THIRD DIVISION

DR. EMMANUEL JARCIA, JR. G.R. No. 187926

and DR. MARILOU BASTAN,
Present:
Petitioners,
CARPIO,* J.,
- versus -
PERALTA,** Acting Chairperson,
PEOPLE OF THE ,
ABAD,
Respondent.
PEREZ,*** and

MENDOZA, JJ.

Promulgated:

February 15, 2012

x --------------------------------------------------------------------------------------- x
DECISION
MENDOZA, J.:
Even early on, patients have consigned their lives to the skill of their doctors. Time and
again, it can be said that the most important goal of the medical profession is the
preservation of life and health of the people. Corollarily, when a physician departs from
his sacred duty and endangers instead the life of his patient, he must be made liable for
the resulting injury. This Court, as this case would show, cannot and will not let the act
go unpunished.[1]
This is a petition for review under Rule 45 of the Rules of Court challenging the August
29, 2008 Decision[2] of the Court of Appeals (CA), and its May 19, 2009 Resolution[3]
in CA-G.R. CR No. 29559, dismissing the appeal and affirming in toto the June 14,
2005 Decision[4] of the Regional Trial Court, Branch 43, Manila (RTC), finding the
accused guilty beyond reasonable doubt of simple imprudence resulting to serious
physical injuries.

THE FACTS
Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of
Investigation (NBI) against the petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr.
Marilou Bastan (Dr. Bastan), for their alleged neglect of professional duty which caused
her son, Roy Alfonso Santiago (Roy Jr.), to suffer serious physical injuries. Upon
investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was rushed to the
Manila Doctors Hospital for an emergency medical treatment; that an X-ray of the
victims ankle was ordered; that the X-ray result showed no fracture as read by Dr.
Jarcia; that Dr. Bastan entered the emergency room (ER) and, after conducting her own
examination of the victim, informed Mrs. Santiago that since it was only the ankle that
was hit, there was no need to examine the upper leg; that eleven (11) days later, Roy Jr.
developed fever, swelling of the right leg and misalignment of the right foot; that Mrs.
Santiago brought him back to the hospital; and that the X-ray revealed a right mid-tibial
fracture and a linear hairline fracture in the shaft of the bone.

The NBI indorsed the matter to the Office of the City Prosecutor of Manila for
preliminary investigation. Probable cause was found and a criminal case for reckless
imprudence resulting to serious physical injuries, was filed against Dr. Jarcia, Dr. Bastan
and Dr. Pamittan,[5] before the RTC, docketed as Criminal Case No. 01-196646.

On , the RTC found the petitioners guilty beyond reasonable doubt of the crime of Simple Imprudence
Resulting to Serious Physical Injuries. The decretal portion of the RTC decision reads:

WHEREFORE, premises considered, the Court finds accused DR. EMMANUEL JARCIA, JR.
and DR. MARILOU BASTAN GUILTY beyond reasonable doubt of the crime of SIMPLE
IMPRUDENCE RESULTING TO SERIOUS PHYSICAL INJURIES and are hereby sentenced
to suffer the penalty of ONE (1) MONTH and ONE (1) DAY to TWO (2) MONTHS and to
indemnify MRS. BELINDA SANTIAGO the amount of ₱3,850.00 representing medical
expenses without subsidiary imprisonment in case of insolvency and to pay the costs.
It appearing that Dr. Pamittan has not been apprehended nor voluntarily surrendered despite
warrant issued for her arrest, let warrant be issued for her arrest and the case against her be
ARCHIVED, to be reinstated upon her apprehension.
SO ORDERED.[6]
The RTC explained:

After a thorough and in depth evaluation of the evidence adduced by the prosecution and the
defense, this court finds that the evidence of the prosecution is the more credible, concrete
and sufficient to create that moral certainty in the mind of the Court that accused herein [are]
criminally responsible. The Court believes that accused are negligent when both failed to
exercise the necessary and reasonable prudence in ascertaining the extent of injury of Alfonso
Santiago, Jr.
However, the negligence exhibited by the two doctors does not approximate negligence of a
reckless nature but merely amounts to simple imprudence. Simple imprudence consists in the
lack of precaution displayed in those cases in which the damage impending to be caused is not
the immediate nor the danger clearly manifest. The elements of simple imprudence are as
follows.
1. that there is lack of precaution on the part of the offender;
and
2. that the damage impending to be caused is not immediate
of the danger is not clearly manifest.
Considering all the evidence on record, The Court finds the
accused guilty for simple imprudence resulting to physical
injuries. Under Article 365 of the Revised Penal Code, the
penalty provided for is arresto mayor in its minimum period.
[7]
Dissatisfied, the petitioners appealed to the CA.

As earlier stated, the CA affirmed the RTC decision in toto. The Decision of the CA pertinently reads:

This Court holds concurrently and finds the foregoing circumstances sufficient to sustain a
judgment of conviction against the accused-appellants for the crime of simple imprudence
resulting in serious physical injuries. The elements of imprudence are: (1) that the offender
does or fails to do an act; (2) that the doing or the failure to do that act is voluntary; (3) that it
be without malice; (4) that material damage results from the imprudence; and (5) that there is
inexcusable lack of precaution on the part of the offender, taking into consideration his
employment or occupation, degree of intelligence, physical condition, and other
circumstances regarding persons, time and place.
Whether or not Dr. Jarcia and Dr. Bastan had committed an inexcusable lack of precaution in
the treatment of their patient is to be determined according to the standard of care observed
by other members of the profession in good standing under similar circumstances, bearing in
mind the advanced state of the profession at the time of treatment or the present state of
medical science. In the case of Leonila Garcia-Rueda v. Pascasio, the Supreme Court stated
that, in accepting a case, a doctor in effect represents that, having the needed training and
skill possessed by physicians and surgeons practicing in the same field, he will employ such
training, care and skill in the treatment of his patients. He therefore has a duty to use at least
the same level of care that any other reasonably competent doctor would use to treat a
condition under the same circumstances.
In litigations involving medical negligence, the plaintiff has the burden of establishing
accused-appellants negligence, and for a reasonable conclusion of negligence, there must be
proof of breach of duty on the part of the physician as well as a causal connection of such
breach and the resulting injury of his patient. The connection between the negligence and the
injury must be a direct and natural sequence of events, unbroken by intervening efficient
causes. In other words, the negligence must be the proximate cause of the injury. Negligence,
no matter in what it consists, cannot create a right of action unless it is the proximate cause of
the injury complained of. The proximate cause of an injury is that cause which, in natural and
continuous sequence, unbroken by any efficient intervening cause, produces the injury and
without which the result would not have occurred.
In the case at bench, the accused-appellants questioned the imputation against them and
argued that there is no causal connection between their failure to diagnose the fracture and
the injury sustained by .
We are not convinced.
The prosecution is however after the cause which prolonged the pain and suffering of and not
on the failure of the accused-appellants to correctly diagnose the extent of the injury sustained
by .
For a more logical presentation of the discussion, we shall first consider the applicability of
the doctrine of res ipsa loquitur to the instant case. Res ipsa loquitur is a Latin phrase which
literally means the thing or the transaction speaks for itself. The doctrine of res ipsa loquitur
is simply a recognition of the postulate that, as a matter of common knowledge and
experience, the very nature of certain types of occurrences may justify an inference of
negligence on the part of the person who controls the instrumentality causing the injury in the
absence of some explanation by the accused-appellant who is charged with negligence. It is
grounded in the superior logic of ordinary human experience and, on the basis of such
experience or common knowledge, negligence may be deduced from the mere occurrence of
the accident itself. Hence, res ipsa loquitur is applied in conjunction with the doctrine of
common knowledge.
The specific acts of negligence was narrated by Mrs. Santiago who accompanied her son
during the latters ordeal at the hospital. She testified as follows:
Fiscal Formoso:
Q: Now, he is an intern did you not consult the doctors, Dr.
Jarcia or Dra. Pamittan to confirm whether you should go
home or not?
A: Dra. Pamittan was inside the cubicle of the nurses and I
asked her, you let us go home and you dont even clean the
wounds of my son.
Q: And what did she [tell] you?
A: They told me they will call a resident doctor, sir.
xxxxxxxxx
Q: Was there a resident doctor [who] came?
A: Yes, Sir. Dra. Bastan arrived.
Q: Did you tell her what you want on you to be done?
A: Yes, sir.
Q: What did you [tell] her?
A: I told her, sir, while she was cleaning the wounds of my
son, are you not going to x-ray up to the knee because my
son was complaining pain from his ankle up to the middle
part of the right leg.
Q: And what did she tell you?
A: According to Dra. Bastan, there is no need to x-ray
because it was the ankle part that was run over.
 Q: What did you do or tell her?
A: I told her, sir, why is it that they did not examine[x] the
whole leg. They just lifted the pants of my son.
Q: So you mean to say there was no treatment made at all?
A: None, sir.
xxxxxxxxx
A: I just listened to them, sir. And I just asked if I will still
return my son.
xxxxxxxxx
Q: And you were present when they were called?
A: Yes, sir.
Q: And what was discussed then by Sis. Retoria?
A: When they were there they admitted that they have
mistakes, sir.
Still, before resort to the doctrine may be allowed, the following requisites must be
satisfactorily shown:
1. The accident is of a kind which ordinarily does not occur
in the absence of someones negligence;
2. It is caused by an instrumentality within the exclusive
control of the defendant or defendants; and
3. The possibility of contributing conduct which would make
the plaintiff responsible is eliminated.
In the above requisites, the fundamental element is the control of the instrumentality which
caused the damage. Such element of control must be shown to be within the dominion of the
accused-appellants. In order to have the benefit of the rule, a plaintiff, in addition to proving
injury or damage, must show a situation where it is applicable and must establish that the
essential elements of the doctrine were present in a particular incident. The early treatment of
the leg of would have lessen his suffering if not entirely relieve him from the fracture. A boy of
tender age whose leg was hit by a vehicle would engender a well-founded belief that his
condition may worsen without proper medical attention. As junior residents who only practice
general surgery and without specialization with the case consulted before them, they should
have referred the matter to a specialist. This omission alone constitutes simple imprudence on
their part. When Mrs. Santiago insisted on having another x-ray of her child on the upper part
of his leg, they refused to do so. The mother would not have asked them if they had no
exclusive control or prerogative to request an x-ray test. Such is a fact because a radiologist
would only conduct the x-ray test upon request of a physician.
The testimony of Mrs. Santiago was corroborated by a bone specialist Dr. Tacata. He further
testified based on his personal knowledge, and not as an expert, as he examined himself the
child Roy. He testified as follows:
Fiscal Macapagal:
Q: And was that the correct respon[se] to the medical
problem that was presented to Dr. Jarcia and Dra. Bastan?
A: I would say at that stage, yes. Because they have
presented the patient and the history. At sabi nila,
nadaanan lang po ito. And then, considering their year of
residency they are still junior residents, and they are not
also orthopedic residents but general surgery residents, its
 entirely different thing. Because if you are an orthopedic
resident, I am not trying to saybut if I were an orthopedic
resident, there would be more precise and accurate decision
compare to a general surgery resident in so far as involved.
Q: You mean to say there is no supervisor attending the
emergency room?
A: At the emergency room, at the Manila Doctors Hospital,
the supervisor there is a consultant that usually comes from
a family medicine. They see where a certain patient have to
go and then if they cannot manage it, they refer it to the
consultant on duty. Now at that time, I dont [know] why
they dont.Because at that time, I think, it is the decision.
Since the x-rays.
Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to
whether a patient has been treated or operated upon with a reasonable degree of skill and
care. However, testimony as to the statements and acts of physicians, external appearances,
and manifest conditions which are observable by any one may be given by non-expert
witnesses. Hence, in cases where the res ipsa loquitur is applicable, the court is permitted to
find a physician negligent upon proper proof of injury to the patient, without the aid of expert
testimony, where the court from its fund of common knowledge can determine the proper
standard of care. Where common knowledge and experience teach that a resulting injury
would not have occurred to the patient if due care had been exercised, an inference of
negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur
without medical evidence, which is ordinarily required to show not only what occurred but
how and why it occurred. In the case at bench, we give credence to the testimony of Mrs.
Santiago by applying the doctrine of res ipsa loquitur.
Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be
cautiously applied, depending upon the circumstances of each case. It is generally restricted to
situations in malpractice cases where a layman is able to say, as a matter of common
knowledge and observation, that the consequences of professional care were not as such as
would ordinarily have followed if due care had been exercised. A distinction must be made
between the failure to secure results and the occurrence of something more unusual and not
ordinarily found if the service or treatment rendered followed the usual procedure of those
skilled in that particular practice. The latter circumstance is the primordial issue that
confronted this Court and we find application of the doctrine of res ipsa loquitur to be in
order.
WHEREFORE, in view of the foregoing, the appeal in this case is hereby DISMISSED and the
assailed decision of the trial court finding accused-appellants guilty beyond reasonable doubt
of simple imprudence resulting in serious physical injuries is hereby AFFIRMED in toto.
SO ORDERED.[8]
The petitioners filed a motion for reconsideration, but it was denied by the CA in its Resolution.

Hence, this petition.

The petitioners pray for the reversal of the decision of both the RTC and the CA anchored on the
following

GROUNDS-
1. IN AFFIRMING ACCUSED-PETITIONERS CONVICTION, THE COURT OF APPEALS
ERRED IN NOT HOLDING THAT THE ACTUAL, DIRECT, IMMEDIATE, AND
PROXIMATE CAUSE OF THE PHYSICAL INJURY OF THE PATIENT (FRACTURE OF
THE LEG BONE OR TIBIA), WHICH REQUIRED MEDICAL ATTENDANCE FOR MORE
THAN THIRTY (30) DAYS AND INCAPACITATED HIM FROM PERFORMING HIS
CUSTOMARY DUTY DURING THE SAME PERIOD OF TIME, WAS THE VEHICULAR
ACCIDENT WHERE THE PATIENTS RIGHT LEG WAS HIT BY A TAXI, NOT THE
FAILURE OF THE ACCUSED-PETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG
TO AN X-RAY EXAMINATION.
2. THE COURT OF APPEALS ERRED IN DISREGARDING ESTABLISHED FACTS
CLEARLY NEGATING PETITIONERS ALLEGED NEGLIGENCE OR IMPRUDENCE.
SIGNIFICANTLY, THE COURT OF APPEALS UNJUSTIFIABLY DISREGARDED THE
OPINION OF THE PROSECUTIONS EXPERT WITNESS, DR. CIRILO TACATA, THAT
PETITIONERS WERE NOT GUILTY OF NEGLIGENCE OR IMPRUDENCE COMPLAINED
OF.
3. THE COURT OF APPEALS ERRED IN HOLDING THAT THE FAILURE OF
PETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY EXAMINATION
PROLONGED THE PAIN AND SUFFERING OF THE PATIENT, SUCH CONCLUSION
BEING UNSUPPORTED BY, AND EVEN CONTRARY TO, THE EVIDENCE ON RECORD.
4. ASSUMING ARGUENDO THAT THE PATIENT EXPERIENCED PROLONGED PAIN AND
SUFFERING, THE COURT OF APPEALS ERRED IN NOT HOLDING THAT THE ALLEGED
PAIN AND SUFFERING WERE DUE TO THE UNJUSTIFIED FAILURE OF THE PATIENTS
MOTHER, A NURSE HERSELF, TO IMMEDIATELY BRING THE PATIENT BACK TO THE
HOSPITAL, AS ADVISED BY THE PETITIONERS, AFTER HE COMPLAINED OF SEVERE
PAIN IN HIS RIGHT LEG WHEN HE REACHED HOME AFTER HE WAS SEEN BY
PETITIONERS AT THE HOSPITAL. THUS, THE PATIENTS ALLEGED INJURY
(PROLONGED PAIN AND SUFFERING) WAS DUE TO HIS OWN MOTHERS ACT OR
OMISSION.
5. THE COURT OF APPEALS ERRED IN NOT HOLDING THAT NO PHYSICIAN-PATIENT
RELATIONSHIP EXISTED BETWEEN PETITIONERS AND PATIENT ALFONSO
SANTIAGO, JR., PETITIONERS NOT BEING THE LATTERS ATTENDING PHYSICIAN AS
THEY WERE MERELY REQUESTED BY THE EMERGENCY ROOM (ER) NURSE TO SEE
THE PATIENT WHILE THEY WERE PASSING BY THE ER FOR THEIR LUNCH.
6. THE COURT OF APPEALS GRAVELY ERRED IN NOT ACQUITTING ACCUSED-
PETITIONERS OF THE CRIME CHARGED.[9]
The foregoing can be synthesized into two basic issues: [1] whether or not the doctrine of res ipsa
loquitur is applicable in this case; and [2] whether or not the petitioners are liable for criminal
negligence.

THE COURTS RULING

The CA is correct in finding that there was negligence on the part of the petitioners.
After a perusal of the records, however, the Court is not convinced that the petitioners
are guilty of criminal negligence complained of. The Court is also of the view that the
CA erred in applying the doctrine of res ipsa loquitur in this particular case.

As to the Application of
The Doctrine of Res Ipsa Loquitur
This doctrine of res ipsa loquitur means "Where the thing which causes injury is shown
to be under the management of the defendant, and the accident is such as in the ordinary
course of things does not happen if those who have the management use proper care, it
affords reasonable evidence, in the absence of an explanation by the defendant, that the
accident arose from want of care." The Black's Law Dictionary defines the said doctrine.
Thus:
The thing speaks for itself. Rebuttable presumption or inference that defendant was negligent,
which arises upon proof that the instrumentality causing injury was in defendant's exclusive
control, and that the accident was one which ordinarily does not happen in absence of
negligence. Res ipsa loquitur is a rule of evidence whereby negligence of the alleged
wrongdoer may be inferred from the mere fact that the accident happened provided the
character of the accident and circumstances attending it lead reasonably to belief that in the
absence of negligence it would not have occurred and that thing which caused injury is shown
to have been under the management and control of the alleged wrongdoer. Under this
doctrine, the happening of an injury permits an inference of negligence where plaintiff
produces substantial evidence that the injury was caused by an agency or instrumentality
under the exclusive control and management of defendant, and that the occurrence was such
that in the ordinary course of things would not happen if reasonable care had been used.[10]
The doctrine of res ipsa loquitur as a rule of evidence is unusual to the law of negligence
which recognizes that prima facie negligence may be established without direct proof
and furnishes a substitute for specific proof of negligence. The doctrine, however, is not
a rule of substantive law, but merely a mode of proof or a mere procedural convenience.
The rule, when applicable to the facts and circumstances of a given case, is not meant to
and does not dispense with the requirement of proof of culpable negligence on the party
charged. It merely determines and regulates what shall be prima facie evidence thereof
and helps the plaintiff in proving a breach of the duty. The doctrine can be invoked when
and only when, under the circumstances involved, direct evidence is absent and not
readily available.[11]
The requisites for the application of the doctrine of res ipsa loquitur are: (1) the accident
was of a kind which does not ordinarily occur unless someone is negligent; (2) the
instrumentality or agency which caused the injury was under the exclusive control of the
person in charge; and (3) the injury suffered must not have been due to any voluntary
action or contribution of the person injured.[12]

In this case, the circumstances that caused patient Roy Jr.s injury and the series of tests
that were supposed to be undergone by him to determine the extent of the injury suffered
were not under the exclusive control of Drs. Jarcia and Bastan. It was established that
they are mere residents of the at that time who attended to the victim at the emergency
room.[13] While it may be true that the circumstances pointed out by the courts below
seem doubtless to constitute reckless imprudence on the part of the petitioners, this
conclusion is still best achieved, not through the scholarly assumptions of a layman like
the patients mother, but by the unquestionable knowledge of expert witness/es. As to
whether the petitioners have exercised the requisite degree of skill and care in treating
patient Roy, Jr. is generally a matter of expert opinion.

As to Dr. Jarcia and

Dr. Bastans negligence
The totality of the evidence on record clearly points to the negligence of the petitioners.
At the risk of being repetitious, the Court, however, is not satisfied that Dr. Jarcia and
Dr. Bastan are criminally negligent in this case.
Negligence is defined as the failure to observe for the protection of the interests of
another person that degree of care, precaution, and vigilance which the circumstances
justly demand, whereby such other person suffers injury.[14]

Reckless imprudence consists of voluntarily doing or failing to do, without malice, an

act from which material damage results by reason of an inexcusable lack of precaution
on the part of the person performing or failing to perform such act.[15]

The elements of simple negligence are: (1) that there is lack of precaution on the part of
the offender, and (2) that the damage impending to be caused is not immediate or the
danger is not clearly manifest.[16]

In this case, the Court is not convinced with moral certainty that the petitioners are
guilty of reckless imprudence or simple negligence. The elements thereof were not
proved by the prosecution beyond reasonable doubt.
The testimony of Dr. Cirilo R. Tacata (Dr. Tacata), a specialist in pediatric orthopedic,
although pointing to some medical procedures that could have been done by Dr. Jarcia
and Dr. Bastan, as physicians on duty, was not clear as to whether the injuries suffered
by patient Roy Jr. were indeed aggravated by the petitioners judgment call and their
diagnosis or appreciation of the condition of the victim at the time they assessed him.
Thus:
Q: Will you please tell us, for the record, doctor, what is your specialization?
A: At present I am the chairman department of orthopedic in UP-PGH and I had special
training in pediatric orthopedic for two (2) years.
Q: In June 1998, doctor, what was your position and what was your specialization at that
time?
A: Since 1980, I have been specialist in pediatric orthopedic.
Q: When Alfonso Santiago, Jr. was brought to you by his mother, what did you do by way of
physicians as first step?
A: As usual, I examined the patient physically and, at that time as I have said, the patient
could not walk so I [began] to suspect that probably he sustained a fracture as a result of a
vehicular accident. So I examined the patient at that time, the involved leg, I dont know if that
is left or right, the involved leg then was swollen and the patient could not walk, so I requested
for the x-ray of [the] lower leg.
Q: What part of the leg, doctor, did you request to be examined?
A: If we refer for an x-ray, usually, we suspect a fracture whether in approximal, middle or
lebistal tinial, we usually x-ray the entire extremity.
Q: And what was the result?
A: Well, I can say that it was a spiral fracture of the mid-tibial, it is the bigger bone of the leg.
Q: And when you say spiral, doctor, how long was this fracture?
A: When we say spiral, it is a sort of letter S, the length was about six (6) to eight (8)
centimeters.
Q: Mid-tibial, will you please point to us, doctor, where the tibial is?
(Witness pointing to his lower leg)
A: The tibial is here, there are two bones here, the bigger one is the tibial and the smaller one
is the fibula. The bigger one is the one that get fractured.
Q: And in the course of your examination of Alfonso Santiago, Jr. did you ask for the history of
such injury?
A: Yes, actually, that was a routine part of our examination that once a patient comes in,
before we actually examine the patient, we request for a detailed history. If it is an accident,
then, we request for the exact mechanism of injuries.
Q: And as far as you can recall, Doctor, what was the history of that injury that was told to
you?
A: The patient was sideswiped, I dont know if it is a car, but it is a vehicular accident.
Q: Who did you interview?
A: The mother.
Q: How about the child himself, Alfonso Santiago, Jr.?
A: Normally, we do not interview the child because, usually, at his age, the answers are not
accurate. So, it was the mother that I interviewed.
Q: And were you informed also of his early medication that was administered on Alfonso
Santiago, Jr.?
A: No, not actually medication. I was informed that this patient was seen initially at the
emergency room by the two (2) physicians that you just mentioned, Dr. Jarcia and Dra.
Bastan, that time who happened to be my residents who were [on] duty at the emergency
room.
xxxx
A: At the emergency room, at the Manila Doctors Hospital, the supervisor there is a
consultant that usually comes from a family medicine. They see where a certain patient have
to go and then if they cannot manage it, they refer it to the consultant on duty. Now at that
time, I dont why they dont Because at that time, I think, it is the decision. Since the x-rays
xxx
Q: You also said, Doctor, that Dr. Jarcia and Dra. Bastan are not even an orthopedic specialist.
A: They are general surgeon residents. You have to man[x] the emergency room, including
neurology, orthopedic, general surgery, they see everything at the emergency room.
xxxx
Q: But if initially, Alfonso Santiago, Jr. and his case was presented to you at the emergency room,
you would have subjected the entire foot to x-ray even if the history that was given to Dr. Jarcia
and Dra. Bastan is the same?
A: I could not directly say yes, because it would still depend on my examination, we cannot
subject the whole body for x-ray if we think that the damaged was only the leg.
Q: Not the entire body but the entire leg?
A: I think, if my examination requires it, I would.
Q: So, you would conduct first an examination?
A: Yes, sir.
Q: And do you think that with that examination that you would have conducted you would
discover the necessity subjecting the entire foot for x-ray?
A: It is also possible but according to them, the foot and the ankle were swollen and not the leg,
which sometimes normally happens that the actual fractured bone do not get swollen.
xxxx
Q: Doctor, if you know that the patient sustained a fracture on the ankle and on the foot and the
history that was told to you is the region that was hit is the region of the foot, will the doctor
subject the entire leg for x-ray?
A: I am an orthopedic surgeon, you have to subject an x-ray of the leg. Because you have to
consider the kind of fracture that the patient sustained would you say the exact mechanism of
injury. For example spiral, paikot yung bale nya, so it was possible that the leg was run over, the
patient fell, and it got twisted. Thats why the leg seems to be fractured.[17] [Emphases supplied]
It can be gleaned from the testimony of Dr. Tacata that a thorough examination was not
performed on Roy Jr. As residents on duty at the emergency room, Dr. Jarcia and Dr.
Bastan were expected to know the medical protocol in treating leg fractures and in
attending to victims of car accidents. There was, however, no precise evidence and
scientific explanation pointing to the fact that the delay in the application of the cast to
the patients fractured leg because of failure to immediately diagnose the specific injury
of the patient, prolonged the pain of the child or aggravated his condition or even caused
further complications. Any person may opine that had patient Roy Jr. been treated
properly and given the extensive X-ray examination, the extent and severity of the
injury, spiral fracture of the mid-tibial part or the bigger bone of the leg, could have been
detected early on and the prolonged pain and suffering of Roy Jr. could have been
prevented. But still, that opinion, even how logical it may seem would not, and could
not, be enough basis to hold one criminally liable; thus, a reasonable doubt as to the
petitioners guilt.
Although the Court sympathizes with the plight of the mother and the child in this case,
the Court is bound by the dictates of justice which hold inviolable the right of the
accused to be presumed innocent until proven guilty beyond reasonable doubt. The
Court, nevertheless, finds the petitioners civilly liable for their failure to sufficiently
attend to Roy Jr.s medical needs when the latter was rushed to the ER, for while a
criminal conviction requires proof beyond reasonable doubt, only a preponderance of
evidence is required to establish civil liability. Taken into account also was the fact that
there was no bad faith on their part.
Dr. Jarcia and Dr. Bastan cannot pass on the liability to the taxi driver who hit the
victim. It may be true that the actual, direct, immediate, and proximate cause of the
injury (fracture of the leg bone or tibia) of Roy Jr. was the vehicular accident when he
was hit by a taxi. The petitioners, however, cannot simply invoke such fact alone to
excuse themselves from any liability. If this would be so, doctors would have a ready
defense should they fail to do their job in attending to victims of hit-and-run,
maltreatment, and other crimes of violence in which the actual, direct, immediate, and
proximate cause of the injury is indubitably the act of the perpetrator/s.
In failing to perform an extensive medical examination to determine the extent of Roy
Jr.s injuries, Dr. Jarcia and Dr. Bastan were remiss of their duties as members of the
medical profession. Assuming for the sake of argument that they did not have the
capacity to make such thorough evaluation at that stage, they should have referred the
patient to another doctor with sufficient training and experience instead of assuring him
and his mother that everything was all right.
This Court cannot also stamp its imprimatur on the petitioners contention that no
physician-patient relationship existed between them and patient Roy Jr., since they were
not his attending physicians at that time. They claim that they were merely requested by
the ER nurse to see the patient while they were passing by the ER for their lunch.
Firstly, this issue was never raised during the trial at the RTC or even before the CA.
The petitioners, therefore, raise the want of doctor-patient relationship for the first time
on appeal with this Court. It has been settled that issues raised for the first time on
appeal cannot be considered because a party is not permitted to change his theory on
appeal. To allow him to do so is unfair to the other party and offensive to the rules of fair
play, justice and due process.[18] Stated differently, basic considerations of due process
dictate that theories, issues and arguments not brought to the attention of the trial court
need not be, and ordinarily will not be, considered by a reviewing court.[19]
Assuming again for the sake of argument that the petitioners may still raise this issue of
no physicianpatient relationship, the Court finds and so holds that there was a
physicianpatient relationship in this case.
In the case of Lucas v. Tuao,[20] the Court wrote that [w]hen a patient engages the
services of a physician, a physician-patient relationship is generated. And in accepting a
case, the physician, for all intents and purposes, represents that he has the needed
training and skill possessed by physicians and surgeons practicing in the same field; and
that he will employ such training, care, and skill in the treatment of the patient. Thus, in
treating his patient, a physician is under a duty to exercise that degree of care, skill and
diligence which physicians in the same general neighborhood and in the same general
line of practice ordinarily possess and exercise in like cases. Stated otherwise, the
physician has the obligation to use at least the same level of care that any other
reasonably competent physician would use to treat the condition under similar
circumstances.

Indubitably, a physician-patient relationship exists between the petitioners and patient

Roy Jr. Notably, the latter and his mother went to the ER for an immediate medical
attention. The petitioners allegedly passed by and were requested to attend to the victim
(contrary to the testimony of Dr. Tacata that they were, at that time, residents on duty at
the ER).[21] They obliged and examined the victim, and later assured the mother that
everything was fine and that they could go home. Clearly, a physician-patient
relationship was established between the petitioners and the patient Roy Jr.

To repeat for clarity and emphasis, if these doctors knew from the start that they were
not in the position to attend to Roy Jr., a vehicular accident victim, with the degree of
diligence and commitment expected of every doctor in a case like this, they should have
not made a baseless assurance that everything was all right. By doing so, they deprived
Roy Jr. of adequate medical attention that placed him in a more dangerous situation than
he was already in. What petitioners should have done, and could have done, was to refer
Roy Jr. to another doctor who could competently and thoroughly examine his injuries.
All told, the petitioners were, indeed, negligent but only civilly, and not criminally,
liable as the facts show.

Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in the
states:

A physician should attend to his patients faithfully and conscientiously. He should secure for
them all possible benefits that may depend upon his professional skill and care. As the sole
tribunal to adjudge the physicians failure to fulfill his obligation to his patients is, in most
cases, his own conscience, violation of this rule on his part is discreditable and inexcusable.
[22]
Established medical procedures and practices, though in constant instability, are devised for the
purpose of preventing complications. In this case, the petitioners failed to observe the most prudent
medical procedure under the circumstances to prevent the complications suffered by a child of tender
age.

As to the Award of
Damages
While no criminal negligence was found in the petitioners failure to administer the
necessary medical attention to Roy Jr., the Court holds them civilly liable for the
resulting damages to their patient. While it was the taxi driver who ran over the foot or
leg of Roy Jr., their negligence was doubtless contributory.

It appears undisputed that the amount of ₱3,850.00, as expenses incurred by patient Roy
Jr., was adequately supported by receipts. The Court, therefore, finds the petitioners
liable to pay this amount by way of actual damages.

The Court is aware that no amount of compassion can suffice to ease the sorrow felt by
the family of the child at that time. Certainly, the award of moral and exemplary
damages in favor of Roy Jr. in the amount of ₱100,000.00 and ₱50,000.00, respectively,
is proper in this case.
It is settled that moral damages are not punitive in nature, but are designed to
compensate and alleviate in some way the physical suffering, mental anguish, fright,
serious anxiety, besmirched reputation, wounded feelings, moral shock, social
humiliation, and similar injury unjustly inflicted on a person. Intended for the restoration
of the psychological or emotional status quo ante, the award of moral damages is
designed to compensate emotional injury suffered, not to impose a penalty on the
wrongdoer.[23]

The Court, likewise, finds the petitioners also liable for exemplary damages in the said amount. Article
2229 of the Civil Code provides that exemplary damages may be imposed by way of example or
correction for the public good.
WHEREFORE, the petition is PARTLY GRANTED. The Decision of the Court of
Appeals dated is REVERSED and SET ASIDE. A new judgment is entered
ACQUITTING Dr. Emmanuel Jarcia, Jr. and Dr. Marilou Bastan of the crime of
reckless imprudence resulting to serious physical injuries but declaring them civilly
liable in the amounts of:

(1) ₱3,850.00 as actual damages;

(2) ₱100,000.00 as moral damages;

(3) ₱50,000.00 as exemplary damages; and

(4) Costs of the suit.

with interest at the rate of 6% per annum from the date of the filing of the Information.
The rate shall be 12% interest per annum from the finality of judgment until fully paid.

SO ORDERED.

Jarcia vs People of the Philippines

GR No. 187926 February 15, 2012
Facts: Belinda Santiago lodged a complaint with the National Bureau of Investigation (NBI) against
the petitioners, Dr. Emanuel Jarcia and Dr. Marilou Bastan, for their alleged neglect of professional
duty which caused her son, Roy Alfonso Santiago, to suffer physical injuries. Upon investigation, the
NBI found that Roy Jr. was hit by a taxicab; that he was rushed to the Manila Doctors Hospital for an
emergency medical treatment; that an X-ray of the victim’s ankle was ordered; that the X-ray result
showed no fracture as read by Dr. Jarcia; that Dr. Bastan entered the emergency room and, after
conducting her own examination of the victim, informed Mrs. Santiago that since it was only the ankle
that was hit there was no need to examine the upper leg; that 11 days later, Roy developed fever,
swelling of the right leg and misalignment of the right foot; that Mrs. Santiago brought him back to the
hospital; and that the x-ray revealed a right mid-tibial fracture and a linear hairline fracture in the shaft
of the bone. A complaint for reckless imprudence resulting physical injuries was filed against the
petitioners for the alleged misconduct in the handling of the illness of Roy.
Issue: Whether or not the petitioners failed to exercise the degree of care expected of them as doctors
and are liable for negligence to the private respondent.
Held: Yes. The doctrine of res ipsa liquitor as a rule of evidence is unusual to the law of negligence
which recognizes that prima facie negligencce may be established without direct proof and furnishes a
substitute for specific proof of negligence. The doctrine however, is not a rule of substantive law, but
merely a mode of proof or a mere procedural convenience the rule when applicable to the facts and
circumstances of a given case, is not meant to and does not dispense with the requirement of proof of
culpable negligence on the party charged. It merely determines and regulates what shall be prima facie
evidence thereof and helps the plaintiff in proving a breach of duty. The doctrine can be invoked when
and only when, under the circumstances involved, direct evidence is absolute and not readily available.
The requisites for the application of the doctrine of res ipsa liquitor are:
1. The accident was of a kind which does not ordinarily occur unless someone is negligent;
2. The instrumentality or agency which caused the injury was under the exclusive control of the
person in charge; and
3. The injury suffered must not have been due to any voluntary action or contribution of the person
injured.
Negligence is defined as the failure to observe for the protection of the interests of another person that
degree of care, precaution and vigilance which the circumstances justly demand whereby such other
person suffers injury.
Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act from which
material damage results by reason of an inexcusable lack of precaution on the part of the person
performing or failing to perform such act.
In failing to perform an extensive medical examination to determine the extent of Roy’s injuries, Dr.
Jarcia and Dr. Bastan were remiss of their duties as members of the medical profession. Assuming for
the sake of argument that they did not have the capacity to make such thorough evaluation at that stage
they should have referred the patient to another doctor with sufficient training and experience instead of
assuring him and his mother that everything was all right.
EN BANC
DR. RUBI LI, G.R. No. 165279

Petitioner, Present:

- versus - , C.J.,

CARPIO,
 CARPIO MORALES,

VELASCO, JR.,

NACHURA,

LEONARDO-DE CASTRO,

BRION,

PERALTA,

BERSAMIN,

CASTILLO,*

ABAD,

VILLARAMA, JR.,

PEREZ,

, and

SERENO, JJ.

SPOUSES REYNALDO and LINA Promulgated:

SOLIMAN, as parents/heirs of
deceased Angelica Soliman, June 7, 2011

Respondents.

x- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
DECISION
VILLARAMA, JR., J.:

Challenged in this petition for review on certiorari is the Decision[1] dated as well as the
Resolution[2] dated of the Court of Appeals (CA) in CA-G.R. CV No. 58013 which
modified the Decision[3] dated of the , Branch 8 in Civil Case No. 8904.

The factual antecedents:

On , respondents 11-year old daughter, Angelica Soliman, underwent a biopsy of the
mass located in her lower extremity at the St. Lukes Medical Center (SLMC). Results
showed that Angelica was suffering from osteosarcoma, osteoblastic type,[4] a high-
grade (highly malignant) cancer of the bone which usually afflicts teenage children.
Following this diagnosis and as primary intervention, Angelicas right leg was amputated
by Dr. Jaime Tamayo in order to remove the tumor. As adjuvant treatment to eliminate
any remaining cancer cells, and hence minimize the chances of recurrence and prevent
the disease from spreading to other parts of the patients body (metastasis),
chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo referred Angelica to another
doctor at SLMC, herein petitioner Dr. Rubi Li, a medical oncologist.

On , Angelica was admitted to SLMC. However, she died on , just eleven (11) days after
the (intravenous) administration of the first cycle of the chemotherapy regimen. Because
SLMC refused to release a death certificate without full payment of their hospital bill,
respondents brought the cadaver of Angelica to the Philippine National Police (PNP)
Crime Laboratory at for post-mortem examination. The Medico-Legal Report issued by
said institution indicated the cause of death as Hypovolemic shock secondary to multiple
organ hemorrhages and Disseminated Intravascular Coagulation.[5]

On the other hand, the Certificate of Death[6] issued by SLMC stated the cause of death
as follows:

Immediate cause : a. Osteosarcoma, Status Post AKA

Antecedent cause : b. (above knee amputation)
Underlying cause : c. Status Post Chemotherapy

On , respondents filed a damage suit[7] against petitioner, Dr. Leo Marbella, Mr. Jose
Ledesma, a certain Dr. Arriete and SLMC. Respondents charged them with negligence
and disregard of Angelicas safety, health and welfare by their careless administration of
the chemotherapy drugs, their failure to observe the essential precautions in detecting
early the symptoms of fatal blood platelet decrease and stopping early on the
chemotherapy, which bleeding led to hypovolemic shock that caused Angelicas untimely
demise. Further, it was specifically averred that petitioner assured the respondents that
Angelica would recover in view of 95% chance of healing with chemotherapy
(Magiging normal na ang anak nyo basta ma-chemo. 95% ang healing) and when asked
regarding the side effects, petitioner mentioned only slight vomiting, hair loss and
weakness (Magsusuka ng kaunti. Malulugas ang buhok. Manghihina). Respondents thus
claimed that they would not have given their consent to chemotherapy had petitioner not
falsely assured them of its side effects.

In her answer,[8] petitioner denied having been negligent in administering the

chemotherapy drugs to Angelica and asserted that she had fully explained to respondents
how the chemotherapy will affect not only the cancer cells but also the patients normal
body parts, including the lowering of white and red blood cells and platelets. She
claimed that what happened to Angelica can be attributed to malignant tumor cells
possibly left behind after surgery. Few as they may be, these have the capacity to
compete for nutrients such that the body becomes so weak structurally (cachexia) and
functionally in the form of lower resistance of the body to combat infection. Such
infection becomes uncontrollable and triggers a chain of events (sepsis or septicemia)
that may lead to bleeding in the form of Disseminated Intravascular Coagulation (DIC),
as what the autopsy report showed in the case of Angelica.

Since the medical records of Angelica were not produced in court, the trial and appellate
courts had to rely on testimonial evidence, principally the declarations of petitioner and
respondents themselves. The following chronology of events was gathered:

On , petitioner saw the respondents at the hospital after Angelicas surgery and discussed
with them Angelicas condition. Petitioner told respondents that Angelica should be given
two to three weeks to recover from the operation before starting chemotherapy.
Respondents were apprehensive due to financial constraints as Reynaldo earns only
from P70,000.00 to P150,000.00 a year from his jewelry and watch repairing business.
[9] Petitioner, however, assured them not to worry about her professional fee and told
them to just save up for the medicines to be used.

Petitioner claimed that she explained to respondents that even when a tumor is removed,
there are still small lesions undetectable to the naked eye, and that adjuvant
chemotherapy is needed to clean out the small lesions in order to lessen the chance of
the cancer to recur. She did not give the respondents any assurance that chemotherapy
will cure Angelicas cancer. During these consultations with respondents, she explained
the following side effects of chemotherapy treatment to respondents: (1) falling hair; (2)
nausea and vomiting; (3) loss of appetite; (4) low count of white blood cells [WBC], red
blood cells [RBC] and platelets; (5) possible sterility due to the effects on Angelicas
ovary; (6) damage to the heart and kidneys; and (7) darkening of the skin especially
when exposed to sunlight. She actually talked with respondents four times, once at the
hospital after the surgery, twice at her clinic and the fourth time when Angelicas mother
called her through long distance.[10] This was disputed by respondents who countered
that petitioner gave them assurance that there is 95% chance of healing for Angelica if
she undergoes chemotherapy and that the only side effects were nausea, vomiting and
hair loss.[11] Those were the only side-effects of chemotherapy treatment mentioned by
petitioner.[12]

On , SLMC discharged Angelica, with instruction from petitioner that she be readmitted
after two or three weeks for the chemotherapy.

