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THIRD DIVISION

G.R. No. 86890 January 21, 1994


LEANDRO CARILLO, petitioner, vs. PEOPLE OF THE PHILIPPINES, respondent.
FELICIANO, J.:
Petitioner Dr. Leandro Carillo, an anesthetist, seeks review of the Decision of the Court of
Appeals dated 28 November 1988, which affirmed his conviction by the Regional Trial
Court of the crime of simple negligence resulting in homicide, for the death of his thirteen
(13) year old patient
Catherine Acosta. The trial court had sentenced him to suffer the penalty of arresto mayor
in its medium period (four [4] months' imprisonment), as well as to pay the heirs of his
patient an indemnity of P30,000.00 for her death, P10,000.00 as reimbursement for actual
expenses incurred, P50,000.00 as moral damages and to pay the costs of the suit. 1
The information filed against petitioner and his co-accused, the surgeon Dr. Emilio Madrid,
alleged the following:
That on or about the 31st of May 1981, in the municipality of Paraaque, Metro Manila,
Philippines and within the jurisdiction of this Honorable Court, the above-named accused,
conspiring and confederating together and mutually helping and aiding with one another,
without taking the necessary care and precaution to avoid injury to person, did then and
there willfully, unlawfully and feloniously operate, in a reckless, careless and imprudent
manner and neglected to exercise their respective medical knowhow and tasks and/or
departed from the recognized standard in their treatment, diagnosis of the condition, and
operation of the patient, one Catherine Acosta, 13 years old, which negligence caused the
death of the said Catherine Acosta. 2
Petitioner and Dr. Emilio Madrid entered pleas of not guilty at arraignment and the case
proceeded to trail with Judge Job B. Madayag presiding. 3
The prosecution presented as its principal evidence the testimony of four (4) witnesses,
namely: 1) Yolanda Acosta, Catherine's mother, who was able to observe the conduct of
the accused outside the operating theater before, during and after the appendectomy
procedure carried out on her daughter; 4 2) Domingo Acosta, Catherine's father, who
corroborated some parts of his wife's
testimony; 5 3) Dr. Horacio Buendia, an expert witness who described before the trial
court the relationship between a surgeon and an anesthetist in the course of a surgical
operation, as well as define the likelihood of cardiac arrest as a post operative
complication; 6 and 4) Dr. Nieto Salvador, an expert witness who analyzed and explained
the significance of the results of the pathological study and autopsy conducted on
Catherine's body by one Dr. Alberto Reyes. 7
After the prosecution had rested its case, the defense was granted leave to file a
demurrer to the evidence. 8 After failing to file the demurrer within the reglementary
period, Judge Manuel Yuzon, who had in the meantime taken over as presiding judge of
the sala where this case was pending, denied the defense motion for extension of time to
file demurrer and declared the case submitted for decision. 9
On 19 September 1985, the trial court promulgated its decision convicting both the
accused of the crime charged. 10

On appeal, the Court of Appeals affirmed the judgment of conviction, and specified that
the civil liability of the two (2) accused was solidary in nature. 11
Petitioner Dr. Carillo alone filed the present Petition for Review with the Court, seeking
reversal of his conviction, or in the alternative, the grant of a new trial. Dr. Madrid did not
try to appeal further the Court of Appeals Decision. Accordingly, the judgment of
conviction became final insofar as the accused surgeon Dr. Madrid is concerned.
The facts of the case as established by the Court of Appeals are as follows:
The deceased, Catherine Acosta, a 13 year old girl, daughter of spouses Domingo and
Yolanda Acosta, complained to her father at about 10:30 o'clock in the morning of May 31,
1981 of pains in the lower part of her abdomen. Catherine was then brought to Dr. Elva
Pea. Dra. Pea called for Dr. Emilio Madrid and the latter examined Catherine Acosta.
According to Dr. Madrid, his findings might be appendicitis. Then Dr. Pea told Catherine's
parents to bring the child to the hospital in Baclaran so that the child will be observed.
At the Baclaran General Hospital, a nurse took blood sample form the child. The findings
became known at around 3:00 o'clock in the afternoon and the child was scheduled for
operation at 5:00 o'clock in the afternoon. The operation took place at 5:45 p.m. because
Dr. Madrid arrived only at that time.
When brought inside the operating room, the child was feeling very well and they did not
subject the child to ECG (electrocardiogram) and
X-ray.
The appellant Dr. Emilio Madrid, a surgeon, operated on Catherine. He was assisted by
appellant, Dr. Leandro Carillo, an anesthesiologists.
During the operation, while Yolanda Acosta, Catherine's mother, was staying outside the
operating room, she "noticed something very unfamiliar." The three nurses who assisted
in the operation were going in and out of the operating room, they were not carrying
anything, but in going out of the operating room, they were already holding something.
Yolanda asked one of the nurses if she could enter the operating room but she was
refused.
At around 6:30 p.m., Dr. Emilio Madrid went outside the operating room and Yolanda
Acosta was allowed to enter the first door.
The appendicitis (sic) was shown to them by Dr. Madrid, because, according to Dr. Madrid,
they might be wondering because he was going to install drainage near the operating
(sic) portion of the child.
When asked, the doctor told them the child was already out of danger but the operation
was not yet finished.
It has also been established that the deceased was not weighed before the administration
of anesthesia on her.

The operation was finished at 7:00 o'clock in the evening and when the child was brought
out from the operating room, she was observed to be shivering (nanginginig); her heart
beat was not normal; she was asleep and did not wake up; she was pale; and as if she had
difficulty in breathing and Dr. Emilio Madrid suggested that she placed under oxygen tank;
that oxygen was administered to the child when she was already in the room.
Witness Yolanda Acosta further testified that shortly before the child was transferred from
the operating room to her room, she (witness) was requested by the anesthesiologist to
go home and get a blanket.
A portion of Yolanda Acosta's testimony on what happened when she returned to the
hospital are reproduced hereunder as follows:
Q
What happened afterward?
A
When I arrived in the hospital, my child was being transferred to her bed.
Q
What else happened?
Q
I noticed that the heartbeat of my daughter was not normal. And I noticed that her
hospital gown is rising up and down.
Q
What transpired after that?
A
I asked Dr. Madrid why it was like that, that the heartbeat of my daughter is not
normal.
Q
And did the doctor make any reply?
A
The doctor said because of the lesion of the child.
Q
What else happened?
A
After they have revived the heartbeat of the child, Dr. Carillo and Dr. Madrid left.
Q
Now do you remember what time was it when Dr. Carillo stepped out?
A
Only a minute after they have transferred the child to the bed.
Q
What happened later on after Dr. Carillo and Dr. Madrid stepped out of the
hospital?
A
After 15 or 30 minutes has lapsed at about 7:15 or 7:30, the child had developed
convulsion and stiffening of the body.
Q
When you observed convulsion and stiffening of the body, did you do anything?
A
We requested the nurse who was attending to her to call for a doctor.
Q
And the nurse who was attending to the patient called for a doctor?
A
They called for Dra. Pea, their family physician.
Q
What transpired afterwards?
A
What Dra. Pea did was call for Dr. Madrid and the cardiologist.
Q
Did this doctor arrived?
A
Yes.
Q
What transpired after the doctor arrived?
A
They examined the child.
Q
After they examined the child, did they inform you of the result of the
examination?
A
The cardiologist was the one whom informed us after he stepped out of the room
when we followed him. The doctor told us that she suffered severe infection which went
up to her head.
Q
After you were informed of the result of his examination, what transpired next?
A
According to them, they will do their best for the child and that they will call for
Dr. Carillo.
Q
Did Dr. Carillo arrived?
A
At around 10:30 in the evening.
Q
Did Dr. Carillo do anything when he arrived on 31 May 1981?

A
When he arrived, he noticed that there were two small bottles and big bottles of
dextrose which were hanging above the bed of the child. Then he said, "What is this?
Christmas tree or what?" He told us that one bottle of dextrose be removed. And the big
one will remain.
Q
What happened after that?
A
After that we talked to Dr. Carillo and asked him how did this happen to the child.
Q
What did Dr. Carillo reply (sic) to you?
A
He answered "that is nothing, the child will regain consciousness and if the child
will not regain consciousness, I will resign (sic) as a doctor." 12 (Emphasis supplied)
When Catherine remained unconscious until noontime the next day, a neurologist
examined her and she was diagnosed as comatose. 13 Three (3) days later, Catherine
died without regaining consciousness. 14
The Court of Appeals held that Catherine had suffered from an overdose of, or an adverse
reaction to, anesthesia, particularly the arbitrary administration of Nubain, a pain killer,
without benefit of prior weighing of the patient's body mass, which weight determines the
dosage of Nubain which can safely be given to a patient. 15 The Court of Appeals held
that this condition triggered off a heart attack as a post-operative complication, depriving
Catherine's brain of oxygen, leading to the brain's hemorrhage. 16 The Court of Appeals
identified such cardiac arrest as the immediate cause of Catherine's death. 17
The Court of Appeals found criminal negligence on the part of petitioner Dr. Carillo and his
co-accused Dr. Madrid, holding that both had failed to observe the required standard of
diligence in the examination of Catherine prior to the actual administration of anesthesia;
18 that it was "a bit rash" on the part of the accused Dr. Carillo "to have administered
Nubain without first weighing Catherine"; 19 and that it was an act of negligence on the
part of both doctors when, (a) they failed to monitor Catherine's heartbeat after the
operation and
(b) they left the hospital immediately after reviving Catherine's heartbeat, depriving the
latter of immediate and expert medical assistance when she suffered a heart attack
approximately fifteen (15) to thirty (30) minutes later. 20
Since neither petitioner nor his co-accused presented evidence in their own behalf, the
present Petition seeks to question the soundness of the factual conclusions drawn by the
Court of Appeals, upon which the affirmance of petitioner's conviction was based.
Close examination of the instant Petition for Review shows that petitioner's main
arguments are two-fold: (1) the Court of Appeals "completely brushed aside" and
"misapprehended" Catherine's death certificate and biopsy report which allegedly showed
that the cause of death was a ruptured appendix, which led to blood poisoning, 21 rather
than faulty anesthetic treatment;
and (2) there was no direct evidence of record showing that Nubain was administered to
Catherine either during the appendectomy procedure or after such operation. 22
Two (2) related issues are thus posed for the Court's consideration. The first is whether the
Court of Appeals so drastically "misapprehended" the relevant, operative facts in this case
as to compel this Court to examine and resolve question(s) of fact which would have a
decisive significance for the disposition of the case. The rule is too firmly settled to require
much documentation that only questions of law may be raised before this Court in a
petition for review on certiorari, subject to certain well-known exceptions. 23 After careful

scrutiny of petitioner's contentions before us and the record of this case, we do not
believe that petitioner has shown "misapprehension of facts" on the part of the Court of
Appeals which would require this Court to overturn the judgment reached by the former.
The second issue is whether or not the findings of fact of the Court of Appeals adequately
support the conclusion that petitioner Dr. Carillo was, along with Dr. Madrid, guilty of
simple negligence which resulted in homicide. Our review of the record leads us to an
affirmative answer.
Petitioner contends that the Court of Appeals seriously erred in finding that an overdose
of, or an allergic reaction to, the anesthetic drug Nubain had led to the death of Catherine
Acosta and that the true cause of Catherine's death was that set out in the death
certificate of Catherine: "Septicemia (or blood poisoning) due to perforated appendix with
peritonitis." 24 The concept of causation in general, and the cause of death in human
beings in particular, are complex and difficult notions. What is fairly clear is that death,
understood as a physical condition involving cessation of vital signs in the brain and
heart, is preceded by a series of physiological events, any one of which events can, with
equal cogency, be described as a "cause of death". The Court of Appeals found that an
overdose of, or an adverse reaction to, Nubain, an anesthetic or
pain-killing drug the appropriate dose of which depends on the body weight or mass of
the patient, had generated or triggered off cardiac arrest, which in
turn led to lack of oxygen in Catherine's brain, which then brought about hemorrhaging in
the brain. Vital activity in the brain thereupon ceased. The medical evidence presented at
the trial was quite consistent with the findings of the Court of Appeals which concluded
that cardiac arrest was the cause of Catherine's death. 25
For his part, petitioner insists that cardiac arrest is not the only cause of oxygen-starvation
of the brain, that septicemia with peritonitis or severe infection which had "gone up to the
head" of Catherine was an equally efficient cause of deprivation of the brain of oxygen
and hence of brain hemorrhage. The medical testimony of the expert witnesses for the
prosecution on which petitioner relies is also consistent with petitioner's theory that
septicemia with peritonitis was, or at least could have been, the cause of Catherine's
death. 26
Indeed, it appears to the Court that there was no medical proof submitted to the trial
court to show that one or the other "cause" was necessarily an exclusive cause of death in
the case of Catherine Acosta; that an overdose or allergic reaction to Nubain could not
have combined with septicemia and peritonitis in bringing about Catherine's death.
What is of critical importance for present purposes is not so much the identification of the
"true cause" or "real cause" of Catherine's death but rather the set of circumstances
which both the trial court and the Court of Appeals found constituted simple (as
distinguished from reckless) negligence on the part of the two accused Dr. Madrid and Dr.
Carillo leading to the death of Catherine.
When the patient was wheeled out of the operating room after completion of surgery, she
manifested signs of medical instability (i.e., shivering, paleness, irregular breathing and
weak heart beat). 27 She was not brought to a properly equipped recovery room, or
intensive care until which the hospital lacked. 28 Such facilities and their professional
staffs, of which an anesthetist is commonly a part, are essential for providing close
observation and patient care while a post-surgery patient is recovering from the effects of

anesthesia and while the normal protective mechanisms are still dull or obtunded. 29
Instead, the patient was merely brought to her assigned hospital bed and was provided
oxygen on the instructions of Dr. Madrid then "revived" her heartbeat. 30 Both doctors
then left their patient and the hospital; approximately fifteen minutes later, she suffered
convulsions and cardiac arrest. 31
The conduct of Dr. Madrid and of the petitioner constituted inadequate care of their
patient in view of her vulnerable condition. Both doctors failed to appreciate the serious
condition of their patient whose adverse physical signs were quite manifest right after
surgery. And after reviving her heartbeat, both doctors failed to monitor their patient
closely or extend further medical care to her; such conduct was especially necessary in
view of the inadequate,
post-operative facilities of the hospital. We do not, of course, seek to hold petitioner
responsible for the inadequate facilities of the Baclaran General Hospital. We consider,
however, that the inadequate nature of those facilities did impose a somewhat higher
standard of professional diligence upon the accused surgeon and anesthetist personally
than would have been called for in a modern fully-equipped hospital.
While Dr. Madrid and a cardiologist were containing the patient's convulsions, and after
the latter had diagnosed that infection had reached the patient's head, these two (2)
apparently after consultation, decided to call-in the petitioner. 32 There is here a strong
implication that the patient's post-operative condition must have been considered by the
two (2) doctors as in some way related to the anesthetic treatment she had received from
the petitioner either during or after the surgical procedure.
Once summoned, petitioner anesthesiologist could not be readily found. When he finally
appeared at 10:30 in the evening, he was evidently in a bad temper, commenting
critically on the dextrose bottles before ordering their removal. 33 This circumstance
indicated he was not disposed to attend to this unexpected call, in violation of the canons
of his profession that as a physician, he should serve the interest of his patient "with the
greatest of solicitude, giving them always his best talent and skill." 34 Indeed, when
petitioner finally saw his patient, he offered the unprofessional bluster to the parents of
Catherine that he would resign if the patient will not regain consciousness. 35 The canons
of medical ethics require a physician to "attend to his patients faithfully and
conscientiously." He should secure for them all possible benefits that may depend upon
his professional skill and care. As the sole tribunal to adjudge the physician's failure to
fulfill his obligation to his patient is, in most cases, his own conscience, violation of this
rule on his part is "discreditable and inexcusable". 36
Nubain was an experimental drug for anesthesia and post-operative pain and the medical
literature required that a patient be weighed first before it is administered and warned
that there was no (or inadequate) experience relating to the administration thereof to a
patient less that eighteen (18) ears of age. 37 Yet, the doctor's order sheet (Exhibit "C")
did not contain this precaution but instead directed a reader to apply the drug only when
warranted by the circumstances. 38 During the offer of Exhibit "C" by the prosecution, Dr.
Madrid admitted that this prescription, which was unsigned, was made in his own
handwriting. 39 It must be observed that the instruction was open-ended in that some
other individual still had to determine if circumstances existed warranting administration
of the drug to the patient. The document thus indicated the abdication of medical
responsibility on an extremely critical matter. Since petitioner anesthesiologist entered
subsequent prescriptions or orders in the same order sheet, which were signed by him, at

7:15 p.m. on the same evening of 31 May 1981, he was in a position to appreciate the
dangers inherent in the prior prescription, which was within his (petitioner's) area of
specialization, and to order measures to correct this anomaly and protect his patient's
well-being. So far as the condition of the evidence shows, he failed to do so. In sum, only
a low level of diligence was exhibited by petitioner and Dr. Madrid in the prescription of
medication for their patient.
As noted earlier, petitioner relied heavily in this proceeding on the testimony on crossexamination of the expert witnesses for the prosecution to show that blood poisoning
resulting from a ruptured appendix could also be responsible for the patient's death.
No suggestion has been made that the rupture of the patient's occurred prior to surgery.
After her blood sample was examined, the patient was merely diagnosed as a case of
appendicitis, without further elaboration. 40 No intensive preoperative preparations, like
the immediate administration of antibiotics, was thereafter undertaken on the patient.
This is a standard procedure for patients who are, after being diagnosed, suspected of
suffering from a perforated appendix and consequent peritonitis. 41 The mother also
testified that petitioner anesthesiologist merely injected a drug, "pre-anesthesia" intended
to put the patient to sleep, into the container of fluids being administered to her daughter
intravenously at her room, prior to surgery. 42 We note further that the surgeon Dr. Madrid
was forty-five minutes late in arriving at the operating theater. 43 Considering that delay
in treatment of appendicitis increases the morbidity of the patient, 44 Dr. Madrid's
conduct can only be explained by a pre-operative diagnosis on his part that the condition
of appendicitis was not yet attended by complications (i.e., a ruptured appendix and
peritonitis).
The above circumstances do strongly indicate that the rupture of the patient's appendix
occurred during the appendectomy procedure, that is, at a time and place the
operating room where the two (2) accused were in full control of the situation and could
determine decisively what needed to be done in respect of the patient. 45 This
circumstance must be considered in conjunction with other related circumstances which
the prosecution had proven: that the patient was ambulatory when brought to the
operating room; 46 that she left the operating room two (2) hours later in obviously
serious condition; and that an appendectomy accompanied or followed by sustained
antibiotic treatment is a fairly common and generally accepted medical procedure for
dealing with ruptured appendix and peritonitis, 47 a fact of which judicial note may be
taken.
As early as in People v. Vistan, 48 the Court defined simple negligence, penalized under
what is now Article 365 of the Revised Penal Code, as "a mere lack of prevision in a
situation where either the threatened harm is
not immediate or the danger not openly visible." Put in a slightly different way, the
gravamen of the offense of simple negligence is the failure to exercise the diligence
necessitated or called for the situation which was not immediately
life-destructive but which culminated, in the present case, in the death of a human being
three (3) days later. Such failure to exercise the necessary degree of care and diligence is
a negative ingredient of the offense charged. The rule in such cases is that while the
prosecution must prove the negative ingredient of the offense, it needs only to present
the best evidence procurable under the circumstances, in order to shift the burden of
disproving or countering the proof of the negative ingredient to the accused, provided
that such initial evidence establishes at least on a prima facie basis the guilt of the

accused. 49 This rule is particularly applicable where the negative ingredient of the
offense is of such a nature or character as, under the circumstances, to be specially within
the knowledge or control of the accused. 50 In the instant case, the Court is bound to
observe that the events which occurred during the surgical procedure (including whether
or not Nubain had in fact been administered as an anesthesia immediately before or
during the surgery) were peculiarly within the knowledge and control of Dr. Carillo and Dr.
Madrid. It was, therefore, incumbent upon the two (2) accused to overturn the prima facie
case which the prosecution had established, by reciting the measures which they had
actually taken to prevent or to counter the obviously serious condition of Catherine Acosta
which was evident right after surgery. This they failed or refused to do so.
Still another circumstance of which account must be taken is that both petitioner and Dr.
Madrid failed to inform the parents of their minor patient of the nature of her illness, or to
explain to them either during the surgery
(if feasible) or at any time after the surgery, the events which comprised the dramatic
deterioration of her condition immediately after surgery as compared with her pre-surgery
condition. To give a truthful explanation to the parents was a duty imposed upon them by
the canons of their profession. 51 Petitioner should have explained to Catherine's parents
the actual circumstances surrounding Catherine's death, how, in other words, a simple
appendectomy procedure upon an ambulatory patient could have led to such fatal
consequences.
By way of resume, in the case at bar, we consider that the chain of circumstances above
noted, namely: (1) the failure of petitioner and Dr. Madrid to appreciate the serious postsurgery condition of their patient and to monitor her condition and provide close patient
care to her; (2) the summons of petitioner by Dr. Madrid and the cardiologist after the
patient's heart attack on the very evening that the surgery was completed; (3) the low
level of care and diligence exhibited by petitioner in failing to correct Dr. Madrid's
prescription of Nubain for post-operative pain; (4) the extraordinary failure or refusal of
petitioner and Dr. Madrid to inform the parents of Catherine Acosta of her true condition
after surgery, in disregard of the requirements of the Code of Medical Ethics; and (5) the
failure of petitioner and Dr. Madrid to prove that they had in fact exercised the necessary
and appropriate degree of care and diligence to prevent the sudden decline in the
condition of Catherine Acosta and her death three (3) days later, leads the Court to the
conclusion, with moral certainty, that petitioner and Dr. Madrid were guilty of simple
negligence resulting in homicide.
In addition to the main arguments raised by petitioner earlier, he also raised an ancillary,
constitutional claim of denial of due process. He contends that he was deprived of his
right to have competent representation at trial, and to have his cause adequately heard,
because his counsel of record, Atty. Jose B. Puerto, was "incompetent" and exhibited
"gross negligence" by manifesting an intent to file a demurrer to the evidence, in failing to
present evidence in his behalf and in omitting to file a defense memorandum for the
benefit of
Judge Yuzon, after the latter took over the case at the end of trial and before the Judge
rendered his decision. 52 Petitioner submits he is entitled to a new trial. 53
These contentions do not persuade. An examination of the record indicates that Atty.
Puerto represented petitioner during trial with reasonable competence. Except for the two
hearing sessions when witnesses Domingo Acosta was cross-examined and recrossexamined by Atty. Puerto, petitioner was present during all the sessions when the other

prosecution witnesses were presented and during which Atty. Puerto extensively crossexamined them in behalf of petitioner and Dr. Madrid. This counsel elicited from the two
(2) expert witnesses for the prosecution testimony favorable to petitioner and which was
relied upon by the latter in this proceeding. 54 The record further indicates that if
petitioner indeed entertained substantial doubts about the capability of Atty. Puerto, he
could have easily terminated the services of that counsel and retained a new one, or
sought from the trial court the appointment of counsel
de oficio, during the ample opportunity given from the time Atty. Puerto manifested his
intent to file a demurrer on 16 October 1985, to the submission of the case for decision on
25 June 1986 and before the promulgation of judgment on 19 September 1986. 55 During
all this time, petitioner could have obtained leave of court to present evidence in his
behalf in lieu of a demurrer, or to submit a memorandum for the defense. After
promulgation of the judgment of conviction, petitioner did not seek a new trial, but
permitted Atty. Puerto to obtain leave from the trial court to continue on bail during the
pendency of the proceedings before the Court of Appeals. 56 Indeed, petitioner replaced
Atty. Puerto as counsel only upon institution of the present petition. 57
Petitioner's constitutional objection is plainly an afterthought.
WHEREFORE, the Decision of the Court of Appeals dated 28 November 1988 is hereby
AFFIRMED, subject only to the modification that the indemnity for the death of Catherine
Acosta is hereby increased to P50,000.00, in line with current jurisprudence. 58
SO ORDERED.

THIRD DIVISION
G.R. No. 118231
July 5, 1996
DR. VICTORIA L. BATIQUIN and ALLAN BATIQUIN, petitioners, vs. COURT OF APPEALS,
SPOUSES QUEDO D. ACOGIDO and FLOTILDE G. VILLEGAS, respondents.
DAVIDE, JR., J.:p
Throughout history, patients have consigned their fates and lives to the skill of their
doctors. For a breach of this trust, men have been quick to demand retribution. Some
4,000 years ago, the Code of Hammurabi 1 then already provided: "If a physician make a
deep incision upon a man with his bronze lancet and cause the man's death, or operate
on the eye socket of a man with his bronze lancet and destroy the man's eyes, they shall
cut off his hand." 2 Subsequently, Hippocrates 3 wrote what was to become part of the
healer's oath: "I will follow that method of treatment which according to my ability and
judgment, I consider for the benefit of my patients, and abstain from whatever is
deleterious and mischievous. . . . While I continue to keep this oath unviolated may it be
granted me to enjoy life and practice the art, respected by all men at all times but should
I trespass and violate this oath, may the reverse be my lot." At present, the primary
objective of the medical profession if the preservation of life and maintenance of the
health of the people. 4
Needless to say then, when a physician strays from his sacred duty and endangers
instead the life of his patient, he must be made to answer therefor. Although society today
cannot and will not tolerate the punishment meted out by the ancients, neither will it and
this Court, as this case would show, let the act go uncondemned.
The petitioners appeal from the decision 5 of the Court of Appeals of 11 May 1994 in CAG.R. CV No. 30851, which reversed the decision 6 of 21 December 1990 of Branch 30 of
the Regional Trial Court (RTC) of Negros Oriental in Civil Case No. 9492.
The facts, as found by the trial court, are as follows:
Dr. Batiquin was a Resident Physician at the Negros Oriental Provincial Hospital,
Dumaguete City from January 9, 1978 to September 1989. Between 1987 and September,
1989 she was also the Actg. Head of the Department of Obstetrics and Gynecology at the
said Hospital.
Mrs. Villegas is a married woman who submitted to Dr. Batiquin for prenatal care as the
latter's private patient sometime before September 21, 1988.
In the morning of September 21, 1988 Dr. Batiquin, with the assistance of Dr. Doris
Teresita Sy who was also a Resident Physician at the same Hospital, C.I. and O.R. Nurse
Arlene Diones and some student nurses performed a simple caesarean section on Mrs.
Villegas at the Negros Oriental Provincial Hospital and after 45 minutes Mrs. Villegas
delivered her first child, Rachel Acogido, at about 11:45 that morning. Thereafter, Plaintiff
remained confined at the Hospital until September 27, 1988 during which period of
confinement she was regularly visited by Dr. Batiquin. On September 28, 1988 Mrs.
Villegas checked out of the Hospital. . . and on that same day she paid Dr. Batiquin, thru
the latter's secretary, the amount of P1,500.00 as "professional fee". . . .

Soon after leaving the Hospital Mrs. Villegas began to suffer abdominal pains and
complained of being feverish. She also gradually lost her appetite, so she consulted Dr.
Batiquin at the latter's polyclinic who prescribed for her certain medicines. . . which she
had been taking up to December, 1988.
In the meantime, Mrs. Villegas was given a Medical Certificate by Dr. Batiquin on October
31, 1988. . . certifying to her physical fitness to return to her work on November 7, 1988.
So, on the second week of November, 1988 Mrs. Villegas returned to her work at the Rural
Bank of Ayungon, Negros Oriental.
The abdominal pains and fever kept on recurring and bothered Mrs. Villegas no end
despite the medications administered by Dr. Batiquin. When the pains became unbearable
and she was rapidly losing weight she consulted Dr. Ma. Salud Kho at the Holy Child's
Hospital in Dumaguete City on January 20, 1989.
The evidence of Plaintiffs show that when Dr. Ma. Salud Kho examined Mrs. Villegas at the
Holy Child's Hospital on January 20, 1989 she found Mrs. Villegas to be feverish, pale and
was breathing fast. Upon examination she felt an abdominal mass one finger below the
umbilicus which she suspected to be either a tumor of the uterus or an ovarian cyst,
either of which could be cancerous. She had an x-ray taken of Mrs. Villegas' chest,
abdomen and kidney. She also took blood tests of Plaintiff. A blood count showed that Mrs.
Villegas had [an] infection inside her abdominal cavity. The results of all those
examinations impelled Dr. Kho to suggest that Mrs. Villegas submit to another surgery to
which the latter agreed.
When Dr. Kho opened the abdomen of Mrs. Villegas she found whitish-yellow discharge
inside, an ovarian cyst on each of the left and right ovaries which gave out pus, dirt and
pus behind the uterus, and a piece of rubber material on the right side of the uterus
embedded on [sic] the ovarian cyst, 2 inches by 3/4 inch in size. This piece of rubber
material which Dr. Kho described as a "foreign body" looked like a piece of a "rubber
glove". . . and which is [sic] also "rubber-drain like". . . . It could have been a torn section
of a surgeon's gloves or could have come from other sources. And this foreign body was
the cause of the infection of the ovaries and consequently of all the discomfort suffered
by Mrs. Villegas after her delivery on September 21, 1988. 7
The piece of rubber allegedly found near private respondent Flotilde Villegas's uterus was
not presented in court, and although Dr. Ma. Salud Kho Testified that she sent it to a
pathologist in Cebu City for examination, 8 it was not mentioned in the pathologist's
Surgical Pathology Report. 9
Aside from Dr. Kho's testimony, the evidence which mentioned the piece of rubber are a
Medical Certificate, 10 a Progress Record, 11 an Anesthesia Record, 12 a Nurse's Record,
13 and a Physician's Discharge Summary. 14 The trial court, however, regarded these
documentary evidence as mere hearsay, "there being no showing that the person or
persons who prepared them are deceased or unable to testify on the facts therein
stated. . . . Except for the Medical Certificate (Exhibit "F"), all the above documents were
allegedly prepared by persons other than Dr. Kho, and she merely affixed her signature on
some of them to express her agreement thereto. . . ." 15 The trial court also refused to
give weight to Dr. Kho's testimony regarding the subject piece of rubber as Dr. Kho "may
not have had first-hand knowledge" thereof, 16 as could be gleaned from her statement,
thus:

A
. . . I have heard somebody that [sic] says [sic] there is [sic] a foreign body that
goes with the tissues but unluckily I don't know where the rubber was. 17
The trial court deemed vital Dr. Victoria Batiquin's testimony that when she confronted Dr.
Kho regarding the piece of rubber, "Dr. Kho answered that there was rubber indeed but
that she threw it away." 18 This statement, the trial court noted, was never denied nor
disputed by Dr. Kho, leading it to conclude:
There are now two different versions on the whereabouts of that offending "rubber" (1)
that it was sent to the Pathologist in Cebu as testified to in Court by Dr. Kho and (2) that
Dr. Kho threw it away as told by her to Defendant. The failure of the Plaintiffs to reconcile
these two different versions serve only to weaken their claim against Defendant Batiquin.
19
All told, the trial court held in favor of the petitioners herein.
The Court of Appeals reviewed the entirety of Dr. Kho's testimony and, even without
admitting the private respondents' documentary evidence, deemed Dr. Kho's positive
testimony to definitely establish that a piece of rubber was found near private respondent
Villegas's uterus. Thus, the Court of Appeals reversed the decision of the trial court,
holding:
4.
The fault or negligence of appellee Dr. Batiquin is established by preponderance
of evidence. The trial court itself had narrated what happened to appellant Flotilde after
the caesarean operation made by appellee doctor. . . . After the second operation,
appellant Flotilde became well and healthy. Appellant Flotilde's troubles were caused by
the infection due to the "rubber" that was left inside her abdomen. Both appellant;
testified that after the operation made by appellee doctor, they did not go to any other
doctor until they finally decided to see another doctor in January, 1989 when she was not
getting any better under the care of appellee Dr. Batiquin. . . . Appellee Dr. Batiquin
admitted on the witness stand that she alone decided when to close the operating area;
that she examined the portion she operated on before closing the same. . . Had she
exercised due diligence, appellee Dr. Batiquin would have found the rubber and removed
it before closing the operating area. 20
The appellate court then ruled:
Appellants' evidence show[s] that they paid a total of P17,000.00 [deposit of P7,100.00
(Exh. G-1-A) plus hospital and medical expenses together with doctor's fees in the total
amount P9,900.00 (Exhs. G and G-2)] for the second operation that saved her life.
For the miseries appellants endured for more than three (3) months, due to the
negligence of appellee Dr. Batiquin they are entitled to moral damages in the amount of
P100,000.00; exemplary damages in the amount of P20,000.00 and attorney's fees in the
amount of P25,000.00.
The fact that appellant Flotilde can no longer bear children because her uterus and
ovaries were removed by Dr. Kho is not taken into consideration as it is not shown that the
removal of said organs were the direct result of the rubber left by appellee Dr. Batiquin
near the uterus. What is established is that the rubber left by appellee caused infection,

placed the life of appellant Flotilde in jeopardy and caused appellant fear, worry and
anxiety. . . .
WHEREFORE, the appealed judgment, dismissing the complaint for damages is REVERSED
and SET ASIDE. Another judgment is hereby entered ordering defendants-appellees to pay
plaintiffs-appellants the amounts of P17,000.00 as and for actual damages; P100,000.00
as and for moral damages; P20,000.00 as and for exemplary damages; and P25,000.00 as
and for attorney's fees plus the costs of litigation.
SO ORDERED. 21
From the above judgment, the petitioners appealed to this Court claiming that the
appellate court: (1) committed grave abuse of discretion by resorting to findings of fact
not supported by the evidence on record, and (2) exceeded its discretion, amounting to
lack or excess of jurisdiction, when it gave credence to testimonies punctured with
contradictions and falsities.
The private respondents commented that the petition raised only questions of fact, which
were not proper for review by this Court.
While the rule is that only questions of law may be raised in a petition for review on
certiorari, there are exceptions, among which are when the factual findings of the trial
court and the appellate court conflict, when the appealed decision is clearly contradicted
by the evidence on record, or when the appellate court misapprehended the facts. 22
After deciphering the cryptic petition, we find that the focal point of the instant appeal is
the appreciation of Dr. Kho's testimony. The petitioners contend that the Court of Appeals
misappreciated the following portion of Dr. Kho's testimony:
Q

What is the purpose of the examination?

A
Just in case, I was just thinking at the back of my mind, just in case this would turn
out to be a medico-legal case, I have heard somebody that [sic] says [sic] there is [sic] a
foreign body that goes with the tissues but unluckily I don't know where the rubber was. It
was not in the Lab, it was not in Cebu. 23 (emphasis supplied)
The petitioners prefer the trial court's interpretation of the above testimony, i.e., that Dr.
Kho's knowledge of the piece of rubber was based on hearsay. The Court of Appeals, on
the other hand, concluded that the underscored phrase was taken out of context by the
trial court. According to the Court of Appeals, the trial court should have likewise
considered the other portions of Dr. Kho's testimony, especially the following:
Q

So you did actually conduct the operation on her?

Yes, I did.

And what was the result?

A
Opening up her abdomen, there was whitish-yellow discharge inside the abdomen,
there was an ovarian cyst on the left and side and there was also an ovarian cyst on the
right which, on opening up or freeing it up from the uterus, turned out to be pus. Both

ovaries turned out. . . to have pus. And then, cleaning up the uterus, at the back of the
uterus it was very dirty, it was full of pus. And there was a [piece of] rubber, we found a
[piece of] rubber on the right
side. 24
We agree with the Court of Appeals. The phrase relied upon by the trial court does not
negate the fact that Dr. Kho saw a piece of rubber in private respondent Villegas's
abdomen, and that she sent it to a laboratory and then to Cebu City for examination by a
pathologist. 25 Not even the Pathologist's Report, although devoid of any mention of a
piece of rubber, could alter what Dr. Kho saw. Furthermore, Dr. Kho's knowledge of the
piece of rubber could not be based on other than first-hand knowledge for, as she
asserted before the trial court:
Q

But you are sure you have seen [the piece of rubber]?

Oh yes. I was not the only one who saw it. 26

The petitioners emphasize that the private respondents never reconciled Dr. Kho's
testimony with Dr. Batiquin's claim on the witness stand that when Dr. Batiquin confronted
Dr. Kho about the foreign body, the latter said that there was a piece of rubber but that
she threw it away. Although hearsay, Dr. Batiquin's claim was not objected to, and hence,
the same is admissible 27 but it carries no probative value. 28 Nevertheless, assuming
otherwise, Dr. Batiquin's statement cannot belie the fact that Dr. Kho found a piece of
rubber near private respondent Villegas's uterus. And even if we were to doubt Dr. Kho as
to what she did to the piece of rubber, i.e., whether she threw it away or sent it to Cebu
City, we are not justified in distrusting her as to her recovery of a piece of rubber from
private respondent Villegas's abdomen. On this score, it is perfectly reasonable to believe
the testimony of a witness with respect to some facts and disbelieve his testimony with
respect to other facts. And it has been aptly said that even when a witness is found to
have deliberately falsified in some material particulars, it is not required that the whole of
his uncorroborated testimony be rejected, but such portions thereof deemed worthy of
belief may be credited. 29
It is here worth noting that the trial court paid heed to the following portions of Dr.
Batiquin's testimony: that no rubber drain was used in the operation, 30 and that there
was neither any tear on Dr. Batiquin's gloves after the operation nor blood smears on her
hands upon removing her gloves. 31 Moreover, the trial court pointed out that the
absence of a rubber drain was corroborated by Dr. Doris Sy, Dr. Batiquin's assistant during
the operation on private respondent Villegas. 32 But the trial court failed to recognize that
the assertions of Drs. Batiquin and Sy were denials or negative testimonies. Well-settled is
the rule that positive testimony is stronger than negative testimony. 33 Of course, as the
petitioners advocate, such positive testimony must come from a credible source, which
leads us to the second assigned error.
While the petitioners claim that contradictions and falsities punctured Dr. Kho's testimony,
a regarding of the said testimony reveals no such infirmity and establishes Dr. Kho as a
credible witness. Dr. Kho was frank throughout her turn on the witness stand.
Furthermore, no motive to state any untruth was ever imputed against Dr. Kho, leaving
her trustworthiness unimpaired. 34 The trial court's following declaration shows that while
it was critical of the lack of care with which Dr. Kho handled the piece of rubber, it was not

prepared to doubt Dr. Kho's credibility, thus only supporting our appraisal of Dr. Kho's
trustworthiness:
This is not to say that she was less than honest when she testified about her findings, but
it can also be said that she did not take the most appropriate precaution to preserve that
"piece of rubber" as an eloquent evidence of what she would reveal should there be a
"legal problem" which she claim[s] to have anticipated. 35
Considering that we have assessed Dr. Kho to be a credible witness, her positive
testimony [that a piece of rubber was indeed found in private respondent Villega's
abdomen] prevails over the negative testimony in favor of the petitioners.
As such, the rule of res ipsa loquitur comes to fore. This Court has had occasion to delve
into the nature and operation of this doctrine:
This doctrine [res ipsa loquitur] is stated thus: "Where the thing which causes injury is
shown to be under the management of the defendant, and the accident is such as in the
ordinary course of things does not happen in those who have the management use proper
care, it affords reasonable evidence, in the absence of an explanation by the defendant,
that the accident arose from want of care." Or as Black's Law Dictionary puts it:
Res ipsa loquitur. The thing speaks for itself. Rebuctable presumption or inference that
defendant was negligent, which arises upon proof that [the] instrumentality causing injury
was in defendant's exclusive control, and that the accident was one which ordinary does
not happen in absence of negligence. Res ipsa loquitur is [a] rule of evidence whereby
negligence of [the] alleged wrongdoer may be inferred from [the] mere fact that [the]
accident happened provided [the] character of [the] accident and circumstances
attending it lead reasonably to belief that in [the] absence of negligence it would not have
occurred and that thing which caused injury is shown to have been under [the]
management and control of [the] alleged wrongdoer. . . . Under [this] doctrine
. . . the happening of an injury permits an inference of negligence where plaintiff produces
substantial evidence that [the] injury was caused by an agency or instrumentality under
[the] exclusive control and management of defendant, and that the occurrence [sic] was
such that in the ordinary course of things would not happen if reasonable care had been
used.
xxx

xxx

xxx

The doctrine of [r]es ipsa loquitur as a rule of evidence is peculiar to the law of negligence
which recognizes that prima facie negligence may be established without direct proof and
furnishes a substitute for specific proof of negligence. The doctrine is not a rule of
substantive law, but merely a mode of proof or a mere procedural convenience. The rule,
when applicable to the facts and circumstances of a particular case, is not intended to and
does not dispense with the requirement of proof of culpable negligence on the party
charged. It merely determines and regulates what shall be prima facie evidence thereof
and facilitates the burden of plaintiff of proving a breach of the duty of due care. The
doctrine can be invoked when and only when, under the circumstances involved, direct
evidence is absent and not readily available. 36
In the instant case, all the requisites for recourse to the doctrine are present. First, the
entire proceedings of the caesarean section were under the exclusive control of Dr.

Batiquin. In this light, the private respondents were bereft of direct evidence as to the
actual culprit or the exact cause of the foreign object finding its way into private
respondent Villegas's body, which, needless to say, does not occur unless through the
intersection of negligence. Second, since aside from the caesarean section, private
respondent Villegas underwent no other operation which could have caused the offending
piece of rubber to appear in her uterus, it stands to reason that such could only have been
a by-product of the caesarean section performed by Dr. Batiquin. The petitioners, in this
regard, failed to overcome the presumption of negligence arising from resort to the
doctrine of res ipsa loquitur. Dr. Batiquin is therefore liable for negligently leaving behind a
piece of rubber in private respondent Villegas's abdomen and for all the adverse effects
thereof.
As a final word, this Court reiterates its recognition of the vital role the medical profession
plays in the lives of the people, 37 and the State's compelling interest to enact measures
to protect the public from "the potentially deadly effects of incompetence and ignorance
in those who would undertake to treat our bodies and minds for disease or trauma." 38
Indeed, a physician is bound to serve the interest of his patients "with the greatest of
solicitude, giving them always his best talent and skill." 39 Through her tortious conduct,
the petitioner endangered the life of Flotilde Villegas, in violation of her profession's rigid
ethical code and in contravention of the legal standards set forth for professionals, in
general, 40 and members of the medical profession, 41 in particular.
WHEREFORE, the challenged decision of 11 May 1994 of the Court of Appeals in CA-G.R.
CV No. 30851 is hereby AFFIRMED in toto.
Costs against the petitioners.
SO ORDERED.

SECOND DIVISION
G.R. No. 118141
September 5, 1997
LEONILA GARCIA-RUEDA, petitioner, vs.
WILFRED L. PASCASIO, RAUL R. ARNAU, ABELARDO L. APORTADERA JR., Honorable
CONRADO M. VASQUEZ, all of the Office of the Ombudsman; JESUS F. GUERRERO,
PORFIRIO MACARAEG, and GREGORIO A. ARIZALA, all of the Office of the City Prosecutor,
Manila, respondents.
ROMERO, J.:
May this Court review the findings of the Office of the Ombudsman? The general rule has been
enunciated in Ocampo v. Ombudsman 1 which states:
In the exercise of its investigative power, this Court has consistently held that courts will not interfere
with the discretion of the fiscal or the Ombudsman to determine the specificity and adequacy of the
averments of the offense charged. He may dismiss the complaint forthwith if he finds it to be
insufficient in form and substance or if he otherwise finds no ground to continue with the inquiry; or
he may proceed with the investigation of the complaint if, in his view, it is in due and proper form.
Does the instant case warrant a departure from the foregoing general rule? When a patient dies soon
after surgery under circumstances which indicate that the attending surgeon and anaesthesiologist
may have been guilty of negligence but upon their being charged, a series of nine prosecutors toss
the responsibility of conducting a preliminary investigation to each other with contradictory
recommendations, "ping-pong" style, perhaps the distraught widow is not to be blamed if she finally
decides to accuse the City Prosecutors at the end of the line for partiality under the Anti-Graft and
Corrupt Practices Act. Nor may she be entirely faulted for finally filing a petition before this Court
against the Ombudsman for grave abuse of discretion in dismissing her complaint against said City
Prosecutors on the ground of lack of evidence. Much as we sympathize with the bereaved widow,
however, this Court is of the opinion that the general rule still finds application in instant case. In
other words, the respondent Ombudsman did not commit grave abuse of discretion in deciding
against filing the necessary information against public respondents of the Office of the City
Prosecutor.

The following facts are borne out by the records.


Florencio V. Rueda, husband of petitioner Leonila Garcia-Rueda, underwent surgical
operation at the UST hospital for the removal of a stone blocking his ureter. He was
attended by Dr. Domingo Antonio, Jr. who was the surgeon, while Dr. Erlinda BalatbatReyes was the anaesthesiologist. Six hours after the surgery, however, Florencio died of
complications of "unknown cause," according to officials of the UST Hospital. 2
Not satisfied with the findings of the hospital, petitioner requested the National Bureau of
Investigation (NBI) to conduct an autopsy on her husband's body. Consequently, the NBI
ruled that Florencio's death was due to lack of care by the attending physician in
administering anaesthesia. Pursuant to its findings, the NBI recommended that Dr.
Domingo Antonio and Dr. Erlinda Balatbat-Reyes be charged for Homicide through
Reckless Imprudence before the Office of the City Prosecutor.
During the preliminary investigation, what transpired was a confounding series of events
which we shall try to disentangle. The case was initially assigned to Prosecutor Antonio M.
Israel, who had to inhibit himself because he was related to the counsel of one of the
doctors. As a result, the case was re-raffled to Prosecutor Norberto G. Leono who was,
however, disqualified on motion of the petitioner since he disregarded prevailing laws and
jurisprudence regarding preliminary investigation. The case was then referred to

Prosecutor Ramon O. Carisma, who issued a resolution recommending that only Dr. Reyes
be held criminally liable and that the complaint against Dr. Antonio be dismissed.
The case took another perplexing turn when Assistant City Prosecutor Josefina Santos
Sioson, in the "interest of justice and peace of mind of the parties," recommended that
the case be re-raffled on the ground that Prosecutor Carisma was partial to the petitioner.
Thus, the case was transferred to Prosecutor Leoncia R. Dimagiba, where a volte face
occurred again with the endorsement that the complaint against Dr. Reyes be dismissed
and instead, a corresponding information be filed against Dr. Antonio. Petitioner filed a
motion for reconsideration, questioning the findings of Prosecutor Dimagiba.
Pending the resolution of petitioner's motion for reconsideration regarding Prosecutor
Dimagiba's resolution, the investigative "pingpong" continued when the case was again
assigned to another prosecutor, Eudoxia T. Gualberto, who recommended that Dr. Reyes
be included in the criminal information of Homicide through Reckless Imprudence. While
the recommendation of Prosecutor Gualberto was pending, the case was transferred to
Senior State Prosecutor Gregorio A. Arizala, who resolved to exonerate Dr. Reyes from any
wrongdoing, a resolution which was approved by both City Prosecutor Porfirio G. Macaraeg
and City Prosecutor Jesus F. Guerrero.
Aggrieved, petitioner filed graft charges specifically for violation of Section 3(e) of
Republic Act No. 3019 3 against Prosecutors Guerrero, Macaraeg, and Arizala for manifest
partiality in favor of Dr. Reyes before the Office of the Ombudsman. However, on July 11,
1994, the Ombudsman issued the assailed resolution dismissing the complaint for lack of
evidence.
In fine, petitioner assails the exercise of the discretionary power of the Ombudsman to
review the recommendations of the government prosecutors and to approve and
disapprove the same. Petitioner faults the Ombudsman for, allegedly in grave abuse of
discretion, refusing to find that there exists probable cause to hold public respondent City
Prosecutors liable for violation of Section 3(e) of R.A. No. 3019.
Preliminarily, the powers and functions of the Ombudsman have generally been
categorized into the following: investigatory powers, prosecutory power, public assistance
function, authority to inquire and obtain information, and function to adopt, institute and
implement preventive measures. 4
As protector of the people, the Office of the Ombudsman has the power, function and duty
"to act promptly on complaints filed in any form or manner against public officials" and "to
investigate any act or omission of any public official when such act or omission appears to
be illegal, unjust, improper or inefficient." 5
While the Ombudsman has the full discretion to determine whether or not a criminal case
should be filed, this Court is not precluded from reviewing the Ombudsman's action when
there is an abuse of discretion, in which case Rule 65 of the Rules of Court may
exceptionally be invoked pursuant to Section I, Article VIII of the 1987 Constitution. 6
In this regard, "grave abuse of discretion" has been defined as "where a power is
exercised in an arbitrary or despotic manner by reason of passion or personal hostility so
patent and gross as to amount to evasion of positive duty or virtual refusal to perform a
duty enjoined by, or in contemplation of law. 7

From a procedural standpoint, it is certainly odd why the successive transfers from one
prosecutor to another were not sufficiently explained in the Resolution of the
Ombudsman. Being the proper investigating authority with respect to misfeasance, nonfeasance and malfeasance of public officials, the Ombudsmans should have been more
vigilant and assiduous in determining the reasons behind the "buckpassing" to ensure
that no irregularity took place.
Whether such transfers were due to any outside pressure or ulterior motive is a matter of
evidence. One would have expected the Ombudsman, however, to inquire into what could
hardly qualify as "standard operating procedure," given the surrounding circumstances of
the case.
While it is true that a preliminary investigation is essentially inquisitorial, and is often the
only means to discover who may be charged with a crime, its function is merely to
determine the existence of probable cause. 8 Probable cause has been defined as "the
existence of such fact and circumstances as would excite the belief, in a reasonable mind,
acting on the facts within the knowledge of the prosecution, that the person charged was
guilty of the crime for which he was prosecuted." 9
"Probable cause is a reasonable ground of presumption that a matter is, or may be, well
founded, such a state of facts in the mind of the prosecutor as would lead a person of
ordinary caution and prudence to believe, or entertain an honest or strong suspicion, that
a thing is so." The term does not mean actual and positive cause nor does it import
absolute certainty. It is merely based on opinion and reasonable belief. Thus, a finding of
probable cause does not require an inquiry into whether there is sufficient evidence to
procure a conviction. It is enough that it is believed that the act or omission complained of
constitutes the offense charged. Precisely, there is a trial for the reception of evidence of
the prosecution in support of the charge. 10
In the instant case, no less than the NBI pronounced after conducting an autopsy that
there was indeed negligence on the part of the attending physicians in administering the
anaesthesia. 11 The fact of want of competence or diligence is evidentiary in nature, the
veracity of which can best be passed upon after a full-blown trial for it is virtually
impossible to ascertain the merits of a medical negligence case without extensive
investigation, research, evaluation and consultations with medical experts. Clearly, the
City Prosecutors are not in a competent position to pass judgment on such a technical
matter, especially when there are conflicting evidence and findings. The bases of a party's
accusation and defenses are better ventilated at the trial proper than at the preliminary
investigation.
A word on medical malpractice or negligence cases.
In its simplest terms, the type of lawsuit which has been called medical malpractice or,
more appropriately, medical negligence, is that type of claim which a victim has available
to him or her to redress a wrong committed by a medical professional which has caused
bodily harm.
In order to successfully pursue such a claim, a patient must prove that a health care
provider, in most cases a physician, either failed to do something which a reasonably
prudent health care provider would have done, or that he or she did something that a

reasonably prudent provider would not have done; and that that failure or action caused
injury to the patient. 12
Hence, there are four elements involved in medical negligence cases: duty, breach, injury
and proximate causation.
Evidently, when the victim employed the services of Dr. Antonio and Dr. Reyes, a
physician-patient relationship was created. In accepting the case, Dr. Antonio and Dr.
Reyes in effect represented that, having the needed training and skill possessed by
physicians and surgeons practicing in the same field, they will employ such training, care
and skill in the treatment of their patients. 13 They have a duty to use at least the same
level of care that any other reasonably competent doctor would use to treat a condition
under the same circumstances. The breach of these professional duties of skill and care,
or their improper performance, by a physician surgeon whereby the patient is injured in
body or in health, constitutes actionable malpractice. 14 Consequently, in the event that
any injury results to the patient from want of due care or skill during the operation, the
surgeons may be held answerable in damages for negligence. 15
Moreover, in malpractice or negligence cases involving the administration of anaesthesia,
the necessity of expert testimony and the availability of the charge of res ipsa loquitur to
the plaintiff; have been applied in actions against anaesthesiologists to hold the
defendant liable for the death or injury of a patient under excessive or improper
anaesthesia. 16 Essentially, it requires two-pronged evidence: evidence as to the
recognized standards of the medical community in the particular kind of case, and a
showing that the physician in question negligently departed from this standard in his
treatment. 17
Another element in medical negligence cases is causation which is divided into two
inquiries: whether the doctor's actions in fact caused the harm to the patient and whether
these were the proximate cause of the patient's injury. 18 Indeed here, a causal
connection is discernible from the occurrence of the victim's death after the negligent act
of the anaesthesiologist in administering the anesthesia, a fact which, if confirmed, should
warrant the filing of the appropriate criminal case. To be sure, the allegation of negligence
is not entirely baseless. Moreover, the NBI deduced that the attending surgeons did not
conduct the necessary interview of the patient prior to the operation. It appears that the
cause of the death of the victim could have been averted had the proper drug been
applied to cope with the symptoms of malignant hyperthermia. Also, we cannot ignore the
fact that an antidote was readily available to counteract whatever deleterious effect the
anaesthesia might produce. 19 Why these precautionary measures were disregarded
must be sufficiently explained.
The City Prosecutors were charged with violating Section 3(e) of the Anti-Graft and Corrupt Practices
Act which requires the following facts:
1.
The accused is a public officer discharging administrative or official functions or private
persons charged in conspiracy with them;
2.
The public officer committed the prohibited act during the performance of his official duty or
in relation to his public position;
3.
The public officer acted with manifest partiality, evident bad faith or gross, inexcusable
negligence; and
4.
His action caused undue injury to the Government or any private party, or gave any party
any unwarranted benefit, advantage or preference to such parties. 20

Why did the complainant, petitioner in instant case, elect to charge respondents under the above
law?
While a party who feels himself aggrieved is at liberty to choose the appropriate "weapon from the
armory," it is with no little surprise that this Court views the choice made by the complainant widow.
To our mind, the better and more logical remedy under the circumstances would have been to appeal
the resolution of the City Prosecutors dismissing the criminal complaint to the Secretary of Justice
under the Department of Justice's Order No. 223, 21 otherwise known as the "1993 Revised Rules on
Appeals From Resolutions In Preliminary Investigations/Reinvestigations," as amended by Department
Order No. 359, Section 1 of which provides:
Sec. 1. What May Be Appealed. Only resolutions of the Chief State Prosecutor/Regional State
Prosecutor/Provincial or City Prosecutor dismissing a criminal complaint may be the subject of an
appeal to the Secretary of Justice except as otherwise provided in Section 4 hereof.
What action may the Secretary of Justice take on the appeal? Section 9 of Order No. 223 states: "The
Secretary of Justice may reverse, affirm or modify the appealed resolution." On the other hand, "He
may motu proprio or on motion of the appellee, dismiss outright the appeal on specified grounds." 22
In exercising his discretion under the circumstances, the Ombudsman acted within his power and
authority in dismissing the complaint against the Prosecutors and this Court will not interfere with the
same.

WHEREFORE, in view of the foregoing, the instant petition is DISMISSED, without prejudice
to the filing of an appeal by the petitioner with the Secretary of Justice assailing the
dismissal of her criminal complaint by the respondent City Prosecutors. No costs. SO
ORDERED.

THIRD DIVISION
G.R. No. 122445
November 18, 1997
DR. NINEVETCH CRUZ, petitioner, vs. COURT OF APPEALS and LYDIA UMALI, respondents.
FRANCISCO, J.:

In substance, the petition brought before this Court raises the issue of whether or not
petitioner's conviction of the crime of reckless imprudence resulting in homicide, arising
from an alleged medical malpractice, is supported by the evidence on record.
First the antecedent facts.

Doctors are protected by a special rule of law. They are not guarantors of care. They do
not even warrant a good result. They are not insurers against mishaps or unusual
consequences. Furthermore they are not liable for honest mistakes of judgment . . . 1
The present case against petitioner is in the nature of a medical malpractice suit, which in
simplest terms 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 caused bodily harm. 2 In this
jurisdiction, however, such claims are most often brought as a civil action for damages
under Article 2176 of the Civil Code, 3 and in some instances, as a criminal case under
Article 365 of the Revised Penal Code 4 with which the civil action for damages is
impliedly instituted. It is via the latter type of action that the heirs of the deceased sought
redress for the petitioner's alleged imprudence and negligence in treating the deceased
thereby causing her death. The petitioner and one Dr. Lina Ercillo who was the attending
anaesthesiologist during the operation of the deceased were charged with "reckless
imprudence and negligence resulting to (sic) homicide" in an information which reads:
That on or about March 23, 1991, in the City of San Pablo, Republic of the Philippines and
within the jurisdiction of this Honorable Court, the accused above named, being then the
attending anaesthesiologist and surgeon, respectively, did then and there, in a negligence
(sic), careless, imprudent, and incompetent manner, and failing to supply or store
sufficient provisions and facilities necessary to meet any and all exigencies apt to arise
before, during and/or after a surgical operation causing by such negligence, carelessness,
imprudence, and incompetence, and causing by such failure, including the lack of
preparation and foresight needed to avert a tragedy, the untimely death of said Lydia
Umali on the day following said surgical operation. 5
Trial ensued after both the petitioner and Dr. Lina Ercillo pleaded not guilty to the abovementioned charge. On March 4, 1994, the Municipal Trial Court in Cities (MTCC) of San
Pablo City rendered a decision, the dispositive portion of which is hereunder quoted as
follows:
WHEREFORE, the court finds the accused Dra. Lina Ercillo not guilty of the offense
charged for insufficiency of evidence while her co-accused Dra. Ninevetch Cruz is hereby
held responsible for the death of Lydia Umali on March 24, 1991, and therefore guilty
under Art. 365 of the Revised Penal Code, and she is hereby sentenced to suffer the
penalty of 2 months and 1 day imprisonment of arresto mayor with costs. 6
The petitioner appealed her conviction to the Regional Trial Court (RTC) which affirmed in
toto the decision of the MTCC 7 prompting the petitioner to file a petition for review with
the Court of Appeals but to no avail. Hence this petition for review on certiorari assailing
the decision promulgated by the Court of Appeals on October 24, 1995 affirming
petitioner's conviction with modification that she is further directed to pay the heirs of
Lydia Umali P50,000.00 as indemnity for her death. 8

On March 22, 1991, prosecution witness, Rowena Umali De Ocampo, accompanied her
mother to the Perpetual Help Clinic and General Hospital situated in Balagtas Street, San
Pablo City, Laguna. They arrived at the said hospital at around 4:30 in the afternoon of the
same day. 9 Prior to
March 22, 1991, Lydia was examined by the petitioner who found a "myoma" 10 in her
uterus, and scheduled her for a hysterectomy operation on March 23,
1991. 11 Rowena and her mother slept in the clinic on the evening of March 22, 1991 as
the latter was to be operated on the next day at 1:00 o'clock in the afternoon. 12
According to Rowena, she noticed that the clinic was untidy and the window and the floor
were very dusty prompting her to ask the attendant for a rag to wipe the window and the
floor with. 13 Because of the untidy state of the clinic, Rowena tried to persuade her
mother not to proceed with the operation. 14 The following day, before her mother was
wheeled into the operating room, Rowena asked the petitioner if the operation could be
postponed. The petitioner called Lydia into her office and the two had a conversation.
Lydia then informed Rowena that the petitioner told her that she must be operated on as
scheduled. 15
Rowena and her other relatives, namely her husband, her sister and two aunts waited
outside the operating room while Lydia underwent operation. While they were waiting, Dr.
Ercillo went out of the operating room and instructed them to buy tagamet ampules which
Rowena's sister immediately bought. About one hour had passed when Dr. Ercillo came
out again this time to ask them to buy blood for Lydia. They bought type "A" blood from
the St. Gerald Blood Bank and the same was brought by the attendant into the operating
room. After the lapse of a few hours, the petitioner informed them that the operation was
finished. The operating staff then went inside the petitioner's clinic to take their snacks.
Some thirty minutes after, Lydia was brought out of the operating room in a stretcher and
the petitioner asked Rowena and the other relatives to buy additional blood for Lydia.
Unfortunately, they were not able to comply with petitioner's order as there was no more
type "A" blood available in the blood bank. Thereafter, a person arrived to donate blood
which was later transfused to Lydia. Rowena then noticed her mother, who was attached
to an oxygen tank, gasping for breath. Apparently the oxygen supply had run out and
Rowena's husband together with the driver of the accused had to go to the San Pablo
District Hospital to get oxygen. Lydia was given the fresh supply of oxygen as soon as it
arrived. 16 But at around 10:00 o'clock P.M. she went into shock and her blood pressure
dropped to 60/50. Lydia's unstable condition necessitated her transfer to the San Pablo
District Hospital so she could be connected to a respirator and further examined. 17 The
transfer to the San Pablo District Hospital was without the prior consent of Rowena nor of
the other relatives present who found out about the intended transfer only when an
ambulance arrived to take Lydia to the San Pablo District Hospital. Rowena and her other
relatives then boarded a tricycle and followed the ambulance. 18
Upon Lydia's arrival at the San Pablo District Hospital, she was wheeled into the operating
room and the petitioner and Dr. Ercillo re-operated on her because there was blood oozing
from the abdominal incision. 19 The attending physicians summoned Dr. Bartolome
Angeles, head of the Obstetrics and Gynecology Department of the San Pablo District

Hospital. However, when Dr. Angeles arrived, Lydia was already in shock and possibly
dead as her blood pressure was already 0/0. Dr. Angeles then informed petitioner and Dr.
Ercillo that there was nothing he could do to help save the patient. 20 While the petitioner
was closing the abdominal wall, the patient died. 21 Thus, on March 24, 1991, at 3:00
o'clock in the morning, Lydia Umali was pronounced dead. Her death certificate states
"shock" as the immediate cause of death and "Disseminated Intravascular Coagulation
(DIC)" as the antecedent cause. 22
In convicting the petitioner, the MTCC found the following circumstances as sufficient
basis to conclude that she was indeed negligent in the performance of the operation:
. . . , the clinic was untidy, there was lack of provision like blood and oxygen to prepare for
any contingency that might happen during the operation. The manner and the fact that
the patient was brought to the San Pablo District Hospital for reoperation indicates that
there was something wrong in the manner in which Dra. Cruz conducted the operation.
There was no showing that before the operation, accused Dra. Cruz had conducted a
cardio pulmonary clearance or any typing of the blood of the patient. It was (sic) said in
medical parlance that the "the abdomen of the person is a temple of surprises" because
you do not know the whole thing the moment it was open (sic) and surgeon must be
prepared for any eventuality thereof. The patient (sic) chart which is a public document
was not presented because it is only there that we could determine the condition of the
patient before the surgery. The court also noticed in Exh. "F-1" that the sister of the
deceased wished to postpone the operation but the patient was prevailed upon by Dra.
Cruz to proceed with the surgery. The court finds that Lydia Umali died because of the
negligence and carelessness of the surgeon Dra. Ninevetch Cruz because of loss of blood
during the operation of the deceased for evident unpreparedness and for lack of skill, the
reason why the patient was brought for operation at the San Pablo City District Hospital.
As such, the surgeon should answer for such negligence. With respect to Dra. Lina Ercillo,
the anaesthesiologist, there is no evidence to indicate that she should be held jointly
liable with Dra. Cruz who actually did the operation. 23
The RTC reiterated the abovementioned findings of the MTCC and upheld the latter's
declaration of "incompetency, negligence and lack of foresight and skill of appellant
(herein petitioner) in handling the subject patient before and after the operation." 24 And
likewise affirming the petitioner's conviction, the Court of Appeals echoed similar
observations, thus:
. . . While we may grant that the untidiness and filthiness of the clinic may not by itself
indicate negligence, it nevertheless shows the absence of due care and supervision over
her subordinate employees. Did this unsanitary condition permeate the operating room?
Were the surgical instruments properly sterilized? Could the conditions in the OR have
contributed to the infection of the patient? Only the petitioner could answer these, but she
opted not to testify. This could only give rise to the presumption that she has nothing
good to testify on her defense. Anyway, the alleged "unverified statement of the
prosecution witness" remains unchallenged and unrebutted.
Likewise undisputed is the prosecution's version indicating the following facts: that the
accused asked the patient's relatives to buy Tagamet capsules while the operation was
already in progress; that after an hour, they were also asked to buy type "A" blood for the
patient; that after the surgery, they were again asked to procure more type "A" blood, but
such was not anymore available from the source; that the oxygen given to the patient was

empty; and that the son-in-law of the patient, together with a driver of the petitioner, had
to rush to the San Pablo City District Hospital to get the much-needed oxygen. All these
conclusively show that the petitioner had not prepared for any unforeseen circumstances
before going into the first surgery, which was not emergency in nature, but was elective
or pre-scheduled; she had no ready antibiotics, no prepared blood, properly typed and
cross-matched, and no sufficient oxygen supply.
Moreover, there are a lot of questions that keep nagging Us. Was the patient given any
cardio-pulmonary clearance, or at least a clearance by an internist, which are standard
requirements before a patient is subjected to surgery. Did the petitioner determine as part
of the pre-operative evaluation, the bleeding parameters of the patient, such as bleeding
time and clotting time? There is no showing that these were done. The petitioner just
appears to have been in a hurry to perform the operation, even as the family wanted a
postponement to April 6, 1991. Obviously, she did not prepare the patient; neither did she
get the family's consent to the operation. Moreover, she did not prepare a medical chart
with instructions for the patient's care. If she did all these, proof thereof should have been
offered. But there is none. Indeed, these are overwhelming evidence of recklessness and
imprudence. 25
This Court, however, holds differently and finds the foregoing circumstances insufficient to
sustain a judgment of conviction against the petitioner for the crime of reckless
imprudence resulting in homicide. The elements of reckless imprudence are: (1) that the
offender does or fails to do an act; (2) that the doing or the failure to do that act is
voluntary; (3) that it be without malice; (4) that material damage results from the reckless
imprudence; and (5) that there is inexcusable lack of precaution on the part of the
offender, taking into consideration his employment or occupation, degree of intelligence,
physical condition, and other circumstances regarding persons, time and place.
Whether or not a physician has committed an "inexcusable lack of precaution" in the
treatment of his patient is to be determined according to the standard of care observed by
other members of the profession in good standing under similar circumstances bearing in
mind the advanced state of the profession at the time of treatment or the present state of
medical science. 26 In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pascasio, et
al., 27 this Court stated that in accepting a case, a doctor in effect represents that, having
the needed training and skill possessed by physicians and surgeons practicing in the
same field, he will employ such training, care and skill in the treatment of his patients. He
therefore has a duty to use at least the same level of care that any other reasonably
competent doctor would use to treat a condition under the same circumstances. It is in
this aspect of medical malpractice that expert testimony is essential to establish not only
the standard of care of the profession but also that the physician's conduct in the
treatment and care falls below such standard. 28 Further, inasmuch as the causes of the
injuries involved in malpractice actions are determinable only in the light of scientific
knowledge, it has been recognized that expert testimony is usually necessary to support
the conclusion as to causation. 29
Immediately apparent from a review of the records of this case is the absence of any
expert testimony on the matter of the standard of care employed by other physicians of
good standing in the conduct of similar operations. The prosecution's expert witnesses in
the persons of Dr. Floresto Arizala and Dr. Nieto Salvador, Jr. of the National Bureau of
Investigation (NBI) only testified as to the possible cause of death but did not venture to

illuminate the court on the matter of the standard of care that petitioner should have
exercised.

Dr. Arizala who conducted an autopsy on the body of the deceased summarized his
findings as follows:

All three courts below bewail the inadequacy of the facilities of the clinic and its
untidiness; the lack of provisions such as blood, oxygen, and certain medicines; the failure
to subject the patient to a cardio-pulmonary test prior to the operation; the omission of
any form of blood typing before transfusion; and even the subsequent transfer of Lydia to
the San Pablo Hospital and the reoperation performed on her by the petitioner. But while it
may be true that the circumstances pointed out by the courts below seemed beyond cavil
to constitute reckless imprudence on the part of the surgeon, this conclusion is still best
arrived at not through the educated surmises nor conjectures of laymen, including judges,
but by the unquestionable knowledge of expert witnesses. For whether a physician or
surgeon has exercised the requisite degree of skill and care in the treatment of his patient
is, in the generality of cases, a matter of expert opinion. 30 The deference of courts to the
expert opinion of qualified physicians stems from its realization that the latter possess
unusual technical skills which laymen in most instances are incapable of intelligently
evaluating. 31 Expert testimony should have been offered to prove that the circumstances
cited by the courts below are constitutive of conduct falling below the standard of care
employed by other physicians in good standing when performing the same operation. It
must be remembered that when the qualifications of a physician are admitted, as in the
instant case, there is an inevitable presumption that in proper cases he takes the
necessary precaution and employs the best of his knowledge and skill in attending to his
clients, unless the contrary is sufficiently established. 32 This presumption is rebuttable
by expert opinion which is so sadly lacking in the case at bench.

Atty. Cachero:

Even granting arguendo that the inadequacy of the facilities and untidiness of the clinic;
the lack of provisions; the failure to conduct pre-operation tests on the patient; and the
subsequent transfer of Lydia to the San Pablo Hospital and the reoperation performed on
her by the petitioner do indicate, even without expert testimony, that petitioner was
recklessly imprudent in the exercise of her duties as a surgeon, no cogent proof exists
that any of these circumstances caused petitioner's death. Thus, the absence of the
fourth element of reckless imprudence: that the injury to the person or property was a
consequence of the reckless imprudence.
In litigations involving medical negligence, the plaintiff has the burden of establishing
appellant's negligence and for a reasonable conclusion of negligence, there must be proof
of breach of duty on the part of the surgeon as well as a causal connection of such breach
and the resulting death of his patient. 33 In Chan Lugay v. St. Luke's Hospital, Inc., 34
where the attending physician was absolved of liability for the death of the complainant's
wife and newborn baby, this Court held that:
In order that there may be a recovery for an injury, however, it must be shown that the
"injury for which recovery is sought must be the legitimate consequence of the wrong
done; the connection between the negligence and the injury must be a direct and natural
sequence of events, unbroken by intervening efficient causes." In other words, the
negligence must be the proximate cause of the injury. For, "negligence, no matter in what
it consists, cannot create a right of action unless it is the proximate cause of the injury
complained of ." And "the proximate cause of an injury is that cause, which, in natural and
continuous sequence, unbroken by any efficient intervening cause, produces the injury,
and without which the result would not have occurred." 35 (Emphasis supplied.)

Q.
You mentioned about your Autopsy Report which has been marked as Exh. "A-1b". There appears here a signature above the typewritten name Floresto Arizala, Jr., whose
signature is that?
A.

That is my signature, sir.

Q.

Do you affirm the truth of all the contents of Exh. "A-1-b"?

A.
Only as to the autopsy report no. 91-09, the time and place and everything after
the post mortem findings, sir.
Q.
You mentioned on your "Post Mortem Findings" about surgical incision, 14:0 cm.,
infraumbilical area, anterior abdominal area, midline, will you please explain that in your
own language?
A.

There was incision wound (sic) the area just below the navel, sir.

Q.
And the last paragraph of the postmortem findings which I read: Uterus, pearshaped and pale measuring 7.5 x 5.5 x 5.0 cm. with some surface nodulation of the fundic
area posteriorly. Cut-section shows diffusely pale myometrium with areas of streak
induration. The ovaries and adnexal structures are missing with the raw surfaces patched
with clotted blood. Surgical sutures were noted on the operative site.
Intestines and mesenteries are pale with blood clots noted between the mesentric folds.
Hemoperitoneum: 300 s.s.,
right paracolic gutter,
50 c.c., left paracolic gutter
200 c.c., mesentric area,
100 c.c., right pelvic gutter
stomach empty.
Other visceral organs, pale.,
will you please explain that on (sic) your own language or in ordinary. . . . . . . . . . . .
A.
There was a uterus which was not attached to the adnexal structures namely
ovaries which were not present and also sign of previous surgical operation and there
were (sic) clotted blood, sir.
Q.

How about the ovaries and adnexal structures?

A.

They are missing, sir.

Q.

You mean to say there are no ovaries?

A.

During that time there are no ovaries, sir.

Q.

And there were likewise sign of surgical sutures?

A.
It means that a person died of blood loss. Meaning a person died of nonreplacement of blood and so the victim before she died there was shock of diminish of
blood of the circulation. She died most probably before the actual complete blood loss, sir.

A.

Yes, sir.

Court: Is it possible doctor that the loss of the blood was due on (sic) operation?

Q.
How about the intestines and mesenteries are place (sic) with blood clots noted
between the mesenteric folds, will you please explain on (sic) this?
A.

In the peritoneal cavity, they are mostly perritonial blood . . . . . . . .

Q.

And what could have caused this blood?

A.
Well, ordinarily blood is found inside the blood vessel. Blood were (sic) outside as
a result of the injuries which destroyed the integrity of the vessel allowing blood to sip
(sic) out, sir.
Q.
By the nature of the postmortem findings indicated in Exh. A-1-B, can you tell the
court the cause of death?
A.
Yes, sir. The cause of death is: Gross findings are compatible with hemorrhagic
shock.
Q.

Can you tell the us what could have caused this hemorrhagic shock?

A.

Well hemorrhagic shock is the result of blood loss.

Q.

What could have the effect of that loss of blood?

A.

Unattended hemorrhage, sir. 36 (Emphasis supplied.)

A.

Based on my pathologist finding, sir.

Q.

What could have caused this loss of blood?

A.
Many, sir. A patient who have undergone surgery. Another may be a blood vessel
may be cut while on operation and this cause (sic) bleeding, or may be set in the course
of operation, or may be (sic) he died after the operation. Of course there are other cause
(sic).
Atty. Cachero:
Q.

Especially so doctor when there was no blood replacement?

A.

Yes, sir. 37 (Emphasis supplied.)

The testimonies of both doctors establish hemorrhage or hemorrhagic shock as the cause
of death. However, as likewise testified to by the expert witnesses in open court,
hemorrhage or hemorrhagic shock during surgery may be caused by several different
factors. Thus, Dr. Salvador's elaboration on the matter:
Atty. Pascual:
Q.
Doctor, among the causes of hemorrhage that you mentioned you said that it
could be at the moment of operation when one losses (sic) control of the presence, is that
correct? During the operation there is lost (sic) of control of the cut vessel?

The foregoing was corroborated by Dr. Nieto Salvador:


Q.
And were you able to determine the cause of death by virtue of the examination
of the specimen submitted by Dr. Arizala?
A.
Without knowledge of the autopsy findings it would be difficult for me to
determine the cause of death, sir.
Q.

A.

Yes, sir.

Q.

Or there is a failure to ligate a vessel of considerable size?

A.

Yes, sir.

Q.

Or even if the vessel were ligated the knot may have slipped later on?

A.

Yes, sir.

Have you also examined the post mortem of Dr. Arizala?

A.
Yes, sir, and by virtue of the autopsy report in connection with your pathology
report.
Q.

What could have caused the death of the victim?

A.

This pathologic examination are (sic) compatible with the person who died, sir.

Q.

Will you explain to us the meaning of hemorrhagic compatible?

Q.
And you also mentioned that it may be possible also to some clotting defect, is
that correct?
A.

May be (sic). 38 (Emphasis supplied).

Defense witness, Dr. Bu C. Castro also gave the following expert opinion:
Q.
Doctor even a patient after an operations (sic) would suffer hemorrage what
would be the possible causes of such hemorrage (sic)?

A.
Among those would be what we call Intravascular Coagulation and this is the
reason for the bleeding, sir, which cannot be prevented by anyone, it will happen to
anyone, anytime and to any persons (sic), sir.

Q:
So, therefore, Doctor, you would not know whether any of the cut structures were
not sutured or tied neither were you able to determine whether any loose suture was
found in the peritoneal cavity?

COURT:

A:

What do you think of the cause of the bleeding, the cutting or the operations done in the
body?

On the other hand, the findings of all three doctors do not preclude the probability that
DIC caused the hemorrhage and consequently, Lydia's death. DIC which is a clotting
defect creates a serious bleeding tendency and when massive DIC occurs as a
complication of surgery leaving raw surface, major hemorrhage occurs. 42 And as testified
to by defense witness, Dr. Bu C. Castro, hemorrhage due to DIC "cannot be prevented, it
will happen to anyone,
anytime." 43 He testified further:

A.
Not related to this one, the bleeding here is not related to any cutting or operation
that I (sic) have done.
Q.
Aside from the DIC what could another causes (sic) that could be the cause for the
hemorrhage or bleeding in a patient by an operations (sic)?

I could not recall any loose sutured (sic), sir. 41

Q.

Now, under that circumstance one of the possibility as you mentioned in (sic) DIC?

A.
In general sir, if there was an operations (sic) and it is possible that the ligature in
the suture was (sic) become (sic) loose, it is (sic) becomes loose if proven..

A.

Yes, sir.

xxx

Q.

And you mentioned that this cannot be prevented?

Q.
If the person who performed an autopsy does not find any untight (sic) clot (sic)
blood vessel or any suture that become (sic) loose the cause of the bleeding could not be
attributed to the fault of the subject?

A.

Yes, sir.

Q.

Can you even predict if it really happen (sic)?

A.

A.

Possible, sir.

xxx

xxx

Definitely, sir. 39 (Emphasis supplied.)

According to both doctors, the possible causes of hemorrhage during an operation are: (1)
the failure of the surgeon to tie or suture a cut blood vessel; (2) allowing a cut blood
vessel to get out of control; (3) the subsequent loosening of the tie or suture applied to a
cut blood vessel; and (4) and a clotting defect known as DIC. It is significant to state at
this juncture that the autopsy conducted by Dr. Arizala on the body of Lydia did not reveal
any untied or unsutured cut blood vessel nor was there any indication that the tie or
suture of a cut blood vessel had become loose thereby causing the hemorrhage. 40 Hence
the following pertinent portion of Dr. Arizala's testimony:
Q:
Doctor, in examining these structures did you know whether these were sutured
ligature or plain ligature
A:

Ligature, sir.

Q.
Are there any specific findings of autopsy that will tell you whether this patient
suffered among such things as DIC?
A.

Well, I did reserve because of the condition of the patient.

