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1. Dr. Ruby Li v. Sps.

Soliman
FACTS:
On July 7, 1993, respondents 11-year old daughter, Angelica Soliman, underwent a biopsy of
the mass located in her lower extremity at the St. Lukes Medical Center (SLMC). Results
showed that Angelica was suffering from 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 Death 6 issued by SLMC stated the cause of death as
follows:
Immediate cause : a. Osteosarcoma, Status Post AKA
Antecedent cause : b. (above knee amputation)
Underlying cause : c. Status Post Chemotherapy
On February 21, 1994, respondents filed a damage suit 7 against petitioner, Dr. Leo Marbella,
Mr. Jose Ledesma, a certain Dr. Arriete and SLMC. Respondents charged them with
negligence and disregard of Angelicas safety, health and welfare by their careless
administration of the chemotherapy drugs, their failure to observe the essential precautions
in detecting early the symptoms of fatal blood platelet decrease and stopping early on the
chemotherapy, which bleeding led to hypovolemic shock that caused Angelicas untimely
demise. Further, it was specifically averred that petitioner assured the respondents that
Angelica would recover in view of 95% chance of healing with chemotherapy ("Magiging
normal na ang anak nyo basta ma-chemo. 95% ang healing") and when asked regarding the
side effects, petitioner mentioned only slight vomiting, hair loss and weakness ("Magsusuka
ng kaunti. Malulugas ang buhok. Manghihina"). Respondents thus claimed that they would
not have given their consent to chemotherapy had petitioner not falsely assured them of its
side effects.
In her answer,8 petitioner denied having been negligent in administering the chemotherapy
drugs to Angelica and asserted that she had fully explained to respondents how the
chemotherapy will affect not only the cancer cells but also the patients normal body parts,
including the lowering of white and red blood cells and platelets. She claimed that what
happened to Angelica can be attributed to malignant tumor cells possibly left behind after
surgery. Few as they may be, these have the capacity to compete for nutrients such that the

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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.
In dismissing the complaint, the trial court held that petitioner was not liable for damages as
she observed the best known procedures and employed her highest skill and knowledge in
the administration of chemotherapy drugs on Angelica but despite all efforts said patient
died. It cited the testimony of Dr. Tamayo who testified that he considered petitioner one of
the most proficient in the treatment of cancer and that the patient in this case was afflicted
with a very aggressive type of cancer necessitating chemotherapy as adjuvant treatment.
Using the standard of negligence laid down in Picart v. Smith, 47 the trial court declared that
petitioner has taken the necessary precaution against the adverse effect of chemotherapy
on the patient, adding that a wrong decision is not by itself negligence. Respondents were
ordered to pay their unpaid hospital bill in the amount of P139,064.43.48
Respondents appealed to the CA which, while concurring with the trial courts finding that
there was no negligence committed by the petitioner in the administration of chemotherapy
treatment to Angelica, found that petitioner as her attending physician failed to fully explain
to the respondents all the known side effects of chemotherapy. The appellate court
stressed that since the respondents have been told of only three side effects of
chemotherapy, they readily consented thereto. Had petitioner made known to
respondents those other side effects which gravely affected their child -- such as
carpo-pedal spasm, sepsis, decrease in the blood platelet count, bleeding,
infections and eventual death -- respondents could have decided differently or
adopted a different course of action which could have delayed or prevented the
early death of their child.
Hence, this petition.
ISSUE:
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.
HELD:
The petition is meritorious.
The type of lawsuit which has been called medical malpractice or, more appropriately,
medical negligence, is that type of claim which a victim has available to him or her to
redress a wrong committed by a medical professional which has caused bodily harm. In
order to successfully pursue such a claim, a patient must prove that a health care provider,
in most cases a physician, either failed to do something which a reasonably prudent health
care provider would have done, or that he or she did something that a reasonably prudent
provider would not have done; and that that failure or action caused injury to the patient. 51

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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).
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 Hospital 53 which involved unwanted
treatment performed by a doctor. Justice Benjamin Cardozos oft-quoted opinion upheld the
basic right of a patient to give consent to any medical procedure or treatment: "Every
human being of adult years and sound mind has a right to determine what shall be done
with his own body; and a surgeon who performs an operation without his patients consent,
commits an assault, for which he is liable in damages." 54 From a purely ethical norm,
informed consent evolved into a general principle of law that a physician has a duty to
disclose what a reasonably prudent physician in the medical community in the exercise of
reasonable care would disclose to his patient as to whatever grave risks of injury might be
incurred from a proposed course of treatment, so that a patient, exercising ordinary care for
his own welfare, and faced with a choice of undergoing the proposed treatment, or
alternative treatment, or none at all, may intelligently exercise his judgment by reasonably
balancing the probable risks against the probable benefits. 55
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

