Republic of the Philippines SUPREME COURT Manila SECOND DIVISION G.R. No.

158996 November 14, 2008

)$ 5rdering the above0named defendant0appellants to ,ointly and severally pay the above0named plaintiff0appellees the sum of P)(,:::.:: by way of actual and compensatory damages; and 4$ eleting the award of attorney=s fees and costs of suit.

/5 5R +R+ . 2hile this case essentially involves >uestions of facts, we opted for the re>uested review in light of >uestions we have on the findings of negligence below, on the awarded damages and costs, and on the importance of this type of ruling on medical practice.) *)C3GROUND )CTS Teresita Pineda #Teresita$ was a 5!0year old unmarried woman living in /to. omingo, 'ueva +ci,a. /he consulted on "pril !., !?@. her townmate, r. 4redelicto 4lores, regarding her medical condition. /he complained of general body weaAness, loss of appetite, fre>uent urination and thirst, and on0and0off vaginal bleeding. r. 4redelicto initially interviewed the patient and asAed for the history of her monthly period to analy8e the probable cause of the vaginal bleeding. 3e advised her to return the following weeA or to go to the 7nited octors Medical Center #UDMC$ in Bue8on City for a general checA0up. "s for her other symptoms, he suspected that Teresita might be suffering from diabetes and told her to continue her medications.4 Teresita did not return the ne<t weeA as advised. 3owever, when her condition persisted, she went to further consult r. 4lores at his 7 MC clinic on "pril *@, !?@., travelling for at least two hours from 'ueva +ci,a to Bue8on City with her sister, 9ucena Pineda. They arrived at 7 MC at around !!1!5 a.m.. 9ucena later testified that her sister was then so weaA that she had to lie down on the couch of the clinic while they waited for the doctor. 2hen r. 4redelicto arrived, he did a routine checA0up and ordered Teresita=s admission to the hospital. 6n the admission slip, he directed the hospital staff to prepare the patient for an Con callC D4C5 operation to be performed by his wife, r. 4elicisima 4lores # Dr. Felicisima$. Teresita was brought to her hospital room at around !* noon; the hospital staff forthwith tooA her blood and urine samples for the laboratory tests( which r. 4redelicto ordered. "t *14: p.m. of that same day, Teresita was taAen to the operating room. 6t was only then that she met r. 4elicisima, an obstetrician and gynecologist. The two doctors 0 r. 4elicisima and r. 4redelicto, conferred on the patient=s medical

SPOUSES REDE!ICTO !ORES "#e$e%&e#' %(# E!ICISIM) !ORES, petitioners, vs. SPOUSES DOMIN)DOR PINED) %(# VIRGINI) S)C!O!O, %(# !ORENCIO, C)NDID), M)RT), GODO REDO, *)!T)+)R %(# !UCEN), %,, &-r(%me# PINED), %& .e/r& o0 1.e #e$e%&e# TERESIT) S. PINED), %(# UNITED DOCTORS MEDIC)! CENTER, INC., respondents. DECISION *RION, J.2 This petition involves a medical negligence case that was elevated to this Court through an appeal bycertiorari under Rule 45 of the Rules of Court. The petition assails the ecision! of the Court of "ppeals #CA$ in C" %.R. C& 'o. ()*)4, which affirmed with modification the ecision* of the Regional Trial Court #RTC$ of 'ueva +ci,a, -ranch ). in Civil Case 'o. / 0!*)). The dispositive portion of the assailed C" decision states1 23+R+45R+, premises considered, the assailed ecision of the Regional Trial Court of -aloc, /to. omingo, 'ueva +ci,a, -ranch ). is hereby "446RM+ but with modifications as follows1 !$ 5rdering defendant0appellants r. and ra. 4redelicto ". 4lores and the 7nited octors Medical Center, 6nc. to ,ointly and severally pay the plaintiff0appellees 0 heirs of Teresita Pineda, namely, /pouses ominador Pineda and &irginia /aclolo and 4lorencio, Candida, Marta, %odofredo, -alta8ar and 9ucena, all surnamed Pineda, the sum of P4::,:::.:: by way of moral damages; *$ 5rdering the above0named defendant0appellants to ,ointly and severally pay the above0named plaintiff0appellees the sum of P!::,:::.:: by way of e<emplary damages;

