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584 SUPREME COURT REPORTS ANNOTATED Ramos vs.

Court of Appeals
Ramos vs. Court of Appeals dant or his servants and the accident is such as in ordinary course
of things does not happen if those who have its management or
G.R. No. 124354. December 29, 1999. *
control use proper care, it affords reasonable evidence, in the
ROGELIO E. RAMOS and ERLINDA RAMOS, in their own absence of explanation by the defendant, that the accident arose
behalf and as natural guardians of the minors, ROMMEL from or was caused by the defendant’s want of care.
RAMOS, ROY RODERICK RAMOS and RON RAYMOND Same; Same; Same; Same; Res Ipsa Loquitur is applied in conjunction with
RAMOS, petitioners, vs. COURT OF APPEALS, DELOS the doctrine of common knowledge.—The doctrine of res ipsa loquitur is
SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and simply a recognition of the postulate that, as a matter of common
DRA. PERFECTA GUTIERREZ, respondents. knowledge and experience, the very nature of certain types of
Remedial Law; Pleadings and Practice; When a party is represented by occurrences may justify an inference of negligence on the part of the
counsel, all notices should be sent to the party’s lawyer at his given person who controls the instrumentality causing the injury in the
address.—It is elementary that when a party is represented by absence of some explanation by the defendant who is charged with
counsel, all notices should be sent to the party’s lawyer at his given negligence. It is grounded in the superior logic of ordinary human
address. With a few exceptions, notice to a litigant without notice experience and on the basis of such experience or common
to his counsel on record is no notice at all. In the present case, since knowledge, negligence may be deduced from the mere occurrence
a copy of the decision of the appellate court was not sent to the of the accident itself. Hence, res ipsa loquitur is applied in
counsel on record of petitioner, there can be no sufficient notice to conjunction with the doctrine of common knowledge.
speak of. Hence, the delay in the filing of the motion for Same; Same; Same; Same; Mere invocation and application of the doctrine
reconsideration cannot be taken against petitioner. does not dispense with the requirement of proof of negligence; Requisites
Same; Evidence; Res Ipsa Loquitur; Doctrine of Res Ipsa Loquitur.—Res before resort to the doctrine may be allowed.—Much has been said that
ipsa loquitur is a Latin phrase which literally means “the thing or the res ipsa loquitur is not a rule of substantive law and, as such, does
transaction speaks for itself.” The phrase “res ipsa loquitur” is a not create or constitute an independent or separate ground of
maxim for the rule that the fact of the occurrence of an injury, taken liability. Instead, it is considered as merely evidentiary or in the
with the surrounding circumstances, may permit an inference or nature of a procedural rule. It is regarded as a mode of proof, or a
raise a presumption of negligence, or make out a plaintiff’s prima mere procedural convenience since it furnishes a substitute for, and
facie case, and present a question of fact for defendant to meet with relieves a plaintiff of, the burden of producing specific proof of
an explanation. Where the thing which caused the injury negligence. In other words, mere invocation and application of the
complained of is shown to be under the management of the defen- doctrine does not dispense with the requirement of proof of
negligence. It is simply a step in the process of such proof,
________________
permitting the plaintiff to present along with the proof of the
* FIRST DIVISION.
accident, enough of the attending circumstances to invoke the
doctrine, creating an inference or presumption of negligence, and
585 to thereby place on the defendant the burden of going forward with
the proof. Still, before resort to the doctrine may be allowed, the
following requisites must be satisfactorily shown: 1. The accident is
VOL. 321, DECEMBER 29, 1999 585
of a kind which ordinarily does not occur in the absence of
someone’s negligence; 2. It is caused by an instrumentality within where a layman is able to say, as a matter of common knowledge
the exclusive control of the defendant or defendants; and 3. The and observation, that the consequences of professional care were
possibility of contributing conduct which would make the plaintiff not as such as would ordinarily have followed if due care had been
responsible is eliminated. exercised.
586 Same; Same; Same; Same; Res ipsa loquitur is not available in a
586 SUPREME COURT REPORTS ANNOTATED malpractice suit if the only showing is that the desired result of an
operation or treatment was not accomplished.—It must be conceded
Ramos vs. Court of Appeals
that the doctrine of res ipsa loquitur can have no application in a suit
Same; Same; Same; Same; When the doctrine of res ipsa loqui-tur is availed against a physician or surgeon which involves the merits of a
by the plaintiff, the need for expert medical testimony is dispensed with diagnosis or of a scientific treatment. The physician or surgeon is
because the injury itself provides the proof of negligence.—Although not required at his peril to explain why any particular diagnosis
generally, expert medical testimony is relied upon in malpractice was not correct, or why any particular scientific treatment did not
suits to prove that a physician has done a negligent act or that he produce
has deviated from the standard medical procedure, when the 587
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 VOL. 321, DECEMBER 29, 1999 587
on the necessity of expert testimony applies only to such matters Ramos vs. Court of Appeals
clearly within the domain of medical science, and not to matters
the desired result. Thus, res ipsa loquitur is not available in a
that are within the common knowledge of mankind which may be
malpractice suit if the only showing is that the desired result of an
testified to by anyone familiar with the facts. Ordinarily, only
operation or treatment was not accomplished.
physicians and surgeons of skill and experience are competent to
testify as to whether a patient has been treated or operated upon Hospitals; Damages; Proximate Cause Defined.—Proximate cause has
with a reasonable degree of skill and care. However, testimony as been defined as that which, in natural and continuous sequence,
to the statements and acts of physicians and surgeons, external unbroken by any efficient intervening cause, produces injury, and
appearances, and manifest conditions which are observable by any without which the result would not have occurred. An injury or
one may be given by non-expert witnesses. damage is proximately caused by an act or a failure to act,
whenever it appears from the evidence in the case, that the act or
Same; Same; Same; Same; Res ipsa loquitur is not a rigid or ordinary
omission played a substantial part in bringing about or actually
doctrine to be perfunctorily used but a rule to be cautiously applied
causing the injury or damage; and that the injury or damage was
depending upon the circumstances of each case.—Despite the fact that
either a direct result or a reasonably probable consequence of the
the scope of res ipsa loquitur has been measurably enlarged, it does
act or omission. It is the dominant, moving or producing cause.
not automatically apply to all cases of medical negligence as to
mechanically shift the burden of proof to the defendant to show Same; Same; For the purpose of allocating responsibility in medical
that he is not guilty of the ascribed negligence. Res ipsa loquitur is negligence cases, an employer-employee relationship in effect exists
not a rigid or ordinary doctrine to be perfunctorily used but a rule between hospitals and their attending and visiting physicians.—Private
to be cautiously applied, depending upon the circumstances of each hospitals, hire, fire and exercise real control over their attending
case. It is generally restricted to situations in malpractice cases 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 loss certain to be suffered but which could not, from the nature of
exercised, the hiring, and the right to terminate consultants all the case, be made with certainty. In other words, temperate
fulfill the important hallmarks of an employer-employee damages can and should be awarded on top of actual or
relationship, with the exception of the payment of wages. In compensatory damages in instances where the injury is chronic and
assessing whether such a relationship in fact exists, the control test continuing. And because of the unique nature of such cases, no
is determining. Accordingly, on the basis of the foregoing, we rule incompatibility arises when both actual and temperate damages are
that for the purpose of allocating responsibility in medical provided for. The reason is that these damages cover two distinct
negligence cases, an employer-employee relationship in effect phases.
exists between hospitals and their attending and visiting PETITION for review on certiorari of a decision of the Court
physicians. This being the case, the question now arises as to of Appeals.
whether or not respondent hospital is solidarily liable with
respondent doctors for petitioner’s condition. The facts are stated in the opinion of the Court.
Same; Same; The basis for holding an employer solidarily responsible for Luis C.A. Sillano for petitioners.
the negligence of its employee is found in Article 2180 of the Civil Code.— Macarius S. Galutera for private respondent De los Santos
The basis for holding an employer solidarily responsible for the Medical Center.
negligence of its employee is found in Article 2180 of the Civil Code
Tanjuatco, Sta. Maria, Tanjuatco collaborating counsel for
which considers a person accountable not only for his own acts but
also for those of others based on the former’s responsibility under
DLSMC.
a relationship of patria potestas. Such responsibility ceases when the Antonio H. Abad & Associates for respondent doctors.
persons or entity concerned prove that they have observed the KAPUNAN, J.:
diligence of a good father of the family to prevent damage. In other
words, while the burden of proving negligence rests
The Hippocratic Oath mandates physicians to give
primordial consideration to the health and welfare of their
588
patients. If a doctor fails to live up to this precept, he is made
accountable for his acts. A mistake, through gross negligence
588 SUPREME COURT REPORTS ANNOTATED or incompetence or plain human error, may spell the
Ramos vs. Court of Appeals difference
on the plaintiffs, once negligence is shown, the burden shifts to the 589
respondents (parent, guardian, teacher or employer) who should VOL. 321, DECEMBER 29, 1999 589
prove that they observed the diligence of a good father of a family
to prevent damage. Ramos vs. Court of Appeals
Same; Same; Amount of damages awarded may be a continuing one where between life and death. In this sense, the doctor plays God on
the injury is chronic and continuing, as when the patient is comatose.— his patient’s fate.
1