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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.
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.
2. PSI v. Agana
FACTS:
On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital (Medical
City Hospital) because of difficulty of bowel movement and bloody anal discharge. After a
series of medical examinations, Dr. Miguel Ampil, petitioner in G.R. No. 127590, diagnosed
her to be suffering from "cancer of the sigmoid."
On April 11, 1984, Dr. Ampil, assisted by the medical staff 4 of the Medical City Hospital,
performed an anterior resection surgery on Natividad. He found that the malignancy in her
sigmoid area had spread on her left ovary, necessitating the removal of certain portions of it.
Thus, Dr. Ampil obtained the consent of 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

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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 foul-smelling
gauze measuring 1.5 inches in width which badly infected her vaginal vault. A recto-vaginal
fistula had formed in her reproductive organs which forced stool to excrete through the
vagina. Another surgical operation was needed to remedy the damage. Thus, in October
1984, Natividad underwent another surgery.
On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, Quezon
City a complaint for damages against the Professional Services, Inc. (PSI), owner of the
Medical City Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil Case No. Q-43322. They
alleged that the latter are liable for negligence for leaving two pieces of gauze inside
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.
On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No. 42062.
Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision 6 in
Administrative Case No. 1690 dismissing the case against Dr. Fuentes. The Board held that
the prosecution failed to show that Dr. Fuentes was the one who left the two pieces of gauze
inside Natividads body; and that he concealed such fact from Natividad.
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:
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

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amount the latter will pay or had paid to the plaintiffs-appellees, the decision appealed from
is hereby AFFIRMED and the instant appeal DISMISSED.
Hence, the instant consolidated petitions.
ISSUES:
1. Whether the Court of Appeals erred in holding Dr. Ampil liable for negligence and
malpractice;
2. Whether the Court of Appeals erred in absolving Dr. Fuentes of any liability; and
3. Whether PSI may be held solidarily liable for the negligence of Dr. Ampil.
HELD:
On the 1st Issue:
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.
On the 2nd Issue:
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

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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.
On the 3rd Issue:
The case of Schloendorff v. Society of New York Hospital 26 was then considered an authority
for this view. The "Schloendorff doctrine" regards a physician, even if employed by a
hospital, as an independent contractor because of the skill he exercises and the lack of
control exerted over his work. Under this doctrine, hospitals are exempt from the application
of the respondeat superior principle for fault or negligence committed by physicians in the
discharge of their profession.
However, the efficacy of the foregoing doctrine has weakened with the significant
developments in medical care. Courts came to realize that modern hospitals are increasingly
taking active role in supplying and regulating medical care to patients. No longer were a
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 Appeals 28 that for purposes of apportioning responsibility in
medical negligence cases, an employer-employee relationship in effect exists
between hospitals and their attending and visiting physicians.

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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
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 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
We now proceed to the doctrine of corporate negligence or corporate responsibility.
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

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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.
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.
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.
3. Cruz v. CCA and Umali
FACTS:
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 Problems occurred during the operation and because the hospital has inadequate
facilities to address the same, Lydia was transferred to San Pablo District Hospital where she
died.
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."
MTCC absolved Ercillo of liability due to insufficiency of evidence but found Cruz guilty of
reckless imprudence resulting to homicide. RTC and CA affirmed the decision of MTCC.
ISSUE:
WON 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.
HELD:

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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.
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

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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.
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.
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. 4
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
4. Flores v. United Medical Doctors
FACTS:
Pineda went to the clinic of Dr. Fredelicto Flores complaining of vaginal bleeding. 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.
He then referred Pineda to his wife Dr. Felicisima Flores, an obstetrician and gynaecologist,
for a D&C operation. Without waiting for the full report of the laboratory tests, the doctors
proceeded with said operation despite Dr. Fredelictos suspicion that Pineda has Diabetes
Milletus.