condition, while the resident physician and the medical intern gave r. 4elicisima their own briefings. /he also interviewed and conducted an internal vaginal e<amination of the patient which lasted for about !5 minutes. r. 4elicisima thereafter called up the laboratory for the results of the tests. "t that time, only the results for the blood sugar # BS$, uric acid determination, cholesterol determination, and complete blood count #CBC$ were available. Teresita=s -/ count was !:.(.mmolDl.and her C-C was !:?gDl.@ -ased on these preparations, r. 4elicisima proceeded with the EC operation with r. 4redelicto administering the general anesthesia. The EC operation lasted for about !: to !5 minutes. -y )14: p.m., Teresita was wheeled bacA to her room. " day after the operation #or on "pril *?, !?@.$, Teresita was sub,ected to an ultrasound e<amination as a confirmatory procedure. The results showed that she had an enlarged uterus and myoma uteri.? r. 4elicisima, however, advised Teresita that she could spend her recovery period at home. /till feeling weaA, Teresita opted for hospital confinement. Teresita=s complete laboratory e<amination results came only on that day #"pril *?, !?@.$. Teresita=s urinalysis showed a three plus sign #FFF$ indicating that the sugar in her urine was very high. /he was then placed under the care of r. "mado Gorge, an internist. -y "pril ):, !?@., Teresita=s condition had worsened. /he e<perienced difficulty in breathing and was rushed to the intensive care unit. 4urther tests confirmed that she was suffering from D/%be1e& Me,,/1-& T56e II.!: 6nsulin was administered on the patient, but the medication might have arrived too late. ue to complications induced by diabetes, Teresita died in the morning of May (, !?@.. !! -elieving that Teresita=s death resulted from the negligent handling of her medical needs, her family #respondents$ instituted an action for damages against r. 4redelicto 4lores and r. 4elicisima 4lores #collectively referred to as the petitioner spouses$ before the RTC of 'ueva +ci,a. The RTC ruled in favor of Teresita=s family and awarded actual, moral, and e<emplary damages, plus attorney=s fees and costs.!* The C" affirmed the ,udgment, but modified the amount of damages awarded and deleted the award for attorney=s fees and costs of suit.!) Through this petition for review on certiorari, the petitioner spouses 0 r. 4redelicto #now deceased$ and r. 4elicisima 4lores 0 allege that the RTC and C" committed

a reversible error in finding them liable through negligence for the death of Teresita Pineda. )SSIGNMENT O ERRORS

The petitioner spouses contend that they e<ercised due care and prudence in the performance of their duties as medical professionals. They had attended to the patient to the best of their abilities and undertooA the management of her case based on her complaint of an on0and0off vaginal bleeding. 6n addition, they claim that nothing on record shows that the death of Teresita could have been averted had they employed means other than what they had adopted in the ministration of the patient. T7E COURT8S RU!ING 9e #o (o1 0/(# 1.e 6e1/1/o( mer/1or/o-&. The respondents= claim for damages is predicated on their allegation that the decision of the petitioner spouses to proceed with the EC operation, notwithstanding Teresita=s condition and the laboratory test results, amounted to negligence. 5n the other hand, the petitioner spouses contend that a EC operation is the proper and accepted procedure to address vaginal bleeding 0 the medical problem presented to them. %iven that the patient died after the EC, the core issue is whether the decision to proceed with the EC operation was an honest mistaAe of ,udgment or one amounting to negligence. Elements of a Medical Negligence Case " me#/$%, (e:,/:e($e $%&e is a type of claim to redress a wrong committed by a medical professional, that has caused bodily harm to or the death of a patient. There are four elements involved in a medical negligence case, namely1 duty, breach, injury, and pro imate causation.!4 uty refers to the standard of behavior which imposes restrictions on one=s conduct.!5 The standard in turn refers to the amount of competence associated with the proper discharge of the profession. " physician is e<pected to use at least the same level of care that any other reasonably competent doctor would use under the same circumstances. -reach of duty occurs when the physician fails to comply with these professional standards. 6f in,ury results to the patient as a result of this breach, the physician is answerable for negligence. !(