In these cases, the amount of damages which should be awarded, if In the case at bar, the Court is called upon to rule whether a
they are to adequately and correctly respond to the injury caused, surgeon, an anesthesiologist and a hospital should be made
should be one which compensates for pecuniary loss incurred and
liable for the unfortunate comatose condition of a patient
proved, up to the time of trial; and one which would meet pecuniary
scheduled for cholecystectomy. 2 590
Petitioners seek the reversal of the decision of the Court of
3 590 SUPREME COURT REPORTS ANNOTATED
Appeals, dated 29 May 1995, which overturned the decision 4 Ramos vs. Court of Appeals
of the Regional Trial Court, dated 30 January 1992, finding Rommel Ramos, Roy Roderick Ramos and Ron Raymond Ramos
private respondents liable for damages arising from (TSN, October 19, 1989, pp. 5-6).
negligence in the performance of their professional duties Because the discomforts somehow interfered with her normal
towards petitioner Erlinda Ramos resulting in her comatose ways, she sought professional advice. She was advised to undergo
condition. an operation for the removal of a stone in her gall bladder (TSN,
The antecedent facts as summarized by the trial court are January 13, 1988, p. 5). She underwent a series of examinations
reproduced hereunder: which included blood and urine tests (Exhs. “A” and “C”) which
indicated she was fit for surgery.
Plaintiff Erlinda Ramos was, until the afternoon of June 17, 1985, a
47-year old (Exh. “A”) robust woman (TSN, October 19, 1989, p. 10). Through the intercession of a mutual friend, Dr. Buenviaje (TSN,
Except for occasional complaints of discomfort due to pains January 13, 1988, p. 7), she and her husband Rogelio met for the first
allegedly caused by the presence of a stone in her gall bladder (TSN, time Dr. Orlino Hozaka (should be Hosaka; see TSN, February 20,
January 13, 1988, pp. 4-5), she was as normal as any other woman. 1990, p. 3), one of the defendants in this case, on June 10, 1985. They
Married to Rogelio E. Ramos, an executive of Philippine Long agreed that their date at the operating table at the DLSMC (another
Distance Telephone Company, she has three children whose names defendant), would be on June 17, 1985 at 9:00 A.M. Dr. Hosaka
are decided that she should undergo a “cholecystectomy” operation
after examining the documents (findings from the Capitol Medical
________________
Center, FEU Hospital and DLSMC) presented to him. Rogelio E.
1 In the United States alone, a great number of people die every year as
Ramos, however, asked Dr. Hosaka to look for a good
a result of medical mishaps. The 13 December 1999 issue of TIME anesthesiologist. Dr. Hosaka, in turn, assured Rogelio that he will
MAGAZINE featured an article on medical negligence entitled
get a good anesthesiologist. Dr. Hosaka charged a fee of P16,000.00,
“Doctors’ Deadly Mistakes” which is quoted in part: “It is hardly news
which was to include the anesthesiologist’s fee and which was to
that medical professionals make mistakes—even dumb, deadly
be paid after the operation (TSN, October 19, 1989, pp. 14-15, 22-23,
mistakes. What is shocking is how often it happens. Depending on
31-33; TSN, February 27, 1990, p. 13; and TSN, November 9, 1989,
which statistics you believe, the number of Americans killed by
medical screw-ups is somewhere between 44,000 and 98,000 every pp. 3-4, 10, 17).
year—the eighth leading cause of death even by the more conservative A day before the scheduled date of operation, she was admitted at
figure, ahead of car crashes, breast cancer and AIDS. More astonishing one of the rooms of the DLSMC, located along E. Rodriguez
than the huge numbers themselves, though, is the fact that public Avenue, Quezon City (TSN, October 19, 1989, p. 11).
health officials had known about the problem for years and hadn’t At around 7:30 A.M. of June 17, 1985 and while still in her room,
made a concerted effort to do something about it.” she was prepared for the operation by the hospital staff. Her sister-
2 Cholecystectomy is the surgical excision of the gall bladder. in-law, Herminda Cruz, who was the Dean of the College of
3 CA Rollo, pp. 129-140. Nursing at the Capitol Medical Center, was also there for moral
4 Records, pp. 270-279. support. She reiterated her previous request for Herminda to be
with her even during the operation. After praying, she was given
injections. Her hands were held by Herminda as they went down arrived as a nurse remarked, “Nandiyan na si Dr. Hosaka,
from her room to the operating room (TSN, January 13, 1988, pp. 9- dumating na raw.” Upon hearing those words, he went down to
11). Her husband, Rogelio, was also with her (TSN, October 19, the lobby and waited for the operation to be completed (id., pp. 16,
1989, p. 18). At the operating room, Herminda saw about two or 29-30).
three nurses and Dr. Perfecta Gutierrez, the other defendant, who At about 12:15 P.M., Herminda Cruz, who was inside the operating
was to administer anesthesia. Although not a member of the room with the patient, heard somebody say that “Dr. Hosaka is
hospital staff, Herminda introduced herself as Dean of the College already here.” She then saw people inside the operating room
of Nursing at the Capitol Medical Center who was to provide moral “moving, doing this and that, [and] preparing the patient for the
591 operation” (TSN, January 13, 1988, p. 16). As she held the hand of
VOL. 321, DECEMBER 29, 1999 591 Erlinda Ramos, she then saw Dr. Gutierrez intubating the hapless
patient. She thereafter heard Dr. Gutierrez say, “ang hirap
Ramos vs. Court of Appeals
maintubate nito, mali yata ang pagkakapasok. O lumalaki ang
support to the patient, to them. Herminda was allowed to stay tiyan” (id., p. 17). Because of the remarks of Dra. Gutierrez, she
inside the operating room. focused her attention on what Dr. Gutierrez was doing. She
At around 9:30 A.M., Dr. Gutierrez reached a nearby phone to look thereafter noticed bluish discoloration of the nailbeds of the left
for Dr. Hosaka who was not yet in (TSN, January 13, 1988, pp. 11- hand of the hapless Erlinda even as Dr. Hosaka approached her.
12). Dr. Gutierrez thereafter informed Herminda Cruz about the She then heard Dr. Hosaka issue an order for someone to call Dr.
prospect of a delay in the arrival of Dr. Hosaka. Herminda then Calderon, another anesthesiologist (id., p. 19). After Dr. Calderon
went back to the patient who asked, “Mindy, wala pa ba ang arrived at the oper-
Doctor”? The former replied, “Huwag kang mag-alaala, darating 592
na iyon” (ibid.). 592 SUPREME COURT REPORTS ANNOTATED
Thereafter, Herminda went out of the operating room and
Ramos vs. Court of Appeals
informed the patient’s husband, Rogelio, that the doctor was not
yet around (id., p. 13). When she returned to the operating room, ating room, she saw this anesthesiologist trying to intubate the
the patient told her, “Mindy, inip na inip na ako, ikuha mo ako ng patient. The patient’s nailbed became bluish and the patient was
ibang Doctor.” So, she went out again and told Rogelio about what placed in a trendelenburg position—a position where the head of
the patient said (id., p. 15). Thereafter, she returned to the operating the patient is placed in a position lower than her feet which is an
room. indication that there is a decrease of blood supply to the patient’s
brain (id., pp. 19-20). Immediately thereafter, she went out of the
At around 10:00 A.M., Rogelio E. Ramos was “already dying [and]
operating room, and she told Rogelio E. Ramos “that something
waiting for the arrival of the doctor” even as he did his best to find
wrong was x x x happening” (ibid.). Dr. Calderon was then able to
somebody who will allow him to pull out his wife from the
intubate the patient (TSN, July 25, 1991, p. 9).
operating room (TSN, October 19, 1989, pp. 19-20). He also thought
of the feeling of his wife, who was inside the operating room Meanwhile, Rogelio, who was outside the operating room, saw a
waiting for the doctor to arrive (ibid.). At almost 12:00 noon, he met respiratory machine being rushed towards the door of the
Dr. Garcia who remarked that he (Dr. Garcia) was also tired of operating room. He also saw several doctors rushing towards the
waiting for Dr. Hosaka to arrive (id., p. 21). While talking to Dr. operating room. When informed by Herminda Cruz that something
Garcia at around 12:10 P.M., he came to know that Dr. Hosaka wrong was happening, he told her (Herminda) to be back with the
patient inside the operating room (TSN, October 19, 1989, pp. 25- 1989, pp. 32-34). She was also diagnosed to be suffering from
28). “diffuse cerebral parenchymal damage” (Exh. “G”; see also TSN,
Herminda Cruz immediately rushed back, and saw that the patient December 21, 1989, p. 6).5
was still in trendelenburg position (TSN, January 13, 1988, p. 20). Thus, on 8 January 1986, petitioners filed a civil case for 6