On , respondents brought Angelica to SLMC for chemotherapy, bringing with them the
results of the laboratory tests requested by petitioner: Angelicas chest x-ray, ultrasound
of the liver, creatinine and complete liver function tests.[13] Petitioner proceeded with
the chemotherapy by first administering hydration fluids to Angelica.[14]

The following day, August 19, petitioner began administering three chemotherapy drugs
Cisplatin,[15] Doxorubicin[16] and Cosmegen[17] intravenously. Petitioner was
supposedly assisted by her trainees Dr. Leo Marbella[18] and Dr. Grace Arriete.[19] In
his testimony, Dr. Marbella denied having any participation in administering the said
chemotherapy drugs.[20]

On the second day of chemotherapy, August 20, respondents noticed reddish

discoloration on Angelicas face.[21] They asked petitioner about it, but she merely
quipped, Wala yan. Epekto ng gamot.[22] Petitioner recalled noticing the skin rashes on
the nose and cheek area of Angelica. At that moment, she entertained the possibility that
Angelica also had systemic lupus and consulted Dr. Victoria Abesamis on the matter.[23]

On the third day of chemotherapy, August 21, Angelica had difficulty breathing and was
thus provided with oxygen inhalation apparatus. This time, the reddish discoloration on
Angelicas face had extended to her neck, but petitioner dismissed it again as merely the
effect of medicines.[24] Petitioner testified that she did not see any discoloration on
Angelicas face, nor did she notice any difficulty in the childs breathing. She claimed that
Angelica merely complained of nausea and was given ice chips.[25]

On , at around in the morning, upon seeing that their child could not anymore bear the
pain, respondents pleaded with petitioner to stop the chemotherapy. Petitioner
supposedly replied: Dapat 15 Cosmegen pa iyan. Okay, lets observe. If pwede na,
bigyan uli ng chemo. At this point, respondents asked petitioners permission to bring
their child home. Later in the evening, Angelica passed black stool and reddish urine.
[26] Petitioner countered that there was no record of blackening of stools but only an
episode of loose bowel movement (LBM). Petitioner also testified that what Angelica
complained of was carpo-pedal spasm, not convulsion or epileptic attack, as respondents
call it (petitioner described it in the vernacular as naninigas ang kamay at paa). She then
requested for a serum calcium determination and stopped the chemotherapy. When
Angelica was given calcium gluconate, the spasm and numbness subsided.[27]

The following day, August 23, petitioner yielded to respondents request to take Angelica
home. But prior to discharging Angelica, petitioner requested for a repeat serum calcium
determination and explained to respondents that the chemotherapy will be temporarily
stopped while she observes Angelicas muscle twitching and serum calcium level. Take-
home medicines were also prescribed for Angelica, with instructions to respondents that
the serum calcium test will have to be repeated after seven days. Petitioner told
respondents that she will see Angelica again after two weeks, but respondents can see
her anytime if any immediate problem arises.[28]

However, Angelica remained in confinement because while still in the premises of

SLMC, her convulsions returned and she also had LBM. Angelica was given oxygen and
administration of calcium continued.[29]

The next day, August 24, respondents claimed that Angelica still suffered from
convulsions. They also noticed that she had a fever and had difficulty breathing.[30]
Petitioner insisted it was carpo-pedal spasm, not convulsions. She verified that at around
that afternoon, Angelica developed difficulty in breathing and had fever. She then
requested for an electrocardiogram analysis, and infused calcium gluconate on the
patient at a stat dose. She further ordered that Angelica be given Bactrim,[31] a synthetic
antibacterial combination drug,[32] to combat any infection on the childs body.[33]

By August 26, Angelica was bleeding through the mouth. Respondents also saw blood
on her anus and urine. When Lina asked petitioner what was happening to her daughter,
petitioner replied, Bagsak ang platelets ng anak mo. Four units of platelet concentrates
were then transfused to Angelica. Petitioner prescribed Solucortef. Considering that
Angelicas fever was high and her white blood cell count was low, petitioner prescribed
Leucomax. About four to eight bags of blood, consisting of packed red blood cells, fresh
whole blood, or platelet concentrate, were transfused to Angelica. For two days (August
27 to 28), Angelica continued bleeding, but petitioner claimed it was lesser in amount
and in frequency. Petitioner also denied that there were gadgets attached to Angelica at
that time.[34]
On August 29, Angelica developed ulcers in her mouth, which petitioner said were blood
clots that should not be removed. Respondents claimed that Angelica passed about half a
liter of blood through her anus at around that evening, which petitioner likewise denied.

On August 30, Angelica continued bleeding. She was restless as endotracheal and
nasogastric tubes were inserted into her weakened body. An aspiration of the nasogastric
tube inserted to Angelica also revealed a bloody content. Angelica was given more
platelet concentrate and fresh whole blood, which petitioner claimed improved her
condition. Petitioner told Angelica not to remove the endotracheal tube because this may
induce further bleeding.[35] She was also transferred to the intensive care unit to avoid
infection.

The next day, respondents claimed that Angelica became hysterical, vomited blood and
her body turned black. Part of Angelicas skin was also noted to be shredding by just
rubbing cotton on it. Angelica was so restless she removed those gadgets attached to her,
saying Ayaw ko na; there were tears in her eyes and she kept turning her head.
Observing her daughter to be at the point of death, Lina asked for a doctor but the latter
could not answer her anymore.[36] At this time, the attending physician was Dr.
Marbella who was shaking his head saying that Angelicas platelets were down and
respondents should pray for their daughter. Reynaldo claimed that he was introduced to
a pediatrician who took over his daughters case, Dr. Abesamis who also told him to pray
for his daughter. Angelica continued to have difficulty in her breathing and blood was
being suctioned from her stomach. A nurse was posted inside Angelicas room to assist
her breathing and at one point they had to revive Angelica by pumping her chest.
Thereafter, Reynaldo claimed that Angelica already experienced difficulty in urinating
and her bowel consisted of blood-like fluid. Angelica requested for an electric fan as she
was in pain. Hospital staff attempted to take blood samples from Angelica but were
unsuccessful because they could not even locate her vein. Angelica asked for a fruit but
when it was given to her, she only smelled it. At this time, Reynaldo claimed he could
not find either petitioner or Dr. Marbella. That night, Angelica became hysterical and
started removing those gadgets attached to her. At in the morning of September priest
came and they prayed before Angelica expired. Petitioner finally came back and
supposedly told respondents that there was malfunction or bogged-down machine.[37]

By petitioners own account, Angelica was merely irritable that day (August 31).
Petitioner noted though that Angelicas skin was indeed sloughing off.[38] She stressed
that at in the evening, Angelica pulled out her endotracheal tube.[39] On September 1,
exactly two weeks after being admitted at SLMC for chemotherapy, Angelica died.[40]
The cause of death, according to petitioner, was septicemia, or overwhelming infection,
which caused Angelicas other organs to fail.[41] Petitioner attributed this to the patients
poor defense mechanism brought about by the cancer itself.[42]

While he was seeking the release of Angelicas cadaver from SLMC, Reynaldo claimed
that petitioner acted arrogantly and called him names. He was asked to sign a
promissory note as he did not have cash to pay the hospital bill.[43]

Respondents also presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-Legal

Officer of the PNP-Crime Laboratory who conducted the autopsy on Angelicas cadaver,
and Dr. Melinda Vergara Balmaceda who is a Medical Specialist employed at the
Department of Health (DOH) Operations and Management Services.

Testifying on the findings stated in her medico-legal report, Dr. Vergara noted the
following: (1) there were fluids recovered from the abdominal cavity, which is not
normal, and was due to hemorrhagic shock secondary to bleeding; (2) there was
hemorrhage at the left side of the heart; (3) bleeding at the upper portion of and areas
adjacent to, the esophagus; (4) lungs were heavy with bleeding at the back and lower
portion, due to accumulation of fluids; (4) yellowish discoloration of the liver; (5)
kidneys showed appearance of facial shock on account of hemorrhages; and (6)
reddishness on external surface of the spleen. All these were the end result of
hypovolemic shock secondary to multiple organ hemorrhages and disseminated
intravascular coagulation. Dr. Vergara opined that this can be attributed to the chemical
agents in the drugs given to the victim, which caused platelet reduction resulting to
bleeding sufficient to cause the victims death. The time lapse for the production of DIC
in the case of Angelica (from the time of diagnosis of sarcoma) was too short,
considering the survival rate of about 3 years. The witness conceded that the victim will
also die of osteosarcoma even with amputation or chemotherapy, but in this case
Angelicas death was not caused by osteosarcoma. Dr. Vergara admitted that she is not a
pathologist but her statements were based on the opinion of an oncologist whom she had
interviewed. This oncologist supposedly said that if the victim already had DIC prior to
the chemotherapy, the hospital staff could have detected it.[44]

On her part, Dr. Balmaceda declared that it is the physicians duty to inform and explain
to the patient or his relatives every known side effect of the procedure or therapeutic
agents to be administered, before securing the consent of the patient or his relatives to
such procedure or therapy. The physician thus bases his assurance to the patient on his
personal assessment of the patients condition and his knowledge of the general effects of
the agents or procedure that will be allowed on the patient. Dr. Balmaceda stressed that
the patient or relatives must be informed of all known side effects based on studies and
observations, even if such will aggravate the patients condition.[45]

Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelicas lower extremity,
testified for the defendants. He explained that in case of malignant tumors, there is no
guarantee that the ablation or removal of the amputated part will completely cure the
cancer. Thus, surgery is not enough. The mortality rate of osteosarcoma at the time of
modern chemotherapy and early diagnosis still remains at 80% to 90%. Usually, deaths
occur from metastasis, or spread of the cancer to other vital organs like the liver, causing
systemic complications. The modes of therapy available are the removal of the primary
source of the cancerous growth and then the residual cancer cells or metastasis should be
treated with chemotherapy. Dr. Tamayo further explained that patients with
osteosarcoma have poor defense mechanism due to the cancer cells in the blood stream.
In the case of Angelica, he had previously explained to her parents that after the surgical
procedure, chemotherapy is imperative so that metastasis of these cancer cells will
hopefully be addressed. He referred the patient to petitioner because he felt that
petitioner is a competent oncologist. Considering that this type of cancer is very
aggressive and will metastasize early, it will cause the demise of the patient should there
be no early intervention (in this case, the patient developed sepsis which caused her
death). Cancer cells in the blood cannot be seen by the naked eye nor detected through
bone scan. On cross-examination, Dr. Tamayo stated that of the more than 50 child
patients who had osteogenic sarcoma he had handled, he thought that probably all of
them died within six months from amputation because he did not see them anymore after
follow-up; it is either they died or had seen another doctor.[46]

In dismissing the complaint, the trial court held that petitioner was not liable for
damages as she observed the best known procedures and employed her highest skill and
knowledge in the administration of chemotherapy drugs on Angelica but despite all
efforts said patient died. It cited the testimony of Dr. Tamayo who testified that he
considered petitioner one of the most proficient in the treatment of cancer and that the
patient in this case was afflicted with a very aggressive type of cancer necessitating
chemotherapy as adjuvant treatment. Using the standard of negligence laid down in
Picart v. Smith,[47] the trial court declared that petitioner has taken the necessary
precaution against the adverse effect of chemotherapy on the patient, adding that a
wrong decision is not by itself negligence. Respondents were ordered to pay their unpaid
hospital bill in the amount of P139,064.43.[48]

Respondents appealed to the CA which, while concurring with the trial courts finding
that there was no negligence committed by the petitioner in the administration of
chemotherapy treatment to Angelica, found that petitioner as her attending physician
failed to fully explain to the respondents all the known side effects of chemotherapy. The
appellate court stressed that since the respondents have been told of only three side
effects of chemotherapy, they readily consented thereto. Had petitioner made known to
respondents those other side effects which gravely affected their child -- such as carpo-
pedal spasm, sepsis, decrease in the blood platelet count, bleeding, infections and
eventual death -- respondents could have decided differently or adopted a different
course of action which could have delayed or prevented the early death of their child.

The CA thus declared:

Plaintiffs-appellants child was suffering from a malignant disease. The attending physician
recommended that she undergo chemotherapy treatment after surgery in order to increase her chances
of survival. Appellants consented to the chemotherapy treatment because they believed in Dr. Rubi Lis
representation that the deceased would have a strong chance of survival after chemotherapy and also
because of the representation of appellee Dr. Rubi Li that there were only three possible side-effects of
the treatment. However, all sorts of painful side-effects resulted from the treatment including the
premature death of Angelica. The appellants were clearly and totally unaware of these other side-
effects which manifested only during the chemotherapy treatment. This was shown by the fact
that every time a problem would take place regarding Angelicas condition (like an unexpected
side-effect manifesting itself), they would immediately seek explanation from Dr. Rubi Li. Surely,
those unexpected side-effects culminating in the loss of a love[d] one caused the appellants so much
trouble, pain and suffering.

On this point therefore, [w]e find defendant-appellee Dr. Rubi Li negligent which would entitle
plaintiffs-appellants to their claim for damages.

xxxx

WHEREFORE, the instant appeal is hereby GRANTED. Accordingly, the assailed decision is hereby
modified to the extent that defendant-appellee Dr. Rubi Li is ordered to pay the plaintiffs-appellants the
following amounts:
1. Actual damages of P139,064.43, plus P9,828.00 for funeral expenses;

2. Moral damages of P200,000.00;

3. Exemplary damages of P50,000.00;

4. Attorneys fee of P30,000.00.

SO ORDERED.[49] (Emphasis supplied.)

Petitioner filed a motion for partial reconsideration which the appellate court denied.

Hence, this petition.

Petitioner assails the CA in finding her guilty of negligence in not explaining to the
respondents all the possible side effects of the chemotherapy on their child, and in
holding her liable for actual, moral and exemplary damages and attorneys fees.
Petitioner emphasized that she was not negligent in the pre-chemotherapy procedures
and in the administration of chemotherapy treatment to Angelica.

On her supposed non-disclosure of all possible side effects of chemotherapy, including

death, petitioner argues that it was foolhardy to imagine her to be all-
knowing/omnipotent. While the theoretical side effects of chemotherapy were explained
by her to the respondents, as these should be known to a competent doctor, petitioner
cannot possibly predict how a particular patients genetic make-up, state of mind, general
health and body constitution would respond to the treatment. These are obviously
dependent on too many known, unknown and immeasurable variables, thus requiring
that Angelica be, as she was, constantly and closely monitored during the treatment.
Petitioner asserts that she did everything within her professional competence to attend to
the medical needs of Angelica.

Citing numerous trainings, distinctions and achievements in her field and her current
position as co-director for clinical affairs of the Medical Oncology, Department of
Medicine of SLMC, petitioner contends that in the absence of any clear showing or
proof, she cannot be charged with negligence in not informing the respondents all the
side effects of chemotherapy or in the pre-treatment procedures done on Angelica.

As to the cause of death, petitioner insists that Angelica did not die of platelet depletion
but of sepsis which is a complication of the cancer itself. Sepsis itself leads to bleeding
and death. She explains that the response rate to chemotherapy of patients with
osteosarcoma is high, so much so that survival rate is favorable to the patient. Petitioner
then points to some probable consequences if Angelica had not undergone
chemotherapy. Thus, without chemotherapy, other medicines and supportive treatment,
the patient might have died the next day because of massive infection, or the cancer cells
might have spread to the brain and brought the patient into a coma, or into the lungs that
the patient could have been hooked to a respirator, or into her kidneys that she would
have to undergo dialysis. Indeed, respondents could have spent as much because of these
complications. The patient would have been deprived of the chance to survive the
ailment, of any hope for life and her quality of life surely compromised. Since she had
not been shown to be at fault, petitioner maintains that the CA erred in holding her liable
for the damages suffered by the respondents.[50]

The issue to be resolved is whether the petitioner can be held liable for failure to fully
disclose serious side effects to the parents of the child patient who died while
undergoing chemotherapy, despite the absence of finding that petitioner was negligent in
administering the said treatment.

The petition is meritorious.

The type of lawsuit which has been called medical malpractice or, more appropriately,
medical negligence, is that type of claim which a victim has available to him or her to
redress a wrong committed by a medical professional which has caused bodily harm. In
order to successfully pursue such a claim, a patient must prove that a health care
provider, in most cases a physician, either failed to do something which a reasonably
prudent health care provider would have done, or that he or she did something that a
reasonably prudent provider would not have done; and that that failure or action caused
injury to the patient.[51]

This Court has recognized that medical negligence cases are best proved by opinions of
expert witnesses belonging in the same general neighborhood and in the same general
line of practice as defendant physician or surgeon. The deference of courts to the expert
opinion of qualified physicians stems from the formers realization that the latter possess
unusual technical skills which laymen in most instances are incapable of intelligently
evaluating, hence the indispensability of expert testimonies.[52]

In this case, both the trial and appellate courts concurred in finding that the alleged
negligence of petitioner in the administration of chemotherapy drugs to respondents
child was not proven considering that Drs. Vergara and Balmaceda, not being
oncologists or cancer specialists, were not qualified to give expert opinion as to whether
petitioners lack of skill, knowledge and professional competence in failing to observe
the standard of care in her line of practice was the proximate cause of the patients death.
Furthermore, respondents case was not at all helped by the non-production of medical
records by the hospital (only the biopsy result and medical bills were submitted to the
court). Nevertheless, the CA found petitioner liable for her failure to inform the
respondents on all possible side effects of chemotherapy before securing their consent to
the said treatment.

The doctrine of informed consent within the context of physician-patient relationships

goes far back into English common law. As early as 1767, doctors were charged with the
tort of battery (i.e., an unauthorized physical contact with a patient) if they had not
gained the consent of their patients prior to performing a surgery or procedure. In the ,
the seminal case was Schoendorff v. Society of New York Hospital[53] which involved
unwanted treatment performed by a doctor. Justice Benjamin Cardozos oft-quoted
opinion upheld the basic right of a patient to give consent to any medical procedure or
treatment: Every human being of adult years and sound mind has a right to determine
what shall be done with his own body; and a surgeon who performs an operation without
his patients consent, commits an assault, for which he is liable in damages.[54] From a
purely ethical norm, informed consent evolved into a general principle of law that a
physician has a duty to disclose what a reasonably prudent physician in the medical
community in the exercise of reasonable care would disclose to his patient as to
whatever grave risks of injury might be incurred from a proposed course of treatment, so
that a patient, exercising ordinary care for his own welfare, and faced with a choice of
undergoing the proposed treatment, or alternative treatment, or none at all, may
intelligently exercise his judgment by reasonably balancing the probable risks against
the probable benefits.[55]

Subsequently, in Canterbury v. Spence[56] the court observed that the duty to disclose
should not be limited to medical usage as to arrogate the decision on revelation to the
physician alone. Thus, respect for the patients right of self-determination on particular
therapy demands a standard set by law for physicians rather than one which physicians
may or may not impose upon themselves.[57] The scope of disclosure is premised on the
fact that patients ordinarily are persons unlearned in the medical sciences. Proficiency in
diagnosis and therapy is not the full measure of a physicians responsibility. It is also his
duty to warn of the dangers lurking in the proposed treatment and to impart information
which the patient has every right to expect. Indeed, the patients reliance upon the
physician is a trust of the kind which traditionally has exacted obligations beyond those
associated with armslength transactions.[58] The physician is not expected to give the
patient a short medical education, the disclosure rule only requires of him a reasonable
explanation, which means generally informing the patient in nontechnical terms as to
what is at stake; the therapy alternatives open to him, the goals expectably to be
achieved, and the risks that may ensue from particular treatment or no treatment.[59] As
to the issue of demonstrating what risks are considered material necessitating disclosure,
it was held that experts are unnecessary to a showing of the materiality of a risk to a
patients decision on treatment, or to the reasonably, expectable effect of risk disclosure
on the decision. Such unrevealed risk that should have been made known must further
materialize, for otherwise the omission, however unpardonable, is without legal
consequence. And, as in malpractice actions generally, there must be a causal
relationship between the physicians failure to divulge and damage to the patient.[60]

Reiterating the foregoing considerations, Cobbs v. Grant[61] deemed it as integral part

of physicians overall obligation to patient, the duty of reasonable disclosure of available
choices with respect to proposed therapy and of dangers inherently and potentially
involved in each. However, the physician is not obliged to discuss relatively minor risks
inherent in common procedures when it is common knowledge that such risks inherent
in procedure of very low incidence. Cited as exceptions to the rule that the patient
should not be denied the opportunity to weigh the risks of surgery or treatment are
emergency cases where it is evident he cannot evaluate data, and where the patient is a
child or incompetent.[62] The court thus concluded that the patients right of self-
decision can only be effectively exercised if the patient possesses adequate information
to enable him in making an intelligent choice. The scope of the physicians
communications to the patient, then must be measured by the patients need, and that
need is whatever information is material to the decision. The test therefore for
determining whether a potential peril must be divulged is its materiality to the patients
decision.[63]

Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that for
liability of the physician for failure to inform patient, there must be causal relationship
between physicians failure to inform and the injury to patient and such connection arises
only if it is established that, had revelation been made, consent to treatment would not
have been given.

There are four essential elements a plaintiff must prove in a malpractice action based
upon the doctrine of informed consent: (1) the physician had a duty to disclose material
risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and
proximate result of the failure to disclose, the patient consented to treatment she
otherwise would not have consented to; and (4) plaintiff was injured by the proposed
treatment. The gravamen in an informed consent case requires the plaintiff to point to
significant undisclosed information relating to the treatment which would have altered
her decision to undergo it.[64]

Examining the evidence on record, we hold that there was adequate disclosure of
material risks inherent in the chemotherapy procedure performed with the consent of
Angelicas parents. Respondents could not have been unaware in the course of initial
treatment and amputation of Angelicas lower extremity, that her immune system was
already weak on account of the malignant tumor in her knee. When petitioner informed
the respondents beforehand of the side effects of chemotherapy which includes lowered
counts of white and red blood cells, decrease in blood platelets, possible kidney or heart
damage and skin darkening, there is reasonable expectation on the part of the doctor that
the respondents understood very well that the severity of these side effects will not be
the same for all patients undergoing the procedure. In other words, by the nature of the
disease itself, each patients reaction to the chemical agents even with pre-treatment
laboratory tests cannot be precisely determined by the physician. That death can
possibly result from complications of the treatment or the underlying cancer itself,
immediately or sometime after the administration of chemotherapy drugs, is a risk that
cannot be ruled out, as with most other major medical procedures, but such conclusion
can be reasonably drawn from the general side effects of chemotherapy already
disclosed.

As a physician, petitioner can reasonably expect the respondents to have considered the
variables in the recommended treatment for their daughter afflicted with a life-
threatening illness. On the other hand, it is difficult to give credence to respondents
claim that petitioner told them of 95% chance of recovery for their daughter, as it was
unlikely for doctors like petitioner who were dealing with grave conditions such as
cancer to have falsely assured patients of chemotherapys success rate. Besides, informed
consent laws in other countries generally require only a reasonable explanation of
potential harms, so specific disclosures such as statistical data, may not be legally
necessary.[65]

The element of ethical duty to disclose material risks in the proposed medical treatment
cannot thus be reduced to one simplistic formula applicable in all instances. Further, in a
medical malpractice action based on lack of informed consent, the plaintiff must prove
both the duty and the breach of that duty through expert testimony.[66] Such expert
testimony must show the customary standard of care of physicians in the same practice
as that of the defendant doctor.[67]

In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medical
Specialist of the DOHs Operational and Management Services charged with receiving
complaints against hospitals, does not qualify as expert testimony to establish the
standard of care in obtaining consent for chemotherapy treatment. In the absence of
expert testimony in this regard, the Court feels hesitant in defining the scope of
mandatory disclosure in cases of malpractice based on lack of informed consent, much
less set a standard of disclosure that, even in foreign jurisdictions, has been noted to be
an evolving one.

As society has grappled with the juxtaposition between personal autonomy and the medical profession's
intrinsic impetus to cure, the law defining adequate disclosure has undergone a dynamic evolution. A
standard once guided solely by the ruminations of physicians is now dependent on what a reasonable
person in the patients position regards as significant. This change in perspective is especially important
as medical breakthroughs move practitioners to the cutting edge of technology, ever encountering new
and heretofore unimagined treatments for currently incurable diseases or ailments. An adaptable
standard is needed to account for this constant progression. Reasonableness analyses permeate our legal
system for the very reason that they are determined by social norms, expanding and contracting with
the ebb and flow of societal evolution.
As we progress toward the twenty-first century, we now realize that the legal standard of disclosure is
not subject to construction as a categorical imperative. Whatever formulae or processes we adopt
are only useful as a foundational starting point; the particular quality or quantity of disclosure will
remain inextricably bound by the facts of each case. Nevertheless, juries that ultimately determine
whether a physician properly informed a patient are inevitably guided by what they perceive as the
common expectation of the medical consumera reasonable person in the patients position when
deciding to accept or reject a recommended medical procedure.[68] (Emphasis supplied.)

WHEREFORE, the petition for review on certiorari is GRANTED. The Decision

dated and the Resolution dated of the Court of Appeals in CA-G.R. CV No. 58013 are
SET ASIDE.
The Decision dated of the , Branch 8, in Civil Case No. 8904 is REINSTATED and
UPHELD.

No costs.

SO ORDERED.

Li vs Spouses Soliman
GR No. 165279 June 7, 2011
Facts: On July 7, 1993, respondents 11 year old daughter, Angelica Soliman underwent a biopsy of the
mass located in her lower extremity at the St. Lukes Medical Center (SLMC). Results showed that
Angelica was suffering from osteosaucoma, ostiobiostic type, a high-grade (highly malignant) cancer
of the bone which usually affects teenage children. Following this diagnosis, Angelica’s right leg was
amputated by Dr. Tamayo in order to remove the tumor. As a adjuvant treatment to eliminate any
remaining cancer cells, and hence minimizing the chances of recurrence and prevent the decease from
spreading to other parts of the patient’s body, chemotherapy was suggested by Dr. Tamayo and referred
Angelica to another doctor at SLMC, herein petitioner Dr. Rubi Li, a medical oncologist.
On July 23, 1993, petitioner saw the respondents at the hospital after Angelica’s surgery and discussed
with them Angelica’s condition. Petitioner told respondents that Angelica should be given 2-3 weeks to
recover from the operation before starting the chemotherapy. Respondents were apprehensive due to
financial constraints as Reynaldo earns only from P70,000-150,000 a year from his jewelry and
watching repair business. Petitioner, however, assured them not to worry about her professional fee and
told them to just save up for medicines to be used.
As the chemotherapy session started, day by day, Angelica experience worsening condition and other
physical effect on the body such as discoloration, nausea, and vomiting.
Petitioner claimed, that she explained to respondents that even when a tumor is removed, there are still
small lesions undetectable to the naked eye and that adjuvant chemotherapy is needed to clean out the
small lesions in order to lessen the chance of cancer to recur. She did not give the respondents any
assurance that chemotherapy will cure Angelica’s cancer. During these consultations with respondents,
she explained the following side effects of chemotherapy treatment to respondents: 1.) Falling hair; 2.)
nausea and vomiting; 3.) loss of appetite; 4.) low count of WBC, RBC, and platelets; 5.) possible
sterility due to the effects on Angelica’s ovary; 6.) Damage to kidney and heart; 7.) darkening of the
skin especially when exposed to sunlight. She actually talked to the respondents four times, once at the
hospital after the surgery, twice at her clinic and fourth when Angelica’s mother called her through long
distance. This was disputed by respondents who countered that petitioner gave them assurance that
there is 95% chance of healing for Angelica if she undergoes chemotherapy and that the only side
effects were nausea, vomiting and hair loss. Those were the only side effects of chemotherapy
mentioned by petitioner.
Issue: Whether or not petitioner committed medical malpractice.
Held: No. The type of lawsuit which has been called medical malpractice or more appropriately,
medical negligence, is that type of claim which a victim has available to him or her to redress a wrong
committed by a medical professional which has caused bodily harm. In order to successfully pursue
such claim, a patient must prove that a health care provider in most cases a physician, either failed to
do something which a reasonably prudent health care provider would have done or that he or she did
something that a reasonably health care provider would not have done; and that failure or action caused
injury to the patient.
Medical negligence cases are best proved by opinions of expert witnesses belonging in the same
general neighborhood and in the same general line of practice as defendant physician or surgeon. The
deference of courts to the expert opinion of qualified physicians stems from the former’s realization
that the latter possess unusual technical skills which layman in most instances are incapable of
intelligently evaluating, hence the indispensability of expert testimonies.
The doctrine of informed consent within the context of physician-patient relationships goes as far back
into english common law. As early as 1767, doctors were charged with the tort of battery if they have
not gained the consent of their patients prior to performing a surgery or procedure. In the United States,
the seminal case was Schoendorff vs Society of New York Hospital which involved unwanted
treatment performed by a doctor. Justice Bejamin Cardozo oft-quoted opinion upheld the basic right of
a patient to give consent to any medical procedure or treatment; every human being of adult year and
sound mind has a right to determine what shall be done with his own body; and a surgeon who
performs an operation without his patient’s consent commits an assault, for which he is liable in
damages. From a purely ethical norm, informed consent evolved into a general principle of law that a
physician has a duty to disclose what a reasonably prudent physician in the medical community in the
exercise of reasonable care would disclose to his patient as to whatever grave risk of injury might be
incurred from a proposed course of treatment, so that a patient, exercising ordinary care for her own
welfare and faced with a choice of undergoing the proposed treatment, as alternative treatment, or none
at all, may intelligently exercise his judgement by reasonably balancing the probable risk against the
probable benefits.
There are four essential elements a plaintiff must proved in a malpractice action based upon the
doctrine of informed consent: 1.) the physician had a duty to disclose material risks; 2.) he failed to
disclose or inadequately disclosed those risks; 3.) as a direct and proximate result of the failure to
disclose, the patient consented to treatment she otherwise would not have consented to; and 4.) plaintiff
was injured by the proposed treatment. The gravamen in an informed consent requires the plaintiff to
point to significant undisclosed information relating to the treatment which could have altered her
decision to undergo it.
Examining the evidence, we hold that there was adequate disclosure of material risks inherent in
chemotherapy procedure performed with the consent of Angelica’s parents. Respondents could not
have been unaware in the course of initial treatment and amputation of Angelica’s lower extremity that
her immune system was already weak on account of the malignant tumor in her knee. When petitioner
informed the respondents beforehand of the side effects of chemotherapy which includes lowered
counts of white and red blood cells, decrease in blood platelets, possible kidney or heart damage and
skin darkening, there is reasonable expectation on the part of the doctor that the respondents understood
very well that the severity of these side effects will not be the same for all patients undergoing the
procedure. In other words, by the nature of the disease itself, each patients reaction to the chemical
agents even with pre-treatment laboratory tests cannot be precisely determined by the physician. That
death can possibly result from complications of the treatment or the underlying cancer itself,
immediately or sometime after the administration of chemotherapy drugs, is a risk that cannot be ruled
out, as with most other major medical procedures, but such conclusion can be reasonably drawn from
the general side effects of chemotherapy already disclosed.

G.R. No. 210445, December 07, 2015

NILO B. ROSIT, Petitioner, v. DAVAO DOCTORS HOSPITAL AND DR. ROLANDO G.
GESTUVO, Respondent.
DECISION
VELASCO JR., J.:
The Case

This is a petition filed under Rule 45 of the Rules of Court assailing the Decision and Resolution dated
January 22, 20131 and November 7, 2013,2 respectively, of the Court of Appeals, Cagayan De Oro City
(CA), in CA-G.R. CV No. 00911-MIN. The CA Decision reversed the Decision dated September 14,
20043 of the Regional Trial Court, Branch 33 in Davao City-(RTC) in Civil Case No. 27,354-99, a suit
for damages thereat which Nilo B. Rosit (Rosit) commenced against Dr. Rolando Gestuvo (Dr.
Gestuvo).
Factual Antecedents

On January 15, 1999, Rosit figured in a motorcycle accident. The X-ray soon taken the next day at the
Davao Doctors Hospital (DDH) showed that he fractured his jaw. Rosit was then referred to Dr.
Gestuvo, a specialist in mandibular injuries, 4 who, on January 19, 1999, operated on Rosit.

During the operation, Dr. Gestuvo used a metal plate fastened to the jaw with metal screws to
immobilize the mandible. As the operation required the smallest screws available, Dr. Gestuvo cut the
screws on hand to make them smaller. Dr. Gestuvo knew that there were smaller titanium screws
available in Manila, but did not so inform Rosit supposing that the latter would not be able to afford the
same.5

Following the procedure, Rosit could not properly open and close his mouth and was in pain. X-rays
done on Rosit two (2) days after the operation showed that the fracture in his jaw was aligned but the
screws used on him touched his molar. Given the X-ray results, Dr. Gestuvo referred Rosit to a dentist.
The dentist who checked Rosit, Dr. Pangan, opined that another operation is necessary and that it is to
be performed in Cebu.6

Alleging that the dentist told him that the operation conducted on his mandible was improperly done,
Rosit went back to Dr. Gestuvo to demand a loan to defray the cost of the additional operation as well
as the expenses of the trip to Cebu. Dr. Gestuvo gave Rosit P4,500.

Rosit went to Cebu on February 19, 1999, still suffering from pain and could hardly open his mouth.

In Cebu, Dr. Pangan removed the plate and screws thus installed by Dr. Gestuvo and replaced them
with smaller titanium plate and screws. Dr. Pangan also extracted Rosit's molar that was hit with a
screw and some bone fragments. Three days after the operation, Rosit was able to eat and speak well
and could open and close his mouth normally.7
On his return to Davao, Rosit demanded that Dr. Gestuvo reimburse him for the cost of the operation
and the expenses he incurred in Cebu amounting to P140,000, as well as for the P50,000 that Rosit
would have to spend for the removal of the plate and screws that Dr. Pangan installed. Dr. Gestuvo
refused to pay.8

Thus, Rosit filed a civil case for damages and attorney's fees with the RTC against Dr. Gestuvo and
DDH, the suit docketed as Civil Case No. 27,354-99.
The Ruling of the Regional Trial Court

The RTC freed DDH from liability on the ground that it exercised the proper diligence in the selection
and supervision of Dr. Gestuvo, but adjudged Dr. Gestuvo negligent and ruled, thus:
FOR ALL THE FOREGOING, finding the plaintiff Nilo B. Rosit to have preponderantly
established his cause of action in the complaint against defendant Dr. Rolando G. Gestuvo
only, judgment is hereby rendered for the plaintiff and against said defendant, ordering the
defendant DR. ROLANDO G. GESTUVO to pay unto plaintiff NILO B. ROSIT the
following: chanRoblesvirtualLawlibrary

a) the sum of ONE HUNDRED FORTY THOUSAND ONE HUNDRED NINETY

NINE PESOS and 13/100 (P140,199.13) representing reimbursement of actual
expenses incurred by plaintiff in the operation and re-operation of his mandible;

b) the sum of TWENTY NINE THOUSAND AND SIXTY EIGHT PESOS

(P29,068.00) representing reimbursement of the filing fees and appearance fees;

c) the sum of ONE HUNDRED FIFTY THOUSAND PESOS (P150,000.00) as and

for attorney's fees;

d) the amount of FIFTY THOUSAND PESOS (P50,000.00) as moral damages;

e) the amount of TEN THOUSAND PESOS (P10,000.00) as exemplary damages; and

f) the costs of the suit.

For lack of merit, the complaint against defendant DAVAO DOCTORS HOSPITAL and the
defendants' counterclaims are hereby ordered DISMISSED.

Cost against Dr. Rolando G. Gestuvo.

SO ORDERED.

In so ruling, the trial court applied the res ipsa loquitur principle holding that "the need for expert,
medical testimony may be dispensed with because the injury itself provides the proof of negligence."

Therefrom, both parties appealed to the CA.

The Ruling of the Court of Appeals
In its January 22, 2013 Decision, the CA modified the appealed judgment by deleting the awards made
by the trial court, disposing as follows:
WHEREFORE, the appeal filed by Gestuvo is GRANTED. The Decision dated September
14, 2004 of the Regional Trial Court, Branch 33, Davao City, rendered in Civil Case No.
27,354-99 is hereby MODIFIED. The monetary awards adjudged in favor of Nilo B. Rosit
are hereby DELETED for lack of basis.

SO ORDERED.

Unlike the RTC, the CA ruled that the res ipsa loquitur principle is not applicable and that the
testimony of an expert witness is necessary for a finding of negligence. The appellate court also gave
credence to Dr. Pangan's letter stating the opinion that Dr. Gestuvo did not commit gross negligence in
his emergency management of Rosit's fractured mandible.

Rosit's motion for reconsideration was denied in the CA's November 7, 2013 Resolution.

Hence, the instant appeal.

The Issue

The ultimate issue for our resolution is whether the appellate court correctly absolved Dr. Gestuvo from
liability.
The Court's Ruling

The petition is impressed with merit.

In Flores v. Pineda,9 the Court explained the concept of a medical negligence case and the elements
required for its prosecution, viz: chanRoblesvirtualLawlibrary

A medical negligence case is a type of claim to redress a wrong committed by a medical professional,
that has caused bodily harm to or the death of a patient. There are four elements involved in a
medical negligence case, namely: duty, breach, injury, and proximate causation.

Duty refers to the standard of behavior which imposes restrictions on one's conduct. The standard in
turn refers to the amount of competence associated with the proper discharge of the profession. A
physician is expected to use at least the same level of care that any other reasonably competent doctor
would use under the same circumstances. Breach of duty occurs when the physician fails to comply
with these professional standards. If injury results to the patient as a result of this breach, the physician
is answerable for negligence. (Emphasis supplied)

An expert witness is not necessary as the res ipsa loquitur doctrine is applicable

To establish medical negligence, this Court has held that an expert testimony is generally required to
define the standard of behavior by which the court may determine whether the physician has properly
performed the requisite duty toward the patient. This is so considering that the requisite degree of skill
and care in the treatment of a patient is usually a matter of expert opinion. 10
Solidum v. People of the Philippines 11 provides an exception. There, the Court explained that where the
application of the principle of res ipsa loquitur is warranted, an expert testimony may be dispensed
with in medical negligence cases:
Although generally, expert medical testimony is relied upon in malpractice suits to
prove that a physician has done a negligent act or that he has deviated from the
standard medical procedure, when the doctrine of res ipsa loquitur is availed by the
plaintiff, the need for expert medical testimony is dispensed with because the injury
itself provides the proof of negligence. The reason is that the general rule on the necessity
of expert testimony applies only to such matters clearly within the domain of medical
science, and not to matters that are within the common knowledge of mankind which may
be testified to by anyone familiar with the facts. x x x

Thus, courts of other jurisdictions have applied the doctrine in the following situations:
leaving of a foreign object in the body of the patient after an operation, injuries sustained
on a healthy part of the body which was not under, or in the area, of treatment, removal of
the wrong part of the body when another part was intended, knocking out a tooth while a
patient's jaw was under anesthetic for the removal of his tonsils, and loss of an eye while
the patient plaintiff was under the influence of anesthetic, during or following an operation
for appendicitis, among others.

We have further held that resort to the doctrine of res ipsa loquitur as an exception to the requirement
of an expert testimony in medical negligence cases may be availed of if the following essential
requisites are satisfied: (1) the accident was of a kind that does not ordinarily occur unless someone is
negligent; (2) the instrumentality or agency that caused the injury was under the exclusive control of
the person charged; and (3) the injury suffered must not have been due to any voluntary action or
contribution of the person injured.12

In its assailed Decision, the CA refused to acknowledge the application of the res ipsa loquitur doctrine
on the ground that the foregoing elements are absent. In particular, the appellate court is of the position
that post-operative pain is not unusual after surgery and that there is no proof that the molar Dr. Pangan
removed is the same molar that was hit by the screw installed by Dr. Gestuvo in Rosit's mandible.
Further, a second operation was conducted within the 5-week usual healing period of the mandibular
fracture so that the second element cannot be considered present. Lastly, the CA pointed out that the X-
ray examination conducted on Rosit prior to his first surgery suggests that he had "chronic
inflammatory lung disease compatible," implying that the injury may have been due to Rosit's peculiar
condition, thus effectively negating the presence of the third element. 13

After careful consideration, this Court cannot accede to the CA's findings as it is at once apparent from
the records that the essential requisites for the application of the doctrine of res ipsa loquitur are
present.

The first element was sufficiently established when Rosit proved that one of the screws installed by Dr.
Gestuvo struck his molar. It was for this issue that Dr. Gestuvo himself referred Rosit to Dr. Pangan. In
fact, the affidavit of Dr. Pangan presented by Dr. Gestuvo himself before the trial court narrated that the
same molar struck with the screw installed by Dr. Gestuvo was examined and eventually operated on
by Dr. Pangan. Dr. Gestuvo cannot now go back and say that Dr. Pangan treated a molar different from
that which was affected by the first operation.
Clearly, had Dr. Gestuvo used the proper size and length of screws and placed the same in the proper
locations, these would not have struck Rosit's teeth causing him pain and requiring him to undergo a
corrective surgery.

Dr. Gestuvo knew that the screws he used on Rosit were too large as, in fact, he cut the same with a
saw.14 He also stated during trial that common sense dictated that the smallest screws available should
be used. More importantly, he also knew that these screws were available locally at the time of the
operation.15 Yet, he did not avail of such items and went ahead with the larger screws and merely
sawed them off. Even assuming that the screws were already at the proper length after Dr. Gestuvo cut
the same, it is apparent that he negligently placed one of the screws in the wrong area thereby striking
one of Rosit's teeth.

In any event, whether the screw hit Rosit's molar because it was too long or improperly placed, both
facts are the product of Dr. Gestuvo's negligence. An average man of common intelligence would know
that striking a tooth with any foreign object much less a screw would cause severe pain. Thus, the first
essential requisite is present in this case.

Anent the second element for the res ipsa loquitur doctrine application, it is sufficient that the operation
which resulted in the screw hitting Rosit's molar was, indeed, performed by Dr. Gestuvo. No other
doctor caused such fact.

The CA finds that Rosit is guilty of contributory negligence in having Dr. Pangan operate on him
during the healing period of his fractured mandible. What the CA overlooked is that it was Dr. Gestuvo
himself who referred Rosit to Dr. Pangan. Nevertheless, Dr. Pangan's participation could not have
contributed to the reality that the screw that Dr. Gestuvo installed hit Rosit's molar.

Lastly, the third element that the injury suffered must not have been due to any voluntary action or
contribution of the person injured was satisfied in this case. It was not shown that Rosit's lung disease
could have contributed to the pain. What is clear is that he suffered because one of the screws that Dr.
Gestuvo installed hit Rosit's molar.

Clearly then, the res ipsa loquitur doctrine finds application in the instant case and no expert
testimony is required to establish the negligence of defendant Dr. Gestuvo.

Petitioner was deprived of the opportunity to make an "informed consent"

What is more damning for Dr. Gestuvo is his failure to inform Rosit that such smaller screws were
available in Manila, albeit at a higher price.16 As testified to by Dr. Gestuvo himself:
Court This titanium materials according to you were already available in the
Alright. Philippines since the time of Rosit's accident?

