assisted by counsel, fact, by treating the symptoms alone, the accused were recklessly and
pleaded not guilty to the charge. wantonly ignoring the same as signs of the graver health problem of JR. This
On February 28, 2003, in convicting both the accused, the trial court found gross negligence on the part of the accused allowed the infection to spread
the following circumstances as sufficient basis to conclude that accused were inside the body of JR unabated. The infection obviously spread so fastand
indeed negligent in the performance of their duties: 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
It is unquestionable that JR was under the medical care of the accused from healthy died [of] Septicemia (Acute Appendicitis) on June 17, 2000.11
the time of his admission for confinement at the Nazareth General Hospital
until his death. Upon his admission, the initial working diagnosis was to On June 4, 2004, in affirming the accused' conviction, the Court of Appeals
consider acute appendicitis. To assist the accused in the consideration of gave similar observations, to wit:
acute appendicitis, Dr. Cabugao requested for a complete blood count (CBC) The foregoing expert testimony clearly revealed such want of reasonable skill
and a diagnostic ultrasound on JR. The findings of the CBC and ultrasound and care on the part of JR's attending physicians, appellants Dr. Cabugao
showed that an inflammatory process or infection was going on inside the and Dr. Ynzon in neglecting to monitor effectively and sufficiently the
body of JR. Said inflammatory process was happening in the periumbilical developments/changes during the observation period and act upon the
region where the appendix could be located. The initial diagnosis of acute situation after said 24-hour period when his abdominal pain subsisted, his
appendicitis appears to be a distinct possibility. x x x. condition even worsened with the appearance of more serious symptoms of
Dr. Ynzon ordered medications to treat the symptoms being manifested by nausea, vomiting and diarrhea. Considering the brief visit only made on
JR. Thereafter, he ordered that JR be observed for 24 hours. However, the regular rounds, the records clearly show such gross negligence in failing to
accused, as the attending physicians, did not personally monitor JR in order take appropriate steps to determine the real cause of JR's abdominal pain so
to check on subtle changes that may occur. Rather, they left the monitoring that the crucial decision to perform surgery (appendectomy) had even been
and actual observation to resident physicians who are just on residency ruled out precisely because of the inexcusable neglect to undertake
training and in doing so, they substituted their own expertise, skill and suchefficient diagnosis by process of elimination, as correctly pointed out by
competence with those of physicians who are merely new doctors still on the trial court. As has been succinctly emphasized by Dr. Mateo, acute
training. Not having personally observed JR during this 24-hour critical period appendicitis was the working diagnosis, and with the emergence of
of observation, the accused relinquished their duty and thereby were unable symptoms after the 24-hour observation (high fever, vomiting, diarrhea) still,
appellants ruled out surgery, not even considering exploratory laparoscopy. APPEALED DECISION SEEMS TO HAVE TREATED BOTH ACCUSED
Dr. Mateo also expressed the opinion that the decision to operate could have DOCTORS TO BE IN CONSPIRACY;
been made after the result of the ultrasound test, considering that acute III
appendicitis was the initial diagnosis by Dr. Cabugao after he had conducted
a rectal examination. WHETHER PETITIONER DR. CABUGAO IS A GENERAL PRACTITIONER
(NOT A SURGEON) AND HAVE EXCLUDED SURGERY FROM THE
Medical records buttress the trial court's finding that in treating JR, appellants LIMITS OFHIS PRACTICE, AND IT WAS NOT AND NEVER HIS DUTY TO