Q.
Now, Doctor you said that you went through the record of the deceased Lydia
Umali looking for the chart, the operated (sic) records, the post mortem findings on the
histophanic (sic) examination based on your examination of record, doctor, can you more
or less says (sic) what part are (sic) concerned could have been the caused (sic) of death
of this Lydia Umali?
A.
As far as the medical record is concern (sic) the caused (sic) of death is
dessimulated (sic) Intra Vascular Coagulation or the DIC which resulted to hemorrhage or
bleedings, sir.

Q:
We will explain that later on. Did you recall if the cut structures were tied by first
suturing it and then tying a knot or the tie was merely placed around the cut structure
and tied?

Q.
Doctor based on your findings then there is knowing (sic) the doctor would say
whether the doctor her (sic) has been (sic) fault?

A:

ATTY. MALVEDA:

I cannot recall, sir.

Q:
As a matter of fact, you cannot recall because you did not even bothered (sic) to
examine, is that correct?

We will moved (sic) to strike out the (sic) based on finding they just read the chart as well
as the other record.

A:

ATTY. PASCUAL:

Well, I bothered enough to know that they were sutured, sir.

Precisely based on this examination.


ATTY. MALVEDA:
Not finding, there was no finding made.
COURT:
He is only reading the record.
ATTY. PASCUAL: Yes, sir.
A.
No, sir, there is no fault on the part of the surgeon, sir. 44
This Court has no recourse but to rely on the expert testimonies rendered by both
prosecution and defense witnesses that substantiate rather than contradict petitioner's
allegation that the cause of Lydia's death was DIC which, as attested to by an expert
witness, cannot be attributed to the petitioner's fault or negligence. The probability that
Lydia's death was caused by DIC was unrebutted during trial and has engendered in the
mind of this Court a reasonable doubt as to the petitioner's guilt. Thus, her acquittal of the
crime of reckless imprudence resulting in homicide. While we condole with the family of
Lydia Umali, our hands are bound by the dictates of justice and fair dealing which hold
inviolable the right of an accused to be presumed innocent until proven guilty beyond
reasonable doubt. Nevertheless, this Court finds the petitioner civilly liable for the death
of Lydia Umali, for while a conviction of a crime requires proof beyond reasonable doubt,
only a preponderance of evidence is required to establish civil liability. 45
The petitioner is a doctor in whose hands a patient puts his life and limb. For insufficiency
of evidence this Court was not able to render a sentence of conviction but it is not blind to
the reckless and imprudent manner in which the petitioner carried out her duties. A
precious life has been lost and the circumstances leading thereto exacerbated the grief of
those left behind. The heirs of the deceased continue to feel the loss of their mother up to
the present time 46 and this Court is aware that no amount of compassion and
commiseration nor words of bereavement can suffice to assuage the sorrow felt for the
loss of a loved one. Certainly, the award of moral and exemplary damages in favor of the
heirs of Lydia Umali are proper in the instant case.
WHEREFORE, premises considered, petitioner DR. NINEVETCH CRUZ is hereby ACQUITTED
of the crime of reckless imprudence resulting in homicide but is ordered to pay the heirs
of the deceased Lydia Umali the amount of FIFTY THOUSAND PESOS (P50,000.00) as civil
liability, ONE HUNDRED THOUSAND PESOS (P100,000.00) as moral damages, and FIFTY
THOUSAND PESOS (P50,000.00) as exemplary damages.
Let a copy of this decision be furnished to the Professional Regulation Commission (PRC)
for appropriate action.
SO ORDERED.

FIRST DIVISION
G.R. No. 124354
December 29, 1999
ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural guardians of
the minors, ROMMEL RAMOS, ROY RODERICK RAMOS and RON RAYMOND RAMOS,
petitioners, vs. COURT OF APPEALS, DELOS SANTOS MEDICAL CENTER, DR. ORLINO
HOSAKA and DRA. PERFECTA GUTIERREZ, respondents.
KAPUNAN, J.:
The Hippocratic Oath mandates physicians to give primordial consideration to the health
and welfare of their patients. If a doctor fails to live up to this precept, he is made
accountable for his acts. A mistake, through gross negligence or incompetence or plain
human error, may spell the difference between life and death. In this sense, the doctor
plays God on his patient's fate. 1
In the case at bar, the Court is called upon to rule whether a surgeon, an anesthesiologist
and a hospital should be made liable for the unfortunate comatose condition of a patient
scheduled for cholecystectomy. 2
Petitioners seek the reversal of the decision 3 of the Court of Appeals, dated 29 May 1995,
which overturned the decision 4 of the Regional Trial Court, dated 30 January 1992,
finding private respondents liable for damages arising from negligence in the performance
of their professional duties towards petitioner Erlinda Ramos resulting in her comatose
condition.
The antecedent facts as summarized by the trial court are reproduced hereunder:
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). Except for occasional complaints of
discomfort due to pains allegedly caused by the presence of a stone in her gall bladder
(TSN, January 13, 1988, pp. 4-5), she was as normal as any other woman. Married to
Rogelio E. Ramos, an executive of Philippine Long Distance Telephone Company, she has
three children whose names are Rommel Ramos, Roy Roderick Ramos and Ron Raymond
Ramos (TSN, October 19, 1989, pp. 5-6).
Because the discomforts somehow interfered with her normal ways, she sought
professional advice. She was advised to undergo an operation for the removal of a stone
in her gall bladder (TSN, January 13, 1988, p. 5). She underwent a series of examinations
which included blood and urine tests (Exhs. "A" and "C") which indicated she was fit for
surgery.
Through the intercession of a mutual friend, Dr. Buenviaje (TSN, January 13, 1988, p. 7),
she and her husband Rogelio met for the first time Dr. Orlino Hozaka (should be Hosaka;
see TSN, February 20, 1990, p. 3), one of the defendants in this case, on June 10, 1985.
They agreed that their date at the operating table at the DLSMC (another defendant),
would be on June 17, 1985 at 9:00 A.M.. Dr. Hosaka 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. Ramos, however,
asked Dr. Hosaka to look for a good anesthesiologist. Dr. Hosaka, in turn, assured Rogelio
that he will get a good anesthesiologist. Dr. Hosaka charged a fee of P16,000.00, which
was to include the anesthesiologist's fee and which was to be paid after the operation

(TSN, October 19, 1989, pp. 14-15, 22-23, 31-33; TSN, February 27, 1990, p. 13; and TSN,
November 9, 1989, pp. 3-4, 10, 17).
A day before the scheduled date of operation, she was admitted at one of the rooms of
the DLSMC, located along E. Rodriguez Avenue, Quezon City (TSN, October 19,1989, p.
11).
At around 7:30 A.M. of June 17, 1985 and while still in her room, she was prepared for the
operation by the hospital staff. Her sister-in-law, Herminda Cruz, who was the Dean of the
College of Nursing at the Capitol Medical Center, was also there for moral 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 from her room to the operating room (TSN, January 13, 1988, pp. 9-11). Her
husband, Rogelio, was also with her (TSN, October 19, 1989, p. 18). At the operating
room, Herminda saw about two or three nurses and Dr. Perfecta Gutierrez, the other
defendant, who was to administer anesthesia. Although not a member of the hospital
staff, Herminda introduced herself as Dean of the College of Nursing at the Capitol
Medical Center who was to provide moral support to the patient, to them. Herminda was
allowed to stay inside the operating room.
At around 9:30 A.M., Dr. Gutierrez reached a nearby phone to look for Dr. Hosaka who was
not yet in (TSN, January 13, 1988, pp. 11-12). Dr. Gutierrez thereafter informed Herminda
Cruz about the prospect of a delay in the arrival of Dr. Hosaka. Herminda then went back
to the patient who asked, "Mindy, wala pa ba ang Doctor"? The former replied, "Huwag
kang mag-alaala, darating na iyon" (Ibid.).
Thereafter, Herminda went out of the operating room and informed the patient's husband,
Rogelio, that the doctor was not yet around (id., p. 13). When she returned to the
operating room, the patient told her, "Mindy, inip na inip na ako, ikuha mo ako ng ibang
Doctor." So, she went out again and told Rogelio about what the patient said (id., p. 15).
Thereafter, she returned to the operating room.
At around 10:00 A.M., Rogelio E. Ramos was "already dying [and] waiting for the arrival of
the doctor" even as he did his best to find somebody who will allow him to pull out his
wife from the operating room (TSN, October 19, 1989, pp. 19-20). He also thought of the
feeling of his wife, who was inside the operating room waiting for the doctor to arrive
(ibid.). At almost 12:00 noon, he met Dr. Garcia who remarked that he (Dr. Garcia) was
also tired of waiting for Dr. Hosaka to arrive (id., p. 21). While talking to Dr. Garcia at
around 12:10 P.M., he came to know that Dr. Hosaka arrived as a nurse remarked,
"Nandiyan na si Dr. Hosaka, dumating na raw." Upon hearing those words, he went down
to the lobby and waited for the operation to be completed (id., pp. 16, 29-30).
At about 12:15 P.M., Herminda Cruz, who was inside the operating room with the patient,
heard somebody say that "Dr. Hosaka is already here." She then saw people inside the
operating room "moving, doing this and that, [and] preparing the patient for the
operation" (TSN, January 13, 1988, p. 16). As she held the hand of Erlinda Ramos, she
then saw Dr. Gutierrez intubating the hapless patient. She thereafter heard Dr. Gutierrez
say, "ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan" (id.,
p. 17). Because of the remarks of Dra. Gutierrez, she focused her attention on what Dr.
Gutierrez was doing. She thereafter noticed bluish discoloration of the nailbeds of the left
hand of the hapless Erlinda even as Dr. Hosaka approached her. She then heard Dr.

Hosaka issue an order for someone to call Dr. Calderon, another anesthesiologist (id., p.
19). After Dr. Calderon arrived at the operating room, she saw this anesthesiologist trying
to intubate the patient. The patient's nailbed became bluish and the patient was placed in
a trendelenburg position a position where the head of the patient is placed in a position
lower than her feet which is an 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 operating
room, and she told Rogelio E. Ramos "that something wrong was . . . happening" (Ibid.).
Dr. Calderon was then able to intubate the patient (TSN, July 25, 1991, p. 9).

to prove that the sustained by Erlinda was due to lack of oxygen in her brain caused by
the faulty management of her airway by private respondents during the anesthesia
phase. On the other hand, private respondents primarily relied on the expert testimony of
Dr. Eduardo Jamora, a pulmonologist, to the effect that the cause of brain damage was
Erlinda's allergic reaction to the anesthetic agent, Thiopental Sodium (Pentothal).

Meanwhile, Rogelio, who was outside the operating room, saw a respiratory machine
being rushed towards the door of the operating room. He also saw several doctors rushing
towards the operating room. When informed by Herminda Cruz that something wrong was
happening, he told her (Herminda) to be back with the patient inside the operating room
(TSN, October 19, 1989, pp. 25-28).

After evaluating the evidence as shown in the finding of facts set forth earlier, and
applying the aforecited provisions of law and jurisprudence to the case at bar, this Court
finds and so holds that defendants are liable to plaintiffs for damages. The defendants
were guilty of, at the very least, negligence in the performance of their duty to plaintiffpatient Erlinda Ramos.

Herminda Cruz immediately rushed back, and saw that the patient was still in
trendelenburg position (TSN, January 13, 1988, p. 20). At almost 3:00 P.M. of that fateful
day, she saw the patient taken to the Intensive Care Unit (ICU).

On the part of Dr. Perfecta Gutierrez, this Court finds that she omitted to exercise
reasonable care in not only intubating the patient, but also in not repeating the
administration of atropine (TSN, August 20, 1991, pp. 5-10), without due regard to the fact
that the patient was inside the operating room for almost three (3) hours. For after she
committed a mistake in intubating [the] patient, the patient's nailbed became bluish and
the patient, thereafter, was placed in trendelenburg position, because of the decrease of
blood supply to the patient's brain. The evidence further shows that the hapless patient
suffered brain damage because of the absence of oxygen in her (patient's) brain for
approximately four to five minutes which, in turn, caused the patient to become
comatose.

About two days thereafter, Rogelio E. Ramos was able to talk to Dr. Hosaka. The latter
informed the former that something went wrong during the intubation. Reacting to what
was told to him, Rogelio reminded the doctor that the condition of his wife would not have
happened, had he (Dr. Hosaka) looked for a good anesthesiologist (TSN, October 19, 1989,
p. 31).
Doctors Gutierrez and Hosaka were also asked by the hospital to explain what happened
to the patient. The doctors explained that the patient had bronchospasm (TSN, November
15, 1990, pp. 26-27).
Erlinda Ramos stayed at the ICU for a month. About four months thereafter or on
November 15, 1985, the patient was released from the hospital.
During the whole period of her confinement, she incurred hospital bills amounting to
P93,542.25 which is the subject of a promissory note and affidavit of undertaking
executed by Rogelio E. Ramos in favor of DLSMC. Since that fateful afternoon of June 17,
1985, she has been in a comatose condition. She cannot do anything. She cannot move
any part of her body. She cannot see or hear. She is living on mechanical means. She
suffered brain damage as a result of the absence of oxygen in her brain for four to five
minutes (TSN, November 9, 1989, pp. 21-22). After being discharged from the hospital,
she has been staying in their residence, still needing constant medical attention, with her
husband Rogelio incurring a monthly expense ranging from P8,000.00 to P10,000.00 (TSN,
October 19, 1989, pp. 32-34). She was also diagnosed to be suffering from "diffuse
cerebral parenchymal damage" (Exh. "G"; see also TSN, December 21, 1989,
p. 6). 5
Thus, on 8 January 1986, petitioners filed a civil case 6 for damages with the Regional Trial
Court of Quezon City against herein private respondents alleging negligence in the
management and care of Erlinda Ramos.
During the trial, both parties presented evidence as to the possible cause of Erlinda's
injury. Plaintiff presented the testimonies of Dean Herminda Cruz and Dr. Mariano Gavino

After considering the evidence from both sides, the Regional Trial Court rendered
judgment in favor of petitioners, to wit:

On the part of Dr. Orlino Hosaka, this Court finds that he is liable for the acts of Dr.
Perfecta Gutierrez whom he had chosen to administer anesthesia on the patient as part of
his obligation to provide the patient a good anesthesiologist', and for arriving for the
scheduled operation almost three (3) hours late.
On the part of DLSMC (the hospital), this Court finds that it is liable for the acts of
negligence of the doctors in their "practice of medicine" in the operating room. Moreover,
the hospital is liable for failing through its responsible officials, to cancel the scheduled
operation after Dr. Hosaka inexcusably failed to arrive on time.
In having held thus, this Court rejects the defense raised by defendants that they have
acted with due care and prudence in rendering medical services to plaintiff-patient. For if
the patient was properly intubated as claimed by them, the patient would not have
become comatose. And, the fact that another anesthesiologist was called to try to
intubate the patient after her (the patient's) nailbed turned bluish, belie their claim.
Furthermore, the defendants should have rescheduled the operation to a later date. This,
they should have done, if defendants acted with due care and prudence as the patient's
case was an elective, not an emergency case.
xxx

xxx

xxx

WHEREFORE, and in view of the foregoing, judgment is rendered in favor of the plaintiffs
and against the defendants. Accordingly, the latter are ordered to pay, jointly and
severally, the former the following sums of money, to wit:

1)
the sum of P8,000.00 as actual monthly expenses for the plaintiff Erlinda Ramos
reckoned from November 15, 1985 or in the total sum of P632,000.00 as of April 15, 1992,
subject to its being updated;

Even assuming admissibility of the Motion for the Reconsideration, but after considering
the Comment/Opposition, the former, for lack of merit, is hereby DENIED.
SO ORDERED. 10

2)

the sum of P100,000.00 as reasonable attorney's fees;

3)
the sum of P800,000.00 by way of moral damages and the further sum of
P200,000,00 by way of exemplary damages; and,
4)

the costs of the suit.

SO ORDERED. 7

A copy of the above resolution was received by Atty. Sillano on 11 April 1996. The next
day, or on 12 April 1996, Atty. Sillano filed before this Court a motion for extension of time
to file the present petition for certiorari under Rule 45. The Court granted the motion for
extension of time and gave petitioners additional thirty (30) days after the expiration of
the fifteen-day (15) period counted from the receipt of the resolution of the Court of
Appeals within which to submit the petition. The due date fell on 27 May 1996. The
petition was filed on 9 May 1996, well within the extended period given by the Court.

Private respondents seasonably interposed an appeal to the Court of Appeals. The


appellate court rendered a Decision, dated 29 May 1995, reversing the findings of the trial
court. The decretal portion of the decision of the appellate court reads:

Petitioners assail the decision of the Court of Appeals on the following grounds:

WHEREFORE, for the foregoing premises the appealed decision is hereby REVERSED, and
the complaint below against the appellants is hereby ordered DISMISSED. The
counterclaim of appellant De Los Santos Medical Center is GRANTED but only insofar as
appellees are hereby ordered to pay the unpaid hospital bills amounting to P93,542.25,
plus legal interest for justice must be tempered with mercy.

IN PUTTING MUCH RELIANCE ON THE TESTIMONIES OF RESPONDENTS DRA. GUTIERREZ,


DRA. CALDERON AND DR. JAMORA;

SO ORDERED. 8
The decision of the Court of Appeals was received on 9 June 1995 by petitioner Rogelio
Ramos who was mistakenly addressed as "Atty. Rogelio Ramos." No copy of the decision,
however, was sent nor received by the Coronel Law Office, then counsel on record of
petitioners. Rogelio referred the decision of the appellate court to a new lawyer, Atty.
Ligsay, only on 20 June 1995, or four (4) days before the expiration of the reglementary
period for filing a motion for reconsideration. On the same day, Atty. Ligsay, filed with the
appellate court a motion for extension of time to file a motion for reconsideration. The
motion for reconsideration was submitted on 4 July 1995. However, the appellate court
denied the motion for extension of time in its Resolution dated 25 July 1995. 9 Meanwhile,
petitioners engaged the services of another counsel, Atty. Sillano, to replace Atty. Ligsay.
Atty. Sillano filed on 7 August 1995 a motion to admit the motion for reconsideration
contending that the period to file the appropriate pleading on the assailed decision had
not yet commenced to run as the Division Clerk of Court of the Court of Appeals had not
yet served a copy thereof to the counsel on record. Despite this explanation, the appellate
court still denied the motion to admit the motion for reconsideration of petitioners in its
Resolution, dated 29 March 1996, primarily on the ground that the fifteen-day (15) period
for filing a motion for reconsideration had already expired, to wit:
We said in our Resolution on July 25, 1995, that the filing of a Motion for Reconsideration
cannot be extended; precisely, the Motion for Extension (Rollo, p. 12) was denied. It is, on
the other hand, admitted in the latter Motion that plaintiffs/appellees received a copy of
the decision as early as June 9, 1995. Computation wise, the period to file a Motion for
Reconsideration expired on June 24. The Motion for Reconsideration, in turn, was received
by the Court of Appeals already on July 4, necessarily, the 15-day period already passed.
For that alone, the latter should be denied.

II
IN FINDING THAT THE NEGLIGENCE OF THE RESPONDENTS DID NOT CAUSE THE
UNFORTUNATE COMATOSE CONDITION OF PETITIONER ERLINDA RAMOS;
III
IN NOT APPLYING THE DOCTRINE OF RES IPSA LOQUITUR. 11
Before we discuss the merits of the case, we shall first dispose of the procedural issue on
the timeliness of the petition in relation to the motion for reconsideration filed by
petitioners with the Court of Appeals. In their
Comment, 12 private respondents contend that the petition should not be given due
course since the motion for reconsideration of the petitioners on the decision of the Court
of Appeals was validly dismissed by the appellate court for having been filed beyond the
reglementary period. We do not agree.
A careful review of the records reveals that the reason behind the delay in filing the
motion for reconsideration is attributable to the fact that the decision of the Court of
Appeals was not sent to then counsel on record of petitioners, the Coronel Law Office. In
fact, a copy of the decision of the appellate court was instead sent to and received by
petitioner Rogelio Ramos on 9 June 1995 wherein he was mistakenly addressed as Atty.
Rogelio Ramos. Based on the other communications received by petitioner Rogelio Ramos,
the appellate court apparently mistook him for the counsel on record. Thus, no copy of the
decision of the counsel on record. Petitioner, not being a lawyer and unaware of the
prescriptive period for filing a motion for reconsideration, referred the same to a legal
counsel only on 20 June 1995.
It is elementary that when a party is represented by counsel, all notices should be sent to
the party's lawyer at his given address. With a few exceptions, notice to a litigant without
notice to his counsel on record is no notice at all. In the present case, since a copy of the

decision of the appellate court was not sent to the counsel on record of petitioner, there
can be no sufficient notice to speak of. Hence, the delay in the filing of the motion for
reconsideration cannot be taken against petitioner. Moreover, since the Court of Appeals
already issued a second Resolution, dated 29 March 1996, which superseded the earlier
resolution issued on 25 July 1995, and denied the motion for reconsideration of petitioner,
we believed that the receipt of the former should be considered in determining the
timeliness of the filing of the present petition. Based on this, the petition before us was
submitted on time.
After resolving the foregoing procedural issue, we shall now look into the merits of the
case. For a more logical presentation of the discussion we shall first consider the issue on
the applicability of the doctrine of res ipsa loquitur to the instant case. Thereafter, the first
two assigned errors shall be tackled in relation to the res ipsa loquitur doctrine.
Res ipsa loquitur is a Latin phrase which literally means "the thing or the transaction
speaks for itself." The phrase "res ipsa loquitur'' is a maxim for the rule that the fact of the
occurrence of an injury, taken with the surrounding circumstances, may permit an
inference or raise a presumption of negligence, or make out a plaintiff's prima facie case,
and present a question of fact for defendant to meet with an explanation. 13 Where the
thing which caused the injury complained of is shown to be under the management of the
defendant or his servants and the accident is such as in ordinary course of things does not
happen if those who have its management or control use proper care, it affords
reasonable evidence, in the absence of explanation by the defendant, that the accident
arose from or was caused by the defendant's want of care. 14
The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a matter
of common knowledge and experience, the very nature of certain types of occurrences
may justify an inference of negligence on the part of the person who controls the
instrumentality causing the injury in the absence of some explanation by the defendant
who is charged with negligence. 15 It is grounded in the superior logic of ordinary human
experience and on the basis of such experience or common knowledge, negligence may
be deduced from the mere occurrence of the accident itself. 16 Hence, res ipsa loquitur is
applied in conjunction with the doctrine of common knowledge.
However, much has been said that res ipsa loquitur is not a rule of substantive law and, as
such, does not create or constitute an independent or separate ground of liability. 17
Instead, it is considered as merely evidentiary or in the nature of a procedural rule. 18 It is
regarded as a mode of proof, or a mere procedural of convenience since it furnishes a
substitute for, and relieves a plaintiff of, the burden of producing specific proof of
negligence. 19 In other words, mere invocation and application of the doctrine does not
dispense with the requirement of proof of negligence. It is simply a step in the process of
such proof, permitting the plaintiff to present along with the proof of the accident, enough
of the attending circumstances to invoke the doctrine, creating an inference or
presumption of negligence, and to thereby place on the defendant the burden of going
forward with the proof. 20 Still, before resort to the doctrine may be allowed, the following
requisites must be satisfactorily shown:
1.
The accident is of a kind which ordinarily does not occur in the absence of
someone's negligence;

2.
It is caused by an instrumentality within the exclusive control of the defendant or
defendants; and
3.
The possibility of contributing conduct which would make the plaintiff responsible
is eliminated. 21
In the above requisites, the fundamental element is the "control of instrumentality" which
caused the damage. 22 Such element of control must be shown to be within the dominion
of the defendant. In order to have the benefit of the rule, a plaintiff, in addition to proving
injury or damage, must show a situation where it is applicable, and must establish that
the essential elements of the doctrine were present in a particular incident. 23
Medical malpractice 24 cases do not escape the application of this doctrine. Thus, res ipsa
loquitur has been applied when the circumstances attendant upon the harm are
themselves of such a character as to justify an inference of negligence as the cause of
that harm. 25 The application of res ipsa loquitur in medical negligence cases presents a
question of law since it is a judicial function to determine whether a certain set of
circumstances does, as a matter of law, permit a given inference. 26
Although generally, expert medical testimony is relied upon in malpractice suits to prove
that a physician has done a negligent act or that he has deviated from the standard
medical procedure, when the doctrine of res ipsa loquitur is availed by the plaintiff, the
need for expert medical testimony is dispensed with because the injury itself provides the
proof of negligence. 27 The reason is that the general rule on the necessity of expert
testimony applies only to such matters clearly within the domain of medical science, and
not to matters that are within the common knowledge of mankind which may be testified
to by anyone familiar with the facts. 28 Ordinarily, only physicians and surgeons of skill
and experience are competent to testify as to whether a patient has been treated or
operated upon with a reasonable degree of skill and care. However, testimony as to the
statements and acts of physicians and surgeons, external appearances, and manifest
conditions which are observable by any one may be given by non-expert witnesses. 29
Hence, in cases where the res ipsa loquitur is applicable, the court is permitted to find a
physician negligent upon proper proof of injury to the patient, without the aid of expert
testimony, where the court from its fund of common knowledge can determine the proper
standard of care. 30 Where common knowledge and experience teach that a resulting
injury would not have occurred to the patient if due care had been exercised, an inference
of negligence may be drawn giving rise to an application of the doctrine of res ipsa
loquitur without medical evidence, which is ordinarily required to show not only what
occurred but how and why it occurred. 31 When the doctrine is appropriate, all that the
patient must do is prove a nexus between the particular act or omission complained of
and the injury sustained while under the custody and management of the defendant
without need to produce expert medical testimony to establish the standard of care.
Resort to res ipsa loquitur is allowed because there is no other way, under usual and
ordinary conditions, by which the patient can obtain redress for injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following situations:
leaving of a foreign object in the body of the patient after an operation, 32 injuries
sustained on a healthy part of the body which was not under, or in the area, of treatment,
33 removal of the wrong part of the body when another part was intended, 34 knocking
out a tooth while a patient's jaw was under anesthetic for the removal of his tonsils, 35

and loss of an eye while the patient plaintiff was under the influence of anesthetic, during
or following an operation for appendicitis, 36 among others.

the true explanation of event is more accessible to the defendants than to the plaintiff for
they had the exclusive control of the instrumentalities of anesthesia.

Nevertheless, despite the fact that the scope of res ipsa loquitur has been measurably
enlarged, it does not automatically apply to all cases of medical negligence as to
mechanically shift the burden of proof to the defendant to show that he is not guilty of the
ascribed negligence. Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily
used but a rule to be cautiously applied, depending upon the circumstances of each case.
It is generally restricted to situations in malpractice cases where a layman is able to say,
as a matter of common knowledge and observation, that the consequences of
professional care were not as such as would ordinarily have followed if due care had been
exercised. 37 A distinction must be made between the failure to secure results, and the
occurrence of something more unusual and not ordinarily found if the service or treatment
rendered followed the usual procedure of those skilled in that particular practice. It must
be conceded that the doctrine of res ipsa loquitur can have no application in a suit against
a physician or surgeon which involves the merits of a diagnosis or of a scientific
treatment. 38 The physician or surgeon is not required at his peril to explain why any
particular diagnosis was not correct, or why any particular scientific treatment did not
produce the desired result. 39 Thus, res ipsa loquitur is not available in a malpractice suit
if the only showing is that the desired result of an operation or treatment was not
accomplished. 40 The real question, therefore, is whether or not in the process of the
operation any extraordinary incident or unusual event outside of the routine performance
occurred which is beyond the regular scope of customary professional activity in such
operations, which, if unexplained would themselves reasonably speak to the average man
as the negligent cause or causes of the untoward consequence. 41 If there was such
extraneous interventions, the doctrine of res ipsa loquitur may be utilized and the
defendant is called upon to explain the matter, by evidence of exculpation, if he could. 42

Upon all the facts, conditions and circumstances alleged in Count II it is held that a cause
of action is stated under the doctrine of res ipsa loquitur. 44

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 operation presents a case for the application of res ipsa loquitur.
A case strikingly similar to the one before us is Voss vs. Bridwell, 43 where the Kansas
Supreme Court in applying the res ipsa loquitur stated:
The plaintiff herein submitted himself for a mastoid operation and delivered his person
over to the care, custody and control of his physician who had complete and exclusive
control over him, but the operation was never performed. At the time of submission he
was neurologically sound and physically fit in mind and body, but he suffered irreparable
damage and injury rendering him decerebrate and totally incapacitated. The injury was
one which does not ordinarily occur in the process of a mastoid operation or in the
absence of negligence in the administration of an anesthetic, and in the use and
employment of an endoctracheal tube. Ordinarily a person being put under anesthesia is
not rendered decerebrate as a consequence of administering such anesthesia in the
absence of negligence. Upon these facts and under these circumstances a layman would
be able to say, as a matter of common knowledge and observation, that the
consequences of professional treatment were not as such as would ordinarily have
followed if due care had been exercised.
Here the plaintiff could not have been guilty of contributory negligence because he was
under the influence of anesthetics and unconscious, and the circumstances are such that

Indeed, the principles enunciated in the aforequoted case apply with equal force here. In
the present case, Erlinda submitted herself for cholecystectomy and expected a routine
general surgery to be performed on her gall bladder. On that fateful day she delivered her
person over to the care, custody and control of private respondents who exercised
complete and exclusive control over her. At the time of submission, Erlinda was
neurologically sound and, except for a few minor discomforts, was likewise physically fit in
mind and body. However, during the administration of anesthesia and prior to the
performance of cholecystectomy she suffered irreparable damage to her brain. Thus,
without undergoing surgery, she went out of the operating room already decerebrate and
totally incapacitated. Obviously, brain damage, which Erlinda sustained, is an injury which
does not normally occur in the process of a gall bladder operation. In fact, this kind of
situation does not in the absence of negligence of someone in the administration of
anesthesia and in the use of endotracheal tube. Normally, a person being put under
anesthesia is not rendered decerebrate as a consequence of administering such
anesthesia if the proper procedure was followed. Furthermore, the instruments used in the
administration of anesthesia, including the endotracheal tube, were all under the
exclusive control of private respondents, who are the physicians-in-charge. Likewise,
petitioner Erlinda could not have been guilty of contributory negligence because she was
under the influence of anesthetics which rendered her unconscious.
Considering that a sound and unaffected member of the body (the brain) is injured or
destroyed while the patient is unconscious and under the immediate and exclusive control
of the physicians, we hold that a practical administration of justice dictates the application
of res ipsa loquitur. Upon these facts and under these circumstances the Court would be
able to say, as a matter of common knowledge and observation, if negligence attended
the management and care of the patient. Moreover, the liability of the physicians and the
hospital in this case is not predicated upon an alleged failure to secure the desired results
of an operation nor on an alleged lack of skill in the diagnosis or treatment as in fact no
operation or treatment was ever performed on Erlinda. Thus, upon all these initial
determination a case is made out for the application of the doctrine of res ipsa loquitur.
Nonetheless, in holding that res ipsa loquitur is available to the present case we are not
saying that the doctrine is applicable in any and all cases where injury occurs to a patient
while under anesthesia, or to any and all anesthesia cases. Each case must be viewed in
its own light and scrutinized in order to be within the res ipsa loquitur coverage.
Having in mind the applicability of the res ipsa loquitur doctrine and the presumption of
negligence allowed therein, the Court now comes to the issue of whether the Court of
Appeals erred in finding that private respondents were not negligent in the care of Erlinda
during the anesthesia phase of the operation and, if in the affirmative, whether the
alleged negligence was the proximate cause of Erlinda's comatose condition. Corollary
thereto, we shall also determine if the Court of Appeals erred in relying on the testimonies
of the witnesses for the private respondents.

In sustaining the position of private respondents, the Court of Appeals relied on the
testimonies of Dra. Gutierrez, Dra. Calderon and Dr. Jamora. In giving weight to the
testimony of Dra. Gutierrez, the Court of Appeals rationalized that she was candid enough
to admit that she experienced some difficulty in the endotracheal intubation 45 of the
patient and thus, cannot be said to be covering her negligence with falsehood. The
appellate court likewise opined that private respondents were able to show that the brain
damage sustained by Erlinda was not caused by the alleged faulty intubation but was due
to the allergic reaction of the patient to the drug Thiopental Sodium (Pentothal), a shortacting barbiturate, as testified on by their expert witness, Dr. Jamora. On the other hand,
the appellate court rejected the testimony of Dean Herminda Cruz offered in favor of
petitioners that the cause of the brain injury was traceable to the wrongful insertion of the
tube since the latter, being a nurse, was allegedly not knowledgeable in the process of
intubation. In so holding, the appellate court returned a verdict in favor of respondents
physicians and hospital and absolved them of any liability towards Erlinda and her family.
We disagree with the findings of the Court of Appeals. We hold that private respondents
were unable to disprove the presumption of negligence on their part in the care of Erlinda
and their negligence was the proximate cause of her piteous condition.

Gutierrez herself. She was saying "Ang hirap ma-intubate nito, mali yata ang
pagkakapasok. O lumalaki ang tiyan.
xxx

xxx

xxx

ATTY. PAJARES:
Q:

From whom did you hear those words "lumalaki ang tiyan"?

A:

From Dra. Perfecta Gutierrez.

xxx

xxx

xxx

Q:
After hearing the phrase "lumalaki ang tiyan," what did you notice on the person
of the patient?
A:
at.

I notice (sic) some bluish discoloration on the nailbeds of the left hand where I was

In the instant case, the records are helpful in furnishing not only the logical scientific
evidence of the pathogenesis of the injury but also in providing the Court the legal nexus
upon which liability is based. As will be shown hereinafter, private respondents' own
testimonies which are reflected in the transcript of stenographic notes are replete of
signposts indicative of their negligence in the care and management of Erlinda.

Q:

Where was Dr. Orlino Ho[s]aka then at that particular time?

A:

I saw him approaching the patient during that time.

Q:

When he approached the patient, what did he do, if any?

With regard to Dra. Gutierrez, we find her negligent in the care of Erlinda during the
anesthesia phase. As borne by the records, respondent Dra. Gutierrez failed to properly
intubate the patient. This fact was attested to by Prof. Herminda Cruz, Dean of the Capitol
Medical Center School of Nursing and petitioner's sister-in-law, who was in the operating
room right beside the patient when the tragic event occurred. Witness Cruz testified to
this effect:

A:

He made an order to call on the anesthesiologist in the person of Dr. Calderon.

Q:

Did Dr. Calderon, upon being called, arrive inside the operating room?

A:

Yes sir.

Q:

What did [s]he do, if any?

A:

[S]he tried to intubate the patient.

Q:

What happened to the patient?

ATTY. PAJARES:
Q:

In particular, what did Dra. Perfecta Gutierrez do, if any on the patient?

A:

In particular, I could see that she was intubating the patient.

Q:
Do you know what happened to that intubation process administered by Dra.
Gutierrez?

A:
When Dr. Calderon try (sic) to intubate the patient, after a while the patient's
nailbed became bluish and I saw the patient was placed in trendelenburg position.
xxx

xxx

xxx

ATTY. ALCERA:
She will be incompetent Your Honor.
COURT:

Q:
Do you know the reason why the patient was placed in that trendelenburg
position?
A:
As far as I know, when a patient is in that position, there is a decrease of blood
supply to the brain. 46

Witness may answer if she knows.


xxx
A:
As have said, I was with the patient, I was beside the stretcher holding the left
hand of the patient and all of a sudden heard some remarks coming from Dra. Perfecta

xxx

xxx

The appellate court, however, disbelieved Dean Cruz's testimony in the trial court by
declaring that:

Q:
In this particular case, Doctora, while you were intubating at your first attempt
(sic), you did not immediately see the trachea?

A perusal of the standard nursing curriculum in our country will show that intubation is not
taught as part of nursing procedures and techniques. Indeed, we take judicial notice of the
fact that nurses do not, and cannot, intubate. Even on the assumption that she is fully
capable of determining whether or not a patient is properly intubated, witness Herminda
Cruz, admittedly, did not peep into the throat of the patient. (TSN, July 25, 1991, p. 13).
More importantly, there is no evidence that she ever auscultated the patient or that she
conducted any type of examination to check if the endotracheal tube was in its proper
place, and to determine the condition of the heart, lungs, and other organs. Thus, witness
Cruz's categorical statements that appellant Dra. Gutierrez failed to intubate the appellee
Erlinda Ramos and that it was Dra. Calderon who succeeded in doing so clearly suffer
from lack of sufficient factual bases. 47

DRA. GUTIERREZ:
A:

Yes sir.

Q:

Did you pull away the tube immediately?

A:

You do not pull the . . .

Q:

Did you or did you not?

A:

I did not pull the tube.

In other words, what the Court of Appeals is trying to impress is that being a nurse, and
considered a layman in the process of intubation, witness Cruz is not competent to testify
on whether or not the intubation was a success.

Q:

When you said "mahirap yata ito," what were you referring to?

A:

"Mahirap yata itong i-intubate," that was the patient.

We do not agree with the above reasoning of the appellate court. Although witness Cruz is
not an anesthesiologist, she can very well testify upon matters on which she is capable of
observing such as, the statements and acts of the physician and surgeon, external
appearances, and manifest conditions which are observable by any one. 48 This is
precisely allowed under the doctrine of res ipsa loquitur where the testimony of expert
witnesses is not required. It is the accepted rule that expert testimony is not necessary for
the proof of negligence in non-technical matters or those of which an ordinary person may
be expected to have knowledge, or where the lack of skill or want of care is so obvious as
to render expert testimony unnecessary. 49 We take judicial notice of the fact that
anesthesia procedures have become so common, that even an ordinary person can tell if
it was administered properly. As such, it would not be too difficult to tell if the tube was
properly inserted. This kind of observation, we believe, does not require a medical degree
to be acceptable.

Q:

So, you found some difficulty in inserting the tube?

A:

Yes, because of (sic) my first attempt, I did not see right away. 51

At any rate, without doubt, petitioner's witness, an experienced clinical nurse whose long
experience and scholarship led to her appointment as Dean of the Capitol Medical Center
School at Nursing, was fully capable of determining whether or not the intubation was a
success. She had extensive clinical experience starting as a staff nurse in Chicago, Illinois;
staff nurse and clinical instructor in a teaching hospital, the FEU-NRMF; Dean of the
Laguna College of Nursing in San Pablo City; and then Dean of the Capitol Medical Center
School of Nursing. 50 Reviewing witness Cruz' statements, we find that the same were
delivered in a straightforward manner, with the kind of detail, clarity, consistency and
spontaneity which would have been difficult to fabricate. With her clinical background as a
nurse, the Court is satisfied that she was able to demonstrate through her testimony what
truly transpired on that fateful day.
Most of all, her testimony was affirmed by no less than respondent Dra. Gutierrez who
admitted that she experienced difficulty in inserting the tube into Erlinda's trachea, to wit:
ATTY. LIGSAY:

Curiously in the case at bar, respondent Dra. Gutierrez made the haphazard defense that
she encountered hardship in the insertion of the tube in the trachea of Erlinda because it
was positioned more anteriorly (slightly deviated from the normal anatomy of a person)
52 making it harder to locate and, since Erlinda is obese and has a short neck and
protruding teeth, it made intubation even more difficult.
The argument does not convince us. If this was indeed observed, private respondents
adduced no evidence demonstrating that they proceeded to make a thorough assessment
of Erlinda's airway, prior to the induction of anesthesia, even if this would mean
postponing the procedure. From their testimonies, it appears that the observation was
made only as an afterthought, as a means of defense.
The pre-operative evaluation of a patient prior to the administration of anesthesia is
universally observed to lessen the possibility of anesthetic accidents. Pre-operative
evaluation and preparation for anesthesia begins when the anesthesiologist reviews the
patient's medical records and visits with the patient, traditionally, the day before elective
surgery. 53 It includes taking the patient's medical history, review of current drug therapy,
physical examination and interpretation of laboratory data. 54 The physical examination
performed by the anesthesiologist is directed primarily toward the central nervous
system, cardiovascular system, lungs and upper airway. 55 A thorough analysis of the
patient's airway normally involves investigating the following: cervical spine mobility,
temporomandibular mobility, prominent central incisors, diseased or artificial teeth, ability
to visualize uvula and the thyromental distance. 56 Thus, physical characteristics of the
patient's upper airway that could make tracheal intubation difficult should be studied. 57
Where the need arises, as when initial assessment indicates possible problems (such as
the alleged short neck and protruding teeth of Erlinda) a thorough examination of the
patient's airway would go a long way towards decreasing patient morbidity and mortality.

In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda for the first
time on the day of the operation itself, on 17 June 1985. Before this date, no prior
consultations with, or pre-operative evaluation of Erlinda was done by her. Until the day of
the operation, respondent Dra. Gutierrez was unaware of the physiological make-up and
needs of Erlinda. She was likewise not properly informed of the possible difficulties she
would face during the administration of anesthesia to Erlinda. Respondent Dra. Gutierrez'
act of seeing her patient for the first time only an hour before the scheduled operative
procedure was, therefore, an act of exceptional negligence and professional
irresponsibility. The measures cautioning prudence and vigilance in dealing with human
lives lie at the core of the physician's centuries-old Hippocratic Oath. Her failure to follow
this medical procedure is, therefore, a clear indicia of her negligence.

determine if the faulty intubation is truly the proximate cause of Erlinda's comatose
condition.

Respondent Dra. Gutierrez, however, attempts to gloss over this omission by playing
around with the trial court's ignorance of clinical procedure, hoping that she could get
away with it. Respondent Dra. Gutierrez tried to muddle the difference between an
elective surgery and an emergency surgery just so her failure to perform the required preoperative evaluation would escape unnoticed. In her testimony she asserted:

First of all, Dr. Jamora cannot be considered an authority in the field of anesthesiology
simply because he is not an anesthesiologist. Since Dr. Jamora is a pulmonologist, he
could not have been capable of properly enlightening the court about anesthesia practice
and procedure and their complications. Dr. Jamora is likewise not an allergologist and
could not therefore properly advance expert opinion on allergic-mediated processes.
Moreover, he is not a pharmacologist and, as such, could not have been capable, as an
expert would, of explaining to the court the pharmacologic and toxic effects of the
supposed culprit, Thiopental Sodium (Pentothal).

ATTY. LIGSAY:
Q:
Would you agree, Doctor, that it is good medical practice to see the patient a day
before so you can introduce yourself to establish good doctor-patient relationship and gain
the trust and confidence of the patient?
DRA. GUTIERREZ:
A:
As I said in my previous statement, it depends on the operative procedure of the
anesthesiologist and in my case, with elective cases and normal cardio-pulmonary
clearance like that, I usually don't do it except on emergency and on cases that have an
abnormalities (sic). 58
However, the exact opposite is true. In an emergency procedure, there is hardly enough
time available for the fastidious demands of pre-operative procedure so that an
anesthesiologist is able to see the patient only a few minutes before surgery, if at all.
Elective procedures, on the other hand, are operative procedures that can wait for days,
weeks or even months. Hence, in these cases, the anesthesiologist possesses the luxury
of time to be at the patient's beside to do a proper interview and clinical evaluation. There
is ample time to explain the method of anesthesia, the drugs to be used, and their
possible hazards for purposes of informed consent. Usually, the pre-operative assessment
is conducted at least one day before the intended surgery, when the patient is relaxed
and cooperative.
Erlinda's case was elective and this was known to respondent Dra. Gutierrez. Thus, she
had all the time to make a thorough evaluation of Erlinda's case prior to the operation and
prepare her for anesthesia. However, she never saw the patient at the bedside. She
herself admitted that she had seen petitioner only in the operating room, and only on the
actual date of the cholecystectomy. She negligently failed to take advantage of this
important opportunity. As such, her attempt to exculpate herself must fail.
Having established that respondent Dra. Gutierrez failed to perform pre-operative
evaluation of the patient which, in turn, resulted to a wrongful intubation, we now

Private respondents repeatedly hammered the view that the cerebral anoxia which led to
Erlinda's coma was due to bronchospasm 59 mediated by her allergic response to the
drug, Thiopental Sodium, introduced into her system. Towards this end, they presented Dr.
Jamora, a Fellow of the Philippine College of Physicians and Diplomate of the Philippine
Specialty Board of Internal Medicine, who advanced private respondents' theory that the
oxygen deprivation which led to anoxic encephalopathy, 60 was due to an unpredictable
drug reaction to the short-acting barbiturate. We find the theory of private respondents
unacceptable.

The inappropriateness and absurdity of accepting Dr. Jamora's testimony as an expert


witness in the anesthetic practice of Pentothal administration is further supported by his
own admission that he formulated his opinions on the drug not from the practical
experience gained by a specialist or expert in the administration and use of Sodium
Pentothal on patients, but only from reading certain references, to wit:
ATTY. LIGSAY: Q:
In your line of expertise on pulmonology, did you have any
occasion to use pentothal as a method of management?
DR. JAMORA: A:We do it in conjunction with the anesthesiologist when they have to
intubate our patient.
Q:
But not in particular when you practice pulmonology?
A:
No.
Q:
In other words, your knowledge about pentothal is based only on what you have
read from books and not by your own personal application of the medicine pentothal?
A:
Based on my personal experience also on pentothal.
Q:
How many times have you used pentothal?
A:
They used it on me. I went into bronchospasm during my appendectomy.
Q:
And because they have used it on you and on account of your own personal
experience you feel that you can testify on pentothal here with medical authority?
A:
No. That is why I used references to support my claims. 61
An anesthetic accident caused by a rare drug-induced bronchospasm properly falls within
the fields of anesthesia, internal medicine-allergy, and clinical pharmacology. The
resulting anoxic encephalopathy belongs to the field of neurology. While admittedly, many
bronchospastic-mediated pulmonary diseases are within the expertise of pulmonary
medicine, Dr. Jamora's field, the anesthetic drug-induced, allergic mediated bronchospasm
alleged in this case is within the disciplines of anesthesiology, allergology and
pharmacology. On the basis of the foregoing transcript, in which the pulmonologist himself
admitted that he could not testify about the drug with medical authority, it is clear that

the appellate court erred in giving weight to Dr. Jamora's testimony as an expert in the
administration of Thiopental Sodium.
The provision in the rules of evidence 62 regarding expert witnesses states:
Sec. 49.
Opinion of expert witness. The opinion of a witness on a matter
requiring special knowledge, skill, experience or training which he is shown to possess,
may be received in evidence.
Generally, to qualify as an expert witness, one must have acquired special knowledge of
the subject matter about which he or she is to testify, either by the study of recognized
authorities on the subject or by practical experience. 63 Clearly, Dr. Jamora does not
qualify as an expert witness based on the above standard since he lacks the necessary
knowledge, skill, and training in the field of anesthesiology. Oddly, apart from submitting
testimony from a specialist in the wrong field, private respondents' intentionally avoided
providing testimony by competent and independent experts in the proper areas.
Moreover, private respondents' theory, that Thiopental Sodium may have produced
Erlinda's coma by triggering an allergic mediated response, has no support in evidence.
No evidence of stridor, skin reactions, or wheezing some of the more common
accompanying signs of an allergic reaction appears on record. No laboratory data were
ever presented to the court.
In any case, private respondents themselves admit that Thiopental induced, allergicmediated bronchospasm happens only very rarely. If courts were to accept private
respondents' hypothesis without supporting medical proof, and against the weight of
available evidence, then every anesthetic accident would be an act of God. Evidently, the
Thiopental-allergy theory vigorously asserted by private respondents was a mere
afterthought. Such an explanation was advanced in order to advanced in order to absolve
them of any and all responsibility for the patient's condition.
In view of the evidence at hand, we are inclined to believe petitioners' stand that it was
the faulty intubation which was the proximate cause of Erlinda's comatose condition.
Proximate cause has been defined as that which, in natural and continuous sequence,
unbroken by any efficient intervening cause, produces injury, and without which the result
would not have occurred. 64 An injury or damage is proximately caused by an act or a
failure to act, whenever it appears from the evidence in the case, that the act or omission
played a substantial part in bringing about or actually causing the injury or damage; and
that the injury or damage was either a direct result or a reasonably probable consequence
of the act or omission. 65 It is the dominant, moving or producing cause.
Applying the above definition in relation to the evidence at hand, faulty intubation is
undeniably the proximate cause which triggered the chain of events leading to Erlinda's
brain damage and, ultimately, her comatosed condition.
Private respondents themselves admitted in their testimony that the first intubation was a
failure. This fact was likewise observed by witness Cruz when she heard respondent Dra.
Gutierrez remarked, "Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki
ang tiyan." Thereafter, witness Cruz noticed abdominal distention on the body of Erlinda.
The development of abdominal distention, together with respiratory embarrassment

indicates that the endotracheal tube entered the esophagus instead of the respiratory
tree. In other words, instead of the intended endotracheal intubation what actually took
place was an esophageal intubation. During intubation, such distention indicates that air
has entered the gastrointestinal tract through the esophagus instead of the lungs through
the trachea. Entry into the esophagus would certainly cause some delay in oxygen
delivery into the lungs as the tube which carries oxygen is in the wrong place. That
abdominal distention had been observed during the first intubation suggests that the
length of time utilized in inserting the endotracheal tube (up to the time the tube was
withdrawn for the second attempt) was fairly significant. Due to the delay in the delivery
of oxygen in her lungs Erlinda showed signs of cyanosis. 66 As stated in the testimony of
Dr. Hosaka, the lack of oxygen became apparent only after he noticed that the nailbeds of
Erlinda were already blue. 67 However, private respondents contend that a second
intubation was executed on Erlinda and this one was successfully done. We do not think
so. No evidence exists on record, beyond private respondents' bare claims, which
supports the contention that the second intubation was successful. Assuming that the
endotracheal tube finally found its way into the proper orifice of the trachea, the same
gave no guarantee of oxygen delivery, the hallmark of a successful intubation. In fact,
cyanosis was again observed immediately after the second intubation. Proceeding from
this event (cyanosis), it could not be claimed, as private respondents insist, that the
second intubation was accomplished. Even granting that the tube was successfully
inserted during the second attempt, it was obviously too late. As aptly explained by the
trial court, Erlinda already suffered brain damage as a result of the inadequate
oxygenation of her brain for about four to five minutes. 68
The above conclusion is not without basis. Scientific studies point out that intubation
problems are responsible for one-third (1/3) of deaths and serious injuries associated with
anesthesia. 69 Nevertheless, ninety-eight percent (98%) or the vast majority of difficult
intubations may be anticipated by performing a thorough evaluation of the patient's
airway prior to the operation. 70 As stated beforehand, respondent Dra. Gutierrez failed to
observe the proper pre-operative protocol which could have prevented this unfortunate
incident. Had appropriate diligence and reasonable care been used in the pre-operative
evaluation, respondent physician could have been much more prepared to meet the
contingency brought about by the perceived anatomic variations in the patient's neck and
oral area, defects which would have been easily overcome by a prior knowledge of those
variations together with a change in technique. 71 In other words, an experienced
anesthesiologist, adequately alerted by a thorough pre-operative evaluation, would have
had little difficulty going around the short neck and protruding teeth. 72 Having failed to
observe common medical standards in pre-operative management and intubation,
respondent Dra. Gutierrez' negligence resulted in cerebral anoxia and eventual coma of
Erlinda.
We now determine the responsibility of respondent Dr. Orlino Hosaka as the head of the
surgical team. As the so-called "captain of the ship," 73 it is the surgeon's responsibility to
see to it that those under him perform their task in the proper manner. Respondent Dr.
Hosaka's negligence can be found in his failure to exercise the proper authority (as the
"captain" of the operative team) in not determining if his anesthesiologist observed
proper anesthesia protocols. In fact, no evidence on record exists to show that respondent
Dr. Hosaka verified if respondent Dra. Gutierrez properly intubated the patient.
Furthermore, it does not escape us that respondent Dr. Hosaka had scheduled another
procedure in a different hospital at the same time as Erlinda's cholecystectomy, and was
in fact over three hours late for the latter's operation. Because of this, he had little or no

time to confer with his anesthesiologist regarding the anesthesia delivery. This indicates
that he was remiss in his professional duties towards his patient. Thus, he shares equal
responsibility for the events which resulted in Erlinda's condition.
We now discuss the responsibility of the hospital in this particular incident. The unique
practice (among private hospitals) of filling up specialist staff with attending and visiting
"consultants," 74 who are allegedly not hospital employees, presents problems in
apportioning responsibility for negligence in medical malpractice cases. However, the
difficulty is only more apparent than real.
In the first place, hospitals exercise significant control in the hiring and firing of
consultants and in the conduct of their work within the hospital premises. Doctors who
apply for "consultant" slots, visiting or attending, are required to submit proof of
completion of residency, their educational qualifications; generally, evidence of
accreditation by the appropriate board (diplomate), evidence of fellowship in most cases,
and references. These requirements are carefully scrutinized by members of the hospital
administration or by a review committee set up by the hospital who either accept or reject
the application. 75 This is particularly true with respondent hospital.
After a physician is accepted, either as a visiting or attending consultant, he is normally
required to attend clinico-pathological conferences, conduct bedside rounds for clerks,
interns and residents, moderate grand rounds and patient audits and perform other tasks
and responsibilities, for the privilege of being able to maintain a clinic in the hospital,
and/or for the privilege of admitting patients into the hospital. In addition to these, the
physician's performance as a specialist is generally evaluated by a peer review committee
on the basis of mortality and morbidity statistics, and feedback from patients, nurses,
interns and residents. A consultant remiss in his duties, or a consultant who regularly falls
short of the minimum standards acceptable to the hospital or its peer review committee,
is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending
and visiting "consultant" staff. While "consultants" are not, technically employees, a point
which respondent hospital asserts in denying all responsibility for the patient's condition,
the control exercised, the hiring, and the right to terminate consultants all fulfill the
important hallmarks of an employer-employee relationship, with the exception of the
payment of wages. In assessing whether such a relationship in fact exists, the control test
is determining. Accordingly, on the basis of the foregoing, we rule that for the purpose of
allocating responsibility in medical negligence cases, an employer-employee relationship
in effect exists between hospitals and their attending and visiting physicians. This being
the case, the question now arises as to whether or not respondent hospital is solidarily
liable with respondent doctors for petitioner's condition. 76
The basis for holding an employer solidarily responsible for the negligence of its employee
is found in Article 2180 of the Civil Code which considers a person accountable not only
for his own acts but also for those of others based on the former's responsibility under a
relationship of patria potestas. 77 Such responsibility ceases when the persons or entity
concerned prove that they have observed the diligence of a good father of the family to
prevent damage. 78 In other words, while the burden of proving negligence rests on the
plaintiffs, once negligence is shown, the burden shifts to the respondents (parent,
guardian, teacher or employer) who should prove that they observed the diligence of a
good father of a family to prevent damage.

In the instant case, respondent hospital, apart from a general denial of its responsibility
over respondent physicians, failed to adduce evidence showing that it exercised the
diligence of a good father of a family in the hiring and supervision of the latter. It failed to
adduce evidence with regard to the degree of supervision which it exercised over its
physicians. In neglecting to offer such proof, or proof of a similar nature, respondent
hospital thereby failed to discharge its burden under the last paragraph of Article 2180.
Having failed to do this, respondent hospital is consequently solidarily responsible with its
physicians for Erlinda's condition.
Based on the foregoing, we hold that the Court of Appeals erred in accepting and relying
on the testimonies of the witnesses for the private respondents. Indeed, as shown by the
above discussions, private respondents were unable to rebut the presumption of
negligence. Upon these disquisitions we hold that private respondents are solidarily liable
for damages under Article 2176 79 of the Civil Code.
We now come to the amount of damages due petitioners. The trial court awarded a total
of P632,000.00 pesos (should be P616,000.00) in compensatory damages to the plaintiff,
"subject to its being updated" covering the period from 15 November 1985 up to 15 April
1992, based on monthly expenses for the care of the patient estimated at P8,000.00.
At current levels, the P8000/monthly amount established by the trial court at the time of
its decision would be grossly inadequate to cover the actual costs of home-based care for
a comatose individual. The calculated amount was not even arrived at by looking at the
actual cost of proper hospice care for the patient. What it reflected were the actual
expenses incurred and proved by the petitioners after they were forced to bring home the
patient to avoid mounting hospital bills.
And yet ideally, a comatose patient should remain in a hospital or be transferred to a
hospice specializing in the care of the chronically ill for the purpose of providing a proper
milieu adequate to meet minimum standards of care. In the instant case for instance,
Erlinda has to be constantly turned from side to side to prevent bedsores and hypostatic
pneumonia. Feeding is done by nasogastric tube. Food preparation should be normally
made by a dietitian to provide her with the correct daily caloric requirements and vitamin
supplements. Furthermore, she has to be seen on a regular basis by a physical therapist
to avoid muscle atrophy, and by a pulmonary therapist to prevent the accumulation of
secretions which can lead to respiratory complications.
Given these considerations, the amount of actual damages recoverable in suits arising
from negligence should at least reflect the correct minimum cost of proper care, not the
cost of the care the family is usually compelled to undertake at home to avoid bankruptcy.
However, the provisions of the Civil Code on actual or compensatory damages present us
with some difficulties.
Well-settled is the rule that actual damages which may be claimed by the plaintiff are
those suffered by him as he has duly proved. The Civil Code provides:
Art. 2199. Except as provided by law or by stipulation, one is entitled to an adequate
compensation only for such pecuniary loss suffered by him as he has duly proved. Such
compensation is referred to as actual or compensatory damages.

Our rules on actual or compensatory damages generally assume that at the time of
litigation, the injury suffered as a consequence of an act of negligence has been
completed and that the cost can be liquidated. However, these provisions neglect to take
into account those situations, as in this case, where the resulting injury might be
continuing and possible future complications directly arising from the injury, while certain
to occur, are difficult to predict.
In these cases, the amount of damages which should be awarded, if they are to
adequately and correctly respond to the injury caused, should be one which compensates
for pecuniary loss incurred and proved, up to the time of trial; and one which would meet
pecuniary loss certain to be suffered but which could not, from the nature of the case, be
made with certainty. 80 In other words, temperate damages can and should be awarded
on top of actual or compensatory damages in instances where the injury is chronic and
continuing. And because of the unique nature of such cases, no incompatibility arises
when both actual and temperate damages are provided for. The reason is that these
damages cover two distinct phases.
As it would not be equitable and certainly not in the best interests of the administration
of justice for the victim in such cases to constantly come before the courts and invoke
their aid in seeking adjustments to the compensatory damages previously awarded
temperate damages are appropriate. The amount given as temperate damages, though to
a certain extent speculative, should take into account the cost of proper care.
In the instant case, petitioners were able to provide only home-based nursing care for a
comatose patient who has remained in that condition for over a decade. Having premised
our award for compensatory damages on the amount provided by petitioners at the onset
of litigation, it would be now much more in step with the interests of justice if the value
awarded for temperate damages would allow petitioners to provide optimal care for their
loved one in a facility which generally specializes in such care. They should not be
compelled by dire circumstances to provide substandard care at home without the aid of
professionals, for anything less would be grossly inadequate. Under the circumstances, an
award of P1,500,000.00 in temperate damages would therefore be reasonable. 81
In Valenzuela vs. Court of Appeals, 82 this Court was confronted with a situation where
the injury suffered by the plaintiff would have led to expenses which were difficult to
estimate because while they would have been a direct result of the injury (amputation),
and were certain to be incurred by the plaintiff, they were likely to arise only in the future.
We awarded P1,000,000.00 in moral damages in that case.

the biological changes of middle-age, menopause and aging. Assuming she reaches
menopause, for example, the prosthetic will have to be adjusted to respond to the
changes in bone resulting from a precipitate decrease in calcium levels observed in the
bones of all post-menopausal women. In other words, the damage done to her would not
only be permanent and lasting, it would also be permanently changing and adjusting to
the physiologic changes which her body would normally undergo through the years. The
replacements, changes, and adjustments will require corresponding adjustive physical and
occupational therapy. All of these adjustments, it has been documented, are painful.
xxx

xxx

xxx

A prosthetic devise, however technologically advanced, will only allow a reasonable


amount of functional restoration of the motor functions of the lower limb. The sensory
functions are forever lost. The resultant anxiety, sleeplessness, psychological injury,
mental and physical pain are inestimable. 83
The injury suffered by Erlinda as a consequence of private respondents' negligence is
certainly much more serious than the amputation in the Valenzuela case.
Petitioner Erlinda Ramos was in her mid-forties when the incident occurred. She has been
in a comatose state for over fourteen years now. The burden of care has so far been
heroically shouldered by her husband and children, who, in the intervening years have
been deprived of the love of a wife and a mother.
Meanwhile, the actual physical, emotional and financial cost of the care of petitioner
would be virtually impossible to quantify. Even the temperate damages herein awarded
would be inadequate if petitioner's condition remains unchanged for the next ten years.
We recognized, in Valenzuela that a discussion of the victim's actual injury would not even
scratch the surface of the resulting moral damage because it would be highly speculative
to estimate the amount of emotional and moral pain, psychological damage and injury
suffered by the victim or those actually affected by the victim's condition. 84 The husband
and the children, all petitioners in this case, will have to live with the day to day
uncertainty of the patient's illness, knowing any hope of recovery is close to nil. They
have fashioned their daily lives around the nursing care of petitioner, altering their long
term goals to take into account their life with a comatose patient. They, not the
respondents, are charged with the moral responsibility of the care of the victim. The
family's moral injury and suffering in this case is clearly a real one. For the foregoing
reasons, an award of P2,000,000.00 in moral damages would be appropriate.

Describing the nature of the injury, the Court therein stated:


As a result of the accident, Ma. Lourdes Valenzuela underwent a traumatic amputation of
her left lower extremity at the distal left thigh just above the knee. Because of this,
Valenzuela will forever be deprived of the full ambulatory functions of her left extremity,
even with the use of state of the art prosthetic technology. Well beyond the period of
hospitalization (which was paid for by Li), she will be required to undergo adjustments in
her prosthetic devise due to the shrinkage of the stump from the process of healing.
These adjustments entail costs, prosthetic replacements and months of physical and
occupational rehabilitation and therapy. During the lifetime, the prosthetic devise will
have to be replaced and readjusted to changes in the size of her lower limb effected by

Finally, by way of example, exemplary damages in the amount of P100,000.00 are hereby
awarded. Considering the length and nature of the instant suit we are of the opinion that
attorney's fees valued at P100,000.00 are likewise proper.
Our courts face unique difficulty in adjudicating medical negligence cases because
physicians are not insurers of life and, they rarely set out to intentionally cause injury or
death to their patients. However, intent is immaterial in negligence cases because where
negligence exists and is proven, the same automatically gives the injured a right to
reparation for the damage caused.

Established medical procedures and practices, though in constant flux are devised for the
purpose of preventing complications. A physician's experience with his patients would
sometimes tempt him to deviate from established community practices, and he may end
a distinguished career using unorthodox methods without incident. However, when failure
to follow established procedure results in the evil precisely sought to be averted by
observance of the procedure and a nexus is made between the deviation and the injury or
damage, the physician would necessarily be called to account for it. In the case at bar, the
failure to observe pre-operative assessment protocol which would have influenced the
intubation in a salutary way was fatal to private respondents' case.
WHEREFORE, the decision and resolution of the appellate court appealed from are hereby
modified so as to award in favor of petitioners, and solidarily against private respondents
the following: 1) P1,352,000.00 as actual damages computed as of the date of
promulgation of this decision plus a monthly payment of P8,000.00 up to the time that
petitioner Erlinda Ramos expires or miraculously survives; 2) P2,000,000.00 as moral
damages, 3) P1,500,000.00 as temperate damages; 4) P100,000.00 each as exemplary
damages and attorney's fees; and, 5) the costs of the suit. SO ORDERED.

SECOND DIVISION
[G.R. No. 130547. October 3, 2000]
LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and minors LLOYD and KRISTINE, all
surnamed REYES, represented by their mother, LEAH ALESNA REYES, petitioners, vs.
SISTERS OF MERCY HOSPITAL, SISTER ROSE PALACIO, DR. MARVIE BLANES, and DR.
MARLYN RICO, respondents.
DECISION
MENDOZA, J.:
This is a petition for review of the decision[1] of the Court of Appeals in CA-G.R. CV No.
36551 affirming the decision of the Regional Trial Court, Branch IX, Cebu City which
dismissed a complaint for damages filed by petitioners against respondents.
The facts are as follows:
Petitioner Leah Alesna Reyes is the wife of the late Jorge Reyes. The other petitioners,
namely, Rose Nahdja, Johnny, Lloyd, and Kristine, all surnamed Reyes, were their children.
Five days before his death on January 8, 1987, Jorge had been suffering from a recurring
fever with chills. After he failed to get relief from some home medication he was taking,
which consisted of analgesic, antipyretic, and antibiotics, he decided to see the doctor.
On January 8, 1987, he was taken to the Mercy Community Clinic by his wife. He was
attended to by respondent Dr. Marlyn Rico, resident physician and admitting physician on
duty, who gave Jorge a physical examination and took his medical history. She noted that
at the time of his admission, Jorge was conscious, ambulatory, oriented, coherent, and
with respiratory distress.[2] Typhoid fever was then prevalent in the locality, as the clinic
had been getting from 15 to 20 cases of typhoid per month.[3] Suspecting that Jorge
could be suffering from this disease, Dr. Rico ordered a Widal Test, a standard test for
typhoid fever, to be performed on Jorge. Blood count, routine urinalysis, stool
examination, and malarial smear were also made.[4] After about an hour, the medical
technician submitted the results of the test from which Dr. Rico concluded that Jorge was
positive for typhoid fever. As her shift was only up to 5:00 p.m., Dr. Rico indorsed Jorge to
respondent Dr. Marvie Blanes.
Dr. Marvie Blanes attended to Jorge at around six in the evening. She also took Jorges
history and gave him a physical examination. Like Dr. Rico, her impression was that Jorge
had typhoid fever. Antibiotics being the accepted treatment for typhoid fever, she ordered
that a compatibility test with the antibiotic chloromycetin be done on Jorge. Said test was
administered by nurse Josephine Pagente who also gave the patient a dose of triglobe. As
she did not observe any adverse reaction by the patient to chloromycetin, Dr. Blanes
ordered the first five hundred milligrams of said antibiotic to be administered on Jorge at
around 9:00 p.m. A second dose was administered on Jorge about three hours later just
before midnight.
At around 1:00 a.m. of January 9, 1987, Dr. Blanes was called as Jorges temperature rose
to 41C. The patient also experienced chills and exhibited respiratory distress, nausea,
vomiting, and convulsions. Dr. Blanes put him under oxygen, used a suction machine, and
administered hydrocortisone, temporarily easing the patients convulsions. When he
regained consciousness, the patient was asked by Dr. Blanes whether he had a previous
heart ailment or had suffered from chest pains in the past. Jorge replied he did not.[5]
After about 15 minutes, however, Jorge again started to vomit, showed restlessness, and

his convulsions returned. Dr. Blanes re-applied the emergency measures taken before
and, in addition, valium was administered. Jorge, however, did not respond to the
treatment and slipped into cyanosis, a bluish or purplish discoloration of the skin or
mucous membrane due to deficient oxygenation of the blood. At around 2:00 a.m., Jorge
died. He was forty years old. The cause of his death was Ventricular Arrythemia
Secondary to Hyperpyrexia and typhoid fever.
On June 3, 1987, petitioners filed before the Regional Trial Court of Cebu City a
complaint[6]for damages against respondents Sisters of Mercy, Sister Rose Palacio, Dr.
Marvie Blanes, Dr. Marlyn Rico, and nurse Josephine Pagente. On September 24, 1987,
petitioners amended their complaint to implead respondent Mercy Community Clinic as
additional defendant and to drop the name of Josephine Pagente as defendant since she
was no longer connected with respondent hospital. Their principal contention was that
Jorge did not die of typhoid fever.[7] Instead, his death was due to the wrongful
administration of chloromycetin. They contended that had respondent doctors exercised
due care and diligence, they would not have recommended and rushed the performance
of the Widal Test, hastily concluded that Jorge was suffering from typhoid fever, and
administered chloromycetin without first conducting sufficient tests on the patients
compatibility with said drug. They charged respondent clinic and its directress, Sister Rose
Palacio, with negligence in failing to provide adequate facilities and in hiring negligent
doctors and nurses.[8]
Respondents denied the charges. During the pre-trial conference, the parties agreed to
limit the issues on the following: (1) whether the death of Jorge Reyes was due to or
caused by the negligence, carelessness, imprudence, and lack of skill or foresight on the
part of defendants; (2) whether respondent Mercy Community Clinic was negligent in the
hiring of its employees; and (3) whether either party was entitled to damages. The case
was then heard by the trial court during which, in addition to the testimonies of the
parties, the testimonies of doctors as expert witnesses were presented.
Petitioners offered the testimony of Dr. Apolinar Vacalares, Chief Pathologist at the
Northern Mindanao Training Hospital, Cagayan de Oro City. On January 9, 1987, Dr.
Vacalares performed an autopsy on Jorge Reyes to determine the cause of his death.
However, he did not open the skull to examine the brain. His findings[9] showed that the
gastro-intestinal tract was normal and without any ulceration or enlargement of the
nodules. Dr. Vacalares testified that Jorge did not die of typhoid fever. He also stated that
he had not seen a patient die of typhoid fever within five days from the onset of the
disease.
For their part, respondents offered the testimonies of Dr. Peter Gotiong and Dr. Ibarra
Panopio. Dr. Gotiong is a diplomate in internal medicine whose expertise is microbiology
and infectious diseases. He is also a consultant at the Cebu City Medical Center and an
associate professor of medicine at the South Western University College of Medicine in
Cebu City. He had treated over a thousand cases of typhoid patients. According to Dr.
Gotiong, the patients history and positive Widal Test results ratio of 1:320 would make
him suspect that the patient had typhoid fever. As to Dr. Vacalares observation regarding
the absence of ulceration in Jorges gastro-intestinal tract, Dr. Gotiong said that such
hyperplasia in the intestines of a typhoid victim may be microscopic. He noted that since
the toxic effect of typhoid fever may lead to meningitis, Dr. Vacalares autopsy should
have included an examination of the brain.[10]

The other doctor presented was Dr. Ibarra Panopio, a member of the American Board of
Pathology, examiner of the Philippine Board of Pathology from 1978 to 1991, fellow of the
Philippine Society of Pathologist, associate professor of the Cebu Institute of Medicine, and
chief pathologist of the Andres Soriano Jr. Memorial Hospital in Toledo City. Dr. Panopio
stated that although he was partial to the use of the culture test for its greater reliability
in the diagnosis of typhoid fever, the Widal Test may also be used. Like Dr. Gotiong, he
agreed that the 1:320 ratio in Jorges case was already the maximum by which a
conclusion of typhoid fever may be made. No additional information may be deduced from
a higher dilution.[11] He said that Dr. Vacalares autopsy on Jorge was incomplete and
thus inconclusive.
On September 12, 1991, the trial court rendered its decision absolving respondents from
the charges of negligence and dismissing petitioners action for damages. The trial court
likewise dismissed respondents counterclaim, holding that, in seeking damages from
respondents, petitioners were impelled by the honest belief that Jorges death was due to
the latters negligence.
Petitioners brought the matter to the Court of Appeals. On July 31, 1997, the Court of
Appeals affirmed the decision of the trial court.
Hence this petition.
Petitioners raise the following assignment of errors:
I. THE HONORABLE COURT OF APPEALS COMMITTED A REVERSIBLE ERROR WHEN IT
RULED THAT THE DOCTRINE OF RES IPSA LOQUITUR IS NOT APPLICABLE IN THE INSTANT
CASE.
II. THE HONORABLE COURT OF APPEALS COMMITTED REVERSIBLE ERROR WHEN IT MADE
AN UNFOUNDED ASSUMPTION THAT THE LEVEL OF MEDICAL PRACTICE IS LOWER IN
ILIGAN CITY.
III. THE HONORABLE COURT OF APPEALS GRAVELY ERRED WHEN IT RULED FOR A LESSER
STANDARD OF CARE AND DEGREE OF DILIGENCE FOR MEDICAL PRACTICE IN ILIGAN CITY
WHEN IT APPRECIATE[D] NO DOCTORS NEGLIGENCE IN THE TREATMENT OF JORGE
REYES.
Petitioners action is for medical malpractice. This is a particular form of negligence which
consists in the failure of a physician or surgeon to apply to his practice of medicine that
degree of care and skill which is ordinarily employed by the profession generally, under
similar conditions, and in like surrounding circumstances.[12] In order to successfully
pursue such a claim, a patient must prove that the physician or surgeon either failed to do
something which a reasonably prudent physician or surgeon would have done, or that he
or she did something that a reasonably prudent physician or surgeon would not have
done, and that the failure or action caused injury to the patient.[13] There are thus four
elements involved in medical negligence cases, namely: duty, breach, injury, and
proximate causation.
In the present case, there is no doubt that a physician-patient relationship existed
between respondent doctors and Jorge Reyes. Respondents were thus duty-bound to use
at least the same level of care that any reasonably competent doctor would use to treat a

condition under the same circumstances. It is breach of this duty which constitutes
actionable malpractice.[14] As to this aspect of medical malpractice, the determination of
the reasonable level of care and the breach thereof, expert testimony is essential.
Inasmuch as the causes of the injuries involved in malpractice actions are determinable
only in the light of scientific knowledge, it has been recognized that expert testimony is
usually necessary to support the conclusion as to causation.[15]
Res Ipsa Loquitur
There is a case when expert testimony may be dispensed with, and that is under the
doctrine of res ipsa loquitur. As held in Ramos v. Court of Appeals:[16]
Although generally, expert medical testimony is relied upon in malpractice suits to prove
that a physician has done a negligent act or that he has deviated from the standard
medical procedure, when the doctrine of res ipsa loquitor is availed by the plaintiff, the
need for expert medical testimony is dispensed with because the injury itself provides the
proof of negligence. The reason is that the general rule on the necessity of expert
testimony applies only to such matters clearly within the domain of medical science, and
not to matters that are within the common knowledge of mankind which may be testified
to by anyone familiar with the facts. Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has been treated or operated
upon with a reasonable degree of skill and care. However, testimony as to the statements
and acts of physicians and surgeons, external appearances, and manifest conditions
which are observable by any one may be given by non-expert witnesses. Hence, in cases
where the res ipsa loquitur is applicable, the court is permitted to find a physician
negligent upon proper proof of injury to the patient, without the aid of expert testimony,
where the court from its fund of common knowledge can determine the proper standard of
care. Where common knowledge and experience teach that a resulting injury would not
have occurred to the patient if due care had been exercised, an inference of negligence
may be drawn giving rise to an application of the doctrine of res ipsa loquitur without
medical evidence, which is ordinarily required to show not only what occurred but how
and why it occurred. When the doctrine is appropriate, all that the patient must do is
prove a nexus between the particular act or omission complained of and the injury
sustained while under the custody and management of the defendant without need to
produce expert medical testimony to establish the standard of care. Resort to res ipsa
loquitor is allowed because there is no other way, under usual and ordinary conditions, by
which the patient can obtain redress for injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following situations:
leaving of a foreign object in the body of the patient after an operation, injuries sustained
on a healthy part of the body which was not under, or in the area, of treatment, removal
of the wrong part of the body when another part was intended, knocking out a tooth while
a patients jaw was under anesthetic for the removal of his tonsils, and loss of an eye
while the patient was under the influence of anesthetic, during or following an operation
for appendicitis, among others.[17]
Petitioners asserted in the Court of Appeals that the doctrine of res ipsa loquitur applies to
the present case because Jorge Reyes was merely experiencing fever and chills for five
days and was fully conscious, coherent, and ambulant when he went to the hospital. Yet,
he died after only ten hours from the time of his admission.

This contention was rejected by the appellate court.


Petitioners now contend that all requisites for the application of res ipsa loquitur were
present, namely: (1) the accident was of a kind which does not ordinarily occur unless
someone is negligent; (2) the instrumentality or agency which caused the injury was
under the exclusive control of the person in charge; and (3) the injury suffered must not
have been due to any voluntary action or contribution of the person injured.[18]
The contention is without merit. We agree with the ruling of the Court of Appeals. In the
Ramos case, the question was whether a surgeon, an anesthesiologist, and a hospital
should be made liable for the comatose condition of a patient scheduled for
cholecystectomy.[19] In that case, the patient was given anesthesia prior to her
operation. Noting that the patient was neurologically sound at the time of her operation,
the Court applied the doctrine of res ipsa loquitur as mental brain damage does not
normally occur in a gallblader operation in the absence of negligence of the
anesthesiologist. Taking judicial notice that anesthesia procedures had become so
common that even an ordinary person could tell if it was administered properly, we
allowed the testimony of a witness who was not an expert. In this case, while it is true
that the patient died just a few hours after professional medical assistance was rendered,
there is really nothing unusual or extraordinary about his death. Prior to his admission, the
patient already had recurring fevers and chills for five days unrelieved by the analgesic,
antipyretic, and antibiotics given him by his wife. This shows that he had been suffering
from a serious illness and professional medical help came too late for him.
Respondents alleged failure to observe due care was not immediately apparent to a
layman so as to justify application of res ipsa loquitur. The question required expert
opinion on the alleged breach by respondents of the standard of care required by the
circumstances. Furthermore, on the issue of the correctness of her diagnosis, no
presumption of negligence can be applied to Dr. Marlyn Rico. As held in Ramos:
. . . . Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule
to be cautiously applied, depending upon the circumstances of each case. It is generally
restricted to situations in malpractice cases where a layman is able to say, as a matter of
common knowledge and observation, that the consequences of professional care were not
as such as would ordinarily have followed if due care had been exercised. A distinction
must be made between the failure to secure results, and the occurrence of something
more unusual and not ordinarily found if the service or treatment rendered followed the
usual procedure of those skilled in that particular practice. It must be conceded that the
doctrine of res ipsa loquitur can have no application in a suit against a physician or a
surgeon which involves the merits of a diagnosis or of a scientific treatment. The
physician or surgeon is not required at his peril to explain why any particular diagnosis
was not correct, or why any particular scientific treatment did not produce the desired
result.[20]
Specific Acts of Negligence
We turn to the question whether petitioners have established specific acts of negligence
allegedly committed by respondent doctors.
Petitioners contend that: (1) Dr. Marlyn Rico hastily and erroneously relied upon the Widal
test, diagnosed Jorges illness as typhoid fever, and immediately prescribed the

administration of the antibiotic chloromycetin;[21] and (2) Dr. Marvie Blanes erred in
ordering the administration of the second dose of 500 milligrams of chloromycetin barely
three hours after the first was given.[22] Petitioners presented the testimony of Dr.
Apolinar Vacalares, Chief Pathologist of the Northern Mindanao Training Hospital, Cagayan
de Oro City, who performed an autopsy on the body of Jorge Reyes. Dr. Vacalares testified
that, based on his findings during the autopsy, Jorge Reyes did not die of typhoid fever but
of shock undetermined, which could be due to allergic reaction or chloromycetin
overdose. We are not persuaded.
First. While petitioners presented Dr. Apolinar Vacalares as an expert witness, we do not
find him to be so as he is not a specialist on infectious diseases like typhoid fever.
Furthermore, although he may have had extensive experience in performing autopsies, he
admitted that he had yet to do one on the body of a typhoid victim at the time he
conducted the postmortem on Jorge Reyes. It is also plain from his testimony that he has
treated only about three cases of typhoid fever. Thus, he testified that:[23]
ATTY. PASCUAL: Q Why? Have you not testified earlier that you have never seen a patient
who died of typhoid fever?
A In autopsy. But, that was when I was a resident physician yet.
Q But you have not performed an autopsy of a patient who died of typhoid fever?
A I have not seen one.
Q And you testified that you have never seen a patient who died of typhoid fever within
five days?
A I have not seen one.
Q How many typhoid fever cases had you seen while you were in the general practice of
medicine?
A In our case we had no widal test that time so we cannot consider that the typhoid fever
is like this and like that. And the widal test does not specify the time of the typhoid fever.
Q The question is: how many typhoid fever cases had you seen in your general practice
regardless of the cases now you practice?
A I had only seen three cases.
Q And that was way back in 1964?
A Way back after my training in UP.
Q Clinically?
A Way back before my training.
He is thus not qualified to prove that Dr. Marlyn Rico erred in her diagnosis. Both lower
courts were therefore correct in discarding his testimony, which is really inadmissible.
In Ramos, the defendants presented the testimony of a pulmonologist to prove that brain
injury was due to oxygen deprivation after the patient had bronchospasms[24] triggered
by her allergic response to a drug,[25] and not due to faulty intubation by the
anesthesiologist. As the issue was whether the intubation was properly performed by an
anesthesiologist, we rejected the opinion of the pulmonologist on the ground that he was
not: (1) an anesthesiologist who could enlighten the court about anesthesia practice,
procedure, and their complications; nor (2) an allergologist who could properly advance
expert opinion on allergic mediated processes; nor (3) a pharmacologist who could explain
the pharmacologic and toxic effects of the drug allegedly responsible for the
bronchospasms.