Page 11 of 39

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.
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
The family of Pineda filed a case of medical negligence with the RTC against the spouses
Flores.
RTC and CA ruled in favour of the defendants.
ISSUE:
Whether the decision to proceed with the D&C operation was an honest mistake of judgment
or one amounting to negligence.
HELD:
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
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

Page 12 of 39

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. Tan 35 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

Page 13 of 39

minimize possible risks and complications. The internist is responsible for generating a
comprehensive evaluation of all medical problems during the pre-operative evaluation. 38
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.
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.
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.
CONCLUSION:
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.
5. Solidum v. People
FACTS:
A three year old boy went a pull through operation for having imperforate anus at the
Ospital ng Maynila. One of the doctors who treated him was the anaesthesiologist Dr.
Solidum. During the operation, the boy experienced bradycardia resulting in the failure of
the oxygen to enter the boys brain. The boy then went into a coma. When he finally awoke,
however, the parents found out that he could no longer see, hear or move.
As such, the parents filed a case of Reckless Imprudence resulting to Serious Physical
Injuries against Dr. Solidum. The RTC fund the doctor guilty of the same. The CA affirmed the
RTCs decision stating that the case is textbook example of res ipsa loquitur, wherein the
basis of the doctors negligence is his failure to properly monitor the levels of anaesthesia

Page 14 of 39

being administered on the boy during the operation which led to the injury suffered by the
latter.
ISSUES:
1. Whether or not the doctrine of res ipsa loquitur was applicable herein; and
2. Whether or not Dr. Solidum was liable for criminal negligence.
HELD:
On the 1st Issue:
Res ipsa loquitur is literally translated as "the thing or the transaction speaks for itself." The
doctrine res ipsa loquitur means that "where the thing which causes injury is shown to be
under the management of the defendant, and the accident is such as in the ordinary course
of things does not happen if those who have the management use proper care, it affords
reasonable evidence, in the absence of an explanation by the defendant, that the accident
arose from want of care."24 It is simply "a recognition of the postulate that, as a matter of
common knowledge and experience, the very nature of certain types of occurrences may
justify an inference of negligence on the part of the person who controls the instrumentality
causing the injury in the absence of some explanation by the defendant who is charged with
negligence. It is grounded in the superior logic of ordinary human experience and on the
basis of such experience or common knowledge, negligence may be deduced from the mere
occurrence of the accident itself.
Hence, res ipsa loquitur is applied in conjunction with the doctrine of common
knowledge."25
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

Page 15 of 39

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.
On the 2nd Issue:
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 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.
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
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.

Page 16 of 39

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:
x

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.
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
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
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 Ospita 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.

Page 17 of 39

x
x
x 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.
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.
6. Cayao-Lasam v. Sps. Ramolete
FACTS:
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 sonogram 4 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."
On July 30, 1994, petitioner performed the D&C procedure. Editha was discharged from the
hospital the following day.
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.
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

Page 18 of 39

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
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 March 4, 1999, the Board of Medicine (the Board) of the PRC rendered a Decision, 14
exonerating petitioner from the charges filed against her.
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
CA dismissed the case due to procedural defects.
ISSUES:
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
HELD:
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

Page 19 of 39

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

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

Page 20 of 39

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.
7. Nogales v. Capitol Medical Center (CMC)
FACTS:

Page 21 of 39

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").
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.
After more than 11 years of trial, the trial court rendered judgment on 22 November 1993
finding Dr. Estrada solely liable for damages.
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

Page 22 of 39

Hence, this petition.


ISSUE:
Basically, the issue in this case is whether CMC is vicariously liable for the negligence of Dr.
Estrada.
HELD:
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.

Page 23 of 39

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 x 40 (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 facilities 43
when Corazon was about to give birth, which CMC considered an emergency. Considering
these circumstances, Dr. Estrada is not an employee of CMC, but an independent contractor.
The question now is whether CMC is automatically exempt from liability considering that Dr.
Estrada is an independent contractor-physician.
In general, a hospital is not liable for the negligence of an independent contractor-physician.
There is, however, an exception to this principle. The hospital may be liable if the
physician is the "ostensible" agent of the hospital. 44 This exception is also known as
the "doctrine of apparent authority."45 In Gilbert v. Sycamore Municipal Hospital,46 the
Illinois Supreme Court explained the doctrine of apparent authority in this wise:
[U]nder the doctrine of apparent authority a hospital can be held vicariously liable for
the negligent acts of a physician providing care at the hospital, regardless of whether
the physician is an independent contractor, unless the patient knows, or should have
known, that the physician is an independent contractor. The elements of the action
have been set out as follows:

Page 24 of 39

"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.
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.