have demonstrated indifference and neglect of the patient's condition as a OPERATE THE PATIENT RODOLFO PALMA JR., THAT WAS WHY HE
serious case. Indeed, appendicitis remains a clinical emergencyand a
REFERRED SUBJECT PATIENT TO A SURGEON, DR. CLENIO YNZON;
surgical disease, as correctly underscored by Dr. Mateo, a practicing
surgeon who has already performed over a thousand appendectomy. In fact, IV
appendectomy is the only rational therapy for acute appendicitis; it avoids WHETHER THE DEFENSE NEVER STATED THAT THERE IS
clinical deterioration and may avoid chronic or recurrent appendicitis. GUARANTEE THAT DOING SURGERY WOULD HAVE SAVED THE
Although difficult, prompt recognition and immediate treatment of the disease PATIENT;
prevent complications. Under the factual circumstances, the inaction, neglect
and indifference of appellants who, after the day of admission and after being V
apprised of the ongoing infection from the CBC and initial diagnosis as acute WHETHER THE WITNESSES FOR THE PROSECUTION INCLUDING
appendicitis from rectal examination and ultrasound testand only briefly PROSECUTION'S EXPERT WITNESSES EVER DECLARED/TESTIFIED
visited JR once during regular rounds and gave medication orders by THAT PETITIONER DR. CABUGAO HAD THE DUTY TO PERFORM
telephone constitutes gross negligenceleading to the continued IMMEDIATE OPERATION ON RODOLFO PALMA, JR., AND THEY FAILED
deterioration of the patient, his infection having spread in sofast a pace that TO STATE/SHOW THAT THE PROXIMATE CAUSE OF DEATH OF JR
he died within just two and a half (2 ) days stay inthe hospital. Authorities WAS ACUTE APPENDICITIS;
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 VI
hasten diagnosis.Even assuming that JR's case had an atypical presentation WHETHER THE EXPERT WITNESSES PRESENTED BY THE
in view of the location of his appendix, laboratory tests could have helped to PROSECUTION EVER QUESTIONED THE MANAGEMENT AND CARE
confirm diagnosis, as Dr. Mateo opined thatthe possibility of JR having a APPLIED BY PETITIONER DR. CABUGAO;
retrocecal appendicitis should have been a strong consideration.
VII
Lamentably, however, as found by the trial court, appellants had not taken
steps towards correct diagnosis and demonstrated laxity even when JR was WHETHER THE EXPERT WITNESSES PRESENTED BY THE DEFENSE
already running a high fever in the morning of June 17, 2000 and continued ARE UNANIMOUS IN APPROVING THE METHOD OF TREATMENT
vomiting with diarrhea, his abdominal pain becoming more intense. This is APPLIED BY BOTH ACCUSED DOCTORS ON SUBJECT PATIENT, AND
the reason why private complainants were not even apprised of the progress THEY DECLARED/AFFIRMED THAT THEY WOULD FIRST PLACE
of appellants' diagnosis appellants have nothing to report because they did SUBJECT THE PATIENT UNDER OBSERVATION, AND WOULD NOT
nothing towards the end and merely gave medications to address the PERFORM IMMEDIATE OPERATION;
symptoms.12 VIII
Thus, these appeals brought beforethis Court raising the following WHETHER THE CONVICTION OF PETITIONER DR. YNZON WAS
arguments: ESTABLISHED WITH THE REQUIRED QUANTUM OF PROOF BEYOND
I REASONABLE DOUBT THAT THE PATIENT WAS SPECIFICALLY
SUFFERING FROM AND DIED OF ACUTE APPENDICITIS; and
WHETHER THE CAUSE OF ACCUSATION AS CONTAINED IN THE
INFORMATION IS "FAILURE TO PERFORM IMMEDIATE OPERATION IX
UPON THE PATIENT ROFOLFO PALMA JR. OF ACUTE APPENDICITIS; WHETHER THE FAILURE TO CONDUCT THE SPECIFIC SURGICAL
II OPERATION KNOWN AS APPENDECTOMY CONSTITUTED CRIMINAL
NEGLIGENCE.
WHETHER THE SUBJECT INFORMATION APPEARS TO HAVE
ACCUSED BOTH ACCUSED DOCTORS OF CONSPIRACY AND THE
In a nutshell, the petition brought before this Court raises the issue of A If this would be appendicitis, the usual progress would be that it would be
whether or not petitioners' conviction of the crime of reckless imprudence ruptured and generalized peritonitis and eventually septicemia, sir.
resulting in homicide, arising from analleged medical malpractice, is Q What do you mean by that doctor?
supported by the evidence on record.