Second. On the other hand, the two doctors presented by respondents clearly were
experts on the subject. They vouched for the correctness of Dr. Marlyn Ricos diagnosis.
Dr. Peter Gotiong, a diplomate whose specialization is infectious diseases and
microbiology and an associate professor at the Southwestern University College of
Medicine and the Gullas College of Medicine, testified that he has already treated over a
thousand cases of typhoid fever.[26] According to him, when a case of typhoid fever is
suspected, the Widal test is normally used,[27] and if the 1:320 results of the Widal test
on Jorge Reyes had been presented to him along with the patients history, his impression
would also be that the patient was suffering from typhoid fever.[28] As to the treatment of
the disease, he stated that chloromycetin was the drug of choice.[29] He also explained
that despite the measures taken by respondent doctors and the intravenous
administration of two doses of chloromycetin, complications of the disease could not be
discounted. His testimony is as follows:[30]
ATTY. PASCUAL: Q If with that count with the test of positive for 1 is to 320, what
treatment if any would be given?
A If those are the findings that would be presented to me, the first thing I would consider
would be typhoid fever.
Q And presently what are the treatments commonly used?
A Drug of choice of chloramphenical.
Q Doctor, if given the same patient and after you have administered chloramphenical
about 3 1/2 hours later, the patient associated with chills, temperature - 41oC, what could
possibly come to your mind?
A Well, when it is change in the clinical finding, you have to think of complication.
Q And what will you consider on the complication of typhoid?
A One must first understand that typhoid fever is toximia. The problem is complications
are caused by toxins produced by the bacteria . . . whether you have suffered
complications to think of -- heart toxic myocardities; then you can consider a toxic
meningitis and other complications and perforations and bleeding in the ilium.
Q Even that 40-year old married patient who received medication of chloromycetin of 500
milligrams intravenous, after the skin test, and received a second dose of chloromycetin
of 500 miligrams, 3 hours later, the patient developed chills . . . rise in temperature to
41oC, and then about 40 minutes later the temperature rose to 100oF, cardiac rate of 150
per minute who appeared to be coherent, restless, nauseating, with seizures: what
significance could you attach to these clinical changes?
A I would then think of toxemia, which was toxic meningitis and probably a toxic
meningitis because of the high cardiac rate.
Q Even if the same patient who, after having given intramuscular valium, became
conscious and coherent about 20 minutes later, have seizure and cyanosis and rolling of
eyeballs and vomitting . . . and death: what significance would you attach to this
development?
A We are probably dealing with typhoid to meningitis.
Q In such case, Doctor, what finding if any could you expect on the post-mortem
examination?
A No, the finding would be more on the meninges or covering of the brain.
Q And in order to see those changes would it require opening the skull?
A Yes.
As regards Dr. Vacalares finding during the autopsy that the deceaseds gastro-intestinal
tract was normal, Dr. Rico explained that, while hyperplasia[31] in the payers patches or

layers of the small intestines is present in typhoid fever, the same may not always be
grossly visible and a microscope was needed to see the texture of the cells.[32]
Respondents also presented the testimony of Dr. Ibarra T. Panopio who is a member of the
Philippine and American Board of Pathology, an examiner of the Philippine Board of
Pathology, and chief pathologist at the MetroCebu Community Hospital, Perpetual Succor
Hospital, and the Andres Soriano Jr. Memorial Medical Center. He stated that, as a clinical
pathologist, he recognized that the Widal test is used for typhoid patients, although he did
not encourage its use because a single test would only give a presumption necessitating
that the test be repeated, becoming more conclusive at the second and third weeks of the
disease.[33] He corroborated Dr. Gotiongs testimony that the danger with typhoid fever is
really the possible complications which could develop like perforation, hemorrhage, as
well as liver and cerebral complications.[34] As regards the 1:320 results of the Widal test
on Jorge Reyes, Dr. Panopio stated that no additional information could be obtained from a
higher ratio.[35] He also agreed with Dr. Gotiong that hyperplasia in the payers patches
may be microscopic.[36]
Indeed, the standard contemplated is not what is actually the average merit among all
known practitioners from the best to the worst and from the most to the least
experienced, but the reasonable average merit among the ordinarily good physicians.[37]
Here, Dr. Marlyn Rico did not depart from the reasonable standard recommended by the
experts as she in fact observed the due care required under the circumstances. Though
the Widal test is not conclusive, it remains a standard diagnostic test for typhoid fever
and, in the present case, greater accuracy through repeated testing was rendered
unobtainable by the early death of the patient. The results of the Widal test and the
patients history of fever with chills for five days, taken with the fact that typhoid fever
was then prevalent as indicated by the fact that the clinic had been getting about 15 to 20
typhoid cases a month, were sufficient to give upon any doctor of reasonable skill the
impression that Jorge Reyes had typhoid fever.
Dr. Rico was also justified in recommending the administration of the drug chloromycetin,
the drug of choice for typhoid fever. The burden of proving that Jorge Reyes was suffering
from any other illness rested with the petitioners. As they failed to present expert opinion
on this, preponderant evidence to support their contention is clearly absent.
Third. Petitioners contend that respondent Dr. Marvie Blanes, who took over from Dr. Rico,
was negligent in ordering the intravenous administration of two doses of 500 milligrams of
chloromycetin at an interval of less than three hours. Petitioners claim that Jorge Reyes
died of anaphylactic shock[38] or possibly from overdose as the second dose should have
been administered five to six hours after the first, per instruction of Dr. Marlyn Rico. As
held by the Court of Appeals, however:
That chloromycetin was likewise a proper prescription is best established by medical
authority. Wilson, et. al., in Harrisons Principle of Internal Medicine, 12th ed. write that
chlorampenicol (which is the generic of chloromycetin) is the drug of choice for typhoid
fever and that no drug has yet proven better in promoting a favorable clinical response.
Chlorampenicol (Chloromycetin) is specifically indicated for bacterial meningitis, typhoid
fever, rickettsial infections, bacteriodes infections, etc. (PIMS Annual, 1994, p. 211) The
dosage likewise including the first administration of five hundred milligrams (500 mg.) at
around nine oclock in the evening and the second dose at around 11:30 the same night
was still within medically acceptable limits, since the recommended dose of chloromycetin

is one (1) gram every six (6) hours. (cf. Pediatric Drug Handbook, 1st Ed., Philippine
Pediatric Society, Committee on Therapeutics and Toxicology, 1996). The intravenous
route is likewise correct. (Mansser, ONick, Pharmacology and Therapeutics) Even if the
test was not administered by the physician-on-duty, the evidence introduced that it was
Dra. Blanes who interpreted the results remain uncontroverted. (Decision, pp. 16-17)
Once more, this Court rejects any claim of professional negligence in this regard.
....
As regards anaphylactic shock, the usual way of guarding against it prior to the
administration of a drug, is the skin test of which, however, it has been observed: Skin
testing with haptenic drugs is generally not reliable. Certain drugs cause nonspecific
histamine release, producing a weal-and-flare reaction in normal individuals. Immunologic
activation of mast cells requires a polyvalent allergen, so a negative skin test to a
univalent haptenic drug does not rule out anaphylactic sensitivity to that drug. (Terr,
Anaphylaxis and Urticaria in Basic and Clinical Immunology, p. 349) What all this means
legally is that even if the deceased suffered from an anaphylactic shock, this, of itself,
would not yet establish the negligence of the appellee-physicians for all that the law
requires of them is that they perform the standard tests and perform standard
procedures. The law cannot require them to predict every possible reaction to all drugs
administered. The onus probandi was on the appellants to establish, before the trial court,
that the appellee-physicians ignored standard medical procedure, prescribed and
administered medication with recklessness and exhibited an absence of the competence
and skills expected of general practitioners similarly situated.[39]
Fourth. Petitioners correctly observe that the medical profession is one which, like the
business of a common carrier, is affected with public interest. Moreover, they assert that
since the law imposes upon common carriers the duty of observing extraordinary
diligence in the vigilance over the goods and for the safety of the passengers,[40]
physicians and surgeons should have the same duty toward their patients.[41] They also
contend that the Court of Appeals erred when it allegedly assumed that the level of
medical practice is lower in Iligan City, thereby reducing the standard of care and degree
of diligence required from physicians and surgeons in Iligan City.
The standard of extraordinary diligence is peculiar to common carriers. The Civil Code
provides:
Art. 1733. Common carriers, from the nature of their business and for reasons of public
policy, are bound to observe extraordinary diligence in the vigilance over the goods and
for the safety of the passengers transported by them, according to the circumstances of
each case. . . .
The practice of medicine is a profession engaged in only by qualified individuals. It is a
right earned through years of education, training, and by first obtaining a license from the
state through professional board examinations. Such license may, at any time and for
cause, be revoked by the government. In addition to state regulation, the conduct of
doctors is also strictly governed by the Hippocratic Oath, an ancient code of discipline and
ethical rules which doctors have imposed upon themselves in recognition and acceptance
of their great responsibility to society. Given these safeguards, there is no need to
expressly require of doctors the observance of extraordinary diligence. As it is now, the
practice of medicine is already conditioned upon the highest degree of diligence. And, as

we have already noted, the standard contemplated for doctors is simply the reasonable
average merit among ordinarily good physicians. That is reasonable diligence for doctors
or, as the Court of Appeals called it, the reasonable skill and competence . . . that a
physician in the same or similar locality . . . should apply.
WHEREFORE, the instant petition is DENIED and the decision of the Court of Appeals is
AFFIRMED.
SO ORDERED.

FIRST DIVISION
G.R. No. 124354
April 11, 2002
ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural guardians of
the minors, ROMMEL RAMOS, ROY RODERICK RAMOS, and RON RAYMOND RAMOS,
petitioners, vs. COURT OF APPEALS, DE LOS SANTOS MEDICAL CENTER, DR. ORLINO
HOSAKA and DR. PERFECTA GUTIERREZ, respondents.
RESOLUTION
KAPUNAN, J.:
Private respondents De Los Santos Medical Center, Dr. Orlino Hosaka and Dr. Perfecta
Gutierrez move for a reconsideration of the Decision, dated December 29, 1999, of this
Court holding them civilly liable for petitioner Erlinda Ramos comatose condition after she
delivered herself to them for their professional care and management.
For better understanding of the issues raised in private respondents respective motions,
we will briefly restate the facts of the case as follows:
Sometime in 1985, petitioner Erlinda Ramos, after seeking professional medical help, was
advised to undergo an operation for the removal of a stone in her gall bladder
(cholecystectomy). She was referred to Dr. Hosaka, a surgeon, who agreed to perform the
operation on her. The operation was scheduled for June 17, 1985 at 9:00 in the morning at
private respondent De Los Santos Medical Center (DLSMC). Since neither petitioner
Erlinda nor her husband, petitioner Rogelio, knew of any anesthesiologist, Dr. Hosaka
recommended to them the services of Dr. Gutierrez.
Petitioner Erlinda was admitted to the DLSMC the day before the scheduled operation. By
7:30 in the morning of the following day, petitioner Erlinda was already being prepared for
operation. Upon the request of petitioner Erlinda, her sister-in-law, Herminda Cruz, who
was then Dean of the College of Nursing at the Capitol Medical Center, was allowed to
accompany her inside the operating room.
At around 9:30 in the morning, Dr. Hosaka had not yet arrived so Dr. Gutierrez tried to get
in touch with him by phone. Thereafter, Dr. Gutierrez informed Cruz that the operation
might be delayed due to the late arrival of Dr. Hosaka. In the meantime, the patient,
petitioner Erlinda said to Cruz, "Mindy, inip na inip na ako, ikuha mo ako ng ibang Doctor."
By 10:00 in the morning, when Dr. Hosaka was still not around, petitioner Rogelio already
wanted to pull out his wife from the operating room. He met Dr. Garcia, who remarked
that he was also tired of waiting for Dr. Hosaka. Dr. Hosaka finally arrived at the hospital
at around 12:10 in the afternoon, or more than three (3) hours after the scheduled
operation.
Cruz, who was then still inside the operating room, heard about Dr. Hosakas arrival. While
she held the hand of Erlinda, Cruz saw Dr. Gutierrez trying to intubate the patient. Cruz
heard Dr. Gutierrez utter: "ang hirap ma-intubate nito, mali yata ang pagkakapasok. O
lumalaki ang tiyan." Cruz noticed a bluish discoloration of Erlindas nailbeds on her left
hand. She (Cruz) then heard Dr. Hosaka instruct someone to call Dr. Calderon, another
anesthesiologist. When he arrived, Dr. Calderon attempted to intubate the patient. The
nailbeds of the patient remained bluish, thus, she was placed in a trendelenburg position
a position where the head of the patient is placed in a position lower than her feet. At this

point, Cruz went out of the operating room to express her concern to petitioner Rogelio
that Erlindas operation was not going well.
Cruz quickly rushed back to the operating room and saw that the patient was still in
trendelenburg position. At almost 3:00 in the afternoon, she saw Erlinda being wheeled to
the Intensive Care Unit (ICU). The doctors explained to petitioner Rogelio that his wife had
bronchospasm. Erlinda stayed in the ICU for a month. She was released from the hospital
only four months later or on November 15, 1985. Since the ill-fated operation, Erlinda
remained in comatose condition until she died on August 3, 1999.1
Petitioners filed with the Regional Trial Court of Quezon City a civil case for damages
against private respondents. After due trial, the court a quo rendered judgment in favor of
petitioners. Essentially, the trial court found that private respondents were negligent in
the performance of their duties to Erlinda. On appeal by private respondents, the Court of
Appeals reversed the trial courts decision and directed petitioners to pay their "unpaid
medical bills" to private respondents.
Petitioners filed with this Court a petition for review on certiorari. The private respondents
were then required to submit their respective comments thereon. On December 29, 1999,
this Court promulgated the decision which private respondents now seek to be
reconsidered. The dispositive portion of said Decision states:
WHEREFORE, the decision and resolution of the appellate court appealed from are hereby
modified so as to award in favor of petitioners, and solidarily against private respondents
the following: 1) P1,352,000.00 as actual damages computed as of the date of
promulgation of this decision plus a monthly payment of P8,000.00 up to the time that
petitioner Erlinda Ramos expires or miraculously survives; 2) P2,000,000.00 as moral
damages, 3) P1,500,000.00 as temperate damages; 4) P100,000.00 each exemplary
damages and attorneys fees; and 5) the costs of the suit.2
In his Motion for Reconsideration, private respondent Dr. Hosaka submits the following as
grounds therefor:
I
THE HONORABLE SUPREME COURT COMMITTED REVERSIBLE ERROR WHEN IT HELD
RESPONDENT DR. HOSAKA LIABLE ON THE BASIS OF THE "CAPTAIN-OF-THE-SHIP"
DOCTRINE.
II
THE HONORABLE SUPREME COURT ERRED IN HOLDING RESPONDENT DR. HOSAKA LIABLE
DESPITE THE FACT THAT NO NEGLIGENCE CAN BE ATTRIBUTABLE TO HIM.
III
ASSUMING WITHOUT ADMITTING THAT RESPONDENT DR. HOSAKA IS LIABLE, THE
HONORABLE SUPREME COURT ERRED IN AWARDING DAMAGES THAT WERE CLEARLY
EXCESSIVE AND WITHOUT LEGAL BASIS.3
Private respondent Dr. Gutierrez, for her part, avers that:

IV
A. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY OVERLOOKED THE FACT
THAT THE COURT OF APPEALS DECISION DATED 29 MAY 1995 HAD ALREADY BECOME
FINAL AND EXECUTORY AS OF 25 JUNE 1995, THEREBY DEPRIVING THIS HONORABLE
COURT OF JURISDICTION OVER THE INSTANT PETITION;
B. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY OVERLOOKED SEVERAL
MATERIAL FACTUAL CIRCUMSTANCES WHICH, IF PROPERLY CONSIDERED, WOULD
INDUBITABLY LEAD TO NO OTHER CONCLUSION BUT THAT PRIVATE RESPONDENT
DOCTORS WERE NOT GUILTY OF ANY NEGLIGENCE IN RESPECT OF THE INSTANT CASE;
B.1 RESPONDENT DOCTOR PERFECTA GUTIERREZ HAS SUFFICIENTLY DISCHARGED THE
BURDEN OF EVIDENCE BY SUBSTANTIAL PROOF OF HER COMPLIANCE WITH THE
STANDARDS OF DUE CARE EXPECTED IN HER RESPECTIVE FIELD OF MEDICAL
SPECIALIZATION.
B.2 RESPONDENT DOCTOR PERFECTA GUTIERREZ HAS SUFFICIENTLY DISCHARGED THE
BURDEN OF EVIDENCE BY SUBSTANTIAL PROOF OF HER HAVING SUCCESSFULLY
INTUBATED PATIENT ERLINDA RAMOS
C. THE SUPREME COURT MAY HAVE INADVERTENTLY PLACED TOO MUCH RELIANCE ON THE
TESTIMONY OF PETITIONERS WITNESS HERMINDA CRUZ, DESPITE THE EXISTENCE OF
SEVERAL FACTUAL CIRCUMSTANCES WHICH RENDERS DOUBT ON HER CREDIBILITY
D. THE SUPREME COURT MAY HAVE INADVERTENTLY DISREGARDED THE EXPERT
TESTIMONY OF DR. JAMORA AND DRA. CALDERON

THE HONORABLE SUPREME COURT ERRED IN INCREASING THE AWARD OF DAMAGES IN


FAVOR OF PETITIONERS.5
In the Resolution of February 21, 2000, this Court denied the motions for reconsideration
of private respondents Drs. Hosaka and Gutierrez. They then filed their respective second
motions for reconsideration. The Philippine College of Surgeons filed its Petition-inIntervention contending in the main that this Court erred in holding private respondent Dr.
Hosaka liable under the captain of the ship doctrine. According to the intervenor, said
doctrine had long been abandoned in the United States in recognition of the
developments in modern medical and hospital practice.6 The Court noted these pleadings
in the Resolution of July 17, 2000.7
On March 19, 2001, the Court heard the oral arguments of the parties, including the
intervenor. Also present during the hearing were the amicii curiae: Dr. Felipe A. Estrella, Jr.,
Consultant of the Philippine Charity Sweepstakes, former Director of the Philippine
General Hospital and former Secretary of Health; Dr. Iluminada T. Camagay, President of
the Philippine Society of Anesthesiologists, Inc. and Professor and Vice-Chair for Research,
Department of Anesthesiology, College of Medicine-Philippine General Hospital, University
of the Philippines; and Dr. Lydia M. Egay, Professor and Vice-Chair for Academics,
Department of Anesthesiology, College of Medicine-Philippine General Hospital, University
of the Philippines.
The Court enumerated the issues to be resolved in this case as follows:
1. WHETHER OR NOT DR. ORLINO HOSAKA (SURGEON) IS LIABLE FOR NEGLIGENCE;

E. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY AWARDED DAMAGES TO


PETITIONERS DESPITE THE FACT THAT THERE WAS NO NEGLIGENCE ON THE PART OF
RESPONDENT DOCTOR.4
Private respondent De Los Santos Medical Center likewise moves for reconsideration on
the following grounds:

2. WHETHER OR NOT DR. PERFECTA GUTIERREZ (ANESTHESIOLOGIST) IS LIABLE FOR


NEGLIGENCE; AND
3. WHETHER OR NOT THE HOSPITAL (DELOS SANTOS MEDICAL CENTER) IS LIABLE FOR
ANY ACT OF NEGLIGENCE COMMITTED BY THEIR VISITING CONSULTANT SURGEON AND
ANESTHESIOLOGIST.8

I
THE HONORABLE COURT ERRED IN GIVING DUE COURSE TO THE INSTANT PETITION AS
THE DECISION OF THE HONORABLE COURT OF APPEALS HAD ALREADY BECOME FINAL
AND EXECUTORY
II
THE HONORABLE SUPREME COURT ERRED IN FINDING THAT AN EMPLOYER-EMPLOYEE
[RELATIONSHIP] EXISTS BETWEEN RESPONDENT DE LOS SANTOS MEDICAL CENTER AND
DRS. ORLINO HOSAKA AND PERFECTA GUTIERREZ
III
THE HONORABLE SUPREME COURT ERRED IN FINDING THAT RESPONDENT DE LOS
SANTOS MEDICAL CENTER IS SOLIDARILY LIABLE WITH RESPONDENT DOCTORS

We shall first resolve the issue pertaining to private respondent Dr. Gutierrez. She
maintains that the Court erred in finding her negligent and in holding that it was the faulty
intubation which was the proximate cause of Erlindas comatose condition. The following
objective facts allegedly negate a finding of negligence on her part: 1) That the outcome
of the procedure was a comatose patient and not a dead one; 2) That the patient had a
cardiac arrest; and 3) That the patient was revived from that cardiac arrest.9 In effect, Dr.
Gutierrez insists that, contrary to the finding of this Court, the intubation she performed
on Erlinda was successful.
Unfortunately, Dr. Gutierrez claim of lack of negligence on her part is belied by the
records of the case. It has been sufficiently established that she failed to exercise the
standards of care in the administration of anesthesia on a patient. Dr. Egay enlightened
the Court on what these standards are:
x x x What are the standards of care that an anesthesiologist should do before we
administer anesthesia? The initial step is the preparation of the patient for surgery and

this is a pre-operative evaluation because the anesthesiologist is responsible for


determining the medical status of the patient, developing the anesthesia plan and
acquainting the patient or the responsible adult particularly if we are referring with the
patient or to adult patient who may not have, who may have some mental handicaps of
the proposed plans. We do pre-operative evaluation because this provides for an
opportunity for us to establish identification and personal acquaintance with the patient. It
also makes us have an opportunity to alleviate anxiety, explain techniques and risks to
the patient, given the patient the choice and establishing consent to proceed with the
plan. And lastly, once this has been agreed upon by all parties concerned the ordering of
pre-operative medications. And following this line at the end of the evaluation we usually
come up on writing, documentation is very important as far as when we train an
anesthesiologist we always emphasize this because we need records for our protection,
well, records. And it entails having brief summary of patient history and physical findings
pertinent to anesthesia, plan, organize as a problem list, the plan anesthesia technique,
the plan post operative, pain management if appropriate, special issues for this particular
patient. There are needs for special care after surgery and if it so it must be written down
there and a request must be made known to proper authorities that such and such care is
necessary. And the request for medical evaluation if there is an indication. When we ask
for a cardio-pulmonary clearance it is not in fact to tell them if this patient is going to be
fit for anesthesia, the decision to give anesthesia rests on the anesthesiologist. What we
ask them is actually to give us the functional capacity of certain systems which maybe
affected by the anesthetic agent or the technique that we are going to use. But the
burden of responsibility in terms of selection of agent and how to administer it rest on the
anesthesiologist.10

consultations with, or pre-operative evaluation of Erlinda was done by her. Until the day of
the operation, respondent Dra. Gutierrez was unaware of the physiological make-up and
needs of Erlinda. She was likewise not properly informed of the possible difficulties she
would face during the administration of anesthesia to Erlinda. Respondent Dra. Gutierrez
act of seeing her patient for the first time only an hour before the scheduled operative
procedure was, therefore, an act of exceptional negligence and professional
irresponsibility. The measures cautioning prudence and vigilance in dealing with human
lives lie at the core of the physicians centuries-old Hippocratic Oath. Her failure to follow
this medical procedure is, therefore, a clear indicia of her negligence.16

The conduct of a preanesthetic/preoperative evaluation prior to an operation, whether


elective or emergency, cannot be dispensed with.11 Such evaluation is necessary for the
formulation of a plan of anesthesia care suited to the needs of the patient concerned.

How do you mean by that, a comatose, a comatose after any other acts were done by Dr.
Gutierrez or comatose before any act was done by her?

Further, there is no cogent reason for the Court to reverse its finding that it was the faulty
intubation on Erlinda that caused her comatose condition. There is no question that
Erlinda became comatose after Dr. Gutierrez performed a medical procedure on her. Even
the counsel of Dr. Gutierrez admitted to this fact during the oral arguments:
CHIEF JUSTICE:
Mr. Counsel, you started your argument saying that this involves a comatose patient?
ATTY. GANA:
Yes, Your Honor.
CHIEF JUSTICE:

ATTY. GANA:
Pre-evaluation for anesthesia involves taking the patients medical history, reviewing his
current drug therapy, conducting physical examination, interpreting laboratory data, and
determining the appropriate prescription of preoperative medications as necessary to the
conduct of anesthesia.12
Physical examination of the patient entails not only evaluating the patients central
nervous system, cardiovascular system and lungs but also the upper airway. Examination
of the upper airway would in turn include an analysis of the patients cervical spine
mobility, temporomandibular mobility, prominent central incisors, deceased or artificial
teeth, ability to visualize uvula and the thyromental distance.13

No, we meant comatose as a final outcome of the procedure.


CHIEF JUSTICE:
Meaning to say, the patient became comatose after some intervention, professional acts
have been done by Dr. Gutierrez?
ATTY. GANA:
Yes, Your Honor.

Nonetheless, Dr. Gutierrez omitted to perform a thorough preoperative evaluation on


Erlinda. As she herself admitted, she saw Erlinda for the first time on the day of the
operation itself, one hour before the scheduled operation. She auscultated14 the patients
heart and lungs and checked the latters blood pressure to determine if Erlinda was
indeed fit for operation.15 However, she did not proceed to examine the patients airway.
Had she been able to check petitioner Erlindas airway prior to the operation, Dr. Gutierrez
would most probably not have experienced difficulty in intubating the former, and thus
the resultant injury could have been avoided. As we have stated in our Decision:

CHIEF JUSTICE:
In other words, the comatose status was a consequence of some acts performed by D.
Gutierrez?
ATTY. GANA:
It was a consequence of the well, (interrupted)

In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda for the first
time on the day of the operation itself, on 17 June 1985. Before this date, no prior

CHIEF JUSTICE:

An acts performed by her, is that not correct?


ATTY. GANA:
Yes, Your Honor.
CHIEF JUSTICE:

some of the more common accompanying signs of an allergic reaction appears on


record. No laboratory data were ever presented to the court."21
Dr. Gutierrez, however, insists that she successfully intubated Erlinda as evidenced by the
fact that she was revived after suffering from cardiac arrest. Dr. Gutierrez faults the Court
for giving credence to the testimony of Cruz on the matter of the administration of
anesthesia when she (Cruz), being a nurse, was allegedly not qualified to testify thereon.
Rather, Dr. Gutierrez invites the Courts attention to her synopsis on what transpired
during Erlindas intubation:

Thank you.17
What is left to be determined therefore is whether Erlindas hapless condition was due to
any fault or negligence on the part of Dr. Gutierrez while she (Erlinda) was under the
latters care. Dr. Gutierrez maintains that the bronchospasm and cardiac arrest resulting in
the patients comatose condition was brought about by the anaphylactic reaction of the
patient to Thiopental Sodium (pentothal).18 In the Decision, we explained why we found
Dr. Gutierrez theory unacceptable. In the first place, Dr. Eduardo Jamora, the witness who
was presented to support her (Dr. Gutierrez) theory, was a pulmonologist. Thus, he could
not be considered an authority on anesthesia practice and procedure and their
complications.19
Secondly, there was no evidence on record to support the theory that Erlinda developed
an allergic reaction to pentothal. Dr. Camagay enlightened the Court as to the
manifestations of an allergic reaction in this wise:
DR. CAMAGAY:

12:15 p.m. Patient was inducted with sodium pentothal 2.5% (250 mg) given by slow IV.
02 was started by mask. After pentothal injection this was followed by IV injection of
Norcuron 4mg. After 2 minutes 02 was given by positive pressure for about one minute.
Intubation with endotracheal tube 7.5 m in diameter was done with slight difficulty (short
neck & slightly prominent upper teeth) chest was examined for breath sounds & checked
if equal on both sides. The tube was then anchored to the mouth by plaster & cuff
inflated. Ethrane 2% with 02 4 liters was given. Blood pressure was checked 120/80 &
heart rate regular and normal 90/min.
12:25 p.m. After 10 minutes patient was cyanotic. Ethrane was discontinued & 02 given
alone. Cyanosis disappeared. Blood pressure and heart beats stable.
12:30 p.m. Cyanosis again reappeared this time with sibilant and sonorous rales all over
the chest. D_5%_H20 & 1 ampule of aminophyline by fast drip was started. Still the
cyanosis was persistent. Patient was connected to a cardiac monitor. Another ampule of of
[sic] aminophyline was given and solu cortef was given.

All right, let us qualify an allergic reaction. In medical terminology an allergic reaction is
something which is not usual response and it is further qualified by the release of a
hormone called histamine and histamine has an effect on all the organs of the body
generally release because the substance that entered the body reacts with the particular
cell, the mass cell, and the mass cell secretes this histamine. In a way it is some form of
response to take away that which is not mine, which is not part of the body. So, histamine
has multiple effects on the body. So, one of the effects as you will see you will have
redness, if you have an allergy you will have tearing of the eyes, you will have swelling,
very crucial swelling sometimes of the larynges which is your voice box main airway, that
swelling may be enough to obstruct the entry of air to the trachea and you could also
have contraction, constriction of the smaller airways beyond the trachea, you see you
have the trachea this way, we brought some visual aids but unfortunately we do not have
a projector. And then you have the smaller airways, the bronchi and then eventually into
the mass of the lungs you have the bronchus. The difference is that these tubes have also
in their walls muscles and this particular kind of muscles is smooth muscle so, when
histamine is released they close up like this and that phenomenon is known as bronco
spasm. However, the effects of histamine also on blood vessels are different. They dilate
blood vessel open up and the patient or whoever has this histamine release has
hypertension or low blood pressure to a point that the patient may have decrease blood
supply to the brain and may collapse so, you may have people who have this.20

12:40 p.m. There was cardiac arrest. Extra cardiac massage and intercardiac injection of
adrenalin was given & heart beat reappeared in less than one minute. Sodium bicarbonate
& another dose of solu cortef was given by IV. Cyanosis slowly disappeared & 02
continuously given & assisted positive pressure. Laboratory exams done (see results in
chart).

These symptoms of an allergic reaction were not shown to have been extant in Erlindas
case. As we held in our Decision, "no evidence of stridor, skin reactions, or wheezing

DR. ESTRELLA
Q
You mentioned that there were two (2) attempts in the intubation period?
DR. GUTIERREZ: Yes.

Patient was transferred to ICU for further management.22


From the foregoing, it can be allegedly seen that there was no withdrawal (extubation) of
the tube. And the fact that the cyanosis allegedly disappeared after pure oxygen was
supplied through the tube proved that it was properly placed.
The Court has reservations on giving evidentiary weight to the entries purportedly
contained in Dr. Gutierrez synopsis. It is significant to note that the said record prepared
by Dr. Gutierrez was made only after Erlinda was taken out of the operating room. The
standard practice in anesthesia is that every single act that the anesthesiologist performs
must be recorded. In Dr. Gutierrez case, she could not account for at least ten (10)
minutes of what happened during the administration of anesthesia on Erlinda. The
following exchange between Dr. Estrella, one of the amicii curiae, and Dr. Gutierrez is
instructive:

Q
There were two attempts. In the first attempt was the tube inserted or was the
laryngoscope only inserted, which was inserted?
A
All the laryngoscope.
Q
All the laryngoscope. But if I remember right somewhere in the re-direct, a certain
lawyer, you were asked that you did a first attempt and the question was did you
withdraw the tube? And you said you never withdrew the tube, is that right?
A
Yes.
Q
Yes. And so if you never withdrew the tube then there was no, there was no
insertion of the tube during that first attempt. Now, the other thing that we have to settle
here is when cyanosis occurred, is it recorded in the anesthesia record when the
cyanosis, in your recording when did the cyanosis occur?
A
(sic)
Q
Is it a standard practice of anesthesia that whatever you do during that period or
from the time of induction to the time that you probably get the patient out of the
operating room that every single action that you do is so recorded in your anesthesia
record?
A
I was not able to record everything I did not have time anymore because I did that
after the, when the patient was about to leave the operating room. When there was
second cyanosis already that was the (interrupted)
Q
When was the first cyanosis?
A
The first cyanosis when I was (interrupted)
Q
What time, more or less?
A
I think it was 12:15 or 12:16.
Q
Well, if the record will show you started induction at 12:15?
A
Yes, Your Honor.
Q
And the first medication you gave was what?
A
The first medication, no, first the patient was oxygenated for around one to two
minutes.
Q
Yes, so, that is about 12:13?
A
Yes, and then, I asked the resident physician to start giving the pentothal very
slowly and that was around one minute.
Q
So, that is about 12:13 no, 12:15, 12:17?
A
Yes, and then, after one minute another oxygenation was given and after
(interrupted)
Q
12:18?
A
Yes, and then after giving the oxygen we start the menorcure which is a relaxant.
After that relaxant (interrupted)
Q
After that relaxant, how long do you wait before you do any manipulation?
A
Usually you wait for two minutes or three minutes.
Q
So, if our estimate of the time is accurate we are now more or less 12:19, is that
right?
A
Maybe.
Q
12:19. And at that time, what would have been done to this patient?
A
After that time you examine the, if there is relaxation of the jaw which you push it
downwards and when I saw that the patient was relax because that monorcure is a
relaxant, you cannot intubate the patient or insert the laryngoscope if it is not keeping
him relax. So, my first attempt when I put the laryngoscope on I saw the trachea was
deeply interiorly. So, what I did ask "mahirap ata ito ah." So, I removed the laryngoscope
and oxygenated again the patient.
Q
So, more or less you attempted to do an intubation after the first attempt as you
claimed that it was only the laryngoscope that was inserted.

A
Yes.
Q
And in the second attempt you inserted the laryngoscope and now possible
intubation?
A
Yes.
Q
And at that point, you made a remark, what remark did you make?
A
I said "mahirap ata ito" when the first attempt I did not see the trachea right away.
That was when I (interrupted)
Q
That was the first attempt?
A
Yes.
Q
What about the second attempt?
A
On the second attempt I was able to intubate right away within two to three
seconds.
Q
At what point, for purposes of discussion without accepting it, at what point did
you make the comment "na mahirap ata to intubate, mali ata ang pinasukan"
A
I did not say "mali ata ang pinasukan" I never said that.
Q
Well, just for the information of the group here the remarks I am making is based
on the documents that were forwarded to me by the Supreme Court. That is why for
purposes of discussion I am trying to clarify this for the sake of enlightenment. So, at what
point did you ever make that comment?
A
Which one, sir?
Q
The "mahirap intubate ito" assuming that you (interrupted)
A
Iyon lang, that is what I only said "mahirap intubate (interrupted)
Q
At what point?
A
When the first attempt when I inserted the laryngoscope for the first time.
Q
So, when you claim that at the first attempt you inserted the laryngoscope, right?
A
Yes.
Q
But in one of the recordings somewhere at the, somewhere in the transcript of
records that when the lawyer of the other party try to inquire from you during the first
attempt that was the time when "mayroon ba kayong hinugot sa tube, I do not remember
the page now, but it seems to me it is there. So, that it was on the second attempt that
(interrupted)
A
I was able to intubate.
Q
And this is more or less about what time 12:21?
A
Maybe, I cannot remember the time, Sir.
Q
Okay, assuming that this was done at 12:21 and looking at the anesthesia records
from 12:20 to 12:30 there was no recording of the vital signs. And can we presume that at
this stage there was already some problems in handling the patient?
A
Not yet.
Q
But why are there no recordings in the anesthesia record?
A
I did not have time.
Q
Ah, you did not have time, why did you not have time?
A
Because it was so fast, I really (at this juncture the witness is laughing)
Q
No, I am just asking. Remember I am not here not to pin point on anybody I am
here just to more or less clarify certainty more ore less on the record.
A
Yes, Sir.
Q
And so it seems that there were no recording during that span of ten (10) minutes.
From 12:20 to 12:30, and going over your narration, it seems to me that the cyanosis
appeared ten (10) minutes after induction, is that right?
A
Yes.
Q
And that is after induction 12:15 that is 12:25 that was the first cyanosis?
A
Yes.

Q
And that the 12:25 is after the 12:20?
A
We cannot (interrupted)
Q
Huwag ho kayong makuwan, we are just trying to enlighten, I am just going over
the record ano, kung mali ito kuwan eh di ano. So, ganoon po ano, that it seems to me
that there is no recording from 12:20 to 12:30, so, I am just wondering why there were no
recordings during the period and then of course the second cyanosis, after the first
cyanosis. I think that was the time Dr. Hosaka came in?
A
No, the first cyanosis (interrupted).23
We cannot thus give full credence to Dr. Gutierrez synopsis in light of her admission that
it does not fully reflect the events that transpired during the administration of anesthesia
on Erlinda. As pointed out by Dr. Estrella, there was a ten-minute gap in Dr. Gutierrez
synopsis, i.e., the vital signs of Erlinda were not recorded during that time. The absence of
these data is particularly significant because, as found by the trial court, it was the
absence of oxygen supply for four (4) to five (5) minutes that caused Erlindas comatose
condition.
On the other hand, the Court has no reason to disbelieve the testimony of Cruz. As we
stated in the Decision, she is competent to testify on matters which she is capable of
observing such as, the statements and acts of the physician and surgeon, external
appearances and manifest conditions which are observable by any one.24 Cruz, Erlindas
sister-in-law, was with her inside the operating room. Moreover, being a nurse and Dean
of the Capitol Medical Center School of Nursing at that, she is not entirely ignorant of
anesthetic procedure. Cruz narrated that she heard Dr. Gutierrez remark, "Ang hirap maintubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan." She observed that the
nailbeds of Erlinda became bluish and thereafter Erlinda was placed in trendelenburg
position.25 Cruz further averred that she noticed that the abdomen of Erlinda became
distended.26
The cyanosis (bluish discoloration of the skin or mucous membranes caused by lack of
oxygen or abnormal hemoglobin in the blood) and enlargement of the stomach of Erlinda
indicate that the endotracheal tube was improperly inserted into the esophagus instead of
the trachea. Consequently, oxygen was delivered not to the lungs but to the
gastrointestinal tract. This conclusion is supported by the fact that Erlinda was placed in
trendelenburg position. This indicates that there was a decrease of blood supply to the
patients brain. The brain was thus temporarily deprived of oxygen supply causing Erlinda
to go into coma.
The injury incurred by petitioner Erlinda does not normally happen absent any negligence
in the administration of anesthesia and in the use of an endotracheal tube. As was noted
in our Decision, the instruments used in the administration of anesthesia, including the
endotracheal tube, were all under the exclusive control of private respondents Dr.
Gutierrez and Dr. Hosaka.27 In Voss vs. Bridwell,28 which involved a patient who suffered
brain damage due to the wrongful administration of anesthesia, and even before the
scheduled mastoid operation could be performed, the Kansas Supreme Court applied the
doctrine of res ipsa loquitur, reasoning that the injury to the patient therein was one which
does not ordinarily take place in the absence of negligence in the administration of an
anesthetic, and in the use and employment of an endotracheal tube. The court went on to
say that "[o]rdinarily a person being put under anesthesia is not rendered decerebrate as
a consequence of administering such anesthesia in the absence of negligence. Upon
these facts and under these circumstances, a layman would be able to say, as a matter of

common knowledge and observation, that the consequences of professional treatment


were not as such as would ordinarily have followed if due care had been exercised."29
Considering the application of the doctrine of res ipsa loquitur, the testimony of Cruz was
properly given credence in the case at bar.
For his part, Dr. Hosaka mainly contends that the Court erred in finding him negligent as a
surgeon by applying the Captain-of-the-Ship doctrine.30 Dr. Hosaka argues that the trend
in United States jurisprudence has been to reject said doctrine in light of the
developments in medical practice. He points out that anesthesiology and surgery are two
distinct and specialized fields in medicine and as a surgeon, he is not deemed to have
control over the acts of Dr. Gutierrez. As anesthesiologist, Dr. Gutierrez is a specialist in
her field and has acquired skills and knowledge in the course of her training which Dr.
Hosaka, as a surgeon, does not possess.31 He states further that current American
jurisprudence on the matter recognizes that the trend towards specialization in medicine
has created situations where surgeons do not always have the right to control all
personnel within the operating room,32 especially a fellow specialist.33
Dr. Hosaka cites the case of Thomas v. Raleigh General Hospital,34 which involved a suit
filed by a patient who lost his voice due to the wrongful insertion of the endotracheal tube
preparatory to the administration of anesthesia in connection with the laparotomy to be
conducted on him. The patient sued both the anesthesiologist and the surgeon for the
injury suffered by him. The Supreme Court of Appeals of West Virginia held that the
surgeon could not be held liable for the loss of the patients voice, considering that the
surgeon did not have a hand in the intubation of the patient. The court rejected the
application of the "Captain-of-the-Ship Doctrine," citing the fact that the field of medicine
has become specialized such that surgeons can no longer be deemed as having control
over the other personnel in the operating room. It held that "[a]n assignment of liability
based on actual control more realistically reflects the actual relationship which exists in a
modern operating room."35 Hence, only the anesthesiologist who inserted the
endotracheal tube into the patients throat was held liable for the injury suffered by the
latter.
This contention fails to persuade.
That there is a trend in American jurisprudence to do away with the Captain-of-the-Ship
doctrine does not mean that this Court will ipso facto follow said trend. Due regard for the
peculiar factual circumstances obtaining in this case justify the application of the Captainof-the-Ship doctrine. From the facts on record it can be logically inferred that Dr. Hosaka
exercised a certain degree of, at the very least, supervision over the procedure then being
performed on Erlinda.
First, it was Dr. Hosaka who recommended to petitioners the services of Dr. Gutierrez. In
effect, he represented to petitioners that Dr. Gutierrez possessed the necessary
competence and skills. Drs. Hosaka and Gutierrez had worked together since 1977.
Whenever Dr. Hosaka performed a surgery, he would always engage the services of Dr.
Gutierrez to administer the anesthesia on his patient.36
Second, Dr. Hosaka himself admitted that he was the attending physician of Erlinda. Thus,
when Erlinda showed signs of cyanosis, it was Dr. Hosaka who gave instructions to call for
another anesthesiologist and cardiologist to help resuscitate Erlinda.37

Third, it is conceded that in performing their responsibilities to the patient, Drs. Hosaka
and Gutierrez worked as a team. Their work cannot be placed in separate watertight
compartments because their duties intersect with each other.38
While the professional services of Dr. Hosaka and Dr. Gutierrez were secured primarily for
their performance of acts within their respective fields of expertise for the treatment of
petitioner Erlinda, and that one does not exercise control over the other, they were
certainly not completely independent of each other so as to absolve one from the
negligent acts of the other physician.
That they were working as a medical team is evident from the fact that Dr. Hosaka was
keeping an eye on the intubation of the patient by Dr. Gutierrez, and while doing so, he
observed that the patients nails had become dusky and had to call Dr. Gutierrezs
attention thereto. The Court also notes that the counsel for Dr. Hosaka admitted that in
practice, the anesthesiologist would also have to observe the surgeons acts during the
surgical process and calls the attention of the surgeon whenever necessary39 in the
course of the treatment. The duties of Dr. Hosaka and those of Dr. Gutierrez in the
treatment of petitioner Erlinda are therefore not as clear-cut as respondents claim them to
be. On the contrary, it is quite apparent that they have a common responsibility to treat
the patient, which responsibility necessitates that they call each others attention to the
condition of the patient while the other physician is performing the necessary medical
procedures.

will not be in control of his body there could be adverse results to surgery and he will be
opened up; a knife is going to open up his body. x x x42
Dr. Hosaka cannot now claim that he was entirely blameless of what happened to Erlinda.
His conduct clearly constituted a breach of his professional duties to Erlinda:
CHIEF JUSTICE:
Two other points. The first, Doctor, you were talking about anxiety, would you consider a
patient's stay on the operating table for three hours sufficient enough to aggravate or
magnify his or her anxiety?
DR. CAMAGAY:
Yes.
CHIEF JUSTICE:
In other words, I understand that in this particular case that was the case, three hours
waiting and the patient was already on the operating table (interrupted)
DR. CAMAGAY:

It is equally important to point out that Dr. Hosaka was remiss in his duty of attending to
petitioner Erlinda promptly, for he arrived more than three (3) hours late for the scheduled
operation. The cholecystectomy was set for June 17, 1985 at 9:00 a.m., but he arrived at
DLSMC only at around 12:10 p.m. In reckless disregard for his patients well being, Dr.
Hosaka scheduled two procedures on the same day, just thirty minutes apart from each
other, at different hospitals. Thus, when the first procedure (protoscopy) at the Sta.
Teresita Hospital did not proceed on time, Erlinda was kept in a state of uncertainty at the
DLSMC.

Yes.

The unreasonable delay in petitioner Erlindas scheduled operation subjected her to


continued starvation and consequently, to the risk of acidosis,40 or the condition of
decreased alkalinity of the blood and tissues, marked by sickly sweet breath, headache,
nausea and vomiting, and visual disturbances.41 The long period that Dr. Hosaka made
Erlinda wait for him certainly aggravated the anxiety that she must have been feeling at
the time. It could be safely said that her anxiety adversely affected the administration of
anesthesia on her. As explained by Dr. Camagay, the patients anxiety usually causes the
outpouring of adrenaline which in turn results in high blood pressure or disturbances in
the heart rhythm:

That this operation did not take place as scheduled is already a source of anxiety and
most operating tables are very narrow and that patients are usually at risk of falling on
the floor so there are restraints that are placed on them and they are never, never left
alone in the operating room by themselves specially if they are already pre-medicated
because they may not be aware of some of their movement that they make which would
contribute to their injury.

CHIEF JUSTICE:
Would you therefore conclude that the surgeon contributed to the aggravation of the
anxiety of the patient?
DR. CAMAGAY:

CHIEF JUSTICE:
In other words due diligence would require a surgeon to come on time?

DR. CAMAGAY:
DR. CAMAGAY:
x x x Pre-operative medication has three main functions: One is to alleviate anxiety.
Second is to dry up the secretions and Third is to relieve pain. Now, it is very important to
alleviate anxiety because anxiety is associated with the outpouring of certain substances
formed in the body called adrenalin. When a patient is anxious there is an outpouring of
adrenalin which would have adverse effect on the patient. One of it is high blood pressure,
the other is that he opens himself to disturbances in the heart rhythm, which would have
adverse implications. So, we would like to alleviate patients anxiety mainly because he

I think it is not even due diligence it is courtesy.


CHIEF JUSTICE:
Courtesy.

DR. CAMAGAY:
And care.
CHIEF JUSTICE:
Duty as a matter of fact?
DR. CAMAGAY:
Yes, Your Honor.43
Dr. Hosaka's irresponsible conduct of arriving very late for the scheduled operation of
petitioner Erlinda is violative, not only of his duty as a physician "to serve the interest of
his patients with the greatest solicitude, giving them always his best talent and skill,"44
but also of Article 19 of the Civil Code which requires a person, in the performance of his
duties, to act with justice and give everyone his due.
Anent private respondent DLSMCs liability for the resulting injury to petitioner Erlinda, we
held that respondent hospital is solidarily liable with respondent doctors therefor under
Article 2180 of the Civil Code45 since there exists an employer-employee relationship
between private respondent DLSMC and Drs. Gutierrez and Hosaka:
In other words, private hospitals, hire, fire and exercise real control over their attending
and visiting "consultant" staff. While "consultants" are not, technically employees, x x x
the control exercised, the hiring and the right to terminate consultants all fulfill the
important hallmarks of an employer-employee relationship, with the exception of the
payment of wages. In assessing whether such a relationship in fact exists, the control test
is determining. x x x46
DLSMC however contends that applying the four-fold test in determining whether such a
relationship exists between it and the respondent doctors, the inescapable conclusion is
that DLSMC cannot be considered an employer of the respondent doctors.
It has been consistently held that in determining whether an employer-employee
relationship exists between the parties, the following elements must be present: (1)
selection and engagement of services; (2) payment of wages; (3) the power to hire and
fire; and (4) the power to control not only the end to be achieved, but the means to be
used in reaching such an end.47
DLSMC maintains that first, a hospital does not hire or engage the services of a
consultant, but rather, accredits the latter and grants him or her the privilege of
maintaining a clinic and/or admitting patients in the hospital upon a showing by the
consultant that he or she possesses the necessary qualifications, such as accreditation by
the appropriate board (diplomate), evidence of fellowship and references.48 Second, it is
not the hospital but the patient who pays the consultants fee for services rendered by the
latter.49 Third, a hospital does not dismiss a consultant; instead, the latter may lose his or
her accreditation or privileges granted by the hospital.50 Lastly, DLSMC argues that when
a doctor refers a patient for admission in a hospital, it is the doctor who prescribes the
treatment to be given to said patient. The hospitals obligation is limited to providing the
patient with the preferred room accommodation, the nutritional diet and medications

prescribed by the doctor, the equipment and facilities necessary for the treatment of the
patient, as well as the services of the hospital staff who perform the ministerial tasks of
ensuring that the doctors orders are carried out strictly.51
After a careful consideration of the arguments raised by DLSMC, the Court finds that
respondent hospitals position on this issue is meritorious. There is no employer-employee
relationship between DLSMC and Drs. Gutierrez and Hosaka which would hold DLSMC
solidarily liable for the injury suffered by petitioner Erlinda under Article 2180 of the Civil
Code.
As explained by respondent hospital, that the admission of a physician to membership in
DLSMCs medical staff as active or visiting consultant is first decided upon by the
Credentials Committee thereof, which is composed of the heads of the various specialty
departments such as the Department of Obstetrics and Gynecology, Pediatrics, Surgery
with the department head of the particular specialty applied for as chairman. The
Credentials Committee then recommends to DLSMC's Medical Director or Hospital
Administrator the acceptance or rejection of the applicant physician, and said director or
administrator validates the committee's recommendation.52 Similarly, in cases where a
disciplinary action is lodged against a consultant, the same is initiated by the department
to whom the consultant concerned belongs and filed with the Ethics Committee consisting
of the department specialty heads. The medical director/hospital administrator merely
acts as ex-officio member of said committee.
Neither is there any showing that it is DLSMC which pays any of its consultants for
medical services rendered by the latter to their respective patients. Moreover, the
contract between the consultant in respondent hospital and his patient is separate and
distinct from the contract between respondent hospital and said patient. The first has for
its object the rendition of medical services by the consultant to the patient, while the
second concerns the provision by the hospital of facilities and services by its staff such as
nurses and laboratory personnel necessary for the proper treatment of the patient.
Further, no evidence was adduced to show that the injury suffered by petitioner Erlinda
was due to a failure on the part of respondent DLSMC to provide for hospital facilities and
staff necessary for her treatment.
For these reasons, we reverse the finding of liability on the part of DLSMC for the injury
suffered by petitioner Erlinda.
Finally, the Court also deems it necessary to modify the award of damages to petitioners
in view of the supervening event of petitioner Erlindas death. In the assailed Decision, the
Court awarded actual damages of One Million Three Hundred Fifty Two Thousand Pesos
(P1,352,000.00) to cover the expenses for petitioner Erlindas treatment and care from
the date of promulgation of the Decision up to the time the patient expires or survives.53
In addition thereto, the Court awarded temperate damages of One Million Five Hundred
Thousand Pesos (P1,500,000.00) in view of the chronic and continuing nature of petitioner
Erlindas injury and the certainty of further pecuniary loss by petitioners as a result of said
injury, the amount of which, however, could not be made with certainty at the time of the
promulgation of the decision. The Court justified such award in this manner:
Our rules on actual or compensatory damages generally assume that at the time of
litigation, the injury suffered as a consequence of an act of negligence has been

completed and that the cost can be liquidated. However, these provisions neglect to take
into account those situations, as in this case, where the resulting injury might be
continuing and possible future complications directly arising from the injury, while certain
to occur, are difficult to predict.
In these cases, the amount of damages which should be awarded, if they are to
adequately and correctly respond to the injury caused, should be one which compensates
for pecuniary loss incurred and proved, up to the time of trial; and one which would meet
pecuniary loss certain to be suffered but which could not, from the nature of the case, be
made with certainty. In other words, temperate damages can and should be awarded on
top of actual or compensatory damages in instances where the injury is chronic and
continuing. And because of the unique nature of such cases, no incompatibility arises
when both actual and temperate damages are provided for. The reason is that these
damages cover two distinct phases.
As it would not be equitableand certainly not in the best interests of the administration
of justicefor the victim in such cases to constantly come before the courts and invoke
their aid in seeking adjustments to the compensatory damages previously awarded
temperate damages are appropriate. The amount given as temperate damages, though to
a certain extent speculative, should take into account the cost of proper care.
In the instant case, petitioners were able to provide only home-based nursing care for a
comatose patient who has remained in that condition for over a decade. Having premised
our award for compensatory damages on the amount provided by petitioners at the onset
of litigation, it would be now much more in step with the interests of justice if the value
awarded for temperate damages would allow petitioners to provide optimal care for their
loved one in a facility which generally specializes in such care. They should not be
compelled by dire circumstances to provide substandard care at home without the aid of
professionals, for anything less would be grossly inadequate. Under the circumstances, an
award of P1,500,000.00 in temperate damages would therefore be reasonable.54
However, subsequent to the promulgation of the Decision, the Court was informed by
petitioner Rogelio that petitioner Erlinda died on August 3, 1999.55 In view of this
supervening event, the award of temperate damages in addition to the actual or
compensatory damages would no longer be justified since the actual damages awarded in
the Decision are sufficient to cover the medical expenses incurred by petitioners for the
patient. Hence, only the amounts representing actual, moral and exemplary damages,
attorneys fees and costs of suit should be awarded to petitioners.
WHEREFORE, the assailed Decision is hereby modified as follows:
(1) Private respondent De Los Santos Medical Center is hereby absolved from liability
arising from the injury suffered by petitioner Erlinda Ramos on June 17, 1985;
(2) Private respondents Dr. Orlino Hosaka and Dr. Perfecta Gutierrez are hereby declared
to be solidarily liable for the injury suffered by petitioner Erlinda on June 17, 1985 and are
ordered to pay petitioners
(a) P1,352,000.00 as actual damages;
(b) P2,000,000.00 as moral damages;

(c) P100,000.00 as exemplary damages;


(d) P100,000.00 as attorneys fees; and
(e) the costs of the suit.
SO ORDERED.

A.M. No. 2005-08-SC December 9, 2005


SAMUEL R. RUEZ, JR., Complainant, vs. MARYBETH V. JURADO, Respondent.
DECISION
AZCUNA, J.:
It is unfortunate that this administrative case involves co-workers in this Court.
Complainant, Samuel R. Ruez, Jr. (Ruez, Jr.), is Chief of the Clearance Section, Checks
Disbursement Division of the FMO-OCA and is the son of the aggrieved party, Samuel V.
Ruez, Sr. (Ruez, Sr.), Driver I for the Motorpool, Property Division of the OCA.
Respondent is Dr. Marybeth V. Jurado (Dr. Jurado), Medical Officer IV of the Medical and
Dental Services. All three were working for the Court at the time of the incident in issue.
The parties agree that on January 12, 2005, at around 4:20 p.m., Ruez, Sr. arrived by
himself at this Courts clinic complaining of dizziness. His blood pressure and pulse rate
were taken by the reception nurse and were registered at 210/100 mmHg and 112 beats a
minute, respectively. What transpired next is disputed. Ruez, Jr. alleged that despite his
fathers medical condition, he was merely advised to go to a hospital and then allowed to
walk out of the clinic on his own. Dr. Jurado, on the other hand, maintained that after
being informed of Ruez, Sr.s blood pressure and heart rate, she instructed the nurse to
administer one tablet of Capoten 25mg, an emergency drug that quickly lowers a
patients blood pressure. She then informed Ruez, Sr. that he will be taken to the
hospital, after which she immediately instructed the ambulance driver, Mr. Jacinto, to
stand by for hospital conduction. Minutes later, after having taken Capoten and being
given a chance to rest, Ruez, Sr. stood up and walked out saying, "Doktora, hanap lang
ho ako ng kasama." Dr. Jurado said she waited for him to return but he failed to show up.
She asked Mr. Almarza, a nurse at the clinic, to look for Ruez, Sr. but he was unable to
locate him.
According to Ruez, Jr., after being informed of his fathers condition, he rushed him to the
Manila Doctors Hospital. There, Ruez, Sr. was treated in the emergency room for
approximately four hours before he was discharged at around 8:30 p.m. and allowed to go
home. However, prior to reaching their house in Balintawak, Caloocan City, Ruez, Sr.
began experiencing nausea, abnormal palpitation and uneasiness and had to be brought
back to the hospital.
Ruez, Sr. and Ruez, Jr.1 arrived at the emergency room of the Manila Doctors Hospital at
around 10:00 p.m. after which Ruez, Sr. underwent a C.T. Scan. The C.T. Scan revealed a
blood clot necessitating him to be admitted for treatment and observation. The following
morning he suffered a stroke and for a moment was on flat line. The doctors were able to
revive him and thereafter he was transferred to the intensive care unit. Unfortunately,
Ruez Sr. never recovered from his ailment and, on September 12, 2005, he passed away
due to medical complications.2
On February 15, 2005, Ruez, Jr. filed a letter-complaint with the Office of the Chief Justice
regarding the alleged lack of attention given to his father by Dr. Jurado. Specifically, he
claims that Dr. Jurado merely advised his father to go to the hospital and then allowed him
to travel to Manila Doctors Hospital despite the availability of an ambulance at the
disposal of the clinic. Ruez, Jr. submits that his father would not have suffered a stroke if
not for the neglect of Dr. Jurado.

The letter-complaint was referred to Atty. Eden T. Candelaria, Deputy Clerk of Court and
Chief of Administrative Services, for investigation. Atty. Candelaria required Dr. Jurado to
submit her comment to the letter-complaint. The comment was submitted on March 18,
2005, together with supporting affidavits from respondents witnesses. This was followed
by Ruez, Jr.s reply to the comment on April 12, 2005 and Dr. Jurados rejoinder on April
22, 2005.3
Atty. Candelaria submitted her report on June 17, 2005. The report gave credence to the
account of Dr. Jurado that Ruez, Sr. was given Capoten, informed that he should be
hospitalized and that the ambulance was placed on standby to take him there. These
factual findings of Atty. Candelaria appear to be supported by the affidavits of the clinics
personnel, including the ambulance driver, who witnessed the events that happened
between Ruez, Sr. and Dr. Jurado.
The issue now for the Court to resolve is whether, given the accepted facts, there is cause
to hold Dr. Jurado administratively liable. Atty. Candelaria is satisfied that Dr. Jurado
provided Ruez, Sr. proper treatment inside the clinic. However, in her opinion, Dr.
Jurados actions after Ruez, Sr. had left were less than the required diligence of a good
father of a family. We quote below the analysis of Atty. Candelaria:
. . . Records will clearly show that minutes after Mr. Ruez, Sr. left the clinic, Dr. Jurado
also left the clinic to go home. This is shown by her time out registered in the Chronolog
Machine on the said date which was 4:31 p.m. and her inclusion in the list of passengers
of Shuttle Bus No. 6. As an efficient and intelligent doctor, Dr. Jurado should have at least
personally exerted all her efforts to determine the whereabouts of Mr. Ruez, Sr. because
of his condition and again at the very least informed his relatives in the Court in order that
they too take the necessary action that very moment. Or in the alternative, if indeed, Dr.
Jurado may have been in a hurry at that time to do some errands, she should have at
least[,] again, turned Mr. Ruez over the a [d]octor who was willing to be left behind after
office hours. These however never happened. All that she relied on was the fact that there
was an emergency treatment and an order for hospital conduction but [the same] didnt
materialize and [she] put [the] blame on Mr. Ruez, Sr. As admitted by complainant, Mr.
Ruez, Sr., is a mere "driver" and perhaps may have no knowledge at all of the
consequences of his 210/100 blood pressure and since he sought refuge from the [c]linic,
the clinic, particularly Dr. Jurado[,] should have made him feel safe and secure in the said
place. . . .
Atty. Candelaria recommends that Dr. Jurado be held liable for simple neglect of duty and
suspended for one (1) month and (1) day. She further recommends that, in light of what
happened, Dr. Prudencio Banzon, SC Senior Staff Officer, Medical and Dental Services, be
directed to prepare a flexi-time schedule (until 5:30 p.m.) for all doctors and nurses in the
clinic to enable it to provide immediate and proper attention in case of any emergency
medical situation.
The Court does not agree that the acts or omission of Dr. Jurado amount to simple neglect
of duty. Simple neglect of duty is defined as failure to give proper attention to a task
expected of an employee resulting from either carelessness or indifference4 or signifies a
disregard of duty resulting from carelessness or indifference.5 In Philippine Retirement
Authority,6 it was stated, "The Court has decided the following, inter alia, as constituting
the less grave offense of Simple Neglect of Duty: delay in the transmittal of court records,
delay in responding to written queries, and delay of more than one (1) year and seven (7)

months in furnishing a party with a copy of the courts decision." In all the instances cited
by the Court, respondents had the duty or were expected to do certain acts which they
failed to do. How do we determine what acts are expected of Dr. Jurado? Atty. Candelarias
report cites the applicable yardstick: a physician or surgeon is expected to apply in his
practice of medicine that degree of care and skill which is ordinarily employed by the
profession, generally, and under similar conditions.7 Therefore, to find Dr. Jurado liable for
simple neglect of duty the Court has to be convinced that those in the medical profession
were also expected to act in the manner illustrated by Atty. Candelaria, i.e., to exert all
efforts to determine the whereabouts of Ruez, Sr., inform his relatives or turn his case
over to a doctor who was available after office hours.

Some people may interpret Dr. Jurados inaction as indifference, while others may view
the same as just proper. Some would applaud Dr. Jurados dedication had she done all the
things mentioned by Atty. Candelaria and yet others would see them as still insufficient.
There will always be a divergence of opinions as to how Dr. Jurado should have conducted
herself but the Court must distinguish between acts that deserve to be emulated or
disdained and those that deserve sanctions. The former is largely a matter of opinion
while the latter can only be imposed if there was a failure to perform a clear duty,
expectation or obligation. People may frown upon certain behaviors and chastise others
for having less compassion, but it does not necessarily follow that those acts translate to
neglect of duty, misconduct or negligence.

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

Dr. Jurado could have exerted greater efforts by searching all over the compound for
Ruez, Sr. but the fact remains that these were not part of her duties nor were they
expected from her. Simple neglect of duty presupposes a task expected of an employee.
Thus, it cannot be present if there was no expected task on her part. That said, the Court
wishes to exhort Dr. Jurado, and all personnel in its clinic, not to be satisfied with merely
fulfilling the minimum, but to go for the magis, the best service they can render by way of
being exemplars for their fellow workers in the Court.

"A physician should attend to his patients faithfully and conscientiously. He should secure
for them all possible benefits that may depend upon his professional skill and care. As the
sole tribunal to adjudge the physicians failure to fulfill his obligation to his patients is, in
most cases, his own conscience, violation of this rule on his part is discreditable and
inexcusable."
A doctors duty to his patient is not required to be extraordinary.8 The standard
contemplated for doctors is simply the reasonable average merit among ordinarily good
physicians, i.e. reasonable skill and competence.9 We are persuaded that Dr. Jurado
fulfilled such a standard when she treated Ruez, Sr. inside the clinic. But what of Dr.
Jurados conduct after Ruez, Sr. left the clinic and failed to return?
It has been held that a patient cannot attribute to a physician damages resulting from his
own failure to follow his advice, even though he was ignorant of the consequences which
would result from his failure.10 If a patient leaves the hospital contrary to instructions, the
physician is not liable for subsequent events.11 There is no expectation from doctors that
they track down each patient who apparently missed their appointments or force them to
comply with their directives. After all, a person is still the master of his own body.12
Dr. Jurado may have allowed Ruez, Sr. to walk out of the clinic despite her earlier
diagnosis of his condition. By that time Ruez, Sr.s condition had temporarily stabilized
and she did not have the authority to stop him just as other doctors have no power, save
in certain instances (such as when the law makes treatment compulsory due to some
communicable disease13 or when consent is withheld by a minor but non-treatment
would be detrimental or when the court of competent jurisdiction orders the treatment),
to force patients into staying under their care. Dr. Jurado relied on Ruez, Sr.s
representation that he would return in order to be brought to the hospital but made no
undertaking to wait for him beyond the clinic hours or to look for him if he did not return.
Thus, when Ruez, Sr. failed to show up as of closing time, and could not be found by the
male nurse who looked for him at her instructions, Dr. Jurado had reason to think that he
had decided to disregard her medical advice, which he in fact did when he and Ruez, Jr.
decided to go to the hospital on their own. Ruez, Sr., still of sound mind, had the right to
accept or ignore his doctors recommendation. Dr. Jurado was obligated to care for Ruez,
Sr. when the latter asked for medical treatment, which she did, but when he left on his
own accord Dr. Jurado was not expected, much less duty-bound, to seek out her patient
and continue being his doctor.

WHEREFORE, the Court finds no reason to hold Dr. Jurado liable for simple neglect of duty,
and, therefore, DISMISSES the complaint for lack of merit. As recommended by Atty. Eden
T. Candelaria, Deputy Clerk of Court and Chief of Administrative Services, Dr. Prudencio
Banzon, Senior Staff Officer, Medical and Dental Services, is DIRECTED to prepare a flexitime schedule for all doctors and nurses in the clinic to further develop its capability to
provide immediate and proper attention in emergency medical situations, and to submit
the same to Atty. Candelaria in 30 days from receipt of a copy of this decision which
should be served upon him forthwith.
SO ORDERED.

THIRD DIVISION
G.R. No. 142625
December 19, 2006
ROGELIO P. NOGALES, for himself and on behalf of the minors, ROGER ANTHONY,
ANGELICA, NANCY, and MICHAEL CHRISTOPHER, all surnamed NOGALES, petitioners, vs.
CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR. ELY VILLAFLOR, DR. ROSA UY, DR.
JOEL ENRIQUEZ, DR. PERPETUA LACSON, DR. NOE ESPINOLA, and NURSE J. DUMLAO,
respondents.
DECISION
CARPIO, J.:
The Case
This petition for review1 assails the 6 February 1998 Decision2 and 21 March 2000
Resolution3 of the Court of Appeals in CA-G.R. CV No. 45641. The Court of Appeals
affirmed in toto the 22 November 1993 Decision4 of the Regional Trial Court of Manila,
Branch 33, finding Dr. Oscar Estrada solely liable for damages for the death of his patient,
Corazon Nogales, while absolving the remaining respondents of any liability. The Court of
Appeals denied petitioners' motion for reconsideration.
The Facts
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 years old,
was under the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada") beginning on
her fourth month of pregnancy or as early as December 1975. While Corazon was on her
last trimester of pregnancy, Dr. Estrada noted an increase in her blood pressure and
development of leg edema5 indicating preeclampsia,6 which is a dangerous complication
of pregnancy.7
Around midnight of 25 May 1976, Corazon started to experience mild labor pains
prompting Corazon and Rogelio Nogales ("Spouses Nogales") to see Dr. Estrada at his
home. After examining Corazon, Dr. Estrada advised her immediate admission to the
Capitol Medical Center ("CMC").
On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the staff nurse
noted the written admission request8 of Dr. Estrada. Upon Corazon's admission at the
CMC, Rogelio Nogales ("Rogelio") executed and signed the "Consent on Admission and
Agreement"9 and "Admission Agreement."10 Corazon was then brought to the labor room
of the CMC.
Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an internal
examination of Corazon. Dr. Uy then called up Dr. Estrada to notify him of her findings.
Based on the Doctor's Order Sheet,11 around 3:00 a.m., Dr. Estrada ordered for 10 mg. of
valium to be administered immediately by intramuscular injection. Dr. Estrada later
ordered the start of intravenous administration of syntocinon admixed with dextrose, 5%,
in lactated Ringers' solution, at the rate of eight to ten micro-drops per minute.
According to the Nurse's Observation Notes,12 Dr. Joel Enriquez ("Dr. Enriquez"), an
anesthesiologist at CMC, was notified at 4:15 a.m. of Corazon's admission. Subsequently,
when asked if he needed the services of an anesthesiologist, Dr. Estrada refused. Despite
Dr. Estrada's refusal, Dr. Enriquez stayed to observe Corazon's condition.

At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10 a.m.,
Corazon's bag of water ruptured spontaneously. At 6:12 a.m., Corazon's cervix was fully
dilated. At 6:13 a.m., Corazon started to experience convulsions.
At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfate.
However, Dr. Ely Villaflor ("Dr. Villaflor"), who was assisting Dr. Estrada, administered only
2.5 grams of magnesium sulfate.
At 6:22 a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract Corazon's
baby. In the process, a 1.0 x 2.5 cm. piece of cervical tissue was allegedly torn. The baby
came out in an apnic, cyanotic, weak and injured condition. Consequently, the baby had
to be intubated and resuscitated by Dr. Enriquez and Dr. Payumo.
At 6:27 a.m., Corazon began to manifest moderate vaginal bleeding which rapidly became
profuse. Corazon's blood pressure dropped from 130/80 to 60/40 within five minutes.
There was continuous profuse vaginal bleeding. The assisting nurse administered hemacel
through a gauge 19 needle as a side drip to the ongoing intravenous injection of dextrose.
At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with bottled blood. It
took approximately 30 minutes for the CMC laboratory, headed by Dr. Perpetua Lacson
("Dr. Lacson"), to comply with Dr. Estrada's order and deliver the blood.
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-Gynecology
Department of the CMC, was apprised of Corazon's condition by telephone. Upon being
informed that Corazon was bleeding profusely, Dr. Espinola ordered immediate
hysterectomy. Rogelio was made to sign a "Consent to Operation."13
Due to the inclement weather then, Dr. Espinola, who was fetched from his residence by
an ambulance, arrived at the CMC about an hour later or at 9:00 a.m. He examined the
patient and ordered some resuscitative measures to be administered. Despite Dr.
Espinola's efforts, Corazon died at 9:15 a.m. The cause of death was "hemorrhage, post
partum."14
On 14 May 1980, petitioners filed a complaint for damages15 with the Regional Trial
Court16 of Manila against CMC, Dr. Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr. Lacson,
Dr. Espinola, and a certain Nurse J. Dumlao for the death of Corazon. Petitioners mainly
contended that defendant physicians and CMC personnel were negligent in the treatment
and management of Corazon's condition. Petitioners charged CMC with negligence in the
selection and supervision of defendant physicians and hospital staff.
For failing to file their answer to the complaint despite service of summons, the trial court
declared Dr. Estrada, Dr. Enriquez, and Nurse Dumlao in default.17 CMC, Dr. Villaflor, Dr.
Uy, Dr. Espinola, and Dr. Lacson filed their respective answers denying and opposing the
allegations in the complaint. Subsequently, trial ensued.
After more than 11 years of trial, the trial court rendered judgment on 22 November 1993
finding Dr. Estrada solely liable for damages. The trial court ruled as follows:
The victim was under his pre-natal care, apparently, his fault began from his incorrect and
inadequate management and lack of treatment of the pre-eclamptic condition of his

patient. It is not disputed that he misapplied the forceps in causing the delivery because it
resulted in a large cervical tear which had caused the profuse bleeding which he also
failed to control with the application of inadequate injection of magnesium sulfate by his
assistant Dra. Ely Villaflor. Dr. Estrada even failed to notice the erroneous administration
by nurse Dumlao of hemacel by way of side drip, instead of direct intravenous injection,
and his failure to consult a senior obstetrician at an early stage of the problem.

Admittedly, Dra. Rosa Uy is a resident physician of the Capitol Medical Center. She was
sued because of her alleged failure to notice the incompetence and negligence of Dr.
Estrada. However, there is no evidence to support such theory. No evidence was adduced
to show that Dra. Rosa Uy as a resident physician of Capitol Medical Center, had
knowledge of the mismanagement of the patient Corazon Nogales, and that
notwithstanding such knowledge, she tolerated the same to happen.

On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr. Joel Enriquez, Dr. Lacson, Dr.
Espinola, nurse J. Dumlao and CMC, the Court finds no legal justification to find them
civilly liable.

In the pre-trial order, plaintiffs and CMC agreed that defendant CMC did not have any
hand or participation in the selection or hiring of Dr. Estrada or his assistant Dra. Ely
Villaflor as attending physician[s] of the deceased. In other words, the two (2) doctors
were not employees of the hospital and therefore the hospital did not have control over
their professional conduct. When Mrs. Nogales was brought to the hospital, it was an
emergency case and defendant CMC had no choice but to admit her. Such being the case,
there is therefore no legal ground to apply the provisions of Article 2176 and 2180 of the
New Civil Code referring to the vicarious liability of an employer for the negligence of its
employees. If ever in this case there is fault or negligence in the treatment of the
deceased on the part of the attending physicians who were employed by the family of the
deceased, such civil liability should be borne by the attending physicians under the
principle of "respondeat superior".

On the part of Dra. Ely Villaflor, she was only taking orders from Dr. Estrada, the principal
physician of Corazon Nogales. She can only make suggestions in the manner the patient
maybe treated but she cannot impose her will as to do so would be to substitute her good
judgment to that of Dr. Estrada. If she failed to correctly diagnose the true cause of the
bleeding which in this case appears to be a cervical laceration, it cannot be safely
concluded by the Court that Dra. Villaflor had the correct diagnosis and she failed to
inform Dr. Estrada. No evidence was introduced to show that indeed Dra. Villaflor had
discovered that there was laceration at the cervical area of the patient's internal organ.
On the part of nurse Dumlao, there is no showing that when she administered the
hemacel as a side drip, she did it on her own. If the correct procedure was directly thru
the veins, it could only be because this was what was probably the orders of Dr. Estrada.
While the evidence of the plaintiffs shows that Dr. Noe Espinola, who was the Chief of the
Department of Obstetrics and Gynecology who attended to the patient Mrs. Nogales, it
was only at 9:00 a.m. That he was able to reach the hospital because of typhoon Didang
(Exhibit 2). While he was able to give prescription in the manner Corazon Nogales may be
treated, the prescription was based on the information given to him by phone and he
acted on the basis of facts as presented to him, believing in good faith that such is the
correct remedy. He was not with Dr. Estrada when the patient was brought to the hospital
at 2:30 o'clock a.m. So, whatever errors that Dr. Estrada committed on the patient before
9:00 o'clock a.m. are certainly the errors of Dr. Estrada and cannot be the mistake of Dr.
Noe Espinola. His failure to come to the hospital on time was due to fortuitous event.

WHEREFORE, premises considered, judgment is hereby rendered finding defendant Dr.


Estrada of Number 13 Pitimini St. San Francisco del Monte, Quezon City civilly liable to pay
plaintiffs: 1) By way of actual damages in the amount of P105,000.00; 2) By way of moral
damages in the amount of P700,000.00; 3) Attorney's fees in the amount of P100,000.00
and to pay the costs of suit.
For failure of the plaintiffs to adduce evidence to support its [sic] allegations against the
other defendants, the complaint is hereby ordered dismissed. While the Court looks with
disfavor the filing of the present complaint against the other defendants by the herein
plaintiffs, as in a way it has caused them personal inconvenience and slight damage on
their name and reputation, the Court cannot accepts [sic] however, the theory of the
remaining defendants that plaintiffs were motivated in bad faith in the filing of this
complaint. For this reason defendants' counterclaims are hereby ordered dismissed.
SO ORDERED.18

On the part of Dr. Joel Enriquez, while he was present in the delivery room, it is not
incumbent upon him to call the attention of Dr. Estrada, Dra. Villaflor and also of Nurse
Dumlao on the alleged errors committed by them. Besides, as anesthesiologist, he has no
authority to control the actuations of Dr. Estrada and Dra. Villaflor. For the Court to
assume that there were errors being committed in the presence of Dr. Enriquez would be
to dwell on conjectures and speculations.
On the civil liability of Dr. Perpetua Lacson, [s]he is a hematologist and in-charge of the
blood bank of the CMC. The Court cannot accept the theory of the plaintiffs that there was
delay in delivering the blood needed by the patient. It was testified, that in order that this
blood will be made available, a laboratory test has to be conducted to determine the type
of blood, cross matching and other matters consistent with medical science so, the lapse
of 30 minutes maybe considered a reasonable time to do all of these things, and not a
delay as the plaintiffs would want the Court to believe.