Page 25 of 39

CMC's defense that all it did was "to extend to [Corazon] its facilities" is untenable. The
Court cannot close its eyes to the reality that hospitals, such as CMC, are in the business of
treatment. In this regard, the Court agrees with the observation made by the Court of
Appeals of North Carolina in Diggs v. Novant Health, Inc., 57 to wit:
"The conception that the hospital does not undertake to treat the patient, does not
undertake to act through its doctors and nurses, but undertakes instead simply to
procure them to act upon their own responsibility, no longer reflects the fact.
Present day hospitals, as their manner of operation plainly demonstrates,
do far more than furnish facilities for treatment. They regularly employ on
a salary basis a large staff of physicians, nurses and internes [sic], as well
as administrative and manual workers, and they charge patients for
medical care and treatment, collecting for such services, if necessary, by
legal action. Certainly, the person who avails himself of 'hospital facilities'
expects that the hospital will attempt to cure him, not that its nurses or
other employees will act on their own responsibility." x x x (Emphasis
supplied)
Likewise unconvincing is CMC's argument that petitioners are estopped from claiming
damages based on the Consent on Admission and Consent to Operation. Both release forms
consist of two parts. The first part gave CMC permission to administer to Corazon any form
of recognized medical treatment which the CMC medical staff deemed advisable. The second
part of the documents, which may properly be described as the releasing part, releases CMC
and its employees "from any and all claims" arising from or by reason of the treatment and
operation.
The documents do not expressly release CMC from liability for injury to Corazon due to
negligence during her treatment or operation. Neither do the consent forms expressly
exempt CMC from liability for Corazon's death due to negligence during such treatment or
operation. Such release forms, being in the nature of contracts of adhesion, are construed
strictly against hospitals. Besides, a blanket release in favor of hospitals "from any and all
claims," which includes claims due to bad faith or gross negligence, would be contrary to
public policy and thus void.
Even simple negligence is not subject to blanket release in favor of establishments like
hospitals but may only mitigate liability depending on the circumstances. 58 When a person
needing urgent medical attention rushes to a hospital, he cannot bargain on equal footing
with the hospital on the terms of admission and operation. Such a person is literally at the
mercy of the hospital. There can be no clearer example of a contract of adhesion than one
arising from such a dire situation. Thus, the release forms of CMC cannot relieve CMC from
liability for the negligent medical treatment of Corazon.
On the Liability of the Other Respondents
Despite this Court's pronouncement in its 9 September 2002 59 Resolution that the filing of
petitioners' Manifestation confined petitioners' claim only against CMC, Dr. Espinola, Dr.
Lacson, and Dr. Uy, who have filed their comments, the Court deems it proper to resolve the
individual liability of the remaining respondents to put an end finally to this more than twodecade old controversy.
a) Dr. Ely Villaflor

Page 26 of 39

Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause of Corazon's bleeding and
to suggest the correct remedy to Dr. Estrada. 60 Petitioners assert that it was Dr. Villaflor's
duty to correct the error of Nurse Dumlao in the administration of hemacel.
The Court is not persuaded. Dr. Villaflor admitted administering a lower dosage of
magnesium sulfate. However, this was after informing Dr. Estrada that Corazon was no
longer in convulsion and that her blood pressure went down to a dangerous level. 61 At that
moment, Dr. Estrada instructed Dr. Villaflor to reduce the dosage of magnesium sulfate from
10 to 2.5 grams. Since petitioners did not dispute Dr. Villaflor's allegation, Dr. Villaflor's
defense remains uncontroverted. Dr. Villaflor's act of administering a lower dosage of
magnesium sulfate was not out of her own volition or was in contravention of Dr. Estrada's
order.
b) Dr. Rosa Uy
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
The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field of expertise is
definitely not obstetrics and gynecology. As such, Dr. Enriquez was not expected to correct
Dr. Estrada's errors. Besides, there was no evidence of Dr. Enriquez's knowledge of any error
committed by Dr. Estrada and his failure to act upon such observation.
d) Dr. Perpetua Lacson
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
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 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,