A That means that infection would spread throughout the body, sir.
Worth noting is that the assigned errors are actually factual in nature, which
as a general rule, findings of factof the trial court and the Court of Appeals Q If unchecked doctor, what will happen?
are binding and conclusiveupon this Court, and we will not normally disturb A It will result to death.17
such factual findings unless the findings of the court are palpably
unsupported by the evidence on record or unless the judgment itself is based xxxx
on misapprehension of facts. Inthe instant case, we find the need to make Q And what would have you doneif you entertain other considerations from
certain exception. the time the patient was admitted?
AS TO DR. YNZON'S LIABILITY: A From the time the patient was admitted until the report of the sonologist, I
Reckless imprudence consists of voluntarily doing or failing to do, without would have made a decision by then.
malice, an act from which material damage results by reason of an Q And when to decide the surgery would it be a particular exact time, would it
inexcusable lack of precautionon the part of the person performing or failing be the same for all surgeons?
to 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 A If you are asking acute appendicitis, it would be about 24 hours because
act is voluntary; (3) that it bewithout malice; (4) that material damage results acute appendicitis is a 24-hour disease, sir.
from the reckless imprudence; and (5) that there is inexcusable lack of Q. And would it be correct to say that it depends on the changes on the
precaution on the part of the offender, taking into consideration his condition of the patient?
employment or occupation, degree of intelligence, physical condition, and
A. Yes, sir.
other circumstances regarding persons, time and place.14
Q. So, are you saying more than 24 hours when there are changes?
With respect to Dr. Ynzon, all the requisites of the offense have been clearly
established by the evidence on record. The court a quoand the appellate A. If there are changes in the patient pointing towards appendicitis then you
court were one in concluding that Dr. Ynzon failed to observe the required have to decide right there and then, sir.
standard of care expected from doctors. Q. So if there are changes in the patient pointing to appendicitis?
In the instant case, it was sufficiently established that to prevent certain A. It depends now on what you are trying to wait for in the observation
death, it was necessary to perform surgery on JR immediately. Even the period, sir.
prosecutions own expert witness, Dr. Antonio Mateo,15 testified during cross-
examination that he would perform surgery on JR: 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
ATTY. CASTRO: period of 24 hours?
Q. Given these data soft non-tender abdomen, ambulatory, watery diarrhea, A. It depends on the emergent development, sir.
Exhibit C which is the ultrasound result, with that laboratory would you
operate the patient? Q. That is the point, if you are the attending physician and there is a change
not pointing to appendicitis, would you extend over a period of 24 hours?
A Yes, I would do surgery.
A. In 24 hours you have to decide, sir.
Q And you should have done surgery with this particular case?"
xxxx
A Yes, sir.16
Q. And that is based on the assessment of the attending physician?
xxxx
A. Yes, sir.18
COURT:
Dr. Mateo further testified on cross-examination:
Q You stated a while ago doctor thatyou are going to [do] surgery to the
patient, why doctor, if you are notgoing to do surgery, what will happen? ATTY. CASTRO:
Q: So you will know yourself, as far as the record is concerned, because if Q. x x x Now if it is to be considered as the primary consideration in the initial
you will agree with me, you did not even touch the patient? working diagnosis, isn't it a fact that it has tobe ruled out in order to consider
A. Yes, I based my opinion on what is put on record, sir. The records show it as not the disease of JR?
that after the observation period, the abdominal pain is still there plus there A. Yes. Sir.
are already other signs and symptoms which are not seen or noted.
Q. Isn't it a fact thatto rule out acute appendicitis as not the disease of JR,
Q. But insofar as you yourself not having touched the abdomen of the surgery or operation must be done, isn't it Doctor?
patient, would you give a comment on that?