Witness Yes, your Honor.

xxxx
 Court Did you inform Rosit about the existence of titanium screws and plates
which according to you is the screws and plates of choice?

Witness No, your Honor.

xxxx

Witness The reason I did not inform him anymore Judge because what I thought he
was already hard up with the down payment. And if I will further introduce
him this screws, the more he will not be able to afford the operation.

xxxx

Court This titanium screws and plates were available then it is up to Rosit to decide
whether to use it or not because after all the material you are using is paid by
the patient himscll, is it not?

Witness Yes, that is true.

Li v. Soliman17 made the following disquisition on the relevant Doctrine of Informed Consent in
relation to medical negligence cases, to wit:
The doctrine of informed consent within the context of physician-patient relationships
goes far back into English common law. x x x From a purely ethical norm, informed
consent evolved into a general principle of law that a physician has a duty to disclose
what a reasonably prudent physician in the medical community in the exercise of
reasonable care would disclose to his patient as to whatever grave risks of injury
might be incurred from a proposed course of treatment, so that a patient, exercising
ordinary care for his own welfare, and faced with a choice of undergoing the proposed
treatment, or alternative treatment, or none at all, may intelligently exercise his
judgment by reasonably balancing the probable risks against the probable benefits.

x x x x

There are four essential elements a plaintiff must prove in a malpractice action based
upon the doctrine of informed consent: "(1) the physician had a duty to disclose
material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a
direct and proximate result of the failure to disclose, the patient consented to
treatment she otherwise would not have consented to; and (4) plaintiff was injured by
the proposed treatment." The gravamen in an informed consent case requires the plaintiff
to "point to significant undisclosed information relating to the treatment which would have
altered her decision to undergo it." (Emphasis supplied)

The four adverted essential elements above are present here.

First, Dr. Gestuvo clearly had the duty of disclosing to Rosit the risks of using the larger screws for the
operation. This was his obligation as the physician undertaking the operation.
Second, Dr. Gestuvo failed to disclose these risks to Rosit, deciding by himself that Rosit could not
afford to get the more expensive titanium screws.

Third, had Rosit been informed that there was a risk that the larger screws are not appropriate for the
operation and that an additional operation replacing the screws might be required to replace the same,
as what happened in this case, Rosit would not have agreed to the operation. It bears pointing out that
Rosit was, in fact, able to afford the use of the smaller titanium screws that were later used by Dr.
Pangan to replace the screws that were used by Dr. Gestuvo.

Fourth, as a result of using the larger screws, Rosit experienced pain and could not heal properly
because one of the screws hit his molar. This was evident from the fact that just three (3) days after Dr.
Pangan repeated the operation conducted by Dr. Gestuvo, Rosit was pain-free and could already speak.
This is compared to the one (1) month that Rosit suffered pain and could not use his mouth after the
operation conducted by Dr. Gestuvo until the operation of Dr. Pangan.

Without a doubt, Dr. Gestuvo is guilty of withholding material information which would have been
vital in the decision of Rosit in going through with the operation with the materials at hand. Thus, Dr.
Gestuvo is also guilty of negligence on this ground.

Dr. Pangan's Affidavit is not admissible

The appellate court's Decision absolving Dr. Gestuvo of negligence was also anchored on a letter
signed by Dr. Pangan who stated the opinion that Dr. Gestuvo did not commit gross negligence in his
emergency management of Mr. Rosit's fractured mandible.18 Clearly, the appellate court overlooked the
elementary principle against hearsay evidence.

In Dantis v. Maghinang, Jr.,19 the Court reiterated the oft-repeated rule that "an affidavit is merely
hearsay evidence where its affiant/maker did not take the witness stand." Here, Dr. Pangan never took
the witness stand to affirm the contents of his affidavit. Thus, the affidavit is inadmissible and cannot
be given any weight. The CA, therefore, erred when it considered the affidavit of Dr. Pangan, mpreso
for considering the same as expert testimony.

Moreover, even if such affidavit is considered as admissible and the testimony of an expert witness, the
Court is not bound by such testimony. As ruled in Ilao-Quianay v. Mapile:20
Indeed, courts are not bound by expert testimonies. They may place whatever weight they
choose upon such testimonies in accordance with the facts of the case. The relative weight
and sufficiency of expert testimony is peculiarly within the province of the trial court to
decide, considering the ability and character of the witness, his actions upon the witness
stand, the weight and process of the reasoning by which he has supported his opinion, his
possible bias in favor of the side for whom he testifies, and any other matters which serve
to illuminate his statements. The opinion of an expert should be considered by the court in
view of all the facts and circumstances of the case. The problem of the evaluation of expert
testimony is left to the discretion of the trial court whose ruling thereupon is not revicwable
in the absence of an abuse of that discretion.

Thus, the belief of Dr. Pangan whether Dr. Gestuvo is guilty of negligence or not will not bind the
Court. The Court must weigh and examine such testimony and decide for itself the merits thereof.
As discussed above, Dr. Gestuvo's negligence is clearly demonstrable by the doctrines of res ipsa
loquitur and informed consent.

Damages

For the foregoing, the trial court properly awarded Rosit actual damages after he was able to prove the
actual expenses that he incurred due to the negligence of Dr. Gestuvo. In Mendoza v. Spouses Gomez,21
the Court explained that a claimant is entitled to actual damages when the damage he sustained is the
natural and probable consequences of the negligent act and he adequately proved the amount of such
damage.

Rosit is also entitled to moral damages as provided under Article 2217 of the Civil Code, 22 given the
unnecessary physical suffering he endured as a consequence of defendant's negligence.

To recall, from the time he was negligently operated upon by Dr. Gestuvo until three (3) days from the
corrective surgery performed by Dr. Pangan, or for a period of one (1) month, Rosit suffered pain and
could not properly use his jaw to speak or eat.

The trial court also properly awarded attorney's fees and costs of suit under Article 2208 of the Civil
Code,23 since Rosit was compelled to litigate due to Dr. Gestuvo's refusal to pay for Rosit's damages.

As to the award of exemplary damages, the same too has to be affirmed. In Mendoza,24 the Court
enumerated the requisites for the award of exemplary damages:
Our jurisprudence sets certain conditions when exemplary damages may be awarded: First,
they may be imposed by way of example or correction only in addition, among others, to
compensatory damages, and cannot be recovered as a matter of right, their determination
depending upon the amount of compensatory damages that may be awarded to the claimant.
Second, the claimant must first establish his right to moral, temperate, liquidated or
compensatory damages. Third, the wrongful act must be accompanied by bad faith, and the
award would be allowed only if the guilty party acted in a wanton, fraudulent, reckless,
oppressive or malevolent manner.

The three (3) requisites are met. Dr. Gestuvo's actions are clearly negligent. Likewise, Dr. Gestuvo
acted in bad faith or in a wanton, fraudulent, reckless, oppressive manner when he was in breach of the
doctrine of informed consent. Dr. Gestuvo had the duty to fully explain to Rosit the risks of using large
screws for the operation. More importantly, he concealed the correct medical procedure of using the
smaller titanium screws mainly because of his erroneous belief that Rosit cannot afford to buy the
expensive titanium screws. Such concealment is clearly a valid basis for an award of exemplary
damages.

WHEREFORE, the instant petition is GRANTED. The CA Decision dated January 22, 2013 and
Resolution dated November 7, 2013 in CA-G.R. CV No. 00911-MIN are hereby REVERSED and
SET ASIDE. Further, the Decision dated September 14, 2004 of the Regional Trial Court, Branch 33 in
Davao City in Civil Case No. 27,345-99 is hereby REINSTATED and AFFIRMED.

SO ORDERED.
SECOND DIVISION

SPOUSES FREDELICTO G.R. No. 158996

FLORES (deceased) and Present:
FELICISIMA FLORES, QUISUMBING, J., Chairperson,
Petitioners, CARPIO MORALES,
- versus - TINGA,
SPOUSES DOMINADOR VELASCO, JR., and
PINEDA and VIRGINIA BRION, JJ.
SACLOLO, and FLORENCIO, Promulgated:
CANDIDA, MARTA, November 14, 2008
GODOFREDO, BALTAZAR and
LUCENA, all surnamed
PINEDA, as heirs of the deceased
TERESITA S. PINEDA, and
UNITED DOCTORS MEDICAL
CENTER, INC.,
Respondents.

x -------------------------------------------------------------------------------------------x

DECISION

BRION, J.:

This petition involves a medical negligence case that was elevated to this Court through
an appeal by certiorari under Rule 45 of the Rules of Court. The petition assails the
Decision[1] of the Court of Appeals (CA) in CA G.R. CV No. 63234, which affirmed
with modification the Decision[2] of the Regional Trial Court (RTC) of Nueva Ecija,
Branch 37 in Civil Case No. SD-1233. The dispositive portion of the assailed CA
decision states:
WHEREFORE, premises considered, the assailed Decision of the Regional Trial Court of Baloc, Sto.
Domingo, Nueva Ecija, Branch 37 is hereby AFFIRMED but with modifications as follows:
1) Ordering defendant-appellants Dr. and Dra. Fredelicto A. Flores and the United Doctors Medical
Center, Inc. to jointly and severally pay the plaintiff-appellees heirs of Teresita Pineda, namely, Spouses
Dominador Pineda and Virginia Saclolo and Florencio, Candida, Marta, Godofredo, Baltazar and
Lucena, all surnamed Pineda, the sum of P400,000.00 by way of moral damages;
2) Ordering the above-named defendant-appellants to jointly and severally pay the above-named
plaintiff-appellees the sum of P100,000.00 by way of exemplary damages;
3) Ordering the above-named defendant-appellants to jointly and severally pay
the above-named plaintiff-appellees the sum of P36,000.00 by way of actual and
compensatory damages; and
4) Deleting the award of attorneys fees and costs of suit.
SO ORDERED.
While this case essentially involves questions of facts, we opted for the requested review
in light of questions we have on the findings of negligence below, on the awarded
damages and costs, and on the importance of this type of ruling on medical practice.[3]
BACKGROUND FACTS
Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto. Domingo,
Nueva Ecija. She consulted on April 17, 1987 her townmate, Dr. Fredelicto Flores,
regarding her medical condition. She complained of general body weakness, loss of
appetite, frequent urination and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto
initially interviewed the patient and asked for the history of her monthly period to
analyze the probable cause of the vaginal bleeding. He advised her to return the
following week or to go to the United Doctors Medical Center (UDMC) in Quezon City
for a general check-up. As for her other symptoms, he suspected that Teresita might be
suffering from diabetes and told her to continue her medications.[4]
Teresita did not return the next week as advised. However, when her condition persisted,
she went to further consult Dr. Flores at his UDMC clinic on April 28, 1987, travelling
for at least two hours from Nueva Ecija to Quezon City with her sister, Lucena Pineda.
They arrived at UDMC at around 11:15 a.m.. Lucena later testified that her sister was
then so weak that she had to lie down on the couch of the clinic while they waited for
the doctor. When Dr. Fredelicto arrived, he did a routine check-up and ordered Teresitas
admission to the hospital. In the admission slip, he directed the hospital staff to prepare
the patient for an on call D&C[5] operation to be performed by his wife, Dr. Felicisima
Flores (Dr. Felicisima). Teresita was brought to her hospital room at around 12 noon; the
hospital staff forthwith took her blood and urine samples for the laboratory tests[6]
which Dr. Fredelicto ordered.
At 2:40 p.m. of that same day, Teresita was taken to the operating room. It was only then
that she met Dr. Felicisima, an obstetrician and gynecologist. The two doctors Dr.
Felicisima and Dr. Fredelicto, conferred on the patients medical condition, while the
resident physician and the medical intern gave Dr. Felicisima their own briefings. She
also interviewed and conducted an internal vaginal examination of the patient which
lasted for about 15 minutes. Dr. Felicisima thereafter called up the laboratory for the
results of the tests. At that time, only the results for the blood sugar (BS), uric acid
determination, cholesterol determination, and complete blood count (CBC) were
available. Teresitas BS count was 10.67mmol/l[7] and her CBC was 109g/l.[8]
Based on these preparations, Dr. Felicisima proceeded with the D&C operation with Dr.
Fredelicto administering the general anesthesia. The D&C operation lasted for about 10
to 15 minutes. By 3:40 p.m., Teresita was wheeled back to her room.
A day after the operation (or on April 29, 1987), Teresita was subjected to an ultrasound
examination as a confirmatory procedure. The results showed that she had an enlarged
uterus and myoma uteri.[9] Dr. Felicisima, however, advised Teresita that she could spend
her recovery period at home. Still feeling weak, Teresita opted for hospital confinement.
Teresitas complete laboratory examination results came only on that day (April 29,
1987). Teresitas urinalysis showed a three plus sign (+++) indicating that the sugar in
her urine was very high. She was then placed under the care of Dr. Amado Jorge, an
internist.
By April 30, 1987, Teresitas condition had worsened. She experienced difficulty in
breathing and was rushed to the intensive care unit. Further tests confirmed that she was
suffering from Diabetes Mellitus Type II.[10] Insulin was administered on the patient,
but the medication might have arrived too late. Due to complications induced by
diabetes, Teresita died in the morning of May 6, 1987.[11]
Believing that Teresitas death resulted from the negligent handling of her medical needs,
her family (respondents) instituted an action for damages against Dr. Fredelicto Flores
and Dr. Felicisima Flores (collectively referred to as the petitioner spouses) before the
RTC of Nueva Ecija.
The RTC ruled in favor of Teresitas family and awarded actual, moral, and exemplary
damages, plus attorneys fees and costs.[12] The CA affirmed the judgment, but modified
the amount of damages awarded and deleted the award for attorneys fees and costs of
suit.[13]
Through this petition for review on certiorari, the petitioner spouses Dr. Fredelicto (now
deceased) and Dr. Felicisima Flores allege that the RTC and CA committed a reversible
error in finding them liable through negligence for the death of Teresita Pineda.

ASSIGNMENT OF ERRORS
The petitioner spouses contend that they exercised due care and prudence in the
performance of their duties as medical professionals. They had attended to the patient to
the best of their abilities and undertook the management of her case based on her
complaint of an on-and-off vaginal bleeding. In addition, they claim that nothing on
record shows that the death of Teresita could have been averted had they employed
means other than what they had adopted in the ministration of the patient.
THE COURTS RULING
We do not find the petition meritorious.
The respondents claim for damages is predicated on their allegation that the decision of
the petitioner spouses to proceed with the D&C operation, notwithstanding Teresitas
condition and the laboratory test results, amounted to negligence. On the other hand, the
petitioner spouses contend that a D&C operation is the proper and accepted procedure to
address vaginal bleeding the medical problem presented to them. Given that the patient
died after the D&C, the core issue is whether the decision to proceed with the D&C
operation was an honest mistake of judgment or one amounting to negligence.
Elements of a Medical Negligence Case
A medical negligence case is a type of claim to redress a wrong committed by a medical
professional, that has caused bodily harm to or the death of a patient. There are four
elements involved in a medical negligence case, namely: duty, breach, injury, and
proximate causation.[14]
Duty refers to the standard of behavior which imposes restrictions on ones conduct.[15]
The standard in turn refers to the amount of competence associated with the proper
discharge of the profession. A physician is expected to use at least the same level of care
that any other reasonably competent doctor would use under the same circumstances.
Breach of duty occurs when the physician fails to comply with these professional
standards. If injury results to the patient as a result of this breach, the physician is
answerable for negligence.[16]
As in any civil action, the burden to prove the existence of the necessary elements rests
with the plaintiff.[17] To successfully pursue a claim, the plaintiff must prove by
preponderance of evidence that, one, the physician either failed to do something which a
reasonably prudent health care provider would have done, or that he did something that
a reasonably prudent provider would not have done; and two, the failure or action
caused injury to the patient.[18] Expert testimony is therefore essential since the factual
issue of whether a physician or surgeon has exercised the requisite degree of skill and
care in the treatment of his patient is generally a matter of expert opinion.[19]
Standard of Care and Breach of Duty
D&C is the classic gynecologic procedure for the evaluation and possible therapeutic
treatment for abnormal vaginal bleeding.[20] That this is the recognized procedure is
confirmed by Drs. Salvador Nieto (Dr. Nieto) and Joselito Mercado (Dr. Mercado), the
expert witnesses presented by the respondents:
DR. NIETO: [W]hat I know among obstetricians, if there is bleeding, they perform what we call D&C
for diagnostic purposes.
xxx xxx xxx
Q: So are you trying to tell the Court that D&C can be a diagnostic treatment?
A: Yes, sir. Any doctor knows this.[21]
Dr. Mercado, however, objected with respect to the time the D&C operation should have
been conducted in Teresitas case. He opined that given the blood sugar level of Teresita,
her diabetic condition should have been
addressed first:
Q: Why do you consider the time of performance of the D&C not
appropriate?
A: Because I have read the record and I have seen the urinalysis, [there
is] spillage in the urine, and blood sugar was 10.67
Q: What is the significance of the spillage in the urine?
A: It is a sign that the blood sugar is very high.
Q: Does it indicate sickness?
A: 80 to 95% it means diabetes mellitus. The blood sugar was 10.67.
xxx xxx xxx
COURT: In other words, the operation conducted on the patient, your
opinion, that it is inappropriate?
A: The timing of [when] the D&C [was] done, based on the record, in
my personal opinion, that D&C should be postponed a day or two.[22]
The petitioner spouses countered that, at the time of the operation, there was nothing to
indicate that Teresita was afflicted with diabetes: a blood sugar level of 10.67mmol/l
did not necessarily mean that she was a diabetic considering that this was random
blood sugar;[23] there were other factors that might have caused Teresitas blood sugar
to rise such as the taking of blood samples during lunchtime and while patient was
being given intra-venous dextrose.[24] Furthermore, they claim that their principal
concern was to determine the cause of and to stop the vaginal bleeding.
The petitioner spouses contentions, in our view, miss several points. First, as early as
April 17, 1987, Teresita was already suspected to be suffering from diabetes.[25] This
suspicion again arose right before the D&C operation on April 28, 1987 when the
laboratory result revealed Teresitas increased blood sugar level.[26] Unfortunately, the
petitioner spouses did not wait for the full medical laboratory results before proceeding
with the D&C, a fact that was never considered in the courts below. Second, the
petitioner spouses were duly advised that the patient was experiencing general body
weakness, loss of appetite, frequent urination, and thirst all of which are classic
symptoms of diabetes.[27] When a patient exhibits symptoms typical of a particular
disease, these symptoms should, at the very least, alert the physician of the possibility
that the patient may be afflicted with the suspected disease:
[Expert testimony for the plaintiff showed that] tests should have been ordered immediately on
admission to the hospital in view of the symptoms presented, and that failure to recognize the existence
of diabetes constitutes negligence.[28]
Third, the petitioner spouses cannot claim that their principal concern was the vaginal
bleeding and should not therefore be held accountable for complications coming from
other sources. This is a very narrow and self-serving view that even reflects on their
competence.
Taken together, we find that reasonable prudence would have shown that diabetes and its
complications were foreseeable harm that should have been taken into consideration by
the petitioner spouses. If a patient suffers from some disability that increases the
magnitude of risk to him, that disability must be taken into account so long as it is
or should have been known to the physician.[29] And when the patient is exposed to
an increased risk, it is incumbent upon the physician to take commensurate and adequate
precautions.
Taking into account Teresitas high blood sugar,[30] Dr. Mendoza opined that the
attending physician should have postponed the D&C operation in order to conduct a
confirmatory test to make a conclusive diagnosis of diabetes and to refer the case to an
internist or diabetologist. This was corroborated by Dr. Delfin Tan (Dr. Tan), an
obstetrician and gynecologist, who stated that the patients diabetes should have been
managed by an internist prior to, during, and after the operation.[31]
Apart from bleeding as a complication of pregnancy, vaginal bleeding is only rarely so
heavy and life-threatening that urgent first-aid measures are required.[32] Indeed, the
expert witnesses declared that a D&C operation on a hyperglycemic patient may be
justified only when it is an emergency case when there is profuse vaginal bleeding. In
this case, we choose not to rely on the assertions of the petitioner spouses that there was
profuse bleeding, not only because the statements were self-serving, but also because the
petitioner spouses were inconsistent in their testimonies. Dr. Fredelicto testified earlier
that on April 28, he personally saw the bleeding,[33] but later on said that he did not see it
and relied only on Teresitas statement that she was bleeding.[34] He went on to state that
he scheduled the D&C operation without conducting any physical examination on the
patient.
The likely story is that although Teresita experienced vaginal bleeding on April 28, it
was not sufficiently profuse to necessitate an immediate emergency D&C operation. Dr.
Tan[35] and Dr. Mendoza[36] both testified that the medical records of Teresita failed to
indicate that there was profuse vaginal bleeding. The claim that there was profuse
vaginal bleeding although this was not reflected in the medical records strikes us as odd
since the main complaint is vaginal bleeding. A medical record is the only document that
maintains a long-term transcription of patient care and as such, its maintenance is
considered a priority in hospital practice. Optimal record-keeping includes all patient
inter-actions. The records should always be clear, objective, and up-to-date.[37] Thus, a
medical record that does not indicate profuse medical bleeding speaks loudly and clearly
of what it does not contain.
That the D&C operation was conducted principally to diagnose the cause of the vaginal
bleeding further leads us to conclude that it was merely an elective procedure, not an
emergency case. In an elective procedure, the physician must conduct a thorough pre-
operative evaluation of the patient in order to adequately prepare her for the operation
and minimize possible risks and complications. The internist is responsible for
generating a comprehensive evaluation of all medical problems during the pre-operative
evaluation.[38]
The aim of pre-operative evaluation is not to screen broadly for undiagnosed disease, but rather to
identify and quantify comorbidity that may impact on the operative outcome. This evaluation is driven
by findings on history and physical examination suggestive of organ system dysfunctionThe goal is to
uncover problem areas that may require further investigation or be amenable to preoperative
optimization.
If the preoperative evaluation uncovers significant comorbidity or evidence of poor control of an
underlying disease process, consultation with an internist or medical specialist may be required to
facilitate the work-up and direct management. In this process, communication between the surgeons
and the consultants is essential to define realistic goals for this optimization process and to expedite
surgical management.[39] [Emphasis supplied.]
Significantly, the evidence strongly suggests that the pre-operative evaluation was less
than complete as the laboratory results were fully reported only on the day following the
D&C operation. Dr. Felicisima only secured a telephone report of the preliminary
laboratory result prior to the D&C. This preliminary report did not include the 3+ status
of sugar in the patients urine[40] a result highly confirmatory of diabetes.
Because the D&C was merely an elective procedure, the patients uncontrolled
hyperglycemia presented a far greater risk than her on-and-off vaginal bleeding. The
presence of hyperglycemia in a surgical patient is associated with poor clinical
outcomes, and aggressive glycemic control positively impacts on morbidity and
mortality.[41] Elective surgery in people with uncontrolled diabetes should preferably be
scheduled after acceptable glycemic control has been achieved.[42] According to Dr.
Mercado, this is done by administering insulin on the patient.[43]
The management approach in this kind of patients always includes insulin therapy in combination with
dextrose and potassium infusion. Insulin xxx promotes glucose uptake by the muscle and fat cells while
decreasing glucose production by the liver xxx. The net effect is to lower blood glucose levels.[44]
The prudent move is to address the patients hyperglycemic state immediately and
promptly before any other procedure is undertaken. In this case, there was no evidence
that insulin was administered on Teresita prior to or during the D&C operation. Insulin
was only administered two days after the operation.
As Dr. Tan testified, the patients hyperglycemic condition should have been managed
not only before and during the operation, but also immediately after. Despite the
possibility that Teresita was afflicted with diabetes, the possibility was casually ignored
even in the post-operative evaluation of the patient; the concern, as the petitioner
spouses expressly admitted, was limited to the complaint of vaginal bleeding.
Interestingly, while the ultrasound test confirmed that Teresita had a myoma in her
uterus, she was advised that she could be discharged a day after the operation and that
her recovery could take place at home. This advice implied that a day after the operation
and even after the complete laboratory results were submitted, the petitioner spouses still
did not recognize any post-operative concern that would require the monitoring of
Teresitas condition in the hospital.
The above facts, point only to one conclusion that the petitioner spouses failed, as
medical professionals, to comply with their duty to observe the standard of care to be
given to hyperglycemic/diabetic patients undergoing surgery. Whether this breach of
duty was the proximate cause of Teresitas death is a matter we shall next determine.
Injury and Causation
As previously mentioned, the critical and clinching factor in a medical negligence case
is proof of the causal connection between the negligence which the evidence
established and the plaintiffs injuries;[45] the plaintiff must plead and prove not only
that he had been injured and defendant has been at fault, but also that the defendants
fault caused the injury. A verdict in a malpractice action cannot be based on speculation
or conjecture. Causation must be proven within a reasonable medical probability based
upon competent expert testimony.[46]
The respondents contend that unnecessarily subjecting Teresita to a D&C operation
without adequately preparing her, aggravated her hyperglycemic state and caused her
untimely demise. The death certificate of Teresita lists down the following causes of
death:
Immediate cause: Cardiorespiratory arrest
Antecedent cause: Septicemic shock, ketoacidocis
Underlying cause: Diabetes Mellitus II
Other significant conditions
contributing to death: Renal Failure Acute[47]
Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C
operation is a form of physical stress. Dr. Mendoza explained how surgical stress can
aggravate the patients hyperglycemia: when stress occurs, the diabetics body, especially
the autonomic system, reacts by secreting hormones which are counter-regulatory; she
can have prolonged hyperglycemia which, if unchecked, could lead to death.[48]
Medical literature further explains that if the blood sugar has become very high, the
patient becomes comatose (diabetic coma). When this happens over several days, the
body uses its own fat to produce energy, and the result is high levels of waste products
(called ketones) in the blood and urine (called diabetic ketoacidiosis, a medical
emergency with a significant mortality).[49] This was apparently what happened in
Teresitas case; in fact, after she had been referred to the internist Dr. Jorge, laboratory
test showed that her blood sugar level shot up to 14.0mmol/l, way above the normal
blood sugar range. Thus, between the D&C and death was the diabetic complication that
could have been prevented with the observance of standard medical precautions. The
D&C operation and Teresitas death due to aggravated diabetic condition is therefore
sufficiently established.
The trial court and the appellate court pinned the liability for Teresitas death on both the
petitioner spouses and this Court finds no reason to rule otherwise. However, we clarify
that Dr. Fredelictos negligence is not solely the act of ordering an on call D&C operation
when he was mainly an anaesthesiologist who had made a very cursory examination of
the patients vaginal bleeding complaint. Rather, it was his failure from the very start to
identify and confirm, despite the patients complaints and his own suspicions, that
diabetes was a risk factor that should be guarded against, and his participation in the
imprudent decision to proceed with the D&C operation despite his early suspicion and
the confirmatory early laboratory results. The latter point comes out clearly from the
following exchange during the trial:
Q: On what aspect did you and your wife consult [with] each other?
A: We discussed on the finding of the laboratory [results] because the hemoglobin was below normal,
the blood sugar was elevated, so that we have to evaluate these laboratory results what it means.
Q: So it was you and your wife who made the evaluation when it was phoned in?
A: Yes, sir.
Q: Did your wife, before performing D&C ask your opinion whether or not she can proceed?
A: Yes, anyway, she asked me whether we can do D&C based on my experience.
Q: And your answer was in the positive notwithstanding the elevation of blood sugar?
A: Yes, sir, it was both our disposition to do the D&C. [Emphasis supplied.][50]
If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not being an
internist or a diabetologist (for which reason he referred Teresita to Dr. Jorge),[51] he
should have likewise refrained from making a decision to proceed with the D&C
operation since he was niether an obstetrician nor a gynecologist.
These findings lead us to the conclusion that the decision to proceed with the D&C
operation, notwithstanding Teresitas hyperglycemia and without adequately preparing
her for the procedure, was contrary to the standards observed by the medical profession.
Deviation from this standard amounted to a breach of duty which resulted in the patients
death. Due to this negligent conduct, liability must attach to the petitioner spouses.
Liability of the Hospital
In the proceedings below, UDMC was the spouses Flores co-defendant. The RTC found
the hospital jointly and severally liable with the petitioner spouses, which decision the
CA affirmed. In a Resolution dated August 28, 2006, this Court however denied UDMCs
petition for review on certiorari. Since UDMCs appeal has been denied and they are not
parties to this case, we find it unnecessary to delve on the matter. Consequently, the
RTCs decision, as affirmed by the CA, stands.
Award of Damages
Both the trial and the appellate court awarded actual damages as compensation for the
pecuniary loss the respondents suffered. The loss was presented in terms of the hospital
bills and expenses the respondents incurred on account of Teresitas confinement and
death. The settled rule is that a plaintiff is entitled to be compensated for proven
pecuniary loss.[52] This proof the respondents successfully presented. Thus, we affirm
the award of actual damages of P36,000.00 representing the hospital expenses the
patient incurred.
In addition to the award for actual damages, the respondent heirs of Teresita are likewise
entitled to P50,000.00 as death indemnity pursuant to Article 2206 of the Civil Code,
which states that the amount of damages for death caused by a xxx quasi-delict shall be
at least three thousand pesos,[53] even though there may have been mitigating
circumstances xxx. This is a question of law that the CA missed in its decision and
which we now decide in the respondents favor.
The same article allows the recovery of moral damages in case of death caused by a
quasi-delict and enumerates the spouse, legitimate or illegitimate ascendants or
descendants as the persons entitled thereto. Moral damages are designed to compensate
the claimant for the injury suffered, that is, for the mental anguish, serious anxiety,
wounded feelings which the respondents herein must have surely felt with the
unexpected loss of their daughter. We affirm the appellate courts award of P400,000.00
by way of moral damages to the respondents.
We similarly affirm the grant of exemplary damages. Exemplary damages are imposed
by way of example or correction for the public good.[54] Because of the petitioner
spouses negligence in subjecting Teresita to an operation without first recognizing and
addressing her diabetic condition, the appellate court awarded exemplary damages to
the respondents in the amount of P100,000.00. Public policy requires such imposition to
suppress the wanton acts of an offender.[55] We therefore affirm the CAs award as an
example to the medical profession and to stress that the public good requires stricter
measures to avoid the repetition of the type of medical malpractice that happened in this
case.
With the award of exemplary damages, the grant of attorneys fees is legally in order.[56]
We therefore reverse the CA decision deleting these awards, and grant the respondents
the amount of P100,000.00 as attorneys fees taking into consideration the legal route
this case has taken.
WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003 in CA G.R.
CV No. 63234 finding petitioner spouses liable for negligent medical practice. We
likewise AFFIRM the awards of actual and compensatory damages of P36,000.00;
moral damages of P400,000.00; and exemplary damages of P100,000.00.
We MODIFY the CA Decision by additionally granting an award of P50,000.00 as
death indemnity and by reversing the deletion of the award of attorneys fees and costs
and restoring the award of P100,000.00 as attorneys fees. Costs of litigation are
adjudged against petitioner spouses.
To summarize, the following awards shall be paid to the family of the late Teresita
Pineda:
1. The sum of P36,000.00 by way of actual and compensatory damages;
2. The sum of P50,000.00 by way of death indemnity;
3. The sum of P400,000.00 by way of moral damages;
4. The sum of P100,000.00 by way of exemplary damages;
5. The sum of P100,000.00 by way of attorneys fees; and
6. Costs.
SO ORDERED.
Spouses Flores vs Spouses Pineda
GR No. 158996 November 14, 2008
Facts: Teresita Pineda consulted her townmate Dr. Fredelicto Flores regarding her medical condition,
complaining about general body weakness, loss of appetite, frequent urination and thirst, and on-and-
off vaginal bleeding. After interviewing Teresita, Dr. Fredelicto advised her to go to United Doctors
Medical Center (UDMC) in Quezon City for a general check-up the following week but the former did
not. As for her other symptoms, he suspected that Teresita might be suffering from diabetes and told her
to continue her medications. When her conditions persisted, she went to UDMC where Dr. Fredelictor
check-up her and ordered her admission and further indicate on call D&C operation to be performed by
his wife, Dra. Felicisima Flores, an Ob-Gyne. Laboratory tests were done on Teresita including internal
vaginal examination, however, only the blood sugar and CBC results came out prior to operation which
indicated of diabetes. D&C operations were still done and thereafter, Dra. Felicisima advised her that
she can go home and continue to rest at home but Teresita opted otherwise. Two days after the
operation, her condition worsened prompting further test to be done which resulted that Teresita have
diabetes melitus type II. Insulin was administered but it might arrived late, she died.
Issue: Whether or not spouses petitioners are liable for medical negligence.
Held: Yes. A medical negligence case is a type of claim to redress a wrong committed by a medical
professional, that caused a bodily harm to or the death of a patient. There are four elements involved in
a medical negligence case, namely: duty, breach, injury, and proximate cause.
Duty refers to the standard of behavior which imposes restrictions on one’s conduct. The standard in
turn refers to the amount of competence associated with the proper discharge of the profession. A
physician is expected to use at least the same level of case that any other reasonably competent doctor
would use under the same circumstances. Breach of duty occurs when the physician fails to comply
with those professional standards. If injury results to the patient as a result of this breach, the physician
is answerable for negligence.
If a patient suffers from some disability that increases the magnitude of risk to him, that disability must
be taken into account as long as it is or should have been known to the physician.
Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C operation is a
form of physical stress. Dr. Mendoza explained how surgical stress can aggravate the patient’s
hyperglycemia: when stress occurs, the diabetic’s body, especially the autonomic system, reacts by
secreting hormones which are counter-regulatory; she can have prolonged hyperglycemia which, if
unchecked, could lead to death. Medical lecture further explains that if the blood sugar has become
very high, the patient becomes comatose (diabetic coma). When this happens over several days, the
body uses its own fats to produce energy, and the result is high level of waste products in the blood and
urine.
These findings leads us to the conclusion that the decision to proceed with the D&C operation
notwithstanding Teresita’s hyperglycemia and without adequately preparing her for the procedure, was
contrary to the standards observed by the medical profession. Deviation from this standard amounted to
a breach of duty which resulted in the patient’s death. Due to this negligent conduct, liability must
attach to the petitioner spouses.