At almost 3:00 P.M. of that fateful day, she saw the patient taken to damages with the Regional Trial Court of Quezon City
the Intensive Care Unit (ICU). against herein private respondents alleging negligence in the
About two days thereafter, Rogelio E. Ramos was able to talk to Dr. management and care of Erlinda Ramos.
Hosaka. The latter informed the former that something went wrong
During the trial, both parties presented evidence as to the
during the intubation. Reacting to what was told to him, Rogelio
possible cause of Erlinda’s injury. Plaintiff presented the
reminded the doctor that the condition of his wife would not have
happened, had he (Dr. Hosaka) looked for a good anesthesiologist testimonies of Dean Herminda Cruz and Dr. Mariano Gavino
(TSN, October 19, 1989, p. 31). to prove that the damage sustained by Erlinda was due to lack
Doctors Gutierrez and Hosaka were also asked by the hospital to
of oxygen in her brain caused by the faulty management of
explain what happened to the patient. The doctors explained that her airway by private respondents during the anesthesia
the patient had bronchospasm (TSN, November 15, 1990, pp. 26- phase. On the other hand, private respondents primarily
27). relied on the expert testimony of Dr. Eduardo Jamora, a
Erlinda Ramos stayed at the ICU for a month. About four months pulmonologist, to the effect that the cause of brain damage
thereafter or on November 15, 1985, the patient was released from was Erlinda’s allergic reaction to the anesthetic agent,
the hospital. Thiopental Sodium (Pentothal).
During the whole period of her confinement, she incurred hospital After considering the evidence from both sides, the Regional
bills amounting to P93,542.25 which is the subject of a promissory Trial Court rendered judgment in favor of petitioners, to wit:
note and affidavit of undertaking executed by Rogelio E. Ramos in After evaluating the evidence as shown in the finding of facts set
favor of DLSMC. Since that fateful afternoon of June 17, 1985, she forth earlier, and applying the aforecited provisions of law and
has been in a comatose condition. She cannot do anything. She jurisprudence to the case at bar, this Court finds and so holds that
cannot move any part of her body. She cannot see or hear. She is defendants are liable to plaintiffs for damages. The defendants
living on mechanical means. She suffered brain damage as a result were guilty of, at the very least, negligence in the performance of
of the absence of oxygen in her brain for four to five minutes (TSN, their duty to plaintiff-patient Erlinda Ramos.
November 9, 1989, pp. 21-22). After being discharged from the
On the part of Dr. Perfecta Gutierrez, this Court finds that she
hospital, she has been staying in their residence, still needing
omitted to exercise reasonable care in not only intubating the
constant
patient, but also in not repeating the administration of atropine
593 (TSN, August 20, 1991, pp. 5-10), without due regard to the fact that
VOL. 321, DECEMBER 29, 1999 593 the patient was inside the operating room for almost three (3)
Ramos vs. Court of Appeals hours. For
medical attention, with her husband Rogelio incurring a monthly ________________
expense ranging from P8,000.00 to P10,000.00 (TSN, October 19, 5 Id. at 270-275.
6 Docketed as Civil Case No. Q-46885. the latter are ordered to pay, jointly and severally, the former the
594 following sums of money, to wit:
594 SUPREME COURT REPORTS ANNOTATED 1 1)
the sum of P8,000.00 as actual monthly expenses for the
Ramos vs. Court of Appeals plaintiff Erlinda Ramos reckoned from November 15, 1985
or in the total sum of P632,000.00 as of April 15, 1992, subject
after she committed a mistake in intubating [the] patient, the to its being updated;
patient’s nailbed became bluish and the patient, thereafter, was
2 2)
the sum of P100,000.00 as reasonable attorney’s fees;
placed in trendelenburg position, because of the decrease of blood
supply to the patient’s brain. The evidence further shows that the 3 3)
the sum of P800,000.00 by way of moral damages and the
hapless patient suffered brain damage because of the absence of further sum of P200,000.00 by way of exemplary damages;
oxygen in her (patient’s) brain for approximately four to five and,
minutes which, in turn, caused the patient to become comatose. 595
On the part of Dr. Orlino Hosaka, this Court finds that he is liable VOL. 321, DECEMBER 29, 1999 595
for the acts of Dr. Perfecta Gutierrez whom he had chosen to
administer anesthesia on the patient as part of his obligation to
Ramos vs. Court of Appeals
provide the patient a ‘good anesthesiologist,’ and for arriving for 4) the costs of the suit.
the scheduled operation almost three (3) hours late. SO ORDERED.7
On the part of DLSMC (the hospital), this Court finds that it is liable Private respondents seasonably interposed an appeal to the
for the acts of negligence of the doctors in their ‘practice of Court of Appeals. The appellate court rendered a Decision,
medicine’ in the operating room. Moreover, the hospital is liable for dated 29 May 1995, reversing the findings of the trial court.
failing through its responsible officials, to cancel the scheduled
The decretal portion of the decision of the appellate court
operation after Dr. Hosaka inexcusably failed to arrive on time.
reads:
In having held thus, this Court rejects the defense raised by
WHEREFORE, for the foregoing premises the appealed decision is
defendants that they have acted with due care and prudence in
hereby REVERSED, and the complaint below against the appellants
rendering medical services to plaintiff-patient. For if the patient
was properly intubated as claimed by them, the patient would not is hereby ordered DISMISSED. The counterclaim of appellant De
Los Santos Medical Center is GRANTED but only insofar as
have become comatose. And, the fact that another anesthesiologist
appellees are hereby ordered to pay the unpaid hospital bills
was called to try to intubate the patient after her (the patient’s)
amounting to P93,542.25, plus legal interest for justice must be
nailbed turned bluish, belie their claim. Furthermore, the
tempered with mercy.
defendants should have rescheduled the operation to a later date.
This, they should have done, if defendants acted with due care and SO ORDERED.8
prudence as the patient’s case was an elective, not an emergency The decision of the Court of Appeals was received on 9 June
case. 1995 by petitioner Rogelio Ramos who was mistakenly
xxx addressed as “Atty. Rogelio Ramos.” No copy of the decision,
WHEREFORE, and in view of the foregoing, judgment is rendered however, was sent nor received by the Coronel Law Office,
in favor of the plaintiffs and against the defendants. Accordingly, then counsel on record of petitioners. Rogelio referred the
decision of the appellate court to a new lawyer, Atty. Ligsay, Computation wise, the period to file a Motion for Reconsideration
only on 20 June 1995, or four (4) days before the expiration of expired on June 24. The Motion for Reconsideration, in turn, was
the reglementary period for filing a motion for received by the Court of Appeals already on July 4, necessarily, the
reconsideration. On the same day, Atty. Ligsay, filed with the 15-day period already passed. For that alone, the latter should be
denied.
appellate court a motion for extension of time to file a motion
for reconsideration. The motion for reconsideration was Even assuming admissibility of the Motion for Reconsideration, but
submitted on 4 July 1995. However, the appellate court after considering the Comment/Opposition, the former, for lack of
merit, is hereby DENIED.
denied the motion for extension of time in its Resolution
dated 25 July 1995. Meanwhile, petitioners engaged the
9
SO ORDERED.10
services of another counsel, Atty. Sillano, to replace Atty. A copy of the above resolution was received by Atty. Sillano
Ligsay. Atty. Sillano filed on 7 August 1995 a motion to admit on 11 April 1996. The next day, or on 12 April 1996, Atty.
the motion for reconsideration contending that the period to Sillano filed before this Court a motion for extension of time
file the appropriate plead- to file the present petition for certiorari under Rule 45. The
________________ Court granted the motion for extension of time and gave
7 Records, pp. 276-278.
petitioners additional thirty (30) days after the expiration of
the fifteen-day (15) period counted from the receipt of the
8 CA Rollo, p. 166.
resolution of the Court of Appeals within which to submit the
9 Id. at 145.
petition. The due date fell on 27 May 1996. The petition was
596 filed on 9 May 1996, well within the extended period given by
596 SUPREME COURT REPORTS ANNOTATED the Court.
Ramos vs. Court of Appeals Petitioners assail the decision of the Court Of Appeals on the
ing on the assailed decision had not yet commenced to run as following grounds:
the Division Clerk of Court of the Court of Appeals had not ________________
yet served a copy thereof to the counsel on record. Despite 10 Id. at 195.
this explanation, the appellate court still denied the motion to 597
admit the motion for reconsideration of petitioners in its VOL. 321, DECEMBER 29, 1999 597
Resolution, dated 29 March 1996, primarily on the ground
Ramos vs. Court of Appeals
that the fifteen-day (15) period for filing a motion for
reconsideration had already expired, to wit: I
We said in our Resolution on July 25, 1995, that the filing of a IN PUTTING MUCH RELIANCE ON THE TESTIMONIES OF
Motion for Reconsideration cannot be extended; precisely, the RESPONDENTS DRA. GUTIERREZ, DRA. CALDERON AND DR.
Motion for Extension (Rollo, p. 12) was denied. It is, on the other JAMORA;
hand, admitted in the latter Motion that plaintiffs/appellees II
received a copy of the decision as early as June 9, 1995. IN FINDING THAT THE NEGLIGENCE OF THE RESPONDENTS
DID NOT CAUSE THE UNFORTUNATE COMATOSE reconsideration, referred the same to a legal counsel only on
CONDITION OF PETITIONER ERLINDA RAMOS; 20 June 1995.
III It is elementary that when a party is represented by counsel,
IN NOT APPLYING THE DOCTRINE OF RES IPSA LOQUITUR.11 all notices should be sent to the party’s lawyer at his given
Before we discuss the merits of the case, we shall first dispose address. With a few exceptions, notice to a litigant without
of the procedural issue on the timeliness of the petition in notice to his counsel on record is no notice at all. In the present
relation to the motion for reconsideration filed by petitioners case, since a copy of the decision of the appellate court was
with the Court of Appeals. In their Comment, private 12 not sent to the counsel on record of petitioner, there can be no
respondents contend that the petition should not be given due sufficient notice to speak of. Hence, the delay in the filing of
course since the motion for reconsideration of the petitioners the motion for reconsideration cannot be taken against
on the decision of the Court of Appeals was validly dismissed petitioner. Moreover, since the Court of Appeals already
by the appellate court for having been filed beyond the issued a second Resolution, dated 29 March 1996, which
reglementary period. We do not agree. superseded the earlier resolution issued on 25 July 1995, and
A careful review of the records reveals that the reason behind denied the motion for reconsideration of petitioner, we
the delay in filing the motion for reconsideration is believe that the receipt of the former should be considered in
attributable to the fact that the decision of the Court of determining the timeliness of the filing of the present petition.
Appeals was not sent to then counsel on record of petitioners, Based on this, the petition before us was submitted on time.
the Coronel Law Office. In fact, a copy of the decision of the After resolving the foregoing procedural issue, we shall now
appellate court was instead sent to and received by petitioner look into the merits of the case. For a more logical
Rogelio Ramos on 9 June 1995 wherein he was mistakenly presentation of the discussion we shall first consider the issue
addressed as Atty. Rogelio Ramos. Based on the other on the applicability of the doctrine of res ipsa loquitur to the
communications received by petitioner Rogelio Ramos, the instant case. Thereafter, the first two assigned errors shall be
appellate court apparently mistook him for the counsel on tackled in relation to the res ipsa loquitur doctrine.
record. Thus, no copy of the decision of the appellate court Res ipsa loquitur is a Latin phrase which literally means
was fur- “the thing or the transaction speaks for itself.” The phrase “res
________________ ipsa loquitur” is a maxim for the rule that the fact of the
11 Rollo, p. 19. occurrence of an injury, taken with the surrounding
12 Id. at 91-98. circumstances, may permit an inference or raise a
598
presumption of negligence, or make out a plaintiff’s prima
facie case, and present a question of fact for defendant to meet
598 SUPREME COURT REPORTS ANNOTATED
with an explanation. Where the thing which caused the
13

Ramos vs. Court of Appeals injury complained of is shown to be under the management
nished to the counsel on record. Petitioner, not being a lawyer of the defendant or his servants and the accident is such as in
and unaware of the prescriptive period for filing a motion for ordinary course of things does not happen if those who have
its man- with the proof of the accident, enough of the attending
________________ circumstances to invoke the doctrine, creating an inference or
13 57B Am Jur 2d, 493 (1989). presumption of negligence, and to thereby place on the
599
defendant the burden
________________
VOL. 321, DECEMBER 29, 1999 599
14 Africa, et al. vs. Caltex (Phil.), Inc., et al., 16 SCRA 449, 454 (1966).
Ramos vs. Court of Appeals
15 57B Am Jur 2d, supra note 13 at 499.
agement or control use proper care, it affords reasonable 16 Ibid.
evidence, in the absence of explanation by the defendant, that
17 Id. at 502.
the accident arose from or was caused by the defendant’s
18 Ibid.
want of care. 14