Page 27 of 39

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.
8. Cantre v. Sps. Go
FACTS:
Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and Gynecology at the Dr. Jesus
Delgado Memorial Hospital. She was the attending physician of respondent Nora S. Go, who
was admitted at the said hospital on April 19, 1992.
At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy. However, at
around 3:30 a.m., Nora suffered profuse bleeding inside her womb due to some parts of the
placenta which were not completely expelled from her womb after delivery. Consequently,
Nora suffered hypovolemic shock, resulting in a drop in her blood pressure to "40" over "0."
Petitioner and the assisting resident physician performed various medical procedures to stop
the bleeding and to restore Noras blood pressure. Her blood pressure was frequently
monitored with the use of a sphygmomanometer. While petitioner was massaging Noras
uterus for it to contract and stop bleeding, she ordered a droplight to warm Nora and her
baby.4 Nora remained unconscious until she recovered.
While in the recovery room, her husband, respondent John David Z. Go noticed a fresh
gaping wound two and a half (2 ) by three and a half (3 ) inches in the inner portion of
her left arm, close to the armpit. 5 He asked the nurses what caused the injury. He was
informed it was a burn. Forthwith, on April 22, 1992, John David filed a request for
investigation.6 In response, Dr. Rainerio S. Abad, the medical director of the hospital, called
petitioner and the assisting resident physician to explain what happened. Petitioner said the
blood pressure cuff caused the injury.
On May 7, 1992, John David brought Nora to the National Bureau of Investigation for a
physical examination, which was conducted by medico-legal officer Dr. Floresto Arizala, Jr. 7
The medico-legal officer later testified that Noras injury appeared to be a burn and that a
droplight when placed near the skin for about 10 minutes could cause such burn. 8 He
dismissed the likelihood that the wound was caused by a blood pressure cuff as the scar was
not around the arm, but just on one side of the arm.9
On May 22, 1992, Noras injury was referred to a plastic surgeon at the Dr. Jesus Delgado
Memorial Hospital for skin grafting.10 Her wound was covered with skin sourced from her
abdomen, which consequently bore a scar as well. About a year after, on April 30, 1993, scar
revision had to be performed at the same hospital. 11 The surgical operation left a healed
linear scar in Noras left arm about three inches in length, the thickest portion rising about
one-fourth (1/4) of an inch from the surface of the skin. The costs of the skin grafting and the
scar revision were shouldered by the hospital.12
Unfortunately, Noras arm would never be the same.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 complaint 13 for damages against
petitioner, Dr. Abad, and the hospital. Finding in favor of respondent spouses.

Page 28 of 39

Petitioner, Dr. Abad, and the hospital all appealed to the Court of Appeals, which affirmed
with modification the trial court decision.
ISSUE:
Is petitioner liable for the injury suffered by respondent Nora Go?
HELD:
In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere
existence of an injury to justify a presumption of negligence on the part of the person who
controls the instrument causing the injury, provided that the following requisites concur:
1. The accident is of a kind which ordinarily does not occur in the absence of
someones negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or
defendants; and
3. The possibility of contributing conduct which would make the plaintiff responsible
is eliminated.18
As to the first requirement, the gaping wound on Noras arm is certainly not an ordinary
occurrence in the act of delivering a baby, far removed as the arm is from the organs
involved in the process of giving birth. Such injury could not have happened unless
negligence had set in somewhere.
Second, whether the injury was caused by the droplight or by the blood pressure
cuff is of no moment. Both instruments are deemed within the exclusive control of
the physician in charge under the "captain of the ship" doctrine. This doctrine holds
the surgeon in charge of an operation liable for the negligence of his assistants during the
time when those assistants are under the surgeons control. 19 In this particular case, it can
be logically inferred that petitioner, the senior consultant in charge during the delivery of
Noras baby, exercised control over the assistants assigned to both the use of the droplight
and the taking of Noras blood pressure. Hence, the use of the droplight and the blood
pressure cuff is also within petitioners exclusive control.
Third, the gaping wound on Noras left arm, by its very nature and considering her condition,
could only be caused by something external to her and outside her control as she was
unconscious while in hypovolemic shock. Hence, Nora could not, by any stretch of the
imagination, have contributed to her own injury.
Petitioners defense that Noras wound was caused not by the droplight but by the constant
taking of her blood pressure, even if the latter was necessary given her condition, does not
absolve her from liability. As testified to by the medico-legal officer, Dr. Arizala, Jr., the
medical practice is to deflate the blood pressure cuff immediately after each use. Otherwise,
the inflated band can cause injury to the patient similar to what could have happened in this
case. Thus, if Noras wound was caused by the blood pressure cuff, then the taking of Noras
blood pressure must have been done so negligently as to have inflicted a gaping wound on
her arm,20 for which petitioner cannot escape liability under the "captain of the ship"
doctrine.