G.R. No. 192123 March 10, 2014

DR. FERNANDO P. SOLIDUM, Petitioner,
vs.
PEOPLE OF THE PHILIPPINES, Respondent.
DECISION
BERSAMIN, J.:
This appeal is taken by a physician-anesthesiologist who has been pronounced guilty of reckless
imprudence resulting in serious physical injuries by the Regional Trial Court (RTC) and the Court of
Appeals (CA). He had been part of the team of anesthesiologists during the surgical pull-through
operation conducted on a three-year old patient born with an imperforate anus.1
The antecedents are as follows:
Gerald Albert Gercayo (Gerald) was born on June 2, 19922 with an imperforate anus. Two days after
his birth, Gerald underwent colostomy, a surgical procedure to bring one end of the large intestine out
through the abdominal wall,3 enabling him to excrete through a colostomy bag attached to the side of
his body.4
On May 17, 1995, Gerald, then three years old, was admitted at the Ospital ng Maynila for a pull-
through operation.5 Dr. Leandro Resurreccion headed the surgical team, and was assisted by Dr.
Joselito Luceño, Dr. Donatella Valeña and Dr. Joseph Tibio. The anesthesiologists included Dr.
Marichu Abella, Dr. Arnel Razon and petitioner Dr. Fernando Solidum (Dr. Solidum).6 During the
operation, Gerald experienced bradycardia,7 and went into a coma.8 His coma lasted for two weeks,9
but he regained consciousness only after a month.10 He could no longer see, hear or move.11
Agitated by her son’s helpless and unexpected condition, Ma. Luz Gercayo (Luz) lodged a complaint
for reckless imprudence resulting in serious physical injuries with the City Prosecutor’s Office of
Manila against the attending physicians.12
Upon a finding of probable cause, the City Prosecutor’s Office filed an information solely against Dr.
Solidum,13 alleging: –
That on or about May 17, 1995, in the City of Manila, Philippines, the said accused, being then an
anesthesiologist at the Ospital ng Maynila, Malate, this City, and as such was tasked to administer the
anesthesia on three-year old baby boy GERALD ALBERT GERCAYO, represented by his mother,
MA. LUZ GERCAYO, the former having been born with an imperforate anus [no anal opening] and
was to undergo an operation for anal opening [pull through operation], did then and there willfully,
unlawfully and feloniously fail and neglect to use the care and diligence as the best of his judgment
would dictate under said circumstance, by failing to monitor and regulate properly the levels of
anesthesia administered to said GERALD ALBERT GERCAYO and using 100% halothane and other
anesthetic medications, causing as a consequence of his said carelessness and negligence, said
GERALD ALBERT GERCAYO suffered a cardiac arrest and consequently a defect called hypoxic
encephalopathy meaning insufficient oxygen supply in the brain, thereby rendering said GERALD
ALBERT GERCAYO incapable of moving his body, seeing, speaking or hearing, to his damage and
prejudice.
Contrary to law.14
The case was initially filed in the Metropolitan Trial Court of Manila, but was transferred to the RTC
pursuant to Section 5 of Republic Act No. 8369 (The Family Courts Act of 1997),15 where it was
docketed as Criminal Case No. 01-190889.
Judgment of the RTC
On July 19, 2004, the RTC rendered its judgment finding Dr. Solidum guilty beyond reasonable doubt
of reckless imprudence resulting to serious physical injuries,16 decreeing:
WHEREFORE, premises considered, the Court finds accused DR. FERNANDO P. SOLIDUM
GUILTY beyond reasonable doubt as principal of the crime charged and is hereby sentenced to suffer
the indeterminate penalty of TWO (2) MONTHS and ONE (1) DAY of arresto mayor as minimum to
ONE (1) YEAR, ONE (1) MONTH and TEN (10) DAYS of prision correccional as maximum and to
indemnify, jointly and severally with the Ospital ng Maynila, Dr. Anita So and Dr. Marichu Abella,
private complainant Luz Gercayo, the amount of ₱500,000.00 as moral damages and ₱100,000.00 as
exemplary damages and to pay the costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby CANCELLED.
SO ORDERED.17
Upon motion of Dr. Anita So and Dr. Marichu Abella to reconsider their solidary liability,18 the RTC
excluded them from solidary liability as to the damages, modifying its decision as follows:
WHEREFORE, premises considered, the Court finds accused Dr. Fernando Solidum, guilty beyond
reasonable doubt as principal of the crime charged and is hereby sentenced to suffer the indeterminate
penalty of two (2) months and one (1) day of arresto mayor as minimum to one (1) year, one (1) month
and ten (10) days of prision correccional as maximum and to indemnify jointly and severally with
Ospital ng Maynila, private complainant Luz Gercayo the amount of ₱500,000.00 as moral damages
and ₱100,000 as exemplary damages and to pay the costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby cancelled.19
Decision of the CA
On January 20, 2010, the CA affirmed the conviction of Dr. Solidum,20 pertinently stating and ruling:
The case appears to be a textbook example of res ipsa loquitur.
xxxx
x x x [P]rior to the operation, the child was evaluated and found fit to undergo a major operation. As
noted by the OSG, the accused himself testified that pre-operation tests were conducted to ensure that
the child could withstand the surgery. Except for his imperforate anus, the child was healthy. The tests
and other procedures failed to reveal that he was suffering from any known ailment or disability that
could turn into a significant risk. There was not a hint that the nature of the operation itself was a
causative factor in the events that finally led to hypoxia.
In short, the lower court has been left with no reasonable hypothesis except to attribute the accident to a
failure in the proper administration of anesthesia, the gravamen of the charge in this case. The High
Court elucidates in Ramos vs. Court of Appeals 321 SCRA 584 –
In cases where the res ipsa loquitur is applicable, the court is permitted to find a physician negligent
upon proper proof of injury to the patient, without the aid of expert testimony, where the court from its
fund of common knowledge can determine the proper standard of care.
Where common knowledge and experience teach that a resulting injury would not have occurred to the
patient if due care had been exercised, an inference of negligence may be drawn giving rise to an
application of the doctrine of res ipsa loquitur without medical evidence, which is ordinarily required to
show not only what occurred but how and why it occurred. When the doctrine is appropriate, all that
the patient must do is prove a nexus between the particular act or omission complained of and the
injury sustained while under the custody and management of the defendant without need to produce
expert medical testimony to establish the standard of care. Resort to res ipsa loquitur is allowed
because there is no other way, under usual and ordinary conditions, by which the patient can obtain
redress for injury suffered by him.
The lower court has found that such a nexus exists between the act complained of and the injury
sustained, and in line with the hornbook rules on evidence, we will afford the factual findings of a trial
court the respect they deserve in the absence of a showing of arbitrariness or disregard of material facts
that might affect the disposition of the case. People v. Paraiso 349 SCRA 335.
The res ipsa loquitur test has been known to be applied in criminal cases. Although it creates a
presumption of negligence, it need not offend due process, as long as the accused is afforded the
opportunity to go forward with his own evidence and prove that he has no criminal intent. It is in this
light not inconsistent with the constitutional presumption of innocence of an accused.
IN VIEW OF THE FOREGOING, the modified decision of the lower court is affirmed.
SO ORDERED.21
Dr. Solidum filed a motion for reconsideration, but the CA denied his motion on May 7, 2010.22
Hence, this appeal.
Issues
Dr. Solidum avers that:
I.
 THE HONORABLE COURT OF APPEALS ERRED IN AFFIRMING THE DECISION OF
THE LOWER COURT IN UPHOLDING THE PETITIONER’S CONVICTION FOR THE
CRIME CHARGED BASED ON THE TRIAL COURT’S OPINION, AND NOT ON THE
BASIS OF THE FACTS ESTABLISHED DURING THE TRIAL. ALSO, THERE IS A CLEAR
MISAPPREHENSION OF FACTS WHICH IF CORRECTED, WILL RESULT TO THE
ACQUITTAL OF THE PETITIONER. FURTHER, THE HONORABLE COURT ERRED IN
AFFIRMING THE SAID DECISION OF THE LOWER COURT, AS THIS BREACHES THE
CRIMINAL LAW PRINCIPLE THAT THE PROSECUTION MUST PROVE THE
ALLEGATIONS OF THE INFORMATION BEYOND REASONABLE DOUBT, AND NOT
ON THE BASIS OF ITS PRESUMPTIVE CONCLUSION.
II.
THE HONORABLE COURT OF APPEALS ERRED IN APPLYING THE PRINCIPLE OF
RES IPSA LOQUITOR (sic) WHEN THE DEFENSE WAS ABLE TO PROVE THAT THERE
IS NO NEGLIGENCE ON THE PART OF THE PETITIONER, AND NO OVERDOSING IN
THE APPLICATION OF THE ANESTHETIC AGENT BECAUSE THERE WAS NO 100%
HALOTHANE ADMINISTERED TO THE CHILD, BUT ONLY ONE (1%) PERCENT AND
THE APPLICATION THEREOF, WAS REGULATED BY AN ANESTHESIA MACHINE.
THUS, THE APPLICATION OF THE PRINCIPLE OF RES IPSA LOQUITOR (sic)
CONTRADICTED THE ESTABLISHED FACTS AND THE LAW APPLICABLE IN THE
CASE.
III.
THE AWARD OF MORAL DAMAGES AND EXEMPLARY DAMAGES IS NOT
JUSTIFIED THERE BEING NO NEGLIGENCE ON THE PART OF THE PETITIONER.
ASSUMING THAT THE CHILD IS ENTITLED TO FINANCIAL CONSIDERATION, IT
SHOULD BE ONLY AS A FINANCIAL ASSISTANCE, BECAUSE THERE WAS NO
NEGLIGENCE, AND NO OVERDOSING OF ANESTHETIC AGENT AND AS SUCH, THE
AWARD IS SO EXCESSIVE, AND NO FACTUAL AND LEGAL BASIS.23
To simplify, the following are the issues for resolution, namely: (a) whether or not the doctrine of res
ipsa loquitur was applicable herein; and (b) whether or not Dr. Solidum was liable for criminal
negligence.
Ruling
The appeal is meritorious.
Applicability of the Doctrine of Res Ipsa Loquitur
Res ipsa loquitur is literally translated as "the thing or the transaction speaks for itself." The doctrine
res ipsa loquitur means that "where the thing which causes injury is shown to be under the management
of the defendant, and the accident is such as in the ordinary course of things does not happen if those
who have the management use proper care, it affords reasonable evidence, in the absence of an
explanation by the defendant, that the accident arose from want of care."24 It is simply "a recognition
of the postulate that, as a matter of common knowledge and experience, the very nature of certain types
of occurrences may justify an inference of negligence on the part of the person who controls the
instrumentality causing the injury in the absence of some explanation by the defendant who is charged
with negligence. It is grounded in the superior logic of ordinary human experience and on the basis of
such experience or common knowledge, negligence may be deduced from the mere occurrence of the
accident itself.
Hence, res ipsa loquitur is applied in conjunction with the doctrine of common knowledge."25
Jarcia, Jr. v. People26 has underscored that the doctrine is not a rule of substantive law, but merely a
mode of proof or a mere procedural convenience. The doctrine, when applicable to the facts and
circumstances of a given case, is not meant to and does not dispense with the requirement of proof of
culpable negligence against the party charged. It merely determines and regulates what shall be prima
facie evidence thereof, and helps the plaintiff in proving a breach of the duty. The doctrine can be
invoked when and only when, under the circumstances involved, direct evidence is absent and not
readily available.27
The applicability of the doctrine of res ipsa loquitur in medical negligence cases was significantly and
exhaustively explained in Ramos v. Court of Appeals,28 where the Court said –
Medical malpractice cases do not escape the application of this doctrine. Thus, res ipsa loquitur has
been applied when the circumstances attendant upon the harm are themselves of such a character as to
justify an inference of negligence as the cause of that harm. The application of res ipsa loquitur in
medical negligence cases presents a question of law since it is a judicial function to determine whether
a certain set of circumstances does, as a matter of law, permit a given inference.
Although generally, expert medical testimony is relied upon in malpractice suits to prove that a
physician has done a negligent act or that he has deviated from the standard medical procedure, when
the doctrine of res ipsa loquitur is availed by the plaintiff, the need for expert medical testimony is
dispensed with because the injury itself provides the proof of negligence. The reason is that the general
rule on the necessity of expert testimony applies only to such matters clearly within the domain of
medical science, and not to matters that are within the common knowledge of mankind which may be
testified to by anyone familiar with the facts. Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has been treated or operated upon with a
reasonable degree of skill and care. However, testimony as to the statements and acts of physicians and
surgeons, external appearances, and manifest conditions which are observable by any one may be given
by non-expert witnesses. Hence, in cases where the res ipsa loquitur is applicable, the court is permitted
to find a physician negligent upon proper proof of injury to the patient, without the aid of expert
testimony, where the court from its fund of common knowledge can determine the proper standard of
care. Where common knowledge and experience teach that a resulting injury would not have occurred
to the patient if due care had been exercised, an inference of negligence may be drawn giving rise to an
application of the doctrine of res ipsa loquitur without medical evidence, which is ordinarily required to
show not only what occurred but how and why it occurred. When the doctrine is appropriate, all that
the patient must do is prove a nexus between the particular act or omission complained of and the
injury sustained while under the custody and management of the defendant without need to produce
expert medical testimony to establish the standard of care. Resort to res ipsa loquitur is allowed
because there is no other way, under usual and ordinary conditions, by which the patient can obtain
redress for injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following situations: leaving of a
foreign object in the body of the patient after an operation, injuries sustained on a healthy part of the
body which was not under, or in the area, of treatment, removal of the wrong part of the body when
another part was intended, knocking out a tooth while a patient’s jaw was under anesthetic for the
removal of his tonsils, and loss of an eye while the patient plaintiff was under the influence of
anesthetic, during or following an operation for appendicitis, among others.
Nevertheless, despite the fact that the scope of res ipsa loquitur has been measurably enlarged, it does
not automatically apply to all cases of medical negligence as to mechanically shift the burden of proof
to the defendant to show that he is not guilty of the ascribed negligence. Res ipsa loquitur is not a rigid
or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied, depending upon the
circumstances of each case. It is generally restricted to situations in malpractice cases where a layman
is able to say, as a matter of common knowledge and observation, that the consequences of professional
care were not as such as would ordinarily have followed if due care had been exercised. A distinction
must be made between the failure to secure results, and the occurrence of something more unusual and
not ordinarily found if the service or treatment rendered followed the usual procedure of those skilled
in that particular practice. It must be conceded that the doctrine of res ipsa loquitur can have no
application in a suit against a physician or surgeon which involves the merits of a diagnosis or of a
scientific treatment. The physician or surgeon is not required at his peril to explain why any particular
diagnosis was not correct, or why any particular scientific treatment did not produce the desired result.
Thus, res ipsa loquitur is not available in a malpractice suit if the only showing is that the desired result
of an operation or treatment was not accomplished. The real question, therefore, is whether or not in the
process of the operation any extraordinary incident or unusual event outside of the routine performance
occurred which is beyond the regular scope of customary professional activity in such operations,
which, if unexplained would themselves reasonably speak to the average man as the negligent cause or
causes of the untoward consequence. If there was such extraneous intervention, the doctrine of res ipsa
loquitur may be utilized and the defendant is called upon to explain the matter, by evidence of
exculpation, if he could.
In order to allow resort to the doctrine, therefore, the following essential requisites must first be
satisfied, to wit: (1) the accident was of a kind that does not ordinarily occur unless someone is
negligent; (2) the instrumentality or agency that caused the injury was under the exclusive control of
the person charged; and (3) the injury suffered must not have been due to any voluntary action or
contribution of the person injured.29
The Court considers the application here of the doctrine of res ipsa loquitur inappropriate. Although it
should be conceded without difficulty that the second and third elements were present, considering that
the anesthetic agent and the instruments were exclusively within the control of Dr. Solidum, and that
the patient, being then unconscious during the operation, could not have been guilty of contributory
negligence, the first element was undeniably wanting. Luz delivered Gerald to the care, custody and
control of his physicians for a pull-through operation. Except for the imperforate anus, Gerald was then
of sound body and mind at the time of his submission to the physicians. Yet, he experienced
bradycardia during the operation, causing loss of his senses and rendering him immobile. Hypoxia, or
the insufficiency of oxygen supply to the brain that caused the slowing of the heart rate, scientifically
termed as bradycardia, would not ordinarily occur in the process of a pull-through operation, or during
the administration of anesthesia to the patient, but such fact alone did not prove that the negligence of
any of his attending physicians, including the anesthesiologists, had caused the injury. In fact, the
anesthesiologists attending to him had sensed in the course of the operation that the lack of oxygen
could have been triggered by the vago-vagal reflex, prompting them to administer atropine to the
patient.30
This conclusion is not unprecedented. It was similarly reached in Swanson v. Brigham,31 relevant
portions of the decision therein being as follows:
On January 7, 1973, Dr. Brigham admitted 15-year-old Randall Swanson to a hospital for the treatment
of infectious mononucleosis. The patient's symptoms had included a swollen throat and some breathing
difficulty. Early in the morning of January 9 the patient was restless, and at 1:30 a.m. Dr. Brigham
examined the patient. His inspection of the patient's air passage revealed that it was in satisfactory
condition. At 4:15 a.m. Dr. Brigham received a telephone call from the hospital, advising him that the
patient was having respiratory difficulty. The doctor ordered that oxygen be administered and he
prepared to leave for the hospital. Ten minutes later, 4:25 a.m., the hospital called a second time to
advise the doctor that the patient was not responding. The doctor ordered that a medicine be
administered, and he departed for the hospital. When he arrived, the physician who had been on call at
the hospital had begun attempts to revive the patient. Dr. Brigham joined him in the effort, but the
patient died.
The doctor who performed the autopsy concluded that the patient died between 4:25 a.m. and 4:30 a.m.
of asphyxia, as a result of a sudden, acute closing of the air passage. He also found that the air passage
had been adequate to maintain life up to 2 or 3 minutes prior to death. He did not know what caused the
air passage to suddenly close.
xxxx
It is a rare occurrence when someone admitted to a hospital for the treatment of infectious
mononucleosis dies of asphyxiation. But that is not sufficient to invoke res ipsa loquitur. The fact that
the injury rarely occurs does not in itself prove that the injury was probably caused by someone's
negligence. Mason v. Ellsworth, 3 Wn. App. 298, 474 P.2d 909 (1970). Nor is a bad result by itself
enough to warrant the application of the doctrine. Nelson v. Murphy, 42 Wn.2d 737, 258 P.2d 472
(1953). See 2 S. Speiser, The Negligence Case – Res Ipsa Loquitur § 24:10 (1972). The evidence
presented is insufficient to establish the first element necessary for application of res ipsa loquitur
doctrine. The acute closing of the patient’s air passage and his resultant asphyxiation took place over a
very short period of time. Under these circumstances it would not be reasonable to infer that the
physician was negligent. There was no palpably negligent act. The common experience of mankind
does not suggest that death would not be expected without negligence. And there is no expert medical
testimony to create an inference that negligence caused the injury.
Negligence of Dr. Solidum
In view of the inapplicability of the doctrine of res ipsa loquitur, the Court next determines whether the
CA correctly affirmed the conviction of Dr. Solidum for criminal negligence.
Negligence is defined as the failure to observe for the protection of the interests of another person that
degree of care, precaution, and vigilance that the circumstances justly demand, whereby such other
person suffers injury.32 Reckless imprudence, on the other hand, consists of voluntarily doing or failing
to do, without malice, an act from which material damage results by reason of an inexcusable lack of
precaution on the part of the person performing or failing to perform such act.33
Dr. Solidum’s conviction by the RTC was primarily based on his failure to monitor and properly
regulate the level of anesthetic agent administered on Gerald by overdosing at 100% halothane. In
affirming the conviction, the CA observed:
On the witness stand, Dr. Vertido made a significant turnaround. He affirmed the findings and
conclusions in his report except for an observation which, to all intents and purposes, has become the
storm center of this dispute. He wanted to correct one piece of information regarding the dosage of the
anesthetic agent administered to the child. He declared that he made a mistake in reporting a 100%
halothane and said that based on the records it should have been 100% oxygen.
The records he was relying on, as he explains, are the following:
(a) the anesthesia record – A portion of the chart in the record was marked as Exhibit 1-A and 1-
B to indicate the administration at intervals of the anesthetic agent.
(b) the clinical abstract – A portion of this record that reads as follows was marked Exhibit 3A.
3B – Approximately 1 hour and 45 minutes through the operation, patient was noted to have
bradycardia (CR = 70) and ATSO4 0.2 mg was immediately administered. However, the
bradycardia persisted, the inhalational agent was shut off, and the patient was ventilated with
 100% oxygen and another dose of ATSO4 0.2 mg was given. However, the patient did not
respond until no cardiac rate can be auscultated and the surgeons were immediately told to stop
the operation. The patient was put on a supine position and CPR was initiated. Patient was given
1 amp of epinephrine initially while continuously doing cardiac massage – still with no cardiac
rate appreciated; another ampule of epinephrine was given and after 45 secs, patient’s vital signs
returned to normal. The entire resuscitation lasted approximately 3-5 mins. The surgeons were
then told to proceed to the closure and the child’s vital signs throughout and until the end of
surgery were: BP = 110/70; CR = 116/min and RR = 20-22 cycles/min (on assisted ventilation).
Dr. Vertido points to the crucial passage in the clinical abstract that the patient was ventilated with
100% oxygen and another dose of ATSO4 when the bradycardia persisted, but for one reason or
another, he read it as 100% halothane. He was asked to read the anesthesia record on the percentage of
the dosage indicated, but he could only sheepishly note I can’t understand the number. There are no
clues in the clinical abstract on the quantity of the anesthetic agent used. It only contains the
information that the anesthetic plan was to put the patient under general anesthesia using a
nonrebreathing system with halothane as the sole anesthetic agent and that 1 hour and 45 minutes after
the operation began, bradycardia occurred after which the inhalational agent was shut off and the
patient administered with 100% oxygen. It would be apparent that the 100% oxygen that Dr. Vertido
said should be read in lieu of 100% halothane was the pure oxygen introduced after something went
amiss in the operation and the halothane itself was reduced or shut off.
The key question remains – what was the quantity of halothane used before bradycardia set in?
The implication of Dr. Vertido’s admission is that there was no overdose of the anesthetic agent, and
the accused Dr. Solidum stakes his liberty and reputation on this conclusion. He made the assurance
that he gave his patient the utmost medical care, never leaving the operating room except for a few
minutes to answer the call of nature but leaving behind the other members of his team Drs. Abella and
Razon to monitor the operation. He insisted that he administered only a point 1% not 100% halothane,
receiving corroboration from Dr. Abella whose initial MA in the record should be enough to show that
she assisted in the operation and was therefore conversant of the things that happened. She revealed
that they were using a machine that closely monitored the concentration of the agent during the
operation.
But most compelling is Dr. Solidum’s interpretation of the anesthesia record itself, as he takes the bull
by the horns, so to speak. In his affidavit, he says, reading from the record, that the quantity of
halothane used in the operation is one percent (1%) delivered at time intervals of 15 minutes. He
studiedly mentions – the concentration of halothane as reflected in the anesthesia record (Annex D of
the complaint-affidavit) is only one percent (1%) – The numbers indicated in 15 minute increments for
halothane is an indication that only 1% halothane is being delivered to the patient Gerard Gercayo for
his entire operation; The amount of halothane delivered in this case which is only one percent cannot be
summated because halothane is constantly being rapidly eliminated by the body during the entire
operation.
xxxx
In finding the accused guilty, despite these explanations, the RTC argued that the volte-face of Dr.
Vertido on the question of the dosage of the anesthetic used on the child would not really validate the
non-guilt of the anesthesiologist. Led to agree that the halothane used was not 100% as initially
believed, he was nonetheless unaware of the implications of the change in his testimony. The court
observed that Dr. Vertido had described the condition of the child as hypoxia which is deprivation of
oxygen, a diagnosis supported by the results of the CT Scan. All the symptoms attributed to a failing
central nervous system such as stupor, loss of consciousness, decrease in heart rate, loss of usual acuity
and abnormal motor function, are manifestations of this condition or syndrome. But why would there
be deprivation of oxygen if 100% oxygen to 1% halothane was used? Ultimately, to the court, whether
oxygen or halothane was the object of mistake, the detrimental effects of the operation are
incontestable, and they can only be led to one conclusion – if the application of anesthesia was really
closely monitored, the event could not have happened.34
The Prosecution did not prove the elements of reckless imprudence beyond reasonable doubt because
the circumstances cited by the CA were insufficient to establish that Dr. Solidum had been guilty of
inexcusable lack of precaution in monitoring the administration of the anesthetic agent to Gerald. The
Court aptly explained in Cruz v. Court of Appeals35 that:
Whether or not a physician has committed an "inexcusable lack of precaution" in the treatment of his
patient is to be determined according to the standard of care observed by other members of the
profession in good standing under similar circumstances bearing in mind the advanced state of the
profession at the time of treatment or the present state of medical science. In the recent case of Leonila
Garcia-Rueda v. Wilfred L. Pacasio, et. al., this Court stated that in accepting a case, a doctor in effect
represents that, having the needed training and skill possessed by physicians and surgeons practicing in
the same field, he will employ such training, care and skill in the treatment of his patients. He therefore
has a duty to use at least the same level of care that any other reasonably competent doctor would use
to treat a condition under the same circumstances. It is in this aspect of medical malpractice that expert
testimony is essential to establish not only the standard of care of the profession but also that the
physician's conduct in the treatment and care falls below such standard. Further, inasmuch as the causes
of the injuries involved in malpractice actions are determinable only in the light of scientific
knowledge, it has been recognized that expert testimony is usually necessary to support the conclusion
as to causation.
xxxx
In litigations involving medical negligence, the plaintiff has the burden of establishing appellant's
negligence and for a reasonable conclusion of negligence, there must be proof of breach of duty on the
part of the surgeon as well as a causal connection of such breach and the resulting death of his patient.
In Chan Lugay v. St Luke's Hospital, Inc., where the attending physician was absolved of liability for
the death of the complainant’s wife and newborn baby, this Court held that:
"In order that there may be a recovery for an injury, however, it must be shown that the ‘injury for
which recovery is sought must be the legitimate consequence of the wrong done; the connection
between the negligence and the injury must be a direct and natural sequence of events, unbroken by
intervening efficient causes.’ In other words, the negligence must be the proximate cause of the injury.
For, ‘negligence, no matter in what it consists, cannot create a right of action unless it is the proximate
cause of the injury complained of.’ And ‘the proximate cause of an injury is that cause, which, in
natural and continuous sequence, unbroken by any efficient intervening cause, produces the injury, and
without which the result would not have occurred.’"
An action upon medical negligence – whether criminal, civil or administrative – calls for the plaintiff to
prove by competent evidence each of the following four elements, namely: (a) the duty owed by the
physician to the patient, as created by the physician-patient relationship, to act in accordance with the
specific norms or standards established by his profession; (b) the breach of the duty by the physician’s
failing to act in accordance with the applicable standard of care; (3) the causation, i.e., there must be a
reasonably close and causal connection between the negligent act or omission and the resulting injury;
and (4) the damages suffered by the patient.36
In the medical profession, specific norms or standards to protect the patient against unreasonable risk,
commonly referred to as standards of care, set the duty of the physician to act in respect of the patient.
Unfortunately, no clear definition of the duty of a particular physician in a particular case exists.
Because most medical malpractice cases are highly technical, witnesses with special medical
qualifications must provide guidance by giving the knowledge necessary to render a fair and just
verdict. As a result, the standard of medical care of a prudent physician must be determined from expert
testimony in most cases; and in the case of a specialist (like an anesthesiologist), the standard of care
by which the specialist is judged is the care and skill commonly possessed and exercised by similar
specialists under similar circumstances. The specialty standard of care may be higher than that required
of the general practitioner.37
The standard of care is an objective standard by which the conduct of a physician sued for negligence
or malpractice may be measured, and it does not depend, therefore, on any individual physician’s own
knowledge either. In attempting to fix a standard by which a court may determine whether the
physician has properly performed the requisite duty toward the patient, expert medical testimony from
both plaintiff and defense experts is required. The judge, as the trier of fact, ultimately determines the
standard of care, after listening to the testimony of all medical experts.38
Here, the Prosecution presented no witnesses with special medical qualifications in anesthesia to
provide guidance to the trial court on what standard of care was applicable. It would consequently be
truly difficult, if not impossible, to determine whether the first three elements of a negligence and
malpractice action were attendant.
Although the Prosecution presented Dr. Benigno Sulit, Jr., an anesthesiologist himself who served as
the Chairman of the Committee on Ethics and Malpractice of the Philippine Society of
Anesthesiologists that investigated the complaint against Dr. Solidum, his testimony mainly focused on
how his Committee had conducted the investigation.39 Even then, the report of his Committee was
favorable to Dr. Solidum,40 to wit:
Presented for review by this committee is the case of a 3 year old male who underwent a pull-thru
operation and was administered general anesthesia by a team of anesthesia residents. The patient, at the
time when the surgeons was manipulating the recto-sigmoid and pulling it down in preparation for the
anastomosis, had bradycardia. The anesthesiologists, sensing that the cause thereof was the triggering
of the vago-vagal reflex, administered atropine to block it but despite the administration of the drug in
two doses, cardiac arrest ensued. As the records show, prompt resuscitative measures were
administered and spontaneous cardiac function re-established in less than five (5) minutes and that
oxygen was continuously being administered throughout, unfortunately, as later become manifest,
patient suffered permanent irreversible brain damage.
In view of the actuations of the anaesthesiologists and the administration of anaesthesia, the committee
find that the same were all in accordance with the universally accepted standards of medical care and
there is no evidence of any fault or negligence on the part of the anaesthesiologists.
Dr. Antonio Vertido, a Senior Medico-Legal Officer of the National Bureau of Investigation, was also
presented as a Prosecution witness, but his testimony concentrated on the results of the physical
examination he had conducted on Gerald, as borne out by the following portions of his direct
examination, to wit:
FISCAL CABARON Doctor, what do you mean by General Anesthetic Agent?
WITNESS General Anesthetic Agent is a substance used in the conduction of Anesthesia and in this
case, halothane was used as a sole anesthetic agent.
xxxx
Q Now under paragraph two of page 1 of your report you mentioned that after one hour and 45 minutes
after the operation, the patient experienced a bradycardia or slowing of heart rate, now as a doctor,
would you be able to tell this Honorable Court as to what cause of the slowing of heart rate as to Gerald
Gercayo?
WITNESS Well honestly sir, I cannot give you the reason why there was a bradycardia of time because
is some reason one way or another that might caused bradycardia.
FISCAL CABARON What could be the possible reason?
A Well bradycardia can be caused by anesthetic agent itself and that is a possibility, we’re talking about
possibility here.
Q What other possibility do you have in mind, doctor?
A Well, because it was an operation, anything can happen within that situation.
FISCAL CABARON Now, this representation would like to ask you about the slowing of heart rate,
now what is the immediate cause of the slowing of the heart rate of a person?
WITNESS Well, one of the more practical reason why there is slowing of the heart rate is when you do
a vagal reflex in the neck wherein the vagal receptors are located at the lateral part of the neck, when
you press that, you produce the slowing of the heart rate that produce bradycardia.
Q I am pro[p]ounding to you another question doctor, what about the deficiency in the supply of
oxygen by the patient, would that also cause the slowing of the heart rate?
A Well that is a possibility sir, I mean not as slowing of the heart rate, if there is a hypoxia or there is a
low oxygen level in the blood, the normal thing for the heart is to pump or to do not a bradycardia but a
… to counter act the Hypoxia that is being experienced by the patient
(sic).
xxxx
Q Now, you made mention also doctor that the use of general anesthesia using 100% halothane and
other anesthetic medications probably were contributory to the production of hypoxia.
A Yes, sir in general sir.41
On cross-examination, Dr. Vertido expounded more specifically on his interpretation of the anesthesia
record and the factors that could have caused Gerald to experience bradycardia, viz:
ATTY. COMIA I noticed in, may I see your report Doctor, page 3, will you kindly read to this
Honorable court your last paragraph and if you will affirm that as if it is correct?
A "The use of General Anesthesia, that is using 100% Halothane probably will be contributory to the
production of Hypoxia and - - - -"
ATTY COMIA And do you affirm the figure you mentioned in this Court Doctor?
WITNESS Based on the records, I know the - - -
Q 100%?
A 100% based on the records.
Q I will show you doctor a clinical record. I am a lawyer I am not a doctor but will you kindly look at
this and tell me where is 100%, the word "one hundred" or 1-0-0, will you kindly look at this Doctor,
this Xerox copy if you can show to this Honorable Court and even to this representation the word "one
hundred" or 1-0-0 and then call me.
 xxxx
ATTY. COMIA Doctor tell this Honorable Court where is that 100, 1-0-0 and if there is, you just call
me and even the attention of the Presiding Judge of this Court. Okay, you read one by one.
WITNESS Well, are you only asking 100%, sir?
ATTY. COMIA I’m asking you, just answer my question, did you see there 100% and 100 figures, tell
me, yes or no?
WITNESS I’m trying to look at the 100%, there is no 100% there sir.
ATTY. COMIA Okay, that was good, so you Honor please, may we request also temporarily, because
this is just a xerox copy presented by the fiscal, that the percentage here that the Halothane
administered by Dr. Solidum to the patient is 1% only so may we request that this portion, temporarily
your Honor, we are marking this anesthesia record as our Exhibit 1 and then this 1% Halothane also be
bracketed and the same be marked as our Exhibit "1-A".
xxxx
ATTY. COMIA Doctor, my attention was called also when you said that there are so many factors that
contributed to Hypoxia is that correct?
WITNESS Yes, sir.
Q I remember doctor, according to you there are so many factors that contributed to what you call
hypoxia and according to you, when this Gerald suffered hypoxia, there are other factors that might
lead to this Hypoxia at the time of this operation is that correct?
WITNESS The possibility is there, sir.
Q And according to you, it might also be the result of such other, some or it might be due to operations
being conducted by the doctor at the time when the operation is being done might also contribute to
that hypoxia is that correct?
A That is a possibility also.
xxxx
ATTY. COMIA How will you classify now the operation conducted to this Gerald, Doctor?
WITNESS Well, that is a major operation sir.
Q In other words, when you say major operation conducted to this Gerald, there is a possibility that this
Gerald might [be] exposed to some risk is that correct?
A That is a possibility sir.
Q And which according to you that Gerald suffered hypoxia is that correct?
A Yes, sir.
Q And that is one of the risk of that major operation is that correct?
A That is the risk sir.42
At the continuation of his cross-examination, Dr. Vertido maintained that Gerald’s operation for his
imperforate anus, considered a major operation, had exposed him to the risk of suffering the same
condition.43 He then corrected his earlier finding that 100% halothane had been administered on
Gerald by saying that it should be 100% oxygen.44
Dr. Solidum was criminally charged for "failing to monitor and regulate properly the levels of
anesthesia administered to said Gerald Albert Gercayo and using 100% halothane and other anesthetic
medications."45 However, the foregoing circumstances, taken together, did not prove beyond
reasonable doubt that Dr. Solidum had been recklessly imprudent in administering the anesthetic agent
to Gerald. Indeed, Dr. Vertido’s findings did not preclude the probability that other factors related to
Gerald’s major operation, which could or could not necessarily be attributed to the administration of the
anesthesia, had caused the hypoxia and had then led Gerald to experience bradycardia. Dr. Vertido
revealingly concluded in his report, instead, that "although the anesthesiologist followed the normal
routine and precautionary procedures, still hypoxia and its corresponding side effects did occur."46
The existence of the probability about other factors causing the hypoxia has engendered in the mind of
the Court a reasonable doubt as to Dr. Solidum’s guilt, and moves us to acquit him of the crime of
reckless imprudence resulting to serious physical injuries. "A reasonable doubt of guilt," according to
United States v. Youthsey:47
x x x is a doubt growing reasonably out of evidence or the lack of it. It is not a captious doubt; not a
doubt engendered merely by sympathy for the unfortunate position of the defendant, or a dislike to
accept the responsibility of convicting a fellow man. If, having weighed the evidence on both sides,
you reach the conclusion that the defendant is guilty, to that degree of certainty as would lead you to act
on the faith of it in the most important and crucial affairs of your life, you may properly convict him.
Proof beyond reasonable doubt is not proof to a mathematical demonstration. It is not proof beyond the
possibility of mistake.
We have to clarify that the acquittal of Dr. Solidum would not immediately exempt him from civil
liability.1âwphi1 But we cannot now find and declare him civilly liable because the circumstances that
have been established here do not present the factual and legal bases for validly doing so. His acquittal
did not derive only from reasonable doubt. There was really no firm and competent showing how the
injury to Gerard had been caused. That meant that the manner of administration of the anesthesia by Dr.
Solidum was not necessarily the cause of the hypoxia that caused the bradycardia experienced by
Gerard. Consequently, to adjudge Dr. Solidum civilly liable would be to speculate on the cause of the
hypoxia. We are not allowed to do so, for civil liability must not rest on speculation but on competent
evidence.
Liability of Ospital ng Maynila
Although the result now reached has resolved the issue of civil liability, we have to address the unusual
decree of the RTC, as affirmed by the CA, of expressly holding Ospital ng Maynila civilly liable jointly
and severally with Dr. Solidum. The decree was flawed in logic and in law.
In criminal prosecutions, the civil action for the recovery of civil liability that is deemed instituted with
the criminal action refers only to that arising from the offense charged.48 It is puzzling, therefore, how
the RTC and the CA could have adjudged Ospital ng Maynila jointly and severally liable with Dr.
Solidum for the damages despite the obvious fact that Ospital ng Maynila, being an artificial entity, had
not been charged along with Dr. Solidum. The lower courts thereby acted capriciously and whimsically,
which rendered their judgment against Ospital ng Maynila void as the product of grave abuse of
discretion amounting to lack of jurisdiction.
Not surprisingly, the flawed decree raises other material concerns that the RTC and the CA overlooked.
We deem it important, then, to express the following observations for the instruction of the Bench and
Bar.
For one, Ospital ng Maynila was not at all a party in the proceedings. Hence, its fundamental right to be
heard was not respected from the outset. The R TC and the CA should have been alert to this
fundamental defect. Verily, no person can be prejudiced by a ruling rendered in an action or proceeding
in which he was not made a party. Such a rule would enforce the constitutional guarantee of due
process of law.
Moreover, Ospital ng Maynila could be held civilly liable only when subsidiary liability would be
properly enforceable pursuant to Article 103 of the Revised Penal Code. But the subsidiary liability
seems far-fetched here. The conditions for subsidiary liability to attach to Ospital ng Maynila should
first be complied with. Firstly, pursuant to Article 103 of the Revised Penal Code, Ospital ng Maynila
must be shown to be a corporation "engaged in any kind of industry." The term industry means any
department or branch of art, occupation or business, especially one that employs labor and capital, and
is engaged in industry.49 However, Ospital ng Maynila, being a public hospital, was not engaged in
industry conducted for profit but purely in charitable and humanitarian work.50 Secondly, assuming
that Ospital ng Maynila was engaged in industry for profit, Dr. Solidum must be shown to be an
employee of Ospital ng Maynila acting in the discharge of his duties during the operation on Gerald.
Yet, he definitely was not such employee but a consultant of the hospital. And, thirdly, assuming that
civil liability was adjudged against Dr. Solidum as an employee (which did not happen here), the
execution against him was unsatisfied due to his being insolvent.
WHEREFORE, the Court GRANTS the petition for review on certiorari; REVERSES AND SETS
ASIDE the decision promulgated on January 20, 2010; ACQUITS Dr. Fernando P. Solidum of the
crime of reckless imprudence resulting to serious physical injuries; and MAKES no pronouncement on
costs of suit.
SO ORDERED.
Solidum vs People of the Philippines
GR No. 192123 March 10, 2014
Facts: Gerald Albert Gercayo was born on June 2, 1992 with an imperforate anus. Two days after his
birth, Gerald under went colostomy, a surgical procedure to bring one end of the large intestine out
through the abdominal walls, enabling him to excrete through a colostomy bag attached to the side of
his body. On May 17, 1995, Gerald was admitted at the Ospital ng Maynila for a pull-through
operation. Dr. Leandro Resurreccionheaded the surgical team, and was assisted by Dr. Joselito Lucerio,
Dr.Donatella Valeria and Dr. Joseph Tibio. The anesthesiologist included Drs. Abella, Razon and
Solidum. During the operation, Gerald experienced bradycardia and went into a coma. His coma lasted
for two weeks , but he regained consciousness only after a month. He could no longer see, hear, or
move. A complaint for reckless imprudence resulting in serious physical injuries were filed by Gerald’s
parents against the team of doctors alleging that there was failure in monitoring the anesthesia
administered to Gerald.
Issues: Whether or not petitioner is liable for medical negligence.
Whether or not res ipsa liquitor can be resorted to in medical negligence cases.
Held: No. Negligence is defined as the failure to observe for the protection of the interests of another
person that degree of care, precaution, and vigilance that the circumstances justly demand, whereby
such other person suffers injury. Reckless imprudence, on the other hand, consists of voluntarily doing
or failing to do, without malice, an act from which material damage results by reason of an inexcusable
lack of precaution on the part of the person to perform or failing to perform such act.
The negligence must be the proximate cause of the injury. For, negligence no matter in what it consists,
cannot create a right of action unless it is the proximate cause of the injury complained of. And the
proximate cause of an injury is that cause, which, in natural and continuous sequence and unbroken by
any efficient intervening cause, produces the injury, and without which the result would not have
occurred.
An action upon medical negligence – whether criminal, civil or administrative – calls for the plaintiff to
prove by competent evidence each of the following four elements namely: a.) the duty owed by the
physician to the patient, as created by the physician-patient relationship, to act in accordance with the
specific norms or standards established by his profession; b.) the breach of the duty by the physician’s
failing to act in accordance with the applicable standard of care; c.) the causation, is, there must be a
reasonably close and casual connection between the negligent act or omission and the resulting injury;
and d.) the damages suffered by the patient.
In the medical profession, specific norms on standard of care to protect the patient against unreasonable
risk, commonly referred to as standards of care, set the duty of the physician in respect of the patient.
The standard of care is an objective standard which conduct of a physician sued for negligence or
malpractice may be measured, and it does not depend therefore, on any individual’s physician’s own
knowledge either. In attempting to fix a standard by which a court may determine whether the
physician has properly performed the requisite duty toward the patient, expert medical testimony from
both plaintiff and defense experts is required.
The doctrine of res ipsa liquitor means that where the thing which causes injury is shown to be under
the management of the defendant, and the accident is such as in ordinary course of things does not
happen if those who have management use proper care, it affords reasonable evidence, in the absence
of an explanation by defendant that the accident arose from want of care.
Nevertheless, despite the fact that the scope of res ipsa liquitor has been measurably enlarged, it does
not automatically apply to all cases of medical negligence as to mechanically shift the burden of proof
to the defendant to show that he is not guilty of the ascribed negligence. Res ipsa liquitor is not a rigid
or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied, depending upon the
circumstances of each case. It is generally restricted to situations in malpractice cases where a layman
is able to say, as a matter of common knowledge and observation, that the consequences of professional
care were not as such as would ordinarily have followed if due care had been exercised. A distinction
must be made between the failure to secure results, and the occurrence of something more unusual and
not ordinarily found if the service or treatment rendered followed the usual procedure of those skilled
in that particular practice. It must be conceded that the doctrine of res ipsa liquitor can have no
application in a suit against a physician or surgeon which involves the merits of a diagnosis or of a
scientific treatment. The physician or surgeon is not required at his peril to explain why any particular
diagnosis was not correct, or why any particular scientific treatment did not produce the desired results.
Thus, res ipsa liquitor is not available in a malpractice suit if the only showing is that the desired result
of an operation or treatment was not accomplished. The real question, therefore, is whether or not in the
process of the operation any extraordinary incident or unusual event outside the routine performance
occurred which is beyond the regular scope of customary professional activity in such operations,
which if unexplained would themselves reasonably speak to the average man as the negligent case or
causes of the untoward consequence. If there was such extraneous intervention, the doctrine of res ipsa
liquitor may be utilized and the dependent is called upon to explain the matter, by evidence of
exculpation, if he could.

RICO ROMMEL ATIENZA,

Petitioner,
G.R. No. 177407
Present:
- versus - NACHURA,

BOARD OF MEDICINE and EDITHA Acting Chairperson,

SIOSON,
PERALTA,
Respondents.
DEL CASTILLO,*

VILLARAMA, JR.,** and

MENDOZA, JJ.

Promulgated:

February 9, 2011

x------------------------------------------------------------------------------------x
DECISION
NACHURA, J.:
Before us is a petition for review on certiorari under Rule 45 of the Rules of Court,
assailing the Decision[1] dated September 22, 2006 of the Court of Appeals (CA) in CA-
G.R. SP No. 87755. The CA dismissed the petition for certiorari filed by petitioner Rico
Rommel Atienza (Atienza), which, in turn, assailed the Orders[2] issued by public
respondent Board of Medicine (BOM) in Administrative Case No. 1882.

The facts, fairly summarized by the appellate court, follow.

Due to her lumbar pains, private respondent Editha Sioson went to Rizal Medical Center (RMC) for
check-up on February 4, 1995. Sometime in 1999, due to the same problem, she was referred to Dr.
Pedro Lantin III of RMC who, accordingly, ordered several diagnostic laboratory tests. The tests
revealed that her right kidney is normal. It was ascertained, however, that her left kidney is non-
functioning and non-visualizing. Thus, she underwent kidney operation in September, 1999.
On February 18, 2000, private respondents husband, Romeo Sioson (as complainant), filed a complaint
for gross negligence and/or incompetence before the [BOM] against the doctors who allegedly
participated in the fateful kidney operation, namely: Dr. Judd dela Vega, Dr. Pedro Lantin, III, Dr.
Gerardo Antonio Florendo and petitioner Rico Rommel Atienza.
It was alleged in the complaint that the gross negligence and/or incompetence committed by the said
doctors, including petitioner, consists of the removal of private respondents fully functional right
kidney, instead of the left non-functioning and non-visualizing kidney.
The complaint was heard by the [BOM]. After complainant Romeo Sioson presented his evidence,
private respondent Editha Sioson, also named as complainant there, filed her formal offer of
documentary evidence. Attached to the formal offer of documentary evidence are her Exhibits A to D,
which she offered for the purpose of proving that her kidneys were both in their proper anatomical
locations at the time she was operated. She described her exhibits, as follows:
EXHIBIT A the certified photocopy of the X-ray Request form dated
December 12, 1996, which is also marked as Annex 2 as it was actually
originally the Annex to x x x Dr. Pedro Lantin, IIIs counter affidavit filed
with the City Prosecutor of Pasig City in connection with the criminal
complaint filed by [Romeo Sioson] with the said office, on which are
handwritten entries which are the interpretation of the results of the
ultrasound examination. Incidentally, this exhibit happens to be the same
as or identical to the certified photocopy of the document marked as
Annex 2 to the Counter-Affidavit dated March 15, 2000, filed by x x x
Dr. Pedro Lantin, III, on May 4, 2000, with this Honorable Board in
answer to this complaint;
EXHIBIT B the certified photo copy of the X-ray request form dated
January 30, 1997, which is also marked as Annex 3 as it was actually
likewise originally an Annex to x x x Dr. Pedro Lantin, IIIs counter-
affidavit filed with the Office of the City Prosecutor of Pasig City in
connection with the criminal complaint filed by the herein complainant
with the said office, on which are handwritten entries which are the
interpretation of the results of the examination. Incidentally, this exhibit
happens to be also the same as or identical to the certified photo copy of
the document marked as Annex 3 which is likewise dated January 30,
1997, which is appended as such Annex 3 to the counter-affidavit dated
March 15, 2000, filed by x x x Dr. Pedro Lantin, III on May 4, 2000, with
this Honorable Board in answer to this complaint.
EXHIBIT C the certified photocopy of the X-ray request form dated
March 16, 1996, which is also marked as Annex 4, on which are
handwritten entries which are the interpretation of the results of the
examination.
EXHIBIT D the certified photocopy of the X-ray request form dated May
20, 1999, which is also marked as Annex 16, on which are handwritten
entries which are the interpretation of the results of the examination.
Incidentally, this exhibit appears to be the draft of the typewritten final
report of the same examination which is the document appended as
Annexes 4 and 1 respectively to the counter-affidavits filed by x x x Dr.
Judd dela Vega and Dr. Pedro Lantin, III in answer to the complaint. In
the case of Dr. dela Vega however, the document which is marked as
Annex 4 is not a certified photocopy, while in the case of Dr. Lantin, the
document marked as Annex 1 is a certified photocopy. Both documents
are of the same date and typewritten contents are the same as that which
are written on Exhibit D.
Petitioner filed his comments/objections to private respondents [Editha
Siosons] formal offer of exhibits. He alleged that said exhibits are
inadmissible because the same are mere photocopies, not properly
identified and authenticated, and intended to establish matters which are
hearsay. He added that the exhibits are incompetent to prove the purpose
 for which they are offered.
Dispositions of the Board of Medicine

The formal offer of documentary exhibits of private respondent [Editha Sioson] was admitted by the
[BOM] per its Order dated May 26, 2004. It reads:
The Formal Offer of Documentary Evidence of [Romeo Sioson], the
Comments/Objections of [herein petitioner] Atienza, [therein
respondents] De la Vega and Lantin, and the Manifestation of [therein]
respondent Florendo are hereby ADMITTED by the [BOM] for whatever
purpose they may serve in the resolution of this case.
Let the hearing be set on July 19, 2004 all at 1:30 p.m. for the reception
of the evidence of the respondents.
SO ORDERED.
Petitioner moved for reconsideration of the abovementioned Order
basically on the same reasons stated in his comment/objections to the
formal offer of exhibits.
The [BOM] denied the motion for reconsideration of petitioner in its Order dated October 8, 2004. It
concluded that it should first admit the evidence being offered so that it can determine its probative
value when it decides the case. According to the Board, it can determine whether the evidence is
relevant or not if it will take a look at it through the process of admission. x x x.[3]
Disagreeing with the BOM, and as previously adverted to, Atienza filed a petition for
certiorari with the CA, assailing the BOMs Orders which admitted Editha Siosons
(Edithas) Formal Offer of Documentary Evidence. The CA dismissed the petition for
certiorari for lack of merit.