Petitioners appealed the trial court's decision. Petitioners claimed that aside from Dr.
Estrada, the remaining respondents should be held equally liable for negligence.
Petitioners pointed out the extent of each respondent's alleged liability.
On 6 February 1998, the Court of Appeals affirmed the decision of the trial court.19
Petitioners filed a motion for reconsideration which the Court of Appeals denied in its
Resolution of 21 March 2000.20
Hence, this petition.
Meanwhile, petitioners filed a Manifestation dated 12 April 200221 stating that
respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao "need no longer be
notified of the petition because they are absolutely not involved in the issue raised before
the [Court], regarding the liability of [CMC]."22 Petitioners stressed that the subject
matter of this petition is the liability of CMC for the negligence of Dr. Estrada.23

The Court issued a Resolution dated 9 September 200224 dispensing with the
requirement to submit the correct and present addresses of respondents Dr. Estrada, Dr.
Enriquez, Dr. Villaflor, and Nurse Dumlao. The Court stated that with the filing of
petitioners' Manifestation, it should be understood that they are claiming only against
respondents CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy who have filed their respective
comments. Petitioners are foregoing further claims against respondents Dr. Estrada, Dr.
Enriquez, Dr. Villaflor, and Nurse Dumlao.

The Court of Appeals concluded that since Rogelio engaged Dr. Estrada as the attending
physician of his wife, any liability for malpractice must be Dr. Estrada's sole responsibility.

The Court noted that Dr. Estrada did not appeal the decision of the Court of Appeals
affirming the decision of the Regional Trial Court. Accordingly, the decision of the Court of
Appeals, affirming the trial court's judgment, is already final as against Dr. Oscar Estrada.

Basically, the issue in this case is whether CMC is vicariously liable for the negligence of
Dr. Estrada. The resolution of this issue rests, on the other hand, on the ascertainment of
the relationship between Dr. Estrada and CMC. The Court also believes that a
determination of the extent of liability of the other respondents is inevitable to finally and
completely dispose of the present controversy.

Petitioners filed a motion for reconsideration25 of the Court's 9 September 2002


Resolution claiming that Dr. Enriquez, Dr. Villaflor and Nurse Dumlao were notified of the
petition at their counsels' last known addresses. Petitioners reiterated their imputation of
negligence on these respondents. The Court denied petitioners' Motion for
Reconsideration in its 18 February 2004 Resolution.26

While it found the amount of damages fair and reasonable, the Court of Appeals held that
no interest could be imposed on unliquidated claims or damages.
The Issue

The Ruling of the Court


The petition is partly meritorious.

The Court of Appeals' Ruling

On the Liability of CMC

In its Decision of 6 February 1998, the Court of Appeals upheld the trial court's ruling. The
Court of Appeals rejected petitioners' view that the doctrine in Darling v. Charleston
Community Memorial Hospital27 applies to this case. According to the Court of Appeals,
the present case differs from the Darling case since Dr. Estrada is an independent
contractor-physician whereas the Darling case involved a physician and a nurse who were
employees of the hospital.

Dr. Estrada's negligence in handling the treatment and management of Corazon's


condition which ultimately resulted in Corazon's death is no longer in issue. Dr. Estrada
did not appeal the decision of the Court of Appeals which affirmed the ruling of the trial
court finding Dr. Estrada solely liable for damages. Accordingly, the finding of the trial
court on Dr. Estrada's negligence is already final.

Citing other American cases, the Court of Appeals further held that the mere fact that a
hospital permitted a physician to practice medicine and use its facilities is not sufficient to
render the hospital liable for the physician's negligence.28 A hospital is not responsible for
the negligence of a physician who is an independent contractor.29
The Court of Appeals found the cases of Davidson v. Conole30 and Campbell v. Emma
Laing Stevens Hospital31 applicable to this case. Quoting Campbell, the Court of Appeals
stated that where there is no proof that defendant physician was an employee of
defendant hospital or that defendant hospital had reason to know that any acts of
malpractice would take place, defendant hospital could not be held liable for its failure to
intervene in the relationship of physician-patient between defendant physician and
plaintiff.

Petitioners maintain that CMC is vicariously liable for Dr. Estrada's negligence based on
Article 2180 in relation to Article 2176 of the Civil Code. These provisions pertinently
state:
Art. 2180. The obligation imposed by article 2176 is demandable not only for one's own
acts or omissions, but also for those of persons for whom one is responsible.
xxxx
Employers shall be liable for the damages caused by their employees and household
helpers acting within the scope of their assigned tasks, even though the former are not
engaged in any business or industry.
xxxx

On the liability of the other respondents, the Court of Appeals applied the "borrowed
servant" doctrine considering that Dr. Estrada was an independent contractor who was
merely exercising hospital privileges. This doctrine provides that once the surgeon enters
the operating room and takes charge of the proceedings, the acts or omissions of
operating room personnel, and any negligence associated with such acts or omissions, are
imputable to the surgeon.32 While the assisting physicians and nurses may be employed
by the hospital, or engaged by the patient, they normally become the temporary servants
or agents of the surgeon in charge while the operation is in progress, and liability may be
imposed upon the surgeon for their negligent acts under the doctrine of respondeat
superior.33

The responsibility treated of in this article shall cease when the persons herein mentioned
prove that they observed all the diligence of a good father of a family to prevent damage.
Art. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done. Such fault or negligence, if there is no
pre-existing contractual relation between the parties, is called a quasi-delict and is
governed by the provisions of this Chapter.

Similarly, in the United States, a hospital which is the employer, master, or principal of a
physician employee, servant, or agent, may be held liable for the physician's negligence
under the doctrine of respondeat superior.34
In the present case, petitioners maintain that CMC, in allowing Dr. Estrada to practice and
admit patients at CMC, should be liable for Dr. Estrada's malpractice. Rogelio claims that
he knew Dr. Estrada as an accredited physician of CMC, though he discovered later that
Dr. Estrada was not a salaried employee of the CMC.35 Rogelio further claims that he was
dealing with CMC, whose primary concern was the treatment and management of his
wife's condition. Dr. Estrada just happened to be the specific person he talked to
representing CMC.36 Moreover, the fact that CMC made Rogelio sign a Consent on
Admission and Admission Agreement37 and a Consent to Operation printed on the
letterhead of CMC indicates that CMC considered Dr. Estrada as a member of its medical
staff.
On the other hand, CMC disclaims liability by asserting that Dr. Estrada was a mere
visiting physician and that it admitted Corazon because her physical condition then was
classified an emergency obstetrics case.38
CMC alleges that Dr. Estrada is an independent contractor "for whose actuations CMC
would be a total stranger." CMC maintains that it had no control or supervision over Dr.
Estrada in the exercise of his medical profession.
The Court had the occasion to determine the relationship between a hospital and a
consultant or visiting physician and the liability of such hospital for that physician's
negligence in Ramos v. Court of Appeals,39 to wit:
In the first place, hospitals exercise significant control in the hiring and firing of
consultants and in the conduct of their work within the hospital premises. Doctors who
apply for "consultant" slots, visiting or attending, are required to submit proof of
completion of residency, their educational qualifications; generally, evidence of
accreditation by the appropriate board (diplomate), evidence of fellowship in most cases,
and references. These requirements are carefully scrutinized by members of the hospital
administration or by a review committee set up by the hospital who either accept or reject
the application. This is particularly true with respondent hospital.
After a physician is accepted, either as a visiting or attending consultant, he is normally
required to attend clinico-pathological conferences, conduct bedside rounds for clerks,
interns and residents, moderate grand rounds and patient audits and perform other tasks
and responsibilities, for the privilege of being able to maintain a clinic in the hospital,
and/or for the privilege of admitting patients into the hospital. In addition to these, the
physician's performance as a specialist is generally evaluated by a peer review committee
on the basis of mortality and morbidity statistics, and feedback from patients, nurses,
interns and residents. A consultant remiss in his duties, or a consultant who regularly falls
short of the minimum standards acceptable to the hospital or its peer review committee,
is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending
and visiting "consultant" staff. While "consultants" are not, technically employees, a point
which respondent hospital asserts in denying all responsibility for the patient's condition,
the control exercised, the hiring, and the right to terminate consultants all fulfill the

important hallmarks of an employer-employee relationship, with the exception of the


payment of wages. In assessing whether such a relationship in fact exists, the control test
is determining. Accordingly, on the basis of the foregoing, we rule that for the purpose of
allocating responsibility in medical negligence cases, an employer-employee relationship
in effect exists between hospitals and their attending and visiting physicians. This being
the case, the question now arises as to whether or not respondent hospital is solidarily
liable with respondent doctors for petitioner's condition.
The basis for holding an employer solidarily responsible for the negligence of its employee
is found in Article 2180 of the Civil Code which considers a person accountable not only
for his own acts but also for those of others based on the former's responsibility under a
relationship of patria potestas. x x x40 (Emphasis supplied)
While the Court in Ramos did not expound on the control test, such test essentially
determines whether an employment relationship exists between a physician and a
hospital based on the exercise of control over the physician as to details. Specifically, the
employer (or the hospital) must have the right to control both the means and the details
of the process by which the employee (or the physician) is to accomplish his task.41
After a thorough examination of the voluminous records of this case, the Court finds no
single evidence pointing to CMC's exercise of control over Dr. Estrada's treatment and
management of Corazon's condition. It is undisputed that throughout Corazon's
pregnancy, she was under the exclusive prenatal care of Dr. Estrada. At the time of
Corazon's admission at CMC and during her delivery, it was Dr. Estrada, assisted by Dr.
Villaflor, who attended to Corazon. There was no showing that CMC had a part in
diagnosing Corazon's condition. While Dr. Estrada enjoyed staff privileges at CMC, such
fact alone did not make him an employee of CMC.42 CMC merely allowed Dr. Estrada to
use its facilities43 when Corazon was about to give birth, which CMC considered an
emergency. Considering these circumstances, Dr. Estrada is not an employee of CMC, but
an independent contractor.
The question now is whether CMC is automatically exempt from liability considering that
Dr. Estrada is an independent contractor-physician.
In general, a hospital is not liable for the negligence of an independent contractorphysician. There is, however, an exception to this principle. The hospital may be liable if
the physician is the "ostensible" agent of the hospital.44 This exception is also known as
the "doctrine of apparent authority."45 In Gilbert v. Sycamore Municipal Hospital,46 the
Illinois Supreme Court explained the doctrine of apparent authority in this wise:
[U]nder the doctrine of apparent authority a hospital can be held vicariously liable for the
negligent acts of a physician providing care at the hospital, regardless of whether the
physician is an independent contractor, unless the patient knows, or should have known,
that the physician is an independent contractor. The elements of the action have been set
out as follows:
"For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show
that: (1) the hospital, or its agent, acted in a manner that would lead a reasonable person
to conclude that the individual who was alleged to be negligent was an employee or agent
of the hospital; (2) where the acts of the agent create the appearance of authority, the
plaintiff must also prove that the hospital had knowledge of and acquiesced in them; and

(3) the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent
with ordinary care and prudence."
The element of "holding out" on the part of the hospital does not require an express
representation by the hospital that the person alleged to be negligent is an employee.
Rather, the element is satisfied if the hospital holds itself out as a provider of emergency
room care without informing the patient that the care is provided by independent
contractors.
The element of justifiable reliance on the part of the plaintiff is satisfied if the plaintiff
relies upon the hospital to provide complete emergency room care, rather than upon a
specific physician.
The doctrine of apparent authority essentially involves two factors to determine the
liability of an independent-contractor physician.
The first factor focuses on the hospital's manifestations and is sometimes described as an
inquiry whether the hospital acted in a manner which would lead a reasonable person to
conclude that the individual who was alleged to be negligent was an employee or agent of
the hospital.47 In this regard, the hospital need not make express representations to the
patient that the treating physician is an employee of the hospital; rather a representation
may be general and implied.48
The doctrine of apparent authority is a species of the doctrine of estoppel. Article 1431 of
the Civil Code provides that "[t]hrough estoppel, an admission or representation is
rendered conclusive upon the person making it, and cannot be denied or disproved as
against the person relying thereon." Estoppel rests on this rule: "Whenever a party has, by
his own declaration, act, or omission, intentionally and deliberately led another to believe
a particular thing true, and to act upon such belief, he cannot, in any litigation arising out
of such declaration, act or omission, be permitted to falsify it."49
In the instant case, CMC impliedly held out Dr. Estrada as a member of its medical staff.
Through CMC's acts, CMC clothed Dr. Estrada with apparent authority thereby leading the
Spouses Nogales to believe that Dr. Estrada was an employee or agent of CMC. CMC
cannot now repudiate such authority.
First, CMC granted staff privileges to Dr. Estrada. CMC extended its medical staff and
facilities to Dr. Estrada. Upon Dr. Estrada's request for Corazon's admission, CMC, through
its personnel, readily accommodated Corazon and updated Dr. Estrada of her condition.
Second, CMC made Rogelio sign consent forms printed on CMC letterhead. Prior to
Corazon's admission and supposed hysterectomy, CMC asked Rogelio to sign release
forms, the contents of which reinforced Rogelio's belief that Dr. Estrada was a member of
CMC's medical staff.50 The Consent on Admission and Agreement explicitly provides:
KNOW ALL MEN BY THESE PRESENTS:
I, Rogelio Nogales, of legal age, a resident of 1974 M. H. Del Pilar St., Malate Mla., being
the father/mother/brother/sister/spouse/relative/ guardian/or person in custody of Ma.
Corazon, and representing his/her family, of my own volition and free will, do consent and
submit said Ma. Corazon to Dr. Oscar Estrada (hereinafter referred to as Physician) for

cure, treatment, retreatment, or emergency measures, that the Physician, personally or


by and through the Capitol Medical Center and/or its staff, may use, adapt, or employ
such means, forms or methods of cure, treatment, retreatment, or emergency measures
as he may see best and most expedient; that Ma. Corazon and I will comply with any and
all rules, regulations, directions, and instructions of the Physician, the Capitol Medical
Center and/or its staff; and, that I will not hold liable or responsible and hereby waive and
forever discharge and hold free the Physician, the Capitol Medical Center and/or its staff,
from any and all claims of whatever kind of nature, arising from directly or indirectly, or by
reason of said cure, treatment, or retreatment, or emergency measures or intervention of
said physician, the Capitol Medical Center and/or its staff.
x x x x51 (Emphasis supplied)
While the Consent to Operation pertinently reads, thus:
I, ROGELIO NOGALES, x x x, of my own volition and free will, do consent and submit said
CORAZON NOGALES to Hysterectomy, by the Surgical Staff and Anesthesiologists of
Capitol Medical Center and/or whatever succeeding operations, treatment, or emergency
measures as may be necessary and most expedient; and, that I will not hold liable or
responsible and hereby waive and forever discharge and hold free the Surgeon, his
assistants, anesthesiologists, the Capitol Medical Center and/or its staff, from any and all
claims of whatever kind of nature, arising from directly or indirectly, or by reason of said
operation or operations, treatment, or emergency measures, or intervention of the
Surgeon, his assistants, anesthesiologists, the Capitol Medical Center and/or its staff.52
(Emphasis supplied)
Without any indication in these consent forms that Dr. Estrada was an independent
contractor-physician, the Spouses Nogales could not have known that Dr. Estrada was an
independent contractor. Significantly, no one from CMC informed the Spouses Nogales
that Dr. Estrada was an independent contractor. On the contrary, Dr. Atencio, who was
then a member of CMC Board of Directors, testified that Dr. Estrada was part of CMC's
surgical staff.53
Third, Dr. Estrada's referral of Corazon's profuse vaginal bleeding to Dr. Espinola, who was
then the Head of the Obstetrics and Gynecology Department of CMC, gave the impression
that Dr. Estrada as a member of CMC's medical staff was collaborating with other CMCemployed specialists in treating Corazon.
The second factor focuses on the patient's reliance. It is sometimes characterized as an
inquiry on whether the plaintiff acted in reliance upon the conduct of the hospital or its
agent, consistent with ordinary care and prudence.54
The records show that the Spouses Nogales relied upon a perceived employment
relationship with CMC in accepting Dr. Estrada's services. Rogelio testified that he and his
wife specifically chose Dr. Estrada to handle Corazon's delivery not only because of their
friend's recommendation, but more importantly because of Dr. Estrada's "connection with
a reputable hospital, the [CMC]."55 In other words, Dr. Estrada's relationship with CMC
played a significant role in the Spouses Nogales' decision in accepting Dr. Estrada's
services as the obstetrician-gynecologist for Corazon's delivery. Moreover, as earlier
stated, there is no showing that before and during Corazon's confinement at CMC, the

Spouses Nogales knew or should have known that Dr. Estrada was not an employee of
CMC.

adhesion than one arising from such a dire situation. Thus, the release forms of CMC
cannot relieve CMC from liability for the negligent medical treatment of Corazon.

Further, the Spouses Nogales looked to CMC to provide the best medical care and support
services for Corazon's delivery. The Court notes that prior to Corazon's fourth pregnancy,
she used to give birth inside a clinic. Considering Corazon's age then, the Spouses
Nogales decided to have their fourth child delivered at CMC, which Rogelio regarded one
of the best hospitals at the time.56 This is precisely because the Spouses Nogales feared
that Corazon might experience complications during her delivery which would be better
addressed and treated in a modern and big hospital such as CMC. Moreover, Rogelio's
consent in Corazon's hysterectomy to be performed by a different physician, namely Dr.
Espinola, is a clear indication of Rogelio's confidence in CMC's surgical staff.

On the Liability of the Other Respondents

CMC's defense that all it did was "to extend to [Corazon] its facilities" is untenable. The
Court cannot close its eyes to the reality that hospitals, such as CMC, are in the business
of treatment. In this regard, the Court agrees with the observation made by the Court of
Appeals of North Carolina in Diggs v. Novant Health, Inc.,57 to wit:

Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause of Corazon's bleeding
and to suggest the correct remedy to Dr. Estrada.60 Petitioners assert that it was Dr.
Villaflor's duty to correct the error of Nurse Dumlao in the administration of hemacel.

"The conception that the hospital does not undertake to treat the patient, does not
undertake to act through its doctors and nurses, but undertakes instead simply to procure
them to act upon their own responsibility, no longer reflects the fact. Present day
hospitals, as their manner of operation plainly demonstrates, do far more than furnish
facilities for treatment. They regularly employ on a salary basis a large staff of physicians,
nurses and internes [sic], as well as administrative and manual workers, and they charge
patients for medical care and treatment, collecting for such services, if necessary, by legal
action. Certainly, the person who avails himself of 'hospital facilities' expects that the
hospital will attempt to cure him, not that its nurses or other employees will act on their
own responsibility." x x x (Emphasis supplied)
Likewise unconvincing is CMC's argument that petitioners are estopped from claiming
damages based on the Consent on Admission and Consent to Operation. Both release
forms consist of two parts. The first part gave CMC permission to administer to Corazon
any form of recognized medical treatment which the CMC medical staff deemed advisable.
The second part of the documents, which may properly be described as the releasing part,
releases CMC and its employees "from any and all claims" arising from or by reason of the
treatment and operation.
The documents do not expressly release CMC from liability for injury to Corazon due to
negligence during her treatment or operation. Neither do the consent forms expressly
exempt CMC from liability for Corazon's death due to negligence during such treatment or
operation. Such release forms, being in the nature of contracts of adhesion, are construed
strictly against hospitals. Besides, a blanket release in favor of hospitals "from any and all
claims," which includes claims due to bad faith or gross negligence, would be contrary to
public policy and thus void.
Even simple negligence is not subject to blanket release in favor of establishments like
hospitals but may only mitigate liability depending on the circumstances.58 When a
person needing urgent medical attention rushes to a hospital, he cannot bargain on equal
footing with the hospital on the terms of admission and operation. Such a person is
literally at the mercy of the hospital. There can be no clearer example of a contract of

Despite this Court's pronouncement in its 9 September 200259 Resolution that the filing
of petitioners' Manifestation confined petitioners' claim only against CMC, Dr. Espinola, Dr.
Lacson, and Dr. Uy, who have filed their comments, the Court deems it proper to resolve
the individual liability of the remaining respondents to put an end finally to this more than
two-decade old controversy.
a) Dr. Ely Villaflor

The Court is not persuaded. Dr. Villaflor admitted administering a lower dosage of
magnesium sulfate. However, this was after informing Dr. Estrada that Corazon was no
longer in convulsion and that her blood pressure went down to a dangerous level.61 At
that moment, Dr. Estrada instructed Dr. Villaflor to reduce the dosage of magnesium
sulfate from 10 to 2.5 grams. Since petitioners did not dispute Dr. Villaflor's allegation, Dr.
Villaflor's defense remains uncontroverted. Dr. Villaflor's act of administering a lower
dosage of magnesium sulfate was not out of her own volition or was in contravention of
Dr. Estrada's order.
b) Dr. Rosa Uy
Dr. Rosa Uy's alleged negligence consisted of her failure (1) to call the attention of Dr.
Estrada on the incorrect dosage of magnesium sulfate administered by Dr. Villaflor; (2) to
take corrective measures; and (3) to correct Nurse Dumlao's wrong method of hemacel
administration.
The Court believes Dr. Uy's claim that as a second year resident physician then at CMC,
she was merely authorized to take the clinical history and physical examination of
Corazon.62 However, that routine internal examination did not ipso facto make Dr. Uy
liable for the errors committed by Dr. Estrada. Further, petitioners' imputation of
negligence rests on their baseless assumption that Dr. Uy was present at the delivery
room. Nothing shows that Dr. Uy participated in delivering Corazon's baby. Further, it is
unexpected from Dr. Uy, a mere resident physician at that time, to call the attention of a
more experienced specialist, if ever she was present at the delivery room.
c) Dr. Joel Enriquez
Petitioners fault Dr. Joel Enriquez also for not calling the attention of Dr. Estrada, Dr.
Villaflor, and Nurse Dumlao about their errors.63 Petitioners insist that Dr. Enriquez should
have taken, or at least suggested, corrective measures to rectify such errors.
The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field of expertise is
definitely not obstetrics and gynecology. As such, Dr. Enriquez was not expected to correct

Dr. Estrada's errors. Besides, there was no evidence of Dr. Enriquez's knowledge of any
error committed by Dr. Estrada and his failure to act upon such observation.

The award of interest on damages is proper and allowed under Article 2211 of the Civil
Code, which states that in crimes and quasi-delicts, interest as a part of the damages
may, in a proper case, be adjudicated in the discretion of the court.68

d) Dr. Perpetua Lacson


Petitioners fault Dr. Perpetua Lacson for her purported delay in the delivery of blood
Corazon needed.64 Petitioners claim that Dr. Lacson was remiss in her duty of supervising
the blood bank staff.
As found by the trial court, there was no unreasonable delay in the delivery of blood from
the time of the request until the transfusion to Corazon. Dr. Lacson competently explained
the procedure before blood could be given to the patient.65 Taking into account the
bleeding time, clotting time and cross-matching, Dr. Lacson stated that it would take
approximately 45-60 minutes before blood could be ready for transfusion.66 Further, no
evidence exists that Dr. Lacson neglected her duties as head of the blood bank.
e) Dr. Noe Espinola
Petitioners argue that Dr. Espinola should not have ordered immediate hysterectomy
without determining the underlying cause of Corazon's bleeding. Dr. Espinola should have
first considered the possibility of cervical injury, and advised a thorough examination of
the cervix, instead of believing outright Dr. Estrada's diagnosis that the cause of bleeding
was uterine atony.
Dr. Espinola's order to do hysterectomy which was based on the information he received
by phone is not negligence. The Court agrees with the trial court's observation that Dr.
Espinola, upon hearing such information about Corazon's condition, believed in good faith
that hysterectomy was the correct remedy. At any rate, the hysterectomy did not push
through because upon Dr. Espinola's arrival, it was already too late. At the time, Corazon
was practically dead.
f) Nurse J. Dumlao
In Moore v. Guthrie Hospital Inc.,67 the US Court of Appeals, Fourth Circuit, held that to
recover, a patient complaining of injuries allegedly resulting when the nurse negligently
injected medicine to him intravenously instead of intramuscularly had to show that (1) an
intravenous injection constituted a lack of reasonable and ordinary care; (2) the nurse
injected medicine intravenously; and (3) such injection was the proximate cause of his
injury.
In the present case, there is no evidence of Nurse Dumlao's alleged failure to follow Dr.
Estrada's specific instructions. Even assuming Nurse Dumlao defied Dr. Estrada's order,
there is no showing that side-drip administration of hemacel proximately caused
Corazon's death. No evidence linking Corazon's death and the alleged wrongful hemacel
administration was introduced. Therefore, there is no basis to hold Nurse Dumlao liable for
negligence.
On the Award of Interest on Damages

WHEREFORE, the Court PARTLY GRANTS the petition. The Court finds respondent Capitol
Medical Center vicariously liable for the negligence of Dr. Oscar Estrada. The amounts of
P105,000 as actual damages and P700,000 as moral damages should each earn legal
interest at the rate of six percent (6%) per annum computed from the date of the
judgment of the trial court. The Court affirms the rest of the Decision dated 6 February
1998 and Resolution dated 21 March 2000 of the Court of Appeals in CA-G.R. CV No.
45641.
SO ORDERED.

FIRST DIVISION
G.R. No. 126297
January 31, 2007
PROFESSIONAL SERVICES, INC., Petitioner, vs. NATIVIDAD and ENRIQUE AGANA,
Respondents.
G.R. No. 126467
January 31, 2007
NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE AGANA, JR.,
EMMA AGANA ANDAYA, JESUS AGANA, and RAYMUND AGANA) and ENRIQUE AGANA,
Petitioners, vs. JUAN FUENTES, Respondent.
G.R. No. 127590
January 31, 2007
MIGUEL AMPIL, Petitioner, vs. NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
DECISION
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankinds most important and delicate endeavors,
must assume the grave responsibility of pursuing it with appropriate care. The care and
service dispensed through this high trust, however technical, complex and esoteric its
character may be, must meet standards of responsibility commensurate with the
undertaking to preserve and protect the health, and indeed, the very lives of those placed
in the hospitals keeping.1
Assailed in these three consolidated petitions for review on certiorari is the Court of
Appeals Decision2 dated September 6, 1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No.
32198 affirming with modification the Decision3 dated March 17, 1993 of the Regional
Trial Court (RTC), Branch 96, Quezon City in Civil Case No. Q-43322 and nullifying its Order
dated September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital
(Medical City Hospital) because of difficulty of bowel movement and bloody anal
discharge. After a series of medical examinations, Dr. Miguel Ampil, petitioner in G.R. No.
127590, diagnosed her to be suffering from "cancer of the sigmoid."
On April 11, 1984, Dr. Ampil, assisted by the medical staff4 of the Medical City Hospital,
performed an anterior resection surgery on Natividad. He found that the malignancy in
her sigmoid area had spread on her left ovary, necessitating the removal of certain
portions of it. Thus, Dr. Ampil obtained the consent of Natividads husband, Enrique
Agana, to permit Dr. Juan Fuentes, respondent in G.R. No. 126467, to perform
hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the
operation and closed the incision.
However, the operation appeared to be flawed. In the corresponding Record of Operation
dated April 11, 1984, the attending nurses entered these remarks:
"sponge count lacking 2
"announced to surgeon searched (sic) done but to no avail continue for closure."

On April 24, 1984, Natividad was released from the hospital. Her hospital and medical
bills, including the doctors fees, amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating pain in her anal region. She
consulted both Dr. Ampil and Dr. Fuentes about it. They told her that the pain was the
natural consequence of the surgery. Dr. Ampil then recommended that she consult an
oncologist to examine the cancerous nodes which were not removed during the operation.
On May 9, 1984, Natividad, accompanied by her husband, went to the United States to
seek further treatment. After four months of consultations and laboratory examinations,
Natividad was told she was free of cancer. Hence, she was advised to return to the
Philippines.
On August 31, 1984, Natividad flew back to the Philippines, still suffering from pains. Two
weeks thereafter, her daughter found a piece of gauze protruding from her vagina. Upon
being informed about it, Dr. Ampil proceeded to her house where he managed to extract
by hand a piece of gauze measuring 1.5 inches in width. He then assured her that the
pains would soon vanish.
Dr. Ampils assurance did not come true. Instead, the pains intensified, prompting
Natividad to seek treatment at the Polymedic General Hospital. While confined there, Dr.
Ramon Gutierrez detected the presence of another foreign object in her vagina -- a foulsmelling gauze measuring 1.5 inches in width which badly infected her vaginal vault. A
recto-vaginal fistula had formed in her reproductive organs which forced stool to excrete
through the vagina. Another surgical operation was needed to remedy the damage. Thus,
in October 1984, Natividad underwent another surgery.
On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, Quezon
City a complaint for damages against the Professional Services, Inc. (PSI), owner of the
Medical City Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil Case No. Q-43322.
They alleged that the latter are liable for negligence for leaving two pieces of gauze inside
Natividads body and malpractice for concealing their acts of negligence.
Meanwhile, Enrique Agana also filed with the Professional Regulation Commission (PRC) an
administrative complaint for gross negligence and malpractice against Dr. Ampil and Dr.
Fuentes, docketed as Administrative Case No. 1690. The PRC Board of Medicine heard the
case only with respect to Dr. Fuentes because it failed to acquire jurisdiction over Dr.
Ampil who was then in the United States.
On February 16, 1986, pending the outcome of the above cases, Natividad died and was
duly substituted by her above-named children (the Aganas).
On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding PSI, Dr.
Ampil and Dr. Fuentes liable for negligence and malpractice, the decretal part of which
reads:
WHEREFORE, judgment is hereby rendered for the plaintiffs ordering the defendants
PROFESSIONAL SERVICES, INC., DR. MIGUEL AMPIL and DR. JUAN FUENTES to pay to the
plaintiffs, jointly and severally, except in respect of the award for exemplary damages and

the interest thereon which are the liabilities of defendants Dr. Ampil and Dr. Fuentes only,
as follows:

On September 6, 1996, the Court of Appeals rendered its Decision jointly disposing of CAG.R. CV No. 42062 and CA-G.R. SP No. 32198, thus:

1. As actual damages, the following amounts:

WHEREFORE, except for the modification that the case against defendant-appellant Dr.
Juan Fuentes is hereby DISMISSED, and with the pronouncement that defendant-appellant
Dr. Miguel Ampil is liable to reimburse defendant-appellant Professional Services, Inc.,
whatever amount the latter will pay or had paid to the plaintiffs-appellees, the decision
appealed from is hereby AFFIRMED and the instant appeal DISMISSED.

a. The equivalent in Philippine Currency of the total of US$19,900.00 at the rate of P21.60US$1.00, as reimbursement of actual expenses incurred in the United States of America;
b. The sum of P4,800.00 as travel taxes of plaintiffs and their physician daughter;
c. The total sum of P45,802.50, representing the cost of hospitalization at Polymedic
Hospital, medical fees, and cost of the saline solution;
2. As moral damages, the sum of P2,000,000.00;

Concomitant with the above, the petition for certiorari and prohibition filed by herein
defendant-appellant Dr. Juan Fuentes in CA-G.R. SP No. 32198 is hereby GRANTED and the
challenged order of the respondent judge dated September 21, 1993, as well as the alias
writ of execution issued pursuant thereto are hereby NULLIFIED and SET ASIDE. The bond
posted by the petitioner in connection with the writ of preliminary injunction issued by this
Court on November 29, 1993 is hereby cancelled.

3. As exemplary damages, the sum of P300,000.00;


Costs against defendants-appellants Dr. Miguel Ampil and Professional Services, Inc.
4. As attorneys fees, the sum of P250,000.00;
SO ORDERED.
5. Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove, from date of filing of
the complaint until full payment; and

Only Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolution7 dated
December 19, 1996.

6. Costs of suit.
Hence, the instant consolidated petitions.
SO ORDERED.
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals,
docketed as CA-G.R. CV No. 42062.
Incidentally, on April 3, 1993, the Aganas filed with the RTC a motion for a partial
execution of its Decision, which was granted in an Order dated May 11, 1993. Thereafter,
the sheriff levied upon certain properties of Dr. Ampil and sold them for P451,275.00 and
delivered the amount to the Aganas.
Following their receipt of the money, the Aganas entered into an agreement with PSI and
Dr. Fuentes to indefinitely suspend any further execution of the RTC Decision. However,
not long thereafter, the Aganas again filed a motion for an alias writ of execution against
the properties of PSI and Dr. Fuentes. On September 21, 1993, the RTC granted the motion
and issued the corresponding writ, prompting Dr. Fuentes to file with the Court of Appeals
a petition for certiorari and prohibition, with prayer for preliminary injunction, docketed as
CA-G.R. SP No. 32198. During its pendency, the Court of Appeals issued a Resolution5
dated October 29, 1993 granting Dr. Fuentes prayer for injunctive relief.
On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No. 42062.
Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision6 in
Administrative Case No. 1690 dismissing the case against Dr. Fuentes. The Board held
that the prosecution failed to show that Dr. Fuentes was the one who left the two pieces of
gauze inside Natividads body; and that he concealed such fact from Natividad.

In G.R. No. 126297, PSI alleged in its petition that the Court of Appeals erred in holding
that: (1) it is estopped from raising the defense that Dr. Ampil is not its employee; (2) it is
solidarily liable with Dr. Ampil; and (3) it is not entitled to its counterclaim against the
Aganas. PSI contends that Dr. Ampil is not its employee, but a mere consultant or
independent contractor. As such, he alone should answer for his negligence.
In G.R. No. 126467, the Aganas maintain that the Court of Appeals erred in finding that Dr.
Fuentes is not guilty of negligence or medical malpractice, invoking the doctrine of res
ipsa loquitur. They contend that the pieces of gauze are prima facie proofs that the
operating surgeons have been negligent.
Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of Appeals erred in finding him
liable for negligence and malpractice sans evidence that he left the two pieces of gauze in
Natividads vagina. He pointed to other probable causes, such as: (1) it was Dr. Fuentes
who used gauzes in performing the hysterectomy; (2) the attending nurses failure to
properly count the gauzes used during surgery; and (3) the medical intervention of the
American doctors who examined Natividad in the United States of America.
For our resolution are these three vital issues: first, whether the Court of Appeals erred in
holding Dr. Ampil liable for negligence and malpractice; second, whether the Court of
Appeals erred in absolving Dr. Fuentes of any liability; and third, whether PSI may be held
solidarily liable for the negligence of Dr. Ampil.
I - G.R. No. 127590
Whether the Court of Appeals Erred in Holding Dr. Ampil

Liable for Negligence and Malpractice.


Dr. Ampil, in an attempt to absolve himself, gears the Courts attention to other possible
causes of Natividads detriment. He argues that the Court should not discount either of
the following possibilities: first, Dr. Fuentes left the gauzes in Natividads body after
performing hysterectomy; second, the attending nurses erred in counting the gauzes; and
third, the American doctors were the ones who placed the gauzes in Natividads body.
Dr. Ampils arguments are purely conjectural and without basis. Records show that he did
not present any evidence to prove that the American doctors were the ones who put or
left the gauzes in Natividads body. Neither did he submit evidence to rebut the
correctness of the record of operation, particularly the number of gauzes used. As to the
alleged negligence of Dr. Fuentes, we are mindful that Dr. Ampil examined his (Dr.
Fuentes) work and found it in order.
The glaring truth is that all the major circumstances, taken together, as specified by the
Court of Appeals, directly point to Dr. Ampil as the negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges to control the bleeding
of the patient during the surgical operation.
Second, immediately after the operation, the nurses who assisted in the surgery noted in
their report that the sponge count (was) lacking 2; that such anomaly was announced to
surgeon and that a search was done but to no avail prompting Dr. Ampil to continue for
closure x x x.
Third, after the operation, two (2) gauzes were extracted from the same spot of the body
of Mrs. Agana where the surgery was performed.

condition to his patients attention, and endeavoring with the means he has at hand to
minimize and avoid untoward results likely to ensue therefrom.
Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he
even misled her that the pain she was experiencing was the ordinary consequence of her
operation. Had he been more candid, Natividad could have taken the immediate and
appropriate medical remedy to remove the gauzes from her body. To our mind, what was
initially an act of negligence by Dr. Ampil has ripened into a deliberate wrongful act of
deceiving his patient.
This is a clear case of medical malpractice or more appropriately, medical negligence. To
successfully pursue this kind of case, a patient must only prove that a health care
provider either failed to do something which a reasonably prudent health care provider
would have done, or that he did something that a reasonably prudent provider would not
have done; and that failure or action caused injury to the patient.11 Simply put, the
elements are duty, breach, injury and proximate causation. Dr, Ampil, as the lead
surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividads
body before closure of the incision. When he failed to do so, it was his duty to inform
Natividad about it. Dr. Ampil breached both duties. Such breach caused injury to
Natividad, necessitating her further examination by American doctors and another
surgery. That Dr. Ampils negligence is the proximate cause12 of Natividads injury could
be traced from his act of closing the incision despite the information given by the
attending nurses that two pieces of gauze were still missing. That they were later on
extracted from Natividads vagina established the causal link between Dr. Ampils
negligence and the injury. And what further aggravated such injury was his deliberate
concealment of the missing gauzes from the knowledge of Natividad and her family.
II - G.R. No. 126467
Whether the Court of Appeals Erred in Absolving

An operation requiring the placing of sponges in the incision is not complete until the
sponges are properly removed, and it is settled that the leaving of sponges or other
foreign substances in the wound after the incision has been closed is at least prima facie
negligence by the operating surgeon.8 To put it simply, such act is considered so
inconsistent with due care as to raise an inference of negligence. There are even legions
of authorities to the effect that such act is negligence per se.9
Of course, the Court is not blind to the reality that there are times when danger to a
patients life precludes a surgeon from further searching missing sponges or foreign
objects left in the body. But this does not leave him free from any obligation. Even if it has
been shown that a surgeon was required by the urgent necessities of the case to leave a
sponge in his patients abdomen, because of the dangers attendant upon delay, still, it is
his legal duty to so inform his patient within a reasonable time thereafter by advising her
of what he had been compelled to do. This is in order that she might seek relief from the
effects of the foreign object left in her body as her condition might permit. The ruling in
Smith v. Zeagler10 is explicit, thus:
The removal of all sponges used is part of a surgical operation, and when a physician or
surgeon fails to remove a sponge he has placed in his patients body that should be
removed as part of the operation, he thereby leaves his operation uncompleted and
creates a new condition which imposes upon him the legal duty of calling the new

Dr. Fuentes of any Liability


The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes on the
ground that it is contrary to the doctrine of res ipsa loquitur. According to them, the fact
that the two pieces of gauze were left inside Natividads body is a prima facie evidence of
Dr. Fuentes negligence.
We are not convinced.
Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule that the fact of
the occurrence of an injury, taken with the surrounding circumstances, may permit an
inference or raise a presumption of negligence, or make out a plaintiffs prima facie case,
and present a question of fact for defendant to meet with an explanation.13 Stated
differently, where the thing which caused the injury, without the fault of the injured, is
under the exclusive control of the defendant and the injury is such that it should not have
occurred if he, having such control used proper care, it affords reasonable evidence, in the
absence of explanation that the injury arose from the defendants want of care, and the
burden of proof is shifted to him to establish that he has observed due care and
diligence.14

From the foregoing statements of the rule, the requisites for the applicability of the
doctrine of res ipsa loquitur are: (1) the occurrence of an injury; (2) the thing which
caused the injury was under the control and management of the defendant; (3) the
occurrence was such that in the ordinary course of things, would not have happened if
those who had control or management used proper care; and (4) the absence of
explanation by the defendant. Of the foregoing requisites, the most instrumental is the
"control and management of the thing which caused the injury."15
We find the element of "control and management of the thing which caused the injury" to
be wanting. Hence, the doctrine of res ipsa loquitur will not lie.
It was duly established that Dr. Ampil was the lead surgeon during the operation of
Natividad. He requested the assistance of Dr. Fuentes only to perform hysterectomy when
he (Dr. Ampil) found that the malignancy in her sigmoid area had spread to her left ovary.
Dr. Fuentes performed the surgery and thereafter reported and showed his work to Dr.
Ampil. The latter examined it and finding everything to be in order, allowed Dr. Fuentes to
leave the operating room. Dr. Ampil then resumed operating on Natividad. He was about
to finish the procedure when the attending nurses informed him that two pieces of gauze
were missing. A "diligent search" was conducted, but the misplaced gauzes were not
found. Dr. Ampil then directed that the incision be closed. During this entire period, Dr.
Fuentes was no longer in the operating room and had, in fact, left the hospital.
Under the "Captain of the Ship" rule, the operating surgeon is the person in complete
charge of the surgery room and all personnel connected with the operation. Their duty is
to obey his orders.16 As stated before, Dr. Ampil was the lead surgeon. In other words, he
was the "Captain of the Ship." That he discharged such role is evident from his following
conduct: (1) calling Dr. Fuentes to perform a hysterectomy; (2) examining the work of Dr.
Fuentes and finding it in order; (3) granting Dr. Fuentes permission to leave; and (4)
ordering the closure of the incision. To our mind, it was this act of ordering the closure of
the incision notwithstanding that two pieces of gauze remained unaccounted for, that
caused injury to Natividads body. Clearly, the control and management of the thing which
caused the injury was in the hands of Dr. Ampil, not Dr. Fuentes.
In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not per se
create or constitute an independent or separate ground of liability, being a mere
evidentiary rule.17 In other words, mere invocation and application of the doctrine does
not dispense with the requirement of proof of negligence. Here, the negligence was
proven to have been committed by Dr. Ampil and not by Dr. Fuentes.
III - G.R. No. 126297
Whether PSI Is Liable for the Negligence of Dr. Ampil
The third issue necessitates a glimpse at the historical development of hospitals and the
resulting theories concerning their liability for the negligence of physicians.
Until the mid-nineteenth century, hospitals were generally charitable institutions,
providing medical services to the lowest classes of society, without regard for a patients
ability to pay.18 Those who could afford medical treatment were usually treated at home
by their doctors.19 However, the days of house calls and philanthropic health care are
over. The modern health care industry continues to distance itself from its charitable past

and has experienced a significant conversion from a not-for-profit health care to for-profit
hospital businesses. Consequently, significant changes in health law have accompanied
the business-related changes in the hospital industry. One important legal change is an
increase in hospital liability for medical malpractice. Many courts now allow claims for
hospital vicarious liability under the theories of respondeat superior, apparent authority,
ostensible authority, or agency by estoppel. 20
In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of the
Civil Code, which reads:
Art. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done. Such fault or negligence, if there is no
pre-existing contractual relation between the parties, is called a quasi-delict and is
governed by the provisions of this Chapter.
A derivative of this provision is Article 2180, the rule governing vicarious liability under
the doctrine of respondeat superior, thus:
ART. 2180. The obligation imposed by Article 2176 is demandable not only for ones own
acts or omissions, but also for those of persons for whom one is responsible.
x x x
x x x
The owners and managers of an establishment or enterprise are likewise responsible for
damages caused by their employees in the service of the branches in which the latter are
employed or on the occasion of their functions.
Employers shall be liable for the damages caused by their employees and household
helpers acting within the scope of their assigned tasks even though the former are not
engaged in any business or industry.
x x x
x x x
The responsibility treated of in this article shall cease when the persons herein mentioned
prove that they observed all the diligence of a good father of a family to prevent damage.
A prominent civilist commented that professionals engaged by an employer, such as
physicians, dentists, and pharmacists, are not "employees" under this article because the
manner in which they perform their work is not within the control of the latter (employer).
In other words, professionals are considered personally liable for the fault or negligence
they commit in the discharge of their duties, and their employer cannot be held liable for
such fault or negligence. In the context of the present case, "a hospital cannot be held
liable for the fault or negligence of a physician or surgeon in the treatment or operation of
patients."21
The foregoing view is grounded on the traditional notion that the professional status and
the very nature of the physicians calling preclude him from being classed as an agent or
employee of a hospital, whenever he acts in a professional capacity.22 It has been said
that medical practice strictly involves highly developed and specialized knowledge,23
such that physicians are generally free to exercise their own skill and judgment in
rendering medical services sans interference.24 Hence, when a doctor practices medicine
in a hospital setting, the hospital and its employees are deemed to subserve him in his
ministrations to the patient and his actions are of his own responsibility.25

The case of Schloendorff v. Society of New York Hospital26 was then considered an
authority for this view. The "Schloendorff doctrine" regards a physician, even if employed
by a hospital, as an independent contractor because of the skill he exercises and the lack
of control exerted over his work. Under this doctrine, hospitals are exempt from the
application of the respondeat superior principle for fault or negligence committed by
physicians in the discharge of their profession.
However, the efficacy of the foregoing doctrine has weakened with the significant
developments in medical care. Courts came to realize that modern hospitals are
increasingly taking active role in supplying and regulating medical care to patients. No
longer were a hospitals functions limited to furnishing room, food, facilities for treatment
and operation, and attendants for its patients. Thus, in Bing v. Thunig,27 the New York
Court of Appeals deviated from the Schloendorff doctrine, noting that modern hospitals
actually do far more than provide facilities for treatment. Rather, they regularly employ,
on a salaried basis, a large staff of physicians, interns, nurses, administrative and manual
workers. They charge patients for medical care and treatment, even collecting for such
services through legal action, if necessary. The court then concluded that there is no
reason to exempt hospitals from the universal rule of respondeat superior.
In our shores, the nature of the relationship between the hospital and the physicians is
rendered inconsequential in view of our categorical pronouncement in Ramos v. Court of
Appeals28 that for purposes of apportioning responsibility in medical negligence cases, an
employer-employee relationship in effect exists between hospitals and their attending and
visiting physicians. This Court held:
"We now discuss the responsibility of the hospital in this particular incident. The unique
practice (among private hospitals) of filling up specialist staff with attending and visiting
"consultants," who are allegedly not hospital employees, presents problems in
apportioning responsibility for negligence in medical malpractice cases. However, the
difficulty is more apparent than real.
In the first place, hospitals exercise significant control in the hiring and firing of
consultants and in the conduct of their work within the hospital premises. Doctors who
apply for consultant slots, visiting or attending, are required to submit proof of
completion of residency, their educational qualifications, generally, evidence of
accreditation by the appropriate board (diplomate), evidence of fellowship in most cases,
and references. These requirements are carefully scrutinized by members of the hospital
administration or by a review committee set up by the hospital who either accept or reject
the application. x x x.
After a physician is accepted, either as a visiting or attending consultant, he is normally
required to attend clinico-pathological conferences, conduct bedside rounds for clerks,
interns and residents, moderate grand rounds and patient audits and perform other tasks
and responsibilities, for the privilege of being able to maintain a clinic in the hospital,
and/or for the privilege of admitting patients into the hospital. In addition to these, the
physicians performance as a specialist is generally evaluated by a peer review committee
on the basis of mortality and morbidity statistics, and feedback from patients, nurses,
interns and residents. A consultant remiss in his duties, or a consultant who regularly falls
short of the minimum standards acceptable to the hospital or its peer review committee,
is normally politely terminated.

In other words, private hospitals, hire, fire and exercise real control over their attending
and visiting consultant staff. While consultants are not, technically employees, x x x,
the control exercised, the hiring, and the right to terminate consultants all fulfill the
important hallmarks of an employer-employee relationship, with the exception of the
payment of wages. In assessing whether such a relationship in fact exists, the control test
is determining. Accordingly, on the basis of the foregoing, we rule that for the purpose of
allocating responsibility in medical negligence cases, an employer-employee relationship
in effect exists between hospitals and their attending and visiting physicians. "
But the Ramos pronouncement is not our only basis in sustaining PSIs liability. Its liability
is also anchored upon the agency principle of apparent authority or agency by estoppel
and the doctrine of corporate negligence which have gained acceptance in the
determination of a hospitals liability for negligent acts of health professionals. The
present case serves as a perfect platform to test the applicability of these doctrines, thus,
enriching our jurisprudence.
Apparent authority, or what is sometimes referred to as the "holding
out" theory, or doctrine of ostensible agency or agency by estoppel,29 has its origin from
the law of agency. It imposes liability, not as the result of the reality of a contractual
relationship, but rather because of the actions of a principal or an employer in somehow
misleading the public into believing that the relationship or the authority exists.30 The
concept is essentially one of estoppel and has been explained in this manner:
"The principal is bound by the acts of his agent with the apparent authority which he
knowingly permits the agent to assume, or which he holds the agent out to the public as
possessing. The question in every case is whether the principal has by his voluntary act
placed the agent in such a situation that a person of ordinary prudence, conversant with
business usages and the nature of the particular business, is justified in presuming that
such agent has authority to perform the particular act in question.31
The applicability of apparent authority in the field of hospital liability was upheld long time
ago in Irving v. Doctor Hospital of Lake Worth, Inc.32 There, it was explicitly stated that
"there does not appear to be any rational basis for excluding the concept of apparent
authority from the field of hospital liability." Thus, in cases where it can be shown that a
hospital, by its actions, has held out a particular physician as its agent and/or employee
and that a patient has accepted treatment from that physician in the reasonable belief
that it is being rendered in behalf of the hospital, then the hospital will be liable for the
physicians negligence.
Our jurisdiction recognizes the concept of an agency by implication or estoppel. Article
1869 of the Civil Code reads:
ART. 1869. Agency may be express, or implied from the acts of the principal, from his
silence or lack of action, or his failure to repudiate the agency, knowing that another
person is acting on his behalf without authority.
In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and
specializations of the physicians associated or accredited by it, including those of Dr.

Ampil and Dr. Fuentes. We concur with the Court of Appeals conclusion that it "is now
estopped from passing all the blame to the physicians whose names it proudly paraded in
the public directory leading the public to believe that it vouched for their skill and
competence." Indeed, PSIs act is tantamount to holding out to the public that Medical
City Hospital, through its accredited physicians, offers quality health care services. By
accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications, the
hospital created the impression that they were its agents, authorized to perform medical
or surgical services for its patients. As expected, these patients, Natividad being one of
them, accepted the services on the reasonable belief that such were being rendered by
the hospital or its employees, agents, or servants. The trial court correctly pointed out:
x x x regardless of the education and status in life of the patient, he ought not be
burdened with the defense of absence of employer-employee relationship between the
hospital and the independent physician whose name and competence are certainly
certified to the general public by the hospitals act of listing him and his specialty in its
lobby directory, as in the case herein. The high costs of todays medical and health care
should at least exact on the hospital greater, if not broader, legal responsibility for the
conduct of treatment and surgery within its facility by its accredited physician or surgeon,
regardless of whether he is independent or employed."33
The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like PSI,
are capable of acting only through other individuals, such as physicians. If these
accredited physicians do their job well, the hospital succeeds in its mission of offering
quality medical services and thus profits financially. Logically, where negligence mars the
quality of its services, the hospital should not be allowed to escape liability for the acts of
its ostensible agents.
We now proceed to the doctrine of corporate negligence or corporate responsibility.
One allegation in the complaint in Civil Case No. Q-43332 for negligence and malpractice
is that PSI as owner, operator and manager of Medical City Hospital, "did not perform the
necessary supervision nor exercise diligent efforts in the supervision of Drs. Ampil and
Fuentes and its nursing staff, resident doctors, and medical interns who assisted Drs.
Ampil and Fuentes in the performance of their duties as surgeons."34 Premised on the
doctrine of corporate negligence, the trial court held that PSI is directly liable for such
breach of duty.
We agree with the trial court.
Recent years have seen the doctrine of corporate negligence as the judicial answer to the
problem of allocating hospitals liability for the negligent acts of health practitioners,
absent facts to support the application of respondeat superior or apparent authority. Its
formulation proceeds from the judiciarys acknowledgment that in these modern times,
the duty of providing quality medical service is no longer the sole prerogative and
responsibility of the physician. The modern hospitals have changed structure. Hospitals
now tend to organize a highly professional medical staff whose competence and
performance need to be monitored by the hospitals commensurate with their inherent
responsibility to provide quality medical care.35
The doctrine has its genesis in Darling v. Charleston Community Hospital.36 There, the
Supreme Court of Illinois held that "the jury could have found a hospital negligent, inter

alia, in failing to have a sufficient number of trained nurses attending the patient; failing
to require a consultation with or examination by members of the hospital staff; and failing
to review the treatment rendered to the patient." On the basis of Darling, other
jurisdictions held that a hospitals corporate negligence extends to permitting a physician
known to be incompetent to practice at the hospital.37 With the passage of time, more
duties were expected from hospitals, among them: (1) the use of reasonable care in the
maintenance of safe and adequate facilities and equipment; (2) the selection and
retention of competent physicians; (3) the overseeing or supervision of all persons who
practice medicine within its walls; and (4) the formulation, adoption and enforcement of
adequate rules and policies that ensure quality care for its patients.38 Thus, in Tucson
Medical Center, Inc. v. Misevich,39 it was held that a hospital, following the doctrine of
corporate responsibility, has the duty to see that it meets the standards of responsibilities
for the care of patients. Such duty includes the proper supervision of the members of its
medical staff. And in Bost v. Riley,40 the court concluded that a patient who enters a
hospital does so with the reasonable expectation that it will attempt to cure him. The
hospital accordingly has the duty to make a reasonable effort to monitor and oversee the
treatment prescribed and administered by the physicians practicing in its premises.
In the present case, it was duly established that PSI operates the Medical City Hospital for
the purpose and under the concept of providing comprehensive medical services to the
public. Accordingly, it has the duty to exercise reasonable care to protect from harm all
patients admitted into its facility for medical treatment. Unfortunately, PSI failed to
perform such duty. The findings of the trial court are convincing, thus:
x x x PSIs liability is traceable to its failure to conduct an investigation of the matter
reported in the nota bene of the count nurse. Such failure established PSIs part in the
dark conspiracy of silence and concealment about the gauzes. Ethical considerations, if
not also legal, dictated the holding of an immediate inquiry into the events, if not for the
benefit of the patient to whom the duty is primarily owed, then in the interest of arriving
at the truth. The Court cannot accept that the medical and the healing professions,
through their members like defendant surgeons, and their institutions like PSIs hospital
facility, can callously turn their backs on and disregard even a mere probability of mistake
or negligence by refusing or failing to investigate a report of such seriousness as the one
in Natividads case.
It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the
assistance of the Medical City Hospitals staff, composed of resident doctors, nurses, and
interns. As such, it is reasonable to conclude that PSI, as the operator of the hospital, has
actual or constructive knowledge of the procedures carried out, particularly the report of
the attending nurses that the two pieces of gauze were missing. In Fridena v. Evans,41 it
was held that a corporation is bound by the knowledge acquired by or notice given to its
agents or officers within the scope of their authority and in reference to a matter to which
their authority extends. This means that the knowledge of any of the staff of Medical City
Hospital constitutes knowledge of PSI. Now, the failure of PSI, despite the attending
nurses report, to investigate and inform Natividad regarding the missing gauzes amounts
to callous negligence. Not only did PSI breach its duties to oversee or supervise all
persons who practice medicine within its walls, it also failed to take an active step in fixing
the negligence committed. This renders PSI, not only vicariously liable for the negligence
of Dr. Ampil under Article 2180 of the Civil Code, but also directly liable for its own
negligence under Article 2176. In Fridena, the Supreme Court of Arizona held:

x x x In recent years, however, the duty of care owed to the patient by the hospital has
expanded. The emerging trend is to hold the hospital responsible where the hospital has
failed to monitor and review medical services being provided within its walls. See Kahn
Hospital Malpractice Prevention, 27 De Paul . Rev. 23 (1977).
Among the cases indicative of the emerging trend is Purcell v. Zimbelman, 18 Ariz. App.
75,500 P. 2d 335 (1972). In Purcell, the hospital argued that it could not be held liable for
the malpractice of a medical practitioner because he was an independent contractor
within the hospital. The Court of Appeals pointed out that the hospital had created a
professional staff whose competence and performance was to be monitored and reviewed
by the governing body of the hospital, and the court held that a hospital would be
negligent where it had knowledge or reason to believe that a doctor using the facilities
was employing a method of treatment or care which fell below the recognized standard of
care.
Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hospital has
certain inherent responsibilities regarding the quality of medical care furnished to patients
within its walls and it must meet the standards of responsibility commensurate with this
undertaking. Beeck v. Tucson General Hospital, 18 Ariz. App. 165, 500 P. 2d 1153 (1972).
This court has confirmed the rulings of the Court of Appeals that a hospital has the duty of
supervising the competence of the doctors on its staff. x x x.
x
x
x
x
x x
In the amended complaint, the plaintiffs did plead that the operation was performed at
the hospital with its knowledge, aid, and assistance, and that the negligence of the
defendants was the proximate cause of the patients injuries. We find that such general
allegations of negligence, along with the evidence produced at the trial of this case, are
sufficient to support the hospitals liability based on the theory of negligent supervision."
Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for damages, let
it be emphasized that PSI, apart from a general denial of its responsibility, failed to
adduce evidence showing that it exercised the diligence of a good father of a family in the
accreditation and supervision of the latter. In neglecting to offer such proof, PSI failed to
discharge its burden under the last paragraph of Article 2180 cited earlier, and, therefore,
must be adjudged solidarily liable with Dr. Ampil. Moreover, as we have discussed, PSI is
also directly liable to the Aganas.
One final word. Once a physician undertakes the treatment and care of a patient, the law
imposes on him certain obligations. In order to escape liability, he must possess that
reasonable degree of learning, skill and experience required by his profession. At the
same time, he must apply reasonable care and diligence in the exercise of his skill and the
application of his knowledge, and exert his best judgment.
WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of the Court
of Appeals in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198.
Costs against petitioners PSI and Dr. Miguel Ampil.
SO ORDERED.

SECOND DIVISION
G.R. No. 160889
April 27, 2007
DR. MILAGROS L. CANTRE, Petitioner, vs. SPS. JOHN DAVID Z. GO and NORA S. GO,
Respondents.
DECISION
QUISUMBING, J.:
For review on certiorari are the Decision1 dated October 3, 2002 and Resolution2 dated
November 19, 2003 of the Court of Appeals in CA-G.R. CV No. 58184, which affirmed with
modification the Decision3 dated March 3, 1997 of the Regional Trial Court of Quezon City,
Branch 98, in Civil Case No. Q-93-16562.

Unfortunately, Noras arm would never be the same.1a\^/phi1.net Aside from the
unsightly mark, the pain in her left arm remains. When sleeping, she has to cradle her
wounded arm. Her movements now are also restricted. Her children cannot play with the
left side of her body as they might accidentally bump the injured arm, which aches at the
slightest touch.
Thus, on June 21, 1993, respondent spouses filed a complaint13 for damages against
petitioner, Dr. Abad, and the hospital. Finding in favor of respondent spouses, the trial
court decreed:
In view of the foregoing consideration, judgment is hereby rendered in favor of the
plaintiffs and against the defendants, directing the latters, (sic) jointly and severally

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


(a) to pay the sum of Five Hundred Thousand Pesos (P500,000.00) in moral damages;
Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and Gynecology at the Dr.
Jesus Delgado Memorial Hospital. She was the attending physician of respondent Nora S.
Go, who was admitted at the said hospital on April 19, 1992.
At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy. However, at
around 3:30 a.m., Nora suffered profuse bleeding inside her womb due to some parts of
the placenta which were not completely expelled from her womb after delivery.
Consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood pressure
to "40" over "0." Petitioner and the assisting resident physician performed various medical
procedures to stop the bleeding and to restore Noras blood pressure. Her blood pressure
was frequently monitored with the use of a sphygmomanometer. While petitioner was
massaging Noras uterus for it to contract and stop bleeding, she ordered a droplight to
warm Nora and her baby.4 Nora remained unconscious until she recovered.
While in the recovery room, her husband, respondent John David Z. Go noticed a fresh
gaping wound two and a half (2 ) by three and a half (3 ) inches in the inner portion of
her left arm, close to the armpit.5 He asked the nurses what caused the injury. He was
informed it was a burn. Forthwith, on April 22, 1992, John David filed a request for
investigation.6 In response, Dr. Rainerio S. Abad, the medical director of the hospital,
called petitioner and the assisting resident physician to explain what happened. Petitioner
said the blood pressure cuff caused the injury.
On May 7, 1992, John David brought Nora to the National Bureau of Investigation for a
physical examination, which was conducted by medico-legal officer Dr. Floresto Arizala,
Jr.7 The medico-legal officer later testified that Noras injury appeared to be a burn and
that a droplight when placed near the skin for about 10 minutes could cause such burn.8
He dismissed the likelihood that the wound was caused by a blood pressure cuff as the
scar was not around the arm, but just on one side of the arm.9
On May 22, 1992, Noras injury was referred to a plastic surgeon at the Dr. Jesus Delgado
Memorial Hospital for skin grafting.10 Her wound was covered with skin sourced from her
abdomen, which consequently bore a scar as well. About a year after, on April 30, 1993,
scar revision had to be performed at the same hospital.11 The surgical operation left a
healed linear scar in Noras left arm about three inches in length, the thickest portion
rising about one-fourth (1/4) of an inch from the surface of the skin. The costs of the skin
grafting and the scar revision were shouldered by the hospital.12

(b) to pay the sum of One Hundred Fifty Thousand Pesos (P150,000.00) exemplary
damages;
(c) to pay the sum of Eighty Thousand Pesos (P80,000.00) nominal damages;
(d) to pay Fifty Thousand Pesos (P50,000.00) for and as attorneys fees; and
(e) to pay Six Thousand Pesos (P6,000.00) litigation expenses.
SO ORDERED.14
Petitioner, Dr. Abad, and the hospital all appealed to the Court of Appeals, which affirmed
with modification the trial court decision, thus:
WHEREFORE, in view of all the foregoing, and finding no reversible error in the appealed
Decision dated March 3, 1997 of Branch 98 of the Regional Trial Court of Quezon City in
Civil Case No. Q-93-16562, the same is hereby AFFIRMED, with the following
MODIFICATIONS:
1. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay plaintiffs-appellees
John David Go and Nora S. Go the sum of P200,000.00 as moral damages;
2. Deleting the award [of] exemplary damages, attorneys fees and expenses of
litigation;1awphi1.nt
3. Dismissing the complaint with respect to defendants-appellants Dr. Rainerio S. Abad
and Delgado Clinic, Inc.;
4. Dismissing the counterclaims of defendants-appellants for lack of merit; and
5. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay the costs.
SO ORDERED.15
Petitioners motion for reconsideration was denied by the Court of Appeals. Hence, the
instant petition assigning the following as errors and issues:

I.

COSMETIC SURGERY MADE THE SCARS EVEN MORE UGLY AND DECLARED THE COSMETIC
SURGERY A FAILURE;

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

VIII.

II.

Petitioner contends that additional documentary exhibits not testified to by any witness
are inadmissible in evidence because they deprived her of her constitutional right to
confront the witnesses against her. Petitioner insists the droplight could not have touched
Noras body. She maintains the injury was due to the constant taking of Noras blood
pressure. Petitioner also insinuates the Court of Appeals was misled by the testimony of
the medico-legal officer who never saw the original injury before plastic surgery was
performed. Finally, petitioner stresses that plastic surgery was not intended to restore
respondents injury to its original state but rather to prevent further complication.

WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION
WHEN, CONTRARY TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE PETITIONER, IT
RULED THAT THE PETITIONER HAS NOT AMPLY SHOWED THAT THE DROPLIGHT DID NOT
TOUCH THE BODY OF MRS. NORA GO, AND THIS DECISION OF THE LOWER COURT WAS
UPHELD BY THE COURT OF APPEALS LIKEWISE COMMITTING GRAVE ABUSE OF
DISCRETION;
III.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION
WHEN, CONTRARY TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE PETITIONER, IT
RULED THAT PETITIONER DRA. CANTRE WAS NOT ABLE TO AMPLY EXPLAIN HOW THE
INJURY (BLISTERS) IN THE LEFT INNER ARM OF RESPONDENT MRS. GO CAME ABOUT;
IV.
WHETHER OR NOT THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF ITS
DISCRETION WHEN IT MADE A RULING ON THE RESPONDENTS INJURY QUOTING THE
TESTIMONY OF SOMEONE WHO WAS NOT PRESENT AND HAS NOT SEEN THE ORIGINAL,
FRESH INJURY OF RESPONDENT MRS. NORA GO;
V.
WHETHER OR NOT THE COURT OF APPEALS GRAVELY ABUSING ITS DISCRETION RULED
THAT PETITIONER DRA. CANTRE SHOULD HAVE INTENDED TO INFLICT THE INJURY TO SAVE
THE LIFE OF RESPONDENT MRS. GO;
VI.
WHETHER OR NOT THE LOWER COURT AND THE COURT [OF] APPEALS COMMITTED GRAVE
ABUSE OF DISCRETION WHEN, CONTRARY TO THE DETAILED PROCEDURES DONE BY
PETITIONER, BOTH RULED THAT THE RESPONDENT WAS LEFT TO THE CARE OF THE
NURSING STAFF;
VII.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF DISCRETION WHEN,
CONTRARY TO THE MEDICAL PURPOSES OF COSMETIC SURGERY, IT RULED THAT THE

WHETHER OR NOT THE LOWER COURT GRAVELY ABUSE OF (SIC) DISCRETION WHEN,
CONTRARY TO RESPONDENTS CONTRARY TESTIMONIES AND THE ABSENCE OF ANY
TESTIMONY, IT RULED THAT THEY ARE ENTITLED TO DAMAGES AND WHICH WAS UPHELD,
ALTHOUGH MODIFIED, BY THE COURT OF APPEALS LIKEWISE ABUSING ITS DISCRETION.16

Respondents, however, counter that the genuineness and due execution of the additional
documentary exhibits were duly admitted by petitioners counsel. Respondents point out
that petitioners blood pressure cuff theory is highly improbable, being unprecedented in
medical history and that the injury was definitely caused by the droplight. At any rate,
they argue, even if the injury was brought about by the blood pressure cuff, petitioner was
still negligent in her duties as Noras attending physician.
Simply put, the threshold issues for resolution are: (1) Are the questioned additional
exhibits admissible in evidence? (2) Is petitioner liable for the injury suffered by
respondent Nora Go? Thereafter, the inquiry is whether the appellate court committed
grave abuse of discretion in its assailed issuances.
As to the first issue, we agree with the Court of Appeals that said exhibits are admissible
in evidence. We note that the questioned exhibits consist mostly of Noras medical
records, which were produced by the hospital during trial pursuant to a subpoena duces
tecum. Petitioners counsel admitted the existence of the same when they were formally
offered for admission by the trial court. In any case, given the particular circumstances of
this case, a ruling on the negligence of petitioner may be made based on the res ipsa
loquitur doctrine even in the absence of such additional exhibits.
Petitioners contention that the medico-legal officer who conducted Noras physical
examination never saw her original injury before plastic surgery was performed is without
basis and contradicted by the records. Records show that the medico-legal officer
conducted the physical examination on May 7, 1992, while the skin grafting and the scar
revision were performed on Nora on May 22, 1992 and April 30, 1993, respectively.
Coming now to the substantive matter, is petitioner liable for the injury suffered by
respondent Nora Go?
The Hippocratic Oath mandates physicians to give primordial consideration to the wellbeing of their patients. If a doctor fails to live up to this precept, he is accountable for his
acts. This notwithstanding, courts face a unique restraint in adjudicating medical

negligence cases because physicians are not guarantors of care and, they never set out to
intentionally cause injury to their patients. However, intent is immaterial in negligence
cases because where negligence exists and is proven, it automatically gives the injured a
right to reparation for the damage caused.17
In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere
existence of an injury to justify a presumption of negligence on the part of the person who
controls the instrument causing the injury, provided that the following requisites concur:

Based on the foregoing, the presumption that petitioner was negligent in the exercise of
her profession stands unrebutted. In this connection, the Civil Code provides:
ART. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done.

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

ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious
anxiety, besmirched reputation, wounded feelings, moral shock, social humiliation, and
similar injury. Though incapable of pecuniary computation, moral damages may be
recovered if they are the proximate result of the defendants wrongful act or omission.

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


defendants; and

Clearly, under the law, petitioner is obliged to pay Nora for moral damages suffered by
the latter as a proximate result of petitioners negligence.

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

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

As to the first requirement, the gaping wound on Noras arm is certainly not an ordinary
occurrence in the act of delivering a baby, far removed as the arm is from the organs
involved in the process of giving birth. Such injury could not have happened unless
negligence had set in somewhere.
Second, whether the injury was caused by the droplight or by the blood pressure cuff is of
no moment. Both instruments are deemed within the exclusive control of the physician in
charge under the "captain of the ship" doctrine. This doctrine holds the surgeon in charge
of an operation liable for the negligence of his assistants during the time when those
assistants are under the surgeons control.19 In this particular case, it can be logically
inferred that petitioner, the senior consultant in charge during the delivery of Noras baby,
exercised control over the assistants assigned to both the use of the droplight and the
taking of Noras blood pressure. Hence, the use of the droplight and the blood pressure
cuff is also within petitioners exclusive control.

Hence, considering the specific circumstances in the instant case, we find no grave abuse
of discretion in the assailed decision and resolution of the Court of Appeals. Further, we
rule that the Court of Appeals award of Two Hundred Thousand Pesos (P200,000) as moral
damages in favor of respondents and against petitioner is just and equitable.21
WHEREFORE, the petition is DENIED. The Decision dated October 3, 2002 and Resolution
dated November 19, 2003 of the Court of Appeals in CA-G.R. CV No. 58184 are AFFIRMED.
No pronouncement as to costs.

Third, the gaping wound on Noras left arm, by its very nature and considering her
condition, could only be caused by something external to her and outside her control as
she was unconscious while in hypovolemic shock. Hence, Nora could not, by any stretch of
the imagination, have contributed to her own injury.
Petitioners defense that Noras wound was caused not by the droplight but by the
constant taking of her blood pressure, even if the latter was necessary given her
condition, does not absolve her from liability. As testified to by the medico-legal officer, Dr.
Arizala, Jr., the medical practice is to deflate the blood pressure cuff immediately after
each use. Otherwise, the inflated band can cause injury to the patient similar to what
could have happened in this case. Thus, if Noras wound was caused by the blood
pressure cuff, then the taking of Noras blood pressure must have been done so
negligently as to have inflicted a gaping wound on her arm,20 for which petitioner cannot
escape liability under the "captain of the ship" doctrine.
Further, petitioners argument that the failed plastic surgery was not intended as a
cosmetic procedure, but rather as a measure to prevent complication does not help her
case. It does not negate negligence on her part.

SO ORDERED.

SECOND DIVISION
G.R. No. 172406
October 11, 2007
CONCEPCION ILAO-ORETA, Petitioner, vs. SPOUSES EVA MARIE and BENEDICTO NOEL
RONQUILLO, Respondents.
DECISION
CARPIO MORALES, J.:
Respondents, spouses Eva Marie Ronquillo (Eva Marie) and Noel Benedicto (Noel)
Ronquillo (the Ronquillo spouses or the spouses), had not been blessed with a child
despite several years of marriage. They thus consulted petitioner, Dr. Concepcion IlaoOreta (Dr. Ilao-Oreta), an obstetrician-gynecologist-consultant at the St. Lukes Medical
Center where she was, at the time material to the case, the chief of the Reproductive
Endocrinology and Infertility Section.
Upon Dr. Ilao-Oretas advice, Eva Marie agreed to undergo a laparoscopic procedure
whereby a laparascope would be inserted through the patients abdominal wall to get a
direct view of her internal reproductive organ in order to determine the real cause of her
infertility.

On appeal by the spouses, the Court of Appeals, by Decision6 of April 21, 2006, finding Dr.
Ilao-Oreta grossly negligent,7 modified the trial courts decision as follows:
WHEREFORE, the trial Courts decision dated March 9, 2001 is affirmed, subject to the
modification that the amount of actual damages, for which both defendants-appellees are
jointly and severally liable to plaintiffs-appellants, is increased to P16,069.40.
Furthermore, defendant-appellee Dr. Ilao-Oreta is also held liable to pay plaintiffappellants the following:
(a) P50,000.00 as moral damages;
(b) P25,000.00 as exemplary damages; and
(c) P20,000.00 as attorneys fees.
SO ORDERED.8 (Underscoring supplied)
Hence, the present Petition for Review9 of Dr. Ilao-Oreta raising the following arguments:

The procedure was scheduled on April 5, 1999 at 2:00 p.m., to be performed by Dr. IlaoOreta. At around 7:00 a.m. of said date, Eva Marie, accompanied by her husband Noel,
checked in at the St. Lukes Medical Center and underwent pre-operative procedures
including the administration of intravenous fluid and enema.

The court a quo erred in finding petitioner to have acted with gross negligence and
awarding moral damages to respondents.10
The court a quo erred in awarding Exemplary Damages to respondents.11

Dr. Ilao-Oreta did not arrive at the scheduled time for the procedure, however, and no
prior notice of its cancellation was received. It turned out that the doctor was on a return
flight from Hawaii to, and arrived at 10:00 p.m. of April 5, 1999 in, Manila.
On May 18, 1999, the Ronquillo spouses filed a complaint1 against Dr. Ilao-Oreta and the
St. Lukes Medical Center for breach of professional and service contract and for damages
before the Regional Trial Court (RTC) of Batangas City. They prayed for the award of actual
damages including alleged loss of income of Noel while accompanying his wife to the
hospital, moral damages, exemplary damages, the costs of litigation, attorneys fees, and
other available reliefs and remedies.2
In her Answer,3 Dr. Ilao-Oreta gave her side of the case as follows: She went on a
honeymoon to Hawaii and was scheduled to leave Hawaii at 3:00 p.m. of April 4, 1999 for
Manila. Aware that her trip from Hawaii to Manila would take about 12 hours, inclusive of a
stop-over at the Narita Airport in Japan, she estimated that she would arrive in Manila in
the early morning of April 5, 1999. She thus believed in utmost good faith that she would
be back in Manila in time for the scheduled conduct of the laparoscopic procedure. She
failed to consider the time difference between Hawaii and the Philippines, however.
In its Answer,4 the St. Lukes Medical Center contended that the spouses have no cause of
action against it since it performed the pre-operative procedures without delay, and any
cause of action they have would be against Dr. Ilao-Oreta.

The court a quo [erred] in awarding Attorneys Fees to respondents.12


The court a quo erred in increasing the award of actual damages in favor of
respondents.13
"Gross negligence" implies a want or absence of or failure to exercise slight care or
diligence, or the entire absence of care. It evinces a thoughtless disregard of
consequences without exerting any effort to avoid them.14 It is characterized by want of
even slight care, acting or omitting to act in a situation where there is a duty to act, not
inadvertently but willfully and intentionally with a conscious indifference to consequences
in so far as other persons may be affected.15
The records show that before leaving for Hawaii, Dr. Ilao-Oreta left an admitting order with
her secretary for one of the spouses to pick up, apprised Eva Marie of the necessary
preparations for the procedure, and instructed the hospital staff to perform pre-operative
treatments.16 These acts of the doctor reflect an earnest intention to perform the
procedure on the day and time scheduled.
The records also show that on realizing that she missed the scheduled procedure, Dr. IlaoOreta, upon arrival in Manila, immediately sought to rectify the same, thus:
[ATTY SINJAN] Q: So, can you tell us the reason why you missed that operation?

By Decision5 of March 9, 2001, Branch 84 of the Batangas RTC, finding that the failure of
the doctor to arrive on time was not intentional, awarded Eva Marie only actual damages
in the total amount of P9,939 and costs of suit. It found no adequate proof that Noel had
been deprived of any job contract while attending to his wife in the hospital.

[DR. ILAO-ORETA] A: When I scheduled her for the surgery, I looked at my ticket and so I
was to leave Hawaii on April 4 at around 4:00 oclock in the afternoon, so I was computing
12 hours of travel including stop-over, then probably I would be in Manila early morning of

April 5, then I have so much time and I can easily do the case at 2:00 oclock, you know it
skipped my mind the change in time.

The doctors act did not, however, reflect gross negligence as defined above. Her
argument that

Q: So when you arrived at 10:00 [PM] in Manila, what did you do?

A: I wanted to call the plaintiffs, but I didnt have their number at that time, so in the
morning I went to my office early at 8:00 and looked for her chart, because her telephone
number was written in the chart. So, I called them right away.

Although petitioner failed to take into consideration the time difference between the
Philippines and Hawaii, the situation then did not present any clear and apparent harm or
injury that even a careless person may perceive. Unlike in situations where the Supreme
Court had found gross negligence to exist, petitioner could not have been conscious of
any foreseeable danger that may occur since she actually believed that she would make it
to the operation that was elective in nature, the only purpose of which was to determine
the real cause of infertility and not to treat and cure a life threatening disease. Thus, in
merely fixing the date of her appointment with respondent Eva Marie Ronquillo, petitioner
was not in the pursuit or performance of conduct which any ordinary person may deem to
probably and naturally result in injury,19 (Underscoring in original)

Q: Were you able to contact them?

thus persuades.

A: I was able to reach Mr. Ronquillo.

It bears noting that when she was scheduling the date of her performance of the
procedure, Dr. Ilao-Oreta had just gotten married and was preparing for her
honeymoon,20 and it is of common human knowledge that excitement attends its
preparations. Her negligence could then be partly attributed to human frailty which rules
out its characterization as gross.

A: I called immediately the hospital and I talked with the nurses, I asked about the patient,
Mrs. Ronquillo, and they told me that she has already left at around 7:00.
Q: And after calling the hospital, what happened?

Q: In the course of your conversation, what did you tell Mr. Ronquillo?
A: I apologized to him, I said I was sorry about the time that I missed the surgery, and I
told him that I can do the case right that same day without Mrs. Ronquillo having to
undergo another [b]arium enema.

The doctors negligence not being gross, the spouses are not entitled to recover moral
damages.

Q: What else did you tell him, if any?


A: I asked him whether I can talk with Mrs. Ronquillo because I wanted to apologize to her
personally.
Q: And what did he say?
A: I could hear on the background that Mrs. Ronquillo was shouting angrily that she didnt
want to talk to me, and that she didnt want re-scheduling of the surgery . . .
ATTY LONTOK: May we move, your Honor, for the striking out of the answer, this is purely
hearsay.

Neither are the spouses entitled to recover exemplary damages in the absence of a
showing that Dr. Ilao-Oreta acted in a wanton, fraudulent, reckless, oppressive or
malevolent manner,21 nor to award of attorneys fees as, contrary to the finding of the
Court of Appeals that the spouses "were compelled to litigate and incur expenses to
protect their interest,"22 the records show that they did not exert enough efforts to settle
the matter before going to court. Eva Marie herself testified:
ATTY. SINJIAN:
Q: Isnt it true that before instituting this present case, you did not make any demand on
Dr. Ilao-Oreta regarding the claims which you have allegedly incurred, because of the
failed laparoscopic surgery operation?

COURT: Remain on the record.


A [EVA MARIE]: I will tell the truth. Dr. Augusto Reyes of St. Lukes . . .
WITNESS [DR. ILAO-ORETA]: . . . and then Mr. Ronquillo told me "Im sorry, Dra., we cannot
re-schedule the surgery."17 (Underscoring supplied)
Noel admitted that indeed Dr. Ilao-Oreta called him up after she arrived in Manila as
related by her.18

Q: But did you demand?