"s in any civil action, the burden to prove the e<istence of the necessary elements rests with the plaintiff.!. To successfully pursue a claim, the plaintiff must prove by preponderance of evidence that, o(e, the physician either !ailed to do somethin" #hich a reasonably prudent health care pro$ider #ould ha$e done, or that he did somethin" that a reasonably prudent pro$ider #ould not ha$e done; and 1;o, the !ailure or action caused injury to the patient .!@ +<pert testimony is therefore essential since the factual issue of whether a physician or surgeon has e<ercised the re>uisite degree of sAill and care in the treatment of his patient is generally a matter of e<pert opinion. !? Standard of Care and Breach of Duty EC is the classic gynecologic procedure for the evaluation and possible therapeutic treatment for abnormal vaginal bleeding. *: That this is the recogni8ed procedure is confirmed by rs. /alvador 'ieto # Dr. %ieto$ and Goselito Mercado #Dr. Mercado$, the e<pert witnesses presented by the respondents1 R. '6+T51 H2Ihat 6 Anow among obstetricians, if there is bleeding, they perform what we call EC for diagnostic purposes. <<< <<< <<< B1 /o are you trying to tell the Court that treatmentJ "1 Kes, sir. "ny doctor Anows this.*! r. Mercado, however, ob,ected with respect to the time the EC operation should have been conducted in Teresita=s case. 3e opined that given the blood sugar level of Teresita, her diabetic condition should have been addressed first1 B1 2hy do you consider the time of performance of the appropriateJ EC not EC can be a diagnostic

B1

oes it indicate sicAnessJ

"1 @: to ?5L it means diabetes mellitus. The blood sugar was !:.(.. <<< <<< <<< C57RT1 6n other words, the operation conducted on the patient, your opinion, that it is inappropriateJ "1 The timing of HwhenI the EC HwasI done, based on the record, in my personal opinion, that EC should be postponed a day or two.** The petitioner spouses countered that, at the time of the operation, there was nothing to indicate that Teresita was afflicted with diabetes1 a blood sugar level of !:.(.mmolDl did not necessarily mean that she was a diabetic considering that this was random blood sugar<*) there were other factors that might have caused Teresita=s blood sugar to rise such as the taAing of blood samples during lunchtime and while patient was being given intra0venous de<trose.*4 4urthermore, they claim that their principal concern was to determine the cause of and to stop the vaginal bleeding. The petitioner spouses= contentions, in our view, miss several points. First, as early as "pril !., !?@., Teresita was already suspected to be suffering from diabetes.*5 This suspicion again arose right beforethe EC operation on "pril *@, !?@. when the laboratory result revealed Teresita=s increased blood sugar level.*( 7nfortunately, the petitioner spouses did not wait for the full medical laboratory results before proceeding with the EC, a fact that was never considered in the courts below. Second, the petitioner spouses were duly advised that the patient was e<periencing general body weaAness, loss of appetite, fre>uent urination, and thirst 0 all of which are classic symptoms of diabetes.*. 2hen a patient e<hibits symptoms typical of a particular disease, these symptoms should, at the very least, alert the physician of the possibility that the patient may be afflicted with the suspected disease1
+<pert testimony for the plaintiff showed thatI tests should have been ordered immediately on admission to the hospital in view of the symptoms presented, and that failure to recogni8e the e<istence of diabetes constitutes negligence.*@

"1 -ecause 6 have read the record and 6 have seen the urinalysis, Hthere isI spillage in the urine, and blood sugar was !:.(. B1 2hat is the significance of the spillage in the urineJ "1 6t is a sign that the blood sugar is very high.

Third, the petitioner spouses cannot claim that their principal concern was the vaginal bleeding and should not therefore be held accountable for complications coming from other sources. This is a very narrow and self0serving view that even reflects on their competence.