Hence, this recourse positing the following issues:

I. PROCEDURAL ISSUE:
WHETHER PETITIONER ATIENZA AVAILED OF THE PROPER REMEDY WHEN HE FILED
THE PETITION FOR CERTIORARI DATED 06 DECEMBER 2004 WITH THE COURT OF
APPEALS UNDER RULE 65 OF THE RULES OF COURT TO ASSAIL THE ORDERS DATED 26
MAY 2004 AND 08 OCTOBER 2004 OF RESPONDENT BOARD.
II. SUBSTANTIVE ISSUE:
WHETHER THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR AND
DECIDED A QUESTION OF SUBSTANCE IN A WAY NOT IN ACCORDANCE WITH LAW AND
THE APPLICABLE DECISIONS OF THE HONORABLE COURT WHEN IT UPHELD THE
ADMISSION OF INCOMPETENT AND INADMISSIBLE EVIDENCE BY RESPONDENT
BOARD, WHICH CAN RESULT IN THE DEPRIVATION OF PROFESSIONAL LICENSE A
PROPERTY RIGHT OR ONES LIVELIHOOD.[4]
We find no reason to depart from the ruling of the CA.

Petitioner is correct when he asserts that a petition for certiorari is the proper remedy to
assail the Orders of the BOM, admitting in evidence the exhibits of Editha. As the
assailed Orders were interlocutory, these cannot be the subject of an appeal separate
from the judgment that completely or finally disposes of the case.[5] At that stage, where
there is no appeal, or any plain, speedy, and adequate remedy in the ordinary course of
law, the only and remaining remedy left to petitioner is a petition for certiorari under
Rule 65 of the Rules of Court on the ground of grave abuse of discretion amounting to
lack or excess of jurisdiction.

However, the writ of certiorari will not issue absent a showing that the BOM has acted
without or in excess of jurisdiction or with grave abuse of discretion. Embedded in the
CAs finding that the BOM did not exceed its jurisdiction or act in grave abuse of
discretion is the issue of whether the exhibits of Editha contained in her Formal Offer of
Documentary Evidence are inadmissible.

Petitioner argues that the exhibits formally offered in evidence by Editha: (1) violate the
best evidence rule; (2) have not been properly identified and authenticated; (3) are
completely hearsay; and (4) are incompetent to prove their purpose. Thus, petitioner
contends that the exhibits are inadmissible evidence.

We disagree.

To begin with, it is well-settled that the rules of evidence are not strictly applied in
proceedings before administrative bodies such as the BOM.[6] Although trial courts are
enjoined to observe strict enforcement of the rules of evidence,[7] in connection with
evidence which may appear to be of doubtful relevancy, incompetency, or admissibility,
we have held that:

[I]t is the safest policy to be liberal, not rejecting them on doubtful or technical grounds, but admitting
them unless plainly irrelevant, immaterial or incompetent, for the reason that their rejection places them
beyond the consideration of the court, if they are thereafter found relevant or competent; on the other
hand, their admission, if they turn out later to be irrelevant or incompetent, can easily be remedied by
completely discarding them or ignoring them.[8]
From the foregoing, we emphasize the distinction between the admissibility of evidence
and the probative weight to be accorded the same pieces of evidence. PNOC Shipping
and Transport Corporation v. Court of Appeals[9] teaches:

Admissibility of evidence refers to the question of whether or not the circumstance (or evidence) is to
be considered at all. On the other hand, the probative value of evidence refers to the question of
whether or not it proves an issue.
Second, petitioners insistence that the admission of Edithas exhibits violated his
substantive rights leading to the loss of his medical license is misplaced. Petitioner
mistakenly relies on Section 20, Article I of the Professional Regulation Commission
Rules of Procedure, which reads:
Section 20. Administrative investigation shall be conducted in accordance with these Rules. The Rules
of Court shall only apply in these proceedings by analogy or on a suppletory character and whenever
practicable and convenient. Technical errors in the admission of evidence which do not prejudice the
substantive rights of either party shall not vitiate the proceedings.[10]
As pointed out by the appellate court, the admission of the exhibits did not prejudice the
substantive rights of petitioner because, at any rate, the fact sought to be proved thereby,
that the two kidneys of Editha were in their proper anatomical locations at the time she
was operated on, is presumed under Section 3, Rule 131 of the Rules of Court:

Sec. 3. Disputable presumptions. The following presumptions are satisfactory if uncontradicted, but
may be contradicted and overcome by other evidence:
xxxx
(y) That things have happened according to the ordinary course of nature and the ordinary habits of life.
The exhibits are certified photocopies of X-ray Request Forms dated December 12,
1996, January 30, 1997, March 16, 1996, and May 20, 1999, filed in connection with
Edithas medical case. The documents contain handwritten entries interpreting the results
of the examination. These exhibits were actually attached as annexes to Dr. Pedro Lantin
IIIs counter affidavit filed with the Office of the City Prosecutor of Pasig City, which
was investigating the criminal complaint for negligence filed by Editha against the
doctors of Rizal Medical Center (RMC) who handled her surgical procedure. To lay the
predicate for her case, Editha offered the exhibits in evidence to prove that her kidneys
were both in their proper anatomical locations at the time of her operation.

The fact sought to be established by the admission of Edithas exhibits, that her kidneys
were both in their proper anatomical locations at the time of her operation, need not be
proved as it is covered by mandatory judicial notice.[11]

Unquestionably, the rules of evidence are merely the means for ascertaining the truth
respecting a matter of fact.[12] Thus, they likewise provide for some facts which are
established and need not be proved, such as those covered by judicial notice, both
mandatory and discretionary.[13] Laws of nature involving the physical sciences,
specifically biology,[14] include the structural make-up and composition of living things
such as human beings. In this case, we may take judicial notice that Edithas kidneys
before, and at the time of, her operation, as with most human beings, were in their
proper anatomical locations.

Third, contrary to the assertion of petitioner, the best evidence rule is inapplicable.
Section 3 of Rule 130 provides:

1. Best Evidence Rule

Sec. 3. Original document must be produced; exceptions. When the subject of inquiry is the contents of
a document, no evidence shall be admissible other than the original document itself, except in the
following cases:
(a) When the original has been lost or destroyed, or cannot be produced in court, without bad faith on
the part of the offeror;
(b) When the original is in the custody or under the control of the party against whom the evidence is
offered, and the latter fails to produce it after reasonable notice;
(c) When the original consists of numerous accounts or other documents which cannot be examined in
court without great loss of time and the fact sought to be established from them is only the general
result of the whole; and
(d) When the original is a public record in the custody of a public officer or is recorded in a public
office.
The subject of inquiry in this case is whether respondent doctors before the BOM are
liable for gross negligence in removing the right functioning kidney of Editha instead of
the left non-functioning kidney, not the proper anatomical locations of Edithas kidneys.
As previously discussed, the proper anatomical locations of Edithas kidneys at the time
of her operation at the RMC may be established not only through the exhibits offered in
evidence.

Finally, these exhibits do not constitute hearsay evidence of the anatomical locations of
Edithas kidneys. To further drive home the point, the anatomical positions, whether left
or right, of Edithas kidneys, and the removal of one or both, may still be established
through a belated ultrasound or x-ray of her abdominal area.

In fact, the introduction of secondary evidence, such as copies of the exhibits, is

allowed.[15] Witness Dr. Nancy Aquino testified that the Records Office of RMC no
longer had the originals of the exhibits because [it] transferred from the previous
building, x x x to the new building.[16] Ultimately, since the originals cannot be
produced, the BOM properly admitted Edithas formal offer of evidence and, thereafter,
the BOM shall determine the probative value thereof when it decides the case.

WHEREFORE, the petition is DENIED. The Decision of the Court of Appeals in CA-
G.R. SP No. 87755 is AFFIRMED. Costs against petitioner.

SO ORDERED.