19 Id.
The doctrine of res ipsa loquitur is simply a recognition of the
postulate that, as a matter of common knowledge and 600
experience, the very nature of certain types of occurrences 600 SUPREME COURT REPORTS ANNOTATED
may justify an inference of negligence on the part of the Ramos vs. Court of Appeals
person who controls the instrumentality causing the injury in of going forward with the proof. Still, before resort to the
20

the absence of some explanation by the defendant who is doctrine may be allowed, the following requisites must be
charged with negligence. It is grounded in the superior logic
15
satisfactorily shown:
of ordinary human experience and on the basis of such
experience or common knowledge, negligence may be 1 1.
The accident is of a kind which ordinarily does not occur
deduced from the mere occurrence of the accident itself. 16
in the absence of someone’s negligence;
Hence, res ipsa loquitur is applied in conjunction with the 2 2.
It is caused by an instrumentality within the exclusive
doctrine of common knowledge. control of the defendant or defendants; and
However, much has been said that res ipsa loquitur is not a rule 3 3.
The possibility of contributing conduct which would
of substantive law and, as such, does not create or constitute make the plaintiff responsible is eliminated. 21

an independent or separate ground of liability. Instead, it is


17
In the above requisites, the fundamental element is the
considered as merely evidentiary or in the nature of a “control of the instrumentality” which caused the damage. 22

procedural rule. It is regarded as a mode of proof, or a mere


18
Such element of control must be shown to be within the
procedural convenience since it furnishes a substitute for, and dominion of the defendant. In order to have the benefit of the
relieves a plaintiff of, the burden of producing specific proof rule, a plaintiff, in addition to proving injury or damage, must
of negligence. In other words, mere invocation and
19
show a situation where it is applicable, and must establish
application of the doctrine does not dispense with the that the essential elements of the doctrine were present in a
requirement of proof of negligence. It is simply a step in the particular incident. 23

process of such proof, permitting the plaintiff to present along


Medical malpractice cases do not escape the application of
24 necessity of expert testimony applies only to such matters
this doctrine. Thus, res ipsa loquitur has been applied when the clearly within the domain of medical science, and not to
circumstances attendant upon the harm are themselves of matters that are within the common knowledge of mankind
such a character as to justify an inference of negligence as the which may be testified to by anyone familiar with the facts. 28

cause of that harm. The application of res ipsa loquitur in


25 Ordinarily, only physicians and surgeons of skill and
medical negligence cases presents a question of law since it is experience are competent to testify as to whether a patient has
________________ been treated or operated upon with a reasonable degree of
20 Id. at 503. skill and care. However, testimony as to the statements and
21Voss vs. Bridwell, 364 P2d 955, 970 (1961) citing Worden v. Union
acts of physicians and surgeons, external appearances, and
Gas System, 182 Kan. 686, 324 P.2d 501; Lamb v. Hartford Accident and manifest conditions which are observable by any one may be
Indemnity Co., Primm v. Kansas Power & Light Co., 173 Kan. 443, 249 given by non-expert witnesses. Hence, in cases where the res
29

P.2d 647. ipsa loquitur is applicable, the court is permitted to find a


22St. John’s Hospital and School of Nursing vs. Chapman, 434 P.2d 160, physician negligent upon proper proof of injury to the
166 (1967). patient, without the aid of expert testimony, where the court
23 57B Am Jur 2d, supra note 13, at 513. from its fund of common knowledge can determine the
proper standard of care. Where common knowledge and
30
24 It is the type of claim which a victim has available to him or her
to redress a wrong committed by a medical professional which has experience teach that a resulting injury would not have
caused bodily harm. (Garcia-Rueda vs. Pascasio, 278 SCRA 769, 778 occurred to the patient if due care had been exercised, an
[1997]). inference of negligence may be drawn giving rise to an
25 Voss vs. Bridwell, supra note 21.
application of the doctrine of res ipsa loquitur without medical
601
evidence, which is ordinarily required to show not only what
occurred but how and why it
VOL. 321, DECEMBER 29, 1999 601
________________
Ramos vs. Court of Appeals 26 Turney vs. Anspaugh, 581 P.2d 1301, 1304 (1978).
a judicial function to determine whether a certain set of 27 SOLIS, MEDICAL JURISPRUDENCE, 239 (1988).
circumstances does, as a matter of law, permit a given 28Voss vs. Bridwell, supra note 21, at 968 citing McMillen vs.
inference. 26
Foncannon, 127 Kan. 573, 274 P. 237.
Although generally, expert medical testimony is relied upon 29Stockham vs. Hall, 65 P. 348, 349 (1937) citing Yard vs. Gibbons, 95
in malpractice suits to prove that a physician has done a Kan. 802, 149 P. 422, 423.
negligent act or that he has deviated from the standard 30 SOLIS, supra note 27, at 239.
medical procedure, when the doctrine of res ipsa loquitur is 602
availed by the plaintiff, the need for expert medical testimony
602 SUPREME COURT REPORTS ANNOTATED
is dispensed with because the injury itself provides the proof
of negligence. The reason is that the general rule on the
27 Ramos vs. Court of Appeals
occurred. When the doctrine is appropriate, all that the
31 33 Thomsen vs. Burgeson, 79 P. 2d 136 (1938).
patient must do is prove a nexus between the particular act or 34 Griffin vs. Norman, 192 NYS 322 (1922).
omission complained of and the injury sustained while under 35 Brown vs. Shortilledge, 277 P. 134 (1929).
the custody and management of the defendant without need 36 Meadows vs. Patterson, 109 S.W. 2d 417 (1937).
to produce expert medical testimony to establish the standard 37 Voss vs. Bridwell, supra note 21, at 969.
of care. Resort to res ipsa loquitur is allowed because there is
603
no other way, under usual and ordinary conditions, by which
the patient can obtain redress for injury suffered by him. VOL. 321, DECEMBER 29, 1999 603
Thus, courts of other jurisdictions have applied the doctrine Ramos vs. Court of Appeals
in the following situations: leaving of a foreign object in the be made between the failure to secure results, and the
body of the patient after an operation, injuries sustained on
32
occurrence of something more unusual and not ordinarily
a healthy part of the body which was not under, or in the area, found if the service or treatment rendered followed the usual
of treatment, removal of the wrong part of the body when
33
procedure of those skilled in that particular practice. It must
another part was intended, knocking out a tooth while a
34
be conceded that the doctrine of res ipsa loquitur can have no
patient’s jaw was under anesthetic for the removal of his application in a suit against a physician or surgeon which
tonsils, and loss of an eye while the patient plaintiff was
35
involves the merits of a diagnosis or of a scientific treatment. 38

under the influence of anesthetic, during or following an The physician or surgeon is not required at his peril to explain
operation for appendicitis, among others.
36
why any particular diagnosis was not correct, or why any
Nevertheless, despite the fact that the scope of res ipsa loquitur particular scientific treatment did not produce the desired
has been measurably enlarged, it does not automatically result. Thus, res ipsa loquitur is not available in a malpractice
39

apply to all cases of medical negligence as to mechanically suit if the only showing is that the desired result of an
shift the burden of proof to the defendant to show that he is operation or treatment was not accomplished. The real 40

not guilty of the ascribed negligence. Res ipsa loquitur is not a question, therefore, is whether or not in the process of the
rigid or ordinary doctrine to be perfunctorily used but a rule operation any extraordinary incident or unusual event
to be cautiously applied, depending upon the circumstances outside of the routine performance occurred which is beyond
of each case. It is generally restricted to situations in the regular scope of customary professional activity in such
malpractice cases where a layman is able to say, as a matter of operations, which, if unexplained would themselves
common knowledge and observation, that the consequences reasonably speak to the average man as the negligent cause or
of professional care were not as such as would ordinarily have causes of the untoward consequence. If there was such
41

followed if due care had been exercised. A distinction must


37 extraneous interventions, the doctrine of res ipsa loquitur may
________________ be utilized and the defendant is called upon to explain the
31 Voss vs. Bridwell, supra note 21 at 970-971.
matter, by evidence of exculpation, if he could. 42

32 Armstrong vs. Wallace, 47 P. 2d 740 (1935).


We find the doctrine of res ipsa loquitur appropriate in the case
at bar. As will hereinafter be explained, the damage sustained
by Erlinda in her brain prior to a scheduled gall bladder negligence because he was under the influence of anesthetics and
operation presents a case for the application of res ipsa unconscious, and the circumstances are such that the true
loquitur. explanation of event is more accessible to the defendants than to the
plaintiff for they had the exclusive control of the instrumentalities
A case strikingly similar to the one before us is Voss vs. of anesthesia.
Bridwell, where the Kansas Supreme Court in applying the
43
Upon all the facts, conditions and circumstances alleged in Count
res ipsa loquitur stated:
II it is held that a cause of action is stated under the doctrine of res
________________ ipsa loquitur.44
38 Id. at 968.
Indeed, the principles enunciated in the aforequoted case
39 Rhodes vs. De Haan, 337 P. 2d. 1043, 1047 (1959). apply with equal force here. In the present case, Erlinda
40 Voss vs. Bridwell, supra note 21, at 968. submitted herself for cholecystectomy and expected a routine
41 Sanders vs. Smith, 27 So. 2d 889, 893 (1946). general surgery to be performed on her gall bladder. On that
42 Ibid. fateful day she delivered her person over to the care, custody
43 Voss vs. Bridwell, supra note 21. and control of private respondents who exercised complete
and exclusive control over her. At the time of submission,
604
Erlinda was neurologically sound and, except for a few minor
604 SUPREME COURT REPORTS ANNOTATED discomforts, was likewise physically fit in mind and body.
Ramos vs. Court of Appeals However, during the administration of anesthesia and prior
The plaintiff herein submitted himself for a mastoid operation and to the performance of cholecystectomy she suffered irreparable
delivered his person over to the care, custody and control of his damage to her brain. Thus, without undergoing surgery, she
physician who had complete and exclusive control over him, but the ________________
operation was never performed. At the time of submission he was 44 Id. at 971.
neurologically sound and physically fit in mind and body, but he
suffered irreparable damage and injury rendering him decerebrate 605
and totally incapacitated. The injury was one which does not VOL. 321, DECEMBER 29, 1999 605
ordinarily occur in the process of a mastoid operation or in the Ramos vs. Court of Appeals
absence of negligence in the administration of an anesthetic, and in
the use and employment of an endoctracheal tube. Ordinarily a went out of the operating room already decerebrate and
person being put under anesthesia is not rendered decerebrate as a totally incapacitated. Obviously, brain damage, which
consequence of administering such anesthesia in the absence of Erlinda sustained, is an injury which does not normally occur
negligence. Upon these facts and under these circumstances a in the process of a gall bladder operation. In fact, this kind of
layman would be able to say, as a matter of common knowledge situation does not happen in the absence of negligence of
and observation, that the consequences of professional treatment someone in the administration of anesthesia and in the use of
were not as such as would ordinarily have followed if due care had endotracheal tube. Normally, a person being put under
been exercised. anesthesia is not rendered decerebrate as a consequence of
Here the plaintiff could not have been guilty of contributory
administering such anesthesia if the proper procedure was Ramos vs. Court of Appeals
followed. Furthermore, the instruments used in the the Court now comes to the issue of whether the Court of
administration of anesthesia, including the endotracheal tube, Appeals erred in finding that private respondents were not
were all under the exclusive control of private respondents, negligent in the care of Erlinda during the anesthesia phase of
who are the physicians-in-charge. Likewise, petitioner the operation and, if in the affirmative, whether the alleged
Erlinda could not have been guilty of contributory negligence negligence was the proximate cause of Erlindas comatose
because she was under the influence of anesthetics which condition. Corollary thereto, we shall also determine if the
rendered her unconscious. Court of Appeals erred in relying on the testimonies of the
Considering that a sound and unaffected member of the body witnesses for the private respondents.
(the brain) is injured or destroyed while the patient is In sustaining the position of private respondents, the Court of
unconscious and under the immediate and exclusive control Appeals relied on the testimonies of Dra. Gutierrez, Dra.
of the physicians, we hold that a practical administration of Calderon and Dr. Jamora. In giving weight to the testimony
justice dictates the application of res ipsa loquitur. Upon these of Dra. Gutierrez, the Court of Appeals rationalized that she
facts and under these circumstances the Court would be able was candid enough to admit that she experienced some
to say, as a matter of common knowledge and observation, if difficulty in the endotracheal intubation of the patient and
45