TaAen together, we find that reasonable prudence would have shown that diabetes and its complications were foreseeable harm that should have been taAen into consideration by the petitioner spouses. I0 % 6%1/e(1 &-00er& 0rom &ome #/&%b/,/15 1.%1 /($re%&e& 1.e m%:(/1-#e o0 r/&= 1o ./m, 1.%1 #/&%b/,/15 m-&1 be 1%=e( /(1o %$$o-(1 &o ,o(: %& /1 /& or &.o-,# .%ve bee( =(o;( 1o 1.e 6.5&/$/%(. *? "nd when the patient is e<posed to an increased risA, it is incumbent upon the physician to taAe commensurate and ade>uate precautions. TaAing into account Teresita=s high blood sugar, ): r. Mendo8a opined that the attending physician should have postponed the EC operation in order to conduct a confirmatory test to maAe a conclusive diagnosis of diabetes and to refer the case to an internist or diabetologist. This was corroborated by r. elfin Tan # Dr. Tan$, an obstetrician and gynecologist, who stated that the patient=s diabetes should have been managed by an internist prior to, durin", and a!ter the operation.)! "part from bleeding as a complication of pregnancy, vaginal bleeding is only rarely so heavy and life0threatening that urgent first0aid measures are re>uired.)* 6ndeed, the e<pert witnesses declared that a EC operation on a hyperglycemic patient may be ,ustified only when it is an emergency case 0 when there is profuse vaginal bleeding. 6n this case, we choose not to rely on the assertions of the petitioner spouses that there was profuse bleeding, not only because the statements were self0serving, but also because the petitioner spouses were inconsistent in their testimonies. r. 4redelicto testified earlier that on "pril *@, he personally saw the bleeding, )) but later on said that he did not see it and relied only on Teresita=s statement that she was bleeding. )4 3e went on to state that he scheduled the EC operation without conducting any physical e<amination on the patient. The liAely story is that although Teresita e<perienced vaginal bleeding on "pril *@, it was not sufficiently profuse to necessitate an immediate emergency EC operation. r. Tan)5 and r. Mendo8a)( both testified that the medical records of Teresita failed to indicate that there was profuse vaginal bleeding. The claim that there was profuse vaginal bleeding although this was not reflected in the medical records striAes us as odd since the main complaint is vaginal bleeding. " medical record is the only document that maintains a long0term transcription of patient care and as such, its maintenance is considered a priority in hospital practice. 5ptimal record0Aeeping includes all patient inter0actions. The records should always be clear, ob,ective, and up0to0date. ). Thus, a medical record that does not indicate profuse medical bleeding speaAs loudly and clearly of what it does not contain.

That the EC operation was conducted principally to diagnose the cause of the vaginal bleeding further leads us to conclude that it was merely an elective procedure, not an emergency case. 6n an elective procedure, the physician must conduct a thorough pre0operative evaluation of the patient in order to ade>uately prepare her for the operation and minimi8e possible risAs and complications. The internist is responsible for generating a comprehensive evaluation of all medical problems during the pre0operative evaluation. )@ The aim of pre0operative evaluation is not to screen broadly for undiagnosed disease, but rather to identify and >uantify comorbidity that may impact on the operative outcome. This evaluation is driven by findings on history and physical e<amination suggestive of organ system dysfunctionMT.e :o%, /& 1o -($over 6rob,em %re%& 1.%1 m%5 re>-/re 0-r1.er /(ve&1/:%1/o( or be %me(%b,e 1o 6reo6er%1/ve o61/m/?%1/o(. 6f the preoperative evaluation uncovers significant comorbidity or evidence of poor control of an underlying disease process, consultation with an internist or medical specialist may be re>uired to facilitate the worA0up and direct management. 6n this process, communication between the surgeons and the consultants is essential to define realistic goals for this optimi8ation process and to e<pedite surgical management. )? H+mphasis supplied.I /ignificantly, the evidence strongly suggests that the pre0operative evaluation was less than complete as the laboratory results were fully reported only on the day following the EC operation. r. 4elicisima only secured a telephone report of the preliminary laboratory result prior to the EC. This preliminary report did not include the )F status of sugar in the patient=s urine 4: 0 a result highly confirmatory of diabetes. -ecause the EC was merely an elective procedure, the patient=s uncontrolled hyperglycemia presented a far greater risA than her on0and0off vaginal bleeding. The presence of hyperglycemia in a surgical patient is associated with poor clinical outcomes, and aggressive glycemic control positively impacts on morbidity and mortality.4! +lective surgery in people with uncontrolled diabetes should preferably be scheduled a!ter acceptable glycemic control has been achieved.4* "ccording to r. Mercado, this is done by administering insulin on the patient.4) The management approach in this Aind of patients always includes insulin therapy in combination with de<trose and potassium infusion. 6nsulin <<< promotes glucose uptaAe by the muscle and fat cells while decreasing