A. You have to correlate all the findings.
A. Yes, based on the record, after 24 hours of observation, the pain Q. Is it yes or no, Doctor?
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 A. Yes.
deteriorating. Q. So, you are saying then that in order to rule out acute appendicitis there
Q. Even though you have not touched the patient? must be an operation, that is right Doctor?
A. I based on what was on the record, sir.19 A. No, sir. If your diagnosis is toreally determine if it is an acute appendicitis,
you have to operate.21
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 xxxx
case. Another expert witness for the defense, Dr. Vivencio Villaflor, Jr. Q. Now Doctor, considering the infection, considering that there was a
testified on direct examination that he would perform a personal and [symptom] that causes pain, considering that JR likewise was feverish and
thorough physical examination of the patient as frequent as every 4 to 6 that he was vomiting, does that not show a disease of acute appendicitis
hours, to wit: Doctor?
ATTY. CASTRO: A. Its possible.
Q. As an expert doctor, if you were faced with a history of abdominal pain Q. So that if that is possible, are we getting the impression then Doctor what
with nausea, vomiting, fever, anurecia (sic), elevated white blood cell count, you have earlier mentioned that the only way to rule out the suspect which is
physical examination of a positive psoas sign, observation of the sonologist acute appendicitis is by surgery, you have said that earlier Doctor, I just want
of abdominal tenderness and the ultrasound findings of the probability of any confirmation of it?
appendiceal (sic) pathology, what will you do if you have faced these
problems, Doctor? A. Yes, sir.22
A. I will examine the patient thoroughly and it will depend on my physical Verily, whether a physician or surgeon has exercised the requisite degree of
examination and that isprobably every 4 to 6 hours, sir.20 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
On cross-examination, Dr. Villaflor affirmed: qualified physicians stems from its realization that the latter possess unusual
Cross Exam. By Atty. Marteja: technical skills which laymen in most instances are incapable of intelligently
evaluating.23 From the testimonies of the expert witnesses presented, it was
Q. x x x However, there are corrections and admissions made at that time, irrefutably proven that Dr. Ynzon failed to practice that degree of skill and
your Honor, do I understand thatT/C does not mean ruled out but rather to care required in the treatment of his patient.
consider the matter?
As correctly observed by the appellate court, Dr. Ynzon revealed want of
A. Yes, now that I have seen the records of the patient, it says here,
reasonable skill and care in attending to the needs of JR by neglecting to
impression and T/C means to consider the appendicitis. monitor effectively the developmentsand changes on JR's condition during
Q. Isn't it that it is worth then to say that the initial working diagnosis on the observation period, and to act upon the situation after the 24-hour period
Rodolfo Palma, Jr., otherwise known as JR, to whom I shall now refer to as when his abdominal pain persisted and his condition worsened. Lamentable,
JR, the primary consideration then is acute appendicitis, is that correct to say Dr. Ynzon appeared to have visited JRbriefly only during regular rounds in
Doctor? the mornings. He was not there during the crucial times on June 16, 2000
A. I think so, that is the impression. 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, prosecution failed to prove these two things. The Court is not convinced with
as he is in the best position considering his skills and experience to know if moral certainty that Dr. Cabugao isguilty of reckless imprudence as the
the patient's condition had deteriorated. While the resident-doctors-onduty elements thereof were not proven by the prosecution beyond a reasonable
could likewise monitor the patientscondition, he is the one directly doubt.
responsible for the patient as the attending surgeon. Indeed, it is reckless
Both the trial court and the appellate court bewail the failure to perform
and gross negligence of duty to relegate his personal responsibility to
appendectomy on JR, or the failure to determine the source of infection
observe the condition of the patient. Again, acute appendicitis was the
which caused the deterioration of JR's condition. However, a review of the
working diagnosis, and with the emergence of graver symptoms after the 24- records fail to show that Dr. Cabugao is in any position to perform the
hour observation, Dr. Ynzon ruled out surgery for no apparent reason. We, required appendectomy.