Atienza vs Board of Medicine

GR No. 177407 February 9, 2011
Facts: Due to her Lumbar parts, private respondent Editha Sioson went to Rizal Medical Center
(RMC) for check-up on February 4, 1995. Sometime in 1999, due to the same problem, she was
referred to Dr. Pedro Lantin III of RMC who, accordingly, ordered several diagnostic laboratory tests.
The tests revealed that her right kidney is normal. It was ascertained, however, that her left kidney is
non-functioning and non-visualizing. This, she underwent kidney operation in 1999, September. On
February 18, 2000, private respondents husband Romeo Sioson, filed a complaint for gross negligence
and/or incompetence before the board of medicine against the doctors who allegedly participated in the
fateful kidney operation. It was alleged in the complaint that the gross negligence and/or incompetence
committed by the said doctors, including petitioner, consists of the removal of private respondents fully
functional right kidney, instead of the left non-functioning and non-visualizing kidney. Among the
evidence presented are certified photocopy of the results of the ultrasound and X-ray conducted to
Editha with the interpretation that both of her kidneys are in their proper anatomical location.
Issue: Whether or not the doctors who conducted the kidney operation are liable for gross negligence
despite the evidence presented were mere photocopies.
Held: Yes. To begin with, it is a well settled rule that the rules of evidence are not strictly applied in
proceedings before administrative bodies such as the Board of Medicine. It is the safest policy to be
liberal, not rejecting them on doubtful or technical grounds, but admitting them unless plainly
irrelevant, immaterial or incompetent, for the reason that their rejection places them beyond the
consideration of the court, if they are thereafter found relevant or competent; on the other hand, their
admission, if they turn out later to be irrelevant or incompetent, can easily be remedied by completely
discarding them or ignoring them.
Unquestionably, the rules of evidence are merely the means for ascertaining the truth respecting a
matter of fact. This, they likewise provide for some facts which are established and need not be proved,
such as those covered by judicial notice, both mandatory and discretionary. Laws of nature involving
the physical sciences, specifically biology include the structural make-up and composition of living
things such as human beings. In this case, we may take judicial notice that Editha’s kidneys before, and
after the time of her operation, as with most human beings, were in their proper anatomical locations.
[G.R. No. 118231. July 5, 1996]
DR. VICTORIA L. BATIQUIN and ALLAN BATIQUIN, petitioners, vs. COURT OF APPEALS,
SPOUSES QUEDO D. ACOGIDO and FLOTILDE G. VILLEGAS, respondents.
DECISION
DAVIDE, JR., J.:
Throughout history, patients have consigned their fates and lives to the skill of their doctors. For a
breach of this trust, men have been quick to demand retribution. Some 4,000 years ago, the Code of
Hammurabi[1] then already provided: "If a physician make a deep incision upon a man with his bronze
lancet and cause the man's death, or operate on the eye socket of a man with his bronze lancet and
destroy the man's eyes, they shall cut off his hand."[2] Subsequently, Hippocrates[3] wrote what was to
become part of the healer's oath: "I will follow that method of treatment which according to my ability
and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and
mischievous . . . . While I continue to keep this oath unviolated may it be granted me to enjoy life and
practice the art, respected by all men at all times but should I trespass and violate this oath, may the
reverse be my lot." At present, the primary objective of the medical profession is the preservation of
life and maintenance of the health of the people.[4]
Needless to say then, when a physician strays from his sacred duty and endangers instead the life of his
patient, he must be made to answer therefor. Although society today cannot and will not tolerate the
punishment meted out by the ancients, neither will it and this Court, as this case would show, let the act
go uncondemned.
The petitioners appeal from the decision[5] of the Court of Appeals of 11 May 1994 in CA-G.R. CV
No. 30851, which reversed the decision[6] of 21 December 1990 of Branch 30 of the Regional Trial
Court (RTC) of Negros Oriental in Civil Case No. 9492.
The facts, as found by the trial court, are as follows:
Dr. Batiquin was a Resident Physician at the Negros Oriental Provincial Hospital, Dumaguete City
from January 9, 1978 to September 1989. Between 1987 and September, 1989 she was also the Actg.
Head of the Department of Obstetrics and Gynecology at the said Hospital.
Mrs. Villegas is a married woman who submitted to Dr. Batiquin for prenatal care as the latter's private
patient sometime before September 21, 1988.
In the morning of September 21, 1988 Dr. Batiquin, with the assistance of Dr. Doris Teresita Sy who
was also a Resident Physician at the same Hospital, C.I. and O.R. Nurse Arlene Diones and some
student nurses performed a simple cesarean section on Mrs. Villegas at the Negros Oriental Provincial
Hospital and after 45 minutes Mrs. Villegas delivered her first child, Rachel Acogido, at about 11:45
that morning. Thereafter, Plaintiff remained confined at the Hospital until September 27, 1988 during
which period of confinement she was regularly visited by Dr. Batiquin. On September 28, 1988, Mrs.
Villegas checked out of the Hospital . . . and on the same day she paid Dr. Batiquin, thru the latter's
secretary, the amount of P1,500.00 as "professional fee" . . . .
Soon after leaving the Hospital Mrs. Villegas began to suffer abdominal pains and complained of being
feverish. She also gradually lost her appetite, so she consulted Dr. Batiquin at the latter's polyclinic who
prescribed for her certain medicines . . . which she had been taking up to December, 1988.
In the meantime, Mrs. Villegas was given a Medical Certificate by Dr. Batiquin on October 31,
1988 . . . certifying to her physical fitness to return to her work on November 7, 1988. So, on the
second week of November, 1988 Mrs. Villegas returned to her work at the Rural Bank of Ayungon,
Negros Oriental.
The abdominal pains and fever kept on recurring and bothered Mrs. Villegas no end and despite the
medications administered by Dr. Batiquin. When the pains become unbearable and she was rapidly
losing weight she consulted Dr. Ma. Salud Kho at the Holy Child's Hospital in Dumaguete City on
January 20, 1989.
The evidence of Plaintiffs show that when Dr. Ma. Salud Kho examined Mrs. Villegas at the Holy
Child's Hospital on January 20, 1989 she found Mrs. Villegas to be feverish, pale and was breathing
fast. Upon examination she felt an abdominal mass one finger below the umbilicus which she suspected
to be either a tumor of the uterus or an ovarian cyst, either of which could be cancerous. She had an x-
ray taken of Mrs. Villegas' chest, abdomen and kidney. She also took blood tests of Plaintiff. A blood
count showed that Mrs. Villegas had [an] infection inside her abdominal cavity. The result of all those
examinations impelled Dr. Kho to suggest that Mrs. Villegas submit to another surgery to which the
latter agreed.
When Dr. Kho opened the abdomen of Mrs. Villegas she found whitish-yellow discharge inside, an
ovarian cyst on each of the left and right ovaries which gave out pus, dirt and pus behind the uterus,
and a piece of rubber materials on the right side of the uterus embedded on [sic] the ovarian cyst, 2
inches by 3/4 inch in size. This piece of rubber material which Dr. Kho described as a "foreign body"
looked like a piece of a "rubber glove" . . . and which is [sic] also "rubber-drain like . . . . It could have
been a torn section of a surgeon's gloves or could have come from other sources. And this foreign body
was the cause of the infection of the ovaries and consequently of all the discomfort suffered by Mrs.
Villegas after her delivery on September 21, 1988.[7]
The piece of rubber allegedly found near private respondent Flotilde Villegas' uterus was not presented
in court, and although Dr. Ma. Salud Kho testified that she sent it to a pathologist in Cebu City for
examination,[8] it was not mentioned in the pathologist's Surgical Pathology Report.[9]
Aside from Dr. Kho's testimony, the evidence which mentioned the piece of rubber are a Medical
Certificate,[10] a Progress Record,[11] an Anesthesia Record,[12] a Nurse's Record,[13] and a
Physician's Discharge Summary.[14] The trial court, however, regarded these documentary evidence as
mere hearsay, "there being no showing that the person or persons who prepared them are deceased or
unable to testify on the facts therein stated . . . . Except for the Medical Certificate (Exhibit "F"), all the
above documents were allegedly prepared by persons other than Dr. Kho, and she merely affixed her
signature on some of them to express her agreement thereto . . . ."[15] The trial court also refused to
give weight to Dr. Kho's testimony regarding the subject piece of rubber as Dr. Kho "may not have had
first-hand knowledge" thereof,[16] as could be gleaned from her statement, thus:
A . . . I have heard somebody that [sic] says [sic] there is [sic] a foreign body that goes with the tissues
but unluckily I don't know where the rubber was.[17]
The trial court deemed vital Dr. Victoria Batiquin's testimony that when she confronted Dr. Kho
regarding the piece of rubber, "Dr. Kho answered that there was rubber indeed but that she threw it
away."[18] This statement, the trial court noted, was never denied nor disputed by Dr. Kho, leading it to
conclude:
There are now two different versions on the whereabouts of that offending "rubber" (1) that it was sent
to the Pathologist in Cebu as testified to in Court by Dr. Kho and (2) that Dr. Kho threw it away as told
by her to Defendant. The failure of the Plaintiffs to reconcile these two different versions serve only to
weaken their claim against Defendant Batiquin.[19]
All told, the trial court held in favor of the petitioners herein.
The Court of Appeals reviewed the entirety of Dr. Kho's testimony and, even without admitting the
private respondents' documentary evidence, deemed Dr. Kho's positive testimony to definitely establish
that a piece of rubber was found near private respondent Villegas' uterus. Thus, the Court of Appeals
reversed the decision of the trial court, holding:
4. The fault or negligence of appellee Dr. Batiquin is established by preponderance of evidence. The
trial court itself had narrated what happened to appellant Flotilde after the cesarean operation made by
appellee doctor . . . . After the second operation, appellant Flotilde became well and healthy. Appellant
Flotilde's troubles were caused by the infection due to the "rubber" that was left inside her abdomen.
Both appellants testified that after the operation made by appellee doctor, they did not go to any other
doctor until they finally decided to see another doctor in January, 1989 when she was not getting any
better under the care of appellee Dr. Batiquin . . . . Appellee Dr. Batiquin admitted on the witness stand
that she alone decided when to close the operating area; that she examined the portion she operated on
before closing the same . . . . Had she exercised due diligence, appellee Dr. Batiquin would have found
the rubber and removed it before closing the operating area.[20]
The appellate court then ruled:
Appellants' evidence show[s] that they paid a total of P17,000.00 [deposit of P7,100.00 (Exh. G-1-A)
plus hospital and medical expenses together with doctor's fees in the total amount P9,900.00 (Exhs. G
and G-2)] for the second operation that saved her life.
For the miseries appellants endured for more than three (3) months, due to the negligence of appellee
Dr. Batiquin, they are entitled to moral damages in the amount of P100,000.00; exemplary damages in
the amount of P20,000.00 and attorney's fees in the amount of P25,000.00.
The fact that appellant Flotilde can no longer bear children because her uterus and ovaries were
removed by Dr. Kho is not taken into consideration as it is not shown that the removal of said organs
were the direct result of the rubber left by appellee Dr. Batiquin near the uterus. What is established is
that the rubber left by appellee cause infection, placed the life of appellant Flotilde in jeopardy and
caused appellants fear, worry and anxiety . . . .
WHEREFORE, the appealed judgment, dismissing the complaint for damages is REVERSED and SET
ASIDE. Another judgment is hereby entered ordering defendants-appellees to pay plaintiffs-appellants
the amounts of P17,000.00 as and for actual damages; P100,000.00 as and for moral damages;
P20,000.00 as and for exemplary damages; and P25,000.00 as and for attorney's fees plus the cost of
litigation.
SO ORDERED.[21]
From the above judgment, the petitioners appealed to this Court claiming that the appellate court; (1)
committed grave abuse of discretion by resorting to findings of fact not supported by the evidence on
record, and (2) exceeded its discretion, amounting to lack or excess of jurisdiction, when it gave
credence to testimonies punctured with contradictions and falsities.
The private respondents commented that the petition raised only questions of fact, which were not
proper for review by this Court.
While the rule is that only questions of law may be raised in a petition for review on certiorari, there
are exceptions, among which are when the factual findings of the trial court and the appellate court
conflict, when the appealed decision is clearly contradicted by the evidence on record, or when the
appellate court misapprehended the facts.[22]
After deciphering the cryptic petition, we find that the focal point of the instant appeal is the
appreciation of Dr. Kho's testimony. The petitioners contend that the Court of Appeals misappreciated
the following portion of Dr. Kho's testimony:
Q What is the purpose of the examination?
A Just in case, I was just thinking at the back of my mind, just in case this would turn out to be a
medico-legal case, I have heard somebody that [sic] says [sic] there is [sic] a foreign body that goes
with the tissues but unluckily I don't know where the rubber was. It was not in the Lab, it was not in
Cebu.[23] (Italics supplied)
The petitioners prefer the trial court's interpretation of the above testimony, i.e., that Dr. Kho's
knowledge of the piece of rubber was based on hearsay. The Court of Appeals, on the other hand,
concluded that the underscored phrase was taken out of context by the trial court. According to the
Court of Appeals, the trial court should have likewise considered the other portions of Dr. Kho's
testimony, especially the following:
Q So you did actually conduct the operation on her?
A Yes, I did.
Q And what was the result?
A Opening up her abdomen, there was whitish-yellow discharge inside the abdomen, there was an
ovarian cyst on the left and side and there was also an ovarian cyst on the right which, on opening up or
freeing it up from the uterus, turned out to be pus. Both ovaries turned out . . . to have pus. And then,
cleaning up the uterus, at the back of the uterus it was very dirty, it was full of pus. And there was a
[piece of] rubber, we found a [piece of] rubber on the right side.[24]
We agree with the Court of Appeals. The phrase relied upon by the trial court does not negate the fact
that Dr. Kho saw a piece of rubber in private respondent Villegas' abdomen, and that she sent it to a
laboratory and then to Cebu City for examination by a pathologist.[25] Not even the Pathologist's
Report, although devoid of any mention of a piece of rubber, could alter what Dr. Kho saw.
Furthermore, Dr. Kho's knowledge of the piece of rubber could not be based on other than first hand
knowledge for, as she asserted before the trial court:
Q But you are sure you have seen [the piece of rubber]?
A Oh yes. I was not the only one who saw it.[26]
The petitioners emphasize that the private respondents never reconciled Dr. Kho's testimony with Dr.
Batiquin's claim on the witness stand that when Dr. Batiquin confronted Dr. Kho about the foreign
body, the latter said that there was a piece of rubber but that she threw it away. Although hearsay, Dr.
Batiquin's claim was not objected to, and hence, the same is admissible[27] but it carries no probative
value.[28] Nevertheless, assuming otherwise, Dr. Batiquin's statement cannot belie the fact that Dr.
Kho found a piece of rubber near private respondent Villegas' uterus. And even if we were to doubt Dr.
Kho as to what she did to the piece of rubber, i.e., whether she threw it away or sent it to Cebu City, we
are not justified in distrusting her as to her recovery of a piece of rubber from private respondent
Villegas' abdomen. On this score, it is perfectly reasonable to believe the testimony of a witness with
respect to some facts and disbelieve his testimony with respect to other facts. And it has been aptly said
that even when a witness is found to have deliberately falsified in some material particulars, it is not
required that the whole of his uncorroborated testimony be rejected, but such portions thereof deemed
worthy of belief may be credited.[29]
It is here worth nothing that the trial court paid heed to the following portions of Dr. Batiquin's
testimony: that no rubber drain was used in the operation,[30] and that there was neither any tear on Dr.
Batiquin's gloves after the operation nor blood smears on her hands upon removing her gloves.[31]
Moreover, the trial court pointed out that the absence of a rubber drain was corroborated by Dr. Doris
Sy, Dr. Batiquin's assistant during the operation on private respondent Villegas.[32] But the trial court
failed to recognize that the assertions of Drs. Batiquin and Sy were denials or negative testimonies.
Well-settled is the rule that positive testimony is stronger than negative testimony.[33] Of course, as the
petitioners advocate, such positive testimony must come from a credible source, which leads us to the
second assigned error.
While the petitioners claim that contradictions and falsities punctured Dr. Kho's testimony, a reading of
the said testimony reveals no such infirmity and establishes Dr. Kho as a credible witness. Dr. Kho was
frank throughout her turn on the witness stand. Furthermore, no motive to state any untruth was ever
imputed against Dr. Kho, leaving her trustworthiness unimpaired.[34] The trial court's following
declaration shows that while it was critical of the lack of care with which Dr. Kho handled the piece of
rubber, it was not prepared to doubt Dr. Kho's credibility, thus only supporting out appraisal of Dr.
Kho's trustworthiness:
This is not to say that she was less than honest when she testified about her findings, but it can also be
said that she did not take the most appropriate precaution to preserve that "piece of rubber" as an
eloquent evidence of what she would reveal should there be a "legal problem" which she claim[s] to
have anticipated.[35]
Considering that we have assessed Dr. Kho to be a credible witness, her positive testimony [that a piece
of rubber was indeed found in private respondent Villegas' abdomen] prevails over the negative
testimony in favor of the petitioners.
As such, the rule of res ipsa loquitur comes to fore. This Court has had occasion to delve into the
nature and operation of this doctrine:
This doctrine [res ipsa loquitur] is stated thus: "Where the thing which causes injury is shown to be
under the management of the defendant, and the accident is such as in the ordinary course of things
does not happen if those who have the management use proper care, it affords reasonable evidence, in
the absence of an explanation by the defendant, that the accident arose from want of care." Or as
Black's Law Dictionary puts it:
Res ipsa loquitur. The thing speaks for itself. Rebuttable presumption or inference that defendant was
negligent, which arises upon proof that [the] instrumentality causing injury was in defendant's
exclusive control, and that the accident was one which ordinary does not happen in absence of
negligence. Res ipsa loquitur is [a] rule of evidence whereby negligence of [the] alleged wrongdoer
may be inferred from [the] mere fact that [the] accident happened provided [the] character of [the]
accident and circumstances attending it lead reasonably to belief that in [the] absence of negligence it
would not have occurred and that thing which caused injury is shown to have been under [the]
management and control of [the] alleged wrongdoer . . . . Under [this] doctrine . . . the happening of an
injury permits an inference of negligence where plaintiff produces substantial evidence that [the] injury
was caused by an agency or instrumentality under [the] exclusive control and management of
defendant, and that the occurrence [sic] was such that in the ordinary course of things would not
happen if reasonable care had been used.
xxx xxx xxx
The doctrine of [r]es ipsa loquitur as a rule of evidence is peculiar to the law of negligence which
recognizes that prima facie negligence may be established without direct proof and furnishes a
substitute for specific proof of negligence. The doctrine is not a rule of substantive law, but merely a
mode of proof or a mere procedural convenience. The rule, when applicable to the facts and
circumstances of a particular case, is not intended to and does not dispense with the requirement of
proof of culpable negligence on the party charged. It merely determines and regulates what shall be
prima facie evidence thereof and facilitates the burden of plaintiff of proving a breach of the duty of
due care. The doctrine can be invoked when and only when, under the circumstances involved, direct
evidence is absent and not readily available.[36]
In the instant case, all the requisites for recourse to the doctrine are present. First, the entire
proceedings of the cesarean section were under the exclusive control of Dr. Batiquin. In this light, the
private respondents were bereft of direct evidence as to the actual culprit or the exact cause of the
foreign object finding its way into private respondent Villegas' body, which, needless to say, does not
occur unless through the intervention of negligence. Second, since aside from the cesarean section,
private respondent Villegas underwent no other operation which could have caused the offending piece
of rubber to appear in her uterus, it stands to reason that such could only have been a by-product of the
cesarean section performed by Dr. Batiquin. The petitioners, in this regard, failed to overcome the
presumption of negligence arising from resort to the doctrine of res ipsa loquitur. Dr. Batiquin is
therefore liable for negligently leaving behind a piece of rubber in private respondent Villegas'
abdomen and for all the adverse effects thereof.
As a final word, this Court reiterates its recognition of the vital role the medical profession plays in the
lives of the people,[37] and State's compelling interest to enact measures to protect the public from "the
potentially deadly effects of incompetence and ignorance in those who would undertake to treat our
bodies and minds for disease or trauma."[38] Indeed, a physician is bound to serve the interest of his
patients "with the greatest of solicitude, giving them always his best talent and skill."[39] Through her
tortious conduct, the petitioner endangered the life of Flotilde Villegas, in violation of her profession's
rigid ethical code and in contravention of the legal standards set forth for professionals, in the general,
[40] and members of the medical profession,[41] in particular.
WHEREFORE, the challenged decision of 11 May 1994 of the Court of Appeals in CA-G.R. CV No.
30851 is hereby AFFIRMED in toto.
Costs against the petitioners.
SO ORDERED.
G.R. No. 124354 April 11, 2002
ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural guardians of
the minors, ROMMEL RAMOS, ROY RODERICK RAMOS, and RON RAYMOND RAMOS,
petitioners,
vs.
COURT OF APPEALS, DE LOS SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and
DR. PERFECTA GUTIERREZ, respondents.
RE S O LUTI ON
KAPUNAN, J.:
Private respondents De Los Santos Medical Center, Dr. Orlino Hosaka and Dr. Perfecta Gutierrez move
for a reconsideration of the Decision, dated December 29, 1999, of this Court holding them civilly
liable for petitioner Erlinda Ramos’ comatose condition after she delivered herself to them for their
professional care and management.
For better understanding of the issues raised in private respondents’ respective motions, we will briefly
restate the facts of the case as follows:
Sometime in 1985, petitioner Erlinda Ramos, after seeking professional medical help, was advised to
undergo an operation for the removal of a stone in her gall bladder (cholecystectomy). She was referred
to Dr. Hosaka, a surgeon, who agreed to perform the operation on her. The operation was scheduled for
June 17, 1985 at 9:00 in the morning at private respondent De Los Santos Medical Center (DLSMC).
Since neither petitioner Erlinda nor her husband, petitioner Rogelio, knew of any anesthesiologist, Dr.
Hosaka recommended to them the services of Dr. Gutierrez.
Petitioner Erlinda was admitted to the DLSMC the day before the scheduled operation. By 7:30 in the
morning of the following day, petitioner Erlinda was already being prepared for operation. Upon the
request of petitioner Erlinda, her sister-in-law, Herminda Cruz, who was then Dean of the College of
Nursing at the Capitol Medical Center, was allowed to accompany her inside the operating room.
At around 9:30 in the morning, Dr. Hosaka had not yet arrived so Dr. Gutierrez tried to get in touch
with him by phone. Thereafter, Dr. Gutierrez informed Cruz that the operation might be delayed due to
the late arrival of Dr. Hosaka. In the meantime, the patient, petitioner Erlinda said to Cruz, "Mindy,
inip na inip na ako, ikuha mo ako ng ibang Doctor."
By 10:00 in the morning, when Dr. Hosaka was still not around, petitioner Rogelio already wanted to
pull out his wife from the operating room. He met Dr. Garcia, who remarked that he was also tired of
waiting for Dr. Hosaka. Dr. Hosaka finally arrived at the hospital at around 12:10 in the afternoon, or
more than three (3) hours after the scheduled operation.
Cruz, who was then still inside the operating room, heard about Dr. Hosaka’s arrival. While she held
the hand of Erlinda, Cruz saw Dr. Gutierrez trying to intubate the patient. Cruz heard Dr. Gutierrez
utter: "ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan." Cruz noticed a
bluish discoloration of Erlinda’s nailbeds on her left hand. She (Cruz) then heard Dr. Hosaka instruct
someone to call Dr. Calderon, another anesthesiologist. When he arrived, Dr. Calderon attempted to
intubate the patient. The nailbeds of the patient remained bluish, thus, she was placed in a
trendelenburg position – a position where the head of the patient is placed in a position lower than her
feet. At this point, Cruz went out of the operating room to express her concern to petitioner Rogelio that
Erlinda’s operation was not going well.
Cruz quickly rushed back to the operating room and saw that the patient was still in trendelenburg
position. At almost 3:00 in the afternoon, she saw Erlinda being wheeled to the Intensive Care Unit
(ICU). The doctors explained to petitioner Rogelio that his wife had bronchospasm. Erlinda stayed in
the ICU for a month. She was released from the hospital only four months later or on November 15,
1985. Since the ill-fated operation, Erlinda remained in comatose condition until she died on August 3,
1999.1
Petitioners filed with the Regional Trial Court of Quezon City a civil case for damages against private
respondents. After due trial, the court a quo rendered judgment in favor of petitioners. Essentially, the
trial court found that private respondents were negligent in the performance of their duties to Erlinda.
On appeal by private respondents, the Court of Appeals reversed the trial court’s decision and directed
petitioners to pay their "unpaid medical bills" to private respondents.
Petitioners filed with this Court a petition for review on certiorari. The private respondents were then
required to submit their respective comments thereon. On December 29, 1999, this Court promulgated
the decision which private respondents now seek to be reconsidered. The dispositive portion of said
Decision states:
WHEREFORE, the decision and resolution of the appellate court appealed from are hereby
modified so as to award in favor of petitioners, and solidarily against private respondents the
following: 1) P1,352,000.00 as actual damages computed as of the date of promulgation of this
decision plus a monthly payment of P8,000.00 up to the time that petitioner Erlinda Ramos
expires or miraculously survives; 2) P2,000,000.00 as moral damages, 3) P1,500,000.00 as
temperate damages; 4) P100,000.00 each exemplary damages and attorney’s fees; and 5) the
costs of the suit.2
In his Motion for Reconsideration, private respondent Dr. Hosaka submits the following as grounds
therefor:
I
THE HONORABLE SUPREME COURT COMMITTED REVERSIBLE ERROR WHEN IT HELD
RESPONDENT DR. HOSAKA LIABLE ON THE BASIS OF THE "CAPTAIN-OF-THE-SHIP"
DOCTRINE.
II
THE HONORABLE SUPREME COURT ERRED IN HOLDING RESPONDENT DR. HOSAKA
LIABLE DESPITE THE FACT THAT NO NEGLIGENCE CAN BE ATTRIBUTABLE TO HIM.
III
ASSUMING WITHOUT ADMITTING THAT RESPONDENT DR. HOSAKA IS LIABLE, THE
HONORABLE SUPREME COURT ERRED IN AWARDING DAMAGES THAT WERE CLEARLY
EXCESSIVE AND WITHOUT LEGAL BASIS.3
Private respondent Dr. Gutierrez, for her part, avers that:
A. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY
OVERLOOKED THE FACT THAT THE COURT OF APPEAL’S DECISION DATED 29
MAY 1995 HAD ALREADY BECOME FINAL AND EXECUTORY AS OF 25 JUNE 1995,
THEREBY DEPRIVING THIS HONORABLE COURT OF JURISDICTION OVER THE
INSTANT PETITION;
B. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY
OVERLOOKED SEVERAL MATERIAL FACTUAL CIRCUMSTANCES WHICH, IF
PROPERLY CONSIDERED, WOULD INDUBITABLY LEAD TO NO OTHER
CONCLUSION BUT THAT PRIVATE RESPONDENT DOCTORS WERE NOT GUILTY OF
ANY NEGLIGENCE IN RESPECT OF THE INSTANT CASE;
B.1 RESPONDENT DOCTOR PERFECTA GUTIERREZ HAS SUFFICIENTLY
DISCHARGED THE BURDEN OF EVIDENCE BY SUBSTANTIAL PROOF OF HER
COMPLIANCE WITH THE STANDARDS OF DUE CARE EXPECTED IN HER
RESPECTIVE FIELD OF MEDICAL SPECIALIZATION.
B.2 RESPONDENT DOCTOR PERFECTA GUTIERREZ HAS SUFFICIENTLY
DISCHARGED THE BURDEN OF EVIDENCE BY SUBSTANTIAL PROOF OF HER
HAVING SUCCESSFULLY INTUBATED PATIENT ERLINDA RAMOS
C. THE SUPREME COURT MAY HAVE INADVERTENTLY PLACED TOO MUCH
RELIANCE ON THE TESTIMONY OF PETITIONER’S WITNESS HERMINDA CRUZ,
DESPITE THE EXISTENCE OF SEVERAL FACTUAL CIRCUMSTANCES WHICH
RENDERS DOUBT ON HER CREDIBILITY
D. THE SUPREME COURT MAY HAVE INADVERTENTLY DISREGARDED THE
EXPERT TESTIMONY OF DR. JAMORA AND DRA. CALDERON
E. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY AWARDED
DAMAGES TO PETITIONERS DESPITE THE FACT THAT THERE WAS NO
NEGLIGENCE ON THE PART OF RESPONDENT DOCTOR.4
Private respondent De Los Santos Medical Center likewise moves for reconsideration on the following
grounds:
I
THE HONORABLE COURT ERRED IN GIVING DUE COURSE TO THE INSTANT PETITION AS
THE DECISION OF THE HONORABLE COURT OF APPEALS HAD ALREADY BECOME FINAL
AND EXECUTORY
 II
THE HONORABLE SUPREME COURT ERRED IN FINDING THAT AN EMPLOYER-
EMPLOYEE [RELATIONSHIP] EXISTS BETWEEN RESPONDENT DE LOS SANTOS MEDICAL
CENTER AND DRS. ORLINO HOSAKA AND PERFECTA GUTIERREZ
III
THE HONORABLE SUPREME COURT ERRED IN FINDING THAT RESPONDENT DE LOS
SANTOS MEDICAL CENTER IS SOLIDARILY LIABLE WITH RESPONDENT DOCTORS
IV
THE HONORABLE SUPREME COURT ERRED IN INCREASING THE AWARD OF DAMAGES
IN FAVOR OF PETITIONERS.5
In the Resolution of February 21, 2000, this Court denied the motions for reconsideration of private
respondents Drs. Hosaka and Gutierrez. They then filed their respective second motions for
reconsideration. The Philippine College of Surgeons filed its Petition-in-Intervention contending in the
main that this Court erred in holding private respondent Dr. Hosaka liable under the captain of the ship
doctrine. According to the intervenor, said doctrine had long been abandoned in the United States in
recognition of the developments in modern medical and hospital practice.6 The Court noted these
pleadings in the Resolution of July 17, 2000.7
On March 19, 2001, the Court heard the oral arguments of the parties, including the intervenor. Also
present during the hearing were the amicii curiae: Dr. Felipe A. Estrella, Jr., Consultant of the
Philippine Charity Sweepstakes, former Director of the Philippine General Hospital and former
Secretary of Health; Dr. Iluminada T. Camagay, President of the Philippine Society of
Anesthesiologists, Inc. and Professor and Vice-Chair for Research, Department of Anesthesiology,
College of Medicine-Philippine General Hospital, University of the Philippines; and Dr. Lydia M.
Egay, Professor and Vice-Chair for Academics, Department of Anesthesiology, College of Medicine-
Philippine General Hospital, University of the Philippines.
The Court enumerated the issues to be resolved in this case as follows:
1. WHETHER OR NOT DR. ORLINO HOSAKA (SURGEON) IS LIABLE FOR
NEGLIGENCE;
2. WHETHER OR NOT DR. PERFECTA GUTIERREZ (ANESTHESIOLOGIST) IS LIABLE
FOR NEGLIGENCE; AND
3. WHETHER OR NOT THE HOSPITAL (DELOS SANTOS MEDICAL CENTER) IS
LIABLE FOR ANY ACT OF NEGLIGENCE COMMITTED BY THEIR VISITING
CONSULTANT SURGEON AND ANESTHESIOLOGIST.8
We shall first resolve the issue pertaining to private respondent Dr. Gutierrez. She maintains that the
Court erred in finding her negligent and in holding that it was the faulty intubation which was the
proximate cause of Erlinda’s comatose condition. The following objective facts allegedly negate a
finding of negligence on her part: 1) That the outcome of the procedure was a comatose patient and not
a dead one; 2) That the patient had a cardiac arrest; and 3) That the patient was revived from that
cardiac arrest.9 In effect, Dr. Gutierrez insists that, contrary to the finding of this Court, the intubation
she performed on Erlinda was successful.
Unfortunately, Dr. Gutierrez’ claim of lack of negligence on her part is belied by the records of the
case. It has been sufficiently established that she failed to exercise the standards of care in the
administration of anesthesia on a patient. Dr. Egay enlightened the Court on what these standards are:
 x x x What are the standards of care that an anesthesiologist should do before we administer
anesthesia? The initial step is the preparation of the patient for surgery and this is a pre-
operative evaluation because the anesthesiologist is responsible for determining the medical
status of the patient, developing the anesthesia plan and acquainting the patient or the
responsible adult particularly if we are referring with the patient or to adult patient who may not
have, who may have some mental handicaps of the proposed plans. We do pre-operative
evaluation because this provides for an opportunity for us to establish identification and
personal acquaintance with the patient. It also makes us have an opportunity to alleviate anxiety,
explain techniques and risks to the patient, given the patient the choice and establishing consent
to proceed with the plan. And lastly, once this has been agreed upon by all parties concerned the
ordering of pre-operative medications. And following this line at the end of the evaluation we
usually come up on writing, documentation is very important as far as when we train an
anesthesiologist we always emphasize this because we need records for our protection, well,
records. And it entails having brief summary of patient history and physical findings pertinent to
anesthesia, plan, organize as a problem list, the plan anesthesia technique, the plan post
operative, pain management if appropriate, special issues for this particular patient. There are
needs for special care after surgery and if it so it must be written down there and a request must
be made known to proper authorities that such and such care is necessary. And the request for
medical evaluation if there is an indication. When we ask for a cardio-pulmonary clearance it is
not in fact to tell them if this patient is going to be fit for anesthesia, the decision to give
anesthesia rests on the anesthesiologist. What we ask them is actually to give us the functional
capacity of certain systems which maybe affected by the anesthetic agent or the technique that
we are going to use. But the burden of responsibility in terms of selection of agent and how to
administer it rest on the anesthesiologist.10
The conduct of a preanesthetic/preoperative evaluation prior to an operation, whether elective or
emergency, cannot be dispensed with.11 Such evaluation is necessary for the formulation of a plan of
anesthesia care suited to the needs of the patient concerned.
Pre-evaluation for anesthesia involves taking the patient’s medical history, reviewing his current drug
therapy, conducting physical examination, interpreting laboratory data, and determining the appropriate
prescription of preoperative medications as necessary to the conduct of anesthesia.12
Physical examination of the patient entails not only evaluating the patient’s central nervous system,
cardiovascular system and lungs but also the upper airway. Examination of the upper airway would in
turn include an analysis of the patient’s cervical spine mobility, temporomandibular mobility,
prominent central incisors, deceased or artificial teeth, ability to visualize uvula and the thyromental
distance.13
Nonetheless, Dr. Gutierrez omitted to perform a thorough preoperative evaluation on Erlinda. As she
herself admitted, she saw Erlinda for the first time on the day of the operation itself, one hour before
the scheduled operation. She auscultated14 the patient’s heart and lungs and checked the latter’s blood
pressure to determine if Erlinda was indeed fit for operation.15 However, she did not proceed to
examine the patient’s airway. Had she been able to check petitioner Erlinda’s airway prior to the
operation, Dr. Gutierrez would most probably not have experienced difficulty in intubating the former,
and thus the resultant injury could have been avoided. As we have stated in our Decision:
In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda for the first time on
the day of the operation itself, on 17 June 1985. Before this date, no prior consultations with, or
pre-operative evaluation of Erlinda was done by her. Until the day of the operation, respondent
Dra. Gutierrez was unaware of the physiological make-up and needs of Erlinda. She was
likewise not properly informed of the possible difficulties she would face during the
 administration of anesthesia to Erlinda. Respondent Dra. Gutierrez’ act of seeing her patient for
the first time only an hour before the scheduled operative procedure was, therefore, an act of
exceptional negligence and professional irresponsibility. The measures cautioning prudence and
vigilance in dealing with human lives lie at the core of the physician’s centuries-old Hippocratic
Oath. Her failure to follow this medical procedure is, therefore, a clear indicia of her
negligence.16
Further, there is no cogent reason for the Court to reverse its finding that it was the faulty intubation on
Erlinda that caused her comatose condition. There is no question that Erlinda became comatose after
Dr. Gutierrez performed a medical procedure on her. Even the counsel of Dr. Gutierrez admitted to this
fact during the oral arguments:
CHIEF JUSTICE:
Mr. Counsel, you started your argument saying that this involves a comatose patient?
ATTY. GANA:
Yes, Your Honor.
CHIEF JUSTICE:
How do you mean by that, a comatose, a comatose after any other acts were done by Dr.
Gutierrez or comatose before any act was done by her?
ATTY. GANA:
No, we meant comatose as a final outcome of the procedure.
CHIEF JUSTICE:
Meaning to say, the patient became comatose after some intervention, professional acts
have been done by Dr. Gutierrez?
ATTY. GANA:
Yes, Your Honor.
CHIEF JUSTICE:
In other words, the comatose status was a consequence of some acts performed by D.
Gutierrez?
ATTY. GANA:
It was a consequence of the well, (interrupted)
CHIEF JUSTICE:
An acts performed by her, is that not correct?
ATTY. GANA:
Yes, Your Honor.
CHIEF JUSTICE:
Thank you.17
What is left to be determined therefore is whether Erlinda’s hapless condition was due to any fault or
negligence on the part of Dr. Gutierrez while she (Erlinda) was under the latter’s care. Dr. Gutierrez
maintains that the bronchospasm and cardiac arrest resulting in the patient’s comatose condition was
brought about by the anaphylactic reaction of the patient to Thiopental Sodium (pentothal).18 In the
Decision, we explained why we found Dr. Gutierrez’ theory unacceptable. In the first place, Dr.
Eduardo Jamora, the witness who was presented to support her (Dr. Gutierrez) theory, was a
pulmonologist. Thus, he could not be considered an authority on anesthesia practice and procedure and
their complications.19
Secondly, there was no evidence on record to support the theory that Erlinda developed an allergic
reaction to pentothal. Dr. Camagay enlightened the Court as to the manifestations of an allergic reaction
in this wise:
DR. CAMAGAY:
All right, let us qualify an allergic reaction. In medical terminology an allergic reaction
is something which is not usual response and it is further qualified by the release of a
hormone called histamine and histamine has an effect on all the organs of the body
generally release because the substance that entered the body reacts with the particular
cell, the mass cell, and the mass cell secretes this histamine. In a way it is some form of
response to take away that which is not mine, which is not part of the body. So,
histamine has multiple effects on the body. So, one of the effects as you will see you will
have redness, if you have an allergy you will have tearing of the eyes, you will have
swelling, very crucial swelling sometimes of the larynges which is your voice box main
airway, that swelling may be enough to obstruct the entry of air to the trachea and you
could also have contraction, constriction of the smaller airways beyond the trachea, you
see you have the trachea this way, we brought some visual aids but unfortunately we do
not have a projector. And then you have the smaller airways, the bronchi and then
eventually into the mass of the lungs you have the bronchus. The difference is that these
tubes have also in their walls muscles and this particular kind of muscles is smooth
muscle so, when histamine is released they close up like this and that phenomenon is
known as bronco spasm. However, the effects of histamine also on blood vessels are
different. They dilate blood vessel open up and the patient or whoever has this histamine
release has hypertension or low blood pressure to a point that the patient may have
decrease blood supply to the brain and may collapse so, you may have people who have
this.20
These symptoms of an allergic reaction were not shown to have been extant in Erlinda’s case. As we
held in our Decision, "no evidence of stridor, skin reactions, or wheezing – some of the more common
accompanying signs of an allergic reaction – appears on record. No laboratory data were ever presented
to the court."21
Dr. Gutierrez, however, insists that she successfully intubated Erlinda as evidenced by the fact that she
was revived after suffering from cardiac arrest. Dr. Gutierrez faults the Court for giving credence to the
testimony of Cruz on the matter of the administration of anesthesia when she (Cruz), being a nurse, was
allegedly not qualified to testify thereon. Rather, Dr. Gutierrez invites the Court’s attention to her
synopsis on what transpired during Erlinda’s intubation:
12:15 p.m. Patient was inducted with sodium pentothal 2.5% (250 mg) given by slow IV. 02
was started by mask. After pentothal injection this was followed by IV injection of Norcuron
4mg. After 2 minutes 02 was given by positive pressure for about one minute. Intubation with
endotracheal tube 7.5 m in diameter was done with slight difficulty (short neck & slightly
prominent upper teeth) chest was examined for breath sounds & checked if equal on both sides.
The tube was then anchored to the mouth by plaster & cuff inflated. Ethrane 2% with 02 4 liters
was given. Blood pressure was checked 120/80 & heart rate regular and normal 90/min.
 12:25 p.m. After 10 minutes patient was cyanotic. Ethrane was discontinued & 02 given alone.
Cyanosis disappeared. Blood pressure and heart beats stable.
12:30 p.m. Cyanosis again reappeared this time with sibilant and sonorous rales all over the
chest. D_5%_H20 & 1 ampule of aminophyline by fast drip was started. Still the cyanosis was
persistent. Patient was connected to a cardiac monitor. Another ampule of of [sic] aminophyline
was given and solu cortef was given.
12:40 p.m. There was cardiac arrest. Extra cardiac massage and intercardiac injection of
adrenalin was given & heart beat reappeared in less than one minute. Sodium bicarbonate &
another dose of solu cortef was given by IV. Cyanosis slowly disappeared & 02 continuously
given & assisted positive pressure. Laboratory exams done (see results in chart).
Patient was transferred to ICU for further management.22
From the foregoing, it can be allegedly seen that there was no withdrawal (extubation) of the tube. And
the fact that the cyanosis allegedly disappeared after pure oxygen was supplied through the tube proved
that it was properly placed.
The Court has reservations on giving evidentiary weight to the entries purportedly contained in Dr.
Gutierrez’ synopsis. It is significant to note that the said record prepared by Dr. Gutierrez was made
only after Erlinda was taken out of the operating room. The standard practice in anesthesia is that every
single act that the anesthesiologist performs must be recorded. In Dr. Gutierrez’ case, she could not
account for at least ten (10) minutes of what happened during the administration of anesthesia on
Erlinda. The following exchange between Dr. Estrella, one of the amicii curiae, and Dr. Gutierrez is
instructive:
DR. ESTRELLA
Q You mentioned that there were two (2) attempts in the intubation period?
DR. GUTIERREZ
Yes.
Q There were two attempts. In the first attempt was the tube inserted or was the
laryngoscope only inserted, which was inserted?
A All the laryngoscope.
Q All the laryngoscope. But if I remember right somewhere in the re-direct, a certain
lawyer, you were asked that you did a first attempt and the question was – did you withdraw the
tube? And you said – you never withdrew the tube, is that right?
A Yes.
Q Yes. And so if you never withdrew the tube then there was no, there was no insertion of
the tube during that first attempt. Now, the other thing that we have to settle here is – when
cyanosis occurred, is it recorded in the anesthesia record when the cyanosis, in your recording
when did the cyanosis occur?
A (sic)
Q Is it a standard practice of anesthesia that whatever you do during that period or from the
time of induction to the time that you probably get the patient out of the operating room that
every single action that you do is so recorded in your anesthesia record?
A I was not able to record everything I did not have time anymore because I did that after
the, when the patient was about to leave the operating room. When there was second cyanosis
already that was the (interrupted)
Q When was the first cyanosis?
A The first cyanosis when I was (interrupted)
Q What time, more or less?
A I think it was 12:15 or 12:16.
Q Well, if the record will show you started induction at 12:15?
A Yes, Your Honor.
Q And the first medication you gave was what?
A The first medication, no, first the patient was oxygenated for around one to two minutes.
Q Yes, so, that is about 12:13?
A Yes, and then, I asked the resident physician to start giving the pentothal very slowly and
that was around one minute.
Q So, that is about 12:13 no, 12:15, 12:17?
A Yes, and then, after one minute another oxygenation was given and after (interrupted)
Q 12:18?
A Yes, and then after giving the oxygen we start the menorcure which is a relaxant. After
that relaxant (interrupted)
Q After that relaxant, how long do you wait before you do any manipulation?
A Usually you wait for two minutes or three minutes.
Q So, if our estimate of the time is accurate we are now more or less 12:19, is that right?
A Maybe.
Q 12:19. And at that time, what would have been done to this patient?
A After that time you examine the, if there is relaxation of the jaw which you push it
downwards and when I saw that the patient was relax because that monorcure is a relaxant, you
cannot intubate the patient or insert the laryngoscope if it is not keeping him relax. So, my first
attempt when I put the laryngoscope on I saw the trachea was deeply interiorly. So, what I did
ask "mahirap ata ito ah." So, I removed the laryngoscope and oxygenated again the patient.
Q So, more or less you attempted to do an intubation after the first attempt as you claimed
that it was only the laryngoscope that was inserted.
A Yes.
Q And in the second attempt you inserted the laryngoscope and now possible intubation?
A Yes.
Q And at that point, you made a remark, what remark did you make?
A I said "mahirap ata ito" when the first attempt I did not see the trachea right away. That
was when I (interrupted)
Q That was the first attempt?
A Yes.
Q What about the second attempt?
A On the second attempt I was able to intubate right away within two to three seconds.
Q At what point, for purposes of discussion without accepting it, at what point did you
make the comment "na mahirap ata to intubate, mali ata ang pinasukan"
A I did not say "mali ata ang pinasukan" I never said that.
Q Well, just for the information of the group here the remarks I am making is based on the
documents that were forwarded to me by the Supreme Court. That is why for purposes of
discussion I am trying to clarify this for the sake of enlightenment. So, at what point did you
ever make that comment?
A Which one, sir?
Q The "mahirap intubate ito" assuming that you (interrupted)
A Iyon lang, that is what I only said "mahirap intubate (interrupted)
Q At what point?
A When the first attempt when I inserted the laryngoscope for the first time.
Q So, when you claim that at the first attempt you inserted the laryngoscope, right?
A Yes.
Q But in one of the recordings somewhere at the, somewhere in the transcript of records
that when the lawyer of the other party try to inquire from you during the first attempt that was
the time when "mayroon ba kayong hinugot sa tube, I do not remember the page now, but it
seems to me it is there. So, that it was on the second attempt that (interrupted)
A I was able to intubate.
Q And this is more or less about what time 12:21?
A Maybe, I cannot remember the time, Sir.
Q Okay, assuming that this was done at 12:21 and looking at the anesthesia records from
12:20 to 12:30 there was no recording of the vital signs. And can we presume that at this stage
there was already some problems in handling the patient?
A Not yet.
Q But why are there no recordings in the anesthesia record?
A I did not have time.
Q Ah, you did not have time, why did you not have time?
A Because it was so fast, I really (at this juncture the witness is laughing)
Q No, I am just asking. Remember I am not here not to pin point on anybody I am here just
to more or less clarify certainty more ore less on the record.
A Yes, Sir.
Q And so it seems that there were no recording during that span of ten (10) minutes. From
12:20 to 12:30, and going over your narration, it seems to me that the cyanosis appeared ten
(10) minutes after induction, is that right?
 A Yes.
Q And that is after induction 12:15 that is 12:25 that was the first cyanosis?
A Yes.
Q And that the 12:25 is after the 12:20?
A We cannot (interrupted)
Q Huwag ho kayong makuwan, we are just trying to enlighten, I am just going over the
record ano, kung mali ito kuwan eh di ano. So, ganoon po ano, that it seems to me that there is
no recording from 12:20 to 12:30, so, I am just wondering why there were no recordings during
the period and then of course the second cyanosis, after the first cyanosis. I think that was the
time Dr. Hosaka came in?
A No, the first cyanosis (interrupted).23
We cannot thus give full credence to Dr. Gutierrez’ synopsis in light of her admission that it does not
fully reflect the events that transpired during the administration of anesthesia on Erlinda. As pointed out
by Dr. Estrella, there was a ten-minute gap in Dr. Gutierrez’ synopsis, i.e., the vital signs of Erlinda
were not recorded during that time. The absence of these data is particularly significant because, as
found by the trial court, it was the absence of oxygen supply for four (4) to five (5) minutes that caused
Erlinda’s comatose condition.
On the other hand, the Court has no reason to disbelieve the testimony of Cruz. As we stated in the
Decision, she is competent to testify on matters which she is capable of observing such as, the
statements and acts of the physician and surgeon, external appearances and manifest conditions which
are observable by any one.24 Cruz, Erlinda’s sister-in-law, was with her inside the operating room.
Moreover, being a nurse and Dean of the Capitol Medical Center School of Nursing at that, she is not
entirely ignorant of anesthetic procedure. Cruz narrated that she heard Dr. Gutierrez remark, "Ang
hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan." She observed that the
nailbeds of Erlinda became bluish and thereafter Erlinda was placed in trendelenburg position.25 Cruz
further averred that she noticed that the abdomen of Erlinda became distended.26
The cyanosis (bluish discoloration of the skin or mucous membranes caused by lack of oxygen or
abnormal hemoglobin in the blood) and enlargement of the stomach of Erlinda indicate that the
endotracheal tube was improperly inserted into the esophagus instead of the trachea. Consequently,
oxygen was delivered not to the lungs but to the gastrointestinal tract. This conclusion is supported by
the fact that Erlinda was placed in trendelenburg position. This indicates that there was a decrease of
blood supply to the patient’s brain. The brain was thus temporarily deprived of oxygen supply causing
Erlinda to go into coma.
The injury incurred by petitioner Erlinda does not normally happen absent any negligence in the
administration of anesthesia and in the use of an endotracheal tube. As was noted in our Decision, the
instruments used in the administration of anesthesia, including the endotracheal tube, were all under the
exclusive control of private respondents Dr. Gutierrez and Dr. Hosaka.27 In Voss vs. Bridwell,28 which
involved a patient who suffered brain damage due to the wrongful administration of anesthesia, and
even before the scheduled mastoid operation could be performed, the Kansas Supreme Court applied
the doctrine of res ipsa loquitur, reasoning that the injury to the patient therein was one which does not
ordinarily take place in the absence of negligence in the administration of an anesthetic, and in the use
and employment of an endotracheal tube. The court went on to say that "[o]rdinarily a person being put
under anesthesia is not rendered decerebrate as a consequence of administering such anesthesia in the
absence of negligence. Upon these facts and under these circumstances, a layman would be able to say,
as a matter of common knowledge and observation, that the consequences of professional treatment
were not as such as would ordinarily have followed if due care had been exercised."29 Considering the
application of the doctrine of res ipsa loquitur, the testimony of Cruz was properly given credence in
the case at bar.
For his part, Dr. Hosaka mainly contends that the Court erred in finding him negligent as a surgeon by
applying the Captain-of-the-Ship doctrine.30 Dr. Hosaka argues that the trend in United States
jurisprudence has been to reject said doctrine in light of the developments in medical practice. He
points out that anesthesiology and surgery are two distinct and specialized fields in medicine and as a
surgeon, he is not deemed to have control over the acts of Dr. Gutierrez. As anesthesiologist, Dr.
Gutierrez is a specialist in her field and has acquired skills and knowledge in the course of her training
which Dr. Hosaka, as a surgeon, does not possess.31 He states further that current American
jurisprudence on the matter recognizes that the trend towards specialization in medicine has created
situations where surgeons do not always have the right to control all personnel within the operating
room,32 especially a fellow specialist.33
Dr. Hosaka cites the case of Thomas v. Raleigh General Hospital,34 which involved a suit filed by a
patient who lost his voice due to the wrongful insertion of the endotracheal tube preparatory to the
administration of anesthesia in connection with the laparotomy to be conducted on him. The patient
sued both the anesthesiologist and the surgeon for the injury suffered by him. The Supreme Court of
Appeals of West Virginia held that the surgeon could not be held liable for the loss of the patient’s
voice, considering that the surgeon did not have a hand in the intubation of the patient. The court
rejected the application of the "Captain-of-the-Ship Doctrine," citing the fact that the field of medicine
has become specialized such that surgeons can no longer be deemed as having control over the other
personnel in the operating room. It held that "[a]n assignment of liability based on actual control more
realistically reflects the actual relationship which exists in a modern operating room."35 Hence, only
the anesthesiologist who inserted the endotracheal tube into the patient’s throat was held liable for the
injury suffered by the latter.
This contention fails to persuade.
That there is a trend in American jurisprudence to do away with the Captain-of-the-Ship doctrine does
not mean that this Court will ipso facto follow said trend. Due regard for the peculiar factual
circumstances obtaining in this case justify the application of the Captain-of-the-Ship doctrine. From
the facts on record it can be logically inferred that Dr. Hosaka exercised a certain degree of, at the very
least, supervision over the procedure then being performed on Erlinda.
First, it was Dr. Hosaka who recommended to petitioners the services of Dr. Gutierrez. In effect, he
represented to petitioners that Dr. Gutierrez possessed the necessary competence and skills. Drs.
Hosaka and Gutierrez had worked together since 1977. Whenever Dr. Hosaka performed a surgery, he
would always engage the services of Dr. Gutierrez to administer the anesthesia on his patient.36
Second, Dr. Hosaka himself admitted that he was the attending physician of Erlinda. Thus, when
Erlinda showed signs of cyanosis, it was Dr. Hosaka who gave instructions to call for another
anesthesiologist and cardiologist to help resuscitate Erlinda.37
Third, it is conceded that in performing their responsibilities to the patient, Drs. Hosaka and Gutierrez
worked as a team. Their work cannot be placed in separate watertight compartments because their
duties intersect with each other.38
While the professional services of Dr. Hosaka and Dr. Gutierrez were secured primarily for their
performance of acts within their respective fields of expertise for the treatment of petitioner Erlinda,
and that one does not exercise control over the other, they were certainly not completely independent of
each other so as to absolve one from the negligent acts of the other physician.
That they were working as a medical team is evident from the fact that Dr. Hosaka was keeping an eye
on the intubation of the patient by Dr. Gutierrez, and while doing so, he observed that the patient’s nails
had become dusky and had to call Dr. Gutierrez’s attention thereto. The Court also notes that the
counsel for Dr. Hosaka admitted that in practice, the anesthesiologist would also have to observe the
surgeon’s acts during the surgical process and calls the attention of the surgeon whenever necessary39
in the course of the treatment. The duties of Dr. Hosaka and those of Dr. Gutierrez in the treatment of
petitioner Erlinda are therefore not as clear-cut as respondents claim them to be. On the contrary, it is
quite apparent that they have a common responsibility to treat the patient, which responsibility
necessitates that they call each other’s attention to the condition of the patient while the other physician
is performing the necessary medical procedures.
It is equally important to point out that Dr. Hosaka was remiss in his duty of attending to petitioner
Erlinda promptly, for he arrived more than three (3) hours late for the scheduled operation. The
cholecystectomy was set for June 17, 1985 at 9:00 a.m., but he arrived at DLSMC only at around 12:10
p.m. In reckless disregard for his patient’s well being, Dr. Hosaka scheduled two procedures on the
same day, just thirty minutes apart from each other, at different hospitals. Thus, when the first
procedure (protoscopy) at the Sta. Teresita Hospital did not proceed on time, Erlinda was kept in a state
of uncertainty at the DLSMC.
The unreasonable delay in petitioner Erlinda’s scheduled operation subjected her to continued
starvation and consequently, to the risk of acidosis,40 or the condition of decreased alkalinity of the
blood and tissues, marked by sickly sweet breath, headache, nausea and vomiting, and visual
disturbances.41 The long period that Dr. Hosaka made Erlinda wait for him certainly aggravated the
anxiety that she must have been feeling at the time. It could be safely said that her anxiety adversely
affected the administration of anesthesia on her. As explained by Dr. Camagay, the patient’s anxiety
usually causes the outpouring of adrenaline which in turn results in high blood pressure or disturbances
in the heart rhythm:
DR. CAMAGAY:
x x x Pre-operative medication has three main functions: One is to alleviate anxiety.
Second is to dry up the secretions and Third is to relieve pain. Now, it is very important
to alleviate anxiety because anxiety is associated with the outpouring of certain
substances formed in the body called adrenalin. When a patient is anxious there is an
outpouring of adrenalin which would have adverse effect on the patient. One of it is high
blood pressure, the other is that he opens himself to disturbances in the heart rhythm,
which would have adverse implications. So, we would like to alleviate patient’s anxiety
mainly because he will not be in control of his body there could be adverse results to
surgery and he will be opened up; a knife is going to open up his body. x x x42
Dr. Hosaka cannot now claim that he was entirely blameless of what happened to Erlinda. His conduct
clearly constituted a breach of his professional duties to Erlinda:
CHIEF JUSTICE:
Two other points. The first, Doctor, you were talking about anxiety, would you consider
a patient's stay on the operating table for three hours sufficient enough to aggravate or
magnify his or her anxiety?
DR. CAMAGAY:
Yes.
 CHIEF JUSTICE:
In other words, I understand that in this particular case that was the case, three hours
waiting and the patient was already on the operating table (interrupted)
DR. CAMAGAY:
Yes.
CHIEF JUSTICE:
Would you therefore conclude that the surgeon contributed to the aggravation of the
anxiety of the patient?
DR. CAMAGAY:
That this operation did not take place as scheduled is already a source of anxiety and
most operating tables are very narrow and that patients are usually at risk of falling on
the floor so there are restraints that are placed on them and they are never, never left
alone in the operating room by themselves specially if they are already pre-medicated
because they may not be aware of some of their movement that they make which would
contribute to their injury.
CHIEF JUSTICE:
In other words due diligence would require a surgeon to come on time?
DR. CAMAGAY:
I think it is not even due diligence it is courtesy.
CHIEF JUSTICE:
Courtesy.
DR. CAMAGAY:
And care.
CHIEF JUSTICE:
Duty as a matter of fact?
DR. CAMAGAY:
Yes, Your Honor.43
Dr. Hosaka's irresponsible conduct of arriving very late for the scheduled operation of petitioner
Erlinda is violative, not only of his duty as a physician "to serve the interest of his patients with the
greatest solicitude, giving them always his best talent and skill,"44 but also of Article 19 of the Civil
Code which requires a person, in the performance of his duties, to act with justice and give everyone
his due.
Anent private respondent DLSMC’s liability for the resulting injury to petitioner Erlinda, we held that
respondent hospital is solidarily liable with respondent doctors therefor under Article 2180 of the Civil
Code45 since there exists an employer-employee relationship between private respondent DLSMC and
Drs. Gutierrez and Hosaka:
In other words, private hospitals, hire, fire and exercise real control over their attending and
visiting "consultant" staff. While "consultants" are not, technically employees, x x x the control
exercised, the hiring and the right to terminate consultants all fulfill the important hallmarks of
 an employer-employee relationship, with the exception of the payment of wages. In assessing
whether such a relationship in fact exists, the control test is determining. x x x46
DLSMC however contends that applying the four-fold test in determining whether such a relationship
exists between it and the respondent doctors, the inescapable conclusion is that DLSMC cannot be
considered an employer of the respondent doctors.
It has been consistently held that in determining whether an employer-employee relationship exists
between the parties, the following elements must be present: (1) selection and engagement of services;
(2) payment of wages; (3) the power to hire and fire; and (4) the power to control not only the end to be
achieved, but the means to be used in reaching such an end.47
DLSMC maintains that first, a hospital does not hire or engage the services of a consultant, but rather,
accredits the latter and grants him or her the privilege of maintaining a clinic and/or admitting patients
in the hospital upon a showing by the consultant that he or she possesses the necessary qualifications,
such as accreditation by the appropriate board (diplomate), evidence of fellowship and references.48
Second, it is not the hospital but the patient who pays the consultant’s fee for services rendered by the
latter.49 Third, a hospital does not dismiss a consultant; instead, the latter may lose his or her
accreditation or privileges granted by the hospital.50 Lastly, DLSMC argues that when a doctor refers a
patient for admission in a hospital, it is the doctor who prescribes the treatment to be given to said
patient. The hospital’s obligation is limited to providing the patient with the preferred room
accommodation, the nutritional diet and medications prescribed by the doctor, the equipment and
facilities necessary for the treatment of the patient, as well as the services of the hospital staff who
perform the ministerial tasks of ensuring that the doctor’s orders are carried out strictly.51
After a careful consideration of the arguments raised by DLSMC, the Court finds that respondent
hospital’s position on this issue is meritorious. There is no employer-employee relationship between
DLSMC and Drs. Gutierrez and Hosaka which would hold DLSMC solidarily liable for the injury
suffered by petitioner Erlinda under Article 2180 of the Civil Code.
As explained by respondent hospital, that the admission of a physician to membership in DLSMC’s
medical staff as active or visiting consultant is first decided upon by the Credentials Committee thereof,
which is composed of the heads of the various specialty departments such as the Department of
Obstetrics and Gynecology, Pediatrics, Surgery with the department head of the particular specialty
applied for as chairman. The Credentials Committee then recommends to DLSMC's Medical Director
or Hospital Administrator the acceptance or rejection of the applicant physician, and said director or
administrator validates the committee's recommendation.52 Similarly, in cases where a disciplinary
action is lodged against a consultant, the same is initiated by the department to whom the consultant
concerned belongs and filed with the Ethics Committee consisting of the department specialty heads.
The medical director/hospital administrator merely acts as ex-officio member of said committee.
Neither is there any showing that it is DLSMC which pays any of its consultants for medical services
rendered by the latter to their respective patients. Moreover, the contract between the consultant in
respondent hospital and his patient is separate and distinct from the contract between respondent
hospital and said patient. The first has for its object the rendition of medical services by the consultant
to the patient, while the second concerns the provision by the hospital of facilities and services by its
staff such as nurses and laboratory personnel necessary for the proper treatment of the patient.
Further, no evidence was adduced to show that the injury suffered by petitioner Erlinda was due to a
failure on the part of respondent DLSMC to provide for hospital facilities and staff necessary for her
treatment.
For these reasons, we reverse the finding of liability on the part of DLSMC for the injury suffered by
petitioner Erlinda.
Finally, the Court also deems it necessary to modify the award of damages to petitioners in view of the
supervening event of petitioner Erlinda’s death. In the assailed Decision, the Court awarded actual
damages of One Million Three Hundred Fifty Two Thousand Pesos (P1,352,000.00) to cover the
expenses for petitioner Erlinda’s treatment and care from the date of promulgation of the Decision up to
the time the patient expires or survives.53 In addition thereto, the Court awarded temperate damages of
One Million Five Hundred Thousand Pesos (P1,500,000.00) in view of the chronic and continuing
nature of petitioner Erlinda’s injury and the certainty of further pecuniary loss by petitioners as a result
of said injury, the amount of which, however, could not be made with certainty at the time of the
promulgation of the decision. The Court justified such award in this manner:
Our rules on actual or compensatory damages generally assume that at the time of litigation, the
injury suffered as a consequence of an act of negligence has been completed and that the cost
can be liquidated. However, these provisions neglect to take into account those situations, as in
this case, where the resulting injury might be continuing and possible future complications
directly arising from the injury, while certain to occur, are difficult to predict.
In these cases, the amount of damages which should be awarded, if they are to adequately and
correctly respond to the injury caused, should be one which compensates for pecuniary loss
incurred and proved, up to the time of trial; and one which would meet pecuniary loss certain to
be suffered but which could not, from the nature of the case, be made with certainty. In other
words, temperate damages can and should be awarded on top of actual or compensatory
damages in instances where the injury is chronic and continuing. And because of the unique
nature of such cases, no incompatibility arises when both actual and temperate damages are
provided for. The reason is that these damages cover two distinct phases.
As it would not be equitable—and certainly not in the best interests of the administration of
justice—for the victim in such cases to constantly come before the courts and invoke their aid in
seeking adjustments to the compensatory damages previously awarded—temperate damages are
appropriate. The amount given as temperate damages, though to a certain extent speculative,
should take into account the cost of proper care.
In the instant case, petitioners were able to provide only home-based nursing care for a
comatose patient who has remained in that condition for over a decade. Having premised our
award for compensatory damages on the amount provided by petitioners at the onset of
litigation, it would be now much more in step with the interests of justice if the value awarded
for temperate damages would allow petitioners to provide optimal care for their loved one in a
facility which generally specializes in such care. They should not be compelled by dire
circumstances to provide substandard care at home without the aid of professionals, for
anything less would be grossly inadequate. Under the circumstances, an award of P1,500,000.00
in temperate damages would therefore be reasonable.54
However, subsequent to the promulgation of the Decision, the Court was informed by petitioner
Rogelio that petitioner Erlinda died on August 3, 1999.55 In view of this supervening event, the award
of temperate damages in addition to the actual or compensatory damages would no longer be justified
since the actual damages awarded in the Decision are sufficient to cover the medical expenses incurred
by petitioners for the patient. Hence, only the amounts representing actual, moral and exemplary
damages, attorney’s fees and costs of suit should be awarded to petitioners.
WHEREFORE, the assailed Decision is hereby modified as follows:
(1) Private respondent De Los Santos Medical Center is hereby absolved from liability arising from the
injury suffered by petitioner Erlinda Ramos on June 17, 1985;
(2) Private respondents Dr. Orlino Hosaka and Dr. Perfecta Gutierrez are hereby declared to be
solidarily liable for the injury suffered by petitioner Erlinda on June 17, 1985 and are ordered to pay
petitioners—
(a) P1,352,000.00 as actual damages;
(b) P2,000,000.00 as moral damages;
(c) P100,000.00 as exemplary damages;
(d) P100,000.00 as attorney’s fees; and
(e) the costs of the suit.
SO ORDERED.
Ramos vs Court of Appeals
GR No. 124354 December 29, 1999
Facts: Plaintiff Erlinda Ramos was, until the afternoon of June 17, 1985 a 47-year old robust woman.
Except for occasional complaints of discomfort due to pains allegedly caused by presence of a stone in
her gall bladder, she was as normal as any other woman. Married to Rogelio Ramos, an executive of
Philippine Long Distance Telephone Company (PLDT), she has three children whose names are
Rommel, Roy Roderick, and Ron Raymond. Because of the discomforts somehow interfered with her
normal ways, she sough professional advice. She was told to undergo an operation for the removal of a
stone in her gall bladder. She underwent series of examination which revealed that she was fit for the
said surgery. Through the intercession of a mutual friend, she and her husband met Dr. Osaka for the
first time and she was advised by Dr. Osaka to go under the operation called cholecystectomy and the
same was agreed to be scheduled on June 17,1985 at 9:00am at the Delos Santos Medical Center.
Rogelio asked Dr. Osaka to look for a good anesthesiologist to which the latter agreed to. A day before
the scheduled operation, she was admitted at the hospital and on the day of the operation, Erlinda’s
sister was with her insider the operating room. Dr. Osaka arrived at the hospital late, Dr. Guttierez, the
anesthesiologist, started to intubate Erlina when Herminda heard her say that intubating Erlinda is quite
difficult and there were complications. This prompt Dr. Osaka to order a call to another
anesthesiologist, Dr. Caldron who successfully intubated Erlina. The patient’s nails became bluish and
the patient was placed in a trendelenburg position. After the operation, Erlina was diagnosed to be
suffering from diffuse cerebral parenchymal damage and that the petitioner alleged that this was due to
lack of oxygen supply to Erlinda’s brain which resulted from the intubation.
Issue: Whether or not the doctors and the hospital are liable for damages against petitioner for the
result to Erlinda of the said operation.
Held: Yes. The private respondents were unable to disprove the presumption of negligence on their part
in the care of Erlinda and their negligence was the proximate case of her piteous condition.
Nevertheless, despite the fact that the scope of res ipsa liquitor has been measurably enlarged, it does
not automatically follow that it apply to all cases of medical negligence as to mechanically shift the
burden of proof to the defendant to show that he is not guilty of the ascribed negligence. Res ipsa
liquitor is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied,
depending upon the circumstances of each case. It is generally restricted to situations in malpractice
cases where a layman is able to say, as a matter of common knowledge and observation, that the
consequences of professional care were not as such as would ordinarily have followed if due care had
been exercised. A distinction must be made between the failure to secure results, and the occurrence of
something more unusual and not ordinarily found if the service or treatment rendered followed the
usual procedure of those skilled in that particular practice. It must be conceded that the doctrine of res
ipsa liquitor can have no application in a suit against a physician or surgeon which involves the merits
of a diagnosis or of a scientific treatment.
Scientific studies point out that intubation problems are responsible for 1/3 of deaths and serious
injuries associated with anesthesia. Nevertheless, 98% or the vast majority of difficult intubation may
be anticipated by performing a thorough evaluation of the patient’s airway prior to the operation. As
stated beforehand, respondent, Dra. Guttierez failed to observe the proper pre-operative protocol which
could have prevented this unfortunate incident. Had appropriate diligence and reasonable care been
used in the pre-operative evaluation, respondent physician could have been more prepared to meet the
contingency brought about by the perceived atomic variations in the patient’s neck and oral area;
defects which could have been easily overcome by a prior knowledge of those variations together with
a change in technique. In other words, an experienced anesthesiologist, adequately alerted by a
thorough pre-operative evaluation, would have had little difficulty going around the short neck and
potruding teeth. Having failed to observe common medical standards in pre-operative management and
intubation, respondent Dra. Guttierez negligence resulted in cerebral anoxia and eventual coma of
Erlinda.
G.R. No. 142625 December 19, 2006
ROGELIO P. NOGALES, for himself and on behalf of the minors, ROGER ANTHONY,
ANGELICA, NANCY, and MICHAEL CHRISTOPHER, all surnamed NOGALES, petitioners,
vs.
CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR. ELY VILLAFLOR, DR. ROSA
UY, DR. JOEL ENRIQUEZ, DR. PERPETUA LACSON, DR. NOE ESPINOLA, and NURSE J.
DUMLAO, respondents.