A: No, I did not demand because
ATTY. SINJIAN: That will be all, your Honor.

The evidence then shows that Dr. Ilao-Oreta, who had traveled more than twice to the
United States where she obtained a fellowship in Reproductive Endocrinology and
Infertility was indeed negligent when she scheduled to perform professional service at
2:00 p.m. on April 5, 1999 without considering the time difference between the Philippines
and Hawaii.

ATTY. LONTOK: The witness is still explaining.


WITNESS: Im explaining first. Dr. Augusto Reyes told me that he will hold the meeting for
me and Dr. Oreta to settle things and reimburse all the money that I spent from the
hospital, and he even suggested Dr. Oreta to personally talk to me.

ATTY. SINJIAN:

The list of expenses cannot replace receipts when they should have been issued as a
matter of course in business transactions29 as in the case of purchase of gasoline and of
food.1wphi1

Q: So it was to Dr. Augusto Reyes that you talked?


A: Yes.

The documented claim for hospital and medical expenses of the spouses is detailed in the
Statement of Account issued by the hospital, the pertinent entries of which read:

Q: But you did not demand anything or write to Dr. Oreta?

xxxx

A: No.
Q: Before instituting this case?
A: No.23 (Underscoring supplied)
Finally, Dr. Ilao-Oretas prayer for the reduction of actual damages is well-taken. Article
2201 of the Civil Code provides:
In contracts and quasi-contracts, the damages for which the obligor who acted in good
faith is liable shall be those which are the natural and probable consequences of the
breach of the obligation, and which the parties have foreseen or could have reasonably
foreseen at the time the obligation was constituted.
In fixing the amount of actual damages, the Court of Appeals and the trial court included
expenses which the spouses incurred prior to April 5, 1999 when the breach of contract
complained of occurred.24 The Court of Appeals also included the alleged P300 spent on
fuel consumption from the spouses residence at San Pascual, Batangas to the St. Lukes
Medical Center in Quezon City and the alleged P500 spent on food in the hospital canteen,
both of which are unsubstantiated by independent or competent proof.25 The only piece
of documentary evidence supporting the food and fuel expenses is an unsigned listing.26
As the fuel and food expenses are not adequately substantiated, they cannot be included
in the computation of the amount of actual damages. So Premiere Development Bank v.
Court of Appeals27 instructs:
In the instant case, the actual damages were proven through the sole testimony of
Themistocles Ruguero, the vice president for administration of Panacor. In his testimony,
the witness affirmed that Panacor incurred losses, specifically, in terms of training and
seminars, leasehold acquisition, procurement of vehicles and office equipment without,
however, adducing receipts to substantiate the same. The documentary evidence marked
as Exhibit "W," which was an ordinary private writing allegedly itemizing the capital
expenditures and losses from the failed operation of Panacor, was not testified to by any
witness to ascertain the veracity of its content. Although the lower court fixed the sum of
P4,520,000.00 as the total expenditures incurred by Panacor, it failed to show how and in
what manner the same were substantiated by the claimant with reasonable certainty.
Hence, the claim for actual damages should be received with extreme caution since it is
only based on bare assertion without support from independent evidence. Premieres
failure to prove actual expenditure consequently conduces to a failure of its claim. In
determining actual damages, the court cannot rely on mere assertions, speculations,
conjectures or guesswork but must depend on competent proof and on the best evidence
obtainable regarding the actual amount of loss.28 (Underscoring supplied)

GROSS HOSPITAL CHARGES


2,416.50
4/5/1999
1699460 DEPOSITOFFICIAL
RECEIPT
(5,000.00)
(5,000.00)
4/5/1999
SECOND
FLOOR 0284893
UNUSED MED
HINOX 500 MG CAP
0439534

(65.55)

SECOND
FLOOR 0284894
UNUSED MED
PHENERGAN 2 ML
0439893
(62.25)
50MG ________
(127.80)
BALANCE DUE
(2,711.30)30
==========
As extrapolated from the above-quoted entries in the Statement of Account, P2,288.70
(the gross hospital charges of P2,416.50 less the unused medicine in the amount of
P127.80) was debited from the P5,000 deposit31 to thus leave a balance of the deposit in
the amount of P2,711.30, which the trial court erroneously denominated as "confinement
fee." The remaining balance of P2,711.30 was the amount refundable to the spouses.
Following Eastern Shipping Lines, Inc. v. Court of Appeals,32 this Court awards interest on
the actual damages to be paid by Dr. Ilao-Oreta at the rate of 6% per annum from the
time of the filing of the complaint on May 18, 1999, and at 12% per annum from the
finality of this judgment until its satisfaction.
WHEREFORE, the petition is GRANTED. The decision appealed from is MODIFIED in that
1) the award to respondents-spouses Noel and Eva Marie Ronquillo of actual damages is
REDUCED to P2,288.70, to bear interest at a rate of 6% per annum from the time of the
filing of the complaint on May 18, 1999 and, upon finality of this judgment, at the rate of
12% per annum until satisfaction; and
2) The award of moral and exemplary damages and attorneys fees is DELETED.
SO ORDERED.

SECOND DIVISION
G.R. No. 158996
November 14, 2008
SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA FLORES, petitioners, vs.
SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO, and FLORENCIO, CANDIDA, MARTA,
GODOFREDO, BALTAZAR and LUCENA, all surnamed PINEDA, as heirs of the deceased
TERESITA S. PINEDA, and UNITED DOCTORS MEDICAL CENTER, INC., respondents.
DECISION
BRION, J.:
This petition involves a medical negligence case that was elevated to this Court through
an appeal by certiorari under Rule 45 of the Rules of Court. The petition assails the
Decision1 of the Court of Appeals (CA) in CA G.R. CV No. 63234, which affirmed with
modification the Decision2 of the Regional Trial Court (RTC) of Nueva Ecija, Branch 37 in
Civil Case No. SD-1233. The dispositive portion of the assailed CA decision states:
WHEREFORE, premises considered, the assailed Decision of the Regional Trial Court of
Baloc, Sto. Domingo, Nueva Ecija, Branch 37 is hereby AFFIRMED but with modifications
as follows:
1) Ordering defendant-appellants Dr. and Dra. Fredelicto A. Flores and the United Doctors
Medical Center, Inc. to jointly and severally pay the plaintiff-appellees - heirs of Teresita
Pineda, namely, Spouses Dominador Pineda and Virginia Saclolo and Florencio, Candida,
Marta, Godofredo, Baltazar and Lucena, all surnamed Pineda, the sum of P400,000.00 by
way of moral damages;
2) Ordering the above-named defendant-appellants to jointly and severally pay the abovenamed plaintiff-appellees the sum of P100,000.00 by way of exemplary damages;
3) Ordering the above-named defendant-appellants to jointly and severally pay the abovenamed plaintiff-appellees the sum of P36,000.00 by way of actual and compensatory
damages; and
4) Deleting the award of attorney's fees and costs of suit.
SO ORDERED.
While this case essentially involves questions of facts, we opted for the requested review
in light of questions we have on the findings of negligence below, on the awarded
damages and costs, and on the importance of this type of ruling on medical practice.3
BACKGROUND FACTS
Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto. Domingo,
Nueva Ecija. She consulted on April 17, 1987 her townmate, Dr. Fredelicto Flores,
regarding her medical condition. She complained of general body weakness, loss of
appetite, frequent urination and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto
initially interviewed the patient and asked for the history of her monthly period to analyze
the probable cause of the vaginal bleeding. He advised her to return the following week or
to go to the United Doctors Medical Center (UDMC) in Quezon City for a general check-up.
As for her other symptoms, he suspected that Teresita might be suffering from diabetes
and told her to continue her medications.4

Teresita did not return the next week as advised. However, when her condition persisted,
she went to further consult Dr. Flores at his UDMC clinic on April 28, 1987, travelling for at
least two hours from Nueva Ecija to Quezon City with her sister, Lucena Pineda. They
arrived at UDMC at around 11:15 a.m.. Lucena later testified that her sister was then so
weak that she had to lie down on the couch of the clinic while they waited for the doctor.
When Dr. Fredelicto arrived, he did a routine check-up and ordered Teresita's admission to
the hospital. In the admission slip, he directed the hospital staff to prepare the patient for
an "on call" D&C5 operation to be performed by his wife, Dr. Felicisima Flores (Dr.
Felicisima). Teresita was brought to her hospital room at around 12 noon; the hospital staff
forthwith took her blood and urine samples for the laboratory tests6 which Dr. Fredelicto
ordered.
At 2:40 p.m. of that same day, Teresita was taken to the operating room. It was only then
that she met Dr. Felicisima, an obstetrician and gynecologist. The two doctors - Dr.
Felicisima and Dr. Fredelicto, conferred on the patient's medical condition, while the
resident physician and the medical intern gave Dr. Felicisima their own briefings. She also
interviewed and conducted an internal vaginal examination of the patient which lasted for
about 15 minutes. Dr. Felicisima thereafter called up the laboratory for the results of the
tests. At that time, only the results for the blood sugar (BS), uric acid determination,
cholesterol determination, and complete blood count (CBC) were available. Teresita's BS
count was 10.67mmol/l7 and her CBC was 109g/l.8
Based on these preparations, Dr. Felicisima proceeded with the D&C operation with Dr.
Fredelicto administering the general anesthesia. The D&C operation lasted for about 10 to
15 minutes. By 3:40 p.m., Teresita was wheeled back to her room.
A day after the operation (or on April 29, 1987), Teresita was subjected to an ultrasound
examination as a confirmatory procedure. The results showed that she had an enlarged
uterus and myoma uteri.9 Dr. Felicisima, however, advised Teresita that she could spend
her recovery period at home. Still feeling weak, Teresita opted for hospital confinement.
Teresita's complete laboratory examination results came only on that day (April 29, 1987).
Teresita's urinalysis showed a three plus sign (+++) indicating that the sugar in her urine
was very high. She was then placed under the care of Dr. Amado Jorge, an internist.
By April 30, 1987, Teresita's condition had worsened. She experienced difficulty in
breathing and was rushed to the intensive care unit. Further tests confirmed that she was
suffering from Diabetes Mellitus Type II.10 Insulin was administered on the patient, but the
medication might have arrived too late. Due to complications induced by diabetes,
Teresita died in the morning of May 6, 1987.11
Believing that Teresita's death resulted from the negligent handling of her medical needs,
her family (respondents) instituted an action for damages against Dr. Fredelicto Flores and
Dr. Felicisima Flores (collectively referred to as the petitioner spouses) before the RTC of
Nueva Ecija.
The RTC ruled in favor of Teresita's family and awarded actual, moral, and exemplary
damages, plus attorney's fees and costs.12 The CA affirmed the judgment, but modified
the amount of damages awarded and deleted the award for attorney's fees and costs of
suit.13

Through this petition for review on certiorari, the petitioner spouses -Dr. Fredelicto (now
deceased) and Dr. Felicisima Flores - allege that the RTC and CA committed a reversible
error in finding them liable through negligence for the death of Teresita Pineda.

D&C is the classic gynecologic procedure for the evaluation and possible therapeutic
treatment for abnormal vaginal bleeding.20 That this is the recognized procedure is
confirmed by Drs. Salvador Nieto (Dr. Nieto) and Joselito Mercado (Dr. Mercado), the
expert witnesses presented by the respondents:

ASSIGNMENT OF ERRORS
The petitioner spouses contend that they exercised due care and prudence in the
performance of their duties as medical professionals. They had attended to the patient to
the best of their abilities and undertook the management of her case based on her
complaint of an on-and-off vaginal bleeding. In addition, they claim that nothing on record
shows that the death of Teresita could have been averted had they employed means
other than what they had adopted in the ministration of the patient.
THE COURT'S RULING
We do not find the petition meritorious.
The respondents' claim for damages is predicated on their allegation that the decision of
the petitioner spouses to proceed with the D&C operation, notwithstanding Teresita's
condition and the laboratory test results, amounted to negligence. On the other hand, the
petitioner spouses contend that a D&C operation is the proper and accepted procedure to
address vaginal bleeding - the medical problem presented to them. Given that the patient
died after the D&C, the core issue is whether the decision to proceed with the D&C
operation was an honest mistake of judgment or one amounting to negligence.
Elements of a Medical Negligence Case
A medical negligence case is a type of claim to redress a wrong committed by a medical
professional, that has caused bodily harm to or the death of a patient. There are four
elements involved in a medical negligence case, namely: duty, breach, injury, and
proximate causation.14
Duty refers to the standard of behavior which imposes restrictions on one's conduct.15
The standard in turn refers to the amount of competence associated with the proper
discharge of the profession. A physician is expected to use at least the same level of care
that any other reasonably competent doctor would use under the same circumstances.
Breach of duty occurs when the physician fails to comply with these professional
standards. If injury results to the patient as a result of this breach, the physician is
answerable for negligence.16
As in any civil action, the burden to prove the existence of the necessary elements rests
with the plaintiff.17 To successfully pursue a claim, the plaintiff must prove by
preponderance of evidence that, one, the physician either failed to do something which a
reasonably prudent health care provider would have done, or that he did something that a
reasonably prudent provider would not have done; and two, the failure or action caused
injury to the patient.18 Expert testimony is therefore essential since the factual issue of
whether a physician or surgeon has exercised the requisite degree of skill and care in the
treatment of his patient is generally a matter of expert opinion.19
Standard of Care and Breach of Duty

DR. NIETO: [W]hat I know among obstetricians, if there is bleeding, they perform what we
call D&C for diagnostic purposes.
xxx xxx xxx
Q: So are you trying to tell the Court that D&C can be a diagnostic treatment?
A: Yes, sir. Any doctor knows this.21
Dr. Mercado, however, objected with respect to the time the D&C operation should have
been conducted in Teresita's case. He opined that given the blood sugar level of Teresita,
her diabetic condition should have been addressed first:
Q: Why do you consider the time of performance of the D&C not appropriate?
A: Because I have read the record and I have seen the urinalysis, [there is] spillage in the
urine, and blood sugar was 10.67
Q: What is the significance of the spillage in the urine?
A: It is a sign that the blood sugar is very high.
Q: Does it indicate sickness?
A: 80 to 95% it means diabetes mellitus. The blood sugar was 10.67.
xxx xxx xxx
COURT: In other words, the operation conducted on the patient, your opinion, that it is
inappropriate?
A: The timing of [when] the D&C [was] done, based on the record, in my personal opinion,
that D&C should be postponed a day or two.22
The petitioner spouses countered that, at the time of the operation, there was nothing to
indicate that Teresita was afflicted with diabetes: a blood sugar level of 10.67mmol/l did
not necessarily mean that she was a diabetic considering that this was random blood
sugar;23 there were other factors that might have caused Teresita's blood sugar to rise
such as the taking of blood samples during lunchtime and while patient was being given
intra-venous dextrose.24 Furthermore, they claim that their principal concern was to
determine the cause of and to stop the vaginal bleeding.
The petitioner spouses' contentions, in our view, miss several points. First, as early as
April 17, 1987, Teresita was already suspected to be suffering from diabetes.25 This
suspicion again arose right before the D&C operation on April 28, 1987 when the
laboratory result revealed Teresita's increased blood sugar level.26 Unfortunately, the
petitioner spouses did not wait for the full medical laboratory results before proceeding
with the D&C, a fact that was never considered in the courts below. Second, the petitioner
spouses were duly advised that the patient was experiencing general body weakness, loss
of appetite, frequent urination, and thirst - all of which are classic symptoms of
diabetes.27 When a patient exhibits symptoms typical of a particular disease, these
symptoms should, at the very least, alert the physician of the possibility that the patient
may be afflicted with the suspected disease:
Expert testimony for the plaintiff showed that] tests should have been ordered
immediately on admission to the hospital in view of the symptoms presented, and that
failure to recognize the existence of diabetes constitutes negligence.28

Third, the petitioner spouses cannot claim that their principal concern was the vaginal
bleeding and should not therefore be held accountable for complications coming from
other sources. This is a very narrow and self-serving view that even reflects on their
competence.
Taken together, we find that reasonable prudence would have shown that diabetes and its
complications were foreseeable harm that should have been taken into consideration by
the petitioner spouses. If a patient suffers from some disability that increases the
magnitude of risk to him, that disability must be taken into account so long as it is or
should have been known to the physician.29 And when the patient is exposed to an
increased risk, it is incumbent upon the physician to take commensurate and adequate
precautions.
Taking into account Teresita's high blood sugar,30 Dr. Mendoza opined that the attending
physician should have postponed the D&C operation in order to conduct a confirmatory
test to make a conclusive diagnosis of diabetes and to refer the case to an internist or
diabetologist. This was corroborated by Dr. Delfin Tan (Dr. Tan), an obstetrician and
gynecologist, who stated that the patient's diabetes should have been managed by an
internist prior to, during, and after the operation.31
Apart from bleeding as a complication of pregnancy, vaginal bleeding is only rarely so
heavy and life-threatening that urgent first-aid measures are required.32 Indeed, the
expert witnesses declared that a D&C operation on a hyperglycemic patient may be
justified only when it is an emergency case - when there is profuse vaginal bleeding. In
this case, we choose not to rely on the assertions of the petitioner spouses that there was
profuse bleeding, not only because the statements were self-serving, but also because the
petitioner spouses were inconsistent in their testimonies. Dr. Fredelicto testified earlier
that on April 28, he personally saw the bleeding,33 but later on said that he did not see it
and relied only on Teresita's statement that she was bleeding.34 He went on to state that
he scheduled the D&C operation without conducting any physical examination on the
patient.
The likely story is that although Teresita experienced vaginal bleeding on April 28, it was
not sufficiently profuse to necessitate an immediate emergency D&C operation. Dr. Tan35
and Dr. Mendoza36 both testified that the medical records of Teresita failed to indicate
that there was profuse vaginal bleeding. The claim that there was profuse vaginal
bleeding although this was not reflected in the medical records strikes us as odd since the
main complaint is vaginal bleeding. A medical record is the only document that maintains
a long-term transcription of patient care and as such, its maintenance is considered a
priority in hospital practice. Optimal record-keeping includes all patient inter-actions. The
records should always be clear, objective, and up-to-date.37 Thus, a medical record that
does not indicate profuse medical bleeding speaks loudly and clearly of what it does not
contain.
That the D&C operation was conducted principally to diagnose the cause of the vaginal
bleeding further leads us to conclude that it was merely an elective procedure, not an
emergency case. In an elective procedure, the physician must conduct a thorough preoperative evaluation of the patient in order to adequately prepare her for the operation
and minimize possible risks and complications. The internist is responsible for generating

a comprehensive evaluation of all medical problems during the pre-operative


evaluation.38
The aim of pre-operative evaluation is not to screen broadly for undiagnosed disease, but
rather to identify and quantify comorbidity that may impact on the operative outcome.
This evaluation is driven by findings on history and physical examination suggestive of
organ system dysfunctionThe goal is to uncover problem areas that may require further
investigation or be amenable to preoperative optimization.
If the preoperative evaluation uncovers significant comorbidity or evidence of poor control
of an underlying disease process, consultation with an internist or medical specialist may
be required to facilitate the work-up and direct management. In this process,
communication between the surgeons and the consultants is essential to define realistic
goals for this optimization process and to expedite surgical management.39 [Emphasis
supplied.]
Significantly, the evidence strongly suggests that the pre-operative evaluation was less
than complete as the laboratory results were fully reported only on the day following the
D&C operation. Dr. Felicisima only secured a telephone report of the preliminary
laboratory result prior to the D&C. This preliminary report did not include the 3+ status of
sugar in the patient's urine40 - a result highly confirmatory of diabetes.
Because the D&C was merely an elective procedure, the patient's uncontrolled
hyperglycemia presented a far greater risk than her on-and-off vaginal bleeding. The
presence of hyperglycemia in a surgical patient is associated with poor clinical outcomes,
and aggressive glycemic control positively impacts on morbidity and mortality.41 Elective
surgery in people with uncontrolled diabetes should preferably be scheduled after
acceptable glycemic control has been achieved.42 According to Dr. Mercado, this is done
by administering insulin on the patient.43
The management approach in this kind of patients always includes insulin therapy in
combination with dextrose and potassium infusion. Insulin xxx promotes glucose uptake
by the muscle and fat cells while decreasing glucose production by the liver xxx. The net
effect is to lower blood glucose levels.44
The prudent move is to address the patient's hyperglycemic state immediately and
promptly before any other procedure is undertaken. In this case, there was no evidence
that insulin was administered on Teresita prior to or during the D&C operation. Insulin was
only administered two days after the operation.
As Dr. Tan testified, the patient's hyperglycemic condition should have been managed not
only before and during the operation, but also immediately after. Despite the possibility
that Teresita was afflicted with diabetes, the possibility was casually ignored even in the
post-operative evaluation of the patient; the concern, as the petitioner spouses expressly
admitted, was limited to the complaint of vaginal bleeding. Interestingly, while the
ultrasound test confirmed that Teresita had a myoma in her uterus, she was advised that
she could be discharged a day after the operation and that her recovery could take place
at home. This advice implied that a day after the operation and even after the complete
laboratory results were submitted, the petitioner spouses still did not recognize any postoperative concern that would require the monitoring of Teresita's condition in the hospital.

The above facts, point only to one conclusion - that the petitioner spouses failed, as
medical professionals, to comply with their duty to observe the standard of care to be
given to hyperglycemic/diabetic patients undergoing surgery. Whether this breach of duty
was the proximate cause of Teresita's death is a matter we shall next determine.
Injury and Causation
As previously mentioned, the critical and clinching factor in a medical negligence case is
proof of the causal connection between the negligence which the evidence established
and the plaintiff's injuries;45 the plaintiff must plead and prove not only that he had been
injured and defendant has been at fault, but also that the defendant's fault caused the
injury. A verdict in a malpractice action cannot be based on speculation or conjecture.
Causation must be proven within a reasonable medical probability based upon competent
expert testimony.46
The respondents contend that unnecessarily subjecting Teresita to a D&C operation
without adequately preparing her, aggravated her hyperglycemic state and caused her
untimely demise. The death certificate of Teresita lists down the following causes of
death:
Immediate cause: Cardiorespiratory arrest
Antecedent cause: Septicemic shock, ketoacidocis
Underlying cause: Diabetes Mellitus II
Other significant conditions contributing to death: Renal Failure - Acute47

Q: On what aspect did you and your wife consult [with] each other?
A: We discussed on the finding of the laboratory [results] because the hemoglobin was
below normal, the blood sugar was elevated, so that we have to evaluate these laboratory
results - what it means.
Q: So it was you and your wife who made the evaluation when it was phoned in?
A: Yes, sir.
Q: Did your wife, before performing D&C ask your opinion whether or not she can
proceed?
A: Yes, anyway, she asked me whether we can do D&C based on my experience.
Q: And your answer was in the positive notwithstanding the elevation of blood sugar?
A: Yes, sir, it was both our disposition to do the D&C. [Emphasis supplied.]50
If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not being an
internist or a diabetologist (for which reason he referred Teresita to Dr. Jorge),51 he should
have likewise refrained from making a decision to proceed with the D&C operation since
he was niether an obstetrician nor a gynecologist.
These findings lead us to the conclusion that the decision to proceed with the D&C
operation, notwithstanding Teresita's hyperglycemia and without adequately preparing
her for the procedure, was contrary to the standards observed by the medical profession.
Deviation from this standard amounted to a breach of duty which resulted in the patient's
death. Due to this negligent conduct, liability must attach to the petitioner spouses.
Liability of the Hospital

Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C
operation is a form of physical stress. Dr. Mendoza explained how surgical stress can
aggravate the patient's hyperglycemia: when stress occurs, the diabetic's body, especially
the autonomic system, reacts by secreting hormones which are counter-regulatory; she
can have prolonged hyperglycemia which, if unchecked, could lead to death.48 Medical
literature further explains that if the blood sugar has become very high, the patient
becomes comatose (diabetic coma). When this happens over several days, the body uses
its own fat to produce energy, and the result is high levels of waste products (called
ketones) in the blood and urine (called diabetic ketoacidiosis, a medical emergency with a
significant mortality).49 This was apparently what happened in Teresita's case; in fact,
after she had been referred to the internist Dr. Jorge, laboratory test showed that her
blood sugar level shot up to 14.0mmol/l, way above the normal blood sugar range. Thus,
between the D&C and death was the diabetic complication that could have been
prevented with the observance of standard medical precautions. The D&C operation and
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. However, we clarify
that Dr. Fredelicto's negligence is not solely the act of ordering an "on call" D&C operation
when he was mainly an anaesthesiologist who had made a very cursory examination of
the 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 risk factor that should be guarded against, and his participation in the
imprudent decision to proceed with the D&C operation despite his early suspicion and the
confirmatory early laboratory results. The latter point comes out clearly from the following
exchange during the trial:

In the proceedings below, UDMC was the spouses Flores' co-defendant. The RTC found the
hospital jointly and severally liable with the petitioner spouses, which decision the CA
affirmed. In a Resolution dated August 28, 2006, this Court however denied UDMC's
petition for review on certiorari. Since UDMC's appeal has been denied and they are not
parties to this case, we find it unnecessary to delve on the matter. Consequently, the
RTC's decision, as affirmed by the CA, stands.
Award of Damages
Both the trial and the appellate court awarded actual damages as compensation for the
pecuniary loss the respondents suffered. The loss was presented in terms of the hospital
bills and expenses the respondents incurred on account of Teresita's confinement and
death. The settled rule is that a plaintiff is entitled to be compensated for proven
pecuniary loss.52 This proof the respondents successfully presented. Thus, we affirm the
award of actual damages of P36,000.00 representing the hospital expenses the patient
incurred.
In addition to the award for actual damages, the respondent heirs of Teresita are likewise
entitled to P50,000.00 as death indemnity pursuant to Article 2206 of the Civil Code,
which states that "the amount of damages for death caused by a xxx quasi-delict shall be
at least three thousand pesos,53 even though there may have been mitigating
circumstances xxx." This is a question of law that the CA missed in its decision and which
we now decide in the respondents' favor.

The same article allows the recovery of moral damages in case of death caused by a
quasi-delict and enumerates the spouse, legitimate or illegitimate ascendants or
descendants as the persons entitled thereto. Moral damages are designed to compensate
the claimant for the injury suffered, that is, for the mental anguish, serious anxiety,
wounded feelings which the respondents herein must have surely felt with the unexpected
loss of their daughter. We affirm the appellate court's award of P400,000.00 by way of
moral damages to the respondents.
We similarly affirm the grant of exemplary damages. Exemplary damages are imposed by
way of example or correction for the public good.54 Because of the petitioner spouses'
negligence in subjecting Teresita to an operation without first recognizing and addressing
her diabetic condition, the appellate court awarded exemplary damages to the
respondents in the amount of P100,000.00. Public policy requires such imposition to
suppress the wanton acts of an offender.55 We therefore affirm the CA's award as an
example to the medical profession and to stress that the public good requires stricter
measures to avoid the repetition of the type of medical malpractice that happened in this
case.
With the award of exemplary damages, the grant of attorney's fees is legally in order.56
We therefore reverse the CA decision deleting these awards, and grant the respondents
the amount of P100,000.00 as attorney's fees taking into consideration the legal route this
case has taken.
WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003 in CA G.R. CV No.
63234 finding petitioner spouses liable for negligent medical practice. We likewise AFFIRM
the awards of actual and compensatory damages of P36,000.00; moral damages of
P400,000.00; and exemplary damages of P100,000.00.
We MODIFY the CA Decision by additionally granting an award of P50,000.00 as death
indemnity and by reversing the deletion of the award of attorney's fees and costs and
restoring the award of P100,000.00 as attorney's fees. Costs of litigation are adjudged
against petitioner spouses.
To summarize, the following awards shall be paid to the family of the late Teresita Pineda:
1.
2.
3.
4.
5.
6.

The sum
The sum
The sum
The sum
The sum
Costs.

of
of
of
of
of

SO ORDERED.

P36,000.00 by way of actual and compensatory damages;


P50,000.00 by way of death indemnity;
P400,000.00 by way of moral damages;
P100,000.00 by way of exemplary damages;
P100,000.00 by way of attorney's fees; and

THIRD DIVISION
G.R. No. 159132
December 18, 2008
FE CAYAO-LASAM, petitioner, vs. SPOUSES CLARO and EDITHA RAMOLETE, respondents.*
DECISION
AUSTRIA-MARTINEZ, J.:

The antecedent facts:

the latters cervix was already open, thus, petitioner discussed the possible D&C
procedure, should the bleeding become more profuse; on July 30 1994, she conducted
another internal examination on Editha, which revealed that the latters cervix was still
open; Editha persistently complained of her vaginal bleeding and her passing out of some
meaty mass in the process of urination and bowel movement; thus, petitioner advised
Editha to undergo D&C procedure which the respondents consented to; petitioner was
very vocal in the operating room about not being able to see an abortus;13 taking the
words of Editha to mean that she was passing out some meaty mass and clotted blood,
she assumed that the abortus must have been expelled in the process of bleeding; it was
Editha who insisted that she wanted to be discharged; petitioner agreed, but she advised
Editha to return for check-up on August 5, 1994, which the latter failed to do.

On July 28, 1994, respondent, three months pregnant Editha Ramolete (Editha) was
brought to the Lorma Medical Center (LMC) in San Fernando, La Union due to vaginal
bleeding. Upon advice of petitioner relayed via telephone, Editha was admitted to the LMC
on the same day. A pelvic sonogram2 was then conducted on Editha revealing the fetus
weak cardiac pulsation.3 The following day, Edithas repeat pelvic sonogram4 showed that
aside from the fetus weak cardiac pulsation, no fetal movement was also appreciated.
Due to persistent and profuse vaginal bleeding, petitioner advised Editha to undergo a
Dilatation and Curettage Procedure (D&C) or "raspa."

Petitioner contended that it was Edithas gross negligence and/or omission in insisting to
be discharged on July 31, 1994 against doctors advice and her unjustified failure to return
for check-up as directed by petitioner that contributed to her life-threatening condition on
September 16, 1994; that Edithas hysterectomy was brought about by her very abnormal
pregnancy known as placenta increta, which was an extremely rare and very unusual case
of abdominal placental implantation. Petitioner argued that whether or not a D&C
procedure was done by her or any other doctor, there would be no difference at all
because at any stage of gestation before term, the uterus would rupture just the same.

On July 30, 1994, petitioner performed the D&C procedure. Editha was discharged from
the hospital the following day.

On March 4, 1999, the Board of Medicine (the Board) of the PRC rendered a Decision,14
exonerating petitioner from the charges filed against her. The Board held:

On September 16, 1994, Editha was once again brought at the LMC, as she was suffering
from vomiting and severe abdominal pains. Editha was attended by Dr. Beatriz de la Cruz,
Dr. Victor B. Mayo and Dr. Juan V. Komiya. Dr. Mayo allegedly informed Editha that there
was a dead fetus in the latters womb. After, Editha underwent laparotomy,5 she was
found to have a massive intra-abdominal hemorrhage and a ruptured uterus. Thus, Editha
had to undergo a procedure for hysterectomy6 and as a result, she has no more chance to
bear a child.

Based on the findings of the doctors who conducted the laparotomy on Editha, hers is a
case of Ectopic Pregnancy Interstitial. This type of ectopic pregnancy is one that is being
protected by the uterine muscles and manifestations may take later than four (4) months
and only attributes to two percent (2%) of ectopic pregnancy cases.

Before the Court is a Petition for Review on Certiorari under Rule 45 of the Rules of Court
filed by Dr. Fe Cayao-Lasam (petitioner) seeking to annul the Decision1 dated July 4, 2003
of the Court of Appeals (CA) in CA-G.R. SP No. 62206.

On November 7, 1994, Editha and her husband Claro Ramolete (respondents) filed a
Complaint7 for Gross Negligence and Malpractice against petitioner before the
Professional Regulations Commission (PRC).
Respondents alleged that Edithas hysterectomy was caused by petitioners unmitigated
negligence and professional incompetence in conducting the D&C procedure and the
petitioners failure to remove the fetus inside Edithas womb.8 Among the alleged acts of
negligence were: first, petitioners failure to check up, visit or administer medication on
Editha during her first day of confinement at the LMC;9 second, petitioner recommended
that a D&C procedure be performed on Editha without conducting any internal
examination prior to the procedure;10 third, petitioner immediately suggested a D&C
procedure instead of closely monitoring the state of pregnancy of Editha.11
In her Answer,12 petitioner denied the allegations of negligence and incompetence with
the following explanations: upon Edithas confirmation that she would seek admission at
the LMC, petitioner immediately called the hospital to anticipate the arrival of Editha and
ordered through the telephone the medicines Editha needed to take, which the nurses
carried out; petitioner visited Editha on the morning of July 28, 1994 during her rounds; on
July 29, 1994, she performed an internal examination on Editha and she discovered that

When complainant Editha was admitted at Lorma Medical Center on July 28, 1994 due to
vaginal bleeding, an ultra-sound was performed upon her and the result of the Sonogram
Test reveals a morbid fetus but did not specify where the fetus was located. Obstetricians
will assume that the pregnancy is within the uterus unless so specified by the Sonologist
who conducted the ultra-sound. Respondent (Dr. Lasam) cannot be faulted if she was not
able to determine that complainant Editha is having an ectopic pregnancy interstitial. The
D&C conducted on Editha is necessary considering that her cervix is already open and so
as to stop the profuse bleeding. Simple curettage cannot remove a fetus if the patient is
having an ectopic pregnancy, since ectopic pregnancy is pregnancy conceived outside the
uterus and curettage is done only within the uterus. Therefore, a more extensive
operation needed in this case of pregnancy in order to remove the fetus.15
Feeling aggrieved, respondents went to the PRC on appeal. On November 22, 2000, the
PRC rendered a Decision16 reversing the findings of the Board and revoking petitioners
authority or license to practice her profession as a physician.17
Petitioner brought the matter to the CA in a Petition for Review under Rule 43 of the Rules
of Court. Petitioner also dubbed her petition as one for certiorari18 under Rule 65 of the
Rules of Court.
In the Decision dated July 4, 2003, the CA held that the Petition for Review under Rule 43
of the Rules of Court was an improper remedy, as the enumeration of the quasi-judicial

agencies in Rule 43 is exclusive.19 PRC is not among the quasi-judicial bodies whose
judgment or final orders are subject of a petition for review to the CA, thus, the petition
for review of the PRC Decision, filed at the CA, was improper. The CA further held that
should the petition be treated as a petition for certiorari under Rule 65, the same would
still be dismissed for being improper and premature. Citing Section 2620 of Republic Act
(R.A.) No. 2382 or the Medical Act of 1959, the CA held that the plain, speedy and
adequate remedy under the ordinary course of law which petitioner should have availed
herself of was to appeal to the Office of the President.21
Hence, herein petition, assailing the decision of the CA on the following grounds:
1. THE COURT OF APPEALS ERRED ON A QUESTION OF LAW IN HOLDING THAT THE
PROFESSIONAL REGULATION[S] COMMISSION (PRC) WAS EXCLUDED AMONG THE QUASIJUDICIAL AGENCIES CONTEMPLATED UNDER RULE 43 OF THE RULES OF CIVIL
PROCEDURE;
2. EVEN ASSUMING, ARGUENDO, THAT PRC WAS EXCLUDED FROM THE PURVIEW OF RULE
43 OF THE RULES OF CIVIL PROCEDURE, THE PETITIONER WAS NOT PRECLUDED FROM
FILING A PETITION FOR CERTIORARI WHERE THE DECISION WAS ALSO ISSUED IN EXCESS
OF OR WITHOUT JURISDICTION, OR WHERE THE DECISION WAS A PATENT NULLITY;
3. HEREIN RESPONDENTS-SPOUSES ARE NOT ALLOWED BY LAW TO APPEAL FROM THE
DECISION OF THE BOARD OF MEDICINE TO THE PROFESSIONAL REGULATION[S]
COMMISSION;
4. THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF DISCRETION IN DENYING FOR
IMPROPER FORUM THE PETITION FOR REVIEW/PETITION FOR CERTIORARI WITHOUT GOING
OVER THE MERITS OF THE GROUNDS RELIED UPON BY THE PETITIONER;
5. PRCS GRAVE OMISSION TO AFFORD HEREIN PETITONER A CHANCE TO BE HEARD ON
APPEAL IS A CLEAR VIOLATION OF HER CONSTITUTIONAL RIGHT TO DUE PROCESS AND
HAS THE EFFECT OF RENDERING THE JUDGMENT NULL AND VOID;
6. COROLLARY TO THE FOURTH ASSIGNED ERROR, PRC COMMITTED GRAVE ABUSE OF
DISCRETION, AMOUNTING TO LACK OF JURISDICTION, IN ACCEPTING AND CONSIDERING
THE MEMORANDUM ON APPEAL WITHOUT PROOF OF SERVICE TO HEREIN PETITIONER,
AND IN VIOLATION OF ART. IV, SEC. 35 OF THE RULES AND REGULATIONS GOVERNING THE
REGULATION AND PRACTICE OF PROFESSIONALS;
7. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN REVOKING PETITIONERS LICENSE TO
PRACTICE MEDICINE WITHOUT AN EXPERT TESTIMONY TO SUPPORT ITS CONCLUSION AS
TO THE CAUSE OF RESPONDENT EDITHAT [SIC] RAMOLETES INJURY;
8. PRC COMMITTED AN EVEN GRAVER ABUSE OF DISCRETION IN TOTALLY DISREGARDING
THE FINDING OF THE BOARD OF MEDICINE, WHICH HAD THE NECESSARY COMPETENCE
AND EXPERTISE TO ESTABLISH THE CAUSE OF RESPONDENT EDITHAS INJURY, AS WELL AS
THE TESTIMONY OF THE EXPERT WITNESS AUGUSTO MANALO, M.D. ;[and]
9. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN MAKING CONCLUSIONS OF FACTS
THAT WERE NOT ONLY UNSUPPORTED BY EVIDENCE BUT WERE ACTUALLY CONTRARY TO
EVIDENCE ON RECORD.22

The Court will first deal with the procedural issues.


Petitioner claims that the law does not allow complainants to appeal to the PRC from the
decision of the Board. She invokes Article IV, Section 35 of the Rules and Regulations
Governing the Regulation and Practice of Professionals, which provides:
Sec. 35. The respondent may appeal the decision of the Board within thirty days from
receipt thereof to the Commission whose decision shall be final. Complainant, when
allowed by law, may interpose an appeal from the Decision of the Board within the same
period. (Emphasis supplied)
Petitioner asserts that a careful reading of the above law indicates that while the
respondent, as a matter of right, may appeal the Decision of the Board to the
Commission, the complainant may interpose an appeal from the decision of the Board
only when so allowed by law.23 Petitioner cited Section 26 of Republic Act No. 2382 or
"The Medical Act of 1959," to wit:
Section 26. Appeal from judgment. The decision of the Board of Medical Examiners (now
Medical Board) shall automatically become final thirty days after the date of its
promulgation unless the respondent, during the same period, has appealed to the
Commissioner of Civil Service (now Professional Regulations Commission) and later to the
Office of the President of the Philippines. If the final decision is not satisfactory, the
respondent may ask for a review of the case, or may file in court a petition for certiorari.
Petitioner posits that the reason why the Medical Act of 1959 allows only the respondent
in an administrative case to file an appeal with the Commission while the complainant is
not allowed to do so is double jeopardy. Petitioner is of the belief that the revocation of
license to practice a profession is penal in nature.24
The Court does not agree.
For one, the principle of double jeopardy finds no application in administrative cases.
Double jeopardy attaches only: (1) upon a valid indictment; (2) before a competent court;
(3) after arraignment; (4) when a valid plea has been entered; and (5) when the
defendant was acquitted or convicted, or the case was dismissed or otherwise terminated
without the express consent of the accused.25 These elements were not present in the
proceedings before the Board of Medicine, as the proceedings involved in the instant case
were administrative and not criminal in nature. The Court has already held that double
jeopardy does not lie in administrative cases.26
Moreover, Section 35 of the Rules and Regulations Governing the Regulation and Practice
of Professionals cited by petitioner was subsequently amended to read:
Sec. 35. The complainant/respondent may appeal the order, the resolution or the decision
of the Board within thirty (30) days from receipt thereof to the Commission whose
decision shall be final and executory. Interlocutory order shall not be appealable to the
Commission. (Amended by Res. 174, Series of 1990).27 (Emphasis supplied)
Whatever doubt was created by the previous provision was settled with said amendment.
It is axiomatic that the right to appeal is not a natural right or a part of due process, but a

mere statutory privilege that may be exercised only in the manner prescribed by law.28 In
this case, the clear intent of the amendment is to render the right to appeal from a
decision of the Board available to both complainants and respondents.
Such conclusion is bolstered by the fact that in 2006, the PRC issued Resolution No. 06342(A), or the New Rules of Procedure in Administrative Investigations in the Professional
Regulations Commission and the Professional Regulatory Boards, which provides for the
method of appeal, to wit:
Sec. 1. Appeal; Period Non-Extendible.- The decision, order or resolution of the Board shall
be final and executory after the lapse of fifteen (15) days from receipt of the decision,
order or resolution without an appeal being perfected or taken by either the respondent or
the complainant. A party aggrieved by the decision, order or resolution may file a notice
of appeal from the decision, order or resolution of the Board to the Commission within
fifteen (15) days from receipt thereof, and serving upon the adverse party a notice of
appeal together with the appellants brief or memorandum on appeal, and paying the
appeal and legal research fees. x x x29
The above-stated provision does not qualify whether only the complainant or respondent
may file an appeal; rather, the new rules provide that "a party aggrieved" may file a
notice of appeal. Thus, either the complainant or the respondent who has been aggrieved
by the decision, order or resolution of the Board may appeal to the Commission. It is an
elementary rule that when the law speaks in clear and categorical language, there is no
need, in the absence of legislative intent to the contrary, for any interpretation.30 Words
and phrases used in the statute should be given their plain, ordinary, and common usage
or meaning.31
Petitioner also submits that appeals from the decisions of the PRC should be with the CA,
as Rule 4332 of the Rules of Court was precisely formulated and adopted to provide for a
uniform rule of appellate procedure for quasi-judicial agencies.33 Petitioner further
contends that a quasi-judicial body is not excluded from the purview of Rule 43 just
because it is not mentioned therein.34
On this point, the Court agrees with the petitioner.
Sec. 1, Rule 43 of the Rules of Court provides:
Section 1. Scope. - This Rule shall apply to appeals from judgments or final orders of the
Court of Tax Appeals, and from awards, judgments, final orders or resolutions of or
authorized by any quasi-judicial agency in the exercise of its quasi-judicial functions.
Among these agencies are the Civil Service Commission, Central Board of Assessment
Appeals, Securities and Exchange Commission, Office of the President, Land Registration
Authority, Social Security Commission, Civil Aeronautics Board, Bureau of Patents,
Trademarks and Technology Transfer, National Electrification Administration, Energy
Regulatory Board, National Telecommunications Commission, Department of Agrarian
Reform under Republic Act No. 6657, Government Service Insurance System, Employees
Compensation Commission, Agricultural Inventions Board, Insurance Commission,
Philippine Atomic Energy Commission, Board of Investments, Construction Industry
Arbitration Commission, and voluntary arbitrators authorized by law. (Emphasis supplied)

Indeed, the PRC is not expressly mentioned as one of the agencies which are expressly
enumerated under Section 1, Rule 43 of the Rules of Court. However, its absence from the
enumeration does not, by this fact alone, imply its exclusion from the coverage of said
Rule.35 The Rule expressly provides that it should be applied to appeals from awards,
judgments final orders or resolutions of any quasi-judicial agency in the exercise of its
quasi-judicial functions. The phrase "among these agencies" confirms that the
enumeration made in the Rule is not exclusive to the agencies therein listed.36
Specifically, the Court, in Yang v. Court of Appeals,37 ruled that Batas Pambansa (B.P.) Blg.
12938 conferred upon the CA exclusive appellate jurisdiction over appeals from decisions
of the PRC. The Court held:
The law has since been changed, however, at least in the matter of the particular court to
which appeals from the Commission should be taken. On August 14, 1981, Batas
Pambansa Bilang 129 became effective and in its Section 29, conferred on the Court of
Appeals "exclusive appellate jurisdiction over all final judgments, decisions, resolutions,
orders or awards of Regional Trial Courts and quasi-judicial agencies, instrumentalities,
boards or commissions except those falling under the appellate jurisdiction of the
Supreme Court. x x x." In virtue of BP 129, appeals from the Professional Regulations
Commission are now exclusively cognizable by the Court of Appeals.39 (Emphasis
supplied)
Clearly, the enactment of B.P. Blg. 129, the precursor of the present Rules of Civil
Procedure,40 lodged with the CA such jurisdiction over the appeals of decisions made by
the PRC.
Anent the substantive merits of the case, petitioner questions the PRC decision for being
without an expert testimony to support its conclusion and to establish the cause of
Edithas injury. Petitioner avers that in cases of medical malpractice, expert testimony is
necessary to support the conclusion as to the cause of the injury.41
Medical malpractice is a particular form of negligence which consists in the failure of a
physician or surgeon to apply to his practice of medicine that degree of care and skill
which is ordinarily employed by the profession generally, under similar conditions, and in
like surrounding circumstances.42 In order to successfully pursue such a claim, a patient
must prove that the physician or surgeon either failed to do something which a
reasonably prudent physician or surgeon would not have done, and that the failure or
action caused injury to the patient.43
There are four elements involved in medical negligence cases: duty, breach, injury and
proximate causation.44
A physician-patient relationship was created when Editha employed the services of the
petitioner. As Edithas physician, petitioner was duty-bound to use at least the same level
of care that any reasonably competent doctor would use to treat a condition under the
same circumstances.45 The breach of these professional duties of skill and care, or their
improper performance by a physician surgeon, whereby the patient is injured in body or in
health, constitutes actionable malpractice.46 As to this aspect of medical malpractice, the
determination of the reasonable level of care and the breach thereof, expert testimony is
essential.47 Further, inasmuch as the causes of the injuries involved in malpractice

actions are determinable only in the light of scientific knowledge, it has been recognized
that expert testimony is usually necessary to support the conclusion as to causation.48
In the present case, respondents did not present any expert testimony to support their
claim that petitioner failed to do something which a reasonably prudent physician or
surgeon would have done.

Atty. Ragonton:
Q:
Doctor, as a practicing OB-Gyne, when do you consider that you have done a good,
correct and ideal dilatation and curettage procedure?

Petitioner, on the other hand, presented the testimony of Dr. Augusto M. Manalo, who was
clearly an expert on the subject.

A:
Well, if the patient recovers. If the patient gets well. Because even after the
procedure, even after the procedure you may feel that you have scraped everything, the
patient stops bleeding, she feels well, I think you should still have some reservations, and
wait a little more time.

Generally, to qualify as an expert witness, one must have acquired special knowledge of
the subject matter about which he or she is to testify, either by the study of recognized
authorities on the subject or by practical experience.49

Q:
If you were the OB-Gyne who performed the procedure on patient Editha Ramolete,
would it be your standard practice to check the fetal parts or fetal tissues that were
allegedly removed?

Dr. Manalo specializes in gynecology and obstetrics, authored and co-authored various
publications on the subject, and is a professor at the University of the Philippines.50
According to him, his diagnosis of Edithas case was "Ectopic Pregnancy Interstitial (also
referred to as Cornual), Ruptured."51 In stating that the D&C procedure was not the
proximate cause of the rupture of Edithas uterus resulting in her hysterectomy, Dr.
Manalo testified as follows:

A:
From what I have removed, yes. But in this particular case, I think it was assumed
that it was part of the meaty mass which was expelled at the time she was urinating and
flushed in the toilet. So theres no way.
Q:

There was [sic] some portions of the fetal parts that were removed?

A:

No, it was described as scanty scraping if I remember it rightscanty.

Atty. Hidalgo:
Q:
Doctor, we want to be clarified on this matter. The complainant had testified here
that the D&C was the proximate cause of the rupture of the uterus. The condition which
she found herself in on the second admission. Will you please tell us whether that is true
or not?
A:
Yah, I do not think so for two reasons. One, as I have said earlier, the instrument
cannot reach the site of the pregnancy, for it to further push the pregnancy outside the
uterus. And, No. 2, I was thinking a while ago about another reason- well, why I dont think
so, because it is the triggering factor for the rupture, it could havethe rupture could have
occurred much earlier, right after the D&C or a few days after the D&C.
Q:
In this particular case, doctor, the rupture occurred to have happened minutes prior
to the hysterectomy or right upon admission on September 15, 1994 which is about 1
months after the patient was discharged, after the D&C was conducted. Would you tell us
whether there is any relation at all of the D&C and the rupture in this particular instance?
A:
I dont think so for the two reasons that I have just mentioned- that it would not be
possible for the instrument to reach the site of pregnancy. And, No. 2, if it is because of
the D&C that rupture could have occurred earlier.52 (Emphases supplied)
Clearly, from the testimony of the expert witness and the reasons given by him, it is
evident that the D&C procedure was not the proximate cause of the rupture of Edithas
uterus.
During his cross-examination, Dr. Manalo testified on how he would have addressed
Edithas condition should he be placed in a similar circumstance as the petitioner. He
stated:

Q:
And you would not mind checking those scant or those little parts that were
removed?
A:
Well, the fact that it was described means, I assume that it was checked, no. It was
described as scanty and the color also, I think was described. Because it would be very
unusual, even improbable that it would not be examined, because when you scrape, the
specimens are right there before your eyes. Its in front of you. You can touch it. In fact,
some of them will stick to the instrument and therefore to peel it off from the instrument,
you have to touch them. So, automatically they are examined closely.
Q:
As a matter of fact, doctor, you also give telephone orders to your patients through
telephone?
A:
Yes, yes, we do that, especially here in Manila because you know, sometimes a
doctor can also be tied-up somewhere and if you have to wait until he arrive at a certain
place before you give the order, then it would be a lot of time wasted. Because if you
know your patient, if you have handled your patient, some of the symptoms you can
interpret that comes with practice. And, I see no reason for not allowing telephone orders
unless it is the first time that you will be encountering the patient. That you have no idea
what the problem is.
Q:

But, doctor, do you discharge patients without seeing them?

A:
Sometimes yes, depending on how familiar I am with the patient. We are on the
question of telephone orders. I am not saying that that is the idle [sic] thing to do, but I
think the reality of present day practice somehow justifies telephone orders. I have
patients whom I have justified and then all of a sudden, late in the afternoon or late in the
evening, would suddenly call they have decided that they will go home inasmuch as they
anticipated that I will discharge them the following day. So, I just call and ask our resident

on duty or the nurse to allow them to go because I have seen that patient and I think I
have full grasp of her problems. So, thats when I make this telephone orders. And, of
course before giving that order I ask about how she feels.53 (Emphases supplied)
From the foregoing testimony, it is clear that the D&C procedure was conducted in
accordance with the standard practice, with the same level of care that any reasonably
competent doctor would use to treat a condition under the same circumstances, and that
there was nothing irregular in the way the petitioner dealt with Editha.
Medical malpractice, in our jurisdiction, is often brought as a civil action for damages
under Article 217654 of the Civil Code. The defenses in an action for damages, provided
for under Article 2179 of the Civil Code are:
Art. 2179. When the plaintiffs own negligence was the immediate and proximate cause of
his injury, he cannot recover damages. But if his negligence was only contributory, the
immediate and proximate cause of the injury being the defendants lack of due care, the
plaintiff may recover damages, but the courts shall mitigate the damages to be awarded.
Proximate cause has been defined as that which, in natural and continuous sequence,
unbroken by any efficient intervening cause, produces injury, and without which the result
would not have occurred.55 An injury or damage is proximately caused by an act or a
failure to act, whenever it appears from the evidence in the case that the act or omission
played a substantial part in bringing about or actually causing the injury or damage; and
that the injury or damage was either a direct result or a reasonably probable consequence
of the act or omission.56
In the present case, the Court notes the findings of the Board of Medicine:
When complainant was discharged on July 31, 1994, herein respondent advised her to
return on August 4, 1994 or four (4) days after the D&C. This advise was clear in
complainants Discharge Sheet. However, complainant failed to do so. This being the
case, the chain of continuity as required in order that the doctrine of proximate cause can
be validly invoked was interrupted. Had she returned, the respondent could have
examined her thoroughly.57 x x x (Emphases supplied)
Also, in the testimony of Dr. Manalo, he stated further that assuming that there was in fact
a misdiagnosis, the same would have been rectified if Editha followed the petitioners
order to return for a check-up on August 4, 1994. Dr. Manalo stated:
Granting that the obstetrician-gynecologist has been misled (justifiably) up to thus point
that there would have been ample opportunity to rectify the misdiagnosis, had the patient
returned, as instructed for her follow-up evaluation. It was one and a half months later
that the patient sought consultation with another doctor. The continued growth of an
ectopic pregnancy, until its eventual rupture, is a dynamic process. Much change in
physical findings could be expected in 1 months, including the emergence of
suggestive ones.58
It is undisputed that Editha did not return for a follow-up evaluation, in defiance of the
petitioners advise. Editha omitted the diligence required by the circumstances which
could have avoided the injury. The omission in not returning for a follow-up evaluation
played a substantial part in bringing about Edithas own injury. Had Editha returned,

petitioner could have conducted the proper medical tests and procedure necessary to
determine Edithas health condition and applied the corresponding treatment which could
have prevented the rupture of Edithas uterus. The D&C procedure having been
conducted in accordance with the standard medical practice, it is clear that Edithas
omission was the proximate cause of her own injury and not merely a contributory
negligence on her part.
Contributory negligence is the act or omission amounting to want of ordinary care on the
part of the person injured, which, concurring with the defendants negligence, is the
proximate cause of the injury.59 Difficulty seems to be apprehended in deciding which
acts of the injured party shall be considered immediate causes of the accident.60 Where
the immediate cause of an accident resulting in an injury is the plaintiffs own act, which
contributed to the principal occurrence as one of its determining factors, he cannot
recover damages for the injury.61 Again, based on the evidence presented in the present
case under review, in which no negligence can be attributed to the petitioner, the
immediate cause of the accident resulting in Edithas injury was her own omission when
she did not return for a follow-up check up, in defiance of petitioners orders. The
immediate cause of Edithas injury was her own act; thus, she cannot recover damages
from the injury.
Lastly, petitioner asserts that her right to due process was violated because she was
never informed by either respondents or by the PRC that an appeal was pending before
the PRC.62 Petitioner claims that a verification with the records section of the PRC
revealed that on April 15, 1999, respondents filed a Memorandum on Appeal before the
PRC, which did not attach the actual registry receipt but was merely indicated therein.63
Respondents, on the other hand avers that if the original registry receipt was not attached
to the Memorandum on Appeal, PRC would not have entertained the appeal or accepted
such pleading for lack of notice or proof of service on the other party.64 Also, the registry
receipt could not be appended to the copy furnished to petitioners former counsel,
because the registry receipt was already appended to the original copy of the
Memorandum of Appeal filed with PRC.65
It is a well-settled rule that when service of notice is an issue, the rule is that the person
alleging that the notice was served must prove the fact of service. The burden of proving
notice rests upon the party asserting its existence.66 In the present case, respondents did
not present any proof that petitioner was served a copy of the Memorandum on Appeal.
Thus, respondents were not able to satisfy the burden of proving that they had in fact
informed the petitioner of the appeal proceedings before the PRC.
In EDI-Staffbuilders International, Inc. v. National Labor Relations Commission,67 in which
the National Labor Relations Commission failed to order the private respondent to furnish
the petitioner a copy of the Appeal Memorandum, the Court held that said failure deprived
the petitioner of procedural due process guaranteed by the Constitution, which could have
served as basis for the nullification of the proceedings in the appeal. The same holds true
in the case at bar. The Court finds that the failure of the respondents to furnish the
petitioner a copy of the Memorandum of Appeal submitted to the PRC constitutes a
violation of due process. Thus, the proceedings before the PRC were null and void.

All told, doctors are protected by a special rule of law. They are not guarantors of care.
They are not insurers against mishaps or unusual consequences68 specially so if the
patient herself did not exercise the proper diligence required to avoid the injury.
WHEREFORE, the petition is GRANTED. The assailed Decision of the Court of Appeals
dated July 4, 2003 in CA-GR SP No. 62206 is hereby REVERSED and SET ASIDE. The
Decision of the Board of Medicine dated March 4, 1999 exonerating petitioner is
AFFIRMED. No pronouncement as to costs.
SO ORDERED.

THIRD DIVISION G.R. No. 178763


April 21, 2009
CHICO-NAZARIO, J.:
PETER PAUL PATRICK LUCAS, FATIMA GLADYS LUCAS, ABBEYGAIL LUCAS AND GILLIAN
LUCAS, Petitioners,
vs. DR. PROSPERO MA. C. TUAO, Respondent.
In this petition for review on certiorari1 under Rule 45 of the Revised Rules of Court, petitioners Peter
Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian Lucas seek the reversal of the 27
September 2006 Decision2 and 3 July 2007 Resolution,3 both of the Court of Appeals in CA-G.R. CV
No. 68666, entitled "Peter Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian Lucas
v. Prospero Ma. C. Tuao."
In the questioned decision and resolution, the Court of Appeals affirmed the 14 July 2000 Decision of
the Regional Trial Court (RTC), Branch 150, Makati City, dismissing the complaint filed by petitioners
in a civil case entitled, "Peter Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian
Lucas v. Prospero Ma. C. Tuao," docketed as Civil Case No. 92-2482.

From the record of the case, the established factual antecedents of the present petition
are:
Sometime in August 1988, petitioner Peter Paul Patrick Lucas (Peter) contracted "sore
eyes" in his right eye.
On 2 September 1988, complaining of a red right eye and swollen eyelid, Peter made use
of his health care insurance issued by Philamcare Health Systems, Inc. (Philamcare), for a
possible consult. The Philamcare Coordinator, Dr. Edwin Oca, M.D., referred Peter to
respondent, Dr. Prospero Ma. C. Tuao, M.D. (Dr. Tuao), an ophthalmologist at St. Lukes
Medical Center, for an eye consult.
Upon consultation with Dr. Tuao, Peter narrated that it had been nine (9) days since the
problem with his right eye began; and that he was already taking Maxitrol to address the
problem in his eye. According to Dr. Tuao, he performed "ocular routine examination" on
Peters eyes, wherein: (1) a gross examination of Peters eyes and their surrounding area
was made; (2) Peters visual acuity were taken; (3) Peters eyes were palpated to check
the intraocular pressure of each; (4) the motility of Peters eyes was observed; and (5) the
ophthalmoscopy4 on Peters eyes was used. On that particular consultation, Dr. Tuao
diagnosed that Peter was suffering from conjunctivitis5 or "sore eyes." Dr. Tuao then
prescribed Spersacet-C6 eye drops for Peter and told the latter to return for follow-up after
one week.
As instructed, Peter went back to Dr. Tuao on 9 September 1988. Upon examination, Dr.
Tuao told Peter that the "sore eyes" in the latters right eye had already cleared up and
he could discontinue the Spersacet-C. However, the same eye developed Epidemic Kerato
Conjunctivitis (EKC),7 a viral infection. To address the new problem with Peters right eye,
Dr. Tuao prescribed to the former a steroid-based eye drop called Maxitrol,8 a dosage of
six (6) drops per day.9 To recall, Peter had already been using Maxitrol prior to his consult
with Dr. Tuao.
On 21 September 1988, Peter saw Dr. Tuao for a follow-up consultation. After examining
both of Peters eyes, Dr. Tuao instructed the former to taper down10 the dosage of
Maxitrol, because the EKC in his right eye had already resolved. Dr. Tuao specifically
cautioned Peter that, being a steroid, Maxitrol had to be withdrawn gradually; otherwise,
the EKC might recur.11

Complaining of feeling as if there was something in his eyes, Peter returned to Dr. Tuao
for another check-up on 6 October 1988. Dr. Tuao examined Peters eyes and found that
the right eye had once more developed EKC. So, Dr. Tuao instructed Peter to resume the
use of Maxitrol at six (6) drops per day.
On his way home, Peter was unable to get a hold of Maxitrol, as it was out of stock.
Consequently, Peter was told by Dr. Tuano to take, instead, Blephamide12 another steroidbased medication, but with a lower concentration, as substitute for the unavailable
Maxitrol, to be used three (3) times a day for five (5) days; two (2) times a day for five (5)
days; and then just once a day.13
Several days later, on 18 October 1988, Peter went to see Dr. Tuao at his clinic, alleging
severe eye pain, feeling as if his eyes were about to "pop-out," a headache and blurred
vision. Dr. Tuao examined Peters eyes and discovered that the EKC was again present in
his right eye. As a result, Dr. Tuao told Peter to resume the maximum dosage of
Blephamide.
Dr. Tuao saw Peter once more at the formers clinic on 4 November 1988. Dr. Tuaos
examination showed that only the periphery of Peters right eye was positive for EKC;
hence, Dr. Tuao prescribed a lower dosage of Blephamide.
It was also about this time that Fatima Gladys Lucas (Fatima), Peters spouse, read the
accompanying literature of Maxitrol and found therein the following warning against the
prolonged use of such steroids:
WARNING:
Prolonged use may result in glaucoma, with damage to the optic nerve, defects in visual
acuity and fields of vision, and posterior, subcapsular cataract formation. Prolonged use
may suppress the host response and thus increase the hazard of secondary ocular
infractions, in those diseases causing thinning of the cornea or sclera, perforations have
been known to occur with the use of topical steroids. In acute purulent conditions of the
eye, steroids may mask infection or enhance existing infection. If these products are used
for 10 days or longer, intraocular pressure should be routinely monitored even though it
may be difficult in children and uncooperative patients.
Employment of steroid medication in the treatment of herpes simplex requires great
caution.
xxxx
ADVERSE REACTIONS:
Adverse reactions have occurred with steroid/anti-infective combination drugs which can
be attributed to the steroid component, the anti-infective component, or the combination.
Exact incidence figures are not available since no denominator of treated patients is
available.
Reactions occurring most often from the presence of the anti-infective ingredients are
allergic sensitizations. The reactions due to the steroid component in decreasing order to
frequency are elevation of intra-ocular pressure (IOP) with possible development of
glaucoma, infrequent optic nerve damage; posterior subcapsular cataract formation; and
delayed wound healing.

Secondary infection: The development of secondary has occurred after use of combination
containing steroids and antimicrobials. Fungal infections of the correa are particularly
prone to develop coincidentally with long-term applications of steroid. The possibility of
fungal invasion must be considered in any persistent corneal ulceration where steroid
treatment has been used.
Secondary bacterial ocular infection following suppression of host responses also occurs.
On 26 November 1988, Peter returned to Dr. Tuaos clinic, complaining of "feeling
worse."14 It appeared that the EKC had spread to the whole of Peters right eye yet again.
Thus, Dr. Tuao instructed Peter to resume the use of Maxitrol. Petitioners averred that
Peter already made mention to Dr. Tuao during said visit of the above-quoted warning
against the prolonged use of steroids, but Dr. Tuao supposedly brushed aside Peters
concern as mere paranoia, even assuring him that the former was taking care of him
(Peter).
Petitioners further alleged that after Peters 26 November 1988 visit to Dr. Tuao, Peter
continued to suffer pain in his right eye, which seemed to "progress," with the ache
intensifying and becoming more frequent.
Upon waking in the morning of 13 December 1988, Peter had no vision in his right eye.
Fatima observed that Peters right eye appeared to be bloody and swollen.15 Thus,
spouses Peter and Fatima rushed to the clinic of Dr. Tuao. Peter reported to Dr. Tuao that
he had been suffering from constant headache in the afternoon and blurring of vision.
Upon examination, Dr. Tuao noted the hardness of Peters right eye. With the use of a
tonometer16 to verify the exact intraocular pressure17 (IOP) of Peters eyes, Dr. Tuao
discovered that the tension in Peters right eye was 39.0 Hg, while that of his left was 17.0
Hg.18 Since the tension in Peters right eye was way over the normal IOP, which merely
ranged from 10.0 Hg to 21.0 Hg,19 Dr. Tuao ordered20 him to immediately discontinue
the use of Maxitrol and prescribed to the latter Diamox21 and Normoglaucon, instead.22
Dr. Tuao also required Peter to go for daily check-up in order for the former to closely
monitor the pressure of the latters eyes.
On 15 December 1988, the tonometer reading of Peters right eye yielded a high normal
level, i.e., 21.0 Hg. Hence, Dr. Tuao told Peter to continue using Diamox and
Normoglaucon. But upon Peters complaint of "stomach pains and tingling sensation in his
fingers,"23 Dr. Tuao discontinued Peters use of Diamox.24
Peter went to see another ophthalmologist, Dr. Ramon T. Batungbacal (Dr. Batungbacal),
on 21 December 1988, who allegedly conducted a complete ophthalmological
examination of Peters eyes. Dr. Batungbacals diagnosis was Glaucoma25 O.D.26 He
recommended Laser Trabeculoplasty27 for Peters right eye.
When Peter returned to Dr. Tuao on 23 December 1988,28 the tonometer measured the
IOP of Peters right eye to be 41.0 Hg,29 again, way above normal. Dr. Tuao addressed
the problem by advising Peter to resume taking Diamox along with Normoglaucon.

During the Christmas holidays, Peter supposedly stayed in bed most of the time and was
not able to celebrate the season with his family because of the debilitating effects of
Diamox.30
On 28 December 1988, during one of Peters regular follow-ups with Dr. Tuao, the doctor
conducted another ocular routine examination of Peters eyes. Dr. Tuao noted the
recurrence of EKC in Peters right eye. Considering, however, that the IOP of Peters right
eye was still quite high at 41.0 Hg, Dr. Tuao was at a loss as to how to balance the
treatment of Peters EKC vis--vis the presence of glaucoma in the same eye. Dr. Tuao,
thus, referred Peter to Dr. Manuel B. Agulto, M.D. (Dr. Agulto), another ophthalmologist
specializing in the treatment of glaucoma.31 Dr. Tuaos letter of referral to Dr. Agulto
stated that:
Referring to you Mr. Peter Lucas for evaluation & possible management. I initially saw him
Sept. 2, 1988 because of conjunctivitis. The latter resolved and he developed EKC for
which I gave Maxitrol. The EKC was recurrent after stopping steroid drops. Around 1 month
of steroid treatment, he noted blurring of vision & pain on the R. however, I continued the
steroids for the sake of the EKC. A month ago, I noted iris atrophy, so I took the IOP and it
was definitely elevated. I stopped the steroids immediately and has (sic) been treating
him medically.
It seems that the IOP can be controlled only with oral Diamox, and at the moment, the
EKC has recurred and Im in a fix whether to resume the steroid or not considering that
the IOP is still uncontrolled.32
On 29 December 1988, Peter went to see Dr. Agulto at the latters clinic. Several tests
were conducted thereat to evaluate the extent of Peters condition. Dr. Agulto wrote Dr.
Tuao a letter containing the following findings and recommendations:
Thanks for sending Peter Lucas. On examination conducted vision was 20/25 R and
20/20L. Tension curve 19 R and 15 L at 1210 H while on Normoglaucon BID OD & Diamox
tab every 6h po.
Slit lamp evaluation33 disclosed subepithelial corneal defect outer OD. There was
circumferential peripheral iris atrophy, OD. The lenses were clear.
Funduscopy34 showed vertical cup disc of 0.85 R and 0.6 L with temporal slope R>L.
Zeiss gonioscopy35 revealed basically open angles both eyes with occasional PAS,36 OD.
Rolly, I feel that Peter Lucas has really sustained significant glaucoma damage. I suggest
that we do a baseline visual fields and push medication to lowest possible levels. If I may
suggest further, I think we should prescribe Timolol37 BID38 OD in lieu of Normoglaucon.
If the IOP is still inadequate, we may try Depifrin39 BID OD (despite low PAS). Im in favor
of retaining Diamox or similar CAI.40
If fields show further loss in say 3 mos. then we should consider trabeculoplasty.
I trust that this approach will prove reasonable for you and Peter.41

Peter went to see Dr. Tuao on 31 December 1988, bearing Dr. Agultos aforementioned
letter. Though Peters right and left eyes then had normal IOP of 21.0 Hg and 17.0 Hg,
respectively, Dr. Tuao still gave him a prescription for Timolol B.I.D. so Peter could
immediately start using said medication. Regrettably, Timolol B.I.D. was out of stock, so
Dr. Tuao instructed Peter to just continue using Diamox and Normoglaucon in the
meantime.
Just two days later, on 2 January 1989, the IOP of Peters right eye remained elevated at
21.0 Hg,42 as he had been without Diamox for the past three (3) days.
On 4 January 1989, Dr. Tuao conducted a visual field study43 of Peters eyes, which
revealed that the latter had tubular vision44 in his right eye, while that of his left eye
remained normal. Dr. Tuao directed Peter to religiously use the Diamox and
Normoglaucon, as the tension of the latters right eye went up even further to 41.0 Hg in
just a matter of two (2) days, in the meantime that Timolol B.I.D. and Depifrin were still
not available in the market. Again, Dr. Tuao advised Peter to come for regular check-up
so his IOP could be monitored.
Obediently, Peter went to see Dr. Tuao on the 7th, 13th, 16th and 20th of January 1989
for check-up and IOP monitoring.
In the interregnum, however, Peter was prodded by his friends to seek a second medical
opinion. On 13 January 1989, Peter consulted Dr. Jaime Lapuz, M.D. (Dr. Lapuz), an
ophthalmologist, who, in turn, referred Peter to Dr. Mario V. Aquino, M.D. (Dr. Aquino),
another ophthalmologist who specializes in the treatment of glaucoma and who could
undertake the long term care of Peters eyes.
According to petitioners, after Dr. Aquino conducted an extensive evaluation of Peters
eyes, the said doctor informed Peter that his eyes were relatively normal, though the right
one sometimes manifested maximum borderline tension. Dr. Aquino also confirmed Dr.
Tuaos diagnosis of tubular vision in Peters right eye. Petitioners claimed that Dr. Aquino
essentially told Peter that the latters condition would require lifetime medication and
follow-ups.
In May 1990 and June 1991, Peter underwent two (2) procedures of laser trabeculoplasty
to attempt to control the high IOP of his right eye.
Claiming to have steroid-induced glaucoma45 and blaming Dr. Tuao for the same, Peter,
joined by: (1) Fatima, his spouse46; (2) Abbeygail, his natural child47; and (3) Gillian, his
legitimate child48 with Fatima, instituted on 1 September 1992, a civil complaint for
damages against Dr. Tuao, before the RTC, Branch 150, Quezon City. The case was
docketed as Civil Case No. 92-2482.
In their Complaint, petitioners specifically averred that as the "direct consequence of
[Peters] prolonged use of Maxitrol, [he] suffered from steroid induced glaucoma which
caused the elevation of his intra-ocular pressure. The elevation of the intra-ocular
pressure of [Peters right eye] caused the impairment of his vision which impairment is
not curable and may even lead to total blindness."49
Petitioners additionally alleged that the visual impairment of Peters right eye caused him
and his family so much grief. Because of his present condition, Peter now needed close

medical supervision forever; he had already undergone two (2) laser surgeries, with the
possibility that more surgeries were still needed in the future; his career in sports casting
had suffered and was continuing to suffer;50 his anticipated income had been greatly
reduced as a result of his "limited" capacity; he continually suffered from "headaches,
nausea, dizziness, heart palpitations, rashes, chronic rhinitis, sinusitis,"51 etc.; Peters
relationships with his spouse and children continued to be strained, as his condition made
him highly irritable and sensitive; his mobility and social life had suffered; his spouse,
Fatima, became the breadwinner in the family;52 and his two children had been deprived
of the opportunity for a better life and educational prospects. Collectively, petitioners
lived in constant fear of Peter becoming completely blind.53
In the end, petitioners sought pecuniary award for their supposed pain and suffering,
which were ultimately brought about by Dr. Tuaos grossly negligent conduct in
prescribing to Peter the medicine Maxitrol for a period of three (3) months, without
monitoring Peters IOP, as required in cases of prolonged use of said medicine, and
notwithstanding Peters constant complaint of intense eye pain while using the same.
Petitioners particularly prayed that Dr. Tuao be adjudged liable for the following amounts:
1. The amount of P2,000,000.00 to plaintiff Peter Lucas as and by way of compensation
for his impaired vision.
2. The amount of P300,000.00 to spouses Lucas as and by way of actual damages plus
such additional amounts that may be proven during trial.
3. The amount of P1,000,000.00 as and by way of moral damages.
4. The amount of P500,000.00 as and by way of exemplary damages.
5. The amount of P200,000.00 as and by way of attorneys fees plus costs of suit.54
In rebutting petitioners complaint, Dr. Tuao asserted that the "treatment made by [him]
more than three years ago has no causal connection to [Peters] present glaucoma or
condition."55 Dr. Tuao explained that "[d]rug-induced glaucoma is temporary and
curable, steroids have the side effect of increasing intraocular pressure. Steroids are
prescribed to treat Epidemic Kerato Conjunctivitis or EKC which is an infiltration of the
cornea as a result of conjunctivitis or sore eyes."56 Dr. Tuao also clarified that (1)
"[c]ontrary to [petitioners] fallacious claim, [he] did NOT continually prescribe the drug
Maxitrol which contained steroids for any prolonged period"57 and "[t]he truth was the
Maxitrol was discontinued x x x as soon as EKC disappeared and was resumed only when
EKC reappeared"58; (2) the entire time he was treating Peter, he "continually monitored
the intraocular pressure of [Peters eyes] by palpating the eyes and by putting pressure on
the eyeballs," and no hardening of the same could be detected, which meant that there
was no increase in the tension or IOP, a possible side reaction to the use of steroid
medications; and (3) it was only on 13 December 1988 that Peter complained of a
headache and blurred vision in his right eye, and upon measuring the IOP of said eye, it
was determined for the first time that the IOP of the right eye had an elevated value.
But granting for the sake of argument that the "steroid treatment of [Peters] EKC caused
the steroid induced glaucoma,"59 Dr. Tuao argued that: [S]uch condition, i.e., elevated
intraocular pressure, is temporary. As soon as the intake of steroids is discontinued, the
intraocular pressure automatically is reduced. Thus, [Peters] glaucoma can only be due to
other causes not attributable to steroids, certainly not attributable to [his] treatment of
more than three years ago x x x.

From a medical point of view, as revealed by more current examination of [Peter], the
latters glaucoma can only be long standing glaucoma, open angle glaucoma, because of
the large C:D ratio. The steroids provoked the latest glaucoma to be revealed earlier as
[Peter] remained asymptomatic prior to steroid application. Hence, the steroid treatment
was in fact beneficial to [Peter] as it revealed the incipient open angle glaucoma of [Peter]
to allow earlier treatment of the same.60
In a Decision dated 14 July 2000, the RTC dismissed Civil Case No. 92-2482 "for
insufficiency of evidence."61 The decretal part of said Decision reads: Wherefore,
premises considered, the instant complaint is dismissed for insufficiency of evidence. The
counter claim (sic) is likewise dismissed in the absence of bad faith or malice on the part
of plaintiff in filing the suit.62
The RTC opined that petitioners failed to prove by preponderance of evidence that Dr.
Tuao was negligent in his treatment of Peters condition. In particular, the record of the
case was bereft of any evidence to establish that the steroid medication and its dosage,
as prescribed by Dr. Tuao, caused Peters glaucoma. The trial court reasoned that the
"recognized standards of the medical community has not been established in this case,
much less has causation been established to render [Tuao] liable."63 According to the
RTC:
[Petitioners] failed to establish the duty required of a medical practitioner against which Peter Pauls
treatment by defendant can be compared with. They did not present any medical expert or even a
medical doctor to convince and expertly explain to the court the established norm or duty required of
a physician treating a patient, or whether the non taking (sic) by Dr. Tuao of Peter Pauls pressure a
deviation from the norm or his non-discovery of the glaucoma in the course of treatment constitutes
negligence. It is important and indispensable to establish such a standard because once it is
established, a medical practitioner who departed thereof breaches his duty and commits negligence
rendering him liable. Without such testimony or enlightenment from an expert, the court is at a loss
as to what is then the established norm of duty of a physician against which defendants conduct can
be compared with to determine negligence.64

The RTC added that in the absence of "any medical evidence to the contrary, this court
cannot accept [petitioners] claim that the use of steroid is the proximate cause of the
damage sustained by [Peters] eye."65
Correspondingly, the RTC accepted Dr. Tuaos medical opinion that "Peter Paul must have
been suffering from normal tension glaucoma, meaning, optic nerve damage was
happening but no elevation of the eye pressure is manifested, that the steroid treatment
actually unmasked the condition that resulted in the earlier treatment of the glaucoma.
There is nothing in the record to contradict such testimony. In fact, plaintiffs Exhibit S
even tends to support them."
Undaunted, petitioners appealed the foregoing RTC decision to the Court of Appeals. Their
appeal was docketed as CA-G.R. CV No. 68666.
On 27 September 2006, the Court of Appeals rendered a decision in CA-G.R. CV No. 68666
denying petitioners recourse and affirming the appealed RTC Decision. The fallo of the
judgment of the appellate court states:
WHEREFORE, the Decision appealed from is AFFIRMED.66
The Court of Appeals faulted petitioners because they

[D]id not present any medical expert to testify that Dr. Tuanos prescription of Maxitrol and
Blephamide for the treatment of EKC on Peters right eye was not proper and that his palpation of
Peters right eye was not enough to detect adverse reaction to steroid. Peter testified that Dr. Manuel
Agulto told him that he should not have used steroid for the treatment of EKC or that he should have
used it only for two (2) weeks, as EKC is only a viral infection which will cure by itself. However, Dr.
Agulto was not presented by [petitioners] as a witness to confirm what he allegedly told Peter and,
therefore, the latters testimony is hearsay. Under Rule 130, Section 36 of the Rules of Court, a
witness can testify only to those facts which he knows of his own personal knowledge, x x x. Familiar
and fundamental is the rule that hearsay testimony is inadmissible as evidence.