glucose production by the liver <<<. The net effect is to lower blood glucose levels.44 The prudent move is to address the patient=s hyperglycemic state immediately and promptly before any other procedure is undertaAen. 6n this case, there was no evidence that insulin was administered on Teresita prior to or during the EC operation. 6nsulin was only administered two days after the operation. "s r. Tan testified, the patient=s hyperglycemic condition should have been managed not only before and during the operation, but also immediately after. espite the possibility that Teresita was afflicted with diabetes, the possibility was casually ignored even in the post0operative evaluation of the patient; the concern, as the petitioner spouses e<pressly admitted, was limited to the complaint of vaginal bleeding. 6nterestingly, while the ultrasound test confirmed that Teresita had a myoma in her uterus, she was advised that she could be discharged a day after the operation and that her recovery could taAe place at home. This advice implied that a day after the operation and even after the complete laboratory results were submitted, the petitioner spouses still did not recogni8e any post0 operative concern that would re>uire the monitoring of Teresita=s condition in the hospital. The above facts, point only to one conclusion 0 that the petitioner spouses failed, as medical professionals, to comply with their duty to observe the standard of care to be given to hyperglycemicDdiabetic patients undergoing surgery. 2hether this breach of duty was the pro<imate cause of Teresita=s death is a matter we shall ne<t determine. Injury and Causation "s previously mentioned, the critical and clinching factor in a medical negligence case is proof of the$%-&%, $o((e$1/o( between the negligence which the evidence established and the plaintiff=s in,uries;45the plaintiff must plead and prove not only that he had been in,ured and defendant has been at fault, but also that the defendant=s fault caused the in,ury. " verdict in a malpractice action cannot be based on speculation or con,ecture. Causation must be proven within a reasonable medical probability based upon competent e<pert testimony. 4( The respondents contend that unnecessarily sub,ecting Teresita to a EC operation without ade>uately preparing her, aggravated her hyperglycemic state and caused her untimely demise. The death certificate of Teresita lists down the following causes of death1

6mmediate cause1 "ntecedent cause1 7nderlying cause1

Cardiorespiratory arrest /epticemic shocA,=e1o%$/#o$/& iabetes Mellitus 66

5ther significant conditions contributing to death1 Renal 4ailure 0 "cute4.

/tress, whether physical or emotional, is a factor that can aggravate diabetes; a EC operation is a form of physical stress. r. Mendo8a e<plained how surgical stress can aggravate the patient=s hyperglycemia1 when stress occurs, the diabetic=s body, especially the autonomic system, reacts by secreting hormones which are counter0regulatory; she can have prolonged hyperglycemia which, if unchecAed, could lead to death. 4@ Medical literature further e<plains that if the blood sugar has become very high, the patient becomes comatose #diabetic coma$. 2hen this happens over several days, the body uses its own fat to produce energy, and the result is high levels of waste products #called Aetones$ in the blood and urine #called #/%be1/$ =e1o%$/#/o&/&, a medical emergency with a significant mortality$.4? This was apparently what happened in Teresita=s case; in fact, after she had been referred to the internist r. Gorge, laboratory test showed that her blood sugar level shot up to !4.:mmolDl, way above the normal blood sugar range. Thus, between the EC and death was the diabetic complication that could have been prevented with the observance of standard medical precautions. The EC operation and Teresita=s death due to aggravated diabetic condition is therefore sufficiently established. The trial court and the appellate court pinned the liability for Teresita=s death on both the petitioner spouses and this Court finds no reason to rule otherwise. 3owever, we clarify that r. 4redelicto=s negligence is not solely the act of ordering an Con callC EC operation when he was mainly an%(%e&1.e&/o,o:/&1 who had made a very cursory e<amination of the patient=s vaginal bleeding complaint. Rather, it was his failure from the very start to identify and confirm, despite the patient=s complaints and his own suspicions, that diabetes was a risA factor that should be guarded against, and his participation in the imprudent decision to proceed with the EC operation despite his early suspicion and the confirmatory early laboratory results. The latter point comes out clearly from the following e<change during the trial1 B1 5n what aspect did you and your wife consult HwithI each otherJ

"1 2e discussed on the finding of the laboratory HresultsI because the hemoglobin was below normal, the blood sugar was elevated, so that we have to evaluate these laboratory results 0 what it means. B1 /o it was you and your wife who made the evaluation when it was phoned inJ "1 Kes, sir. B1 id your wife, before performing she can proceedJ EC asA your opinion whether or not