likewise, note that the records are devoid of showing of any reasonable
cause which would lead Dr. Ynzon tooverrule appendectomy despite the Immediately apparent from a review of the records of this case is the fact that
initial diagnosis of appendicitis. Neitherwas there any showing that he was Dr. Cabugao is not a surgeon,but a general practitioner specializing in family
entertaining another diagnosis nor he took appropriate steps towards another medicine;27 thus, even if he wanted to, he cannot do an operation, much less
diagnosis. 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
Among the elements constitutive of reckless imprudence, what perhaps is
expert witness, emphasized the role of the surgeon during direct
most central to a finding of guilt is the conclusive determination that the
examination, to wit:
accused has exhibited, by his voluntary act without malice, an inexcusable
lack of precaution. It is that which supplies the criminal intent so ATTY. MARTEJA:
indispensable as tobring an act of mere negligence and imprudence under Q. You had mentioned that under this circumstances and condition, you have
the operation of the penal law. This is because a conscious indifference to mentioned that surgery is the solution, would you have allowed then a 24
the consequences of the conduct is all that is required from the standpoint of hour observation?
the frame of mind of the accused.24 Quasioffenses penalize the mental
attitudeor condition behind the act, the dangerous recklessness, the lack of A. If there is a lingering doubt, inshort period of observation of 18-24 hours
care or foresight, the "imprudencia punible," unlike willful offenses which can be allowed provided that there would be close monitoring of the patient,
punish the intentional criminal act.25 This is precisely where this Court found sir.
Dr. Ynzon to be guilty of - his seemingly indifference to the deteriorating Q. Would you please tell us who would be doing the monitoring doctor?
condition of JR that he as a consequence, failed to exercise lack of
precaution which eventually led to JR's death. A. The best person should be the first examiner, the best surgeon, sir.

To be sure, whether or not a physician has committed an "inexcusable lack Q. So that would you say that it is incumbent on the surgeon attending to the
of precaution" in the treatment of his patient is to be determined according to case to have been the one to observe within the period of observation?
the standard of care observed by other members of the profession in good A. Yes, because he will be in the best position to observe the sudden
standing under similar circumstances bearing in mind the advanced state of changes in the condition of the patient, sir.
the profession at the time of treatment or the present state of medical
Q. And how often would in your experience doctor, how often would the
science. In accepting a case, a doctor in effect represents that, having the
surgeon re-assist (sic) the condition of the patient during the period of
needed training and skill possessed by physicians and surgeons practicing in
observation?
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 A. Most foreign authors would recommend every four (4) hours, some
that any other reasonably competent doctor would use to treat a condition centers will recommend hourly or every two hours but here in the Philippines,
under the same circumstances.26 Sadly, Dr. Ynzon did not display that would recommend for 4 to 6 hours, sir.28
degree of care and precaution demanded by the circumstances. Dr. Cabugaos supervision does not cease upon his endorsement of his
AS TO DR. CABUGAO'S LIABILITY: patient to the surgeon. Here, Dr. Cabugao has shown to have exerted all
efforts to monitor his patient and under these circumstances he did not have
Every criminal conviction requires of the prosecution to prove two things
any cause to doubt Dr. Ynzons competence and diligence. Expert
the fact of the crime, i.e., the presence of all the elements of the crime for
testimonies have been offered to prove the circumstances surrounding the
which the accused stands charged, and the fact that the accused is the
perpetrator of the crime. Based on the above disquisitions, however, the
case of JR and the need to perform an operation. Defense witness, Dr. Moreover, while both appeared to be the attending physicians of JR during
Villaflor, on cross examination testified, to wit: his hospital confinement, it cannot be said that the finding of guilt on Dr.
Q. Isn't it a fact that torule out acute appendicitis as notthe disease of JR, Ynzon necessitates the same finding on the co-accused Dr. Cabugao.