negligence attended the management and care of the patient. thus, cannot be said to be covering her negligence with
Moreover, the liability of the physicians and the hospital in falsehood. The appellate court likewise opined that private
this case is not predicated upon an alleged failure to secure respondents were able to show that the brain damage
the desired results of an operation nor on an alleged lack of sustained by Erlinda was not caused by the alleged faulty
skill in the diagnosis or treatment as in fact no operation or intubation but was due to the allergic reaction of the patient
treatment was ever performed on Erlinda. Thus, upon all to the drug Thiopental Sodium (Pentothal), a short-acting
these initial determination a case is made out for the barbiturate, as testified on by their expert witness, Dr. Jamora.
application of the doctrine of res ipsa loquitur. On the other hand, the appellate court rejected the testimony
Nonetheless, in holding that res ipsa loquitur is available to the of Dean Herminda Cruz offered in favor of petitioners that
present case we are not saying that the doctrine is applicable the cause of the brain injury was traceable to the wrongful
in any and all cases where injury occurs to a patient while insertion of the tube since the latter, being a nurse, was
under anesthesia, or to any and all anesthesia cases. Each case allegedly not knowledgeable in the process of intubation. In
must be viewed in its own light and scrutinized in order to be so holding, the appellate court returned a verdict in favor of
within the res ipsa loquitur coverage. respondents physicians
Having in mind the applicability of the res ipsa loquitur ________________
doctrine and the presumption of negligence allowed therein, 45 It is the method of intubating a patient through the oral cavity.
606 Under this procedure, after the patient has been preoxygenated and
606 SUPREME COURT REPORTS ANNOTATED paralyzed and is no longer breathing on his own, the anesthetist
inserts an instrument called a laryngoscope into the patient’s oral
pharynx. The patient’s neck is hyperextended, that is, bent back as Q: In particular, what did Dra. Perfecta Gutierrez do, if
far as possible so that the anesthetist can see or “visualize” the any on the patient?
patient’s epiglottis and vocal cords. The anesthetist will then thread
A: In particular, I could see that she was intubating the
the endotracheal tube between the patient’s vocal cords into the
trachea, and then hook the tube to the breathing bag and anesthetic
patient.
machine. Q: Do you know what happened to that intubation
607 process administered by Dra. Gutierrez?
VOL. 321, DECEMBER 29, 1999 607 ATTY. ALCERA:
Ramos vs. Court of Appeals She will be incompetent Your Honor.
and hospital and absolved them of any liability towards Er- COURT:
linda and her family. Witness may answer if she knows.
We disagree with the findings of the Court of Appeals. We A: As I have said, I was with the patient, I was beside the
hold that private respondents were unable to disprove the stretcher holding the left hand of the patient and all of
presumption of negligence on their part in the care of Erlinda a sudden I heard some remarks coming from Dra.
and their negligence was the proximate cause of her piteous Perfecta
condition. 608
In the instant case, the records are helpful in furnishing not 608 SUPREME COURT REPORTS ANNOTATED
only the logical scientific evidence of the pathogenesis of the Ramos vs. Court of Appeals
injury but also in providing the Court the legal nexus upon
Gutierrez herself. She was saying “Ang hirap
which liability is based. As will be shown hereinafter, private
maintubate nito, mali yata ang pagkakapasok. O
respondents’ own testimonies which are reflected in the
lumalaki ang tiyan.”
transcript of stenographic notes are replete of signposts
indicative of their negligence in the care and management of xxx
Erlinda. ATTY. PAJARES:
With regard to Dra. Gutierrez, we find her negligent in the Q: From whom did you hear those words “lumalaki ang
care of Erlinda during the anesthesia phase. As borne by the tiyan?
records, respondent Dra. Gutierrez failed to properly intubate A: From Dra. Perfecta Gutierrez.
the patient. This fact was attested to by Prof. Herminda Cruz, xxx
Dean of the Capitol Medical Center School of Nursing and
Q. After hearing the phrase “lumalaki ang tiyan,” what
petitioner’s sister-in-law, who was in the operating room
did you notice on the person of the patient?
right beside the patient when the tragic event occurred.
Witness Cruz testified to this effect: A: I notice (sic) some bluish discoloration on the
nailbeds ofthe left hand where I was at.
ATTY. PAJARES:
Q: Where was Dr. Orlino Ho[s]aka then at that A perusal of the standard nursing curriculum in our country will
particulartime? show that intubation is not taught as part of nursing procedures
and techniques. Indeed, we take judicial notice of the fact that
A: I saw him approaching the patient during that time.
nurses do not, and cannot, intubate. Even on the assumption that
Q: When he approached the patient, what did he do, if she is fully capable of determining whether or not a patient is
any? properly intubated, witness Herminda Cruz, admittedly, did not
A: He made an order to call on the anesthesiologist in peep into the throat of the patient. (TSN, July 25, 1991, p. 13). More
the person of Dr. Calderon. importantly, there is no evidence that she ever auscultated the
patient or that she conducted any type of examination to check if
Q: Did Dr. Calderon, upon being called, arrive inside the endotracheal tube was in its proper place, and to determine the
the operating room? condition of the heart, lungs, and other organs. Thus, witness
A: Yes sir. Cruz’s categorical statements that appellant Dra. Gutierrez failed to
Q: What did [s]he do, if any? intubate the appellee Erlinda Ramos and that it was Dra. Calderon
who succeeded in doing so clearly suffer from lack of sufficient
A: [S]he tried to intubate the patient. factual bases.47
Q: What happened to the patient? In other words, what the Court of Appeals is trying to impress
A: When Dr. Calderon try (sic) to intubate the patient, is that being a nurse, and considered a layman in the process
after a while the patient’s nailbed became bluish and of intubation, witness Cruz is not competent to testify on
I saw thepatient was placed in trendelenburg whether or not the intubation was a success.
position. We do not agree with the above reasoning of the appellate
xxx court. Although witness Cruz is not an anesthesiologist, she
Q: Do you know the reason why the patient was placed can very well testify upon matters on which she is capable of
in that trendelenburg position? observing such as, the statements and acts of the physician
A: As far as I know, when a patient is in that position, and surgeon, external appearances, and manifest conditions
there is a decrease of blood supply to the brain.
46
which are observable by any one. This is precisely allowed
48

under the doctrine of res ipsa loquitur where the testimony of


xxx
expert witnesses is not required. It is the accepted rule that
________________ expert testimony is not necessary for the proof of negligence
46 TSN, January 13, 1988, pp. 16-20. in nontechnical matters or those of which an ordinary person
609 may be expected to have knowledge, or where the lack of skill
VOL. 321, DECEMBER 29, 1999 609 or want of care is so obvious as to render expert testimony
Ramos vs. Court of Appeals ________________
47 CA Rollo, pp. 134-135.
The appellate court, however, disbelieved Dean Cruz’s
48 Stockham vs. Hall, supra note 29.
testimony in the trial court by declaring that:
610
610 SUPREME COURT REPORTS ANNOTATED DRA. GUTIERREZ:
Ramos vs. Court of Appeals A: Yes sir.
unnecessary. We take judicial notice of the fact that
49 Q: Did you pull away the tube immediately?
anesthesia procedures have become so common, that even an A: You do not pull the . . .
ordinary person can tell if it was administered properly. As ________________
such, it would not be too difficult to tell if the tube was 49 61 Am Jur 2d, 513 (1989).
properly inserted. This kind of observation, we believe, does
50 TSN, January 13, 1988, p. 3.
not require a medical degree to be acceptable.
611
At any rate, without doubt, petitioner’s witness, an
VOL. 321, DECEMBER 29, 611
experienced clinical nurse whose long experience and
1999
scholarship led to her appointment as Dean of the Capitol
Medical Center School of Nursing, was fully capable of Ramos vs. Court of Appeals
determining whether or not the intubation was a success. She Q: Did you or did you not?
had extensive clinical experience starting as a staff nurse in A: I did not pull the tube.
Chicago, Illinois; staff nurse and clinical instructor in a
Q: When you said “mahirap
teaching hospital, the FEU-NRMF; Dean of the Laguna
yata ito, what were you
College of Nursing in San Pablo City; and then Dean of the
referring to?
Capitol Medical Center School of Nursing. Reviewing
50

witness Cruz’ statements, we find that the same were A: “Mahirap yata itong i-
delivered in a straightforward manner, with the kind of intubate,” that was the
detail, clarity, consistency and spontaneity which would have patient.
been difficult to fabricate. With her clinical background as a Q: So, you found some
nurse, the Court is satisfied that she was able to demonstrate difficulty in inserting the
through her testimony what truly transpired on that fateful tube?
day. A: Yes, because of (sic) my first
Most of all, her testimony was affirmed by no less than attempt, I did not see right
respondent Dra. Gutierrez who admitted that she away. 51