DECISION

CARPIO, J.:
The Case
This petition for review1 assails the 6 February 1998 Decision2 and 21 March 2000 Resolution3 of the
Court of Appeals in CA-G.R. CV No. 45641. The Court of Appeals affirmed in toto the 22 November
1993 Decision4 of the Regional Trial Court of Manila, Branch 33, finding Dr. Oscar Estrada solely
liable for damages for the death of his patient, Corazon Nogales, while absolving the remaining
respondents of any liability. The Court of Appeals denied petitioners' motion for reconsideration.
The Facts
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 years old, was under
the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada") beginning on her fourth month of
pregnancy or as early as December 1975. While Corazon was on her last trimester of pregnancy, Dr.
Estrada noted an increase in her blood pressure and development of leg edema5 indicating
preeclampsia,6 which is a dangerous complication of pregnancy.7
Around midnight of 25 May 1976, Corazon started to experience mild labor pains prompting Corazon
and Rogelio Nogales ("Spouses Nogales") to see Dr. Estrada at his home. After examining Corazon, Dr.
Estrada advised her immediate admission to the Capitol Medical Center ("CMC").
On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the staff nurse noted the written
admission request8 of Dr. Estrada. Upon Corazon's admission at the CMC, Rogelio Nogales
("Rogelio") executed and signed the "Consent on Admission and Agreement" 9 and "Admission
Agreement."10 Corazon was then brought to the labor room of the CMC.
Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an internal examination
of Corazon. Dr. Uy then called up Dr. Estrada to notify him of her findings.
Based on the Doctor's Order Sheet,11 around 3:00 a.m., Dr. Estrada ordered for 10 mg. of valium to be
administered immediately by intramuscular injection. Dr. Estrada later ordered the start of intravenous
administration of syntocinon admixed with dextrose, 5%, in lactated Ringers' solution, at the rate of
eight to ten micro-drops per minute.
According to the Nurse's Observation Notes,12 Dr. Joel Enriquez ("Dr. Enriquez"), an anesthesiologist
at CMC, was notified at 4:15 a.m. of Corazon's admission. Subsequently, when asked if he needed the
services of an anesthesiologist, Dr. Estrada refused. Despite Dr. Estrada's refusal, Dr. Enriquez stayed
to observe Corazon's condition.
At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10 a.m., Corazon's
bag of water ruptured spontaneously. At 6:12 a.m., Corazon's cervix was fully dilated. At 6:13 a.m.,
Corazon started to experience convulsions.
At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfate. However, Dr. Ely
Villaflor ("Dr. Villaflor"), who was assisting Dr. Estrada, administered only 2.5 grams of magnesium
sulfate.
At 6:22 a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract Corazon's baby. In the
process, a 1.0 x 2.5 cm. piece of cervical tissue was allegedly torn. The baby came out in an apnic,
cyanotic, weak and injured condition. Consequently, the baby had to be intubated and resuscitated by
Dr. Enriquez and Dr. Payumo.
At 6:27 a.m., Corazon began to manifest moderate vaginal bleeding which rapidly became profuse.
Corazon's blood pressure dropped from 130/80 to 60/40 within five minutes. There was continuous
profuse vaginal bleeding. The assisting nurse administered hemacel through a gauge 19 needle as a side
drip to the ongoing intravenous injection of dextrose.
At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with bottled blood. It took
approximately 30 minutes for the CMC laboratory, headed by Dr. Perpetua Lacson ("Dr. Lacson"), to
comply with Dr. Estrada's order and deliver the blood.
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-Gynecology Department of the
CMC, was apprised of Corazon's condition by telephone. Upon being informed that Corazon was
bleeding profusely, Dr. Espinola ordered immediate hysterectomy. Rogelio was made to sign a
"Consent to Operation."13
Due to the inclement weather then, Dr. Espinola, who was fetched from his residence by an ambulance,
arrived at the CMC about an hour later or at 9:00 a.m. He examined the patient and ordered some
resuscitative measures to be administered. Despite Dr. Espinola's efforts, Corazon died at 9:15 a.m. The
cause of death was "hemorrhage, post partum."14
On 14 May 1980, petitioners filed a complaint for damages 15 with the Regional Trial Court16 of Manila
against CMC, Dr. Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr. Lacson, Dr. Espinola, and a certain
Nurse J. Dumlao for the death of Corazon. Petitioners mainly contended that defendant physicians and
CMC personnel were negligent in the treatment and management of Corazon's condition. Petitioners
charged CMC with negligence in the selection and supervision of defendant physicians and hospital
staff.
For failing to file their answer to the complaint despite service of summons, the trial court declared Dr.
Estrada, Dr. Enriquez, and Nurse Dumlao in default.17 CMC, Dr. Villaflor, Dr. Uy, Dr. Espinola, and
Dr. Lacson filed their respective answers denying and opposing the allegations in the complaint.
Subsequently, trial ensued.
After more than 11 years of trial, the trial court rendered judgment on 22 November 1993 finding Dr.
Estrada solely liable for damages. The trial court ruled as follows:
The victim was under his pre-natal care, apparently, his fault began from his incorrect and
inadequate management and lack of treatment of the pre-eclamptic condition of his patient. It is
not disputed that he misapplied the forceps in causing the delivery because it resulted in a large
cervical tear which had caused the profuse bleeding which he also failed to control with the
application of inadequate injection of magnesium sulfate by his assistant Dra. Ely Villaflor. Dr.
Estrada even failed to notice the erroneous administration by nurse Dumlao of hemacel by way
of side drip, instead of direct intravenous injection, and his failure to consult a senior
obstetrician at an early stage of the problem.
On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr. Joel Enriquez, Dr. Lacson, Dr.
Espinola, nurse J. Dumlao and CMC, the Court finds no legal justification to find them civilly
liable.
On the part of Dra. Ely Villaflor, she was only taking orders from Dr. Estrada, the principal
physician of Corazon Nogales. She can only make suggestions in the manner the patient maybe
treated but she cannot impose her will as to do so would be to substitute her good judgment to
that of Dr. Estrada. If she failed to correctly diagnose the true cause of the bleeding which in
this case appears to be a cervical laceration, it cannot be safely concluded by the Court that Dra.
Villaflor had the correct diagnosis and she failed to inform Dr. Estrada. No evidence was
introduced to show that indeed Dra. Villaflor had discovered that there was laceration at the
cervical area of the patient's internal organ.
On the part of nurse Dumlao, there is no showing that when she administered the hemacel as a
side drip, she did it on her own. If the correct procedure was directly thru the veins, it could
only be because this was what was probably the orders of Dr. Estrada.
While the evidence of the plaintiffs shows that Dr. Noe Espinola, who was the Chief of the
Department of Obstetrics and Gynecology who attended to the patient Mrs. Nogales, it was only
at 9:00 a.m. That he was able to reach the hospital because of typhoon Didang (Exhibit 2).
While he was able to give prescription in the manner Corazon Nogales may be treated, the
prescription was based on the information given to him by phone and he acted on the basis of
facts as presented to him, believing in good faith that such is the correct remedy. He was not
with Dr. Estrada when the patient was brought to the hospital at 2:30 o'clock a.m. So, whatever
errors that Dr. Estrada committed on the patient before 9:00 o'clock a.m. are certainly the errors
of Dr. Estrada and cannot be the mistake of Dr. Noe Espinola. His failure to come to the hospital
on time was due to fortuitous event.
On the part of Dr. Joel Enriquez, while he was present in the delivery room, it is not incumbent
upon him to call the attention of Dr. Estrada, Dra. Villaflor and also of Nurse Dumlao on the
alleged errors committed by them. Besides, as anesthesiologist, he has no authority to control
the actuations of Dr. Estrada and Dra. Villaflor. For the Court to assume that there were errors
being committed in the presence of Dr. Enriquez would be to dwell on conjectures and
 speculations.
On the civil liability of Dr. Perpetua Lacson, [s]he is a hematologist and in-charge of the blood
bank of the CMC. The Court cannot accept the theory of the plaintiffs that there was delay in
delivering the blood needed by the patient. It was testified, that in order that this blood will be
made available, a laboratory test has to be conducted to determine the type of blood, cross
matching and other matters consistent with medical science so, the lapse of 30 minutes maybe
considered a reasonable time to do all of these things, and not a delay as the plaintiffs would
want the Court to believe.
Admittedly, Dra. Rosa Uy is a resident physician of the Capitol Medical Center. She was sued
because of her alleged failure to notice the incompetence and negligence of Dr. Estrada.
However, there is no evidence to support such theory. No evidence was adduced to show that
Dra. Rosa Uy as a resident physician of Capitol Medical Center, had knowledge of the
mismanagement of the patient Corazon Nogales, and that notwithstanding such knowledge, she
tolerated the same to happen.
In the pre-trial order, plaintiffs and CMC agreed that defendant CMC did not have any hand or
participation in the selection or hiring of Dr. Estrada or his assistant Dra. Ely Villaflor as
attending physician[s] of the deceased. In other words, the two (2) doctors were not employees
of the hospital and therefore the hospital did not have control over their professional conduct.
When Mrs. Nogales was brought to the hospital, it was an emergency case and defendant CMC
had no choice but to admit her. Such being the case, there is therefore no legal ground to apply
the provisions of Article 2176 and 2180 of the New Civil Code referring to the vicarious
liability of an employer for the negligence of its employees. If ever in this case there is fault or
negligence in the treatment of the deceased on the part of the attending physicians who were
employed by the family of the deceased, such civil liability should be borne by the attending
physicians under the principle of "respondeat superior".
WHEREFORE, premises considered, judgment is hereby rendered finding defendant Dr.
Estrada of Number 13 Pitimini St. San Francisco del Monte, Quezon City civilly liable to pay
plaintiffs: 1) By way of actual damages in the amount of P105,000.00; 2) By way of moral
damages in the amount of P700,000.00; 3) Attorney's fees in the amount of P100,000.00 and to
pay the costs of suit.
For failure of the plaintiffs to adduce evidence to support its [sic] allegations against the other
defendants, the complaint is hereby ordered dismissed. While the Court looks with disfavor the
filing of the present complaint against the other defendants by the herein plaintiffs, as in a way
it has caused them personal inconvenience and slight damage on their name and reputation, the
Court cannot accepts [sic] however, the theory of the remaining defendants that plaintiffs were
motivated in bad faith in the filing of this complaint. For this reason defendants' counterclaims
are hereby ordered dismissed.
SO ORDERED.18
Petitioners appealed the trial court's decision. Petitioners claimed that aside from Dr. Estrada, the
remaining respondents should be held equally liable for negligence. Petitioners pointed out the extent
of each respondent's alleged liability.
On 6 February 1998, the Court of Appeals affirmed the decision of the trial court. 19 Petitioners filed a
motion for reconsideration which the Court of Appeals denied in its Resolution of 21 March 2000.20
Hence, this petition.
Meanwhile, petitioners filed a Manifestation dated 12 April 2002 21 stating that respondents Dr. Estrada,
Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao "need no longer be notified of the petition because they
are absolutely not involved in the issue raised before the [Court], regarding the liability of [CMC]." 22
Petitioners stressed that the subject matter of this petition is the liability of CMC for the negligence of
Dr. Estrada.23
The Court issued a Resolution dated 9 September 200224 dispensing with the requirement to submit the
correct and present addresses of respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse
Dumlao. The Court stated that with the filing of petitioners' Manifestation, it should be understood that
they are claiming only against respondents CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy who have filed
their respective comments. Petitioners are foregoing further claims against respondents Dr. Estrada, Dr.
Enriquez, Dr. Villaflor, and Nurse Dumlao.
The Court noted that Dr. Estrada did not appeal the decision of the Court of Appeals affirming the
decision of the Regional Trial Court. Accordingly, the decision of the Court of Appeals, affirming the
trial court's judgment, is already final as against Dr. Oscar Estrada.
Petitioners filed a motion for reconsideration 25 of the Court's 9 September 2002 Resolution claiming
that Dr. Enriquez, Dr. Villaflor and Nurse Dumlao were notified of the petition at their counsels' last
known addresses. Petitioners reiterated their imputation of negligence on these respondents. The Court
denied petitioners' Motion for Reconsideration in its 18 February 2004 Resolution.26
The Court of Appeals' Ruling
In its Decision of 6 February 1998, the Court of Appeals upheld the trial court's ruling. The Court of
Appeals rejected petitioners' view that the doctrine in Darling v. Charleston Community Memorial
Hospital27 applies to this case. According to the Court of Appeals, the present case differs from the
Darling case since Dr. Estrada is an independent contractor-physician whereas the Darling case
involved a physician and a nurse who were employees of the hospital.
Citing other American cases, the Court of Appeals further held that the mere fact that a hospital
permitted a physician to practice medicine and use its facilities is not sufficient to render the hospital
liable for the physician's negligence.28 A hospital is not responsible for the negligence of a physician
who is an independent contractor.29
The Court of Appeals found the cases of Davidson v. Conole30 and Campbell v. Emma Laing Stevens
Hospital31 applicable to this case. Quoting Campbell, the Court of Appeals stated that where there is no
proof that defendant physician was an employee of defendant hospital or that defendant hospital had
reason to know that any acts of malpractice would take place, defendant hospital could not be held
liable for its failure to intervene in the relationship of physician-patient between defendant physician
and plaintiff.
On the liability of the other respondents, the Court of Appeals applied the "borrowed servant" doctrine
considering that Dr. Estrada was an independent contractor who was merely exercising hospital
privileges. This doctrine provides that once the surgeon enters the operating room and takes charge of
the proceedings, the acts or omissions of operating room personnel, and any negligence associated with
such acts or omissions, are imputable to the surgeon. 32 While the assisting physicians and nurses may
be employed by the hospital, or engaged by the patient, they normally become the temporary servants
or agents of the surgeon in charge while the operation is in progress, and liability may be imposed upon
the surgeon for their negligent acts under the doctrine of respondeat superior.33
The Court of Appeals concluded that since Rogelio engaged Dr. Estrada as the attending physician of
his wife, any liability for malpractice must be Dr. Estrada's sole responsibility.
While it found the amount of damages fair and reasonable, the Court of Appeals held that no interest
could be imposed on unliquidated claims or damages.
The Issue
Basically, the issue in this case is whether CMC is vicariously liable for the negligence of Dr. Estrada.
The resolution of this issue rests, on the other hand, on the ascertainment of the relationship between
Dr. Estrada and CMC. The Court also believes that a determination of the extent of liability of the other
respondents is inevitable to finally and completely dispose of the present controversy.
The Ruling of the Court
The petition is partly meritorious.
On the Liability of CMC
Dr. Estrada's negligence in handling the treatment and management of Corazon's condition which
ultimately resulted in Corazon's death is no longer in issue. Dr. Estrada did not appeal the decision of
the Court of Appeals which affirmed the ruling of the trial court finding Dr. Estrada solely liable for
damages. Accordingly, the finding of the trial court on Dr. Estrada's negligence is already final.
Petitioners maintain that CMC is vicariously liable for Dr. Estrada's negligence based on Article 2180
in relation to Article 2176 of the Civil Code. These provisions pertinently state:
Art. 2180. The obligation imposed by article 2176 is demandable not only for one's own acts or
omissions, but also for those of persons for whom one is responsible.
xxxx
Employers shall be liable for the damages caused by their employees and household helpers
acting within the scope of their assigned tasks, even though the former are not engaged in any
business or industry.
xxxx
The responsibility treated of in this article shall cease when the persons herein mentioned prove
that they observed all the diligence of a good father of a family to prevent damage.
Art. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done. Such fault or negligence, if there is no pre-
existing contractual relation between the parties, is called a quasi-delict and is governed by the
provisions of this Chapter.
Similarly, in the United States, a hospital which is the employer, master, or principal of a physician
employee, servant, or agent, may be held liable for the physician's negligence under the doctrine of
respondeat superior.34
In the present case, petitioners maintain that CMC, in allowing Dr. Estrada to practice and admit
patients at CMC, should be liable for Dr. Estrada's malpractice. Rogelio claims that he knew Dr.
Estrada as an accredited physician of CMC, though he discovered later that Dr. Estrada was not a
salaried employee of the CMC.35 Rogelio further claims that he was dealing with CMC, whose primary
concern was the treatment and management of his wife's condition. Dr. Estrada just happened to be the
specific person he talked to representing CMC.36 Moreover, the fact that CMC made Rogelio sign a
Consent on Admission and Admission Agreement37 and a Consent to Operation printed on the
letterhead of CMC indicates that CMC considered Dr. Estrada as a member of its medical staff.
On the other hand, CMC disclaims liability by asserting that Dr. Estrada was a mere visiting physician
and that it admitted Corazon because her physical condition then was classified an emergency
obstetrics case.38
CMC alleges that Dr. Estrada is an independent contractor "for whose actuations CMC would be a total
stranger." CMC maintains that it had no control or supervision over Dr. Estrada in the exercise of his
medical profession.
The Court had the occasion to determine the relationship between a hospital and a consultant or visiting
physician and the liability of such hospital for that physician's negligence in Ramos v. Court of
Appeals,39 to wit:
In the first place, hospitals exercise significant control in the hiring and firing of consultants and
in the conduct of their work within the hospital premises. Doctors who apply for "consultant"
slots, visiting or attending, are required to submit proof of completion of residency, their
educational qualifications; generally, evidence of accreditation by the appropriate board
(diplomate), evidence of fellowship in most cases, and references. These requirements are
carefully scrutinized by members of the hospital administration or by a review committee set up
by the hospital who either accept or reject the application. This is particularly true with
respondent hospital.
After a physician is accepted, either as a visiting or attending consultant, he is normally required
to attend clinico-pathological conferences, conduct bedside rounds for clerks, interns and
residents, moderate grand rounds and patient audits and perform other tasks and responsibilities,
for the privilege of being able to maintain a clinic in the hospital, and/or for the privilege of
admitting patients into the hospital. In addition to these, the physician's performance as a
specialist is generally evaluated by a peer review committee on the basis of mortality and
morbidity statistics, and feedback from patients, nurses, interns and residents. A consultant
remiss in his duties, or a consultant who regularly falls short of the minimum standards
acceptable to the hospital or its peer review committee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and
visiting "consultant" staff. While "consultants" are not, technically employees, a point
which respondent hospital asserts in denying all responsibility for the patient's condition,
the control exercised, the hiring, and the right to terminate consultants all fulfill the
important hallmarks of an employer-employee relationship, with the exception of the
payment of wages. In assessing whether such a relationship in fact exists, the control test is
determining. Accordingly, on the basis of the foregoing, we rule that for the purpose of
allocating responsibility in medical negligence cases, an employer-employee relationship in
effect exists between hospitals and their attending and visiting physicians. This being the
case, the question now arises as to whether or not respondent hospital is solidarily liable with
respondent doctors for petitioner's condition.
The basis for holding an employer solidarily responsible for the negligence of its employee is
found in Article 2180 of the Civil Code which considers a person accountable not only for his
own acts but also for those of others based on the former's responsibility under a relationship of
patria potestas. x x x40 (Emphasis supplied)
While the Court in Ramos did not expound on the control test, such test essentially determines whether
an employment relationship exists between a physician and a hospital based on the exercise of control
over the physician as to details. Specifically, the employer (or the hospital) must have the right to
control both the means and the details of the process by which the employee (or the physician) is to
accomplish his task.41
After a thorough examination of the voluminous records of this case, the Court finds no single evidence
pointing to CMC's exercise of control over Dr. Estrada's treatment and management of Corazon's
condition. It is undisputed that throughout Corazon's pregnancy, she was under the exclusive prenatal
care of Dr. Estrada. At the time of Corazon's admission at CMC and during her delivery, it was Dr.
Estrada, assisted by Dr. Villaflor, who attended to Corazon. There was no showing that CMC had a part
in diagnosing Corazon's condition. While Dr. Estrada enjoyed staff privileges at CMC, such fact alone
did not make him an employee of CMC.42 CMC merely allowed Dr. Estrada to use its facilities43 when
Corazon was about to give birth, which CMC considered an emergency. Considering these
circumstances, Dr. Estrada is not an employee of CMC, but an independent contractor.
The question now is whether CMC is automatically exempt from liability considering that Dr. Estrada
is an independent contractor-physician.
In general, a hospital is not liable for the negligence of an independent contractor-physician. There is,
however, an exception to this principle. The hospital may be liable if the physician is the "ostensible"
agent of the hospital.44 This exception is also known as the "doctrine of apparent authority." 45 In
Gilbert v. Sycamore Municipal Hospital,46 the Illinois Supreme Court explained the doctrine of
apparent authority in this wise:
[U]nder the doctrine of apparent authority a hospital can be held vicariously liable for the
negligent acts of a physician providing care at the hospital, regardless of whether the physician
is an independent contractor, unless the patient knows, or should have known, that the physician
is an independent contractor. The elements of the action have been set out as follows:
"For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show that:
(1) the hospital, or its agent, acted in a manner that would lead a reasonable person to conclude
that the individual who was alleged to be negligent was an employee or agent of the hospital;
(2) where the acts of the agent create the appearance of authority, the plaintiff must also prove
that the hospital had knowledge of and acquiesced in them; and (3) the plaintiff acted in reliance
upon the conduct of the hospital or its agent, consistent with ordinary care and prudence."
The element of "holding out" on the part of the hospital does not require an express
representation by the hospital that the person alleged to be negligent is an employee. Rather, the
element is satisfied if the hospital holds itself out as a provider of emergency room care without
informing the patient that the care is provided by independent contractors.
The element of justifiable reliance on the part of the plaintiff is satisfied if the plaintiff relies
upon the hospital to provide complete emergency room care, rather than upon a specific
physician.
The doctrine of apparent authority essentially involves two factors to determine the liability of an
independent-contractor physician.
The first factor focuses on the hospital's manifestations and is sometimes described as an inquiry
whether the hospital acted in a manner which would lead a reasonable person to conclude that the
individual who was alleged to be negligent was an employee or agent of the hospital. 47 In this regard,
the hospital need not make express representations to the patient that the treating physician is an
employee of the hospital; rather a representation may be general and implied.48
The doctrine of apparent authority is a species of the doctrine of estoppel. Article 1431 of the Civil
Code provides that "[t]hrough estoppel, an admission or representation is rendered conclusive upon the
person making it, and cannot be denied or disproved as against the person relying thereon." Estoppel
rests on this rule: "Whenever a party has, by his own declaration, act, or omission, intentionally and
deliberately led another to believe a particular thing true, and to act upon such belief, he cannot, in any
litigation arising out of such declaration, act or omission, be permitted to falsify it."49
In the instant case, CMC impliedly held out Dr. Estrada as a member of its medical staff. Through
CMC's acts, CMC clothed Dr. Estrada with apparent authority thereby leading the Spouses Nogales to
believe that Dr. Estrada was an employee or agent of CMC. CMC cannot now repudiate such authority.
First, CMC granted staff privileges to Dr. Estrada. CMC extended its medical staff and facilities to Dr.
Estrada. Upon Dr. Estrada's request for Corazon's admission, CMC, through its personnel, readily
accommodated Corazon and updated Dr. Estrada of her condition.
Second, CMC made Rogelio sign consent forms printed on CMC letterhead. Prior to Corazon's
admission and supposed hysterectomy, CMC asked Rogelio to sign release forms, the contents of
which reinforced Rogelio's belief that Dr. Estrada was a member of CMC's medical staff. 50 The
Consent on Admission and Agreement explicitly provides:
KNOW ALL MEN BY THESE PRESENTS:
I, Rogelio Nogales, of legal age, a resident of 1974 M. H. Del Pilar St., Malate Mla., being the
father/mother/brother/sister/spouse/relative/ guardian/or person in custody of Ma. Corazon, and
representing his/her family, of my own volition and free will, do consent and submit said Ma.
Corazon to Dr. Oscar Estrada (hereinafter referred to as Physician) for cure, treatment,
retreatment, or emergency measures, that the Physician, personally or by and through the
Capitol Medical Center and/or its staff, may use, adapt, or employ such means, forms or
methods of cure, treatment, retreatment, or emergency measures as he may see best and
most expedient; that Ma. Corazon and I will comply with any and all rules, regulations,
directions, and instructions of the Physician, the Capitol Medical Center and/or its staff;
and, that I will not hold liable or responsible and hereby waive and forever discharge and hold
free the Physician, the Capitol Medical Center and/or its staff, from any and all claims of
whatever kind of nature, arising from directly or indirectly, or by reason of said cure, treatment,
or retreatment, or emergency measures or intervention of said physician, the Capitol Medical
Center and/or its staff.
x x x x51 (Emphasis supplied)
While the Consent to Operation pertinently reads, thus:
I, ROGELIO NOGALES, x x x, of my own volition and free will, do consent and submit said
CORAZON NOGALES to Hysterectomy, by the Surgical Staff and Anesthesiologists of
Capitol Medical Center and/or whatever succeeding operations, treatment, or emergency
measures as may be necessary and most expedient; and, that I will not hold liable or responsible
and hereby waive and forever discharge and hold free the Surgeon, his assistants,
anesthesiologists, the Capitol Medical Center and/or its staff, from any and all claims of
whatever kind of nature, arising from directly or indirectly, or by reason of said operation or
operations, treatment, or emergency measures, or intervention of the Surgeon, his assistants,
anesthesiologists, the Capitol Medical Center and/or its staff.52 (Emphasis supplied)
Without any indication in these consent forms that Dr. Estrada was an independent contractor-
physician, the Spouses Nogales could not have known that Dr. Estrada was an independent contractor.
Significantly, no one from CMC informed the Spouses Nogales that Dr. Estrada was an independent
contractor. On the contrary, Dr. Atencio, who was then a member of CMC Board of Directors, testified
that Dr. Estrada was part of CMC's surgical staff.53
Third, Dr. Estrada's referral of Corazon's profuse vaginal bleeding to Dr. Espinola, who was then the
Head of the Obstetrics and Gynecology Department of CMC, gave the impression that Dr. Estrada as a
member of CMC's medical staff was collaborating with other CMC-employed specialists in treating
Corazon.
The second factor focuses on the patient's reliance. It is sometimes characterized as an inquiry on
whether the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with
ordinary care and prudence.54
The records show that the Spouses Nogales relied upon a perceived employment relationship with
CMC in accepting Dr. Estrada's services. Rogelio testified that he and his wife specifically chose Dr.
Estrada to handle Corazon's delivery not only because of their friend's recommendation, but more
importantly because of Dr. Estrada's "connection with a reputable hospital, the [CMC]." 55 In other
words, Dr. Estrada's relationship with CMC played a significant role in the Spouses Nogales' decision
in accepting Dr. Estrada's services as the obstetrician-gynecologist for Corazon's delivery. Moreover, as
earlier stated, there is no showing that before and during Corazon's confinement at CMC, the Spouses
Nogales knew or should have known that Dr. Estrada was not an employee of CMC.
Further, the Spouses Nogales looked to CMC to provide the best medical care and support services for
Corazon's delivery. The Court notes that prior to Corazon's fourth pregnancy, she used to give birth
inside a clinic. Considering Corazon's age then, the Spouses Nogales decided to have their fourth child
delivered at CMC, which Rogelio regarded one of the best hospitals at the time.56 This is precisely
because the Spouses Nogales feared that Corazon might experience complications during her delivery
which would be better addressed and treated in a modern and big hospital such as CMC. Moreover,
Rogelio's consent in Corazon's hysterectomy to be performed by a different physician, namely Dr.
Espinola, is a clear indication of Rogelio's confidence in CMC's surgical staff.
CMC's defense that all it did was "to extend to [Corazon] its facilities" is untenable. The Court cannot
close its eyes to the reality that hospitals, such as CMC, are in the business of treatment. In this regard,
the Court agrees with the observation made by the Court of Appeals of North Carolina in Diggs v.
Novant Health, Inc.,57 to wit:
"The conception that the hospital does not undertake to treat the patient, does not undertake to
act through its doctors and nurses, but undertakes instead simply to procure them to act upon
their own responsibility, no longer reflects the fact. Present day hospitals, as their manner of
operation plainly demonstrates, do far more than furnish facilities for treatment. They
regularly employ on a salary basis a large staff of physicians, nurses and internes [sic], as
well as administrative and manual workers, and they charge patients for medical care and
treatment, collecting for such services, if necessary, by legal action. Certainly, the person
who avails himself of 'hospital facilities' expects that the hospital will attempt to cure him,
not that its nurses or other employees will act on their own responsibility." x x x (Emphasis
supplied)
Likewise unconvincing is CMC's argument that petitioners are estopped from claiming damages based
on the Consent on Admission and Consent to Operation. Both release forms consist of two parts. The
first part gave CMC permission to administer to Corazon any form of recognized medical treatment
which the CMC medical staff deemed advisable. The second part of the documents, which may
properly be described as the releasing part, releases CMC and its employees "from any and all claims"
arising from or by reason of the treatment and operation.
The documents do not expressly release CMC from liability for injury to Corazon due to negligence
during her treatment or operation. Neither do the consent forms expressly exempt CMC from liability
for Corazon's death due to negligence during such treatment or operation. Such release forms, being in
the nature of contracts of adhesion, are construed strictly against hospitals. Besides, a blanket release in
favor of hospitals "from any and all claims," which includes claims due to bad faith or gross
negligence, would be contrary to public policy and thus void.
Even simple negligence is not subject to blanket release in favor of establishments like hospitals but
may only mitigate liability depending on the circumstances. 58 When a person needing urgent medical
attention rushes to a hospital, he cannot bargain on equal footing with the hospital on the terms of
admission and operation. Such a person is literally at the mercy of the hospital. There can be no clearer
example of a contract of adhesion than one arising from such a dire situation. Thus, the release forms of
CMC cannot relieve CMC from liability for the negligent medical treatment of Corazon.
On the Liability of the Other Respondents
Despite this Court's pronouncement in its 9 September 2002 59 Resolution that the filing of petitioners'
Manifestation confined petitioners' claim only against CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy, who
have filed their comments, the Court deems it proper to resolve the individual liability of the remaining
respondents to put an end finally to this more than two-decade old controversy.
a) Dr. Ely Villaflor
Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause of Corazon's bleeding and to
suggest the correct remedy to Dr. Estrada.60 Petitioners assert that it was Dr. Villaflor's duty to correct
the error of Nurse Dumlao in the administration of hemacel.
The Court is not persuaded. Dr. Villaflor admitted administering a lower dosage of magnesium sulfate.
However, this was after informing Dr. Estrada that Corazon was no longer in convulsion and that her
blood pressure went down to a dangerous level. 61 At that moment, Dr. Estrada instructed Dr. Villaflor
to reduce the dosage of magnesium sulfate from 10 to 2.5 grams. Since petitioners did not dispute Dr.
Villaflor's allegation, Dr. Villaflor's defense remains uncontroverted. Dr. Villaflor's act of administering
a lower dosage of magnesium sulfate was not out of her own volition or was in contravention of Dr.
Estrada's order.
b) Dr. Rosa Uy
Dr. Rosa Uy's alleged negligence consisted of her failure (1) to call the attention of Dr. Estrada on the
incorrect dosage of magnesium sulfate administered by Dr. Villaflor; (2) to take corrective measures;
and (3) to correct Nurse Dumlao's wrong method of hemacel administration.
The Court believes Dr. Uy's claim that as a second year resident physician then at CMC, she was
merely authorized to take the clinical history and physical examination of Corazon. 62 However, that
routine internal examination did not ipso facto make Dr. Uy liable for the errors committed by Dr.
Estrada. Further, petitioners' imputation of negligence rests on their baseless assumption that Dr. Uy
was present at the delivery room. Nothing shows that Dr. Uy participated in delivering Corazon's baby.
Further, it is unexpected from Dr. Uy, a mere resident physician at that time, to call the attention of a
more experienced specialist, if ever she was present at the delivery room.
c) Dr. Joel Enriquez
Petitioners fault Dr. Joel Enriquez also for not calling the attention of Dr. Estrada, Dr. Villaflor, and
Nurse Dumlao about their errors.63 Petitioners insist that Dr. Enriquez should have taken, or at least
suggested, corrective measures to rectify such errors.
The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field of expertise is definitely
not obstetrics and gynecology. As such, Dr. Enriquez was not expected to correct Dr. Estrada's errors.
Besides, there was no evidence of Dr. Enriquez's knowledge of any error committed by Dr. Estrada and
his failure to act upon such observation.
d) Dr. Perpetua Lacson
Petitioners fault Dr. Perpetua Lacson for her purported delay in the delivery of blood Corazon
needed.64 Petitioners claim that Dr. Lacson was remiss in her duty of supervising the blood bank staff.
As found by the trial court, there was no unreasonable delay in the delivery of blood from the time of
the request until the transfusion to Corazon. Dr. Lacson competently explained the procedure before
blood could be given to the patient.65 Taking into account the bleeding time, clotting time and cross-
matching, Dr. Lacson stated that it would take approximately 45-60 minutes before blood could be
ready for transfusion.66 Further, no evidence exists that Dr. Lacson neglected her duties as head of the
blood bank.
e) Dr. Noe Espinola
Petitioners argue that Dr. Espinola should not have ordered immediate hysterectomy without
determining the underlying cause of Corazon's bleeding. Dr. Espinola should have first considered the
possibility of cervical injury, and advised a thorough examination of the cervix, instead of believing
outright Dr. Estrada's diagnosis that the cause of bleeding was uterine atony.
Dr. Espinola's order to do hysterectomy which was based on the information he received by phone is
not negligence. The Court agrees with the trial court's observation that Dr. Espinola, upon hearing such
information about Corazon's condition, believed in good faith that hysterectomy was the correct
remedy. At any rate, the hysterectomy did not push through because upon Dr. Espinola's arrival, it was
already too late. At the time, Corazon was practically dead.
f) Nurse J. Dumlao
In Moore v. Guthrie Hospital Inc.,67 the US Court of Appeals, Fourth Circuit, held that to recover, a
patient complaining of injuries allegedly resulting when the nurse negligently injected medicine to him
intravenously instead of intramuscularly had to show that (1) an intravenous injection constituted a lack
of reasonable and ordinary care; (2) the nurse injected medicine intravenously; and (3) such injection
was the proximate cause of his injury.
In the present case, there is no evidence of Nurse Dumlao's alleged failure to follow Dr. Estrada's
specific instructions. Even assuming Nurse Dumlao defied Dr. Estrada's order, there is no showing that
side-drip administration of hemacel proximately caused Corazon's death. No evidence linking
Corazon's death and the alleged wrongful hemacel administration was introduced. Therefore, there is
no basis to hold Nurse Dumlao liable for negligence.
On the Award of Interest on Damages
The award of interest on damages is proper and allowed under Article 2211 of the Civil Code, which
states that in crimes and quasi-delicts, interest as a part of the damages may, in a proper case, be
adjudicated in the discretion of the court.68
WHEREFORE, the Court PARTLY GRANTS the petition. The Court finds respondent Capitol
Medical Center vicariously liable for the negligence of Dr. Oscar Estrada. The amounts of P105,000 as
actual damages and P700,000 as moral damages should each earn legal interest at the rate of six percent
(6%) per annum computed from the date of the judgment of the trial court. The Court affirms the rest of
the Decision dated 6 February 1998 and Resolution dated 21 March 2000 of the Court of Appeals in
CA-G.R. CV No. 45641.
SO ORDERED.
Nogales vs Capitol Medical Center
GR No. 142625 December 19, 2006
Facts: Pregnant with her fourth child, Corazon Nogales, who was then 37 y/o was under the exclusive
prenatal care of Dr. Oscar Estrada beginning on her fourth month of pregnancy or as early as December
1975. While Corazon was on her last trimester of pregnancy, Dr. Estrada noted an increase in her blood
pressure and development of leg edemas indicating preeclampsia which is a dangerous complication of
pregnancy. Around midnight of May 26, 1976, Corazon started to experience mild labor pains
prompting Corazon and Rogelio Nogales to see Dr. Estrada at his home. After examining Corazon, Dr.
Estrada advised her immediate admission to Capitol Medical Center (CMC). Upon her admission, an
internal examination was conducted upon her by a resident-physician. Based on the doctor’s sheet,
around 3am, Dr. Estrada advised for 10mg valium to be administered immediately by intramuscular
injection, he later ordered the start of intravenous administration of syntociron admixed with dextrose,
5% in lactated ringer’s solution, at the rate of 8-10 micro-drops per minute. When asked if he needed
the services of anesthesiologist, he refused. Corazon’s bag of water ruptured spontaneously and her
cervix was fully dilated and she experienced convulsions. Dr. Estrada ordered the injection of 10g of
magnesium sulfate but his assisting Doctor, Dr. Villaflor, only administered 2.5g. She also applied low
forceps to extract Corazon’s baby. In the process, a 10 x 2.5cm piece of cervical tissue was allegedly
torn. The baby came out in an apric, cyanatic weak and injured condition. Consequently the baby had
to be intubated and resuscitated. Corazon had professed vaginal bleeding where a blood typing was
ordered and she was supposed to undergo hysterectomy, however, upon the arrival of the doctor, she
was already pronounced dead due to hemorrhage.
Issue: Whether or not in the conduct of child delivery, the doctors and the respondent hospital is liable
for negligence.
Held: Yes. In general, a hospital is not liable for the negligence of an independent contractor-physician.
There is, however an exception to this principle. The hospital may be liable if the physician is the
ostensible agent of the hospital. This exception is also known as the doctrine of apparent authority.
Under the doctrine of apparent authority a hospital can be held vicariously liable for the negligent acts
of a physician providing care at the hospital, regardless of whether the physician is an independent
contractor, unless the patient knows, or should have known, that the physician is an independent
contractor.
For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show that 1.) the
hospital, or its agent, acted in a manner that would lead a reasonable person to conclude that the
individual who was alleged to be negligent was an employee or agent of the hospital; 2.) Where the acts
of the agent create the appearance of authority, the plaintiff must also prove that the hospital had
knowledge of and acquired in them; and 3.) the plaintiff acted in reliance upon the conduct of the
hospital or its agent, consistent with ordinary care and prudence.
Borrowed servant doctrine provides that once a surgeon enters the operating room and takes charge of
the acts or omissions of operating room personnel and any negligence associated with each acts or
omissions are imputable to the surgeon, while the assisting physicians and nurses may be employed by
the hospital, or engaged by the patient, they normally become the temporary servants or agents of the
surgeon in charge while the operation is in progress, and liability may be imposed upon the surgeon for
their negligent acts under the doctrine of respondeat superior.
G.R. No. 126297 January 31, 2007
PROFESSIONAL SERVICES, INC., Petitioner,
vs.
NATIVIDAD and ENRIQUE AGANA, Respondents.
x-----------------------x
G.R. No. 126467 January 31, 2007
NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE AGANA, JR.,
EMMA AGANA ANDAYA, JESUS AGANA, and RAYMUND AGANA) and ENRIQUE AGANA,
Petitioners,
vs.
JUAN FUENTES, Respondent.
x- - - - - - - - - - - - - - - - - - - -- - - - x
G.R. No. 127590 January 31, 2007
MIGUEL AMPIL, Petitioner,
vs.
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
DECISION
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankind’s most important and delicate endeavors, must assume
the grave responsibility of pursuing it with appropriate care. The care and service dispensed through
this high trust, however technical, complex and esoteric its character may be, must meet standards of
responsibility commensurate with the undertaking to preserve and protect the health, and indeed, the
very lives of those placed in the hospital’s keeping.1
Assailed in these three consolidated petitions for review on certiorari is the Court of Appeals’ Decision 2
dated September 6, 1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198 affirming with
modification the Decision3 dated March 17, 1993 of the Regional Trial Court (RTC), Branch 96,
Quezon City in Civil Case No. Q-43322 and nullifying its Order dated September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital (Medical City
Hospital) because of difficulty of bowel movement and bloody anal discharge. After a series of medical
examinations, Dr. Miguel Ampil, petitioner in G.R. No. 127590, diagnosed her to be suffering from
"cancer of the sigmoid."
On April 11, 1984, Dr. Ampil, assisted by the medical staff 4 of the Medical City Hospital, performed an
anterior resection surgery on Natividad. He found that the malignancy in her sigmoid area had spread
on her left ovary, necessitating the removal of certain portions of it. Thus, Dr. Ampil obtained the
consent of Natividad’s husband, Enrique Agana, to permit Dr. Juan Fuentes, respondent in G.R. No.
126467, to perform hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and
closed the incision.
However, the operation appeared to be flawed. In the corresponding Record of Operation dated April
11, 1984, the attending nurses entered these remarks:
"sponge count lacking 2
"announced to surgeon searched (sic) done but to no avail continue for closure."
On April 24, 1984, Natividad was released from the hospital. Her hospital and medical bills, including
the doctors’ fees, amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating pain in her anal region. She consulted
both Dr. Ampil and Dr. Fuentes about it. They told her that the pain was the natural consequence of the
surgery. Dr. Ampil then recommended that she consult an oncologist to examine the cancerous nodes
which were not removed during the operation.
On May 9, 1984, Natividad, accompanied by her husband, went to the United States to seek further
treatment. After four months of consultations and laboratory examinations, Natividad was told she was
free of cancer. Hence, she was advised to return to the Philippines.
On August 31, 1984, Natividad flew back to the Philippines, still suffering from pains. Two weeks
thereafter, her daughter found a piece of gauze protruding from her vagina. Upon being informed about
it, Dr. Ampil proceeded to her house where he managed to extract by hand a piece of gauze measuring
1.5 inches in width. He then assured her that the pains would soon vanish.
Dr. Ampil’s assurance did not come true. Instead, the pains intensified, prompting Natividad to seek
treatment at the Polymedic General Hospital. While confined there, Dr. Ramon Gutierrez detected the
presence of another foreign object in her vagina -- a foul-smelling gauze measuring 1.5 inches in width
which badly infected her vaginal vault. A recto-vaginal fistula had formed in her reproductive organs
which forced stool to excrete through the vagina. Another surgical operation was needed to remedy the
damage. Thus, in October 1984, Natividad underwent another surgery.
On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, Quezon City a
complaint for damages against the Professional Services, Inc. (PSI), owner of the Medical City
Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil Case No. Q-43322. They alleged that the latter
are liable for negligence for leaving two pieces of gauze inside Natividad’s body and malpractice for
concealing their acts of negligence.
Meanwhile, Enrique Agana also filed with the Professional Regulation Commission (PRC) an
administrative complaint for gross negligence and malpractice against Dr. Ampil and Dr. Fuentes,
docketed as Administrative Case No. 1690. The PRC Board of Medicine heard the case only with
respect to Dr. Fuentes because it failed to acquire jurisdiction over Dr. Ampil who was then in the
United States.
On February 16, 1986, pending the outcome of the above cases, Natividad died and was duly
substituted by her above-named children (the Aganas).
On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and
Dr. Fuentes liable for negligence and malpractice, the decretal part of which reads:
WHEREFORE, judgment is hereby rendered for the plaintiffs ordering the defendants
PROFESSIONAL SERVICES, INC., DR. MIGUEL AMPIL and DR. JUAN FUENTES to pay to the
plaintiffs, jointly and severally, except in respect of the award for exemplary damages and the interest
thereon which are the liabilities of defendants Dr. Ampil and Dr. Fuentes only, as follows:
1. As actual damages, the following amounts:
a. The equivalent in Philippine Currency of the total of US$19,900.00 at the rate of
P21.60-US$1.00, as reimbursement of actual expenses incurred in the United States of
America;
 b. The sum of P4,800.00 as travel taxes of plaintiffs and their physician daughter;
c. The total sum of P45,802.50, representing the cost of hospitalization at Polymedic
Hospital, medical fees, and cost of the saline solution;
2. As moral damages, the sum of P2,000,000.00;
3. As exemplary damages, the sum of P300,000.00;
4. As attorney’s fees, the sum of P250,000.00;
5. Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove, from date of filing of the
complaint until full payment; and
6. Costs of suit.
SO ORDERED.
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals, docketed as
CA-G.R. CV No. 42062.
Incidentally, on April 3, 1993, the Aganas filed with the RTC a motion for a partial execution of its
Decision, which was granted in an Order dated May 11, 1993. Thereafter, the sheriff levied upon
certain properties of Dr. Ampil and sold them for P451,275.00 and delivered the amount to the Aganas.
Following their receipt of the money, the Aganas entered into an agreement with PSI and Dr. Fuentes to
indefinitely suspend any further execution of the RTC Decision. However, not long thereafter, the
Aganas again filed a motion for an alias writ of execution against the properties of PSI and Dr. Fuentes.
On September 21, 1993, the RTC granted the motion and issued the corresponding writ, prompting Dr.
Fuentes to file with the Court of Appeals a petition for certiorari and prohibition, with prayer for
preliminary injunction, docketed as CA-G.R. SP No. 32198. During its pendency, the Court of Appeals
issued a Resolution5 dated October 29, 1993 granting Dr. Fuentes’ prayer for injunctive relief.
On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No. 42062.
Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision 6 in Administrative
Case No. 1690 dismissing the case against Dr. Fuentes. The Board held that the prosecution failed to
show that Dr. Fuentes was the one who left the two pieces of gauze inside Natividad’s body; and that he
concealed such fact from Natividad.
On September 6, 1996, the Court of Appeals rendered its Decision jointly disposing of CA-G.R. CV
No. 42062 and CA-G.R. SP No. 32198, thus:
WHEREFORE, except for the modification that the case against defendant-appellant Dr. Juan Fuentes
is hereby DISMISSED, and with the pronouncement that defendant-appellant Dr. Miguel Ampil is
liable to reimburse defendant-appellant Professional Services, Inc., whatever amount the latter will pay
or had paid to the plaintiffs-appellees, the decision appealed from is hereby AFFIRMED and the instant
appeal DISMISSED.
Concomitant with the above, the petition for certiorari and prohibition filed by herein defendant-
appellant Dr. Juan Fuentes in CA-G.R. SP No. 32198 is hereby GRANTED and the challenged order of
the respondent judge dated September 21, 1993, as well as the alias writ of execution issued pursuant
thereto are hereby NULLIFIED and SET ASIDE. The bond posted by the petitioner in connection with
the writ of preliminary injunction issued by this Court on November 29, 1993 is hereby cancelled.
Costs against defendants-appellants Dr. Miguel Ampil and Professional Services, Inc.
SO ORDERED.
Only Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolution 7 dated December
19, 1996.
Hence, the instant consolidated petitions.
In G.R. No. 126297, PSI alleged in its petition that the Court of Appeals erred in holding that: (1) it is
estopped from raising the defense that Dr. Ampil is not its employee; (2) it is solidarily liable with Dr.
Ampil; and (3) it is not entitled to its counterclaim against the Aganas. PSI contends that Dr. Ampil is
not its employee, but a mere consultant or independent contractor. As such, he alone should answer for
his negligence.
In G.R. No. 126467, the Aganas maintain that the Court of Appeals erred in finding that Dr. Fuentes is
not guilty of negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. They
contend that the pieces of gauze are prima facie proofs that the operating surgeons have been negligent.
Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of Appeals erred in finding him liable for
negligence and malpractice sans evidence that he left the two pieces of gauze in Natividad’s vagina. He
pointed to other probable causes, such as: (1) it was Dr. Fuentes who used gauzes in performing the
hysterectomy; (2) the attending nurses’ failure to properly count the gauzes used during surgery; and
(3) the medical intervention of the American doctors who examined Natividad in the United States of
America.
For our resolution are these three vital issues: first, whether the Court of Appeals erred in holding Dr.
Ampil liable for negligence and malpractice; second, whether the Court of Appeals erred in absolving
Dr. Fuentes of any liability; and third, whether PSI may be held solidarily liable for the negligence of
Dr. Ampil.
I - G.R. No. 127590
Whether the Court of Appeals Erred in Holding Dr. Ampil
Liable for Negligence and Malpractice.
Dr. Ampil, in an attempt to absolve himself, gears the Court’s attention to other possible causes of
Natividad’s detriment. He argues that the Court should not discount either of the following
possibilities: first, Dr. Fuentes left the gauzes in Natividad’s body after performing hysterectomy;
second, the attending nurses erred in counting the gauzes; and third, the American doctors were the
ones who placed the gauzes in Natividad’s body.
Dr. Ampil’s arguments are purely conjectural and without basis. Records show that he did not present
any evidence to prove that the American doctors were the ones who put or left the gauzes in
Natividad’s body. Neither did he submit evidence to rebut the correctness of the record of operation,
particularly the number of gauzes used. As to the alleged negligence of Dr. Fuentes, we are mindful that
Dr. Ampil examined his (Dr. Fuentes’) work and found it in order.
The glaring truth is that all the major circumstances, taken together, as specified by the Court of
Appeals, directly point to Dr. Ampil as the negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges to control the bleeding of the
patient during the surgical operation.
Second, immediately after the operation, the nurses who assisted in the surgery noted in their
report that the ‘sponge count (was) lacking 2’; that such anomaly was ‘announced to surgeon’
and that a ‘search was done but to no avail’ prompting Dr. Ampil to ‘continue for closure’ x x x.
Third, after the operation, two (2) gauzes were extracted from the same spot of the body of Mrs.
 Agana where the surgery was performed.
An operation requiring the placing of sponges in the incision is not complete until the sponges are
properly removed, and it is settled that the leaving of sponges or other foreign substances in the wound
after the incision has been closed is at least prima facie negligence by the operating surgeon. 8 To put it
simply, such act is considered so inconsistent with due care as to raise an inference of negligence.
There are even legions of authorities to the effect that such act is negligence per se.9
Of course, the Court is not blind to the reality that there are times when danger to a patient’s life
precludes a surgeon from further searching missing sponges or foreign objects left in the body. But this
does not leave him free from any obligation. Even if it has been shown that a surgeon was required by
the urgent necessities of the case to leave a sponge in his patient’s abdomen, because of the dangers
attendant upon delay, still, it is his legal duty to so inform his patient within a reasonable time thereafter
by advising her of what he had been compelled to do. This is in order that she might seek relief from
the effects of the foreign object left in her body as her condition might permit. The ruling in Smith v.
Zeagler10 is explicit, thus:
The removal of all sponges used is part of a surgical operation, and when a physician or surgeon fails to
remove a sponge he has placed in his patient’s body that should be removed as part of the operation, he
thereby leaves his operation uncompleted and creates a new condition which imposes upon him the
legal duty of calling the new condition to his patient’s attention, and endeavoring with the means he has
at hand to minimize and avoid untoward results likely to ensue therefrom.
Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even
misled her that the pain she was experiencing was the ordinary consequence of her operation. Had he
been more candid, Natividad could have taken the immediate and appropriate medical remedy to
remove the gauzes from her body. To our mind, what was initially an act of negligence by Dr. Ampil
has ripened into a deliberate wrongful act of deceiving his patient.
This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully
pursue this kind of case, a patient must only prove that a health care provider either failed to do
something which a reasonably prudent health care provider would have done, or that he did something
that a reasonably prudent provider would not have done; and that failure or action caused injury to the
patient.11 Simply put, the elements are duty, breach, injury and proximate causation. Dr, Ampil, as the
lead surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividad’s body before
closure of the incision. When he failed to do so, it was his duty to inform Natividad about it. Dr. Ampil
breached both duties. Such breach caused injury to Natividad, necessitating her further examination by
American doctors and another surgery. That Dr. Ampil’s negligence is the proximate cause 12 of
Natividad’s injury could be traced from his act of closing the incision despite the information given by
the attending nurses that two pieces of gauze were still missing. That they were later on extracted from
Natividad’s vagina established the causal link between Dr. Ampil’s negligence and the injury. And what
further aggravated such injury was his deliberate concealment of the missing gauzes from the
knowledge of Natividad and her family.
II - G.R. No. 126467
Whether the Court of Appeals Erred in Absolving
Dr. Fuentes of any Liability
The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes on the ground that it
is contrary to the doctrine of res ipsa loquitur. According to them, the fact that the two pieces of gauze
were left inside Natividad’s body is a prima facie evidence of Dr. Fuentes’ negligence.
We are not convinced.
Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule that the fact of the
occurrence of an injury, taken with the surrounding circumstances, may permit an inference or raise a
presumption of negligence, or make out a plaintiff’s prima facie case, and present a question of fact for
defendant to meet with an explanation.13 Stated differently, where the thing which caused the injury,
without the fault of the injured, is under the exclusive control of the defendant and the injury is such
that it should not have occurred if he, having such control used proper care, it affords reasonable
evidence, in the absence of explanation that the injury arose from the defendant’s want of care, and the
burden of proof is shifted to him to establish that he has observed due care and diligence.14
From the foregoing statements of the rule, the requisites for the applicability of the doctrine of res ipsa
loquitur are: (1) the occurrence of an injury; (2) the thing which caused the injury was under the control
and management of the defendant; (3) the occurrence was such that in the ordinary course of things,
would not have happened if those who had control or management used proper care; and (4) the
absence of explanation by the defendant. Of the foregoing requisites, the most instrumental is the
"control and management of the thing which caused the injury."15
We find the element of "control and management of the thing which caused the injury" to be wanting.
Hence, the doctrine of res ipsa loquitur will not lie.
It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He
requested the assistance of Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil) found that
the malignancy in her sigmoid area had spread to her left ovary. Dr. Fuentes performed the surgery and
thereafter reported and showed his work to Dr. Ampil. The latter examined it and finding everything to
be in order, allowed Dr. Fuentes to leave the operating room. Dr. Ampil then resumed operating on
Natividad. He was about to finish the procedure when the attending nurses informed him that two
pieces of gauze were missing. A "diligent search" was conducted, but the misplaced gauzes were not
found. Dr. Ampil then directed that the incision be closed. During this entire period, Dr. Fuentes was no
longer in the operating room and had, in fact, left the hospital.
Under the "Captain of the Ship" rule, the operating surgeon is the person in complete charge of the
surgery room and all personnel connected with the operation. Their duty is to obey his orders. 16 As
stated before, Dr. Ampil was the lead surgeon. In other words, he was the "Captain of the Ship." That
he discharged such role is evident from his following conduct: (1) calling Dr. Fuentes to perform a
hysterectomy; (2) examining the work of Dr. Fuentes and finding it in order; (3) granting Dr. Fuentes’
permission to leave; and (4) ordering the closure of the incision. To our mind, it was this act of ordering
the closure of the incision notwithstanding that two pieces of gauze remained unaccounted for, that
caused injury to Natividad’s body. Clearly, the control and management of the thing which caused the
injury was in the hands of Dr. Ampil, not Dr. Fuentes.
In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not per se create or
constitute an independent or separate ground of liability, being a mere evidentiary rule. 17 In other
words, mere invocation and application of the doctrine does not dispense with the requirement of proof
of negligence. Here, the negligence was proven to have been committed by Dr. Ampil and not by Dr.
Fuentes.
III - G.R. No. 126297
Whether PSI Is Liable for the Negligence of Dr. Ampil
The third issue necessitates a glimpse at the historical development of hospitals and the resulting
theories concerning their liability for the negligence of physicians.
Until the mid-nineteenth century, hospitals were generally charitable institutions, providing medical
services to the lowest classes of society, without regard for a patient’s ability to pay. 18 Those who could
afford medical treatment were usually treated at home by their doctors. 19 However, the days of house
calls and philanthropic health care are over. The modern health care industry continues to distance itself
from its charitable past and has experienced a significant conversion from a not-for-profit health care to
for-profit hospital businesses. Consequently, significant changes in health law have accompanied the
business-related changes in the hospital industry. One important legal change is an increase in hospital
liability for medical malpractice. Many courts now allow claims for hospital vicarious liability under
the theories of respondeat superior, apparent authority, ostensible authority, or agency by estoppel. 20
In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of the Civil Code,
which reads:
Art. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is
obliged to pay for the damage done. Such fault or negligence, if there is no pre-existing contractual
relation between the parties, is called a quasi-delict and is governed by the provisions of this Chapter.
A derivative of this provision is Article 2180, the rule governing vicarious liability under the doctrine
of respondeat superior, thus:
ART. 2180. The obligation imposed by Article 2176 is demandable not only for one’s own acts or
omissions, but also for those of persons for whom one is responsible.
x x x x
x x