Conspiracy is inconsistent with the idea of a felony committed by means of
surgery or operation mustbe done, isn't it Doctor?
culpa.32 Thus, the accused-doctors to be found guilty of reckless imprudence
A. You have to [correlate] all the findings. resulting in homicide, it must be shown that both accused-doctors
Q. Is it yes or no, Doctor? demonstratedan act executed without malice or criminal intent but with lack
of foresight, carelessness, or negligence. Noteworthy, the evidence on
A. Yes. record clearly points to the reckless imprudence of Dr. Ynzon; however, the
Q. So, you are saying then that in order to rule out acute appendicitis there same cannot be said in Dr. Cabugao's case.
must be an operation, that is right Doctor? AS TO CIVIL LIABILITY
A. No, sir. If your diagnosis is to really determine if it is an acute appendicitis, While this case is pending appeal, counsel for petitioner Dr. Ynzon informed
you have to operate.29 the Court that the latter died on December 23, 2011 due to "multiorgan
xxxx 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
Q. Now Doctor, considering the infection, considering that there was a his criminal and pecuniary liabilities should be in accordance to People v.
[symptom] that causes pain, considering that JR likewise was feverish and Bayotas,34 wherein the Court laid down the rules in case the accused dies
that he was vomitting, does that not show a disease of acute appendicitis prior to final judgment:
Doctor?
1. Death of the accused pending appeal of his conviction
A. Its possible. extinguishes his criminal liability as well as the civil liability based
Q. So that if that is possible, are we getting the impression then Doctor what solely thereon. As opined by Justice Regalado, in this regard, "the
you have earlier mentioned that the only way to rule out the suspect which is death of the accused prior to final judgment terminates his criminal
acute appendicitis is by surgery, you have said that earlier Doctor, I just want liability and only the civil liability directly arising from and based
any confirmation of it? solely on the offense committed, i.e.,civil liability ex delictoin senso
strictiore."
A. Yes, sir.30
2. Corollarily, the claim for civil liability survives notwithstanding the
Neither do we find evidence that Dr. Cabugao has been negligent or lacked
death of accused, if the same may also be predicated on a source of
the necessary precaution in his performance of his duty as a family doctor.
obligation other than delict. Article 1157 of the Civil Code
On the contrary, a perusal ofthe medical records would show that during the
enumerates these other sources of obligation fromwhich the civil
24-hour monitoring on JR, it was Dr. Cabugao who frequently made orders
liability may arise as a result of the same act or omission:
on the administration of antibiotics and pain relievers. There was also
repetitive instructions from Dr. Cabugao to refer JR to Dr. Ynzon as it a) Law
appeared that he is suspecting appendicitis. The referral of JR to Dr. Ynzon, b) Contracts
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 c) Quasi-contracts
best of his knowledge and skill in attending to JR's condition, even after the d) x x x x x x x x x
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 e) Quasi-delicts
to handle JRs case belies the finding that he displayed inexcusable lack of 3. Where the civil liability survives, as explained in Number 2 above,
precaution in handling his patient.31 an action for recovery therefor may be pursued but only by way of
We likewise note that Dr. Cabugao was out of town when JR's condition filing a separate civil action and subject to Section 1, Rule 111 of the
began to deteriorate. Even so, before he left, he made endorsement and 1985 Rules on Criminal Procedure as amended. This separate civil
notified the resident-doctor and nurses-on-duty that he will be on leave. 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 Section 1. Actions which may and which may not be brought against
right to file this separate civil action by prescription, in cases where executor or administrator. No action upon a claim for the recovery of
during the prosecution of the criminal action and prior to its money or debtor interest thereon shall be commenced against the executor
extinction, the private-offended party instituted together therewith the or administrator; but to recover real or personal property, or an interest
civil action. In such case, the statute of limitationson the civil liability therein, from the estate, or to enforce a lien thereon, and actions to recover
is deemed interrupted during the pendency of the criminal case, damages for an injury to person or property, real or personal, may be
conformably with provisions of Article 1155 of the Civil Code, that commenced against him. (Emphases ours)
should thereby avoid any apprehension on a possible privation of Conversely, if the offended party desires to recover damages from the same
right by prescription.35 act or omission complained of arising from contract, the filing of a separate