"#ard of Damages -oth the trial and the appellate court awarded actual damages as compensation for the pecuniary loss the respondents suffered. The loss was presented in terms of the hospital bills and e<penses the respondents incurred on account of Teresita=s confinement and death. The settled rule is that a plaintiff is entitled to be compensated for proven pecuniary loss.5* This proof the respondents successfully presented. Thus, we affirm the award of %$1-%, #%m%:e& of P)(,:::.:: representing the hospital e<penses the patient incurred. 6n addition to the award for actual damages, the respondent heirs of Teresita are liAewise entitled toP5:,:::.:: as #e%1. /(#em(/15 pursuant to "rticle **:( of the Civil Code, which states that Cthe amount of damages for death caused by a <<< &uasi'delict shall be at least three thousand pesos, 5)even though there may have been mitigating circumstances <<<.C This is a &uestion o! la# that the CA missed in its decision and #hich #e no# decide in the respondents( !a$or . The same article allows the recovery of moral damages in case of death caused by a &uasi'delict and enumerates the spouse, legitimate or illegitimate ascendants or descendants as the persons entitled thereto. Moral damages are designed to compensate the claimant for the in,ury suffered, that is, for the mental anguish, serious an<iety, wounded feelings which the respondents herein must have surely felt with the une<pected loss of their daughter. 2e affirm the appellate court=s award of P4::,:::.:: by way of mor%, #%m%:e& to the respondents. 2e similarly affirm the grant of e<emplary damages. +<emplary damages are imposed by way of e<ample or correction for the public good. 54 -ecause of the petitioner spouses= negligence in sub,ecting Teresita to an operation without first recogni8ing and addressing her diabetic condition, the appellate court awarded eCem6,%r5 #%m%:e& to the respondents in the amount of P!::,:::.::. Public policy re>uires such imposition to suppress the wanton acts of an offender.55 2e therefore affirm the C"=s award as an e<ample to the medical profession and to stress that the public good re>uires stricter measures to avoid the repetition of the type of medical malpractice that happened in this case. 2ith the award of e<emplary damages, the grant of attorney=s fees is legally in order.5( 2e therefore reverse the C" decision deleting these awards, and grant the respondents the amount of P!::,:::.:: as %11or(e58& 0ee& taAing into consideration the legal route this case has taAen.

"1 Kes, anyway, she asAed me whether we can do e<perience.

EC based on my

@2 )(# 5o-r %(&;er ;%& /( 1.e 6o&/1/ve (o1;/1.&1%(#/(: 1.e e,ev%1/o( o0 b,oo# &-:%rA )2 Be&, &/r, /1 ;%& bo1. o-r #/&6o&/1/o( 1o #o 1.e D4C. H+mphasis supplied.I5: 6f r. 4redelicto believed himself to be incompetent to treat the diabetes, not being an internist or a diabetologist #for which reason he referred Teresita to r. Gorge$,5! he should have liAewise refrained from maAing a decision to proceed with the EC operation since he was niether an obstetrician nor a gynecologist. These findings lead us to the conclusion that the decision to proceed with the EC operation, notwithstanding Teresita=s hyperglycemia and without ade>uately preparing her for the procedure, was contrary to the standards observed by the medical profession. eviation from this standard amounted to a breach of duty which resulted in the patient=s death. ue to this negligent conduct, liability must attach to the petitioner spouses. Liability of the os!ital

6n the proceedings below, 7 MC was the spouses 4lores= co0defendant. The RTC found the hospital ,ointly and severally liable with the petitioner spouses, which decision the C" affirmed. 6n a Resolution dated "ugust *@, *::(, this Court however denied 7 MC=s petition for review on certiorari. /ince 7 MC=s appeal has been denied and they are not parties to this case, we find it unnecessary to delve on the matter. Conse>uently, the RTC=s decision, as affirmed by the C", stands.

97ERE ORE, we ) IRM the ecision of the C" dated Gune *:, *::) in C" %.R. C& 'o. ()*)4 finding petitioner spouses liable for negligent medical practice. 2e liAewise ) IRM the awards of actual and compensatory damages of P)(,:::.::; moral damages of P4::,:::.::; and e<emplary damages of P!::,:::.::. 2e MODI B the C" ecision by additionally granting an award of P5:,:::.:: as death indemnity and by reversing the deletion of the award of attorney=s fees and costs and restoring the award ofP!::,:::.:: as attorney=s fees. Costs of litigation are ad,udged against petitioner spouses. To summari8e, the following awards shall be paid to the family of the late Teresita Pineda1 !. The sum of P)(,:::.:: by way of actual and compensatory damages; *. The sum of P5:,:::.:: by way of death indemnity; ). The sum of P4::,:::.:: by way of moral damages; 4. The sum of P!::,:::.:: by way of e<emplary damages; 5. The sum of P!::,:::.:: by way of attorney=s fees; and (. Costs. SO ORDERED.