Like the RTC, the Court of Appeals gave great weight to Dr. Tuaos medical judgment,
specifically the latters explanation that:
[W]hen a doctor sees a patient, he cannot determine whether or not the latter would react
adversely to the use of steroids, that it was only on December 13, 1989, when Peter complained for
the first time of headache and blurred vision that he observed that the pressure of the eye of Peter
was elevated, and it was only then that he suspected that Peter belongs to the 5% of the population
who reacts adversely to steroids.68

Petitioners Motion for Reconsideration was denied by the Court of Appeals in a Resolution
dated 3 July 2007.
Hence, this Petition for Review on Certiorari under Rule 45 of the Revised Rules of Court
premised on the following assignment of errors:
I. THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN AFFIRMING THE DECISION
OF THE TRIAL COURT DISMISSING THE PETITIONERS COMPLAINT FOR DAMAGES AGAINST THE
RESPONDENT ON THE GROUND OF INSUFFICIENCY OF EVIDENCE;
II. THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN DISMISSING THE
PETITIONERS COMPLAINT FOR DAMAGES AGAINST THE RESPONDENT ON THE GROUND THAT NO
MEDICAL EXPERT WAS PRESENTED BY THE PETITIONERS TO PROVE THEIR CLAIM FOR MEDICAL
NEGLIGENCE AGAINST THE RESPONDENT; AND
III. THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN NOT FINDING THE
RESPONDENT LIABLE TO THE PETITIONERS FOR ACTUAL, MORAL AND EXEMPLARY DAMAGES, ASIDE
FROM ATTORNEYS FEES, COSTS OF SUIT, AS A RESULT OF HIS GROSS NEGLIGENCE.69

A reading of the afore-quoted reversible errors supposedly committed by the Court of


Appeals in its Decision and Resolution would reveal that petitioners are fundamentally
assailing the finding of the Court of Appeals that the evidence on record is insufficient to
establish petitioners entitlement to any kind of damage. Therefore, it could be said that
the sole issue for our resolution in the Petition at bar is whether the Court of Appeals
committed reversible error in affirming the judgment of the RTC that petitioners failed to
prove, by preponderance of evidence, their claim for damages against Dr. Tuao.
Evidently, said issue constitutes a question of fact, as we are asked to revisit anew the
factual findings of the Court of Appeals, as well as of the RTC. In effect, petitioners would
have us sift through the evidence on record and pass upon whether there is sufficient
basis to establish Dr. Tuaos negligence in his treatment of Peters eye condition. This
question clearly involves a factual inquiry, the determination of which is not within the
ambit of this Courts power of review under Rule 45 of the 1997 Rules Civil Procedure, as
amended.70
Elementary is the principle that this Court is not a trier of facts; only errors of law are
generally reviewed in petitions for review on certiorari criticizing decisions of the Court of
Appeals. Questions of fact are not entertained.71

Nonetheless, the general rule that only questions of law may be raised on appeal in a
petition for review under Rule 45 of the Rules of Court admits of certain exceptions,
including the circumstance when the finding of fact of the Court of Appeals is premised on
the supposed absence of evidence, but is contradicted by the evidence on record.
Although petitioners may not explicitly invoke said exception, it may be gleaned from
their allegations and arguments in the instant Petition.1avvphi1.zw+
Petitioners contend, that "[c]ontrary to the findings of the Honorable Court of Appeals,
[they] were more than able to establish that: Dr. Tuao ignored the standard medical
procedure for ophthalmologists, administered medication with recklessness, and exhibited
an absence of competence and skills expected from him."72 Petitioners reject the
necessity of presenting expert and/or medical testimony to establish (1) the standard of
care respecting the treatment of the disorder affecting Peters eye; and (2) whether or not
negligence attended Dr. Tuaos treatment of Peter, because, in their words
That Dr. Tuao was grossly negligent in the treatment of Peters simple eye ailment is a simple
case of cause and effect. With mere documentary evidence and based on the facts presented by the
petitioners, respondent can readily be held liable for damages even without any expert testimony. In
any case, however, and contrary to the finding of the trial court and the Court of Appeals, there was a
medical expert presented by the petitioner showing the recklessness committed by [Dr. Tuao] Dr.
Tuao himself. [Emphasis supplied.]

They insist that Dr. Tuao himself gave sufficient evidence to establish his gross
negligence that ultimately caused the impairment of the vision of Peters right eye,73 i.e.,
that "[d]espite [Dr. Tuaos] knowledge that 5% of the population reacts adversely to
Maxitrol, [he] had no qualms whatsoever in prescribing said steroid to Peter without first
determining whether or not the (sic) Peter belongs to the 5%."74
We are not convinced. The judgments of both the Court of Appeals and the RTC are in
accord with the evidence on record, and we are accordingly bound by the findings of fact
made therein.
Petitioners position, in sum, is that Peters glaucoma is the direct result of Dr. Tuaos
negligence in his improper administration of the drug Maxitrol; "thus, [the latter] should
be liable for all the damages suffered and to be suffered by [petitioners]."75 Clearly, the
present controversy is a classic illustration of a medical negligence case against a
physician based on the latters professional negligence. In this type of suit, the patient or
his heirs, in order to prevail, is required to prove by preponderance of evidence that the
physician failed to exercise that degree of skill, care, and learning possessed by other
persons in the same profession; and that as a proximate result of such failure, the patient
or his heirs suffered damages.
For lack of a specific law geared towards the type of negligence committed by members
of the medical profession, such claim for damages is almost always anchored on the
alleged violation of Article 2176 of the Civil Code, which states that:
ART. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done. Such fault or negligence, if there is no pre-existing
contractual relation between the parties, is called a quasi-delict and is governed by the provisions of
this Chapter.

In medical negligence cases, also called medical malpractice suits, there exist a physicianpatient relationship between the doctor and the victim. But just like any other proceeding
for damages, four essential (4) elements i.e., (1) duty; (2) breach; (3) injury; and (4)

proximate causation,76 must be established by the plaintiff/s. All the four (4) elements
must co-exist in order to find the physician negligent and, thus, liable for damages.
When a patient engages the services of a physician, a physician-patient relationship is
generated. And in accepting a case, the physician, for all intents and purposes, represents
that he has the needed training and skill possessed by physicians and surgeons practicing
in the same field; and that he will employ such training, care, and skill in the treatment of
the patient.77 Thus, in treating his patient, a physician is under a duty to [the former] to
exercise that degree of care, skill and diligence which physicians in the same general
neighborhood and in the same general line of practice ordinarily possess and exercise in
like cases.78 Stated otherwise, the physician has the duty to use at least the same level
of care that any other reasonably competent physician would use to treat the condition
under similar circumstances.
This standard level of care, skill and diligence is a matter best addressed by expert
medical testimony, because the standard of care in a medical malpractice case is a
matter peculiarly within the knowledge of experts in the field.79
There is breach of duty of care, skill and diligence, or the improper performance of such
duty, by the attending physician when the patient is injured in body or in health [and this]
constitutes the actionable malpractice.80 Proof of such breach must likewise rest upon the
testimony of an expert witness that the treatment accorded to the patient failed to meet
the standard level of care, skill and diligence which physicians in the same general
neighborhood and in the same general line of practice ordinarily possess and exercise in
like cases.
Even so, proof of breach of duty on the part of the attending physician is insufficient, for
there must be a causal connection between said breach and the resulting injury sustained
by the patient. Put in another way, in order that there may be a recovery for an injury, it
must be shown that the "injury for which recovery is sought must be the legitimate
consequence of the wrong done; the connection between the negligence and the injury
must be a direct and natural sequence of events, unbroken by intervening efficient
causes";81 that is, the negligence must be the proximate cause of the injury. And the
proximate cause of an injury is that cause, which, in the natural and continuous sequence,
unbroken by any efficient intervening cause, produces the injury, and without which the
result would not have occurred.82
Just as with the elements of duty and breach of the same, in order to establish the
proximate cause [of the injury] by a preponderance of the evidence in a medical
malpractice action, [the patient] must similarly use expert testimony, because the
question of whether the alleged professional negligence caused [the patients] injury is
generally one for specialized expert knowledge beyond the ken of the average layperson;
using the specialized knowledge and training of his field, the experts role is to present to
the [court] a realistic assessment of the likelihood that [the physicians] alleged
negligence caused [the patients] injury.83
From the foregoing, it is apparent that medical negligence cases are best proved by
opinions of expert witnesses belonging in the same general neighborhood and in the
same general line of practice as defendant physician or surgeon. The deference of courts
to the expert opinion of qualified physicians [or surgeons] stems from the formers
realization that the latter possess unusual technical skills which laymen in most instances

are incapable of intelligently evaluating;84 hence, the indispensability of expert


testimonies.

tests/procedures every time Peter went to see him for follow-up consultation and/or
check-up.

In the case at bar, there is no question that a physician-patient relationship developed


between Dr. Tuao and Peter when Peter went to see the doctor on 2 September 1988,
seeking a consult for the treatment of his sore eyes. Admittedly, Dr. Tuao, an
ophthalmologist, prescribed Maxitrol when Peter developed and had recurrent EKC.
Maxitrol or neomycin/polymyxin B sulfates/dexamethasone ophthalmic ointment is a
multiple-dose anti-infective steroid combination in sterile form for topical application.85 It
is the drug which petitioners claim to have caused Peters glaucoma.

We cannot but agree with Dr. Tuaos assertion that when a doctor sees a patient, he
cannot determine immediately whether the latter would react adversely to the use of
steroids; all the doctor can do is map out a course of treatment recognized as correct by
the standards of the medical profession. It must be remembered that a physician is not an
insurer of the good result of treatment. The mere fact that the patient does not get well or
that a bad result occurs does not in itself indicate failure to exercise due care.89 The
result is not determinative of the performance [of the physician] and he is not required to
be infallible.90

However, as correctly pointed out by the Court of Appeals, "[t]he onus probandi was on
the patient to establish before the trial court that the physicians ignored standard medical
procedure, prescribed and administered medication with recklessness and exhibited an
absence of the competence and skills expected of general practitioners similarly
situated."86 Unfortunately, in this case, there was absolute failure on the part of
petitioners to present any expert testimony to establish: (1) the standard of care to be
implemented by competent physicians in treating the same condition as Peters under
similar circumstances; (2) that, in his treatment of Peter, Dr. Tuao failed in his duty to
exercise said standard of care that any other competent physician would use in treating
the same condition as Peters under similar circumstances; and (3) that the injury or
damage to Peters right eye, i.e., his glaucoma, was the result of his use of Maxitrol, as
prescribed by Dr. Tuao. Petitioners failure to prove the first element alone is already fatal
to their cause.
Petitioners maintain that Dr. Tuao failed to follow in Peters case the required procedure
for the prolonged use of Maxitrol. But what is actually the required procedure in situations
such as in the case at bar? To be precise, what is the standard operating procedure when
ophthalmologists prescribe steroid medications which, admittedly, carry some modicum of
risk?
Absent a definitive standard of care or diligence required of Dr. Tuao under the
circumstances, we have no means to determine whether he was able to comply with the
same in his diagnosis and treatment of Peter. This Court has no yardstick upon which to
evaluate or weigh the attendant facts of this case to be able to state with confidence that
the acts complained of, indeed, constituted negligence and, thus, should be the subject of
pecuniary reparation.
Petitioners assert that prior to prescribing Maxitrol, Dr. Tuao should have determined first
whether Peter was a "steroid responder."87 Yet again, petitioners did not present any
convincing proof that such determination is actually part of the standard operating
procedure which ophthalmologists should unerringly follow prior to prescribing steroid
medications.
In contrast, Dr. Tuao was able to clearly explain that what is only required of
ophthalmologists, in cases such as Peters, is the conduct of standard tests/procedures
known as "ocular routine examination,"88 composed of five (5) tests/procedures
specifically, gross examination of the eyes and the surrounding area; taking of the visual
acuity of the patient; checking the intraocular pressure of the patient; checking the
motility of the eyes; and using ophthalmoscopy on the patients eye and he did all those

Moreover, that Dr. Tuao saw it fit to prescribe Maxitrol to Peter was justified by the fact
that the latter was already using the same medication when he first came to see Dr. Tuao
on 2 September 1988 and had exhibited no previous untoward reaction to that particular
drug. 91
Also, Dr. Tuao categorically denied petitioners claim that he never monitored the tension
of Peters eyes while the latter was on Maxitrol. Dr. Tuao testified that he palpated
Peters eyes every time the latter came for a check-up as part of the doctors ocular
routine examination, a fact which petitioners failed to rebut. Dr. Tuaos regular conduct of
examinations and tests to ascertain the state of Peters eyes negate the very basis of
petitioners complaint for damages. As to whether Dr. Tuaos actuations conformed to
the standard of care and diligence required in like circumstances, it is presumed to have
so conformed in the absence of evidence to the contrary.
Even if we are to assume that Dr. Tuao committed negligent acts in his treatment of
Peters condition, the causal connection between Dr. Tuaos supposed negligence and
Peters injury still needed to be established. The critical and clinching factor in a medical
negligence case is proof of the causal connection between the negligence which the
evidence established and the plaintiffs injuries.92 The plaintiff must plead and prove not
only that he has been injured and defendant has been at fault, but also that the
defendants fault caused the injury. A verdict in a malpractice action cannot be based on
speculation or conjecture. Causation must be proven within a reasonable medical
probability based upon competent expert testimony.93
The causation between the physicians negligence and the patients injury may only be
established by the presentation of proof that Peters glaucoma would not have occurred
but for Dr. Tuaos supposed negligent conduct. Once more, petitioners failed in this
regard.
Dr. Tuao does not deny that the use of Maxitrol involves the risk of increasing a patients
IOP. In fact, this was the reason why he made it a point to palpate Peters eyes every time
the latter went to see him -- so he could monitor the tension of Peters eyes. But to say
that said medication conclusively caused Peters glaucoma is purely speculative. Peter
was diagnosed with open-angle glaucoma. This kind of glaucoma is characterized by an
almost complete absence of symptoms and a chronic, insidious course.94 In open-angle
glaucoma, halos around lights and blurring of vision do not occur unless there has been a
sudden increase in the intraocular vision.95 Visual acuity remains good until late in the
course of the disease.96 Hence, Dr. Tuao claims that Peters glaucoma "can only be long
standing x x x because of the large C:D97 ratio," and that "[t]he steroids provoked the

latest glaucoma to be revealed earlier" was a blessing in disguise "as [Peter] remained
asymptomatic prior to steroid application."
Who between petitioners and Dr. Tuao is in a better position to determine and evaluate
the necessity of using Maxitrol to cure Peters EKC vis--vis the attendant risks of using
the same?
That Dr. Tuao has the necessary training and skill to practice his chosen field is beyond
cavil. Petitioners do not dispute Dr. Tuaos qualifications that he has been a physician
for close to a decade and a half at the time Peter first came to see him; that he has had
various medical training; that he has authored numerous papers in the field of
ophthalmology, here and abroad; that he is a Diplomate of the Philippine Board of
Ophthalmology; that he occupies various teaching posts (at the time of the filing of the
present complaint, he was the Chair of the Department of Ophthalmology and an
Associate Professor at the University of the Philippines-Philippine General Hospital and St.
Lukes Medical Center, respectively); and that he held an assortment of positions in
numerous medical organizations like the Philippine Medical Association, Philippine
Academy of Ophthalmology, Philippine Board of Ophthalmology, Philippine Society of
Ophthalmic Plastic and Reconstructive Surgery, Philippine Journal of Ophthalmology,
Association of Philippine Ophthalmology Professors, et al.
It must be remembered that when the qualifications of a physician are admitted, as in the
instant case, there is an inevitable presumption that in proper cases, he takes the
necessary precaution and employs the best of his knowledge and skill in attending to his
clients, unless the contrary is sufficiently established.98 In making the judgment call of
treating Peters EKC with Maxitrol, Dr. Tuao took the necessary precaution by palpating
Peters eyes to monitor their IOP every time the latter went for a check-up, and he
employed the best of his knowledge and skill earned from years of training and practice.
In contrast, without supporting expert medical opinions, petitioners bare assertions of
negligence on Dr. Tuaos part, which resulted in Peters glaucoma, deserve scant credit.
Our disposition of the present controversy might have been vastly different had
petitioners presented a medical expert to establish their theory respecting Dr. Tuaos socalled negligence. In fact, the record of the case reveals that petitioners counsel
recognized the necessity of presenting such evidence. Petitioners even gave an
undertaking to the RTC judge that Dr. Agulto or Dr. Aquino would be presented. Alas, no
follow-through on said undertaking was made.1avvphi1
The plaintiff in a civil case has the burden of proof as he alleges the affirmative of the
issue. However, in the course of trial in a civil case, once plaintiff makes out a prima facie
case in his favor, the duty or the burden of evidence shifts to defendant to controvert
plaintiffs prima facie case; otherwise, a verdict must be returned in favor of plaintiff.99
The party having the burden of proof must establish his case by a preponderance of
evidence.100 The concept of "preponderance of evidence" refers to evidence which is of
greater weight or more convincing than that which is offered in opposition to it;101 in the
last analysis, it means probability of truth. It is evidence which is more convincing to the
court as worthy of belief than that which is offered in opposition thereto.102 Rule 133,
Section 1 of the Revised Rules of Court provides the guidelines for determining
preponderance of evidence, thus:

In civil cases, the party having the burden of proof must establish his case by a
preponderance of evidence. In determining where the preponderance or superior weight
of evidence on the issues involved lies the court may consider all the facts and
circumstances of the case, the witnesses manner of testifying, their intelligence, their
means and opportunity of knowing the facts to which they are testifying, the nature of the
facts to which they testify, the probability or improbability of their testimony, their interest
or want of interest, and also their personal credibility so far as the same legitimately
appear upon the trial. The court may also consider the number of witnesses, though the
preponderance is not necessarily with the greater number.
Herein, the burden of proof was clearly upon petitioners, as plaintiffs in the lower court, to
establish their case by a preponderance of evidence showing a reasonable connection
between Dr. Tuaos alleged breach of duty and the damage sustained by Peters right
eye. This, they did not do. In reality, petitioners complaint for damages is merely
anchored on a statement in the literature of Maxitrol identifying the risks of its use, and
the purported comment of Dr. Agulto another doctor not presented as witness before the
RTC concerning the prolonged use of Maxitrol for the treatment of EKC.
It seems basic that what constitutes proper medical treatment is a medical question that
should have been presented to experts. If no standard is established through expert
medical witnesses, then courts have no standard by which to gauge the basic issue of
breach thereof by the physician or surgeon. The RTC and Court of Appeals, and even this
Court, could not be expected to determine on its own what medical technique should have
been utilized for a certain disease or injury. Absent expert medical opinion, the courts
would be dangerously engaging in speculations.
All told, we are hard pressed to find Dr. Tuao liable for any medical negligence or
malpractice where there is no evidence, in the nature of expert testimony, to establish
that in treating Peter, Dr. Tuao failed to exercise reasonable care, diligence and skill
generally required in medical practice. Dr. Tuaos testimony, that his treatment of Peter
conformed in all respects to standard medical practice in this locality, stands unrefuted.
Consequently, the RTC and the Court of Appeals correctly held that they had no basis at
all to rule that petitioners were deserving of the various damages prayed for in their
Complaint.
WHEREFORE, premises considered, the instant petition is DENIED for lack of merit. The
assailed Decision dated 27 September 2006 and Resolution dated 3 July 2007, both of the
Court of Appeals in CA-G.R. CV No. 68666, are hereby AFFIRMED. No cost.
SO ORDERED.

EN BANC
G.R. No. 126297
February 2, 2010
PROFESSIONAL SERVICES, INC., Petitioner, vs. THE COURT OF APPEALS and NATIVIDAD
and ENRIQUE AGANA, Respondents.
G.R. No. 126467
NATIVIDAD [substituted by her children Marcelino Agana III, Enrique Agana, Jr., Emma
Agana-Andaya, Jesus Agana and Raymund Agana] and ENRIQUE AGANA, Petitioners, vs.
THE COURT OF APPEALS and JUAN FUENTES, Respondents.
G.R. No. 127590
MIGUEL AMPIL, Petitioner, vs. NATIVIDAD and ENRIQUE AGANA, Respondents.
RESOLUTION
CORONA, J.:
With prior leave of court,1 petitioner Professional Services, Inc. (PSI) filed a second motion
for reconsideration2 urging referral thereof to the Court en banc and seeking modification
of the decision dated January 31, 2007 and resolution dated February 11, 2008 which
affirmed its vicarious and direct liability for damages to respondents Enrique Agana and
the heirs of Natividad Agana (Aganas).

The Court premised the direct liability of PSI to the Aganas on the following facts and law:
First, there existed between PSI and Dr. Ampil an employer-employee relationship as
contemplated in the December 29, 1999 decision in Ramos v. Court of Appeals18 that "for
purposes of allocating responsibility in medical negligence cases, an employer-employee
relationship exists between hospitals and their consultants."19 Although the Court in
Ramos later issued a Resolution dated April 11, 200220 reversing its earlier finding on the
existence of an employment relationship between hospital and doctor, a similar reversal
was not warranted in the present case because the defense raised by PSI consisted of a
mere general denial of control or responsibility over the actions of Dr. Ampil.21
Second, by accrediting Dr. Ampil and advertising his qualifications, PSI created the public
impression that he was its agent.22 Enrique testified that it was on account of Dr. Ampil's
accreditation with PSI that he conferred with said doctor about his wife's (Natividad's)
condition.23 After his meeting with Dr. Ampil, Enrique asked Natividad to personally
consult Dr. Ampil.24 In effect, when Enrigue and Natividad engaged the services of Dr.
Ampil, at the back of their minds was that the latter was a staff member of a prestigious
hospital. Thus, under the doctrine of apparent authority applied in Nogales, et al. v.
Capitol Medical Center, et al.,25 PSI was liable for the negligence of Dr. Ampil.

Manila Medical Services, Inc. (MMSI),3 Asian Hospital, Inc. (AHI),4 and Private Hospital
Association of the Philippines (PHAP)5 all sought to intervene in these cases invoking the
common ground that, unless modified, the assailed decision and resolution will jeopardize
the financial viability of private hospitals and jack up the cost of health care.

Finally, as owner and operator of Medical City General Hospital, PSI was bound by its duty
to provide comprehensive medical services to Natividad Agana, to exercise reasonable
care to protect her from harm,26 to oversee or supervise all persons who practiced
medicine within its walls, and to take active steps in fixing any form of negligence
committed within its premises.27 PSI committed a serious breach of its corporate duty
when it failed to conduct an immediate investigation into the reported missing gauzes.28

The Special First Division of the Court granted the motions for intervention of MMSI, AHI
and PHAP (hereafter intervenors),6 and referred en consulta to the Court en banc the
motion for prior leave of court and the second motion for reconsideration of PSI.7

PSI is now asking this Court to reconsider the foregoing rulings for these reasons:
I

Due to paramount public interest, the Court en banc accepted the referral8 and heard the
parties on oral arguments on one particular issue: whether a hospital may be held liable
for the negligence of physicians-consultants allowed to practice in its premises.9
To recall the salient facts, PSI, together with Dr. Miguel Ampil (Dr. Ampil) and Dr. Juan
Fuentes (Dr. Fuentes), was impleaded by Enrique Agana and Natividad Agana (later
substituted by her heirs), in a complaint10 for damages filed in the Regional Trial Court
(RTC) of Quezon City, Branch 96, for the injuries suffered by Natividad when Dr. Ampil and
Dr. Fuentes neglected to remove from her body two gauzes11 which were used in the
surgery they performed on her on April 11, 1984 at the Medical City General Hospital. PSI
was impleaded as owner, operator and manager of the hospital.

The declaration in the 31 January 2007 Decision vis-a-vis the 11 February 2009 Resolution
that the ruling in Ramos vs. Court of Appeals (G.R. No. 134354, December 29, 1999) that
"an employer-employee relations exists between hospital and their consultants" stays
should be set aside for being inconsistent with or contrary to the import of the resolution
granting the hospital's motion for reconsideration in Ramos vs. Court of Appeals (G.R. No.
134354, April 11, 2002), which is applicable to PSI since the Aganas failed to prove an
employer-employee relationship between PSI and Dr. Ampil and PSI proved that it has no
control over Dr. Ampil. In fact, the trial court has found that there is no employeremployee relationship in this case and that the doctor's are independent contractors.
II

In a decision12 dated March 17, 1993, the RTC held PSI solidarily liable with Dr. Ampil and
Dr. Fuentes for damages.13 On appeal, the Court of Appeals (CA), absolved Dr. Fuentes
but affirmed the liability of Dr. Ampil and PSI, subject to the right of PSI to claim
reimbursement from Dr. Ampil.141avvphi1
On petition for review, this Court, in its January 31, 2007 decision, affirmed the CA
decision.15 PSI filed a motion for reconsideration16 but the Court denied it in a resolution
dated February 11, 2008.17

Respondents Aganas engaged Dr. Miguel Ampil as their doctor and did not primarily and
specifically look to the Medical City Hospital (PSI) for medical care and support; otherwise
stated, respondents Aganas did not select Medical City Hospital (PSI) to provide medical
care because of any apparent authority of Dr. Miguel Ampil as its agent since the latter
was chosen primarily and specifically based on his qualifications and being friend and
neighbor.
III

PSI cannot be liable under doctrine of corporate negligence since the proximate cause of
Mrs. Agana's injury was the negligence of Dr. Ampil, which is an element of the principle
of corporate negligence.29

eight hours each week and which were strictly to be observed under pain of
administrative sanctions.

In their respective memoranda, intervenors raise parallel arguments that the Court's
ruling on the existence of an employer-employee relationship between private hospitals
and consultants will force a drastic and complex alteration in the long-established and
currently prevailing relationships among patient, physician and hospital, with burdensome
operational and financial consequences and adverse effects on all three parties.30

That petitioner exercised control over respondents gains light from the undisputed fact
that in the emergency room, the operating room, or any department or ward for that
matter, respondents' work is monitored through its nursing supervisors, charge nurses
and orderlies. Without the approval or consent of petitioner or its medical director, no
operations can be undertaken in those areas. For control test to apply, it is not essential
for the employer to actually supervise the performance of duties of the employee, it being
enough that it has the right to wield the power. (emphasis supplied)

The Aganas comment that the arguments of PSI need no longer be entertained for they
have all been traversed in the assailed decision and resolution.31

Even in its December 29, 1999 decision41 and April 11, 2002 resolution42 in Ramos, the
Court found the control test decisive.

After gathering its thoughts on the issues, this Court holds that PSI is liable to the Aganas,
not under the principle of respondeat superior for lack of evidence of an employment
relationship with Dr. Ampil but under the principle of ostensible agency for the negligence
of Dr. Ampil and, pro hac vice, under the principle of corporate negligence for its failure to
perform its duties as a hospital.

In the present case, it appears to have escaped the Court's attention that both the RTC
and the CA found no employment relationship between PSI and Dr. Ampil, and that the
Aganas did not question such finding. In its March 17, 1993 decision, the RTC found "that
defendant doctors were not employees of PSI in its hospital, they being merely
consultants without any employer-employee relationship and in the capacity of
independent contractors."43 The Aganas never questioned such finding.

While in theory a hospital as a juridical entity cannot practice medicine,32 in reality it


utilizes doctors, surgeons and medical practitioners in the conduct of its business of
facilitating medical and surgical treatment.33 Within that reality, three legal relationships
crisscross: (1) between the hospital and the doctor practicing within its premises; (2)
between the hospital and the patient being treated or examined within its premises and
(3) between the patient and the doctor. The exact nature of each relationship determines
the basis and extent of the liability of the hospital for the negligence of the doctor.
Where an employment relationship exists, the hospital may be held vicariously liable
under Article 217634 in relation to Article 218035 of the Civil Code or the principle of
respondeat superior. Even when no employment relationship exists but it is shown that
the hospital holds out to the patient that the doctor is its agent, the hospital may still be
vicariously liable under Article 2176 in relation to Article 143136 and Article 186937 of the
Civil Code or the principle of apparent authority.38 Moreover, regardless of its relationship
with the doctor, the hospital may be held directly liable to the patient for its own
negligence or failure to follow established standard of conduct to which it should conform
as a corporation.39
This Court still employs the "control test" to determine the existence of an employeremployee relationship between hospital and doctor. In Calamba Medical Center, Inc. v.
National Labor Relations Commission, et al.40 it held:
Under the "control test", an employment relationship exists between a physician and a
hospital if the hospital controls both the means and the details of the process by which
the physician is to accomplish his task.
xxx

xxx

PSI, Dr. Ampil and Dr. Fuentes appealed44 from the RTC decision but only on the issues of
negligence, agency and corporate liability. In its September 6, 1996 decision, the CA
mistakenly referred to PSI and Dr. Ampil as employer-employee, but it was clear in its
discussion on the matter that it viewed their relationship as one of mere apparent
agency.45
The Aganas appealed from the CA decision, but only to question the exoneration of Dr.
Fuentes.46 PSI also appealed from the CA decision, and it was then that the issue of
employment, though long settled, was unwittingly resurrected.
In fine, as there was no dispute over the RTC finding that PSI and Dr. Ampil had no
employer-employee relationship, such finding became final and conclusive even to this
Court.47 There was no reason for PSI to have raised it as an issue in its petition. Thus,
whatever discussion on the matter that may have ensued was purely academic.
Nonetheless, to allay the anxiety of the intervenors, the Court holds that, in this particular
instance, the concurrent finding of the RTC and the CA that PSI was not the employer of
Dr. Ampil is correct. Control as a determinative factor in testing the employer-employee
relationship between doctor and hospital under which the hospital could be held
vicariously liable to a patient in medical negligence cases is a requisite fact to be
established by preponderance of evidence. Here, there was insufficient evidence that PSI
exercised the power of control or wielded such power over the means and the details of
the specific process by which Dr. Ampil applied his skills in the treatment of Natividad.
Consequently, PSI cannot be held vicariously liable for the negligence of Dr. Ampil under
the principle of respondeat superior.

xxx

As priorly stated, private respondents maintained specific work-schedules, as determined


by petitioner through its medical director, which consisted of 24-hour shifts totaling forty-

There is, however, ample evidence that the hospital (PSI) held out to the patient
(Natividad)48 that the doctor (Dr. Ampil) was its agent. Present are the two factors that
determine apparent authority: first, the hospital's implied manifestation to the patient
which led the latter to conclude that the doctor was the hospital's agent; and second, the

patients reliance upon the conduct of the hospital and the doctor, consistent with
ordinary care and prudence.49
Enrique testified that on April 2, 1984, he consulted Dr. Ampil regarding the condition of
his wife; that after the meeting and as advised by Dr. Ampil, he "asked [his] wife to go to
Medical City to be examined by [Dr. Ampil]"; and that the next day, April 3, he told his
daughter to take her mother to Dr. Ampil.50 This timeline indicates that it was Enrique
who actually made the decision on whom Natividad should consult and where, and that
the latter merely acceded to it. It explains the testimony of Natividad that she consulted
Dr. Ampil at the instigation of her daughter.51
Moreover, when asked what impelled him to choose Dr. Ampil, Enrique testified:
Atty. Agcaoili
On that particular occasion, April 2, 1984, what was your reason for choosing Dr. Ampil to
contact with in connection with your wife's illness?
A. First, before that, I have known him to be a specialist on that part of the body as a
surgeon, second, I have known him to be a staff member of the Medical City which is a
prominent and known hospital. And third, because he is a neighbor, I expect more than
the usual medical service to be given to us, than his ordinary patients.52 (emphasis
supplied)
Clearly, the decision made by Enrique for Natividad to consult Dr. Ampil was significantly
influenced by the impression that Dr. Ampil was a staff member of Medical City General
Hospital, and that said hospital was well known and prominent. Enrique looked upon Dr.
Ampil not as independent of but as integrally related to Medical City.
PSI's acts tended to confirm and reinforce, rather than negate, Enrique's view. It is of
record that PSI required a "consent for hospital care"53 to be signed preparatory to the
surgery of Natividad. The form reads:

known hospital. After his meeting with Dr. Ampil, Enrique advised his wife Natividad to go
to the Medical City General Hospital to be examined by said doctor, and the hospital acted
in a way that fortified Enrique's belief.
This Court must therefore maintain the ruling that PSI is vicariously liable for the
negligence of Dr. Ampil as its ostensible agent.
Moving on to the next issue, the Court notes that PSI made the following admission in its
Motion for Reconsideration:
51. Clearly, not being an agent or employee of petitioner PSI, PSI [sic] is not liable for Dr.
Ampil's acts during the operation. Considering further that Dr. Ampil was personally
engaged as a doctor by Mrs. Agana, it is incumbent upon Dr. Ampil, as "Captain of the
Ship", and as the Agana's doctor to advise her on what to do with her situation vis-a-vis
the two missing gauzes. In addition to noting the missing gauzes, regular check-ups were
made and no signs of complications were exhibited during her stay at the hospital, which
could have alerted petitioner PSI's hospital to render and provide post-operation services
to and tread on Dr. Ampil's role as the doctor of Mrs. Agana. The absence of negligence of
PSI from the patient's admission up to her discharge is borne by the finding of facts in this
case. Likewise evident therefrom is the absence of any complaint from Mrs. Agana after
her discharge from the hospital which had she brought to the hospital's attention, could
have alerted petitioner PSI to act accordingly and bring the matter to Dr. Ampil's
attention. But this was not the case. Ms. Agana complained ONLY to Drs. Ampil and
Fuentes, not the hospital. How then could PSI possibly do something to fix the negligence
committed by Dr. Ampil when it was not informed about it at all.55 (emphasis supplied)
PSI reiterated its admission when it stated that had Natividad Agana "informed the
hospital of her discomfort and pain, the hospital would have been obliged to act on it."56
The significance of the foregoing statements is critical.

Permission is hereby given to the medical, nursing and laboratory staff of the Medical City
General Hospital to perform such diagnostic procedures and to administer such
medications and treatments as may be deemed necessary or advisable by the physicians
of this hospital for and during the confinement of xxx. (emphasis supplied)

First, they constitute judicial admission by PSI that while it had no power to control the
means or method by which Dr. Ampil conducted the surgery on Natividad Agana, it had
the power to review or cause the review of what may have irregularly transpired within its
walls strictly for the purpose of determining whether some form of negligence may have
attended any procedure done inside its premises, with the ultimate end of protecting its
patients.

By such statement, PSI virtually reinforced the public impression that Dr. Ampil was a
physician of its hospital, rather than one independently practicing in it; that the
medications and treatments he prescribed were necessary and desirable; and that the
hospital staff was prepared to carry them out.1avvphi1

Second, it is a judicial admission that, by virtue of the nature of its business as well as its
prominence57 in the hospital industry, it assumed a duty to "tread on" the "captain of the
ship" role of any doctor rendering services within its premises for the purpose of ensuring
the safety of the patients availing themselves of its services and facilities.

PSI pointed out in its memorandum that Dr. Ampil's hospital affiliation was not the
exclusive basis of the Aganas decision to have Natividad treated in Medical City General
Hospital, meaning that, had Dr. Ampil been affiliated with another hospital, he would still
have been chosen by the Aganas as Natividad's surgeon.54

Third, by such admission, PSI defined the standards of its corporate conduct under the
circumstances of this case, specifically: (a) that it had a corporate duty to Natividad even
after her operation to ensure her safety as a patient; (b) that its corporate duty was not
limited to having its nursing staff note or record the two missing gauzes and (c) that its
corporate duty extended to determining Dr. Ampil's role in it, bringing the matter to his
attention, and correcting his negligence.

The Court cannot speculate on what could have been behind the Aganas decision but
would rather adhere strictly to the fact that, under the circumstances at that time, Enrique
decided to consult Dr. Ampil for he believed him to be a staff member of a prominent and

And finally, by such admission, PSI barred itself from arguing in its second motion for
reconsideration that the concept of corporate responsibility was not yet in existence at
the time Natividad underwent treatment;58 and that if it had any corporate responsibility,
the same was limited to reporting the missing gauzes and did not include "taking an
active step in fixing the negligence committed."59 An admission made in the pleading
cannot be controverted by the party making such admission and is conclusive as to him,
and all proofs submitted by him contrary thereto or inconsistent therewith should be
ignored, whether or not objection is interposed by a party.60
Given the standard of conduct that PSI defined for itself, the next relevant inquiry is
whether the hospital measured up to it.
PSI excuses itself from fulfilling its corporate duty on the ground that Dr. Ampil assumed
the personal responsibility of informing Natividad about the two missing gauzes.61 Dr.
Ricardo Jocson, who was part of the group of doctors that attended to Natividad, testified
that toward the end of the surgery, their group talked about the missing gauzes but Dr.
Ampil assured them that he would personally notify the patient about it.62 Furthermore,
PSI claimed that there was no reason for it to act on the report on the two missing gauzes
because Natividad Agana showed no signs of complications. She did not even inform the
hospital about her discomfort.63
The excuses proffered by PSI are totally unacceptable.
To begin with, PSI could not simply wave off the problem and nonchalantly delegate to Dr.
Ampil the duty to review what transpired during the operation. The purpose of such
review would have been to pinpoint when, how and by whom two surgical gauzes were
mislaid so that necessary remedial measures could be taken to avert any jeopardy to
Natividads recovery. Certainly, PSI could not have expected that purpose to be achieved
by merely hoping that the person likely to have mislaid the gauzes might be able to
retrace his own steps. By its own standard of corporate conduct, PSI's duty to initiate the
review was non-delegable.
While Dr. Ampil may have had the primary responsibility of notifying Natividad about the
missing gauzes, PSI imposed upon itself the separate and independent responsibility of
initiating the inquiry into the missing gauzes. The purpose of the first would have been to
apprise Natividad of what transpired during her surgery, while the purpose of the second
would have been to pinpoint any lapse in procedure that led to the gauze count
discrepancy, so as to prevent a recurrence thereof and to determine corrective measures
that would ensure the safety of Natividad. That Dr. Ampil negligently failed to notify
Natividad did not release PSI from its self-imposed separate responsibility.
Corollary to its non-delegable undertaking to review potential incidents of negligence
committed within its premises, PSI had the duty to take notice of medical records
prepared by its own staff and submitted to its custody, especially when these bear
earmarks of a surgery gone awry. Thus, the record taken during the operation of Natividad
which reported a gauze count discrepancy should have given PSI sufficient reason to
initiate a review. It should not have waited for Natividad to complain.
As it happened, PSI took no heed of the record of operation and consequently did not
initiate a review of what transpired during Natividads operation. Rather, it shirked its
responsibility and passed it on to others to Dr. Ampil whom it expected to inform

Natividad, and to Natividad herself to complain before it took any meaningful step. By its
inaction, therefore, PSI failed its own standard of hospital care. It committed corporate
negligence.
It should be borne in mind that the corporate negligence ascribed to PSI is different from
the medical negligence attributed to Dr. Ampil. The duties of the hospital are distinct from
those of the doctor-consultant practicing within its premises in relation to the patient;
hence, the failure of PSI to fulfill its duties as a hospital corporation gave rise to a direct
liability to the Aganas distinct from that of Dr. Ampil.
All this notwithstanding, we make it clear that PSIs hospital liability based on ostensible
agency and corporate negligence applies only to this case, pro hac vice. It is not intended
to set a precedent and should not serve as a basis to hold hospitals liable for every form
of negligence of their doctors-consultants under any and all circumstances. The ruling is
unique to this case, for the liability of PSI arose from an implied agency with Dr. Ampil and
an admitted corporate duty to Natividad.64
Other circumstances peculiar to this case warrant this ruling,65 not the least of which
being that the agony wrought upon the Aganas has gone on for 26 long years, with
Natividad coming to the end of her days racked in pain and agony. Such wretchedness
could have been avoided had PSI simply done what was logical: heed the report of a
guaze count discrepancy, initiate a review of what went wrong and take corrective
measures to ensure the safety of Nativad. Rather, for 26 years, PSI hemmed and hawed at
every turn, disowning any such responsibility to its patient. Meanwhile, the options left to
the Aganas have all but dwindled, for the status of Dr. Ampil can no longer be
ascertained.66
Therefore, taking all the equities of this case into consideration, this Court believes P15
million would be a fair and reasonable liability of PSI, subject to 12% p.a. interest from the
finality of this resolution to full satisfaction.
WHEREFORE, the second motion for reconsideration is DENIED and the motions for
intervention are NOTED.
Professional Services, Inc. is ORDERED pro hac vice to pay Natividad (substituted by her
children Marcelino Agana III, Enrique Agana, Jr., Emma Agana-Andaya, Jesus Agana and
Raymund Agana) and Enrique Agana the total amount of P15 million, subject to 12% p.a.
interest from the finality of this resolution to full satisfaction.
No further pleadings by any party shall be entertained in this case.
Let the long-delayed entry of judgment be made in this case upon receipt by all
concerned parties of this resolution.
SO ORDERED.

EN BANC
G.R. No. 165279
June 7, 2011
DR. RUBI LI, Petitioner, vs. SPOUSES REYNALDO and LINA SOLIMAN, as parents/heirs of
deceased Angelica Soliman, Respondents.
DECISION
VILLARAMA, JR., J.:
Challenged in this petition for review on certiorari is the Decision1 dated June 15, 2004 as
well as the Resolution2 dated September 1, 2004 of the Court of Appeals (CA) in CA-G.R.
CV No. 58013 which modified the Decision3 dated September 5, 1997 of the Regional Trial
Court of Legazpi City, Branch 8 in Civil Case No. 8904.
The factual antecedents:
On July 7, 1993, respondents 11-year old daughter, Angelica Soliman, underwent a biopsy
of the mass located in her lower extremity at the St. Lukes Medical Center (SLMC).
Results showed that Angelica was suffering from osteosarcoma, osteoblastic type,4 a
high-grade (highly malignant) cancer of the bone which usually afflicts teenage children.
Following this diagnosis and as primary intervention, Angelicas right leg was amputated
by Dr. Jaime Tamayo in order to remove the tumor. As adjuvant treatment to eliminate any
remaining cancer cells, and hence minimize the chances of recurrence and prevent the
disease from spreading to other parts of the patients body (metastasis), chemotherapy
was suggested by Dr. Tamayo. Dr. Tamayo referred Angelica to another doctor at SLMC,
herein petitioner Dr. Rubi Li, a medical oncologist.
On August 18, 1993, Angelica was admitted to SLMC. However, she died on September 1,
1993, just eleven (11) days after the (intravenous) administration of the first cycle of the
chemotherapy regimen. Because SLMC refused to release a death certificate without full
payment of their hospital bill, respondents brought the cadaver of Angelica to the
Philippine National Police (PNP) Crime Laboratory at Camp Crame for post-mortem
examination. The Medico-Legal Report issued by said institution indicated the cause of
death as "Hypovolemic shock secondary to multiple organ hemorrhages and
Disseminated Intravascular Coagulation."5
On the other hand, the Certificate of Death6 issued by SLMC stated the cause of death as
follows:
Immediate cause : a. Osteosarcoma, Status Post AKA
Antecedent cause : b. (above knee amputation)
Underlying cause : c. Status Post Chemotherapy
On February 21, 1994, respondents filed a damage suit7 against petitioner, Dr. Leo
Marbella, Mr. Jose Ledesma, a certain Dr. Arriete and SLMC. Respondents charged them
with negligence and disregard of Angelicas safety, health and welfare by their careless
administration of the chemotherapy drugs, their failure to observe the essential
precautions in detecting early the symptoms of fatal blood platelet decrease and stopping
early on the chemotherapy, which bleeding led to hypovolemic shock that caused
Angelicas untimely demise. Further, it was specifically averred that petitioner assured the
respondents that Angelica would recover in view of 95% chance of healing with

chemotherapy ("Magiging normal na ang anak nyo basta ma-chemo. 95% ang healing")
and when asked regarding the side effects, petitioner mentioned only slight vomiting, hair
loss and weakness ("Magsusuka ng kaunti. Malulugas ang buhok. Manghihina").
Respondents thus claimed that they would not have given their consent to chemotherapy
had petitioner not falsely assured them of its side effects.
In her answer,8 petitioner denied having been negligent in administering the
chemotherapy drugs to Angelica and asserted that she had fully explained to respondents
how the chemotherapy will affect not only the cancer cells but also the patients normal
body parts, including the lowering of white and red blood cells and platelets. She claimed
that what happened to Angelica can be attributed to malignant tumor cells possibly left
behind after surgery. Few as they may be, these have the capacity to compete for
nutrients such that the body becomes so weak structurally (cachexia) and functionally in
the form of lower resistance of the body to combat infection. Such infection becomes
uncontrollable and triggers a chain of events (sepsis or septicemia) that may lead to
bleeding in the form of Disseminated Intravascular Coagulation (DIC), as what the autopsy
report showed in the case of Angelica.
Since the medical records of Angelica were not produced in court, the trial and appellate
courts had to rely on testimonial evidence, principally the declarations of petitioner and
respondents themselves. The following chronology of events was gathered:
On July 23, 1993, petitioner saw the respondents at the hospital after Angelicas surgery
and discussed with them Angelicas condition. Petitioner told respondents that Angelica
should be given two to three weeks to recover from the operation before starting
chemotherapy. Respondents were apprehensive due to financial constraints as Reynaldo
earns only from P70,000.00 to P150,000.00 a year from his jewelry and watch repairing
business.9 Petitioner, however, assured them not to worry about her professional fee and
told them to just save up for the medicines to be used.
Petitioner claimed that she explained to respondents that even when a tumor is removed,
there are still small lesions undetectable to the naked eye, and that adjuvant
chemotherapy is needed to clean out the small lesions in order to lessen the chance of
the cancer to recur. She did not give the respondents any assurance that chemotherapy
will cure Angelicas cancer. During these consultations with respondents, she explained
the following side effects of chemotherapy treatment to respondents: (1) falling hair; (2)
nausea and vomiting; (3) loss of appetite; (4) low count of white blood cells [WBC], red
blood cells [RBC] and platelets; (5) possible sterility due to the effects on Angelicas
ovary; (6) damage to the heart and kidneys; and (7) darkening of the skin especially when
exposed to sunlight. She actually talked with respondents four times, once at the hospital
after the surgery, twice at her clinic and the fourth time when Angelicas mother called
her through long distance.10 This was disputed by respondents who countered that
petitioner gave them assurance that there is 95% chance of healing for Angelica if she
undergoes chemotherapy and that the only side effects were nausea, vomiting and hair
loss.11 Those were the only side-effects of chemotherapy treatment mentioned by
petitioner.12
On July 27, 1993, SLMC discharged Angelica, with instruction from petitioner that she be
readmitted after two or three weeks for the chemotherapy.

On August 18, 1993, respondents brought Angelica to SLMC for chemotherapy, bringing
with them the results of the laboratory tests requested by petitioner: Angelicas chest xray, ultrasound of the liver, creatinine and complete liver function tests.13 Petitioner
proceeded with the chemotherapy by first administering hydration fluids to Angelica.14
The following day, August 19, petitioner began administering three chemotherapy drugs
Cisplatin,15 Doxorubicin16 and Cosmegen17 intravenously. Petitioner was supposedly
assisted by her trainees Dr. Leo Marbella18 and Dr. Grace Arriete.19 In his testimony, Dr.
Marbella denied having any participation in administering the said chemotherapy
drugs.20
On the second day of chemotherapy, August 20, respondents noticed reddish
discoloration on Angelicas face.21 They asked petitioner about it, but she merely
quipped, "Wala yan. Epekto ng gamot."22 Petitioner recalled noticing the skin rashes on
the nose and cheek area of Angelica. At that moment, she entertained the possibility that
Angelica also had systemic lupus and consulted Dr. Victoria Abesamis on the matter.23
On the third day of chemotherapy, August 21, Angelica had difficulty breathing and was
thus provided with oxygen inhalation apparatus. This time, the reddish discoloration on
Angelicas face had extended to her neck, but petitioner dismissed it again as merely the
effect of medicines.24 Petitioner testified that she did not see any discoloration on
Angelicas face, nor did she notice any difficulty in the childs breathing. She claimed that
Angelica merely complained of nausea and was given ice chips.251avvphi1
On August 22, 1993, at around ten oclock in the morning, upon seeing that their child
could not anymore bear the pain, respondents pleaded with petitioner to stop the
chemotherapy. Petitioner supposedly replied: "Dapat 15 Cosmegen pa iyan. Okay, lets
observe. If pwede na, bigyan uli ng chemo." At this point, respondents asked petitioners
permission to bring their child home. Later in the evening, Angelica passed black stool
and reddish urine.26 Petitioner countered that there was no record of blackening of stools
but only an episode of loose bowel movement (LBM). Petitioner also testified that what
Angelica complained of was carpo-pedal spasm, not convulsion or epileptic attack, as
respondents call it (petitioner described it in the vernacular as "naninigas ang kamay at
paa"). She then requested for a serum calcium determination and stopped the
chemotherapy. When Angelica was given calcium gluconate, the spasm and numbness
subsided.27
The following day, August 23, petitioner yielded to respondents request to take Angelica
home. But prior to discharging Angelica, petitioner requested for a repeat serum calcium
determination and explained to respondents that the chemotherapy will be temporarily
stopped while she observes Angelicas muscle twitching and serum calcium level. Takehome medicines were also prescribed for Angelica, with instructions to respondents that
the serum calcium test will have to be repeated after seven days. Petitioner told
respondents that she will see Angelica again after two weeks, but respondents can see
her anytime if any immediate problem arises.28
However, Angelica remained in confinement because while still in the premises of SLMC,
her "convulsions" returned and she also had LBM. Angelica was given oxygen and
administration of calcium continued.29

The next day, August 24, respondents claimed that Angelica still suffered from
convulsions. They also noticed that she had a fever and had difficulty breathing.30
Petitioner insisted it was carpo-pedal spasm, not convulsions. She verified that at around
4:50 that afternoon, Angelica developed difficulty in breathing and had fever. She then
requested for an electrocardiogram analysis, and infused calcium gluconate on the patient
at a "stat dose." She further ordered that Angelica be given Bactrim,31 a synthetic
antibacterial combination drug,32 to combat any infection on the childs body.33
By August 26, Angelica was bleeding through the mouth. Respondents also saw blood on
her anus and urine. When Lina asked petitioner what was happening to her daughter,
petitioner replied, "Bagsak ang platelets ng anak mo." Four units of platelet concentrates
were then transfused to Angelica. Petitioner prescribed Solucortef. Considering that
Angelicas fever was high and her white blood cell count was low, petitioner prescribed
Leucomax. About four to eight bags of blood, consisting of packed red blood cells, fresh
whole blood, or platelet concentrate, were transfused to Angelica. For two days (August
27 to 28), Angelica continued bleeding, but petitioner claimed it was lesser in amount and
in frequency. Petitioner also denied that there were gadgets attached to Angelica at that
time.34
On August 29, Angelica developed ulcers in her mouth, which petitioner said were blood
clots that should not be removed. Respondents claimed that Angelica passed about half a
liter of blood through her anus at around seven oclock that evening, which petitioner
likewise denied.
On August 30, Angelica continued bleeding. She was restless as endotracheal and
nasogastric tubes were inserted into her weakened body. An aspiration of the nasogastric
tube inserted to Angelica also revealed a bloody content. Angelica was given more
platelet concentrate and fresh whole blood, which petitioner claimed improved her
condition. Petitioner told Angelica not to remove the endotracheal tube because this may
induce further bleeding.35 She was also transferred to the intensive care unit to avoid
infection.
The next day, respondents claimed that Angelica became hysterical, vomited blood and
her body turned black. Part of Angelicas skin was also noted to be shredding by just
rubbing cotton on it. Angelica was so restless she removed those gadgets attached to her,
saying "Ayaw ko na"; there were tears in her eyes and she kept turning her head.
Observing her daughter to be at the point of death, Lina asked for a doctor but the latter
could not answer her anymore.36 At this time, the attending physician was Dr. Marbella
who was shaking his head saying that Angelicas platelets were down and respondents
should pray for their daughter. Reynaldo claimed that he was introduced to a pediatrician
who took over his daughters case, Dr. Abesamis who also told him to pray for his
daughter. Angelica continued to have difficulty in her breathing and blood was being
suctioned from her stomach. A nurse was posted inside Angelicas room to assist her
breathing and at one point they had to revive Angelica by pumping her chest. Thereafter,
Reynaldo claimed that Angelica already experienced difficulty in urinating and her bowel
consisted of blood-like fluid. Angelica requested for an electric fan as she was in pain.
Hospital staff attempted to take blood samples from Angelica but were unsuccessful
because they could not even locate her vein. Angelica asked for a fruit but when it was
given to her, she only smelled it. At this time, Reynaldo claimed he could not find either
petitioner or Dr. Marbella. That night, Angelica became hysterical and started removing
those gadgets attached to her. At three oclock in the morning of September 1, a priest

came and they prayed before Angelica expired. Petitioner finally came back and
supposedly told respondents that there was "malfunction" or bogged-down machine.37
By petitioners own account, Angelica was merely irritable that day (August 31). Petitioner
noted though that Angelicas skin was indeed sloughing off.38 She stressed that at 9:30 in
the evening, Angelica pulled out her endotracheal tube.39 On September 1, exactly two
weeks after being admitted at SLMC for chemotherapy, Angelica died.40 The cause of
death, according to petitioner, was septicemia, or overwhelming infection, which caused
Angelicas other organs to fail.41 Petitioner attributed this to the patients poor defense
mechanism brought about by the cancer itself.42
While he was seeking the release of Angelicas cadaver from SLMC, Reynaldo claimed that
petitioner acted arrogantly and called him names. He was asked to sign a promissory note
as he did not have cash to pay the hospital bill.43
Respondents also presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-Legal Officer
of the PNP-Crime Laboratory who conducted the autopsy on Angelicas cadaver, and Dr.
Melinda Vergara Balmaceda who is a Medical Specialist employed at the Department of
Health (DOH) Operations and Management Services.
Testifying on the findings stated in her medico-legal report, Dr. Vergara noted the
following: (1) there were fluids recovered from the abdominal cavity, which is not normal,
and was due to hemorrhagic shock secondary to bleeding; (2) there was hemorrhage at
the left side of the heart; (3) bleeding at the upper portion of and areas adjacent to, the
esophagus; (4) lungs were heavy with bleeding at the back and lower portion, due to
accumulation of fluids; (4) yellowish discoloration of the liver; (5) kidneys showed
appearance of facial shock on account of hemorrhages; and (6) reddishness on external
surface of the spleen. All these were the end result of "hypovolemic shock secondary to
multiple organ hemorrhages and disseminated intravascular coagulation." Dr. Vergara
opined that this can be attributed to the chemical agents in the drugs given to the victim,
which caused platelet reduction resulting to bleeding sufficient to cause the victims
death. The time lapse for the production of DIC in the case of Angelica (from the time of
diagnosis of sarcoma) was too short, considering the survival rate of about 3 years. The
witness conceded that the victim will also die of osteosarcoma even with amputation or
chemotherapy, but in this case Angelicas death was not caused by osteosarcoma. Dr.
Vergara admitted that she is not a pathologist but her statements were based on the
opinion of an oncologist whom she had interviewed. This oncologist supposedly said that
if the victim already had DIC prior to the chemotherapy, the hospital staff could have
detected it.44
On her part, Dr. Balmaceda declared that it is the physicians duty to inform and explain
to the patient or his relatives every known side effect of the procedure or therapeutic
agents to be administered, before securing the consent of the patient or his relatives to
such procedure or therapy. The physician thus bases his assurance to the patient on his
personal assessment of the patients condition and his knowledge of the general effects of
the agents or procedure that will be allowed on the patient. Dr. Balmaceda stressed that
the patient or relatives must be informed of all known side effects based on studies and
observations, even if such will aggravate the patients condition.45
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelicas lower extremity,
testified for the defendants. He explained that in case of malignant tumors, there is no

guarantee that the ablation or removal of the amputated part will completely cure the
cancer. Thus, surgery is not enough. The mortality rate of osteosarcoma at the time of
modern chemotherapy and early diagnosis still remains at 80% to 90%. Usually, deaths
occur from metastasis, or spread of the cancer to other vital organs like the liver, causing
systemic complications. The modes of therapy available are the removal of the primary
source of the cancerous growth and then the residual cancer cells or metastasis should be
treated with chemotherapy. Dr. Tamayo further explained that patients with osteosarcoma
have poor defense mechanism due to the cancer cells in the blood stream. In the case of
Angelica, he had previously explained to her parents that after the surgical procedure,
chemotherapy is imperative so that metastasis of these cancer cells will hopefully be
addressed. He referred the patient to petitioner because he felt that petitioner is a
competent oncologist. Considering that this type of cancer is very aggressive and will
metastasize early, it will cause the demise of the patient should there be no early
intervention (in this case, the patient developed sepsis which caused her death). Cancer
cells in the blood cannot be seen by the naked eye nor detected through bone scan. On
cross-examination, Dr. Tamayo stated that of the more than 50 child patients who had
osteogenic sarcoma he had handled, he thought that probably all of them died within six
months from amputation because he did not see them anymore after follow-up; it is either
they died or had seen another doctor.46
In dismissing the complaint, the trial court held that petitioner was not liable for damages
as she observed the best known procedures and employed her highest skill and
knowledge in the administration of chemotherapy drugs on Angelica but despite all efforts
said patient died. It cited the testimony of Dr. Tamayo who testified that he considered
petitioner one of the most proficient in the treatment of cancer and that the patient in this
case was afflicted with a very aggressive type of cancer necessitating chemotherapy as
adjuvant treatment. Using the standard of negligence laid down in Picart v. Smith,47 the
trial court declared that petitioner has taken the necessary precaution against the adverse
effect of chemotherapy on the patient, adding that a wrong decision is not by itself
negligence. Respondents were ordered to pay their unpaid hospital bill in the amount of
P139,064.43.48
Respondents appealed to the CA which, while concurring with the trial courts finding that
there was no negligence committed by the petitioner in the administration of
chemotherapy treatment to Angelica, found that petitioner as her attending physician
failed to fully explain to the respondents all the known side effects of chemotherapy. The
appellate court stressed that since the respondents have been told of only three side
effects of chemotherapy, they readily consented thereto. Had petitioner made known to
respondents those other side effects which gravely affected their child -- such as carpopedal spasm, sepsis, decrease in the blood platelet count, bleeding, infections and
eventual death -- respondents could have decided differently or adopted a different
course of action which could have delayed or prevented the early death of their child.
The CA thus declared:
Plaintiffs-appellants child was suffering from a malignant disease. The attending
physician recommended that she undergo chemotherapy treatment after surgery in order
to increase her chances of survival. Appellants consented to the chemotherapy treatment
because they believed in Dr. Rubi Lis representation that the deceased would have a
strong chance of survival after chemotherapy and also because of the representation of
appellee Dr. Rubi Li that there were only three possible side-effects of the treatment.

However, all sorts of painful side-effects resulted from the treatment including the
premature death of Angelica. The appellants were clearly and totally unaware of these
other side-effects which manifested only during the chemotherapy treatment. This was
shown by the fact that every time a problem would take place regarding Angelicas
condition (like an unexpected side-effect manifesting itself), they would immediately seek
explanation from Dr. Rubi Li. Surely, those unexpected side-effects culminating in the loss
of a love[d] one caused the appellants so much trouble, pain and suffering.
On this point therefore, [w]e find defendant-appellee Dr. Rubi Li negligent which would
entitle plaintiffs-appellants to their claim for damages.
xxxx
WHEREFORE, the instant appeal is hereby GRANTED. Accordingly, the assailed decision is
hereby modified to the extent that defendant-appellee Dr. Rubi Li is ordered to pay the
plaintiffs-appellants the following amounts:

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

1. Actual damages of P139,064.43, plus P9,828.00 for funeral expenses;

3. Exemplary damages of P50,000.00;

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

4. Attorneys fee of P30,000.00.

The petition is meritorious.

SO ORDERED.49 (Emphasis supplied.)

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

2. Moral damages of P200,000.00;

Petitioner filed a motion for partial reconsideration which the appellate court denied.
Hence, this petition.
Petitioner assails the CA in finding her guilty of negligence in not explaining to the
respondents all the possible side effects of the chemotherapy on their child, and in
holding her liable for actual, moral and exemplary damages and attorneys fees. Petitioner
emphasized that she was not negligent in the pre-chemotherapy procedures and in the
administration of chemotherapy treatment to Angelica.
On her supposed non-disclosure of all possible side effects of chemotherapy, including
death, petitioner argues that it was foolhardy to imagine her to be allknowing/omnipotent. While the theoretical side effects of chemotherapy were explained
by her to the respondents, as these should be known to a competent doctor, petitioner
cannot possibly predict how a particular patients genetic make-up, state of mind, general
health and body constitution would respond to the treatment. These are obviously
dependent on too many known, unknown and immeasurable variables, thus requiring that
Angelica be, as she was, constantly and closely monitored during the treatment. Petitioner
asserts that she did everything within her professional competence to attend to the
medical needs of Angelica.
Citing numerous trainings, distinctions and achievements in her field and her current
position as co-director for clinical affairs of the Medical Oncology, Department of Medicine
of SLMC, petitioner contends that in the absence of any clear showing or proof, she

This Court has recognized that medical negligence cases are best proved by opinions of
expert witnesses belonging in the same general neighborhood and in the same general
line of practice as defendant physician or surgeon. The deference of courts to the expert
opinion of qualified physicians stems from the formers realization that the latter possess
unusual technical skills which laymen in most instances are incapable of intelligently
evaluating, hence the indispensability of expert testimonies.52
In this case, both the trial and appellate courts concurred in finding that the alleged
negligence of petitioner in the administration of chemotherapy drugs to respondents
child was not proven considering that Drs. Vergara and Balmaceda, not being oncologists
or cancer specialists, were not qualified to give expert opinion as to whether petitioners
lack of skill, knowledge and professional competence in failing to observe the standard of
care in her line of practice was the proximate cause of the patients death. Furthermore,
respondents case was not at all helped by the non-production of medical records by the
hospital (only the biopsy result and medical bills were submitted to the court).
Nevertheless, the CA found petitioner liable for her failure to inform the respondents on all
possible side effects of chemotherapy before securing their consent to the said treatment.

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


goes far back into English common law. As early as 1767, doctors were charged with the
tort of "battery" (i.e., an unauthorized physical contact with a patient) if they had not
gained the consent of their patients prior to performing a surgery or procedure. In the
United States, the seminal case was Schoendorff v. Society of New York Hospital53 which
involved unwanted treatment performed by a doctor. Justice Benjamin Cardozos oftquoted opinion upheld the basic right of a patient to give consent to any medical
procedure or treatment: "Every human being of adult years and sound mind has a right to
determine what shall be done with his own body; and a surgeon who performs an
operation without his patients consent, commits an assault, for which he is liable in
damages."54 From a purely ethical norm, informed consent evolved into a general
principle of law that a physician has a duty to disclose what a reasonably prudent
physician in the medical community in the exercise of reasonable care would disclose to
his patient as to whatever grave risks of injury might be incurred from a proposed course
of treatment, so that a patient, exercising ordinary care for his own welfare, and faced
with a choice of undergoing the proposed treatment, or alternative treatment, or none at
all, may intelligently exercise his judgment by reasonably balancing the probable risks
against the probable benefits.55
Subsequently, in Canterbury v. Spence56 the court observed that the duty to disclose
should not be limited to medical usage as to arrogate the decision on revelation to the
physician alone. Thus, respect for the patients right of self-determination on particular
therapy demands a standard set by law for physicians rather than one which physicians
may or may not impose upon themselves.57 The scope of disclosure is premised on the
fact that patients ordinarily are persons unlearned in the medical sciences. Proficiency in
diagnosis and therapy is not the full measure of a physicians responsibility. It is also his
duty to warn of the dangers lurking in the proposed treatment and to impart information
which the patient has every right to expect. Indeed, the patients reliance upon the
physician is a trust of the kind which traditionally has exacted obligations beyond those
associated with armslength transactions.58 The physician is not expected to give the
patient a short medical education, the disclosure rule only requires of him a reasonable
explanation, which means generally informing the patient in nontechnical terms as to
what is at stake; the therapy alternatives open to him, the goals expectably to be
achieved, and the risks that may ensue from particular treatment or no treatment.59 As
to the issue of demonstrating what risks are considered material necessitating disclosure,
it was held that experts are unnecessary to a showing of the materiality of a risk to a
patients decision on treatment, or to the reasonably, expectable effect of risk disclosure
on the decision. Such unrevealed risk that should have been made known must further
materialize, for otherwise the omission, however unpardonable, is without legal
consequence. And, as in malpractice actions generally, there must be a causal
relationship between the physicians failure to divulge and damage to the patient.60
Reiterating the foregoing considerations, Cobbs v. Grant61 deemed it as integral part of
physicians overall obligation to patient, the duty of reasonable disclosure of available
choices with respect to proposed therapy and of dangers inherently and potentially
involved in each. However, the physician is not obliged to discuss relatively minor risks
inherent in common procedures when it is common knowledge that such risks inherent in
procedure of very low incidence. Cited as exceptions to the rule that the patient should
not be denied the opportunity to weigh the risks of surgery or treatment are emergency
cases where it is evident he cannot evaluate data, and where the patient is a child or

incompetent.62 The court thus concluded that the patients right of self-decision can only
be effectively exercised if the patient possesses adequate information to enable him in
making an intelligent choice. The scope of the physicians communications to the patient,
then must be measured by the patients need, and that need is whatever information is
material to the decision. The test therefore for determining whether a potential peril must
be divulged is its materiality to the patients decision.63
Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that for
liability of the physician for failure to inform patient, there must be causal relationship
between physicians failure to inform and the injury to patient and such connection arises
only if it is established that, had revelation been made, consent to treatment would not
have been given.
There are four essential elements a plaintiff must prove in a malpractice action based
upon the doctrine of informed consent: "(1) the physician had a duty to disclose material
risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and
proximate result of the failure to disclose, the patient consented to treatment she
otherwise would not have consented to; and (4) plaintiff was injured by the proposed
treatment." The gravamen in an informed consent case requires the plaintiff to "point to
significant undisclosed information relating to the treatment which would have altered her
decision to undergo it.64
Examining the evidence on record, we hold that there was adequate disclosure of material
risks inherent in the chemotherapy procedure performed with the consent of Angelicas
parents. Respondents could not have been unaware in the course of initial treatment and
amputation of Angelicas lower extremity, that her immune system was already weak on
account of the malignant tumor in her knee. When petitioner informed the respondents
beforehand of the side effects of chemotherapy which includes lowered counts of white
and red blood cells, decrease in blood platelets, possible kidney or heart damage and skin
darkening, there is reasonable expectation on the part of the doctor that the respondents
understood very well that the severity of these side effects will not be the same for all
patients undergoing the procedure. In other words, by the nature of the disease itself,
each patients reaction to the chemical agents even with pre-treatment laboratory tests
cannot be precisely determined by the physician. That death can possibly result from
complications of the treatment or the underlying cancer itself, immediately or sometime
after the administration of chemotherapy drugs, is a risk that cannot be ruled out, as with
most other major medical procedures, but such conclusion can be reasonably drawn from
the general side effects of chemotherapy already disclosed.
As a physician, petitioner can reasonably expect the respondents to have considered the
variables in the recommended treatment for their daughter afflicted with a lifethreatening illness. On the other hand, it is difficult to give credence to respondents claim
that petitioner told them of 95% chance of recovery for their daughter, as it was unlikely
for doctors like petitioner who were dealing with grave conditions such as cancer to have
falsely assured patients of chemotherapys success rate. Besides, informed consent laws
in other countries generally require only a reasonable explanation of potential harms, so
specific disclosures such as statistical data, may not be legally necessary.65
The element of ethical duty to disclose material risks in the proposed medical treatment
cannot thus be reduced to one simplistic formula applicable in all instances. Further, in a
medical malpractice action based on lack of informed consent, "the plaintiff must prove

both the duty and the breach of that duty through expert testimony.66 Such expert
testimony must show the customary standard of care of physicians in the same practice
as that of the defendant doctor.67
In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medical
Specialist of the DOHs Operational and Management Services charged with receiving
complaints against hospitals, does not qualify as expert testimony to establish the
standard of care in obtaining consent for chemotherapy treatment. In the absence of
expert testimony in this regard, the Court feels hesitant in defining the scope of
mandatory disclosure in cases of malpractice based on lack of informed consent, much
less set a standard of disclosure that, even in foreign jurisdictions, has been noted to be
an evolving one.
As society has grappled with the juxtaposition between personal autonomy and the
medical profession's intrinsic impetus to cure, the law defining "adequate" disclosure has
undergone a dynamic evolution. A standard once guided solely by the ruminations of
physicians is now dependent on what a reasonable person in the patients position
regards as significant. This change in perspective is especially important as medical
breakthroughs move practitioners to the cutting edge of technology, ever encountering
new and heretofore unimagined treatments for currently incurable diseases or ailments.
An adaptable standard is needed to account for this constant progression.
Reasonableness analyses permeate our legal system for the very reason that they are
determined by social norms, expanding and contracting with the ebb and flow of societal
evolution.
As we progress toward the twenty-first century, we now realize that the legal standard of
disclosure is not subject to construction as a categorical imperative. Whatever formulae or
processes we adopt are only useful as a foundational starting point; the particular quality
or quantity of disclosure will remain inextricably bound by the facts of each case.
Nevertheless, juries that ultimately determine whether a physician properly informed a
patient are inevitably guided by what they perceive as the common expectation of the
medical consumer"a reasonable person in the patients position when deciding to
accept or reject a recommended medical procedure."68 (Emphasis supplied.)
WHEREFORE, the petition for review on certiorari is GRANTED. The Decision dated June
15, 2004 and the Resolution dated September 1, 2004 of the Court of Appeals in CA-G.R.
CV No. 58013 are SET ASIDE.
The Decision dated September 5, 1997 of the Regional Trial Court of Legazpi City, Branch
8, in Civil Case No. 8904 is REINSTATED and UPHELD.
No costs.
SO ORDERED.

SECOND DIVISION
G.R. No. 177407
February 9, 2011
NACHURA, J.:
RICO ROMMEL ATIENZA, Petitioner, vs. BOARD OF MEDICINE and EDITHA SIOSON,
Respondents.

"EXHIBIT C the certified photocopy of the X-ray request form dated March 16, 1996, which is
also marked as Annex 4, on which are handwritten entries which are the interpretation of the
results of the examination.

Before us is a petition for review on certiorari under Rule 45 of the Rules of Court, assailing the
Decision1 dated September 22, 2006 of the Court of Appeals (CA) in CA-G.R. SP No. 87755. The
CA dismissed the petition for certiorari filed by petitioner Rico Rommel Atienza (Atienza), which,
in turn, assailed the Orders2 issued by public respondent Board of Medicine (BOM) in
Administrative Case No. 1882.

"EXHIBIT D the certified photocopy of the X-ray request form dated May 20, 1999, which is
also marked as Annex 16, on which are handwritten entries which are the interpretation of the
results of the examination. Incidentally, this exhibit appears to be the draft of the typewritten
final report of the same examination which is the document appended as Annexes 4 and 1
respectively to the counter-affidavits filed by x x x Dr. Judd dela Vega and Dr. Pedro Lantin, III in
answer to the complaint. In the case of Dr. dela Vega however, the document which is marked
as Annex 4 is not a certified photocopy, while in the case of Dr. Lantin, the document marked
as Annex 1 is a certified photocopy. Both documents are of the same date and typewritten
contents are the same as that which are written on Exhibit D.

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


Due to her lumbar pains, private respondent Editha Sioson went to Rizal Medical Center (RMC)
for check-up on February 4, 1995. Sometime in 1999, due to the same problem, she was
referred to Dr. Pedro Lantin III of RMC who, accordingly, ordered several diagnostic laboratory
tests. The tests revealed that her right kidney is normal. It was ascertained, however, that her
left kidney is non-functioning and non-visualizing. Thus, she underwent kidney operation in
September, 1999.
On February 18, 2000, private respondents husband, Romeo Sioson (as complainant), filed a
complaint for gross negligence and/or incompetence before the [BOM] against the doctors who
allegedly participated in the fateful kidney operation, namely: Dr. Judd dela Vega, Dr. Pedro
Lantin, III, Dr. Gerardo Antonio Florendo and petitioner Rico Rommel Atienza.
It was alleged in the complaint that the gross negligence and/or incompetence committed by
the said doctors, including petitioner, consists of the removal of private respondents fully
functional right kidney, instead of the left non-functioning and non-visualizing kidney.
The complaint was heard by the [BOM]. After complainant Romeo Sioson presented his
evidence, private respondent Editha Sioson, also named as complainant there, filed her formal
offer of documentary evidence. Attached to the formal offer of documentary evidence are her
Exhibits "A" to "D," which she offered for the purpose of proving that her kidneys were both in
their proper anatomical locations at the time she was operated. She described her exhibits, as
follows:
"EXHIBIT A the certified photocopy of the X-ray Request form dated December 12, 1996,
which is also marked as Annex 2 as it was actually originally the Annex to x x x Dr. Pedro
Lantin, IIIs counter affidavit filed with the City Prosecutor of Pasig City in connection with the
criminal complaint filed by [Romeo Sioson] with the said office, on which are handwritten
entries which are the interpretation of the results of the ultrasound examination. Incidentally,
this exhibit happens to be the same as or identical to the certified photocopy of the document
marked as Annex 2 to the Counter-Affidavit dated March 15, 2000, filed by x x x Dr. Pedro
Lantin, III, on May 4, 2000, with this Honorable Board in answer to this complaint;
"EXHIBIT B the certified photo copy of the X-ray request form dated January 30, 1997, which
is also marked as Annex 3 as it was actually likewise originally an Annex to x x x Dr. Pedro
Lantin, IIIs counter-affidavit filed with the Office of the City Prosecutor of Pasig City in
connection with the criminal complaint filed by the herein complainant with the said office, on
which are handwritten entries which are the interpretation of the results of the examination.
Incidentally, this exhibit happens to be also the same as or identical to the certified photo copy
of the document marked as Annex 3 which is likewise dated January 30, 1997, which is
appended as such Annex 3 to the counter-affidavit dated March 15, 2000, filed by x x x Dr.
Pedro Lantin, III on May 4, 2000, with this Honorable Board in answer to this complaint.

Petitioner filed his comments/objections to private respondents [Editha Siosons] formal offer
of exhibits. He alleged that said exhibits are inadmissible because the same are mere
photocopies, not properly identified and authenticated, and intended to establish matters
which are hearsay. He added that the exhibits are incompetent to prove the purpose for which
they are offered.
Dispositions of the Board of Medicine
The formal offer of documentary exhibits of private respondent [Editha Sioson] was admitted by
the [BOM] per its Order dated May 26, 2004. It reads:
"The Formal Offer of Documentary Evidence of [Romeo Sioson], the Comments/Objections of
[herein petitioner] Atienza, [therein respondents] De la Vega and Lantin, and the Manifestation
of [therein] respondent Florendo are hereby ADMITTED by the [BOM] for whatever purpose they
may serve in the resolution of this case.
"Let the hearing be set on July 19, 2004 all at 1:30 p.m. for the reception of the evidence of the
respondents.
"SO ORDERED."
Petitioner moved for reconsideration of the abovementioned Order basically on the same
reasons stated in his comment/objections to the formal offer of exhibits.
The [BOM] denied the motion for reconsideration of petitioner in its Order dated October 8,
2004. It concluded that it should first admit the evidence being offered so that it can determine
its probative value when it decides the case. According to the Board, it can determine whether
the evidence is relevant or not if it will take a look at it through the process of admission. x x
x.3
Disagreeing with the BOM, and as previously adverted to, Atienza filed a petition for certiorari
with the CA, assailing the BOMs Orders which admitted Editha Siosons (Edithas) Formal Offer
of Documentary Evidence. The CA dismissed the petition for certiorari for lack of merit.
Hence, this recourse positing the following issues:
I. PROCEDURAL ISSUE: WHETHER PETITIONER ATIENZA AVAILED OF THE PROPER REMEDY WHEN
HE FILED THE PETITION FOR CERTIORARI DATED 06 DECEMBER 2004 WITH THE COURT OF
APPEALS UNDER RULE 65 OF THE RULES OF COURT TO ASSAIL THE ORDERS DATED 26 MAY
2004 AND 08 OCTOBER 2004 OF RESPONDENT BOARD.