In view of the foregoing, it is clear that the death of the accused Dr. Ynzon civil action must be filed against the estate, pursuant to Section 5, Rule 86 of
pending appeal of his conviction extinguishes his criminal liability. However, the Rules of Court, to wit:
the recovery of civil liability subsists as the same is not based on delictbut by Section 5. Claims which must be filed under the notice. If not filed, barred;
contract and the reckless imprudence he was guilty of under Article 365 of exceptions. All claims for money against the decent, arising from contract,
the Revised Penal Code.1wphi1For this reason, a separate civil action may
express or implied, whether the same be due, not due, or contingent, all
be enforced either against the executor/administrator or the estate of the
claims for funeral expenses and expense for the last sickness of the
accused, depending on the source of obligation upon which the same is
decedent, and judgment for money against the decent, must be filed within
based,36 and in accordance with Section 4, Rule 111 of the Rules on Criminal
the time limited in the notice; otherwise they are barred forever, except that
Procedure, we quote: they may be set forth as counterclaims in any action that the executor or
Sec. 4. Effect of death on civil actions. The death of the accused after administrator may bring against the claimants. Where an executor or
arraignment and during the pendency of the criminal action shall extinguish administrator commencesan action, or prosecutes an action already
the civil liability arising from the delict. However, the independent civil action commenced by the deceased in his lifetime, the debtor may set forth by
instituted under section 3 of this Rule or which thereafter is instituted to answer the claims he has against the decedent, instead of presenting them
enforce liability arising from other sources of obligation may be continued independently to the court as herein provided, and mutual claims may be set
against the estate or legal representative of the accused after proper off against each other in such action; and if final judgment is rendered in
substitution or against said estate, as the case may be. The heirs of the favor of the defendant, the amount so determined shall be considered the
accused may besubstituted for the deceased without requiring the true balance against the estate, as though the claim had been presented
appointment of an executor or administrator and the court may appoint a directly beforethe court in the administration proceedings. Claims not yet
guardian ad litem for the minor heirs. due, or contingent, may be approved at their present value.
The court shall forthwith order said legal representative or representatives to As a final note, we reiterate thatthe policy against double recovery requires
appear and be substituted within a period of thirty (30) days from notice. that only one action be maintained for the same act or omission whether the
A final judgment entered in favor of the offended party shall be enforced in action is brought against the executor or administrator, or the estate.39 The
the manner especially provided in these rules for prosecuting claims against heirs of JR must choose which of the available causes of action for damages
they will bring.
the estate of the deceased.
WHEREFORE, premises considered, petitioner DR. ANTONIO P.
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 CABUGAO is hereby ACQUITTEDof the crime of reckless imprudence
the deceased. (Emphases ours) resulting to homicide.
Due to the death of accused Dr. Clenio Ynzon prior to the disposition of this
In sum, upon the extinction of the criminal liability and the offended party
case, his criminal liability is extinguished; however, his civil liability subsists.
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 A separate civil action may be filed either against the executor/administrator,
obligation in accordance with Section 4, Rule 111.37 If the same act or or the estateof Dr. Ynzon, depending on the source of obligation upon which
the same are based.
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 SO ORDERED.
the accused, pursuant to Section 1, Rule 87 of the Rules of Court:38
DIOSDADO M. PERALTA I attest that the conclusions in the above Decision had been reached in
Associate Justice consultation before the case was assigned to the writer of the opinion of the
WE CONCUR: Court's Division.
PRESBITERO J. VELASCO, JR.
PRESBITERO J. VELASCO, JR.
Associate Justice
Associate Justice
Chairperson Chairperson, Third Division
CERTIFICATION
LUCAS P. BERSAMIN* JOSE CATRAL MENDOZA Pursuant to Section 13, Article VIII of the Constitution and the Division
Associate Justice Associate Justice Chairperson's Attestation, I certify that the conclusions in the above Decision
had been reached in consultation before the case was assigned to the writer
MARVIC MARIO VICTOR F. LEONEN of the opinion of the Court's Division.
Associate Justice
MARIA LOURDES P. A. SERENO
ATTESTATION Chief Justice

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