experienced difficulty in inserting the tube into Erlinda’s Curiously in the case at bar, respondent Dra. Gutierrez made
trachea, to wit: the haphazard defense that she encountered hardship in the
ATTY. LIGSAY: insertion of the tube in the trachea of Erlinda because it was
Q: In this particular case, Doctora, while you were positioned more anteriorly (slightly deviated from the normal
intubating at your first attempt (sic), you did not anatomy of a person) making it harder to locate and, since
52

immediately see the trachea? Erlinda is obese and has a short neck and protruding teeth, it
made intubation even more difficult. diseased or artificial teeth, ability to visualize uvula and the
The argument does not convince us. If this was indeed thyromental distance. Thus, physical characteristics of the
56

observed, private respondents adduced no evidence patient’s upper airway that could make tracheal intubation
demonstrating that they proceeded to make a thorough difficult should be studied. Where the need arises, as when
57

assessment of Erlindas airway, prior to the induction of initial assessment indicates possible problems (such as the
anesthesia, even if this would mean postponing the alleged short neck and protruding teeth of Erlinda) a
procedure. From their testimonies, it appears that the thorough examination of the patient’s airway would go a long
observation was made only as an afterthought, as a means of way towards decreasing patient morbidity and mortality.
defense. In the case at bar, respondent Dra. Gutierrez admitted that she
The pre-operative evaluation of a patient prior to the saw Erlinda for the first time on the day of the operation itself,
administration of anesthesia is universally observed to lessen on 17 June 1985. Before this date, no prior consultations with,
the possibility of anesthetic accidents. Pre-operative or pre-operative evaluation of Erlinda was done by her. Until
evaluation and preparation for anesthesia begins when the the day of the operation, respondent Dra. Gutierrez was
anesthesiologist reviews the patient’s medical records and unaware of the physiological make-up and needs of Erlinda.
visits with the patient, traditionally, the day before elective She was likewise not properly informed of the possible
surgery. It includes taking the patient’s medical history,
53 difficulties she would face during the administration of
review of current drug therapy, physical examination and anesthesia to Erlinda. Respondent Dra. Gutierrez’ act of
interpretation of laboratory data. The physical examination
54 seeing her patient for the first time only an hour before the
performed by the scheduled operative procedure was, therefore, an act of
________________ exceptional negligence and professional irresponsibility. The
measures cautioning prudence and vigilance in dealing with
51 TSN, November 15, 1990, p. 11.
human lives lie at the core of the physician’s centuries-old
52 TSN, October 9, 1990, p. 13.
Hippocratic Oath. Her failure to follow this medical
53 STOELTING and MILLER, BASICS OF ANESTHESIA, 103 procedure is, therefore, a clear indicia of her negligence.
(1994).
Respondent Dra. Gutierrez, however, attempts to gloss over
54 Ibid.
this omission by playing around with the trial court’s
612 ignorance of clinical procedure, hoping that she could get
612 SUPREME COURT REPORTS ANNOTATED away with it. Respondent Dra. Gutierrez tried to muddle the
Ramos vs. Court of Appeals difference between an elective surgery and an emergency
anesthesiologist is directed primarily toward the central ________________
nervous system, cardiovascular system, lungs and upper 55 Id. at 105 (Italics supplied).

airway. A thorough analysis of the patient’s airway normally


55 56 Id. at 106.
involves investigating the following: cervical spine mobility, 57 Id.
temporomandibular mobility, prominent central incisors,
613 relaxed and cooperative.
VOL. 321, DECEMBER 29, 1999 613 Erlinda’s case was elective and this was known to respondent
Ramos vs. Court of Appeals Dra. Gutierrez. Thus, she had all the time to make a thorough
evaluation of Erlinda’s case prior to the operation and prepare
surgery just so her failure to perform the required pre-
her for anesthesia. However, she never saw the patient at the
operative evaluation would escape unnoticed. In her
bedside. She herself admitted that she had seen
testimony she asserted:
________________
ATTY. LIGSAY:
58 TSN, November 15, 1990, p. 6.
Q: Would you agree, Doctor, that it is good medical
614
practice to see the patient a day before so you can
introduce yourself to establish good doctor-patient 614 SUPREME COURT REPORTS ANNOTATED
relationship and gainthe trust and confidence of the Ramos vs. Court of Appeals
patient? petitioner only in the operating room, and only on the actual
DRA. GUTIERREZ: date of the cholecystectomy. She negligently failed to take
A: As I said in my previous statement, it depends on the advantage of this important opportunity. As such, her
operative procedure of the anesthesiologist and in my attempt
case, with elective cases and normal cardio- to exculpate herself must fail. Having established that
pulmonary clearance like that, I usually don’t do it respondent Dra. Gutierrez failed to perform pre-operative
except on emergency and on cases that have an evaluation of the patient which, in turn, resulted to a
abnormalities (sic).
58
wrongful intubation, we now determine if the faulty
However, the exact opposite is true. In an emergency intubation is truly the proximate cause of Erlinda’s comatose
procedure, there is hardly enough time available for the condition.
fastidious demands of preoperative procedure so that an Private respondents repeatedly hammered the view that the
anesthesiologist is able to see the patient only a few minutes cerebral anoxia which led to Erlinda’s coma was due to
before surgery, if at all. Elective procedures, on the other bronchospasm mediated by her allergic response to the drug,
59

hand, are operative procedures that can wait for days, weeks Thiopental Sodium, introduced into her system. Towards this
or even months. Hence, in these cases, the anesthesiologist end, they presented Dr. Jamora, a Fellow of the Philippine
possesses the luxury of time to make a proper assessment, College of Physicians and Diplomate of the Philippine
including the time to be at the patient’s bedside to do a proper Specialty Board of Internal Medicine, who advanced private
interview and clinical evaluation. There is ample time to re-spondents’ theory that the oxygen deprivation which led
explain the method of anesthesia, the drugs to be used, and to anoxic encephalopathy, was due to an unpredictable drug
60

their possible hazards for purposes of informed consent. reaction to the short-acting barbiturate. We find the theory of
Usually, the pre-operative assessment is conducted at least private respondents unacceptable.
one day before the intended surgery, when the patient is
First of all, Dr. Jamora cannot be considered an authority in A: We do it in conjunction with the anesthesiologist
the field of anesthesiology simply because he is not an when they have to intubate our patient.
anesthesiologist. Since Dr. Jamora is a pulmonologist, he Q: But not in particular when you practice pulmonology?
could not have been capable of properly enlightening the A: No.
court about anesthesia practice and procedure and their
complications. Dr. Jamora is likewise not an allergologist and Q: In other words, your knowledge about pentothal is
could not therefore properly advance expert opinion on based only on what you have read from books and not
allergic-mediated processes. Moreover, he is not a by your own personal application of the medicine
pharmacologist and, as such, could not have been capable, as pentothal?
an expert would, of explaining to the court the pharmacologic A: Based on my personal experience also on pentothal.
and toxic effects of the supposed culprit, Thiopental Sodium Q: How many times have you used pentothal?
(Pentothal). A: They used it on me. I went into bronchospasm during
The inappropriateness and absurdity of accepting Dr. my appendectomy.
Jamora’s testimony as an expert witness in the anesthetic Q: And because they have used it on you and on account
________________ of your own personal experience you feel that you can
59 Constriction of the air passages of the lung by spasmodic testify on pentothal here with medical authority?
contraction of the bronchial muscles (as in asthma). A: No. That is why I used references to support my
60 Permanent damage to the brain caused by inadequate claims.61

oxygenation.
An anesthetic accident caused by a rare drug-induced
615 bronchospasm properly falls within the fields of anesthesia,
VOL. 321, DECEMBER 29, 1999 615 internal medicine-allergy, and clinical pharmacology. The
Ramos vs. Court of Appeals resulting anoxic encephalopathy belongs to the field of
neurology. While admittedly, many bronchospastic-mediated
practice of Pentothal administration is further supported by
pulmonary diseases are within the expertise of pulmonary
his own admission that he formulated his opinions on the
medicine, Dr. Jamoras field, the anesthetic drug-induced,
drug not from the practical experience gained by a specialist
allergic mediated bronchospasm alleged in this case is within
or expert in the administration and use of Sodium Pentothal
on patients, but only from reading certain references, to wit: the disciplines of anesthesiology, allergology and
pharmacology. On the basis of
ATTY. LIGSAY:
________________
Q: In your line of expertise on pulmonology, did you 61 TSN, February 28, 1991, pp. 10-11.
have any occasion to use pentothal as a method of
616
management?
616 SUPREME COURT REPORTS ANNOTATED
DR. JAMORA:
Ramos vs. Court of Appeals and against the weight of available evidence, then every
the foregoing transcript, in which the pulmonologist himself anesthetic accident
admitted that he could not testify about the drug with medical ________________
authority, it is clear that the appellate court erred in giving 62 Rule 130, RULES OF COURT.
weight to Dr. Jamora’s testimony as an expert in the 63 61 Am Jur 2d, supra note 49, 516.
administration of Thiopental Sodium. 617
The provision in the rules of evidence regarding expert
62
VOL. 321, DECEMBER 29, 1999 617
witnesses states:
Ramos vs. Court of Appeals
Sec. 49. Opinion of expert witness.—The opinion of a witness on a
matter requiring special knowledge, skill, experience or training would be an act of God. Evidently, the Thiopentalallergy
which he is shown to possess, may be received in evidence. theory vigorously asserted by private respondents was a mere
Generally, to qualify as an expert witness, one must have afterthought. Such an explanation was advanced in order to
acquired special knowledge of the subject matter about which absolve them of any and all responsibility for the patient’s
he or she is to testify, either by the study of recognized condition.
authorities on the subject or by practical experience. Clearly,
63 In view of the evidence at hand, we are inclined to believe
Dr. Jamora does not qualify as an expert witness based on the petitioners’ stand that it was the faulty intubation which was
above standard since he lacks the necessary knowledge, skill, the proximate cause of Erlinda’s comatose condition.
and training in the field of anesthesiology. Oddly, apart from Proximate cause has been defined as that which, in natural
submitting testimony from a specialist in the wrong field, and continuous sequence, unbroken by any efficient
private respondents’ intentionally avoided providing intervening cause, produces injury, and without which the
testimony by competent and independent experts in the result would not have occurred. An injury or damage is
64

proper areas. proximately caused by an act or a failure to act, whenever it


Moreover, private respondents’ theory, that Thiopental appears from the evidence in the case, that the act or omission
Sodium may have produced Erlinda’s coma by triggering an played a substantial part in bringing about or actually causing
allergic mediated response, has no support in evidence. No the injury or damage; and that the injury or damage was
evidence of stridor, skin reactions, or wheezing—some of the either a direct result or a reasonably probable consequence of
more common accompanying signs of an allergic reaction— the act or omission. It is the dominant, moving or producing
65

appears on record. No laboratory data were ever presented to cause.