II. SUBSTANTIVE ISSUE: WHETHER THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE
ERROR AND DECIDED A QUESTION OF SUBSTANCE IN A WAY NOT IN ACCORDANCE WITH LAW
AND THE APPLICABLE DECISIONS OF THE HONORABLE COURT WHEN IT UPHELD THE
ADMISSION OF INCOMPETENT AND INADMISSIBLE EVIDENCE BY RESPONDENT BOARD, WHICH
CAN RESULT IN THE DEPRIVATION OF PROFESSIONAL LICENSE A PROPERTY RIGHT OR ONES
LIVELIHOOD.4
We find no reason to depart from the ruling of the CA.
Petitioner is correct when he asserts that a petition for certiorari is the proper remedy to assail
the Orders of the BOM, admitting in evidence the exhibits of Editha. As the assailed Orders
were interlocutory, these cannot be the subject of an appeal separate from the judgment that
completely or finally disposes of the case.5 At that stage, where there is no appeal, or any
plain, speedy, and adequate remedy in the ordinary course of law, the only and remaining
remedy left to petitioner is a petition for certiorari under Rule 65 of the Rules of Court on the
ground of grave abuse of discretion amounting to lack or excess of jurisdiction.
However, the writ of certiorari will not issue absent a showing that the BOM has acted without
or in excess of jurisdiction or with grave abuse of discretion. Embedded in the CAs finding that
the BOM did not exceed its jurisdiction or act in grave abuse of discretion is the issue of
whether the exhibits of Editha contained in her Formal Offer of Documentary Evidence are
inadmissible.
Petitioner argues that the exhibits formally offered in evidence by Editha: (1) violate the best
evidence rule; (2) have not been properly identified and authenticated; (3) are completely
hearsay; and (4) are incompetent to prove their purpose. Thus, petitioner contends that the
exhibits are inadmissible evidence.
We disagree.
To begin with, it is well-settled that the rules of evidence are not strictly applied in proceedings
before administrative bodies such as the BOM.6 Although trial courts are enjoined to observe
strict enforcement of the rules of evidence,7 in connection with evidence which may appear to
be of doubtful relevancy, incompetency, or admissibility, we have held that:
[I]t is the safest policy to be liberal, not rejecting them on doubtful or technical grounds, but
admitting them unless plainly irrelevant, immaterial or incompetent, for the reason that their
rejection places them beyond the consideration of the court, if they are thereafter found
relevant or competent; on the other hand, their admission, if they turn out later to be irrelevant
or incompetent, can easily be remedied by completely discarding them or ignoring them.8
From the foregoing, we emphasize the distinction between the admissibility of evidence and
the probative weight to be accorded the same pieces of evidence. PNOC Shipping and Transport
Corporation v. Court of Appeals9 teaches:
Admissibility of evidence refers to the question of whether or not the circumstance (or
evidence) is to be considered at all. On the other hand, the probative value of evidence refers
to the question of whether or not it proves an issue.
Second, petitioners insistence that the admission of Edithas exhibits violated his substantive
rights leading to the loss of his medical license is misplaced. Petitioner mistakenly relies on
Section 20, Article I of the Professional Regulation Commission Rules of Procedure, which reads:

Section 20. Administrative investigation shall be conducted in accordance with these Rules. The
Rules of Court shall only apply in these proceedings by analogy or on a suppletory character
and whenever practicable and convenient. Technical errors in the admission of evidence which
do not prejudice the substantive rights of either party shall not vitiate the proceedings.10
As pointed out by the appellate court, the admission of the exhibits did not prejudice the
substantive rights of petitioner because, at any rate, the fact sought to be proved thereby, that
the two kidneys of Editha were in their proper anatomical locations at the time she was
operated on, is presumed under Section 3, Rule 131 of the Rules of Court:
Sec. 3. Disputable presumptions. The following presumptions are satisfactory if
uncontradicted, but may be contradicted and overcome by other evidence:
xxxx
(y) That things have happened according to the ordinary course of nature and the ordinary
habits of life.
The exhibits are certified photocopies of X-ray Request Forms dated December 12, 1996,
January 30, 1997, March 16, 1996, and May 20, 1999, filed in connection with Edithas medical
case. The documents contain handwritten entries interpreting the results of the examination.
These exhibits were actually attached as annexes to Dr. Pedro Lantin IIIs counter affidavit filed
with the Office of the City Prosecutor of Pasig City, which was investigating the criminal
complaint for negligence filed by Editha against the doctors of Rizal Medical Center (RMC) who
handled her surgical procedure. To lay the predicate for her case, Editha offered the exhibits in
evidence to prove that her "kidneys were both in their proper anatomical locations at the time"
of her operation.
The fact sought to be established by the admission of Edithas exhibits, that her "kidneys were
both in their proper anatomical locations at the time" of her operation, need not be proved as it
is covered by mandatory judicial notice.11
Unquestionably, the rules of evidence are merely the means for ascertaining the truth
respecting a matter of fact.12 Thus, they likewise provide for some facts which are established
and need not be proved, such as those covered by judicial notice, both mandatory and
discretionary.13 Laws of nature involving the physical sciences, specifically biology,14 include
the structural make-up and composition of living things such as human beings. In this case, we
may take judicial notice that Edithas kidneys before, and at the time of, her operation, as with
most human beings, were in their proper anatomical locations.
Third, contrary to the assertion of petitioner, the best evidence rule is inapplicable.1awphil
Section 3 of Rule 130 provides:
1. Best Evidence Rule
Sec. 3. Original document must be produced; exceptions. When the subject of inquiry is the
contents of a document, no evidence shall be admissible other than the original document
itself, except in the following cases:
(a) When the original has been lost or destroyed, or cannot be produced in court, without bad
faith on the part of the offeror;
(b) When the original is in the custody or under the control of the party against whom the
evidence is offered, and the latter fails to produce it after reasonable notice;
(c) When the original consists of numerous accounts or other documents which cannot be
examined in court without great loss of time and the fact sought to be established from them is
only the general result of the whole; and

(d) When the original is a public record in the custody of a public officer or is recorded in a
public office.
The subject of inquiry in this case is whether respondent doctors before the BOM are liable for
gross negligence in removing the right functioning kidney of Editha instead of the left nonfunctioning kidney, not the proper anatomical locations of Edithas kidneys. As previously
discussed, the proper anatomical locations of Edithas kidneys at the time of her operation at
the RMC may be established not only through the exhibits offered in evidence.
Finally, these exhibits do not constitute hearsay evidence of the anatomical locations of
Edithas kidneys. To further drive home the point, the anatomical positions, whether left or
right, of Edithas kidneys, and the removal of one or both, may still be established through a
belated ultrasound or x-ray of her abdominal area.
In fact, the introduction of secondary evidence, such as copies of the exhibits, is allowed.15
Witness Dr. Nancy Aquino testified that the Records Office of RMC no longer had the originals of
the exhibits "because [it] transferred from the previous building, x x x to the new building."16
Ultimately, since the originals cannot be produced, the BOM properly admitted Edithas formal
offer of evidence and, thereafter, the BOM shall determine the probative value thereof when it
decides the case.
WHEREFORE, the petition is DENIED. The Decision of the Court of Appeals in CA-G.R. SP No.
87755 is AFFIRMED. Costs against petitioner. SO ORDERED.

G.R. No. 187926


February 15, 2012
Dr. EMMANUEL JARCIA, Jr. and Dr. MARILOU BASTAN, Petitioners, vs. PEOPLE OF THE
PHILIPPINES, Respondent.
DECISION
MENDOZA, J.:

It appearing that Dr. Pamittan has not been apprehended nor voluntarily surrendered
despite warrant issued for her arrest, let warrant be issued for her arrest and the case
against her be ARCHIVED, to be reinstated upon her apprehension.

Even early on, patients have consigned their lives to the skill of their doctors. Time and
again, it can be said that the most important goal of the medical profession is the
preservation of life and health of the people. Corollarily, when a physician departs from
his sacred duty and endangers instead the life of his patient, he must be made liable for
the resulting injury. This Court, as this case would show, cannot and will not let the act go
unpunished.1

The RTC explained:

This is a petition for review under Rule 45 of the Rules of Court challenging the August 29,
2008 Decision2 of the Court of Appeals (CA), and its May 19, 2009 Resolution3 in CA-G.R.
CR No. 29559, dismissing the appeal and affirming in toto the June 14, 2005 Decision4 of
the Regional Trial Court, Branch 43, Manila (RTC), finding the accused guilty beyond
reasonable doubt of simple imprudence resulting to serious physical injuries.
THE FACTS

SO ORDERED.6

After a thorough and in depth evaluation of the evidence adduced by the prosecution and
the defense, this court finds that the evidence of the prosecution is the more credible,
concrete and sufficient to create that moral certainty in the mind of the Court that
accused herein [are] criminally responsible. The Court believes that accused are negligent
when both failed to exercise the necessary and reasonable prudence in ascertaining the
extent of injury of Alfonso Santiago, Jr.
However, the negligence exhibited by the two doctors does not approximate negligence of
a reckless nature but merely amounts to simple imprudence. Simple imprudence consists
in the lack of precaution displayed in those cases in which the damage impending to be
caused is not the immediate nor the danger clearly manifest. The elements of simple
imprudence are as follows.

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

1. that there is lack of precaution on the part of the offender; and

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

This Court holds concurrently and finds the foregoing circumstances sufficient to sustain a
judgment of conviction against the accused-appellants for the crime of simple imprudence
resulting in serious physical injuries. The elements of imprudence are: (1) that the
offender does or fails to do an act; (2) that the doing or the failure to do that act is
voluntary; (3) that it be without malice; (4) that material damage results from the
imprudence; and (5) that there is inexcusable lack of precaution on the part of the
offender, taking into consideration his employment or occupation, degree of intelligence,
physical condition, and other circumstances regarding persons, time and place.

On June 14, 2005, the RTC found the petitioners guilty beyond reasonable doubt of the
crime of Simple Imprudence Resulting to Serious Physical Injuries. The decretal portion of
the RTC decision reads:
WHEREFORE, premises considered, the Court finds accused DR. EMMANUEL JARCIA, JR.
and DR. MARILOU BASTAN GUILTY beyond reasonable doubt of the crime of SIMPLE
IMPRUDENCE RESULTING TO SERIOUS PHYSICAL INJURIES and are hereby sentenced to
suffer the penalty of ONE (1) MONTH and ONE (1) DAY to TWO (2) MONTHS and to
indemnify MRS. BELINDA SANTIAGO the amount of P 3,850.00 representing medical
expenses without subsidiary imprisonment in case of insolvency and to pay the costs.

2. that the damage impending to be caused is not immediate of the danger is not clearly
manifest.
Considering all the evidence on record, The Court finds the accused guilty for simple
imprudence resulting to physical injuries. Under Article 365 of the Revised Penal Code, the
penalty provided for is arresto mayor in its minimum period.7
Dissatisfied, the petitioners appealed to the CA.
As earlier stated, the CA affirmed the RTC decision in toto. The August 29, 2008 Decision
of the CA pertinently reads:

Whether or not Dr. Jarcia and Dr. Bastan had committed an "inexcusable lack of
precaution" in the treatment of their patient is to be determined according to the standard
of care observed by other members of the profession in good standing under similar
circumstances, bearing in mind the advanced state of the profession at the time of
treatment or the present state of medical science. In the case of Leonila Garcia-Rueda v.
Pascasio, the Supreme Court stated that, in accepting a case, a doctor in effect represents
that, having the needed training and skill possessed by physicians and surgeons

practicing in the same field, he will employ such training, care and skill in the treatment of
his patients. He therefore has a duty to use at least the same level of care that any other
reasonably competent doctor would use to treat a condition under the same
circumstances.
In litigations involving medical negligence, the plaintiff has the burden of establishing
accused-appellants negligence, and for a reasonable conclusion of negligence, there
must be proof of breach of duty on the part of the physician as well as a causal
connection of such breach and the resulting injury of his patient. The connection between
the negligence and the injury must be a direct and natural sequence of events, unbroken
by intervening efficient causes. In other words, the negligence must be the proximate
cause of the injury. Negligence, no matter in what it consists, cannot create a right of
action unless it is the proximate cause of the injury complained of. The proximate cause of
an injury is that cause which, in natural and continuous sequence, unbroken by any
efficient intervening cause, produces the injury and without which the result would not
have occurred.
In the case at bench, the accused-appellants questioned the imputation against them and
argued that there is no causal connection between their failure to diagnose the fracture
and the injury sustained by Roy.
We are not convinced.
The prosecution is however after the cause which prolonged the pain and suffering of Roy
and not on the failure of the accused-appellants to correctly diagnose the extent of the
injury sustained by Roy.
For a more logical presentation of the discussion, we shall first consider the applicability of
the doctrine of res ipsa loquitur to the instant case. Res ipsa loquitur is a Latin phrase
which literally means "the thing or the transaction speaks for itself. The doctrine of res
ipsa loquitur is simply a recognition of the postulate that, as a matter of common
knowledge and experience, the very nature of certain types of occurrences may justify an
inference of negligence on the part of the person who controls the instrumentality causing
the injury in the absence of some explanation by the accused-appellant who is charged
with negligence. It is grounded in the superior logic of ordinary human experience and, on
the basis of such experience or common knowledge, negligence may be deduced from the
mere occurrence of the accident itself. Hence, res ipsa loquitur is applied in conjunction
with the doctrine of common knowledge.
The specific acts of negligence was narrated by Mrs. Santiago who accompanied her son
during the latters ordeal at the hospital. She testified as follows:

A: They told me they will call a resident doctor, sir.


xxx

xxx

xxx

Q: Was there a resident doctor [who] came?


A: Yes, Sir. Dra. Bastan arrived.
Q: Did you tell her what you want on you to be done?
A: Yes, sir.
Q: What did you [tell] her?
A: I told her, sir, while she was cleaning the wounds of my son, are you not going to x-ray
up to the knee because my son was complaining pain from his ankle up to the middle part
of the right leg.
Q: And what did she tell you?
A: According to Dra. Bastan, there is no need to x-ray because it was the ankle part that
was run over.
Q: What did you do or tell her?
A: I told her, sir, why is it that they did not examine[x] the whole leg. They just lifted the
pants of my son.
Q: So you mean to say there was no treatment made at all?
A: None, sir.
xxx

xxx

xxx

xxx

xxx

xxx

A: I just listened to them, sir. And I just asked if I will still return my son.
xxx

xxx

xxx

xxx

xxx

xxx

Fiscal Formoso:
Q: And you were present when they were called?
Q: Now, he is an intern did you not consult the doctors, Dr. Jarcia or Dra. Pamittan to
confirm whether you should go home or not?
A: Dra. Pamittan was inside the cubicle of the nurses and I asked her, you let us go home
and you dont even clean the wounds of my son.

A: Yes, sir.
Q: And what was discussed then by Sis. Retoria?
A: When they were there they admitted that they have mistakes, sir.

Q: And what did she [tell] you?

Still, before resort to the doctrine may be allowed, the following requisites must be
satisfactorily shown:
1. The accident is of a kind which ordinarily does not occur in the absence of someones
negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or
defendants; and
3. The possibility of contributing conduct which would make the plaintiff responsible is
eliminated.
In the above requisites, the fundamental element is the "control of the instrumentality"
which caused the damage. Such element of control must be shown to be within the
dominion of the accused-appellants. In order to have the benefit of the rule, a plaintiff, in
addition to proving injury or damage, must show a situation where it is applicable and
must establish that the essential elements of the doctrine were present in a particular
incident. The early treatment of the leg of Roy would have lessen his suffering if not
entirely relieve him from the fracture. A boy of tender age whose leg was hit by a vehicle
would engender a well-founded belief that his condition may worsen without proper
medical attention. As junior residents who only practice general surgery and without
specialization with the case consulted before them, they should have referred the matter
to a specialist. This omission alone constitutes simple imprudence on their part. When
Mrs. Santiago insisted on having another x-ray of her child on the upper part of his leg,
they refused to do so. The mother would not have asked them if they had no exclusive
control or prerogative to request an x-ray test. Such is a fact because a radiologist would
only conduct the x-ray test upon request of a physician.
The testimony of Mrs. Santiago was corroborated by a bone specialist Dr. Tacata. He
further testified based on his personal knowledge, and not as an expert, as he examined
himself the child Roy. He testified as follows:

Ordinarily, only physicians and surgeons of skill and experience are competent to testify
as to whether a patient has been treated or operated upon with a reasonable degree of
skill and care. However, testimony as to the statements and acts of physicians, external
appearances, and manifest conditions which are observable by any one may be given by
non-expert witnesses. Hence, in cases where the res ipsa loquitur is applicable, the court
is permitted to find a physician negligent upon proper proof of injury to the patient,
without the aid of expert testimony, where the court from its fund of common knowledge
can determine the proper standard of care. Where common knowledge and experience
teach that a resulting injury would not have occurred to the patient if due care had been
exercised, an inference of negligence may be drawn giving rise to an application of the
doctrine of res ipsa loquitur without medical evidence, which is ordinarily required to show
not only what occurred but how and why it occurred. In the case at bench, we give
credence to the testimony of Mrs. Santiago by applying the doctrine of res ipsa loquitur.
Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be
cautiously applied, depending upon the circumstances of each case. It is generally
restricted to situations in malpractice cases where a layman is able to say, as a matter of
common knowledge and observation, that the consequences of professional care were not
as such as would ordinarily have followed if due care had been exercised. A distinction
must be made between the failure to secure results and the occurrence of something
more unusual and not ordinarily found if the service or treatment rendered followed the
usual procedure of those skilled in that particular practice. The latter circumstance is the
primordial issue that confronted this Court and we find application of the doctrine of res
ipsa loquitur to be in order.
WHEREFORE, in view of the foregoing, the appeal in this case is hereby DISMISSED and
the assailed decision of the trial court finding accused-appellants guilty beyond
reasonable doubt of simple imprudence resulting in serious physical injuries is hereby
AFFIRMED in toto.
SO ORDERED.8

Fiscal Macapagal:
Q: And was that the correct respon[se] to the medical problem that was presented to Dr.
Jarcia and Dra. Bastan?

The petitioners filed a motion for reconsideration, but it was denied by the CA in its May
19, 2009 Resolution.
Hence, this petition.

A: I would say at that stage, yes. Because they have presented the patient and the
history. "At sabi nila, nadaanan lang po ito." And then, considering their year of residency
they are still junior residents, and they are not also orthopedic residents but general
surgery residents, its entirely different thing. Because if you are an orthopedic resident, I
am not trying to saybut if I were an orthopedic resident, there would be more precise
and accurate decision compare to a general surgery resident in so far as involved.
Q: You mean to say there is no supervisor attending the emergency room?
A: At the emergency room, at the Manila Doctors Hospital, the supervisor there is a
consultant that usually comes from a family medicine. They see where a certain patient
have to go and then if they cannot manage it, they refer it to the consultant on duty. Now
at that time, I dont [know] why they dont.Because at that time, I think, it is the
decision. Since the x-rays.

The petitioners pray for the reversal of the decision of both the RTC and the CA anchored
on the following
GROUNDS1. IN AFFIRMING ACCUSED-PETITIONERS CONVICTION, THE COURT OF APPEALS ERRED IN
NOT HOLDING THAT THE ACTUAL, DIRECT, IMMEDIATE, AND PROXIMATE CAUSE OF THE
PHYSICAL INJURY OF THE PATIENT (FRACTURE OF THE LEG BONE OR TIBIA), WHICH
REQUIRED MEDICAL ATTENDANCE FOR MORE THAN THIRTY (30) DAYS AND
INCAPACITATED HIM FROM PERFORMING HIS CUSTOMARY DUTY DURING THE SAME
PERIOD OF TIME, WAS THE VEHICULAR ACCIDENT WHERE THE PATIENTS RIGHT LEG WAS
HIT BY A TAXI, NOT THE FAILURE OF THE ACCUSED-PETITIONERS TO SUBJECT THE
PATIENTS WHOLE LEG TO AN X-RAY EXAMINATION.

2. THE COURT OF APPEALS ERRED IN DISREGARDING ESTABLISHED FACTS CLEARLY


NEGATING PETITIONERS ALLEGED NEGLIGENCE OR IMPRUDENCE. SIGNIFICANTLY, THE
COURT OF APPEALS UNJUSTIFIABLY DISREGARDED THE OPINION OF THE PROSECUTIONS
EXPERT WITNESS, DR. CIRILO TACATA, THAT PETITIONERS WERE NOT GUILTY OF
NEGLIGENCE OR IMPRUDENCE COMPLAINED OF.
3. THE COURT OF APPEALS ERRED IN HOLDING THAT THE FAILURE OF PETITIONERS TO
SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY EXAMINATION PROLONGED THE PAIN
AND SUFFERING OF THE PATIENT, SUCH CONCLUSION BEING UNSUPPORTED BY, AND
EVEN CONTRARY TO, THE EVIDENCE ON RECORD.
4. ASSUMING ARGUENDO THAT THE PATIENT EXPERIENCED PROLONGED PAIN AND
SUFFERING, THE COURT OF APPEALS ERRED IN NOT HOLDING THAT THE ALLEGED PAIN
AND SUFFERING WERE DUE TO THE UNJUSTIFIED FAILURE OF THE PATIENTS MOTHER, A
NURSE HERSELF, TO IMMEDIATELY BRING THE PATIENT BACK TO THE HOSPITAL, AS
ADVISED BY THE PETITIONERS, AFTER HE COMPLAINED OF SEVERE PAIN IN HIS RIGHT LEG
WHEN HE REACHED HOME AFTER HE WAS SEEN BY PETITIONERS AT THE HOSPITAL. THUS,
THE PATIENTS ALLEGED INJURY (PROLONGED PAIN AND SUFFERING) WAS DUE TO HIS
OWN MOTHERS ACT OR OMISSION.
5. THE COURT OF APPEALS ERRED IN NOT HOLDING THAT NO PHYSICIAN-PATIENT
RELATIONSHIP EXISTED BETWEEN PETITIONERS AND PATIENT ALFONSO SANTIAGO, JR.,
PETITIONERS NOT BEING THE LATTERS ATTENDING PHYSICIAN AS THEY WERE MERELY
REQUESTED BY THE EMERGENCY ROOM (ER) NURSE TO SEE THE PATIENT WHILE THEY
WERE PASSING BY THE ER FOR THEIR LUNCH.
6. THE COURT OF APPEALS GRAVELY ERRED IN NOT ACQUITTING ACCUSED-PETITIONERS
OF THE CRIME CHARGED."9
The foregoing can be synthesized into two basic issues: [1] whether or not the doctrine of
res ipsa loquitur is applicable in this case; and [2] whether or not the petitioners are liable
for criminal negligence.
THE COURTS RULING
The CA is correct in finding that there was negligence on the part of the petitioners. After
a perusal of the records, however, the Court is not convinced that the petitioners are
guilty of criminal negligence complained of. The Court is also of the view that the CA erred
in applying the doctrine of res ipsa loquitur in this particular case.

The thing speaks for itself. Rebuttable presumption or inference that defendant was
negligent, which arises upon proof that the instrumentality causing injury was in
defendant's exclusive control, and that the accident was one which ordinarily does not
happen in absence of negligence. Res ipsa loquitur is a rule of evidence whereby
negligence of the alleged wrongdoer may be inferred from the mere fact that the accident
happened provided the character of the accident and circumstances attending it lead
reasonably to belief that in the absence of negligence it would not have occurred and that
thing which caused injury is shown to have been under the management and control of
the alleged wrongdoer. Under this doctrine, the happening of an injury permits an
inference of negligence where plaintiff produces substantial evidence that the injury was
caused by an agency or instrumentality under the exclusive control and management of
defendant, and that the occurrence was such that in the ordinary course of things would
not happen if reasonable care had been used.10
The doctrine of res ipsa loquitur as a rule of evidence is unusual to the law of negligence
which recognizes that prima facie negligence may be established without direct proof and
furnishes a substitute for specific proof of negligence. The doctrine, however, is not a rule
of substantive law, but merely a mode of proof or a mere procedural convenience. The
rule, when applicable to the facts and circumstances of a given case, is not meant to and
does not dispense with the requirement of proof of culpable negligence on the party
charged. It merely determines and regulates what shall be prima facie evidence thereof
and helps the plaintiff in proving a breach of the duty. The doctrine can be invoked when
and only when, under the circumstances involved, direct evidence is absent and not
readily available.11
The requisites for the application of the doctrine of res ipsa loquitur are: (1) the accident
was of a kind which does not ordinarily occur unless someone is negligent; (2) the
instrumentality or agency which caused the injury was under the exclusive control of the
person in charge; and (3) the injury suffered must not have been due to any voluntary
action or contribution of the person injured.12
In this case, the circumstances that caused patient Roy Jr.s injury and the series of tests
that were supposed to be undergone by him to determine the extent of the injury suffered
were not under the exclusive control of Drs. Jarcia and Bastan. It was established that they
are mere residents of the Manila Doctors Hospital at that time who attended to the victim
at the emergency room.13 While it may be true that the circumstances pointed out by the
courts below seem doubtless to constitute reckless imprudence on the part of the
petitioners, this conclusion is still best achieved, not through the scholarly assumptions of
a layman like the patients mother, but by the unquestionable knowledge of expert
witness/es. As to whether the petitioners have exercised the requisite degree of skill and
care in treating patient Roy, Jr. is generally a matter of expert opinion.

As to the Application of The Doctrine of Res Ipsa Loquitur


As to Dr. Jarcia and Dr. Bastans negligence
This doctrine of res ipsa loquitur means "Where the thing which causes injury is shown to
be under the management of the defendant, and the accident is such as in the ordinary
course of things does not happen if those who have the management use proper care, it
affords reasonable evidence, in the absence of an explanation by the defendant, that the
accident arose from want of care." The Black's Law Dictionary defines the said doctrine.
Thus:

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

Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act
from which material damage results by reason of an inexcusable lack of precaution on the
part of the person performing or failing to perform such act.15
The elements of simple negligence are: (1) that there is lack of precaution on the part of
the offender, and (2) that the damage impending to be caused is not immediate or the
danger is not clearly manifest.16
In this case, the Court is not convinced with moral certainty that the petitioners are guilty
of reckless imprudence or simple negligence. The elements thereof were not proved by
the prosecution beyond reasonable doubt.
The testimony of Dr. Cirilo R. Tacata (Dr. Tacata), a specialist in pediatric orthopedic,
although pointing to some medical procedures that could have been done by Dr. Jarcia
and Dr. Bastan, as physicians on duty, was not clear as to whether the injuries suffered by
patient Roy Jr. were indeed aggravated by the petitioners judgment call and their
diagnosis or appreciation of the condition of the victim at the time they assessed him.
Thus:
Q: Will you please tell us, for the record, doctor, what is your specialization?
A: At present I am the chairman department of orthopedic in UP-PGH and I had special
training in pediatric orthopedic for two (2) years.
Q: In June 1998, doctor, what was your position and what was your specialization at that
time?
A: Since 1980, I have been specialist in pediatric orthopedic.
Q: When Alfonso Santiago, Jr. was brought to you by his mother, what did you do by way
of physicians as first step?
A: As usual, I examined the patient physically and, at that time as I have said, the patient
could not walk so I [began] to suspect that probably he sustained a fracture as a result of
a vehicular accident. So I examined the patient at that time, the involved leg, I dont know
if that is left or right, the involved leg then was swollen and the patient could not walk, so
I requested for the x-ray of [the] lower leg.
Q: What part of the leg, doctor, did you request to be examined?
A: If we refer for an x-ray, usually, we suspect a fracture whether in approximal, middle or
lebistal tinial, we usually x-ray the entire extremity.
Q: And what was the result?
A: Well, I can say that it was a spiral fracture of the mid-tibial, it is the bigger bone of the
leg.
Q: And when you say spiral, doctor, how long was this fracture?
A: When we say spiral, it is a sort of letter S, the length was about six (6) to eight (8)
centimeters.
Q: Mid-tibial, will you please point to us, doctor, where the tibial is?
(Witness pointing to his lower leg)
A: The tibial is here, there are two bones here, the bigger one is the tibial and the smaller
one is the fibula. The bigger one is the one that get fractured.
Q: And in the course of your examination of Alfonso Santiago, Jr. did you ask for the
history of such injury?
A: Yes, actually, that was a routine part of our examination that once a patient comes in,
before we actually examine the patient, we request for a detailed history. If it is an
accident, then, we request for the exact mechanism of injuries.

Q: And as far as you can recall, Doctor, what was the history of that injury that was told to
you?
A: The patient was sideswiped, I dont know if it is a car, but it is a vehicular accident.
Q: Who did you interview?
A: The mother.
Q: How about the child himself, Alfonso Santiago, Jr.?
A: Normally, we do not interview the child because, usually, at his age, the answers are
not accurate. So, it was the mother that I interviewed.
Q: And were you informed also of his early medication that was administered on Alfonso
Santiago, Jr.?
A: No, not actually medication. I was informed that this patient was seen initially at the
emergency room by the two (2) physicians that you just mentioned, Dr. Jarcia and Dra.
Bastan, that time who happened to be my residents who were [on] duty at the emergency
room.
xxxx
A: At the emergency room, at the Manila Doctors Hospital, the supervisor there is a
consultant that usually comes from a family medicine. They see where a certain patient
have to go and then if they cannot manage it, they refer it to the consultant on duty. Now
at that time, I dont why they dont Because at that time, I think, it is the decision.
Since the x-rays
xxx
Q: You also said, Doctor, that Dr. Jarcia and Dra. Bastan are not even an orthopedic
specialist.
A: They are general surgeon residents. You have to man[x] the emergency room, including
neurology, orthopedic, general surgery, they see everything at the emergency room.
xxxx
Q: But if initially, Alfonso Santiago, Jr. and his case was presented to you at the
emergency room, you would have subjected the entire foot to x-ray even if the history
that was given to Dr. Jarcia and Dra. Bastan is the same?
A: I could not directly say yes, because it would still depend on my examination, we
cannot subject the whole body for x-ray if we think that the damaged was only the leg.
Q: Not the entire body but the entire leg?
A: I think, if my examination requires it, I would.
Q: So, you would conduct first an examination?
A: Yes, sir.
Q: And do you think that with that examination that you would have conducted you would
discover the necessity subjecting the entire foot for x-ray?
A: It is also possible but according to them, the foot and the ankle were swollen and not
the leg, which sometimes normally happens that the actual fractured bone do not get
swollen.
xxxx
Q: Doctor, if you know that the patient sustained a fracture on the ankle and on the foot
and the history that was told to you is the region that was hit is the region of the foot, will
the doctor subject the entire leg for x-ray?
A: I am an orthopedic surgeon, you have to subject an x-ray of the leg. Because you have
to consider the kind of fracture that the patient sustained would you say the exact

mechanism of injury. For example spiral, "paikot yung bale nya," so it was possible that
the leg was run over, the patient fell, and it got twisted. Thats why the leg seems to be
fractured.17 [Emphases supplied]
It can be gleaned from the testimony of Dr. Tacata that a thorough examination was not
performed on Roy Jr. As residents on duty at the emergency room, Dr. Jarcia and Dr.
Bastan were expected to know the medical protocol in treating leg fractures and in
attending to victims of car accidents. There was, however, no precise evidence and
scientific explanation pointing to the fact that the delay in the application of the cast to
the patients fractured leg because of failure to immediately diagnose the specific injury
of the patient, prolonged the pain of the child or aggravated his condition or even caused
further complications. Any person may opine that had patient Roy Jr. been treated
properly and given the extensive X-ray examination, the extent and severity of the injury,
spiral fracture of the mid-tibial part or the bigger bone of the leg, could have been
detected early on and the prolonged pain and suffering of Roy Jr. could have been
prevented. But still, that opinion, even how logical it may seem would not, and could not,
be enough basis to hold one criminally liable; thus, a reasonable doubt as to the
petitioners guilt.
Although the Court sympathizes with the plight of the mother and the child in this case,
the Court is bound by the dictates of justice which hold inviolable the right of the accused
to be presumed innocent until proven guilty beyond reasonable doubt. The Court,
nevertheless, finds the petitioners civilly liable for their failure to sufficiently attend to Roy
Jr.s medical needs when the latter was rushed to the ER, for while a criminal conviction
requires proof beyond reasonable doubt, only a preponderance of evidence is required to
establish civil liability. Taken into account also was the fact that there was no bad faith on
their part.
Dr. Jarcia and Dr. Bastan cannot pass on the liability to the taxi driver who hit the victim. It
may be true that the actual, direct, immediate, and proximate cause of the injury (fracture
of the leg bone or tibia) of Roy Jr. was the vehicular accident when he was hit by a taxi.
The petitioners, however, cannot simply invoke such fact alone to excuse themselves from
any liability. If this would be so, doctors would have a ready defense should they fail to do
their job in attending to victims of hit-and-run, maltreatment, and other crimes of violence
in which the actual, direct, immediate, and proximate cause of the injury is indubitably the
act of the perpetrator/s.
In failing to perform an extensive medical examination to determine the extent of Roy Jr.s
injuries, Dr. Jarcia and Dr. Bastan were remiss of their duties as members of the medical
profession. Assuming for the sake of argument that they did not have the capacity to
make such thorough evaluation at that stage, they should have referred the patient to
another doctor with sufficient training and experience instead of assuring him and his
mother that everything was all right.
This Court cannot also stamp its imprimatur on the petitioners contention that no
physician-patient relationship existed between them and patient Roy Jr., since they were
not his attending physicians at that time. They claim that they were merely requested by
the ER nurse to see the patient while they were passing by the ER for their lunch. Firstly,
this issue was never raised during the trial at the RTC or even before the CA. The
petitioners, therefore, raise the want of doctor-patient relationship for the first time on
appeal with this Court. It has been settled that "issues raised for the first time on appeal

cannot be considered because a party is not permitted to change his theory on appeal. To
allow him to do so is unfair to the other party and offensive to the rules of fair play, justice
and due process."18 Stated differently, basic considerations of due process dictate that
theories, issues and arguments not brought to the attention of the trial court need not be,
and ordinarily will not be, considered by a reviewing court.19
Assuming again for the sake of argument that the petitioners may still raise this issue of
"no physicianpatient relationship," the Court finds and so holds that there was a
"physicianpatient" relationship in this case.
In the case of Lucas v. Tuao,20 the Court wrote that "[w]hen a patient engages the
services of a physician, a physician-patient relationship is generated. And in accepting a
case, the physician, for all intents and purposes, represents that he has the needed
training and skill possessed by physicians and surgeons practicing in the same field; and
that he will employ such training, care, and skill in the treatment of the patient. Thus, in
treating his patient, a physician is under a duty to exercise that degree of care, skill and
diligence which physicians in the same general neighborhood and in the same general
line of practice ordinarily possess and exercise in like cases. Stated otherwise, the
physician has the obligation to use at least the same level of care that any other
reasonably competent physician would use to treat the condition under similar
circumstances."
Indubitably, a physician-patient relationship exists between the petitioners and patient
Roy Jr. Notably, the latter and his mother went to the ER for an immediate medical
attention. The petitioners allegedly passed by and were requested to attend to the victim
(contrary to the testimony of Dr. Tacata that they were, at that time, residents on duty at
the ER).21 They obliged and examined the victim, and later assured the mother that
everything was fine and that they could go home. Clearly, a physician-patient relationship
was established between the petitioners and the patient Roy Jr.
To repeat for clarity and emphasis, if these doctors knew from the start that they were not
in the position to attend to Roy Jr., a vehicular accident victim, with the degree of
diligence and commitment expected of every doctor in a case like this, they should have
not made a baseless assurance that everything was all right. By doing so, they deprived
Roy Jr. of adequate medical attention that placed him in a more dangerous situation than
he was already in. What petitioners should have done, and could have done, was to refer
Roy Jr. to another doctor who could competently and thoroughly examine his injuries.
All told, the petitioners were, indeed, negligent but only civilly, and not criminally, liable
as the facts show.
Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in the
Philippines states:
A physician should attend to his patients faithfully and conscientiously. He should secure
for them all possible benefits that may depend upon his professional skill and care. As the
sole tribunal to adjudge the physicians failure to fulfill his obligation to his patients is, in
most cases, his own conscience, violation of this rule on his part is discreditable and
inexcusable.22

Established medical procedures and practices, though in constant instability, are devised
for the purpose of preventing complications. In this case, the petitioners failed to observe
the most prudent medical procedure under the circumstances to prevent the
complications suffered by a child of tender age.
As to the Award of Damages
While no criminal negligence was found in the petitioners failure to administer the
necessary medical attention to Roy Jr., the Court holds them civilly liable for the resulting
damages to their patient. While it was the taxi driver who ran over the foot or leg of Roy
Jr., their negligence was doubtless contributory.
It appears undisputed that the amount of P 3,850.00, as expenses incurred by patient Roy
Jr., was adequately supported by receipts. The Court, therefore, finds the petitioners liable
to pay this amount by way of actual damages.
The Court is aware that no amount of compassion can suffice to ease the sorrow felt by
the family of the child at that time. Certainly, the award of moral and exemplary damages
in favor of Roy Jr. in the amount of P 100,000.00 and P 50,000.00, respectively, is proper
in this case.
It is settled that moral damages are not punitive in nature, but are designed to
compensate and alleviate in some way the physical suffering, mental anguish, fright,
serious anxiety, besmirched reputation, wounded feelings, moral shock, social humiliation,
and similar injury unjustly inflicted on a person. Intended for the restoration of the
psychological or emotional status quo ante, the award of moral damages is designed to
compensate emotional injury suffered, not to impose a penalty on the wrongdoer.23
The Court, likewise, finds the petitioners also liable for exemplary damages in the said
amount.1wphi1 Article 2229 of the Civil Code provides that exemplary damages may be
imposed by way of example or correction for the public good.
WHEREFORE, the petition is PARTLY GRANTED. The Decision of the Court of Appeals dated
August 29, 2008 is REVERSED and SET ASIDE. A new judgment is entered ACQUITTING Dr.
Emmanuel Jarcia, Jr. and Dr. Marilou Bastan of the crime of reckless imprudence resulting
to serious physical injuries but declaring them civilly liable in the amounts of:
(1)
(2)
(3)
(4)

P 3,850.00 as actual damages;


P 100,000.00 as moral damages;
P 50,000.00 as exemplary damages; and
Costs of the suit.

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

THIRD DIVISION G.R. No. 158461, August 22, 2012 DR. EDUARDO AQUINO, PETITIONER, VS.
HEIRS OF RAYMUNDA CALAYAG, NAMELY: RODRIGO, WILMA, WILLIE, WILLIAM, WILSON, WENDY,
WHITNEY AND WARREN, ALL SURNAMED CALAYAG, REPRESENTED BY RODRIGO CALAYAG,
RESPONDENTS.
[G.R. NO. 158634] DR. ALBERTO C. REYES, PETITIONER, VS. HEIRS OF RAYMUNDA CALAYAG,
NAMELY, WILMA, WILLIE, WILLIAM, WILSON, WENDY, WHITNEY AND WARREN, ALL SURNAMED
CALAYAG, REPRESENTED BY WILMA CALAYAG, RESPONDENTS.
[G.R. NO. 158818] DR. DIVINIA UNITE, PETITIONER, VS. HEIRS OF RAYMUNDA CALAYAG, NAMELY
RODRIGO, WILMA, WILLIE, WILLIAM, WILSON, WENDY, WHITNEY AND WARREN, ALL SURNAMED
CALAYAG, REPRESENTED BY RODRIGO CALAYAG, RESPONDENTS.
ABAD, J.:

day, however, Raymunda's wound split open, causing part of her intestines to jut out. MCM's
Dr. Benito Chua re-sutured the wound.[16]
Raymunda never regained consciousness, prompting her MCM doctors to advise Rodrigo to take
her home since they could do no more to improve her condition. MCM discharged her on
November 30, 1990 and she died 15 days later on December 14, 1990.
Rodrigo filed, together with his seven children, a complaint[17] for damages against Dr. Unite,
Dr. Aquino, and Dr. Reyes before the Regional Trial Court (RTC) of Malolos. Rodrigo claimed that
Dr. Unite and Dr. Aquino failed to exercise the diligence required for operating on Raymunda. As
for Dr. Reyes, Rodrigo averred that he was negligent in supervising the .work of Dr. Unite and
Dr. Aquino.

These cases involve the liability of the surgeon, the anesthesiologist, and the hospital owner
arising from a botched caesarean section that resulted in the patient going into a coma.

Defendant doctors uniformly denied the charge of negligence against them. Page 3 of 13They
claimed that they exercised the diligence required of them and that causes other than
negligence brought about Raymunda's condition.

The Facts and the Case


When his wife Raymunda went into labor pains and began bleeding on November 13, 1990,
respondent Rodrigo Calayag (Rodrigo)[1] brought her to St. Michael's Clinic of petitioner Dr.
Divinia Unite (Dr. Unite) at Malolos, Bulacan. After initial examination, the doctor told Rodrigo
that Raymunda had to have a caesarean section for her baby but this had to be done at the
better-equipped Sacred Heart Hospital (SHH), owned and operated by petitioner Dr. Alberto
Reyes (Dr. Reyes).

On August 22, 1994, after hearing the parties on their evidence, the RTC rendered a decision,
finding the three doctors liable for negligence. The proximate cause of Raymunda's cardiac
arrest, said the RTC, was an anesthetic accident, occasioned by injecting her with a high spinal
anesthesia. The operating doctors failed to correctly monitor her condition, resulting in a critical
delay in resuscitating her after the cardiac arrest. The RTC ordered the doctors to pay
Raymunda's heirs P153,270.80 as actual damages, P300,000.00 as moral damages, and
P80,000.00 as attorney's fees and cost of suit.

SHH admitted Raymunda at 2:16 p.m. of the same day.[2] To prepare her, the attending
anesthesiologist, petitioner Dr. Eduardo Aquino (Dr. Aquino), injected her at about 2:30 p.m.
with a preliminary "Hipnotic."[3] At 2:48 p.m., he administered an anesthesia on her spine.[4] A
few minutes later, at 2:53 p.m.,[5] Dr. Unite delivered a stillborn eight-month-old baby.[6]

On appeal,[18] the Court of Appeals entirely affirmed the findings of the RTC.[19] Undaunted,
Dr. Unite, Dr. Aquino, and Dr. Reyes filed separate petitions for review that the Court
subsequently consolidated.

A few minutes later or at around 3:00 p.m., the operating team[7] noticed that Raymunda had
become cyanotic.[8] Her blood darkened for lack of oxygen and, all of a sudden, her vital signs
were gone.[9] The team worked on her for about 5 to 7 minutes until these were restored.[10]
Rodrigo claimed that when he saw Raymunda after the operation, her skin appeared dark
("nangingitim ang katawan") and the white of her eyes showed ("nakatirik ang mata"). When
he asked Dr. Unite why his wife did not look well, she replied that this was merely the effect of
the anesthesia and that she would regain consciousness in about eight hours.
When Raymunda's condition did not improve after a day, Dr. Unite referred her to Dr. Farinas,
an internist, who found that she suffered a cardiac arrest during the operation, which explained
her comatose state. Dr. Farinas referred Raymunda to a neurologist who advised Rodrigo to
move her to a better-equipped hospital.[11] SHH discharged her on November 16, 1990, four
days after her admission.
Raymunda was directly moved to Medical Center Manila (MCM) where Dr. Rogelio Libarnes (Dr.
Libarnes), a neurologist, examined her. He found Raymunda in a "vegetative state,"[12] having
suffered from an anoxic injury[13] due to cardio-respiratory arrest during operation.[14] Dr.
Libarnes was reluctant, however, to further proceed without consulting Dr. Unite, Raymunda's
surgeon, and Dr. Aquino, the anesthesiologist.
On November 23, 1990 Dr. Unite went to MCM to remove the stitches from Raymunda's surgical
wound. Dr. Unite noted that the wound had dried with slight lochial discharge.[15] Later that

In her petition, Dr. Unite washed her hands of any responsibility in Raymunda's operation. She
claimed that it was not her suturing that caused the splitting open of the patient's surgical
wound. Further, although some negligence may have attende'd the operation, this could be
traced to the anesthesiologist, Dr. Aquino.
Dr. Aquino claims, on the other hand, that the evidence was insufficient to support the
conclusion that anesthetic accident caused the cardio-respiratory arrest since, as testified,
other factors may have caused the same.
Finally, Dr. Reyes claims that he cannot be held liable for Raymunda's death since Dr. Unite and
Dr. Aquino were not his employees. Based on the control test, he did not exercise control and
supervision over their work. They merely used his hospital's facilities for the operation.
The Issues Presented
The cases present two issues:
1. Whether or not Dr. Unite (the surgeon) and Dr. Aquino (the anesthesiologist) acted
negligently in handling Raymunda's operation, resulting in her death; and
2. Whether or not Dr. Reyes is liable, as hospital owner, for the negligence of Dr. Unite and Dr.
Aquino.
The Court's Rulings
The cause of action against the doctors in these cases is commonly known as medical
malpractice. It is a form of negligence which consists in the physician or surgeon's failure to
apply to his practice that degree of care and skill that the profession generally and ordinarily
employs under similar conditions and circumstances.[20]

For this reason, the Court always seeks guidance from expert testimonies in determining
whether or not the defendant in a medical malpractice case exercised the degree of care and
diligence required of him.[21] The Court has to face up to the fact that physicians have
extraordinary technical skills that laymen do not have.[22]
To successfully mount a medical malpractice action, the plaintiff should establish four basic
things: (1) duty; (2) breach; (3) injury; and (4) proximate causation.[23] The evidence should
show that the physician or surgeon, either failed to do something which a reasonably prudent
physician or surgeon would have done, or that he or she did something that a reasonably
prudent physician or surgeon would not have done; and that the failure or action caused injury
to the patient.[24]
Here, to prove Dr. Unite and Dr. Aquino's negligence, Rodrigo presented Dr. Libarnes,
Raymunda's attending neurologist, and Dr. Chua, the general surgeon who re-stitched her
wound. Page 5 of 13Dr. Libarnes- explained that it was cyanosis or lack of oxygen in the brain
that caused Raymunda's vegetative state. Her brain began to starve for oxygen from the
moment she suffered cardio-respiratory arrest during caesarean section. That arrest, said Dr.
Libarnes, could in turn be traced to the anesthetic accident that resulted when Dr. Aquino
placed her under anesthesia.[25]
Dr. Libarnes also blamed the doctors who operated on Raymunda for not properly keeping track
of her vital signs during the caesarean procedure resulting in their failure to promptly address
the cyanosis when it set in.[26] Dr. Chua, on the other hand, testified that Raymunda's surgical
wound would not have split open if it had been properly closed.[27]
For their defense, Dr. Unite and Dr. Aquino presented Dr. Reyes, their codefendant, who
practiced general surgery. Dr. Reyes testified that Raymunda's cardio-respiratory arrest could
have been caused by factors other than high spinal anesthesia, like sudden release of intraabdominal pressure and amniotic fluid embolism.[28] Insofar as Raymunda's dehiscence or
splitting open of wound was concerned, Dr. Reyes testified that Raymunda's poor nutrition as
well as the medication contributed to the dehiscence.
While the Court cannot question the expertise of Dr. Reyes as a general surgeon, it cannot
regard him as a neutral witness. Given that he himself was a defendant in the case, he had a
natural bias for testifying to favor his codefendants.[29] Further, since he had no opportunity to
actually examine Raymunda, Dr. Reyes could only invoke textbook medical principles that he
could not clearly and directly relate to the patient's specific condition.
In contrast, as a neurologist with expertise in the human nervous system, including the brain,
Dr. Libarnes was in a better position to explain Raymunda's "vegetative" condition and its
cause. In his opinion, an anesthetic accident .during her caesarean section caused a cardiorespiratory arrest that Page 6 of 13deprived her brain of oxygen, severely damaging it. That
damage could have been averted had the attending doctors promptly detected the situation
and resuscitated her on time. Thus, Dr. Libarnes said:
Atty. Lazaro: What could have been the probable cause of this cardiorespiratory arrest now
Doctor?
Dr. Libarnes: Well, most common cause of intra-operative cardiorespiratory arrest is anesthesia,
an anesthetic accident.
Q: Will you kindly explain that in layman's language now Doctor?
A: The spinal anesthesia can re [suit] in depression of respiratory function. Respiratory arrest if
significantly prolonged] can lead to cardiac arrest. Cardiac arrest of significant duration can
res[ult] in brain injury.[30]

xxxx
Q: Now, when you refer to anoxic injury Doctor, you are referring to the lack of supply of
oxygen going to the brain that is what you mean?
A: Yes.
Q: And this is due to the weak pumping of the heart, that is correct Doctor?
A: Yes.
Q: And. the weak pumping of the heart under the events indicated by you could have been due
to anesthesia accident, that is correct?
A: Hypoxia meaning lobe of the lung not providing oxygen, the heart has been stressed under
hypoxic condition eventually giving out. Yes, that is correct.[31]
Dr. Aquino administered to Raymunda a high spinal anesthesia when he should have given her
only a low or mid-spinal anesthesia.[32] Notably, Dr. Unite corroborated the fact that
Raymunda suffered from cyanosis due to deprivation of oxygen. This was Dr. Unite's
explanation when Rodrigo, seeing his wife after the operation, asked why she had a bluish
color. Moreover, Dr. Unite admitted in her petition, that the proximate cause of Raymunda's
brain injury was Dr. Aquino's acts as anesthesiologist.[33]
But Dr. Unite cannot exempt herself from liability. Dr. Aquino was not feeling well on the day of
the operation as he was in fact on sick leave.[34] As surgeon in charge, Dr. Unite should not
have allowed Dr. Aquino to take part in the operation.
Besides, as the RTC found; the record of the operation contained no notation just when
Raymunda had a cardio-respiratory arrest and ceased to take in oxygen. This notation played a
critical role since the surgeons had between 6 to 8 minutes from the time of arrest, called the
golden period of reversibility, within which to save her from becoming a vegetable. The
absence of the notation on record, an important entry because the absence of which is itself a
ground for malpractice,[35] implies that the surgeons had no inkling when the cardiorespiratory arrest occurred and how much time they had left to revive their patient. Indeed, it
took a subsequent examination by an internist for them to realize that Raymunda had suffered
a cardiorespiratory arrest.
As for Dr. Reyes, the hospital owner, there appears no concrete proof to show that Dr. Unite and
Dr. Aquino were under the hospital's payroll. Indeed, Dr. Aquino appeared to be a government
physician connected with the Integrated Provincial Health Office of Bulacan.[36] Dr. Unite
appeared to be a self-employed doctor. The hospital allowed these doctors to operate on their
patients, using its operating room and assisting staffs for a fee. No evidence has been
presented that Raymunda suffered her fate because of Page 8 of 13defective hospital facilities
or poor staff support to the surgeons.
That Dr. Reyes and his wife rushed to the operating room the moment they heard that
Raymunda's vital signs had ceased is not an evidence that they exercised supervision over the
conduct of the operation. They evidently came to see what was happening possibly to provide
help if needed. Their showing up after the operation is not a proof that they had control and
supervision over the work of the two doctors.
Nor would the doctrine of ostensible agency or doctrine of apparent authority make Dr. Reyes
liable to Raymunda's heirs for her death. Two factors must be present under this doctrine: 1)
the hospital acted in a manner which would lead a reasonable person to believe that the person
claimed to be negligent was its agent or employee; and 2) the patient relied on such belief.
Here, there is no evidence that the hospital acted in a way that made Raymunda and her
husband believe that the two doctors were in the hospital's employ. Indeed, the couple had
been consulting Dr. Unite at St. Michael's Clinic, which she owned and operated in Malolos,
Bulacan. She convinced them that the caesarean section had to be performed at the SHH

because it had the facilities that such operation required. If the Court were to allow damages
against the hospital under this arrangement, independently licensed surgeons would be
unreasonably denied access to properly equipped operating rooms in big hospitals. As to the
award of damages, following precedents set in Flores v. Pineda[37] respondent heirs of
Raymunda are entitled to P50,000.00 as death indemnity pursuant to Article 2206 of the Civil
Code. WHEREFORE, premises considered, this Court DENIES the petitions and AFFIRMS the
decision of the Court of Appeals dated November 28, 2002 and resolution dated May 27, 2003
subject to MODIFICATION directing petitioners, Dr. Divinia Unite and Dr. Eduardo Aquino to pay
the Page 9 of 13heirs of Raymunda Calayag, in addition to the damages that the Court of
Appeals awarded them, P50,000.00 as death indemnity. SO ORDERED.

SECOND DIVISION
G.R. No. 167366
September 26, 2012
DR. PEDRO DENNIS CERENO, and DR. SANTOS ZAFE, Petitioners, vs. COURT OF APPEALS,
SPOUSES DIOGENES S. OLAVERE and FE R. SERRANO, Respondents.
DECISION
PEREZ, J.:
Before the Court is a Petition for Review on Certiorari 1 under Rule 45 of the Rules of Court
seeking the annulment and setting aside of the 21 February 2005 decision2 of the Court
of Appeals (CA) in CA-G.R. CV No. 65800. In the assailed decision, the CA affirmed in toto
the decision of the Regional Trial Court (R TC), Branch 22, Nag a City finding herein
petitioners Dr. Pedro Dennis Cereno (Dr. Cereno) and Dr. Santos Zafe (Dr. Zafe) liable for
damages.

At 11:15 P.M., Deogenes and Andrew Olavere returned to the BRMC with a bag containing
the requested 500 cc type "O" blood. They handed over the bag of blood to Dr. Realuyo.
After Dr. Tatad finished her work with the Lilia Aguila operation, petitioners immediately
started their operation on Raymond at around 12:15 A.M. of 17 September 1995. Upon
opening of Raymonds thoracic cavity, they found that 3,200 cc of blood was stocked
therein. The blood was evacuated and petitioners found a puncture at the inferior pole of
the left lung.
In his testimony, Dr. Cereno stated that considering the loss of blood suffered by
Raymond, he did not immediately transfuse blood because he had to control the bleeders
first.4

Culled from the records are the following antecedent facts:

Blood was finally transfused on Raymond at 1:40 A.M. At 1:45 A.M., while the operation
was on-going, Raymond suffered a cardiac arrest. The operation ended at 1:50 A.M. and
Raymond was pronounced dead at 2:30 A.M.

At about 9:15 in the evening of 16 September 1995, Raymond S. Olavere (Raymond), a


victim of a stabbing incident, was rushed to the emergency room of the Bicol Regional
Medical Center (BRMC). There, Raymond was attended to by Nurse Arlene Balares (Nurse
Balares) and Dr. Ruel Levy Realuyo (Dr. Realuyo) the emergency room resident
physician.

Raymonds death certificate5 indicated that the immediate cause of death was
"hypovolemic shock" or the cessation of the functions of the organs of the body due to
loss of blood.6

Subsequently, the parents of Raymondthe spouses Deogenes Olavere (Deogenes) and


Fe R. Serranoarrived at the BRMC. They were accompanied by one Andrew Olavere, the
uncle of Raymond.
After extending initial medical treatment to Raymond, Dr. Realuyo recommended that the
patient undergo "emergency exploratory laparotomy." Dr. Realuyo then requested the
parents of Raymond to procure 500 cc of type "O" blood needed for the operation.
Complying with the request, Deogenes and Andrew Olavere went to the Philippine
National Red Cross to secure the required blood.
At 10:30 P.M., Raymond was wheeled inside the operating room. During that time, the
hospital surgeons, Drs. Zafe and Cereno, were busy operating on gunshot victim Charles
Maluluy-on. Assisting them in the said operation was Dr. Rosalina Tatad (Dr. Tatad), who
was the only senior anesthesiologist on duty at BRMC that night. Dr. Tatad also happened
to be the head of Anesthesiology Department of the BRMC.

Claiming that there was negligence on the part of those who attended to their son, the
parents of Raymond, on 25 October 1995, filed before the RTC, Branch 22, Naga City a
complaint for damages7 against Nurse Balares, Dr. Realuyo and attending surgeons Dr.
Cereno and Dr. Zafe.
During trial, the parents of Raymond testified on their own behalf. They also presented the
testimonies of Andrew Olavere and one Loira Oira, the aunt of Raymond. On the other
hand, Dr. Cereno, Dr. Realuyo, Nurse Balares and Security Guard Diego Reposo testified
for the defense. On rebuttal, the parents of Raymond presented Dr. Tatad, among others.
On 15 October 1999, the trial court rendered a decision8 the dispositive portion of which
reads:
WHEREFORE, premises considered, this Court hereby renders judgment:
1. Dismissing the case against Dr. Ruel Levy Realuyo and Arlene Balares for lack of merit;

Just before the operation on Maluluy-on was finished, another emergency case involving
Lilia Aguila, a woman who was giving birth to triplets, was brought to the operating room.

2. Ordering defendants Dr. Santos Zafe and Dr. Dennis Cereno to pay the heirs of
Raymond Olavere, jointly and severally the following amounts:

At 10:59 P.M., the operation on Charles Maluluy-on was finished. By that time, however,
Dr. Tatad was already working with the obstetricians who will perform surgery on Lilia
Aguila. There being no other available anesthesiologist to assist them, Drs. Zafe and
Cereno decided to defer the operation on Raymond.

1. P 50,000.00 for the death of the victim;


2. P 150,000.00 as moral damages;
3. P 100,000.00 as exemplary damages;

Drs. Zafe and Cereno, in the meantime, proceeded to examine Raymond and they found
that the latters blood pressure was normal and "nothing in him was significant."3 Dr.
Cereno reported that based on the xray result he interpreted, the fluid inside the thoracic
cavity of Raymond was minimal at around 200-300 cc.

4. P 30,000.00 for attorneys fees; and


5. Cost of suit.9

x x x x.
The trial court found petitioners negligent in not immediately conducting surgery on
Raymond. It noted that petitioners have already finished operating on Charles Maluluy-on
as early as 10:30 in the evening, and yet they only started the operation on Raymond at
around 12:15 early morning of the following day. The trial court held that had the surgery
been performed promptly, Raymond would not have lost so much blood and, therefore,
could have been saved.10
The trial court also held that the non-availability of Dr. Tatad after the operation on
Maluluy-on was not a sufficient excuse for the petitioners to not immediately operate on
Raymond. It called attention to the testimony of Dr. Tatad herself, which disclosed the
possibility of calling a standby anesthesiologist in that situation. The trial court opined
that the petitioners could have just requested for the standby anesthesiologist from Dr.
Tatad, but they did not.
Lastly, the trial court faulted petitioners for the delay in the transfusion of blood on
Raymond.
On appeal, the CA in a decision dated 21 February 2005 affirmed in toto the judgment
rendered by the RTC finding herein petitioners guilty of gross negligence in the
performance of their duties and awarding damages to private respondents.
Hence, this petition for review on certiorari under Rule 45 of the Rules of Court assailing
the CA decision on the following grounds:
1. THAT THE CA ERRED IN RULING THAT PETITIONERS WERE GROSSLY NEGLIGENT IN THE
PERFORMANCE OF THEIR DUTIES;
2. THAT THE CA ERRED IN NOT CONSIDERING THE BICOL REGIONAL MEDICAL CENTER AS
AN INDISPENSABLE PARTY AND SUBSIDIARILY LIABLE SHOULD PETITIONERS BE FOUND
LIABLE FOR DAMAGES; and
3. THAT THE CA ERRED IN NOT FINDING THE AWARD OF MORAL AND EXEMPLARY
DAMAGES AS WELL AS ATTORNEYS FEES EXORBITANT OR EXCESSIVE.
We grant the petition
It is well-settled that under Rule 45 of the Rules of Court, only questions of law may be
raised. The reason behind this is that this Court is not a trier of facts and will not reexamine and re-evaluate the evidence on record.11 Factual findings of the CA, affirming
that of the trial court, are therefore generally final and conclusive on this Court. This rule
is subject to the following exceptions: (1) the conclusion is grounded on speculations,
surmises or conjectures; (2) the inference is manifestly mistaken, absurd or impossible;
(3) there is grave abuse of discretion; (4) the judgment is based on a misapprehension of
facts; (5) the findings of fact are conflicting; (6) there is no citation of specific evidence on
which the factual findings are based; (7) the findings of absence of fact are contradicted
by the presence of evidence on record; (8) the findings of the CA are contrary to those of
the trial court; (9) the CA manifestly overlooked certain relevant and undisputed facts
that, if properly considered, would justify a different conclusion; (10) the findings of the CA

are beyond the issues of the case; and (11) such findings are contrary to the admissions
of both parties.12 In this case, We find exceptions (1) and (4) to be applicable.
The type of lawsuit which has been called medical malpractice or, more appropriately,
medical negligence, is that type of claim which a victim has available to him or her to
redress a wrong committed by a medical professional which has caused bodily harm. In
order to successfully pursue such a claim, a patient must prove that a health care
provider, in most cases a physician, either failed to do something which a reasonably
prudent health care provider would have done, or that he or she did something that a
reasonably prudent provider would not have done; and that the failure or action caused
injury to the patient.13 Stated otherwise, the complainant must prove: (1) that the health
care provider, either by his act or omission, had been negligent, and (2) that such act or
omission proximately caused the injury complained of.
The best way to prove these is through the opinions of expert witnesses belonging in the
same neighborhood and in the same general line of practice as defendant physician or
surgeon. The deference of courts to the expert opinion of qualified physicians stems from
the formers realization that the latter possess unusual technical skills which laymen in
most instances are incapable of intelligently evaluating, hence, the indispensability of
expert testimonies.14
Guided by the foregoing standards, We dissect the issues at hand.
Petitioners Not Negligent
The trial court first imputed negligence on the part of the petitioners by their failure to
perform the operation on Raymond immediately after finishing the Maluluy-on operation.
It rejected as an excuse the nonavailability of Dr. Tatad. The trial court relied on the
testimony of Dr. Tatad about a "BRMC protocol" that introduces the possibility that a
standby anesthesiologist could have been called upon. The pertinent portions of the
testimony of Dr. Tatad provides:
Q: Aside from you and Dr. Rebancos, who was the standby anesthesiologist?
A: We have a protocol at the Bicol Medical Center to have a consultant who is on call.
Q: How many of them?
A: One.
Q: Who is she?
A: Dra. Flores.
Q: What is the first name?
A: Rosalina Flores.
Q: Is she residing in Naga City?
A: In Camaligan.
Q: She is on call anytime when there is an emergency case to be attended to in the Bicol
Medical Center?
A: Yes sir.15
Dr. Tatad further testified:
Q: Alright (sic), considering that you said you could not attend to Raymond Olavere
because another patient was coming in the person of Lilia Aguila, did you not suggest to
Dr. Cereno to call the standby anesthesiologist?
A: They are not ones to do that. They have no right to call for the standby
anesthesiologist.

Q: Then, who should call for the standby anesthesiologist?


A: It is me if the surgeon requested.
Q: But in this case, the surgeon did not request you?
A: No. It is their prerogative.
Q: I just want to know that in this case the surgeon did not request you to call for the
standby anesthesiologist?
A: No sir.16
From there, the trial court concluded that it was the duty of the petitioners to request Dr.
Tatad to call on Dr. Rosalina Flores, the standby anesthesiologist. Since petitioners failed
to do so, their inability to promptly perform the operation on Raymond becomes
negligence on their part.
This Court does not agree with the aforesaid conclusion.
First. There is nothing in the testimony of Dr. Tatad, or in any evidence on the record for
that matter, which shows that the petitioners were aware of the "BRMC protocol" that the
hospital keeps a standby anesthesiologist available on call. Indeed, other than the
testimony of Dr. Tatad, there is no evidence that proves that any such "BRMC protocol" is
being practiced by the hospitals surgeons at all.
Evidence to the effect that petitioners knew of the "BRMC protocol" is essential, especially
in view of the contrary assertion of the petitioners that the matter of assigning
anesthesiologists rests within the full discretion of the BRMC Anesthesiology Department.
Without any prior knowledge of the "BRMC protocol," We find that it is quite reasonable for
the petitioners to assume that matters regarding the administration of anesthesia and the
assignment of anesthesiologists are concerns of the Anesthesiology Department, while
matters pertaining to the surgery itself fall under the concern of the surgeons. Certainly,
We cannot hold petitioners accountable for not complying with something that they, in the
first place, do not know.
Second. Even assuming ex gratia argumenti that there is such "BRMC protocol" and that
petitioners knew about it, We find that their failure to request for the assistance of the
standby anesthesiologist to be reasonable when taken in the proper context. There is
simply no competent evidence to the contrary.
From the testimony of Dr. Tatad herself, it is clear that the matter of requesting for a
standby anaesthesiologist is not within the full discretion of petitioners. The "BRMC
protocol" described in the testimony requires the petitioners to course such request to Dr.
Tatad who, as head of the Department of Anesthesiology, has the final say of calling the
standby anesthesiologist.
As revealed by the facts, however, after the Maluluy-on operation, Dr. Tatad was already
assisting in the Lilia Aguila operation. Drs. Zafe and Cereno then proceeded to examine
Raymond and they found that the latters blood pressure was normal and "nothing in him
was significant."17 Dr. Cereno even concluded that based on the x-ray result he
interpreted, the fluid inside the thoracic cavity of Raymond was minimal at around 200300 cc. Such findings of Drs. Cereno and Zafe were never challenged and were
unrebutted.

Given that Dr. Tatad was already engaged in another urgent operation and that Raymond
was not showing any symptom of suffering from major blood loss requiring an immediate
operation, We find it reasonable that petitioners decided to wait for Dr. Tatad to finish her
surgery and not to call the standby anesthesiologist anymore. There is, after all, no
evidence that shows that a prudent surgeon faced with similar circumstances would
decide otherwise.
Here, there were no expert witnesses presented to testify that the course of action taken
by petitioners were not in accord with those adopted by other reasonable surgeons in
similar situations. Neither was there any testimony given, except that of Dr. Tatads, on
which it may be inferred that petitioners failed to exercise the standard of care, diligence,
learning and skill expected from practitioners of their profession. Dr. Tatad, however, is an
expert neither in the field of surgery nor of surgical practices and diagnoses. Her expertise
is in the administration of anesthesia and not in the determination of whether surgery
ought or not ought to be performed.
Another ground relied upon by the trial court in holding petitioners negligent was their
failure to immediately transfuse blood on Raymond. Such failure allegedly led to the
eventual death of Raymond through "hypovolemic shock." The trial court relied on the
following testimony of Dr. Tatad:
Q: In this case of Raymond Olavere was blood transfused to him while he was inside the
operating room?
A: The blood arrived at 1:40 a.m. and that was the time when this blood was hooked to
the patient.
xxxx
Q: Prior to the arrival of the blood, you did not request for blood?
A: I requested for blood.
Q: From whom?
A: From the attending physician, Dr. Realuyo.
Q: What time was that?
xxx
A: 9:30.
xxxx
Q: Had this blood been given to you before the operation you could have transfused the
blood to the patient?
A: Of course, yes.
Q: And the blood was transfused only after the operation?
A: Because that was the time when the blood was given to us.
xxxx
Q: Have you monitored the condition of Raymond Olavere?
A: I monitored the condition during the time when I would administer anesthesia.
Q: What time was that?
A: 11:45 already.
Q: What was the condition of the blood pressure at that time?
A: 60/40 initial.
Q: With that kind of blood pressure the patient must have been in critical condition?
A: At the time when the blood pressure was 60/40 I again told Dr. Cereno that blood was
already needed.

Q: With that condition, Doctor, that the patient had 60/40 blood pressure you did not
decide on transfusing blood to him?
A: I was asking for blood but there was no blood available.
Q: From whom did you ask?
A: From the surgeon. According to Dr. Zafe there was only 500 cc but still for crossmatching.18

the latters left lung. Even then, however, immediate blood transfusion was not feasible
because:

From the aforesaid testimony, the trial court ruled that there was negligence on the part
of petitioners for their failure to have the blood ready for transfusion. It was alleged that
at 11:15 P.M., the 500 cc of blood was given to Dr. Realuyo by Raymonds parents. At
11:45 P.M., when Dr. Tatad was asking for the blood, 30 minutes had passed. Yet, the
blood was not ready for transfusion as it was still being cross-matched.19 It took another
two hours before blood was finally transfused to Raymond at 1:40 A.M. of 17 September
1995.

A: I did not transfuse blood because I had to control the bleeders. If you will transfuse
blood just the same the blood that you transfuse will be lost. After evacuation of blood
and there is no more bleeding

Again, such is a mistaken conclusion.

Q: So what was the cause of the delay why you only transfuse blood after 45 minutes?

First, the alleged delay in the cross-matching of the blood, if there was any, cannot be
attributed as the fault of the petitioners. The petitioners were never shown to be
responsible for such delay. It is highly unreasonable and the height of injustice if
petitioners were to be sanctioned for lapses in procedure that does not fall within their
duties and beyond their control.

A: We have to look for some other lesions. It does not mean that when you slice the chest
you will see the lesions already.21

Second, Dr. Cereno, in his unchallenged testimony, aptly explained the apparent delay in
the transfusion of blood on Raymond before and during the operation.
Before the operation, Dr. Cereno explained that the reason why no blood transfusion was
made on Raymond was because they did not then see the need to administer such
transfusion, viz:
Q: Now, you stated in your affidavit that prior to the operation you were informed that
there was 500 cc of blood available and was still to be cross-matched. What time was that
when you were informed that 500 cc of blood was due for crossmatching?
A: I am not sure of the time.
Q: But certainly, you learned of that fact that there was 500 cc of blood, which was due
for crossmatching immediately prior to the operation?
A: Yes, sir.
Q: And the operation was done at 12:15 of September 17?
A: Yes, sir.
Q: And that was the reason why you could not use the blood because it was being
crossmatched?
A: No, sir. That was done only for a few minutes. We did not transfuse at that time
because there was no need. There is a necessity to transfuse blood when we saw there is
gross bleeding inside the body. 20 (Emphasis supplied)
During the operation, on the other hand, Dr. Cereno was already able to discover that
3,200 cc of blood was stocked in the thoracic cavity of Raymond due to the puncture in

Q: Now considering the loss of blood suffered by Raymund Olavere, why did you not
immediately transfuse blood to the patient and you waited for 45 minutes to elapse
before transfusing the blood?

Q: It took you 45 minutes to evacuate the blood?


A: The evacuation did not take 45 minutes.

(Emphasis supplied)
Again, the foregoing testimonies of Dr. Cereno went unchallenged or unrebutted. The
parents of Raymond were not able to present any expert witness to dispute the course of
action taken by the petitioners.
Causation Not Proven
In medical negligence cases, it is settled that the complainant has the burden of
establishing breach of duty on the part of the doctors or surgeons. It must be proven that
such breach of duty has a causal connection to the resulting death of the patient.22 A
verdict in malpractice action cannot be based on speculation or conjecture. Causation
must be proven within a reasonable medical probability based upon competent expert
testimony.
The parents of Raymond failed in this respect. Aside from their failure to prove negligence
on the part of the petitioners, they also failed to prove that it was petitioners fault that
caused the injury. Their cause stands on the mere assumption that Raymonds life would
have been saved had petitioner surgeons immediately operated on him; had the blood
been cross-matched immediately and had the blood been transfused immediately. There
was, however, no proof presented that Raymonds life would have been saved had those
things been done. Those are mere assumptions and cannot guarantee their desired result.
Such cannot be made basis of a decision in this case, especially considering that the
name, reputation and career of petitioners are at stake.
The Court understands the parents grief over their sons death.1wphi1 That
notwithstanding, it cannot hold petitioners liable. It was noted that Raymond, who was a
victim of a stabbing incident, had multiple wounds when brought to the hospital. Upon
opening of his thoracic cavity, it was discovered that there was gross bleeding inside the
body. Thus, the need for petitioners to control first what was causing the bleeding. Despite
the situation that evening i.e. numerous patients being brought to the hospital for

emergency treatment considering that it was the height of the Peafrancia Fiesta, it was
evident that petitioners exerted earnest efforts to save the life of Raymond. It was just
unfortunate that the loss of his life was not prevented.
In the case of Dr. Cruz v. CA, it was held that "[d]octors are protected by a special law.
They are not guarantors of care. They do not even warrant a good result. They are not
insurers against mishaps or unusual consequences. Furthermore, they are not liable for
honest mistake of judgment"23
This Court affirms the ruling of the CA that the BRMC is not an indispensible party. The
core issue as agreed upon by the parties and stated in the pre-trial order is whether
petitioners were negligent in the performance of their duties. It pertains to acts/omissions
of petitioners for which they could be held liable. The cause of action against petitioners
may be prosecuted fully and the determination of their liability may be arrived at without
impleading the hospital where they are employed. As such, the BRMC cannot be
considered an indispensible party without whom no final determination can be had of an
action.24
IN THE LIGHT OF THE FOREGOING, the instant Petition for Review on Certiorari is hereby
GRANTED. The Court of Appeals decision dated 21 February 2005 in CA-G.R. CV No. 65800
is hereby REVERSED and SET ASIDE. No costs.
SO ORDERED.

FIRST DIVISION
G.R. No. 163753
January 15, 2014
DR. ENCARNACION C. LUMANTAS, M.D., Petitioner, vs. HANZ CALAPIZ, REPRESENTED BY
HIS PARENTS, HILARIO CALAPIZ, JR. and HERLITA CALAPIZ, Respondent.
DECISION
BERSAMIN, J.:
The acquittal of the accused does not necessarily mean his absolution from civil liability.
The Case
In this appeal, an accused desires the reversal of the decision promulgated on February
20, 2003,1 whereby the Court of Appeals (CA) affirmed the judgment rendered on August
6, 1999 by the Regional Trial Court (RTC), Branch 13, in Oroquieta City ordering him to pay
moral damages despite his acquittal of the crime of reckless imprudence resulting in
serious physical injuries charged against him.2
Antecedents
On January 16, 1995, Spouses Hilario Calapiz, Jr. and Herlita Calapiz brought their 8-yearold son, Hanz Calapiz (Hanz), to the Misamis Occidental Provincial Hospital, Oroquieta
City, for an emergency appendectomy. Hanz was attended to by the petitioner, who
suggested to the parents that Hanz also undergo circumcision at no added cost to spare
him the pain. With the parents consent, the petitioner performed the coronal type of
circumcision on Hanz after his appendectomy. On the following day, Hanz complained of
pain in his penis, which exhibited blisters. His testicles were swollen. The parents noticed
that the child urinated abnormally after the petitioner forcibly removed the catheter, but
the petitioner dismissed the abnormality as normal. On January 30, 1995, Hanz was
discharged from the hospital over his parents protestations, and was directed to continue
taking antibiotics.
On February 8, 1995, Hanz was confined in a hospital because of the abscess formation
between the base and the shaft of his penis. Presuming that the ulceration was brought
about by Hanzs appendicitis, the petitioner referred him to Dr. Henry Go, an urologist,
who diagnosed the boy to have a damaged urethra. Thus, Hanz underwent cystostomy,
and thereafter was operated on three times to repair his damaged urethra.
When his damaged urethra could not be fully repaired and reconstructed, Hanzs parents
brought a criminal charge against the petitioner for reckless imprudence resulting to
serious physical injuries. On April 17, 1997, the information3 was filed in the Municipal
Trial Court in Cities of Oroquieta City (MTCC), to which the latter pleaded not guilty on May
22, 1998.4 Under the order of April 30, 1999, the case was transferred to the RTC
pursuant to Supreme Court Circular No. 11-99.5
At the trial, the Prosecution presented several witnesses, including Dr. Rufino Agudera as
an expert witness and as the physician who had operated on Hanz twice to repair the
damaged urethra. Dr. Agudera testified that Hanz had been diagnosed to have urethral
stricture and cavernosal injury left secondary to trauma that had necessitated the conduct
of two operations to strengthen and to lengthen the urethra. Although satisfactorily
explaining that the injury to the urethra had been caused by trauma, Dr. Agudera could
not determine the kind of trauma that had caused the injury.

In his defense, the petitioner denied the charge. He contended that at the time of his
examination of Hanz on January 16, 1995, he had found an accumulation of pus at the
vicinity of the appendix two to three inches from the penis that had required immediate
surgical operation; that after performing the appendectomy, he had circumcised Hanz
with his parents consent by using a congo instrument, thereby debunking the parents
claim that their child had been cauterized; that he had then cleared Hanz on January 27,
1995 once his fever had subsided; that he had found no complications when Hanz
returned for his follow up check-up on February 2, 1995; and that the abscess formation
between the base and the shaft of the penis had been brought about by Hanzs burst
appendicitis.
Ruling of the RTC
In its decision rendered on August 6, 1999,6 the RTC acquitted the petitioner of the crime
charged for insufficiency of the evidence. It held that the Prosecutions evidence did not
show the required standard of care to be observed by other members of the medical
profession under similar circumstances. Nonetheless, the RTC ruled that the petitioner was
liable for moral damages because there was a preponderance of evidence showing that
Hanz had received the injurious trauma from his circumcision by the petitioner. The
decision disposed as follows:
WHEREFORE, for insufficiency of evidence, this court renders judgment acquitting the
accused, Dr. Encarnacion Lumantas, of reckless imprudence resulting in serious physical
injuries, but ordering him to pay Hanz Calapiz P50,000.00 as moral damages. No costs.
SO ORDERED.
Ruling of the CA
On appeal, the CA affirmed the RTC,7 sustaining the award of moral damages. It opined
that even if the petitioner had been acquitted of the crime charged, the acquittal did not
necessarily mean that he had not incurred civil liability considering that the Prosecution
had preponderantly established the sufferings of Hanz as the result of the circumcision.
The petitioner moved for reconsideration, but the CA denied the motion on April 28,
2004.8
Hence, this appeal.
Issue
Whether the CA erred in affirming the petitioners civil liability despite his acquittal of the
crime of reckless imprudence resulting in serious physical injuries.
Ruling
The petition for review lacks merit.
It is axiomatic that every person criminally liable for a felony is also civilly liable.9
Nevertheless, the acquittal of an accused of the crime charged does not necessarily

extinguish his civil liability. In Manantan v. Court of Appeals,10 the Court elucidates on the
two kinds of acquittal recognized by our law as well as on the different effects of acquittal
on the civil liability of the accused, viz:
Our law recognizes two kinds of acquittal, with different effects on the civil liability of the
accused.1wphi1 First is an acquittal on the ground that the accused is not the author of
the act or omission complained of. This instance closes the door to civil liability, for a
person who has been found to be not the perpetrator of any act or omission cannot and
can never be held liable for such act or omission. There being no delict, civil liability ex
delicto is out of the question, and the civil action, if any, which may be instituted must be
based on grounds other than the delict complained of. This is the situation contemplated
in Rule 111 of the Rules of Court. The second instance is an acquittal based on reasonable
doubt on the guilt of the accused. In this case, even if the guilt of the accused has not
been satisfactorily established, he is not exempt from civil liability which may be proved
by preponderance of evidence only.
The Rules of Court requires that in case of an acquittal, the judgment shall state "whether
the evidence of the prosecution absolutely failed to prove the guilt of the accused or
merely failed to prove his guilt beyond reasonable doubt. In either case, the judgment
shall determine if the act or omission from which the civil liability might arise did not
exist."11
Conformably with the foregoing, therefore, the acquittal of an accused does not prevent a
judgment from still being rendered against him on the civil aspect of the criminal case
unless the court finds and declares that the fact from which the civil liability might arise
did not exist.
Although it found the Prosecutions evidence insufficient to sustain a judgment of
conviction against the petitioner for the crime charged, the RTC did not err in determining
and adjudging his civil liability for the same act complained of based on mere
preponderance of evidence.12 In this connection, the Court reminds that the acquittal for
insufficiency of the evidence did not require that the complainants recovery of civil
liability should be through the institution of a separate civil action for that purpose.13
The petitioners contention that he could not be held civilly liable because there was no
proof of his negligence deserves scant consideration. The failure of the Prosecution to
prove his criminal negligence with moral certainty did not forbid a finding against him that
there was preponderant evidence of his negligence to hold him civilly liable.14 With the
RTC and the CA both finding that Hanz had sustained the injurious trauma from the hands
of the petitioner on the occasion of or incidental to the circumcision, and that the trauma
could have been avoided, the Court must concur with their uniform findings. In that
regard, the Court need not analyze and weigh again the evidence considered in the
proceedings a quo. The Court, by virtue of its not being a trier of facts, should now accord
the highest respect to the factual findings of the trial court as affirmed by the CA in the
absence of a clear showing by the petitioner that such findings were tainted with
arbitrariness, capriciousness or palpable error.
Every person is entitled to the physical integrity of his body.1wphi1 Although we have
long advocated the view that any physical injury, like the loss or diminution of the use of
any part of ones body, is not equatable to a pecuniary loss, and is not susceptible of
exact monetary estimation, civil damages should be assessed once that integrity has

been violated. The assessment is but an imperfect estimation of the true value of ones
body. The usual practice is to award moral damages for the physical injuries sustained.15
In Hanzs case, the undesirable outcome of the circumcision performed by the petitioner
forced the young child to endure several other procedures on his penis in order to repair
his damaged urethra. Surely, his physical and moral sufferings properly warranted the
amount of P50,000.00 awarded as moral damages.
Many years have gone by since Hanz suffered the injury. Interest of 6% per annum should
then be imposed on the award as a sincere means of adjusting the value of the award to a
level that is not only reasonable but just and commensurate. Unless we make the
adjustment in the permissible manner by prescribing legal interest on the award, his
sufferings would be unduly compounded. For that purpose, the reckoning of interest
should be from the filing of the criminal information on April 17, 1997, the making of the
judicial demand for the liability of the petitioner.
WHEREFORE, the Court AFFIRMS the decision promulgated on February 20, 2003, with the
modification that legal interest of 6% per annum to start from April 17, 1997 is imposed
on the award of:P50,000.00 as moral damages; and ORDERS the petitioner to pay the
costs of suit.
SO ORDERED.