The owners and managers of an establishment or enterprise are likewise responsible for damages
caused by their employees in the service of the branches in which the latter are employed or on the
occasion of their functions.
Employers shall be liable for the damages caused by their employees and household helpers acting
within the scope of their assigned tasks even though the former are not engaged in any business or
industry.
x x x
x x x

The responsibility treated of in this article shall cease when the persons herein mentioned prove that
they observed all the diligence of a good father of a family to prevent damage.
A prominent civilist commented that professionals engaged by an employer, such as physicians,
dentists, and pharmacists, are not "employees" under this article because the manner in which they
perform their work is not within the control of the latter (employer). In other words, professionals are
considered personally liable for the fault or negligence they commit in the discharge of their duties, and
their employer cannot be held liable for such fault or negligence. In the context of the present case, "a
hospital cannot be held liable for the fault or negligence of a physician or surgeon in the treatment or
operation of patients."21
The foregoing view is grounded on the traditional notion that the professional status and the very nature
of the physician’s calling preclude him from being classed as an agent or employee of a hospital,
whenever he acts in a professional capacity.22 It has been said that medical practice strictly involves
highly developed and specialized knowledge,23 such that physicians are generally free to exercise their
own skill and judgment in rendering medical services sans interference. 24 Hence, when a doctor
practices medicine in a hospital setting, the hospital and its employees are deemed to subserve him in
his ministrations to the patient and his actions are of his own responsibility.25
The case of Schloendorff v. Society of New York Hospital 26 was then considered an authority for this
view. The "Schloendorff doctrine" regards a physician, even if employed by a hospital, as an
independent contractor because of the skill he exercises and the lack of control exerted over his work.
Under this doctrine, hospitals are exempt from the application of the respondeat superior principle for
fault or negligence committed by physicians in the discharge of their profession.
However, the efficacy of the foregoing doctrine has weakened with the significant developments in
medical care. Courts came to realize that modern hospitals are increasingly taking active role in
supplying and regulating medical care to patients. No longer were a hospital’s functions limited to
furnishing room, food, facilities for treatment and operation, and attendants for its patients. Thus, in
Bing v. Thunig,27 the New York Court of Appeals deviated from the Schloendorff doctrine, noting that
modern hospitals actually do far more than provide facilities for treatment. Rather, they regularly
employ, on a salaried basis, a large staff of physicians, interns, nurses, administrative and manual
workers. They charge patients for medical care and treatment, even collecting for such services through
legal action, if necessary. The court then concluded that there is no reason to exempt hospitals from the
universal rule of respondeat superior.
In our shores, the nature of the relationship between the hospital and the physicians is rendered
inconsequential in view of our categorical pronouncement in Ramos v. Court of Appeals 28 that for
purposes of apportioning responsibility in medical negligence cases, an employer-employee
relationship in effect exists between hospitals and their attending and visiting physicians. This Court
held:
"We now discuss the responsibility of the hospital in this particular incident. The unique practice
(among private hospitals) of filling up specialist staff with attending and visiting "consultants," who are
allegedly not hospital employees, presents problems in apportioning responsibility for negligence in
medical malpractice cases. However, the difficulty is more apparent than real.
In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the
conduct of their work within the hospital premises. Doctors who apply for ‘consultant’ slots, visiting or
attending, are required to submit proof of completion of residency, their educational qualifications,
generally, evidence of accreditation by the appropriate board (diplomate), evidence of fellowship in
most cases, and references. These requirements are carefully scrutinized by members of the hospital
administration or by a review committee set up by the hospital who either accept or reject the
application. x x x.
After a physician is accepted, either as a visiting or attending consultant, he is normally required to
attend clinico-pathological conferences, conduct bedside rounds for clerks, interns and residents,
moderate grand rounds and patient audits and perform other tasks and responsibilities, for the privilege
of being able to maintain a clinic in the hospital, and/or for the privilege of admitting patients into the
hospital. In addition to these, the physician’s performance as a specialist is generally evaluated by a
peer review committee on the basis of mortality and morbidity statistics, and feedback from patients,
nurses, interns and residents. A consultant remiss in his duties, or a consultant who regularly falls short
of the minimum standards acceptable to the hospital or its peer review committee, is normally politely
terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and visiting
‘consultant’ staff. While ‘consultants’ are not, technically employees, x x x, the control exercised, the
hiring, and the right to terminate consultants all fulfill the important hallmarks of an employer-
employee relationship, with the exception of the payment of wages. In assessing whether such a
relationship in fact exists, the control test is determining. Accordingly, on the basis of the foregoing, we
rule that for the purpose of allocating responsibility in medical negligence cases, an employer-
employee relationship in effect exists between hospitals and their attending and visiting physicians. "
But the Ramos pronouncement is not our only basis in sustaining PSI’s liability. Its liability is also
anchored upon the agency principle of apparent authority or agency by estoppel and the doctrine of
corporate negligence which have gained acceptance in the determination of a hospital’s liability for
negligent acts of health professionals. The present case serves as a perfect platform to test the
applicability of these doctrines, thus, enriching our jurisprudence.
Apparent authority, or what is sometimes referred to as the "holding
out" theory, or doctrine of ostensible agency or agency by estoppel, 29 has its origin from the law of
agency. It imposes liability, not as the result of the reality of a contractual relationship, but rather
because of the actions of a principal or an employer in somehow misleading the public into believing
that the relationship or the authority exists.30 The concept is essentially one of estoppel and has been
explained in this manner:
"The principal is bound by the acts of his agent with the apparent authority which he knowingly
permits the agent to assume, or which he holds the agent out to the public as possessing. The question
in every case is whether the principal has by his voluntary act placed the agent in such a situation that a
person of ordinary prudence, conversant with business usages and the nature of the particular business,
is justified in presuming that such agent has authority to perform the particular act in question.31
The applicability of apparent authority in the field of hospital liability was upheld long time ago in
Irving v. Doctor Hospital of Lake Worth, Inc. 32 There, it was explicitly stated that "there does not
appear to be any rational basis for excluding the concept of apparent authority from the field of hospital
liability." Thus, in cases where it can be shown that a hospital, by its actions, has held out a particular
physician as its agent and/or employee and that a patient has accepted treatment from that physician in
the reasonable belief that it is being rendered in behalf of the hospital, then the hospital will be liable
for the physician’s negligence.
Our jurisdiction recognizes the concept of an agency by implication or estoppel. Article 1869 of the
Civil Code reads:
ART. 1869. Agency may be express, or implied from the acts of the principal, from his silence or lack
of action, or his failure to repudiate the agency, knowing that another person is acting on his behalf
without authority.
In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and
specializations of the physicians associated or accredited by it, including those of Dr. Ampil and Dr.
Fuentes. We concur with the Court of Appeals’ conclusion that it "is now estopped from passing all the
blame to the physicians whose names it proudly paraded in the public directory leading the public to
believe that it vouched for their skill and competence." Indeed, PSI’s act is tantamount to holding out to
the public that Medical City Hospital, through its accredited physicians, offers quality health care
services. By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications, the
hospital created the impression that they were its agents, authorized to perform medical or surgical
services for its patients. As expected, these patients, Natividad being one of them, accepted the services
on the reasonable belief that such were being rendered by the hospital or its employees, agents, or
servants. The trial court correctly pointed out:
x x x regardless of the education and status in life of the patient, he ought not be burdened with the
defense of absence of employer-employee relationship between the hospital and the independent
physician whose name and competence are certainly certified to the general public by the hospital’s act
of listing him and his specialty in its lobby directory, as in the case herein. The high costs of today’s
medical and health care should at least exact on the hospital greater, if not broader, legal responsibility
for the conduct of treatment and surgery within its facility by its accredited physician or surgeon,
regardless of whether he is independent or employed."33
The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like PSI, are capable of
acting only through other individuals, such as physicians. If these accredited physicians do their job
well, the hospital succeeds in its mission of offering quality medical services and thus profits
financially. Logically, where negligence mars the quality of its services, the hospital should not be
allowed to escape liability for the acts of its ostensible agents.
We now proceed to the doctrine of corporate negligence or corporate responsibility.
One allegation in the complaint in Civil Case No. Q-43332 for negligence and malpractice is that PSI
as owner, operator and manager of Medical City Hospital, "did not perform the necessary supervision
nor exercise diligent efforts in the supervision of Drs. Ampil and Fuentes and its nursing staff, resident
doctors, and medical interns who assisted Drs. Ampil and Fuentes in the performance of their duties as
surgeons."34 Premised on the doctrine of corporate negligence, the trial court held that PSI is directly
liable for such breach of duty.
We agree with the trial court.
Recent years have seen the doctrine of corporate negligence as the judicial answer to the problem of
allocating hospital’s liability for the negligent acts of health practitioners, absent facts to support the
application of respondeat superior or apparent authority. Its formulation proceeds from the judiciary’s
acknowledgment that in these modern times, the duty of providing quality medical service is no longer
the sole prerogative and responsibility of the physician. The modern hospitals have changed structure.
Hospitals now tend to organize a highly professional medical staff whose competence and performance
need to be monitored by the hospitals commensurate with their inherent responsibility to provide
quality medical care.35
The doctrine has its genesis in Darling v. Charleston Community Hospital. 36 There, the Supreme Court
of Illinois held that "the jury could have found a hospital negligent, inter alia, in failing to have a
sufficient number of trained nurses attending the patient; failing to require a consultation with or
examination by members of the hospital staff; and failing to review the treatment rendered to the
patient." On the basis of Darling, other jurisdictions held that a hospital’s corporate negligence extends
to permitting a physician known to be incompetent to practice at the hospital. 37 With the passage of
time, more duties were expected from hospitals, among them: (1) the use of reasonable care in the
maintenance of safe and adequate facilities and equipment; (2) the selection and retention of competent
physicians; (3) the overseeing or supervision of all persons who practice medicine within its walls; and
(4) the formulation, adoption and enforcement of adequate rules and policies that ensure quality care
for its patients.38 Thus, in Tucson Medical Center, Inc. v. Misevich, 39 it was held that a hospital,
following the doctrine of corporate responsibility, has the duty to see that it meets the standards of
responsibilities for the care of patients. Such duty includes the proper supervision of the members of its
medical staff. And in Bost v. Riley,40 the court concluded that a patient who enters a hospital does so
with the reasonable expectation that it will attempt to cure him. The hospital accordingly has the duty
to make a reasonable effort to monitor and oversee the treatment prescribed and administered by the
physicians practicing in its premises.
In the present case, it was duly established that PSI operates the Medical City Hospital for the purpose
and under the concept of providing comprehensive medical services to the public. Accordingly, it has
the duty to exercise reasonable care to protect from harm all patients admitted into its facility for
medical treatment. Unfortunately, PSI failed to perform such duty. The findings of the trial court are
convincing, thus:
x x x PSI’s liability is traceable to its failure to conduct an investigation of the matter reported in the
nota bene of the count nurse. Such failure established PSI’s part in the dark conspiracy of silence and
concealment about the gauzes. Ethical considerations, if not also legal, dictated the holding of an
immediate inquiry into the events, if not for the benefit of the patient to whom the duty is primarily
owed, then in the interest of arriving at the truth. The Court cannot accept that the medical and the
healing professions, through their members like defendant surgeons, and their institutions like PSI’s
hospital facility, can callously turn their backs on and disregard even a mere probability of mistake or
negligence by refusing or failing to investigate a report of such seriousness as the one in Natividad’s
case.
It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the assistance of the
Medical City Hospital’s staff, composed of resident doctors, nurses, and interns. As such, it is
reasonable to conclude that PSI, as the operator of the hospital, has actual or constructive knowledge of
the procedures carried out, particularly the report of the attending nurses that the two pieces of gauze
were missing. In Fridena v. Evans,41 it was held that a corporation is bound by the knowledge acquired
by or notice given to its agents or officers within the scope of their authority and in reference to a
matter to which their authority extends. This means that the knowledge of any of the staff of Medical
City Hospital constitutes knowledge of PSI. Now, the failure of PSI, despite the attending nurses’
report, to investigate and inform Natividad regarding the missing gauzes amounts to callous
negligence. Not only did PSI breach its duties to oversee or supervise all persons who practice
medicine within its walls, it also failed to take an active step in fixing the negligence committed. This
renders PSI, not only vicariously liable for the negligence of Dr. Ampil under Article 2180 of the Civil
Code, but also directly liable for its own negligence under Article 2176. In Fridena, the Supreme Court
of Arizona held:
x x x In recent years, however, the duty of care owed to the patient by the hospital has expanded. The
emerging trend is to hold the hospital responsible where the hospital has failed to monitor and review
medical services being provided within its walls. See Kahn Hospital Malpractice Prevention, 27 De
Paul . Rev. 23 (1977).
Among the cases indicative of the ‘emerging trend’ is Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d
335 (1972). In Purcell, the hospital argued that it could not be held liable for the malpractice of a
medical practitioner because he was an independent contractor within the hospital. The Court of
Appeals pointed out that the hospital had created a professional staff whose competence and
performance was to be monitored and reviewed by the governing body of the hospital, and the court
held that a hospital would be negligent where it had knowledge or reason to believe that a doctor using
the facilities was employing a method of treatment or care which fell below the recognized standard of
care.
Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hospital has certain
inherent responsibilities regarding the quality of medical care furnished to patients within its walls and
it must meet the standards of responsibility commensurate with this undertaking. Beeck v. Tucson
General Hospital, 18 Ariz. App. 165, 500 P. 2d 1153 (1972). This court has confirmed the rulings of the
Court of Appeals that a hospital has the duty of supervising the competence of the doctors on its staff. x
x x.
x x x x x x

In the amended complaint, the plaintiffs did plead that the operation was performed at the hospital with
its knowledge, aid, and assistance, and that the negligence of the defendants was the proximate cause of
the patient’s injuries. We find that such general allegations of negligence, along with the evidence
produced at the trial of this case, are sufficient to support the hospital’s liability based on the theory of
negligent supervision."
Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for damages, let it be
emphasized that PSI, apart from a general denial of its responsibility, failed to adduce evidence
showing that it exercised the diligence of a good father of a family in the accreditation and supervision
of the latter. In neglecting to offer such proof, PSI failed to discharge its burden under the last
paragraph of Article 2180 cited earlier, and, therefore, must be adjudged solidarily liable with Dr.
Ampil. Moreover, as we have discussed, PSI is also directly liable to the Aganas.
One final word. Once a physician undertakes the treatment and care of a patient, the law imposes on
him certain obligations. In order to escape liability, he must possess that reasonable degree of learning,
skill and experience required by his profession. At the same time, he must apply reasonable care and
diligence in the exercise of his skill and the application of his knowledge, and exert his best judgment.
WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of the Court of
Appeals in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198.
Costs against petitioners PSI and Dr. Miguel Ampil.
SO ORDERED.
Professional Services Inc. vs Agana
GR No. 126297 January 31, 2007
Facts: On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital because of
difficulty of bowel movement and bloody anal discharge. After a series of medical examinations, Dr.
Miguel Ampil diagnosed her to be suffering from Cancer of the sigmoid. On April 11, 1984, Dr. Ampil
assisted by the medical staff of the Medical City Hospital performed an Anterior resection surgery on
Natividad. He found that the malignancy on her sigmoid area had spread on her left ovary, necessitating
the removal of certain portions of it. Thus, Dr. Ampil obtained the consent of Natividad’s husband,
Enrique Agana, to permit Dr. Juan Fuentes to perform hysterectomy on her. After Dr. Fuentes had
completed the hysterectomy, Dr. Ampil took over, completed the operation and closed the incision after
searching for the missing 2 gauzes as indicated by the assisting nurses but failed to locate it. After a
couple of days, Natividad complained of excruciating pains in her anal region but Dr. Ampil said it is a
natural consequence of the operation/surgery and recommended that she consult an oncologist to
examine the cancerous nodes which were not removed during the operation. Natividad and her husband
went to the US to seek further treatment and she was declared free from cancer. A piece of gauze
portruding from Natividad’s vagina was found by her daughter which was then removed by hand by Dr.
Ampil and assured that the pains will vanished. However, it didn’t. The pains intensified prompting
Natividad to seek treatment at the Polymedic General Hospital. While confined there, Dr. Ramon
Guttierez detected the presence of another foreign object in her vagina – a foul smelling gauze
measuring 1.5 inches in width which badly infected her vagina. A recto-vaginal fistula had forced stool
to excrete through her vagina. Another surgical operation was needed to remedy the damage.
Issue: Whether or not Dr. Ampil and Fuentes are liable for medical malpractice and the PSI for
damages due to the negligence of the said doctors.
Held: Yes. No. Yes. An operation requiring the placing of sponges in the incision is not complete until
the sponges are properly removed and it is settled that the leaving of sponges or other foreign
substances in the wound after the incision has been closed is at least prima facie negligence by the
operating surgeon. To put it simply, such act is considered so inconsistent with due care as to raise
inference of negligence. There are even legions of authorities to the effect that such act is negligence
per se.
This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully
pursue this kind of case, a patient must only prove that a health care provider either failed to do
something which a reasonably prudent health care provider would have done, or that he did something
that a reasonably prudent provider would not have done; and that failure or action caused injury to the
patient. Simply puts the elements are duty, breach, injury, and proximate causation. Dr. Ampil, as the
lead surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividad’s body before
closure of the incision. When he failed to do so, it was his duty to inform Natividad about it. Dr. Ampil
breached both duties. Such breach caused injury to Natividad, necessitating her further examination by
American doctors and another surgery. That Dr. Ampil’s negligence is the proximate cause of
Natividad’s injury could be traced from his act of closing the incision despite the information given by
the attending nurses that 2 pieces of gauze were still missing. That they were later on extracted from
Natividad’s vagina established the causal link between Dr. Ampil’s negligence and the injury. And what
further aggravated such injury was his deliberate concealment of this missing gauzes from the
knowledge of Natividad and her family.
The requisites for the applicability of the doctrine of res ipsa liquitor are:
1. Occurrence of an injury;
2. The thing which caused the injury was under the control and management of the defendant;
3. The occurrence was such that in the ordinary course of things would not have happened if those
who had control or management used proper care, and;
4. The absence of explanation by the defendant
Of the foregoing, the most instrumental is the “Control and management of the thing which caused the
injury.”
Under the “Captain of the ship” rule, the operating surgeon is the person in complete charge of the
surgery room and all personnel connected with the operation.
The knowledge of any of the staff of Medical City constitutes knowledge of PSI.
The doctrine of corporate responsibility, has the duty to see that it meets the standards of
responsibilities for the care of patients. Such duty includes the proper supervision of the members of its
medical staff. The hospital accordingly has the duty to make a reasonable effort to monitor and over see
the treatment prescribed and administered by the physician practicing in its premises.

DR. MILAGROS L. CANTRE,

G.R. No. 160889
Petitioner,

- versus - Present:

QUISUMBING, J., Chairperson,

 CARPIO,

CARPIO MORALES,
TINGA, and

VELASCO, JR., JJ.

SPS. JOHN DAVID Z. GO and NORA Promulgated:

S. GO,
April 27, 2007
Respondents.

x------------------------------------------------x

DECISION
QUISUMBING, J.:
For review on certiorari are the Decision[1] dated October 3, 2002 and Resolution[2]
dated November 19, 2003 of the Court of Appeals in CA-G.R. CV No. 58184, which
affirmed with modification the Decision[3] dated March 3, 1997 of the Regional Trial
Court of Quezon City, Branch 98, in Civil Case No. Q-93-16562.

The facts, culled from the records, are as follows:

Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and Gynecology at the Dr.
Jesus Delgado Memorial Hospital. She was the attending physician of respondent Nora
S. Go, who was admitted at the said hospital on April 19, 1992.

At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy. However,
at around 3:30 a.m., Nora suffered profuse bleeding inside her womb due to some parts
of the placenta which were not completely expelled from her womb after delivery.
Consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood
pressure to 40 over 0. Petitioner and the assisting resident physician performed various
medical procedures to stop the bleeding and to restore Noras blood pressure. Her blood
pressure was frequently monitored with the use of a sphygmomanometer. While
petitioner was massaging Noras uterus for it to contract and stop bleeding, she ordered a
droplight to warm Nora and her baby.[4] Nora remained unconscious until she
recovered.

While in the recovery room, her husband, respondent John David Z. Go noticed a fresh
gaping wound two and a half (2 ) by three and a half (3 ) inches in the inner portion of
her left arm, close to the armpit.[5] He asked the nurses what caused the injury. He was
informed it was a burn. Forthwith, on April 22, 1992, John David filed a request for
investigation.[6] In response, Dr. Rainerio S. Abad, the medical director of the hospital,
called petitioner and the assisting resident physician to explain what happened.
Petitioner said the blood pressure cuff caused the injury.

On May 7, 1992, John David brought Nora to the National Bureau of Investigation for a
physical examination, which was conducted by medico-legal officer Dr. Floresto
Arizala, Jr.[7] The medico-legal officer later testified that Noras injury appeared to be a
burn and that a droplight when placed near the skin for about 10 minutes could cause
such burn.[8] He dismissed the likelihood that the wound was caused by a blood
pressure cuff as the scar was not around the arm, but just on one side of the arm.[9]

On May 22, 1992, Noras injury was referred to a plastic surgeon at the Dr. Jesus
Delgado Memorial Hospital for skin grafting.[10] Her wound was covered with skin
sourced from her abdomen, which consequently bore a scar as well. About a year after,
on April 30, 1993, scar revision had to be performed at the same hospital.[11] The
surgical operation left a healed linear scar in Noras left arm about three inches in length,
the thickest portion rising about one-fourth (1/4) of an inch from the surface of the skin.
The costs of the skin grafting and the scar revision were shouldered by the hospital.[12]

Unfortunately, Noras arm would never be the same. Aside from the unsightly mark, the
pain in her left arm remains. When sleeping, she has to cradle her wounded arm. Her
movements now are also restricted. Her children cannot play with the left side of her
body as they might accidentally bump the injured arm, which aches at the slightest
touch.
Thus, on June 21, 1993, respondent spouses filed a complaint[13] for damages against
petitioner, Dr. Abad, and the hospital. Finding in favor of respondent spouses, the trial
court decreed:

In view of the foregoing consideration, judgment is hereby rendered in favor of the plaintiffs and
against the defendants, directing the latters, (sic) jointly and severally

(a) to pay the sum of Five Hundred Thousand Pesos (P500,000.00) in moral damages;

(b) to pay the sum of One Hundred Fifty Thousand Pesos (P150,000.00) exemplary damages;

(c) to pay the sum of Eighty Thousand Pesos (P80,000.00) nominal damages;

(d) to pay Fifty Thousand Pesos (P50,000.00) for and as attorneys fees; and

(e) to pay Six Thousand Pesos (P6,000.00) litigation expenses.

SO ORDERED.[14]

Petitioner, Dr. Abad, and the hospital all appealed to the Court of Appeals, which
affirmed with modification the trial court decision, thus:

WHEREFORE, in view of all the foregoing, and finding no reversible error in the appealed Decision
dated of Branch 98 of the Regional Trial Court of Quezon City in Civil Case No. Q-93-16562, the same
is hereby AFFIRMED, with the following MODIFICATIONS:

1. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay plaintiffs-appellees John
David Go and Nora S. Go the sum of P200,000.00 as moral damages;

2. Deleting the award [of] exemplary damages, attorneys fees and expenses of litigation;

3. Dismissing the complaint with respect to defendants-appellants Dr. Rainerio S. Abad and
Delgado Clinic, Inc.;

4. Dismissing the counterclaims of defendants-appellants for lack of merit; and

5. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay the costs.

SO ORDERED.[15]
Petitioners motion for reconsideration was denied by the Court of Appeals.
Hence, the instant petition assigning the following as errors and issues:
 I.

WHETHER OR NOT, THE LOWER COURT, AND THE COURT OF APPEALS COMMITTED
GRAVE ABUSE OF THEIR DISCRETION WHEN, NOTWITHSTANDING THAT BOTH PARTIES
HAVE RESTED THEIR RESPECTIVE CASES, THE LOWER COURT ADMITTED THE
ADDITIONAL EXHIBITS FURTHER OFFERED BY RESPONDENTS NOT TESTIFIED TO BY
ANY WITNESS AND THIS DECISION OF THE LOWER COURT WAS UPHELD BY THE COURT
OF APPEALS LIKEWISE COMMITTING GRAVE ABUSE OF DISCRETION;

II.

WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION
WHEN, CONTRARY TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE
PETITIONER, IT RULED THAT THE PETITIONER HAS NOT AMPLY SHOWED THAT THE
DROPLIGHT DID NOT TOUCH THE BODY OF MRS. NORA GO, AND THIS DECISION OF THE
LOWER COURT WAS UPHELD BY THE COURT OF APPEALS LIKEWISE COMMITTING
GRAVE ABUSE OF DISCRETION;

III.

WHETHER OR NOT THE COMMITTED GRAVE ABUSE OF ITS DISCRETION WHEN,

CONTRARY TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE PETITIONER, IT
RULED THAT PETITIONER DRA. CANTRE WAS NOT ABLE TO AMPLY EXPLAIN HOW THE
INJURY (BLISTERS) IN THE LEFT INNER ARM OF RESPONDENT MRS. GO CAME ABOUT;

IV.

WHETHER OR NOT THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF ITS

DISCRETION WHEN IT MADE A RULING ON THE RESPONDENTS INJURY QUOTING THE
TESTIMONY OF SOMEONE WHO WAS NOT PRESENT AND HAS NOT SEEN THE ORIGINAL,
FRESH INJURY OF RESPONDENT MRS. NORA GO;

V.

WHETHER OR NOT THE COURT OF APPEALS GRAVELY ABUSING ITS DISCRETION RULED
THAT PETITIONER DRA. CANTRE SHOULD HAVE INTENDED TO INFLICT THE INJURY TO
SAVE THE LIFE OF RESPONDENT MRS. GO;

VI.

WHETHER OR NOT THE LOWER COURT AND THE COURT [OF] APPEALS COMMITTED
GRAVE ABUSE OF DISCRETION WHEN, CONTRARY TO THE DETAILED PROCEDURES
DONE BY PETITIONER, BOTH RULED THAT THE RESPONDENT WAS LEFT TO THE CARE
OF THE NURSING STAFF;
 VII.

WHETHER OR NOT THE COMMITTED GRAVE ABUSE OF DISCRETION WHEN, CONTRARY

TO THE MEDICAL PURPOSES OF COSMETIC SURGERY, IT RULED THAT THE COSMETIC
SURGERY MADE THE SCARS EVEN MORE UGLY AND DECLARED THE COSMETIC
SURGERY A FAILURE;

VIII.

WHETHER OR NOT THE LOWER COURT GRAVELY ABUSE OF (SIC) DISCRETION WHEN,
CONTRARY TO RESPONDENTS CONTRARY TESTIMONIES AND THE ABSENCE OF ANY
TESTIMONY, IT RULED THAT THEY ARE ENTITLED TO DAMAGES AND WHICH WAS
UPHELD, ALTHOUGH MODIFIED, BY THE COURT OF APPEALS LIKEWISE ABUSING ITS
DISCRETION.[16]
Petitioner contends that additional documentary exhibits not testified to by any witness
are inadmissible in evidence because they deprived her of her constitutional right to
confront the witnesses against her. Petitioner insists the droplight could not have touched
Noras body. She maintains the injury was due to the constant taking of Noras blood
pressure. Petitioner also insinuates the Court of Appeals was misled by the testimony of
the medico-legal officer who never saw the original injury before plastic surgery was
performed. Finally, petitioner stresses that plastic surgery was not intended to restore
respondents injury to its original state but rather to prevent further complication.

Respondents, however, counter that the genuineness and due execution of the additional
documentary exhibits were duly admitted by petitioners counsel. Respondents point out
that petitioners blood pressure cuff theory is highly improbable, being unprecedented in
medical history and that the injury was definitely caused by the droplight. At any rate,
they argue, even if the injury was brought about by the blood pressure cuff, petitioner
was still negligent in her duties as Noras attending physician.

Simply put, the threshold issues for resolution are: (1) Are the questioned additional
exhibits admissible in evidence? (2) Is petitioner liable for the injury suffered by
respondent Nora Go? Thereafter, the inquiry is whether the appellate court committed
grave abuse of discretion in its assailed issuances.
As to the first issue, we agree with the Court of Appeals that said exhibits are admissible
in evidence. We note that the questioned exhibits consist mostly of Noras medical
records, which were produced by the hospital during trial pursuant to a subpoena duces
tecum. Petitioners counsel admitted the existence of the same when they were formally
offered for admission by the trial court. In any case, given the particular circumstances
of this case, a ruling on the negligence of petitioner may be made based on the res ipsa
loquitur doctrine even in the absence of such additional exhibits.

Petitioners contention that the medico-legal officer who conducted Noras physical
examination never saw her original injury before plastic surgery was performed is
without basis and contradicted by the records. Records show that the medico-legal
officer conducted the physical examination on May 7, 1992, while the skin grafting and
the scar revision were performed on Nora on May 22, 1992 and April 30, 1993,
respectively.

Coming now to the substantive matter, is petitioner liable for the injury suffered by
respondent Nora Go?

The Hippocratic Oath mandates physicians to give primordial consideration to the well-
being of their patients. If a doctor fails to live up to this precept, he is accountable for his
acts. This notwithstanding, courts face a unique restraint in adjudicating medical
negligence cases because physicians are not guarantors of care and, they never set out to
intentionally cause injury to their patients. However, intent is immaterial in negligence
cases because where negligence exists and is proven, it automatically gives the injured a
right to reparation for the damage caused.[17]
In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere
existence of an injury to justify a presumption of negligence on the part of the person
who controls the instrument causing the injury, provided that the following requisites
concur:

1. The accident is of a kind which ordinarily does not occur in the absence of someones
negligence;

2. It is caused by an instrumentality within the exclusive control of the defendant or

defendants; and

3. The possibility of contributing conduct which would make the plaintiff responsible is
eliminated.[18]

As to the first requirement, the gaping wound on Noras arm is certainly not an ordinary
occurrence in the act of delivering a baby, far removed as the arm is from the organs
involved in the process of giving birth. Such injury could not have happened unless
negligence had set in somewhere.

Second, whether the injury was caused by the droplight or by the blood pressure cuff is
of no moment. Both instruments are deemed within the exclusive control of the
physician in charge under the captain of the ship doctrine. This doctrine holds the
surgeon in charge of an operation liable for the negligence of his assistants during the
time when those assistants are under the surgeons control.[19] In this particular case, it
can be logically inferred that petitioner, the senior consultant in charge during the
delivery of Noras baby, exercised control over the assistants assigned to both the use of
the droplight and the taking of Noras blood pressure. Hence, the use of the droplight and
the blood pressure cuff is also within petitioners exclusive control.

Third, the gaping wound on Noras left arm, by its very nature and considering her
condition, could only be caused by something external to her and outside her control as
she was unconscious while in hypovolemic shock. Hence, Nora could not, by any stretch
of the imagination, have contributed to her own injury.

Petitioners defense that Noras wound was caused not by the droplight but by the
constant taking of her blood pressure, even if the latter was necessary given her
condition, does not absolve her from liability. As testified to by the medico-legal officer,
Dr. Arizala, Jr., the medical practice is to deflate the blood pressure cuff immediately
after each use. Otherwise, the inflated band can cause injury to the patient similar to
what could have happened in this case. Thus, if Noras wound was caused by the blood
pressure cuff, then the taking of Noras blood pressure must have been done so
negligently as to have inflicted a gaping wound on her arm,[20] for which petitioner
cannot escape liability under the captain of the ship doctrine.

Further, petitioners argument that the failed plastic surgery was not intended as a
cosmetic procedure, but rather as a measure to prevent complication does not help her
case. It does not negate negligence on her part.

Based on the foregoing, the presumption that petitioner was negligent in the exercise of
her profession stands unrebutted. In this connection, the Civil Code provides:

ART. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is
obliged to pay for the damage done.

ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious anxiety,
besmirched reputation, wounded feelings, moral shock, social humiliation, and similar injury. Though
incapable of pecuniary computation, moral damages may be recovered if they are the proximate result
of the defendants wrongful act or omission.
Clearly, under the law, petitioner is obliged to pay Nora for moral damages suffered by
the latter as a proximate result of petitioners negligence.

We note, however, that petitioner has served well as Noras obstetrician for her past three
successful deliveries. This is the first time petitioner is being held liable for damages due
to negligence in the practice of her profession. The fact that petitioner promptly took
care of Noras wound before infection and other complications set in is also indicative of
petitioners good intentions. We also take note of the fact that Nora was suffering from a
critical condition when the injury happened, such that saving her life became petitioners
elemental concern. Nonetheless, it should be stressed that all these could not justify
negligence on the part of petitioner.

Hence, considering the specific circumstances in the instant case, we find no grave
abuse of discretion in the assailed decision and resolution of the Court of Appeals.
Further, we rule that the Court of Appeals award of Two Hundred Thousand Pesos
(P200,000) as moral damages in favor of respondents and against petitioner is just and
equitable.[21]

WHEREFORE, the petition is DENIED. The Decision dated October 3, 2002 and
Resolution dated November 19, 2003 of the Court of Appeals in CA-G.R. CV No. 58184
are AFFIRMED.

No pronouncement as to costs.

SO ORDERED.
Cantre vs Go
GR No. 160889 April 27, 2007
Facts: Petitioner Dr. Milagros L. Cantre is a specialist in obstetrics and gynecology at the Dr. Jesus
Delgado memorial Hospital. She was the attending physician of respondent Nora Go, who was
admitted at the said hospital on April 19, 1992. At 1:30am of April 20, 1992, Nora gave birth to her
fourth child, a baby boy. However, at around 3:30am Nora suffered profuse bleeding insider her womb
due to some parts of the placenta were not completely expelled from her womb after delivery
consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood pressure to 40/0.
Petitioner said the assisting resident physician performed various medical procedures to stop the
bleeding and to restore Nora’s blood pressure. Her blood pressure was frequently monitored with the
use of a sphygmamometer. While petitioner was massaging Nora’s uterus for it to contract and stop
bleeding, she ordered a drop light to warm Nora and her baby. Nora remained unconscious until she
recovered. While in the recovery room, her husband, respondent John David Z. Go noticed a fresh
gasping wound 2 1/2″ x 3 1/2″ in the inner portion of her left arm, close to the armpit. He asked the
nurses what caused the injury. He was informed, it was a burn. An investigation was filed by Nora’s
husband and found out from the petitioner that it was caused by the blood pressure cuff, however, this
was contrary to the findings from a medico-legal report which stated that it was indeed a burn and that
a drop light when placed near a skin for about 10mins could cause such burn. Nora was referred to a
plastic surgeon from the hospital and skin grafting was done on her and scar revision but both still left a
mark on Nora’s arm compelling the respondent spouse to file a complaint for damages against
petitioner.
Issue: Whether or not petitioner is liable for the injury referred by Nora.
Held: Yes. The Hippocratic oath mandates physicians to give primordial consideration to the well-
being of their patients. If a doctor fails to live up to his precept, he is accountable for his acts. This is
notwithstanding, courts face a unique restraint in adjudicating medical negligence cases because
physicians are not guardians of care and they never set out to intentionally cause injury to their patients.
However, intent is immaterial in negligence cases because where negligence exist and is proven, it
automatically gives the injured a right to reparation for the damage caused.
In cases, involving medical negligence, the doctrine of res ipsa liquitor allows the mere existence of an
injury to justify a presumption of negligence on the part of the person who controls the instrument
causing the injury, provided that the following requisites concur:
 1. The accident is of a kind which ordinarily does not occur in the absence of someone’s
negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or defendants;
3. The possibility of contributing conduct which would make the plaintiff responsible is
eliminated.
All of these three requisites were present in the case at bar.
Under the the captain of the ship doctrine, the surgeon in charge of the operation is liable for the
negligence of his assistants during the time when those are under the surgeons control.