the court. Applying the above definition in relation to the evidence at
In any case, private respondents themselves admit that hand, faulty intubation is undeniably the proximate cause
Thiopental induced, allergic-mediated bronchospasm which triggered the chain of events leading to Erlindas brain
happens only very rarely. If courts were to accept private damage and, ultimately, her comatosed condition.
respondents’ hypothesis without supporting medical proof, Private respondents themselves admitted in their testimony
that the first intubation was a failure. This fact was likewise on record, beyond private respondents’ bare claims, which
observed by witness Cruz when she heard respondent Dra. supports the contention that the second intubation was
Gutierrez remarked, “Ang hirap ma-intubate nito, mali yata successful. Assuming that the endotracheal tube finally found
ang pagkakapasok. O lumalaki ang tiyan.” Thereafter, its way into the proper orifice of the trachea, the same gave no
witness Cruz noticed abdominal distention on the body of guarantee of oxygen delivery, the hallmark of a successful
Erlinda. The development of abdominal distention, together intubation. In fact, cyanosis was again observed immediately
with respiratory embarrassment indicates that the after the second intubation. Proceeding from this event
endotracheal tube entered the esophagus instead of the (cyanosis), it could not be claimed, as private respondents
respiratory tree. In other words, instead of the intended insist, that the second intubation was accomplished. Even
endotracheal granting that the tube was successfully inserted during the
________________ second attempt, it was obviously too late. As aptly explained
64 BLACK’S LAW DICTIONARY (FIFTH EDITION), 1103 (1979). by the trial court, Erlinda already suffered brain damage as a
65 Ibid.
result of the inadequate oxygenation of her brain for about
four to five minutes. 68
618
The above conclusion is not without basis. Scientific studies
618 SUPREME COURT REPORTS ANNOTATED
point out that intubation problems are responsible for one-
Ramos vs. Court of Appeals third (1/3) of deaths and serious injuries associated with anes-
intubation what actually took place was an esophageal ________________
intubation. During intubation, such distention indicates that 66 It is a bluish coloration of the skin or mucous membranes caused
air has entered the gastrointestinal tract through the by lack of oxygen or abnormal hemoglobin in the blood.
esophagus instead of the lungs through the trachea. Entry into 67 TSN, March 27, 1990, p. 22.
the esophagus would certainly cause some delay in oxygen 68 Records, p. 274.
delivery into the lungs as the tube which carries oxygen is in
619
the wrong place. That abdominal distention had been
observed during the first intubation suggests that the length VOL. 321, DECEMBER 29, 1999 619
of time utilized in inserting the endotracheal tube (up to the Ramos vs. Court of Appeals
time the tube was withdrawn for the second attempt) was thesia. Nevertheless, ninety-eight percent (98%) or the vast
69

fairly significant. Due to the delay in the delivery of oxygen majority of difficult intubations may be anticipated by
in her lungs Erlinda showed signs of cyanosis. As stated in
66
performing a thorough evaluation of the patient’s airway
the testimony of Dr. Hosaka, the lack of oxygen became prior to the operation. As stated beforehand, respondent
70

apparent only after he noticed that the nailbeds of Erlinda Dra. Gutierrez failed to observe the proper pre-operative
were already blue. However, private respondents contend
67
protocol which could have prevented this unfortunate
that a second intubation was executed on Erlinda and this one incident. Had appropriate diligence and reasonable care been
was successfully done. We do not think so. No evidence exists used in the pre-operative evaluation, respondent physician
could have been much more prepared to meet the 620 SUPREME COURT REPORTS ANNOTATED
contingency brought about by the perceived anatomic Ramos vs. Court of Appeals
variations in the patient’s neck and oral area, defects which
the operative team) in not determining if his anesthesiologist
would have been easily overcome by a prior knowledge of
observed proper anesthesia protocols. In fact, no evidence on
those variations together with a change in technique. In other
71

record exists to show that respondent Dr. Hosaka verified if


words, an experienced anesthesiologist, adequately alerted
respondent Dra. Gutierrez properly intubated the patient.
by a thorough pre-operative evaluation, would have had little
Furthermore, it does not escape us that respondent Dr.
difficulty going around the short neck and protruding teeth. 72

Hosaka had scheduled another procedure in a different


Having failed to observe common medical standards in pre-
hospital at the same time as Erlindas cholecystectomy, and was
operative management and intubation, respondent Dra.
in fact over three hours late for the latter’s operation. Because
Gutierrez’ negligence resulted in cerebral anoxia and
of this, he had little or no time to confer with his
eventual coma of Erlinda.
anesthesiologist regarding the anesthesia delivery. This
We now determine the responsibility of respondent Dr. indicates that he was remiss in his professional duties
Orlino Hosaka as the head of the surgical team. As the so- towards his patient. Thus, he shares equal responsibility for
called “captain of the ship,” it is the surgeon’s responsibility
73
the events which resulted in Erlinda’s condition.
to see to it that those under him perform their task in the
We now discuss the responsibility of the hospital in this
proper manner. Respondent Dr. Hosaka’s negligence can be
particular incident. The unique practice (among private
found in his failure to exercise the proper authority (as the
hospitals) of filling up specialist staff with attending and
“captain” of
visiting “consultants,” who are allegedly not hospital
74

________________
employees, presents problems in apportioning responsibility
69 FINUCAINE, AIRWAY MANAGEMENT, 82 (1990). for negligence in medical malpractice cases. However, the
70 Ibid. difficulty is only more apparent than real.
71Id., The book provides a thorough discussion on the management In the first place, hospitals exercise significant control in the
of difficult intubations. hiring and firing of consultants and in the conduct of their
72 Id. work within the hospital premises. Doctors who apply for
73Under this doctrine, the surgeon is likened to a ship captain who “consultant” slots, visiting or attending, are required to
must not only be responsible for the safety of the crew but also of submit proof of completion of residency, their educational
the passengers of the vessel. The head surgeon is made responsible qualifications; generally, evidence of accreditation by the
for everything that goes wrong within the four corners of the appropriate board (diplomate), evidence of fellowship in
operating room. It enunciates the liability of the surgeon not only
most cases, and references. These requirements are carefully
for the wrongful acts of those who are under his physical control
but also those wherein he has extension of control.
scrutinized by members of the hospital administration or by
a review committee set up by the hospital who either accept
620
or reject
________________ assessing whether such a relationship in fact exists, the
74 The term “consultant” is loosely used by hospitals to distinguish control test is determining. Accordingly, on the basis of the
their attending and visiting physicians from the residents, who are foregoing, we rule that for the purpose of allocating
also physicians. In most hospitals abroad, the term visiting or responsibility in medical negligence cases, an employer-
attending physician, not consultant, is used. employee relationship in effect exists between hospitals and
621 their attending and visiting physicians. This being the case,
VOL. 321, DECEMBER 29, 1999 621 the question now arises as to whether or not respondent
Ramos vs. Court of Appeals hospital is solidarily liable with respondent doctors for
petitioner’s condition. 76

the application. This is particularly true with respondent


75
________________
hospital.
75These requirements are in fact found in the standard application
After a physician is accepted, either as a visiting or attending forms for visiting and attending physicians of respondent hospital.
consultant, he is normally required to attend clinico-
76 The hospital’s control over respondent physicians is all the more
pathological conferences, conduct bedside rounds for clerks, significant when one considers the fact that it controls every-
interns and residents, moderate grand rounds and patient
622
audits and perform other tasks and responsibilities, for the
privilege of being able to maintain a clinic in the hospital, 622 SUPREME COURT REPORTS ANNOTATED
and/or for the privilege of admitting patients into the Ramos vs. Court of Appeals
hospital. In addition to these, the physician’s performance as The basis for holding an employer solidarily responsible for
a specialist is generally evaluated by a peer review committee the negligence of its employee is found in Article 2180 of the
on the basis of mortality and morbidity statistics, and Civil Code which considers a person accountable not only for
feedback from patients, nurses, interns and residents. A his own acts but also for those of others based on the former’s
consultant remiss in his duties, or a consultant who regularly responsibility under a relationship of patria potestas. Such77

falls short of the minimum standards acceptable to the responsibility ceases when the persons or entity concerned
hospital or its peer review committee, is normally politely prove that they have observed the diligence of a good father
terminated. of the family to prevent damage. In other words, while the
78

In other words, private hospitals, hire, fire and exercise real burden of proving negligence rests on the plaintiffs, once
control over their attending and visiting “consultant” staff. negligence is shown, the burden shifts to the respondents
While “consultants” are not, technically employees, a point (parent, guardian, teacher or employer) who should prove
which respondent hospital asserts in denying all that they observed the diligence of a good father of a family
responsibility for the patient’s condition, the control to prevent damage.
exercised, the hiring, and the right to terminate consultants all In the instant case, respondent hospital, apart from a general
fulfill the important hallmarks of an employer-employee denial of its responsibility over respondent physicians, failed
relationship, with the exception of the payment of wages. In to adduce evidence showing that it exercised the diligence of
a good father of a family in the hiring and supervi- solidarily responsible with its physicians for Erlinda’s
________________ condition.
thing which occurs in an operating room, through its nursing Based on the foregoing, we hold that the Court of Appeals
supervisors and charge nurses. No operations can be undertaken erred in accepting and relying on the testimonies of the
without the hospital’s direct or indirect consent. witnesses for the private respondents. Indeed, as shown by
77 VITUG, COMPENDIUM OF CIVIL LAW AND the above discussions, private respondents were unable to
JURISPRUDENCE, 822 (1993). rebut the presumption of negligence. Upon these
78 Art. 2180 of the Civil Code provides: The obligation imposed by disquisitions we hold that private respondents are solidarily
Article 2176 is demandable not only for one’s own acts or liable for damages under Article 2176 of the Civil Code.
79