FIRST DIVISION
G.R. No. 192123
March 10, 2014
DR. FERNANDO P. SOLIDUM, Petitioner, vs. PEOPLE OF THE PHILIPPINES, Respondent.
DECISION
BERSAMIN, J.:

The case was initially filed in the Metropolitan Trial Court of Manila, but was transferred to
the RTC pursuant to Section 5 of Republic Act No. 8369 (The Family Courts Act of 1997),15
where it was docketed as Criminal Case No. 01-190889.

This appeal is taken by a physician-anesthesiologist who has been pronounced guilty of


reckless imprudence resulting in serious physical injuries by the Regional Trial Court (RTC)
and the Court of Appeals (CA). He had been part of the team of anesthesiologists during
the surgical pull-through operation conducted on a three-year old patient born with an
imperforate anus.1

On July 19, 2004, the RTC rendered its judgment finding Dr. Solidum guilty beyond
reasonable doubt of reckless imprudence resulting to serious physical injuries,16
decreeing:

The antecedents are as follows:


Gerald Albert Gercayo (Gerald) was born on June 2, 19922 with an imperforate anus. Two
days after his birth, Gerald underwent colostomy, a surgical procedure to bring one end of
the large intestine out through the abdominal wall,3 enabling him to excrete through a
colostomy bag attached to the side of his body.4
On May 17, 1995, Gerald, then three years old, was admitted at the Ospital ng Maynila for
a pull-through operation.5 Dr. Leandro Resurreccion headed the surgical team, and was
assisted by Dr. Joselito Luceo, Dr. Donatella Valea and Dr. Joseph Tibio. The
anesthesiologists included Dr. Marichu Abella, Dr. Arnel Razon and petitioner Dr. Fernando
Solidum (Dr. Solidum).6 During the operation, Gerald experienced bradycardia,7 and went
into a coma.8 His coma lasted for two weeks,9 but he regained consciousness only after a
month.10 He could no longer see, hear or move.11
Agitated by her sons helpless and unexpected condition, Ma. Luz Gercayo (Luz) lodged a
complaint for reckless imprudence resulting in serious physical injuries with the City
Prosecutors Office of Manila against the attending physicians.12
Upon a finding of probable cause, the City Prosecutors Office filed an information solely
against Dr. Solidum,13 alleging:
That on or about May 17, 1995, in the City of Manila, Philippines, the said accused, being
then an anesthesiologist at the Ospital ng Maynila, Malate, this City, and as such was
tasked to administer the anesthesia on three-year old baby boy GERALD ALBERT
GERCAYO, represented by his mother, MA. LUZ GERCAYO, the former having been born
with an imperforate anus [no anal opening] and was to undergo an operation for anal
opening [pull through operation], did then and there willfully, unlawfully and feloniously
fail and neglect to use the care and diligence as the best of his judgment would dictate
under said circumstance, by failing to monitor and regulate properly the levels of
anesthesia administered to said GERALD ALBERT GERCAYO and using 100% halothane and
other anesthetic medications, causing as a consequence of his said carelessness and
negligence, said GERALD ALBERT GERCAYO suffered a cardiac arrest and consequently a
defect called hypoxic encephalopathy meaning insufficient oxygen supply in the brain,
thereby rendering said GERALD ALBERT GERCAYO incapable of moving his body, seeing,
speaking or hearing, to his damage and prejudice.
Contrary to law.14

Judgment of the RTC

WHEREFORE, premises considered, the Court finds accused DR. FERNANDO P. SOLIDUM
GUILTY beyond reasonable doubt as principal of the crime charged and is hereby
sentenced to suffer the indeterminate penalty of TWO (2) MONTHS and ONE (1) DAY of
arresto mayor as minimum to ONE (1) YEAR, ONE (1) MONTH and TEN (10) DAYS of prision
correccional as maximum and to indemnify, jointly and severally with the Ospital ng
Maynila, Dr. Anita So and Dr. Marichu Abella, private complainant Luz Gercayo, the
amount of P500,000.00 as moral damages and P100,000.00 as exemplary damages and
to pay the costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby
CANCELLED.
SO ORDERED.17
Upon motion of Dr. Anita So and Dr. Marichu Abella to reconsider their solidary liability,18
the RTC excluded them from solidary liability as to the damages, modifying its decision as
follows:
WHEREFORE, premises considered, the Court finds accused Dr. Fernando Solidum, guilty
beyond reasonable doubt as principal of the crime charged and is hereby sentenced to
suffer the indeterminate penalty of two (2) months and one (1) day of arresto mayor as
minimum to one (1) year, one (1) month and ten (10) days of prision correccional as
maximum and to indemnify jointly and severally with Ospital ng Maynila, private
complainant Luz Gercayo the amount of P500,000.00 as moral damages and P100,000 as
exemplary damages and to pay the costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby
cancelled.19
Decision of the CA
On January 20, 2010, the CA affirmed the conviction of Dr. Solidum,20 pertinently stating
and ruling:
The case appears to be a textbook example of res ipsa loquitur.
xxxx
x x x [P]rior to the operation, the child was evaluated and found fit to undergo a major
operation. As noted by the OSG, the accused himself testified that pre-operation tests
were conducted to ensure that the child could withstand the surgery. Except for his

imperforate anus, the child was healthy. The tests and other procedures failed to reveal
that he was suffering from any known ailment or disability that could turn into a
significant risk. There was not a hint that the nature of the operation itself was a causative
factor in the events that finally led to hypoxia.
In short, the lower court has been left with no reasonable hypothesis except to attribute
the accident to a failure in the proper administration of anesthesia, the gravamen of the
charge in this case. The High Court elucidates in Ramos vs. Court of Appeals 321 SCRA
584
In cases where the res ipsa loquitur is applicable, the court is permitted to find a physician
negligent upon proper proof of injury to the patient, without the aid of expert testimony,
where the court from its fund of common knowledge can determine the proper standard of
care.
Where common knowledge and experience teach that a resulting injury would not have
occurred to the patient if due care had been exercised, an inference of negligence may be
drawn giving rise to an application of the doctrine of res ipsa loquitur without medical
evidence, which is ordinarily required to show not only what occurred but how and why it
occurred. When the doctrine is appropriate, all that the patient must do is prove a nexus
between the particular act or omission complained of and the injury sustained while under
the custody and management of the defendant without need to produce expert medical
testimony to establish the standard of care. Resort to res ipsa loquitur is allowed because
there is no other way, under usual and ordinary conditions, by which the patient can
obtain redress for injury suffered by him.
The lower court has found that such a nexus exists between the act complained of and
the injury sustained, and in line with the hornbook rules on evidence, we will afford the
factual findings of a trial court the respect they deserve in the absence of a showing of
arbitrariness or disregard of material facts that might affect the disposition of the case.
People v. Paraiso 349 SCRA 335.

I.
THE HONORABLE COURT OF APPEALS ERRED IN AFFIRMING THE DECISION OF THE LOWER
COURT IN UPHOLDING THE PETITIONERS CONVICTION FOR THE CRIME CHARGED BASED
ON THE TRIAL COURTS OPINION, AND NOT ON THE BASIS OF THE FACTS ESTABLISHED
DURING THE TRIAL. ALSO, THERE IS A CLEAR MISAPPREHENSION OF FACTS WHICH IF
CORRECTED, WILL RESULT TO THE ACQUITTAL OF THE PETITIONER. FURTHER, THE
HONORABLE COURT ERRED IN AFFIRMING THE SAID DECISION OF THE LOWER COURT, AS
THIS BREACHES THE CRIMINAL LAW PRINCIPLE THAT THE PROSECUTION MUST PROVE THE
ALLEGATIONS OF THE INFORMATION BEYOND REASONABLE DOUBT, AND NOT ON THE
BASIS OF ITS PRESUMPTIVE CONCLUSION.
II.
THE HONORABLE COURT OF APPEALS ERRED IN APPLYING THE PRINCIPLE OF RES IPSA
LOQUITOR (sic) WHEN THE DEFENSE WAS ABLE TO PROVE THAT THERE IS NO
NEGLIGENCE ON THE PART OF THE PETITIONER, AND NO OVERDOSING IN THE
APPLICATION OF THE ANESTHETIC AGENT BECAUSE THERE WAS NO 100% HALOTHANE
ADMINISTERED TO THE CHILD, BUT ONLY ONE (1%) PERCENT AND THE APPLICATION
THEREOF, WAS REGULATED BY AN ANESTHESIA MACHINE. THUS, THE APPLICATION OF
THE PRINCIPLE OF RES IPSA LOQUITOR (sic) CONTRADICTED THE ESTABLISHED FACTS
AND THE LAW APPLICABLE IN THE CASE.
III.
THE AWARD OF MORAL DAMAGES AND EXEMPLARY DAMAGES IS NOT JUSTIFIED THERE
BEING NO NEGLIGENCE ON THE PART OF THE PETITIONER. ASSUMING THAT THE CHILD IS
ENTITLED TO FINANCIAL CONSIDERATION, IT SHOULD BE ONLY AS A FINANCIAL
ASSISTANCE, BECAUSE THERE WAS NO NEGLIGENCE, AND NO OVERDOSING OF
ANESTHETIC AGENT AND AS SUCH, THE AWARD IS SO EXCESSIVE, AND NO FACTUAL AND
LEGAL BASIS.23

The res ipsa loquitur test has been known to be applied in criminal cases. Although it
creates a presumption of negligence, it need not offend due process, as long as the
accused is afforded the opportunity to go forward with his own evidence and prove that
he has no criminal intent. It is in this light not inconsistent with the constitutional
presumption of innocence of an accused.

To simplify, the following are the issues for resolution, namely: (a) whether or not the
doctrine of res ipsa loquitur was applicable herein; and (b) whether or not Dr. Solidum was
liable for criminal negligence.

IN VIEW OF THE FOREGOING, the modified decision of the lower court is affirmed.

The appeal is meritorious.

SO ORDERED.21

Applicability of the Doctrine of Res Ipsa Loquitur

Dr. Solidum filed a motion for reconsideration, but the CA denied his motion on May 7,
2010.22

Res ipsa loquitur is literally translated as "the thing or the transaction speaks for itself."
The doctrine res ipsa loquitur means that "where the thing which causes injury is shown to
be under the management of the defendant, and the accident is such as in the ordinary
course of things does not happen if those who have the management use proper care, it
affords reasonable evidence, in the absence of an explanation by the defendant, that the
accident arose from want of care."24 It is simply "a recognition of the postulate that, as a
matter of common knowledge and experience, the very nature of certain types of
occurrences may justify an inference of negligence on the part of the person who controls
the instrumentality causing the injury in the absence of some explanation by the

Hence, this appeal.


Issues
Dr. Solidum avers that:

Ruling

defendant who is charged with negligence. It is grounded in the superior logic of ordinary
human experience and on the basis of such experience or common knowledge,
negligence may be deduced from the mere occurrence of the accident itself.
Hence, res ipsa loquitur is applied in conjunction with the doctrine of common
knowledge."25
Jarcia, Jr. v. People26 has underscored that the doctrine is not a rule of substantive law,
but merely a mode of proof or a mere procedural convenience. The doctrine, when
applicable to the facts and circumstances of a given case, is not meant to and does not
dispense with the requirement of proof of culpable negligence against the party charged.
It merely determines and regulates what shall be prima facie evidence thereof, and helps
the plaintiff in proving a breach of the duty. The doctrine can be invoked when and only
when, under the circumstances involved, direct evidence is absent and not readily
available.27
The applicability of the doctrine of res ipsa loquitur in medical negligence cases was
significantly and exhaustively explained in Ramos v. Court of Appeals,28 where the Court
said
Medical malpractice cases do not escape the application of this doctrine. Thus, res ipsa
loquitur has been applied when the circumstances attendant upon the harm are
themselves of such a character as to justify an inference of negligence as the cause of
that harm. The application of res ipsa loquitur in medical negligence cases presents a
question of law since it is a judicial function to determine whether a certain set of
circumstances does, as a matter of law, permit a given inference.
Although generally, expert medical testimony is relied upon in malpractice suits to prove
that a physician has done a negligent act or that he has deviated from the standard
medical procedure, when the doctrine of res ipsa loquitur is availed by the plaintiff, the
need for expert medical testimony is dispensed with because the injury itself provides the
proof of negligence. The reason is that the general rule on the necessity of expert
testimony applies only to such matters clearly within the domain of medical science, and
not to matters that are within the common knowledge of mankind which may be testified
to by anyone familiar with the facts. Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has been treated or operated
upon with a reasonable degree of skill and care. However, testimony as to the statements
and acts of physicians and surgeons, external appearances, and manifest conditions
which are observable by any one may be given by non-expert witnesses. Hence, in cases
where the res ipsa loquitur is applicable, the court is permitted to find a physician
negligent upon proper proof of injury to the patient, without the aid of expert testimony,
where the court from its fund of common knowledge can determine the proper standard of
care. Where common knowledge and experience teach that a resulting injury would not
have occurred to the patient if due care had been exercised, an inference of negligence
may be drawn giving rise to an application of the doctrine of res ipsa loquitur without
medical evidence, which is ordinarily required to show not only what occurred but how
and why it occurred. When the doctrine is appropriate, all that the patient must do is
prove a nexus between the particular act or omission complained of and the injury
sustained while under the custody and management of the defendant without need to
produce expert medical testimony to establish the standard of care. Resort to res ipsa

loquitur is allowed because there is no other way, under usual and ordinary conditions, by
which the patient can obtain redress for injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following situations:
leaving of a foreign object in the body of the patient after an operation, injuries sustained
on a healthy part of the body which was not under, or in the area, of treatment, removal
of the wrong part of the body when another part was intended, knocking out a tooth while
a patients jaw was under anesthetic for the removal of his tonsils, and loss of an eye
while the patient plaintiff was under the influence of anesthetic, during or following an
operation for appendicitis, among others.
Nevertheless, despite the fact that the scope of res ipsa loquitur has been measurably
enlarged, it does not automatically apply to all cases of medical negligence as to
mechanically shift the burden of proof to the defendant to show that he is not guilty of the
ascribed negligence. Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily
used but a rule to be cautiously applied, depending upon the circumstances of each case.
It is generally restricted to situations in malpractice cases where a layman is able to say,
as a matter of common knowledge and observation, that the consequences of
professional care were not as such as would ordinarily have followed if due care had been
exercised. A distinction must be made between the failure to secure results, and the
occurrence of something more unusual and not ordinarily found if the service or treatment
rendered followed the usual procedure of those skilled in that particular practice. It must
be conceded that the doctrine of res ipsa loquitur can have no application in a suit against
a physician or surgeon which involves the merits of a diagnosis or of a scientific
treatment. The physician or surgeon is not required at his peril to explain why any
particular diagnosis was not correct, or why any particular scientific treatment did not
produce the desired result. Thus, res ipsa loquitur is not available in a malpractice suit if
the only showing is that the desired result of an operation or treatment was not
accomplished. The real question, therefore, is whether or not in the process of the
operation any extraordinary incident or unusual event outside of the routine performance
occurred which is beyond the regular scope of customary professional activity in such
operations, which, if unexplained would themselves reasonably speak to the average man
as the negligent cause or causes of the untoward consequence. If there was such
extraneous intervention, the doctrine of res ipsa loquitur may be utilized and the
defendant is called upon to explain the matter, by evidence of exculpation, if he could.
In order to allow resort to the doctrine, therefore, the following essential requisites must
first be satisfied, to wit: (1) the accident was of a kind that does not ordinarily occur
unless someone is negligent; (2) the instrumentality or agency that caused the injury was
under the exclusive control of the person charged; and (3) the injury suffered must not
have been due to any voluntary action or contribution of the person injured.29
The Court considers the application here of the doctrine of res ipsa loquitur inappropriate.
Although it should be conceded without difficulty that the second and third elements were
present, considering that the anesthetic agent and the instruments were exclusively
within the control of Dr. Solidum, and that the patient, being then unconscious during the
operation, could not have been guilty of contributory negligence, the first element was
undeniably wanting. Luz delivered Gerald to the care, custody and control of his
physicians for a pull-through operation. Except for the imperforate anus, Gerald was then
of sound body and mind at the time of his submission to the physicians. Yet, he
experienced bradycardia during the operation, causing loss of his senses and rendering

him immobile. Hypoxia, or the insufficiency of oxygen supply to the brain that caused the
slowing of the heart rate, scientifically termed as bradycardia, would not ordinarily occur
in the process of a pull-through operation, or during the administration of anesthesia to
the patient, but such fact alone did not prove that the negligence of any of his attending
physicians, including the anesthesiologists, had caused the injury. In fact, the
anesthesiologists attending to him had sensed in the course of the operation that the lack
of oxygen could have been triggered by the vago-vagal reflex, prompting them to
administer atropine to the patient.30
This conclusion is not unprecedented. It was similarly reached in Swanson v. Brigham,31
relevant portions of the decision therein being as follows:
On January 7, 1973, Dr. Brigham admitted 15-year-old Randall Swanson to a hospital for
the treatment of infectious mononucleosis. The patient's symptoms had included a
swollen throat and some breathing difficulty. Early in the morning of January 9 the patient
was restless, and at 1:30 a.m. Dr. Brigham examined the patient. His inspection of the
patient's air passage revealed that it was in satisfactory condition. At 4:15 a.m. Dr.
Brigham received a telephone call from the hospital, advising him that the patient was
having respiratory difficulty. The doctor ordered that oxygen be administered and he
prepared to leave for the hospital. Ten minutes later, 4:25 a.m., the hospital called a
second time to advise the doctor that the patient was not responding. The doctor ordered
that a medicine be administered, and he departed for the hospital. When he arrived, the
physician who had been on call at the hospital had begun attempts to revive the patient.
Dr. Brigham joined him in the effort, but the patient died.
The doctor who performed the autopsy concluded that the patient died between 4:25 a.m.
and 4:30 a.m. of asphyxia, as a result of a sudden, acute closing of the air passage. He
also found that the air passage had been adequate to maintain life up to 2 or 3 minutes
prior to death. He did not know what caused the air passage to suddenly close.
xxxx
It is a rare occurrence when someone admitted to a hospital for the treatment of
infectious mononucleosis dies of asphyxiation. But that is not sufficient to invoke res ipsa
loquitur. The fact that the injury rarely occurs does not in itself prove that the injury was
probably caused by someone's negligence. Mason v. Ellsworth, 3 Wn. App. 298, 474 P.2d
909 (1970). Nor is a bad result by itself enough to warrant the application of the doctrine.
Nelson v. Murphy, 42 Wn.2d 737, 258 P.2d 472 (1953). See 2 S. Speiser, The Negligence
Case Res Ipsa Loquitur 24:10 (1972). The evidence presented is insufficient to
establish the first element necessary for application of res ipsa loquitur doctrine. The
acute closing of the patients air passage and his resultant asphyxiation took place over a
very short period of time. Under these circumstances it would not be reasonable to infer
that the physician was negligent. There was no palpably negligent act. The common
experience of mankind does not suggest that death would not be expected without
negligence. And there is no expert medical testimony to create an inference that
negligence caused the injury.
Negligence of Dr. Solidum
In view of the inapplicability of the doctrine of res ipsa loquitur, the Court next determines
whether the CA correctly affirmed the conviction of Dr. Solidum for criminal negligence.

Negligence is defined as the failure to observe for the protection of the interests of
another person that degree of care, precaution, and vigilance that the circumstances
justly demand, whereby such other person suffers injury.32 Reckless imprudence, on the
other hand, consists of voluntarily doing or failing to do, without malice, an act from which
material damage results by reason of an inexcusable lack of precaution on the part of the
person performing or failing to perform such act.33
Dr. Solidums conviction by the RTC was primarily based on his failure to monitor and
properly regulate the level of anesthetic agent administered on Gerald by overdosing at
100% halothane. In affirming the conviction, the CA observed:
On the witness stand, Dr. Vertido made a significant turnaround. He affirmed the findings
and conclusions in his report except for an observation which, to all intents and purposes,
has become the storm center of this dispute. He wanted to correct one piece of
information regarding the dosage of the anesthetic agent administered to the child. He
declared that he made a mistake in reporting a 100% halothane and said that based on
the records it should have been 100% oxygen.
The records he was relying on, as he explains, are the following:
(a) the anesthesia record A portion of the chart in the record was marked as Exhibit 1-A
and 1-B to indicate the administration at intervals of the anesthetic agent.
(b) the clinical abstract A portion of this record that reads as follows was marked Exhibit
3A. 3B Approximately 1 hour and 45 minutes through the operation, patient was noted
to have bradycardia (CR = 70) and ATSO4 0.2 mg was immediately administered.
However, the bradycardia persisted, the inhalational agent was shut off, and the patient
was ventilated with 100% oxygen and another dose of ATSO4 0.2 mg was given. However,
the patient did not respond until no cardiac rate can be auscultated and the surgeons
were immediately told to stop the operation. The patient was put on a supine position and
CPR was initiated. Patient was given 1 amp of epinephrine initially while continuously
doing cardiac massage still with no cardiac rate appreciated; another ampule of
epinephrine was given and after 45 secs, patients vital signs returned to normal. The
entire resuscitation lasted approximately 3-5 mins. The surgeons were then told to
proceed to the closure and the childs vital signs throughout and until the end of surgery
were: BP = 110/70; CR = 116/min and RR = 20-22 cycles/min (on assisted ventilation).
Dr. Vertido points to the crucial passage in the clinical abstract that the patient was
ventilated with 100% oxygen and another dose of ATSO4 when the bradycardia persisted,
but for one reason or another, he read it as 100% halothane. He was asked to read the
anesthesia record on the percentage of the dosage indicated, but he could only
sheepishly note I cant understand the number. There are no clues in the clinical abstract
on the quantity of the anesthetic agent used. It only contains the information that the
anesthetic plan was to put the patient under general anesthesia using a nonrebreathing
system with halothane as the sole anesthetic agent and that 1 hour and 45 minutes after
the operation began, bradycardia occurred after which the inhalational agent was shut off
and the patient administered with 100% oxygen. It would be apparent that the 100%
oxygen that Dr. Vertido said should be read in lieu of 100% halothane was the pure
oxygen introduced after something went amiss in the operation and the halothane itself
was reduced or shut off.

The key question remains what was the quantity of halothane used before bradycardia
set in?
The implication of Dr. Vertidos admission is that there was no overdose of the anesthetic
agent, and the accused Dr. Solidum stakes his liberty and reputation on this conclusion.
He made the assurance that he gave his patient the utmost medical care, never leaving
the operating room except for a few minutes to answer the call of nature but leaving
behind the other members of his team Drs. Abella and Razon to monitor the operation. He
insisted that he administered only a point 1% not 100% halothane, receiving
corroboration from Dr. Abella whose initial MA in the record should be enough to show that
she assisted in the operation and was therefore conversant of the things that happened.
She revealed that they were using a machine that closely monitored the concentration of
the agent during the operation.
But most compelling is Dr. Solidums interpretation of the anesthesia record itself, as he
takes the bull by the horns, so to speak. In his affidavit, he says, reading from the record,
that the quantity of halothane used in the operation is one percent (1%) delivered at time
intervals of 15 minutes. He studiedly mentions the concentration of halothane as
reflected in the anesthesia record (Annex D of the complaint-affidavit) is only one percent
(1%) The numbers indicated in 15 minute increments for halothane is an indication that
only 1% halothane is being delivered to the patient Gerard Gercayo for his entire
operation; The amount of halothane delivered in this case which is only one percent
cannot be summated because halothane is constantly being rapidly eliminated by the
body during the entire operation.
xxxx
In finding the accused guilty, despite these explanations, the RTC argued that the volteface of Dr. Vertido on the question of the dosage of the anesthetic used on the child would
not really validate the non-guilt of the anesthesiologist. Led to agree that the halothane
used was not 100% as initially believed, he was nonetheless unaware of the implications
of the change in his testimony. The court observed that Dr. Vertido had described the
condition of the child as hypoxia which is deprivation of oxygen, a diagnosis supported by
the results of the CT Scan. All the symptoms attributed to a failing central nervous system
such as stupor, loss of consciousness, decrease in heart rate, loss of usual acuity and
abnormal motor function, are manifestations of this condition or syndrome. But why would
there be deprivation of oxygen if 100% oxygen to 1% halothane was used? Ultimately, to
the court, whether oxygen or halothane was the object of mistake, the detrimental effects
of the operation are incontestable, and they can only be led to one conclusion if the
application of anesthesia was really closely monitored, the event could not have
happened.34
The Prosecution did not prove the elements of reckless imprudence beyond reasonable
doubt because the circumstances cited by the CA were insufficient to establish that Dr.
Solidum had been guilty of inexcusable lack of precaution in monitoring the administration
of the anesthetic agent to Gerald. The Court aptly explained in Cruz v. Court of Appeals35
that:
Whether or not a physician has committed an "inexcusable lack of precaution" in the
treatment of his patient is to be determined according to the standard of care observed by

other members of the profession in good standing under similar circumstances bearing in
mind the advanced state of the profession at the time of treatment or the present state of
medical science. In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pacasio, et. al.,
this Court stated that in accepting a case, a doctor in effect represents that, having the
needed training and skill possessed by physicians and surgeons practicing in the same
field, he will employ such training, care and skill in the treatment of his patients. He
therefore has a duty to use at least the same level of care that any other reasonably
competent doctor would use to treat a condition under the same circumstances. It is in
this aspect of medical malpractice that expert testimony is essential to establish not only
the standard of care of the profession but also that the physician's conduct in the
treatment and care falls below such standard. Further, inasmuch as the causes of the
injuries involved in malpractice actions are determinable only in the light of scientific
knowledge, it has been recognized that expert testimony is usually necessary to support
the conclusion as to causation.
xxxx
In litigations involving medical negligence, the plaintiff has the burden of establishing
appellant's negligence and for a reasonable conclusion of negligence, there must be proof
of breach of duty on the part of the surgeon as well as a causal connection of such breach
and the resulting death of his patient. In Chan Lugay v. St Luke's Hospital, Inc., where the
attending physician was absolved of liability for the death of the complainants wife and
newborn baby, this Court held that:
"In order that there may be a recovery for an injury, however, it must be shown that the
injury for which recovery is sought must be the legitimate consequence of the wrong
done; the connection between the negligence and the injury must be a direct and natural
sequence of events, unbroken by intervening efficient causes. In other words, the
negligence must be the proximate cause of the injury. For, negligence, no matter in what
it consists, cannot create a right of action unless it is the proximate cause of the injury
complained of. And the proximate cause of an injury is that cause, which, in natural and
continuous sequence, unbroken by any efficient intervening cause, produces the injury,
and without which the result would not have occurred."
An action upon medical negligence whether criminal, civil or administrative calls for
the plaintiff to prove by competent evidence each of the following four elements, namely:
(a) the duty owed by the physician to the patient, as created by the physician-patient
relationship, to act in accordance with the specific norms or standards established by his
profession; (b) the breach of the duty by the physicians failing to act in accordance with
the applicable standard of care; (3) the causation, i.e., there must be a reasonably close
and causal connection between the negligent act or omission and the resulting injury; and
(4) the damages suffered by the patient.36
In the medical profession, specific norms or standards to protect the patient against
unreasonable risk, commonly referred to as standards of care, set the duty of the
physician to act in respect of the patient. Unfortunately, no clear definition of the duty of a
particular physician in a particular case exists. Because most medical malpractice cases
are highly technical, witnesses with special medical qualifications must provide guidance
by giving the knowledge necessary to render a fair and just verdict. As a result, the
standard of medical care of a prudent physician must be determined from expert
testimony in most cases; and in the case of a specialist (like an anesthesiologist), the

standard of care by which the specialist is judged is the care and skill commonly
possessed and exercised by similar specialists under similar circumstances. The specialty
standard of care may be higher than that required of the general practitioner.37
The standard of care is an objective standard by which the conduct of a physician sued for
negligence or malpractice may be measured, and it does not depend, therefore, on any
individual physicians own knowledge either. In attempting to fix a standard by which a
court may determine whether the physician has properly performed the requisite duty
toward the patient, expert medical testimony from both plaintiff and defense experts is
required. The judge, as the trier of fact, ultimately determines the standard of care, after
listening to the testimony of all medical experts.38
Here, the Prosecution presented no witnesses with special medical qualifications in
anesthesia to provide guidance to the trial court on what standard of care was applicable.
It would consequently be truly difficult, if not impossible, to determine whether the first
three elements of a negligence and malpractice action were attendant.
Although the Prosecution presented Dr. Benigno Sulit, Jr., an anesthesiologist himself who
served as the Chairman of the Committee on Ethics and Malpractice of the Philippine
Society of Anesthesiologists that investigated the complaint against Dr. Solidum, his
testimony mainly focused on how his Committee had conducted the investigation.39 Even
then, the report of his Committee was favorable to Dr. Solidum,40 to wit:
Presented for review by this committee is the case of a 3 year old male who underwent a
pull-thru operation and was administered general anesthesia by a team of anesthesia
residents. The patient, at the time when the surgeons was manipulating the recto-sigmoid
and pulling it down in preparation for the anastomosis, had bradycardia. The
anesthesiologists, sensing that the cause thereof was the triggering of the vago-vagal
reflex, administered atropine to block it but despite the administration of the drug in two
doses, cardiac arrest ensued. As the records show, prompt resuscitative measures were
administered and spontaneous cardiac function re-established in less than five (5)
minutes and that oxygen was continuously being administered throughout, unfortunately,
as later become manifest, patient suffered permanent irreversible brain damage.

Q Now under paragraph two of page 1 of your report you mentioned that after one hour
and 45 minutes after the operation, the patient experienced a bradycardia or slowing of
heart rate, now as a doctor, would you be able to tell this Honorable Court as to what
cause of the slowing of heart rate as to Gerald Gercayo?
WITNESS Well honestly sir, I cannot give you the reason why there was a bradycardia of
time because is some reason one way or another that might caused bradycardia.
FISCAL CABARON What could be the possible reason?
A Well bradycardia can be caused by anesthetic agent itself and that is a possibility, were
talking about possibility here.
Q What other possibility do you have in mind, doctor?
A Well, because it was an operation, anything can happen within that situation.
FISCAL CABARON Now, this representation would like to ask you about the slowing of
heart rate, now what is the immediate cause of the slowing of the heart rate of a person?
WITNESS Well, one of the more practical reason why there is slowing of the heart rate is
when you do a vagal reflex in the neck wherein the vagal receptors are located at the
lateral part of the neck, when you press that, you produce the slowing of the heart rate
that produce bradycardia.
Q I am pro[p]ounding to you another question doctor, what about the deficiency in the
supply of oxygen by the patient, would that also cause the slowing of the heart rate?
A Well that is a possibility sir, I mean not as slowing of the heart rate, if there is a hypoxia
or there is a low oxygen level in the blood, the normal thing for the heart is to pump or to
do not a bradycardia but a to counter act the Hypoxia that is being experienced by the
patient
(sic).

In view of the actuations of the anaesthesiologists and the administration of anaesthesia,


the committee find that the same were all in accordance with the universally accepted
standards of medical care and there is no evidence of any fault or negligence on the part
of the anaesthesiologists.
Dr. Antonio Vertido, a Senior Medico-Legal Officer of the National Bureau of Investigation,
was also presented as a Prosecution witness, but his testimony concentrated on the
results of the physical examination he had conducted on Gerald, as borne out by the
following portions of his direct examination, to wit:
FISCAL CABARON Doctor, what do you mean by General Anesthetic Agent?
WITNESS General Anesthetic Agent is a substance used in the conduction of Anesthesia
and in this case, halothane was used as a sole anesthetic agent.
xxxx

xxxx
Q Now, you made mention also doctor that the use of general anesthesia using 100%
halothane and other anesthetic medications probably were contributory to the production
of hypoxia.
A Yes, sir in general sir.41
On cross-examination, Dr. Vertido expounded more specifically on his interpretation of the
anesthesia record and the factors that could have caused Gerald to experience
bradycardia, viz:
ATTY. COMIA I noticed in, may I see your report Doctor, page 3, will you kindly read to this
Honorable court your last paragraph and if you will affirm that as if it is correct?

A "The use of General Anesthesia, that is using 100% Halothane probably will be
contributory to the production of Hypoxia and - - - -"

Q And according to you, it might also be the result of such other, some or it might be due
to operations being conducted by the doctor at the time when the operation is being done
might also contribute to that hypoxia is that correct?

ATTY COMIA And do you affirm the figure you mentioned in this Court Doctor?
A That is a possibility also.
WITNESS Based on the records, I know the - - xxxx
Q 100%?
ATTY. COMIA How will you classify now the operation conducted to this Gerald, Doctor?
A 100% based on the records.
WITNESS Well, that is a major operation sir.
Q I will show you doctor a clinical record. I am a lawyer I am not a doctor but will you
kindly look at this and tell me where is 100%, the word "one hundred" or 1-0-0, will you
kindly look at this Doctor, this Xerox copy if you can show to this Honorable Court and
even to this representation the word "one hundred" or 1-0-0 and then call me.

Q In other words, when you say major operation conducted to this Gerald, there is a
possibility that this Gerald might [be] exposed to some risk is that correct?
A That is a possibility sir.

xxxx
Q And which according to you that Gerald suffered hypoxia is that correct?
ATTY. COMIA Doctor tell this Honorable Court where is that 100, 1-0-0 and if there is, you
just call me and even the attention of the Presiding Judge of this Court. Okay, you read
one by one.

A Yes, sir.
Q And that is one of the risk of that major operation is that correct?

WITNESS Well, are you only asking 100%, sir?


A That is the risk sir.42
ATTY. COMIA Im asking you, just answer my question, did you see there 100% and 100
figures, tell me, yes or no?
WITNESS Im trying to look at the 100%, there is no 100% there sir.
ATTY. COMIA Okay, that was good, so you Honor please, may we request also temporarily,
because this is just a xerox copy presented by the fiscal, that the percentage here that
the Halothane administered by Dr. Solidum to the patient is 1% only so may we request
that this portion, temporarily your Honor, we are marking this anesthesia record as our
Exhibit 1 and then this 1% Halothane also be bracketed and the same be marked as our
Exhibit "1-A".
xxxx
ATTY. COMIA Doctor, my attention was called also when you said that there are so many
factors that contributed to Hypoxia is that correct?

At the continuation of his cross-examination, Dr. Vertido maintained that Geralds


operation for his imperforate anus, considered a major operation, had exposed him to the
risk of suffering the same condition.43 He then corrected his earlier finding that 100%
halothane had been administered on Gerald by saying that it should be 100% oxygen.44
Dr. Solidum was criminally charged for "failing to monitor and regulate properly the levels
of anesthesia administered to said Gerald Albert Gercayo and using 100% halothane and
other anesthetic medications."45 However, the foregoing circumstances, taken together,
did not prove beyond reasonable doubt that Dr. Solidum had been recklessly imprudent in
administering the anesthetic agent to Gerald. Indeed, Dr. Vertidos findings did not
preclude the probability that other factors related to Geralds major operation, which
could or could not necessarily be attributed to the administration of the anesthesia, had
caused the hypoxia and had then led Gerald to experience bradycardia. Dr. Vertido
revealingly concluded in his report, instead, that "although the anesthesiologist followed
the normal routine and precautionary procedures, still hypoxia and its corresponding side
effects did occur."46

WITNESS Yes, sir.


Q I remember doctor, according to you there are so many factors that contributed to what
you call hypoxia and according to you, when this Gerald suffered hypoxia, there are other
factors that might lead to this Hypoxia at the time of this operation is that correct?
WITNESS The possibility is there, sir.

The existence of the probability about other factors causing the hypoxia has engendered
in the mind of the Court a reasonable doubt as to Dr. Solidums guilt, and moves us to
acquit him of the crime of reckless imprudence resulting to serious physical injuries. "A
reasonable doubt of guilt," according to United States v. Youthsey:47
x x x is a doubt growing reasonably out of evidence or the lack of it. It is not a captious
doubt; not a doubt engendered merely by sympathy for the unfortunate position of the
defendant, or a dislike to accept the responsibility of convicting a fellow man. If, having
weighed the evidence on both sides, you reach the conclusion that the defendant is

guilty, to that degree of certainty as would lead you to act on the faith of it in the most
important and crucial affairs of your life, you may properly convict him. Proof beyond
reasonable doubt is not proof to a mathematical demonstration. It is not proof beyond the
possibility of mistake.
We have to clarify that the acquittal of Dr. Solidum would not immediately exempt him
from civil liability.1wphi1 But we cannot now find and declare him civilly liable because
the circumstances that have been established here do not present the factual and legal
bases for validly doing so. His acquittal did not derive only from reasonable doubt. There
was really no firm and competent showing how the injury to Gerard had been caused.
That meant that the manner of administration of the anesthesia by Dr. Solidum was not
necessarily the cause of the hypoxia that caused the bradycardia experienced by Gerard.
Consequently, to adjudge Dr. Solidum civilly liable would be to speculate on the cause of
the hypoxia. We are not allowed to do so, for civil liability must not rest on speculation but
on competent evidence.
Liability of Ospital ng Maynila
Although the result now reached has resolved the issue of civil liability, we have to
address the unusual decree of the RTC, as affirmed by the CA, of expressly holding Ospital
ng Maynila civilly liable jointly and severally with Dr. Solidum. The decree was flawed in
logic and in law.
In criminal prosecutions, the civil action for the recovery of civil liability that is deemed
instituted with the criminal action refers only to that arising from the offense charged.48 It
is puzzling, therefore, how the RTC and the CA could have adjudged Ospital ng Maynila
jointly and severally liable with Dr. Solidum for the damages despite the obvious fact that
Ospital ng Maynila, being an artificial entity, had not been charged along with Dr. Solidum.
The lower courts thereby acted capriciously and whimsically, which rendered their
judgment against Ospital ng Maynila void as the product of grave abuse of discretion
amounting to lack of jurisdiction.
Not surprisingly, the flawed decree raises other material concerns that the RTC and the CA
overlooked. We deem it important, then, to express the following observations for the
instruction of the Bench and Bar.
For one, Ospital ng Maynila was not at all a party in the proceedings. Hence, its
fundamental right to be heard was not respected from the outset. The R TC and the CA
should have been alert to this fundamental defect. Verily, no person can be prejudiced by
a ruling rendered in an action or proceeding in which he was not made a party. Such a rule
would enforce the constitutional guarantee of due process of law.
Moreover, Ospital ng Maynila could be held civilly liable only when subsidiary liability
would be properly enforceable pursuant to Article 103 of the Revised Penal Code. But the
subsidiary liability seems far-fetched here. The conditions for subsidiary liability to attach
to Ospital ng Maynila should first be complied with. Firstly, pursuant to Article 103 of the
Revised Penal Code, Ospital ng Maynila must be shown to be a corporation "engaged in
any kind of industry." The term industry means any department or branch of art,
occupation or business, especially one that employs labor and capital, and is engaged in
industry.49 However, Ospital ng Maynila, being a public hospital, was not engaged in
industry conducted for profit but purely in charitable and humanitarian work.50 Secondly,

assuming that Ospital ng Maynila was engaged in industry for profit, Dr. Solidum must be
shown to be an employee of Ospital ng Maynila acting in the discharge of his duties
during the operation on Gerald. Yet, he definitely was not such employee but a consultant
of the hospital. And, thirdly, assuming that civil liability was adjudged against Dr. Solidum
as an employee (which did not happen here), the execution against him was unsatisfied
due to his being insolvent.
WHEREFORE, the Court GRANTS the petition for review on certiorari; REVERSES AND SETS
ASIDE the decision promulgated on January 20, 2010; ACQUITS Dr. Fernando P. Solidum of
the crime of reckless imprudence resulting to serious physical injuries; and MAKES no
pronouncement on costs of suit.
SO ORDERED.

FIRST DIVISION
G.R. No. 150355
July 31, 2006
MANILA DOCTORS HOSPITAL, petitioner, vs. SO UN CHUA and VICKY TY, respondents.
DECISION
AUSTRIA-MARTINEZ, J.:
Before this Court is a Petition for Review on Certiorari under Rule 45 questioning the
Decision1 dated October 2, 2001 promulgated by the Court of Appeals (CA) in CA-G.R. CV
No. 61581, which affirmed the Decision dated September 30, 1997 of the Regional Trial
Court (RTC), Branch 159, Pasig City, but which reduced the award of damages.
This case originated from an action for damages filed with the RTC by respondents So Un
Chua and Vicky Ty against petitioner Manila Doctors Hospital.2 The complaint is premised
on the alleged unwarranted actuations of the petitioner towards its patient, respondent So
Un Chua (Chua), who was confined for hypertension, diabetes, and related illnesses.
The antecedents of the case follow:
On December 13, 1993, respondents filed a Complaint averring that on October 30, 1990,
respondent Chua, the mother of respondent Vicky Ty, was admitted in petitioner's hospital
for hypertension and diabetes; that while respondent Chua was confined, Judith Chua, the
sister of respondent Ty, had been likewise confined for injuries suffered in a vehicular
accident; that partial payments of the hospital bills were made, totaling P435,800.00; that
after the discharge of Judith Chua, respondent Chua remained in confinement and the
hospital bills for both patients accumulated; that respondent Chua was pressured by the
petitioner, through its Credit and Collection Department, to settle the unpaid bills; that
respondent Ty represented that she will settle the bills as soon as the funds become
available; that respondent Ty pleaded to the management that in view of the physical
condition of her mother, respondent Chua, the correspondences relating to the settlement
of the unpaid hospital bills should be relayed to the former; that these pleas were
unheeded by the petitioner; that petitioner threatened to implement unpleasant measures
unless respondent Ty undertakes her mother's obligation as well as the obligation of her
sister, Judith Chua, to pay the hospitalization expenses; that petitioner made good its
threat and employed unethical, unpleasant and unlawful methods which allegedly
worsened the condition of respondent Chua, particularly, by (i) cutting off the telephone
line in her room and removing the air-conditioning unit, television set, and refrigerator, (ii)
refusing to render medical attendance and to change the hospital gown and bed sheets,
and (iii) barring the private nurses or midwives from assisting the patient. Respondents
thus prayed for the award of moral damages, exemplary damages, and attorney's fees.
In its Answer, Amended Answer, and Rejoinder, petitioner specifically denied the material
averments of the Complaint and Reply, and interposed its counterclaims arguing that as
early as one week after respondent Chua had been admitted to its hospital, Dr. Rody Sy,
her attending physician, had already given instructions for her to be discharged, but
respondents insisted that Chua remain in confinement; that, through its staff, petitioner
accordingly administered medical examinations, all of which yielded negative results; that
respondent Ty voluntarily undertook, jointly and severally, to pay the hospital bills for both
patients; that although respondent Ty paid up to P435,000.00, more or less, she reneged
on her commitment to pay the balance in violation of the Contract for Admission and
Acknowledgment of Responsibility for Payment dated October 30, 1990 which she
voluntarily executed; that she signed a Promissory Note on June 5, 1992 for the unpaid

balance of P1,075,592.95 and issued postdated checks to cover the same; that no such
undue pressure had been imposed upon respondent Chua to settle the bills, the truth
being that, as a matter of standard procedure, the reminders to settle the bills were
transmitted not to the patients but to their relatives who usually undertook to pay the
same; that respondent Ty deliberately evaded the staff of the Credit and Collection
Department; that the cutting-off of the telephone line and removal of the air-conditioning
unit, television set, and refrigerator cannot constitute unwarranted actuations, for the
same were resorted to as cost-cutting measures and to minimize respondents' charges
that were already piling up, especially after respondent Ty refused to settle the balance
notwithstanding frequent demands; that respondent Ty evaded the staff when the latter
attempted to inform her that the room facilities will be cut off to minimize the rising
charges; and that respondents instituted the present civil case purposely as leverage
against the petitioner after the latter had filed criminal charges for violation of Batas
Pambansa (B.P.) Blg. 22 against respondent Ty for issuing checks, later dishonored,
totaling P1,075,592.95, the amount referring to the unpaid hospital bills. In its compulsory
counterclaim, petitioner prayed, among other items, for the award of no less than
P1,000,000.00 as compensatory damages due to the filing of a malicious and unfounded
suit, and, in its permissive counterclaim, petitioner prayed for respondents to pay
P1,075,592.95, the amount representing the due and demandable obligation under the
Promissory Note dated June 5, 1992, including the stipulated interest therein and the 25
percent of the total amount due as attorney's fees.
During pre-trial, the parties stipulated on the following issues: First, whether the
respondents are liable to the petitioner to pay the hospital bills arising from the
hospitalization of respondent Chua and Judith Chua; and second, whether the parties are
entitled to their respective claims for damages.3 Furthermore, the parties stipulated on
the following facts: a) Judith Chua was confined from June 14, 1991 to May 2, 1992; b)
respondents failed to pay the balance despite repeated reminders; c) the said reminders
referred to the hospital bills of respondent Chua and Judith Chua; d) one of the attending
physicians of respondent Chua was Dr. Rody Sy; and e) the petitioner ordered the removal
of the facilities in question from the room of its patient, respondent Chua, with the
qualification that they were constrained to discontinue the same after the representative
of respondent Chua refused to update the hospital bills or refused to transfer her to semideluxe room or ward to lessen costs.4
On September 30, 1997, the RTC rendered its Decision in favor of the respondents, the
dispositive portion of which states:
WHEREFORE, premises considered, judgment on the complaint is hereby rendered in favor
of the [respondents] as against the [petitioner] as follows:
[O]rdering the [petitioner] to pay the [respondents] the following, to wit:
a) P200,000.00 as moral damages;
b) P100,000.00 as exemplary damages; and
c) P50,000.00 as attorney's fees and the amount of P50,000.00 as litigation costs.
SO ORDERED.5

In brief, the RTC held that the removal of the facilities of the room triggered the
hypertension of respondent Chua; that the petitioner acted in bad faith in removing the
facilities without prior notice; that her condition was aggravated by the pressure
employed by the administration upon her to pay the hospital bills; that the food always
came late as compared to the other patients; that the beddings and clothes of respondent
Chua were no longer changed and, as a result, bed sores emerged on her body; that there
was an utter lack of medical attendance; that, because of these, respondent Chua
suffered from self-pity and depression; that petitioner clearly discriminated against the
respondents; that respondent Ty had no choice but to sign the promissory notes in order
to secure the release of her mother, respondent Chua; that the foregoing actuations
constitute an abuse of rights; that petitioner failed to establish the pecuniary loss it
suffered and, hence, it is not entitled to compensatory damages; and that, since the
promissory note is a contract of adhesion, the petitioner is not entitled to the award of
attorney's fees as stipulated thereon.

B.P. Blg. 22 and ordering her to pay the private complainant, herein petitioner, the total
amount of the dishonored checks.

On appeal to the CA, the petitioner assigned the following errors:

The principal questions are, first, whether the actuations of the petitioner amount to
actionable wrongs, and second, whether the counterclaims of the petitioner can be
backed up by the measure of preponderant evidence.

A.
THE HONORABLE TRIAL COURT COMMITTED REVERSIBLE ERROR BY FINDING THE
ACTUATIONS OF THE ADMINISTRATION OF DEFENDANT-APPELLANT TO BE IN BAD FAITH,
OPPRESSIVE AND UNNECESSARY AS TO MAKE IT LIABLE TO PLAINTIFFS-APPELLEES FOR
DAMAGES AND ATTORNEY'S FEES.
B.
THE HONORABLE TRIAL COURT COMMITTED REVERSIBLE ERROR BY NOT RULING UPON
THE PERMISSIVE COUNTERCLAIM OF DEFENDANT-APPELLANT WITH RESPECT TO THE
P1,075,592.95 REPRESENTING THE HOSPITAL BILL OF PLAINTIFFS-APPELLEES, WHICH
OBLIGATION IS NOT DISPUTED AND WHICH AMOUNT WAS NEVER CONTROVERTED BY
PLAINTIFFS-APPELLEES.6
On October 2, 2001, the CA promulgated its Decision the dispositive portion of which
reads:
IN VIEW OF ALL THE FOREGOING, the appealed Decision is hereby AFFIRMED with the
modification that the award of moral damages, exemplary damages as well as attorney's
fees is reduced to Seventy Five Thousand Pesos (P75,000.00), Thirty Thousand Pesos
(P30,000.00) and Twenty Thousand Pesos (P20,000.00), respectively. Litigation costs are
hereby deleted. Costs against appellant.
SO ORDERED.7
Apart from the reduction in the award of damages, the CA affirmed all salient portions of
the RTC Decision and declined to disturb the findings of fact.
Petitioner is now before this Court raising essentially the same grounds heard by the CA.
Incidentally, with respect to the related criminal case against respondent Ty, this Court, on
September 27, 2004, promulgated its Decision entitled Ty v. People of the Philippines,8
which affirmed the decisions of the lower courts finding respondent Ty guilty of violating

The petition is impressed with merit.


While, as a rule, only questions of law may be raised in a petition for review on certiorari
under Rule 45, under certain exceptions, the Court may re-examine the evidence
presented by the parties during the trial. At least four exceptions exist in this case,
namely: (a) when the conclusion is a finding grounded entirely on speculation, surmises,
or conjectures; (b) when the judgment is based on a misapprehension of facts; (c) when
the findings of fact are premised on the supposed absence of evidence and contradicted
by the evidence on record; and (d) when the courts a quo manifestly overlooked certain
relevant facts not disputed by the parties and which, if properly considered, would justify
a different conclusion.9

In brief, the courts a quo concurred in the holding that the petitioner and its staff failed to
take into consideration the physical condition of its patient, respondent Chua, when it
removed the facilities provided in her room;10 that the removal of these facilities, namely,
the air-conditioner, telephone lines, television, and refrigerator, aggravated the condition
of the patient, triggered her hypertension, and caused her blood pressure to fluctuate,11
considering that there was no proper ventilation in the room.12 In view of the foregoing,
the courts a quo concluded that the actuations of the petitioner were oppressive,
unnecessary,13 and anti-social,14 done in bad faith without proper notice,15 with no
intention other than to harass or irritate the respondents,16 all of which constitute an
abuse of rights.17
We do not agree. The conclusions of the courts a quo are either haphazard conjectures, or
founded on a misapprehension of facts. The record is replete with evidence that justifies a
different conclusion.
Indeed the operation of private pay hospitals and medical clinics is impressed with public
interest and imbued with a heavy social responsibility. But the hospital is also a business,
and, as a business, it has a right to institute all measures of efficiency commensurate to
the ends for which it is designed, especially to ensure its economic viability and survival.
And in the legitimate pursuit of economic considerations, the extent to which the public
may be served and cured is expanded, the pulse and life of the medical sector quickens,
and the regeneration of the people as a whole becomes more visibly attainable. In the
institution of cost-cutting measures, the hospital has a right to reduce the facilities and
services that are deemed to be non-essential, such that their reduction or removal would
not be detrimental to the medical condition of the patient.18 For the moment, the
question to be considered is whether the subject facilities are indeed non-essential the
air-conditioner, telephone, television, and refrigerator the removal of which would cause
the adverse health effects and emotional trauma the respondents so claimed. Corollary to
this question is whether the petitioner observed the diligence of a good father of the
family19 in the course of ascertaining the possible repercussions of the removal of the
facilities prior to the removal itself and for a reasonable time thereafter, with a view to
prevent damage.20

After an extensive analysis of the record, it becomes rather worrisome to this Court that
the courts a quo unreservedly drew their conclusions from the self-serving and
uncorroborated testimonies of the respondents the probative value of which is highly
questionable.21 We hold that the respondents failed to prove the damages so claimed.
The evidence in the record firmly establishes that the staff of the petitioner took proactive
steps to inform the relatives of respondent Chua of the removal of facilities prior thereto,
and to carry out the necessary precautionary measures to ensure that her health and
well-being would not be adversely affected: as early as around two weeks after her
admission on October 30, 1990, to the time when the facilities had been removed
sometime in the middle of May 1992,22 and even up to the point when she actually left
the premises of the hospital three weeks later, or during the first week of June 1992,23
the medical condition of respondent Chua, as consistently and indisputably confirmed by
her attending physician, Dr. Rody Sy, a cardiologist, who was called as witness for both
parties,24 whom even respondent Chua repeatedly praised to be "my doctor" and "a very
good doctor"25 at that, and whose statements at times had been corroborated as well by
Sister Mary Philip Galeno, SPC, the Administrator of the hospital and who also happens to
be a registered nurse, had been "relatively well,"26 "ambulatory,"27 "walking around in
the room,"28 and that she was "able to leave the hospital on her own without any
assistance;"29 that although she complained of symptoms such as dizziness,
weakness,30 and abdominal discomfort,31 Dr. Sy requested several medical
examinations, such as the laboratory tests, renal tests, MRI, ultrasound, and CT scan,32
all of which were administered after procuring the consent of respondent Chua's family33
as admitted by respondent Ty herself,34 and even called on other specialists, such as a
neurologist, endocrinologist, and gastroenterologist, to look into her condition35 and
conduct other tests as well36 according to their fields of specialty, all of which yielded no
serious finding;37 that her illnesses were "lifelong illnesses"38 at a stage where they
cannot be totally removed or abolished,39 making it clear to her family that "one hundred
percent recovery is not possible" despite being given daily medication in the hospital;40
but that her condition, nonetheless, is not serious,41 as the blood pressure is more or less
controlled and within acceptable limits,42 "not that critical to precipitate any acute
attack,"43 nor likely to fall into any emergency,44 nor yet does she require continuous or
prolonged hospitalization45 since she was stable enough to be treated at home and on an
"out-patient" basis, so much so that Dr. Sy encouraged her to exercise and avoid resting
all the

corroborated by respondent Chua's own doctor himself.56 When Dr. Sy testified as


rebuttal witness for the respondents themselves and whose credibility respondents failed
to impeach, he categorically stated that he consented to the removal since the removal of
the said facilities would not by itself be detrimental to the health of his patient,
respondent Chua.57 And in this respect, he had been advising respondent Ty, the
daughter of the patient, that the facilities, such as the air-conditioner, television,
refrigerator, and telephone, are not absolutely necessary, and, that although they may
add to the comfort of the patient, if absent, they will not cause any significant
deterioration of her condition,58 given that, in his experience as a cardiologist, and after
personally attending respondent Chua on a daily basis before, during, and after the
removal and even up to the time of her actual discharge,59 he concluded that many
hypertensive and diabetic patients, as in her case, do not at all need in particular an airconditioning unit, among the other facilities aforementioned.60 And, contrary to the
findings of the courts a quo and the self-serving testimonies of respondents that the lack
of ventilation, after the removal of the air-conditioner, triggered her hypertension, Dr. Sy
categorically stated that during his daily rounds with the patient he was certain that,
although admittedly the blood pressure in general would fluctuate daily, there had been
no adverse effect on her, and that her blood pressure were within acceptable limits,61
especially considering that he treated the patient on a daily basis up to the point of actual
discharge,62 and accordingly, as confirmed by the medical records, he made no change in
the medications thereafter.63 In support of Dr. Sy's findings, Sister Galeno, testified that
she knew the condition of the ventilation of the patient's deluxe room, located at the fifth
floor, even without the air-conditioning, notably in times of brownout, and that there had
been enough ventilation since the grilled window of that room was large enough which, if
opened, would permit sufficient ventilation.64 The Court finds that the premise of the RTC
judgment refers merely to hypothetical statements which fail to establish any clear and
direct link to the injury allegedly suffered by the patient:
Q You found it safe to remove these facilities from the room of the patient suffering
from diabetes and hypertension?
A Yes, Sir. Many hypertensive, diabetic patients do not need air-conditioning, or T.V. or
refrigerator.
Q Do you agree with me that hypertension is triggered sometimes by excitement,
anger or (sic) a person suffering from such illness?

time,46 and recommended that "anytime she may be discharged"47

A Hypertension can be triggered by anything.

even in just "two weeks after confinement,"48 the propriety of his order of discharge
concurred upon by the other specialists as well,49 had it not been for respondents'
insistence to stay in the hospital in view of their hope for absolute recovery50 despite the
admission of respondent Chua herself that she cannot anymore be totally cured.51

Court:
Q And even in other words the discomfort can also trigger?
A Sometimes mental stress can trigger.

It is also undisputed that the hospital administrator, Sister Galeno, prior to the removal of
the facilities, consulted the attending physician, Dr. Sy.52 To Sister Galeno, also a
registered nurse, the matter of removal and its possible repercussions on the health of the
patient, as a matter of hospital policy, is a critical and sensitive maneuver, and, hence, it
is carried out only after discussing with the doctors to evaluate all important factors.53
The fact of prior consultation54 as well as the medical determination to the effect that it
was safe to remove the facilities and would cause no harmful effect55 had been amply

xxxx
Court:
Q You mentioned earlier that this hypertension may be triggered mentally?

A Yes, Your Honor.


Court:
Q Will the removal of these facilities not affect the patient including the relatives?
A It may to a certain extent. And well, maybe the days after the removal would prove
that fluctuation in blood pressure are within acceptable limits.65
With respect to the findings of the courts a quo that bed sores appeared on the body of
respondent Chua, that she suffered from depression after the disconnection of the said
facilities, that her private midwives were barred, and that the delivery of food was
delayed, this Court holds, as above, that these conclusions are bereft of sound evidentiary
basis, self-serving and uncorroborated as they are. Again, Dr. Sy affirmed that during the
daily rounds he would make on the patient, he did not detect any skin lesion or any other
abnormality up to the time she was actually discharged.66 Nor did he find any sign of
depression, although, admittedly, he observed that she had been "very angry" because of
the removal of the facilities.67 All the while he did not receive any complaint from
respondent Chua indicating that she suffered from the foregoing infirmities,68 considering
that it is the responsibility of the family of the patient to specifically inform the attending
physician or the nurses during their rounds whatever they feel is important, or if there
were any new developments since the last visit.69 As corroborated by Sister Galeno,
throughout respondent Chua's confinement, she never received any complaint from the
latter or her relatives that she had not been attended to by the nursing staff.70 Worth
noting again is the fact that the nursing staff and the attending physicians, which included
Dr. Sy, in accordance with hospital policy, would routinely make their rounds on a daily
basis, or would visit the patient whenever they are called for any problem,71 and, in the
case of the specialists other than the attending physician, they would visit the patient
about once a week.72 The nurses, on the other hand, would make their rounds more
frequently, that is, at least once per shift, or every eight hours.73 Apart from the selfserving statements of respondents, which by now have become rather indicative of being
mere afterthoughts, there is no clear showing from the record that the petitioner and its
medical staff deviated from the foregoing policy and practice, nor had they been called
upon to look into the alleged physical reactions or emotional trauma respondent Chua
claims to have suffered during and after the removal of the facilities. It must be
emphasized that, as stated above, respondent Chua herself explicitly found Dr. Sy to be a
"very good doctor" because he personally attended to her "almost every hour."74 And
throughout her confinement, Dr. Sy positively stated that her family employed a private
midwife who attended to her all the time.75

of the one who benefits from these, nevertheless, all things considered, and given the
degree of diligence the petitioner duly exerted, not every suppression of the things that
one has grown accustomed to enjoy amounts to an actionable wrong, nor does every
physical or emotional discomfort amount to the kind of anguish that warrants the award of
moral damages under the general principles of tort. The underlying basis for the award of
tort damages is the premise that an individual was injured in contemplation of law. Thus,
there must first be the breach of some duty and the imposition of liability for that breach
before damages may be awarded; it is not sufficient to state that there should be tort
liability merely because the plaintiff suffered some pain and suffering.76
Moreover, this Court must reiterate the standard of tort to arrive at a proper award for
damages premised on matters that suggest the application of medical knowledge,
especially in the description of the causal link between external or environmental factors,
on one hand, and their effect unto the physical or emotional health of the patient, on the
other, expert opinion, as discussed in Cruz v. Court of Appeals,77 is generally required:
All three courts below bewail the inadequacy of the facilities of the clinic and its
untidiness; the lack of provisions such as blood, oxygen, and certain medicines; the failure
to subject the patient to a cardio-pulmonary test prior to the operation; the omission of
any form of blood typing before transfusion; and even the subsequent transfer of Lydia to
the San Pablo Hospital and the reoperation performed on her by the petitioner. But while it
may be true that the circumstances pointed out by the courts below seemed beyond cavil
to constitute reckless imprudence on the part of the surgeon, this conclusion is still best
arrived at not through the educated surmises nor conjectures of laymen, including judges,
but by the unquestionable knowledge of expert witnesses. For whether a physician or
surgeon has exercised the requisite degree of skill and care in the treatment of his patient
is, in the generality of cases, a matter of expert opinion. The deference of courts to the
expert opinions of qualified physicians stems from its realization that the latter possess
unusual technical skills which laymen in most instances are incapable of intelligently
evaluating. Expert testimony should have been offered to prove that the circumstances
cited by the courts below are constitutive of conduct falling below the standard of care
employed by other physicians in good standing when performing the same operation. It
must be remembered that when the qualifications of a physician are admitted, as in the
instant case, there is an inevitable presumption that in proper cases he takes the
necessary precaution and employs the best of his knowledge and skill in attending to his
clients, unless the contrary is sufficiently established. This presumption is rebuttable by
expert opinion which is so sadly lacking in the case at bench.78

The evidence in the record overwhelmingly demonstrates that respondent Chua had been
adequately attended to, and this Court cannot understand why the courts a quo had
declared that there was an "utter lack of medical attendance," or that her health suffered
during the period after the removal of the facilities. The Court finds that the facilities in
question are non-essential for the care of respondent Chua and, hence, they may be
lessened or removed by the petitioner for the sake of economic necessity and survival.

With respect to the propriety of the notice of removal of facilities, the evidence shows that
the hospital staff, accompanied by Sister Gladys Lim, SPC, Finance Administrative
Assistant of the hospital,79 through written and verbal notices as per hospital policy,
forewarned the respondents, through respondent Ty and her sister, Judith Chua, of the
impending removal of the facilities over a week beforehand80 in view of their obstinate
refusal to vacate and transfer to a lower rate room81 or to update the mounting hospital
bills82 which, by then, had swollen to approximately one million pesos.83 Respondent Ty
refused to read many of the written notices sent by the Credit

Though human experience would show that the deactivation of the air-conditioner may
cause a temperature differential that may trigger some physical discomfort, or that the
removal of entertainment facilities such as the television set, or the disconnection of
communication devices such as the telephone, may cause some exasperation on the part

Department.84 After repeated attempts to contact respondent Ty85 and before the actual
removal of the facilities, the staff of the petitioner tried to personally serve the final notice
dated April 23, 1992,86 signed by Sister Gladys Lim, addressed to respondent Ty, which
adopted the tenor of the prior verbal warnings, and which expressly and sternly warned

the respondents that the hospital shall be constrained to take legal action and that they
shall be compelled to transfer the patient, respondent Chua, to a lower rate room unless
the balance could be satisfied.87 Respondent Ty, for no justifiable reason, and sticking to
her inclination to avoid the staff, refused to receive or acknowledge this letter as well.88
Worth noting is that Sister Galeno, testified that, as a matter of hospital policy the tenor of
which respondents, by virtue of the Contract for Admission dated October 30, 1990,
agreed to comply with,89 the hospital can only cut off the non-essential facilities and
only in extreme cases90 if the patient occupies a private room all to herself; had the
room been semi-private shared by other patients, or had it been the ward, the hospital
cannot disconnect the facilities since this would unduly prejudice the other patients. But
respondent Chua herself insisted on staying in a private room despite her being fully
aware of the ballooning charges,91 and even if she could have freely gone home anytime
to her condominium unit which, as admitted, was equipped with an air-conditioner.92 With
respect to the "pressure" and "harassment" respondents allegedly suffered daily
whenever the hospital staff would follow up the billing during odd hours, or at 10pm,
11pm, 12 midnight, 1am, or 2am,93 this averment had been convincingly refuted by the
witnesses for the petitioner, namely, Editha L. Vecino, the Head of Credit and Collection,
and Sister Galeno, in that the Credit and Collection Department would only hold office
hours from 8am to 5pm and, hence, it is impossible to "harass" the respondents during
the times they so claimed.94
The courts a quo found that respondent Ty had "no choice but to sign the promissory note
in order for her mother to be released from the hospital,"95 thus suggesting that the
hospital refused to actually discharge or bodily release its patient, respondent Chua, until
arrangements had been made to settle the charges.
While there are portions of the testimonies of the witnesses for the petitioner which state
that although, as per standard procedure, the patient "cannot leave"96 the hospital
without the "discharge,"97 "clearance" or "gate pass" issued only after
arrangements on the settlement of bills had been made,98 still, it must be understood
that these are only demonstrative of the precondition that a patient cannot step out of the
premises "without the consent" of the hospital, or, in other words, that the "clearance"
merely indicates that the hospital expressly consented to the actual release of the
patient,99 but, even without its consent, the patient is still free to leave "anytime" as a
matter of policy, in spite of the refusal to issue a "clearance" or "gate pass,"100 or even in
cases where the accounts have not yet been liquidated or settled,101 or yet even if no
promissory note or post-dated check were executed in favor of the petitioner, as testified
by no less than Sister Galeno,102 and corroborated by Editha Vecino;103 and that,
petitioner, a private hospital established for profit,104 being also a business, by warning
respondents that it shall withhold clearance, is simply exercising its right to protest
against an absconding patient as a precursor to avail of other appropriate legal remedies;
that, on the contrary, the respondents opted not to leave because of their own promise
not to leave unless the hospital bills were fully settled;105 that the accusations found in
the Demand Letter dated May 19, 1992, and signed by the counsel for the
respondents,106 particularly, that the petitioner "refused to discharge the patient,
[respondent Chua,] despite orders from the attending physician, Dr. Rody Sy," had all
been refuted by Sister Galeno when she read its contents in front of the counsel for
respondents, emphatically telling him that "we are not detaining his clients;" that
"[respondent Ty] was the one who told us that they are not going to leave the hospital
unless they have fully paid the hospital;"107 and that, most importantly, no physical

restraint upon the person of respondent Chua or upon the person of her relatives had
been imposed by the staff.
Authorities, including those of common law origin, explicitly declare that a patient cannot
be detained in a hospital for non-payment of the hospital bill. If the patient cannot pay the
hospital or physician's bill, the law provides a remedy for them to pursue, that is, by filing
the necessary suit in court for the recovery of such fee or bill.108 If the patient is
prevented from leaving the hospital for his inability to pay the bill, any person who can act
on his behalf can apply in court for the issuance of the writ of habeas corpus.109
The form of restraint must be total; movement must be restrained in all directions. If
restraint is partial, e.g., in a particular direction with freedom to proceed in another, the
restraint on the person's liberty is not total.110 However, the hospital may legally detain a
patient against his will when he is a detained or convicted prisoner, or when the patient is
suffering from a very contagious disease where his release will be prejudicial to public
health, or when the patient is mentally ill such that his release will endanger public
safety,111 or in other exigent cases as may be provided by law. Moreover, under the
common law doctrines on tort, it does not constitute a trespass to the person to
momentarily prevent him from leaving the premises or any part thereof because he
refuses to comply with some reasonable condition subject to which he entered them. In all
cases, the condition of this kind of restraint must be reasonable in the light of the
circumstances.112 At any rate, as stated above, the patient is free to leave the premises,
even in the ostensible violation of these conditions, after being momentarily interrupted
by the hospital staff for purposes of informing him of those reasonable conditions, such as
the assessment of whether the patient is fit to leave, insane, or suffering from a
contagious disease, etc., or simply for purposes of making a demand to settle the bill. If
the patient chooses to abscond or leave without the consent of the hospital in violation of
any of the conditions deemed to be reasonable under the circumstances, the hospital may
nonetheless register its protest and may choose to pursue the legal remedies available
under law, provided that the hospital may not physically detain the patient, unless the
case falls under the exceptions abovestated.
Authorities are of the view that, ordinarily, a hospital, especially if it is a private pay
hospital,113 is entitled to be compensated for its services, by either an express or an
implied contract, and if no express contract exists, there is generally an implied
agreement that the patient will pay the reasonable value of the services rendered;114
when a hospital treats a patient's injuries, it has an enforceable claim for full payment for
its services, regardless of the patient's financial status.115 At this juncture, it must be
noted that there is testimony, though to a degree disputable, to the effect that the
execution of the promissory note and the issuance of postdated checks were conditions
imposed not by the petitioner but voluntarily offered by the counsel for respondents.116
At any rate, however, this Court holds, in view of the foregoing authorities, that the
requirement to have the relative of respondent Chua to execute a promissory note as part
of the arrangement to settle the unpaid obligations is a formality that converts any
implied contract into written form and, moreover, amounts to a reasonable condition, the
non-fulfillment of which, in itself, however, as discussed, cannot allow the hospital to
detain the patient. It must also be stressed, contrary to the findings of the courts a quo,
that such an agreement embodied in a promissory note, as well as the Contract for
Admission and Acknowledgment of Responsibility for Payment dated October 30, 1990, do
not become contracts of adhesion simply because the person signing it was under stress
that was not the result of the actions of the hospital,117 especially taking into account

that there is testimony to the effect that respondent Ty signed the Promissory Note dated
June 5, 1992 in the presence of counsel and acting under his advise.118
But as to the propriety of the circumstances surrounding the issuance of the postdated
checks to cover the amount stated in the Promissory Note dated June 5, 1992, this Court
must refer to the discussion of the recent case of Ty v. People of the Philippines119 where
this Court affirmed the conviction of respondent Ty for the issuance of bouncing checks
addressed to the petitioner herein. While the instant case is to be distinguished from the
Ty case in nature, applicable law, the standards of evidence, and in the defenses available
to the parties, hence, the judgment of conviction in that case should not at all prejudice
the disposition of this case, even if the facts coincide, nonetheless, for purposes of
convenience and instructive utility, the Court quotes the relevant portions:
In this case, far from it, the fear, if any, harbored by Ty was not real and imminent. Ty
claims that she was compelled to issue the checks a condition the hospital allegedly
demanded of her before her mother could be discharged for fear that her mother's health
might deteriorate further due to the inhumane treatment of the hospital or worse, her
mother might commit suicide. This is speculative fear; it is not the uncontrollable fear
contemplated by law.
To begin with, there was no showing that the mother's illness was so life-threatening such
that her continued stay in the hospital suffering all its alleged unethical treatment would
induce a well-grounded apprehension of her death. Secondly, it is not the law's intent to
say that any fear exempts one from criminal liability much less petitioner's flimsy fear that
her mother might commit suicide. In other words, the fear she invokes was not impending
or insuperable as to deprive her of all volition and to make her a mere instrument without
will, moved exclusively by the hospital's threats or demands.

In the instant case, the evil sought to be avoided is merely expected or anticipated. If the
evil sought to be avoided is merely expected or anticipated or may happen in the future,
this defense is not applicable. Ty could have taken advantage of an available option to
avoid committing a crime. By her own admission, she had the choice to give jewelry or
other forms of security instead of postdated checks to secure her obligation.
Moreover, for the defense of state of necessity to be availing, the greater injury feared
should not have been brought about by the negligence or imprudence, more so, the willful
inaction of the actor. In this case, the issuance of the bounced checks was brought about
by Ty's own failure to pay her mother's hospital bills.
The Court also thinks it rather odd that Ty has chosen the exempting circumstance of
uncontrollable fear and the justifying circumstance of state of necessity to absolve her of
liability. It would not have been half as bizarre had Ty been able to prove that the issuance
of the bounced checks was done without her full volition. Under the circumstances,
however, it is quite clear that neither uncontrollable fear nor avoidance of a greater evil or
injury prompted the issuance of the bounced checks.
Parenthetically, the findings of fact in the Decision of the trial court in the Civil Case for
damages filed by Ty's mother against the hospital is wholly irrelevant for purposes of
disposing the case at bench. While the findings therein may establish a claim for damages
which, we may add, need only be supported by a preponderance of evidence, it does not
necessarily engender reasonable doubt as to free Ty from liability.120

Ty has also failed to convince the Court that she was left with no choice but to commit a
crime. She did not take advantage of the many opportunities available to her to avoid
committing one. By her very own words, she admitted that the collateral or security the
hospital required prior to the discharge of her mother may be in the form of postdated
checks or jewelry. And if indeed she was coerced to open an account with the bank and
issue the checks, she had all the opportunity to leave the scene to avoid involvement.

In view of the foregoing, the Court therefore holds that the courts a quo committed
serious errors in finding that the petitioner was "biased,"121 "discriminated" against the
respondents,122 and "purposely intended to irritate"123 or "harass"124 them; that it
"acted in bad faith in removing the facilities without prior notice;"125 and that its acts
were "anti-social."126 The aforequoted declarations of the witnesses, significant portions
of which this Court considers as expert testimony, are reliable and remain considerably
trustworthy to controvert respondents' assertions as well as to reverse the conclusions of
fact and law of the CA and the RTC that respondent Chua suffered the physical and
emotional anguish so claimed, and so, for these reasons, the Court holds that the
petitioner inflicted no actionable wrong.

Moreover, petitioner had sufficient knowledge that the issuance of checks without funds
may result in a violation of B.P. 22. She even testified that her counsel advised her not to
open a current account nor issue postdated checks "because the moment I will not have
funds it will be a big problem." Besides, apart from petitioner's bare assertion, the record
is bereft of any evidence to corroborate and bolster her claim that she was compelled or
coerced to cooperate with and give in to the hospital's demands.

This Court observes that the courts a quo awarded both respondents moral damages. But
it is well-settled that in case of physical injuries, with some exceptions,127 moral
damages are recoverable only by the party injured and not by her spouse, next of kin, or
relative who happened to sympathize with the injured party.128 Hence, even if the courts
a quo were correct in their basis for damages, they should have declined to award
damages to respondent Ty.

Ty likewise suggests . . . that the justifying circumstance of state of necessity under par. 4,
Art. 11 of the Revised Penal Code may find application in this case.

The last issue to be resolved is the question whether the counterclaims of the petitioner
are supported by a preponderance of evidence.

We do not agree. The law prescribes the presence of three requisites to exempt the actor
from liability under this paragraph: (1) that the evil sought to be avoided actually exists;
(2) that the injury feared be greater than the one done to avoid it; (3) that there be no
other practical and less harmful means of preventing it.

We agree with the petitioner that the courts a quo seriously erred in mistaking the case of
its compulsory counterclaim for its permissive counterclaim and for failing to consider the
evidence which impressively supports the latter. First, for failure without justifiable cause
of respondents' counsel to comment on the Partial Formal Offer of Evidence dated
February 14, 1996129 filed by the petitioner, the RTC issued an order during the course of
the trial, which counsel for respondents neither contested nor raised on appeal, admitting

Exhibits "1" to "16", together with their submarkings and the purposes for which the same
were offered,130 all of which had also been previously authenticated and their contents
verified by the witnesses for the petitioner.131 These documents include the Contract for
Admission of respondent Chua dated October 30, 1990, duly executed by respondent Ty,
incorporating therein the rules and regulations of the hospital, including the duty to
understand the same132 as well as the undertaking of respondent Ty to be jointly and
severally liable for the payment of the hospital bills of respondent Chua;133 the
Promissory Note dated June 5, 1992 in the amount of P1,075,592.95 duly executed by
respondent Ty in favor of the petitioner agreeing to be jointly and severally liable to pay
the unpaid obligations of respondent Chua and Judith Chua, including interest and
attorney's fees in case of default;134 the Undertakings signed by respondent Ty dated
March 3, 1992 and April 7, 1992 to maintain regular deposits;135 and the credit memos
and statements of account that support the amount referring to the unpaid obligation.136
Second, the parties stipulated during pre-trial that respondents failed to pay the balance
despite repeated reminders.137 And third, respondent Ty in open court identified and
admitted that she signed the Contract of Admission dated October 30, 1990 as well as the
Undertakings dated March 3, 1992 and April 7, 1992 but which, for no justifiable reason,
she "did not bother to read,"138 and, what is more, she repeatedly admitted during the
course of the trial that she failed to fully settle the foregoing hospital bills.139 In fact,
while the Ty case cannot control the incidents of the instant case as heretofore stated, it is
still worth mentioning, at least for informative purposes, the findings of this Court in Ty
with respect to respondents' obligations to the petitioner:
Ty's mother and sister availed of the services and the facilities of the hospital. For the care
given to her kin, Ty had a legitimate obligation to pay the hospital by virtue of her
relationship with them and by force of her signature on her mother's Contract of
Admission acknowledging responsibility for payment, and on the promissory note she
executed in favor of the hospital.140
In view of all these findings, the Court earnestly disagrees with the sweeping conclusion of
the CA that "[Petitioner] failed to present any iota of evidence to prove his claim,"141 a
statement apparently referring to the permissive counterclaim of P1,075,592.95.
However, with respect to the compulsory counterclaim predicated on the filing of a
baseless suit and injury to its reputation, petitioner did not raise this matter on appeal
and, hence, is deemed to have waived the same.

But the Court in Ty made a partial finding on the civil liability of respondent Ty with
respect to the amount covered by seven of the several dishonored checks she issued
equivalent to
P210,000.00.142 Since this amount forms a fraction of her total civil liability, then this
amount, in deference to Ty, should be deducted therefrom.
The claim for attorney's fees, as stipulated under the Promissory Note dated June 5, 1992,
should be reduced for being unreasonable under the circumstances, from 25 percent to 12
percent of the total amount due.143
As a final word, the Court takes judicial notice of the pending Senate Bill No. 337, entitled
"An Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds
of Non-Payment of Hospital Bills or Medical Expenses," which declares, among others, that
it shall be unlawful for any hospital or medical clinic to cause directly or indirectly the
detention of patients for non-payment, in part or in full, of their hospital bills,144 and,
furthermore, requires patients who have fully recovered and are financially incapable to
settle the hospitalization expenses to execute a promissory note, co-signed by another
individual, to the extent of the unpaid obligation before leaving the hospital.145 While this
Court may have touched upon these matters in the adjudication of the instant case, it
must be stated that this decision should in no way preempt any constitutional challenge
to the provisions of Senate Bill No. 337 if passed into law, bearing in mind the standards
for the exercise of the power of judicial review146 as well as the recognition that the tenor
of the bill may adjust with the times, or that the bill itself may fail to pass, according to
the dynamism of the legislative process, especially in light of the objections interposed by
interest groups to date.147
WHEREFORE, the petition is GRANTED. The Decision of the Court of Appeals dated
October 2, 2001, together with the Decision dated September 30, 1997 of the Regional
Trial Court in Civil Case No. 63958, is REVERSED and SET ASIDE. Another judgment is
entered dismissing the Complaint and ordering respondents, jointly and severally, to pay
the petitioner the amount of P865,592.95, with stipulated interest of 12 percent reckoned
from the date of extrajudicial demand until full payment, and 12 percent of the total
amount due as attorney's fees.
No pronouncement as to costs.
SO ORDERED.