omissions, but also for those of persons for whom one is We now come to the amount of damages due petitioners. The
responsible.
trial court awarded a total of P632,000.00 pesos (should be
The father and, in case of his death or incapacity, the mother, are P616,000.00) in compensatory damages to the plaintiff,
responsible for the damages caused by the minor children who live “subject to its being updated” covering the period from 15
in their company.
November 1985 up to 15 April 1992, based on monthly
Guardians are liable for damages caused by the minors or expenses for the care of the patient estimated at P8,000.00.
incapacitated persons who are under their authority and live in
their company. At current levels, the P8,000/monthly amount established by
the trial court at the time of its decision would be grossly
The owners and managers of an establishment or enterprise are
likewise responsible for damages caused by their employees in the inadequate to cover the actual costs of home-based care for a
service of the branches in which the latter are employed or on the comatose individual. The calculated amount was not even
occasion of their functions. arrived at by looking at the actual cost of proper hospice care
Employers shall be liable for the damages caused by their for the patient. What it reflected were the actual expenses
employees and household helpers acting within the scope of their incurred and proved by the petitioners after they were forced
assigned tasks, even though the former are not engaged in any to bring home the patient to avoid mounting hospital bills.
business or industry. And yet ideally, a comatose patient should remain in a
623 hospital or be transferred to a hospice specializing in the care
VOL. 321, DECEMBER 29, 1999 623 of the chronically ill for the purpose of providing a proper
milieu adequate to meet minimum standards of care. In the
Ramos vs. Court of Appeals
instant case for instance, Erlinda has to be constantly turned
sion of the latter. It failed to adduce evidence with regard to from side to side to prevent bedsores and hypostatic
the degree of supervision which it exercised over its pneumonia.
physicians. In neglecting to offer such proof, or proof of a
________________
similar nature, respondent hospital thereby failed to
79Whoever by act or omission causes damage to another, there
discharge its burden under the last paragraph of Article 2180.
being fault or negligence, is obliged to pay for the damage done.
Having failed to do this, respondent hospital is consequently
624 awarded, if they are to adequately and correctly respond to
624 SUPREME COURT REPORTS ANNOTATED the injury caused, should be one which compensates for
Ramos vs. Court of Appeals pecuniary loss incurred and proved, up to the time of trial;
and one which would meet pecuniary loss certain to be
Feeding is done by nasogastric tube. Food preparation should suffered but which could not, from the nature of the case, be
be normally made by a dietitian to provide her with the made
correct daily caloric requirements and vitamin supplements.
625
Furthermore, she has to be seen on a regular basis by a
physical therapist to avoid muscle atrophy, and by a VOL. 321, DECEMBER 29, 1999 625
pulmonary therapist to prevent the accumulation of Ramos vs. Court of Appeals
secretions which can lead to respiratory complications. with certainty. In other words, temperate damages can and
80

Given these considerations, the amount of actual damages should be awarded on top of actual or compensatory
recoverable in suits arising from negligence should at least damages in instances where the injury is chronic and
reflect the correct minimum cost of proper care, not the cost continuing. And because of the unique nature of such cases,
of the care the family is usually compelled to undertake at no incompatibility arises when both actual and temperate
home to avoid bankruptcy. However, the provisions of the damages are provided for. The reason is that these damages
Civil Code on actual or compensatory damages present us cover two distinct phases.
with some difficulties. As it would not be equitable—and certainly not in the best
Well-settled is the rule that actual damages which may be interests of the administration of justice—for the victim in
claimed by the plaintiff are those suffered by him as he has such cases to constantly come before the courts and invoke
duly proved. The Civil Code provides: their aid in seeking adjustments to the compensatory
Art. 2199.—Except as provided by law or by stipulation, one is damages previously awarded—temperate damages are
entitled to an adequate compensation only for such pecuniary loss appropriate. The amount given as temperate damages,
suffered by him as he has duly proved. Such compensation is though to a certain extent speculative, should take into
referred to as actual or compensatory damages. account the cost of proper care.
Our rules on actual or compensatory damages generally In the instant case, petitioners were able to provide only
assume that at the time of litigation, the injury suffered as a home-based nursing care for a comatose patient who has
consequence of an act of negligence has been completed and remained in that condition for over a decade. Having
that the cost can be liquidated. However, these provisions premised our award for compensatory damages on the
neglect to take into account those situations, as in this case, amount provided by petitioners at the onset of litigation, it
where the resulting injury might be continuing and possible would be now much more in step with the interests of justice
future complications directly arising from the injury, while if the value awarded for temperate damages would allow
certain to occur, are difficult to predict. petitioners to provide optimal care for their loved one in a
In these cases, the amount of damages which should be facility which generally specializes in such care. They should
not be compelled by dire circumstances to provide and readjusted to changes in the size of her lower limb effected by
substandard care at home without the aid of professionals, for the biological changes of middle-age, menopause and aging.
anything less would be grossly inadequate. Under the Assuming she reaches menopause, for example, the prosthetic will
circumstances, an award of P1,500,000.00 in temperate have to be adjusted to respond to the changes in bone resulting
from a precipitate decrease in calcium levels observed in the bones
damages would therefore be reasonable. 81
of all postmenopausal women. In other words, the damage done to
In Valenzuela vs. Court of Appeals, this Court was confronted
82
her would not only be permanent and lasting, it would also be
with a situation where the injury suffered by the plaintiff permanently changing and adjusting to the physiologic changes
would have led to expenses which were difficult to which her body would normally undergo through the years. The
________________ replacements, changes, and adjustments will require
80 Art. 2224, CIVIL CODE. corresponding adjustive physical and occupational therapy. All of
these adjustments, it has been documented, are painful.
81Should petitioner remain in the same condition for another ten
x x x.
years, the amount awarded in the form of temperate damages
would in fact, be inadequate. A prosthetic devise, however technologically advanced, will only
82 253 SCRA 303 (1996). allow a reasonable amount of functional restoration of the motor
functions of the lower limb. The sensory functions are forever lost.
626 The resultant anxiety, sleeplessness, psychological injury, mental
626 SUPREME COURT REPORTS ANNOTATED and physical pain are inestimable.83
Ramos vs. Court of Appeals ________________
estimate because while they would have been a direct result 83 Id. at 327-328.
of the injury (amputation), and were certain to be incurred by 627
the plaintiff, they were likely to arise only in the future. We VOL. 321, DECEMBER 29, 1999 627
awarded P1,000,000.00 in moral damages in that case. Ramos vs. Court of Appeals
Describing the nature of the injury, the Court therein stated:
The injury suffered by Erlinda as a consequence of private
As a result of the accident, Ma. Lourdes Valenzuela underwent a respondents’ negligence is certainly much more serious than
traumatic amputation of her left lower extremity at the distal left the amputation in the Valenzuela case.
thigh just above the knee. Because of this, Valenzuela will forever
be deprived of the full ambulatory functions of her left extremity, Petitioner Erlinda Ramos was in her mid-forties when the
even with the use of state of the art prosthetic technology. Well incident occurred. She has been in a comatose state for over
beyond the period of hospitalization (which was paid for by Li), she fourteen years now. The burden of care has so far been
will be required to undergo adjustments in her prosthetic devise heroically shouldered by her husband and children, who, in
due to the shrinkage of the stump from the process of healing. the intervening years have been deprived of the love of a wife
These adjustments entail costs, prosthetic replacements and and a mother.
months of physical and occupational rehabilitation and therapy. Meanwhile, the actual physical, emotional and financial cost
During her lifetime, the prosthetic devise will have to be replaced of the care of petitioner would be virtually impossible to
quantify. Even the temperate damages herein awarded would automatically gives the injured a right to reparation for the
be inadequate if petitioner’s condition remains unchanged for damage caused.
the next ten years. Established medical procedures and practices, though in
We recognized, in Valenzuela that a discussion of the victim’s constant flux are devised for the purpose of preventing
actual injury would not even scratch the surface of the complications. A physician’s experience with his patients
resulting moral damage because it would be highly would sometimes tempt him to deviate from established
speculative to estimate the amount of emotional and moral community practices, and he may end a distinguished career
pain, psychological damage and injury suffered by the victim using unorthodox methods without incident. However, when
or those actually affected by the victim’s condition. The 84 failure to follow established procedure results in the evil
husband and the children, all petitioners in this case, will have precisely sought to be averted by observance of the procedure
to live with the day to day uncertainty of the patient’s illness, and a nexus is made between the deviation and the injury or
knowing any hope of recovery is close to nil. They have damage, the physician would necessarily be called to account
fashioned their daily lives around the nursing care of for it. In the case at bar, the failure to observe preoperative
petitioner, altering their long term goals to take into account assessment protocol which would have influenced the
their life with a comatose patient. They, not the respondents, intubation in a salutary way was fatal to private respondents’
are charged with the moral responsibility of the care of the case.
victim. The family’s moral injury and suffering in this case is WHEREFORE, the decision and resolution of the
clearly a real one. For the foregoing reasons, an award of appellate court appealed from are hereby modified so as to
P2,000,000.00 in moral damages would be appropriate. award in favor of petitioners, and solidarily against private
Finally, by way of example, exemplary damages in the respondents the following: 1) P1,352,000.00 as actual damages
amount of P100,000.00 are hereby awarded. Considering the computed as of the date of promulgation of this decision plus
length and nature of the instant suit we are of the opinion that a monthly payment of P8,000.00 up to the time that petitioner
attorney’s fees valued at P100,000.00 are likewise proper. Erlinda Ramos expires or miraculously survives; 2)
________________ P2,000,000.00 as moral damages; 3) P1,500,000.00 as temperate
84 Id. at 328. damages; 4) P100,000.00 each as exemplary damages and
628
attorney’s fees; and, 5) the costs of the suit.
628 SUPREME COURT REPORTS ANNOTATED SO ORDERED.
Ramos vs. Court of Appeals Davide, Jr. (C.J., Chairman), Puno, Pardo and Ynares-
Santiago, JJ., concur.
Our courts face unique difficulty in adjudicating medical
Judgment modified.
negligence cases because physicians are not insurers of life
629
and, they rarely set out to intentionally cause injury or death
to their patients. However, intent is immaterial in negligence VOL. 321, DECEMBER 29, 1999 629
cases because where negligence exists and is proven, the same
Land Bank of the Philippines vs. Court of Appeals
Note.—Proximate cause is determined on the facts of each
case upon mixed considerations of logic, common sense,
policy and precedent. (Philippine Bank of Commerce vs. Court of
Appeals, 269 SCRA 695 [1997])
——o0o——
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