Page 29 of 39

Further, petitioners argument that the failed plastic surgery was not intended as a cosmetic
procedure, but rather as a measure to prevent complication does not help her case. It does
not negate negligence on her part.
Based on the foregoing, the presumption that petitioner was negligent in the exercise of her
profession stands unrebutted. In this connection, the Civil Code provides:
ART. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done.
ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious anxiety,
besmirched reputation, wounded feelings, moral shock, social humiliation, and similar injury.
Though incapable of pecuniary computation, moral damages may be recovered if they are
the proximate result of the defendants wrongful act or omission.
Clearly, under the law, petitioner is obliged to pay Nora for moral damages suffered by the
latter as a proximate result of petitioners negligence.
9. Ramos v. CA
FACTS:
Due to gall stones, Erlinda Ramos went to Dr. Hosaka to undergo a "cholecystectomy"
operation. During the consultation, Rogeliio, the husband, asked Dr. Hosaka to look for a
good anaesthesiologist for his wife for the operation. Dr. Hosaka scheduled the operation at
DLMSC on June 17, 1985.
The plaintiffs waited for Dr. Hosaka for three hours before he arrived at the hospital for the
operation apparently because he has a scheduled operation in another hospital as well.
Erlinda was accompanied by her sister-in-law, Herminda Cruz, who was the Dean of the
College of Nursing at the Capitol Medical Center, during the operation to give her moral
support.
Suddenly, Cruz heard Dr. Cruz, the anaesthesiologist saying "ang hirap ma-intubate nito,
mali yata ang pagkakapasok. O lumalaki ang tiyan." Thereafter, Cruz noticed that the
nailbeds of Erlinda turned bluish. Alarmed by this, Cruz went to Rogelio and informed him
that something is wrong with the operation. Later on, Erlinda became comatose.
The plaintiffs then filed a case against the doctors who operated on Erlinda as well as to the
hospital with the RTC, which ruled in their favour.
On appeal, the CA reversed the decision of the RTC.
ISSUES:
1. Is the doctrine of res ipsa loquitur applicable in this case?
2. Are Dr. Guittierrez, Dr. Hosaka and the hospital liable to Ramos?
HELD:
On the 1st Issue:

Page 30 of 39

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
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

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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.
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
We find the doctrine of res ipsa loquitur appropriate in the case at bar.
x

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

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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.
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.
On the 2nd Issue:
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.
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.
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.
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.

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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.
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.
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.
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).
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

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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 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.
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

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

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resulting to serious physical injuries, was filed against Dr. Jarcia, Dr. Bastan and Dr.
Pamittan,5 before the RTC, docketed as Criminal Case No. 01-196646.
On June 14, 2005, the RTC found the petitioners guilty beyond reasonable doubt of the crime
of Simple Imprudence Resulting to Serious Physical Injuries.
Dissatisfied, the petitioners appealed to the CA.
As earlier stated, the CA affirmed the RTC decision in toto.
ISSUES:
1. WON the doctrine of res ipsa loquitur is applicable in this case; and
2. WON the petitioners are liable for criminal negligence.
HELD:
On the 1st Issue:
As to the Application of The Doctrine of Res Ipsa Loquitur
This doctrine of res ipsa loquitur means "Where the thing which causes injury is shown to be
under the management of the defendant, and the accident is such as in the ordinary course
of things does not happen if those who have the management use proper care, it affords
reasonable evidence, in the absence of an explanation by the defendant, that the accident
arose from want of care." The Black's Law Dictionary defines the said doctrine. Thus:
The thing speaks for itself. Rebuttable presumption or inference that defendant was
negligent, which arises upon proof that the instrumentality causing injury was in defendant's
exclusive control, and that the accident was one which ordinarily does not happen in
absence of negligence. Res ipsa loquitur is a rule of evidence whereby negligence of the
alleged wrongdoer may be inferred from the mere fact that the accident happened provided
the character of the accident and circumstances attending it lead reasonably to belief that in
the absence of negligence it would not have occurred and that thing which caused injury is
shown to have been under the management and control of the alleged wrongdoer. Under
this doctrine, the happening of an injury permits an inference of negligence where plaintiff
produces substantial evidence that the injury was caused by an agency or instrumentality
under the exclusive control and management of defendant, and that the occurrence was
such that in the ordinary course of things would not happen if reasonable care had been
used.10
The doctrine of res ipsa loquitur as a rule of evidence is unusual to the law of negligence
which recognizes that prima facie negligence may be established without direct proof and
furnishes a substitute for specific proof of negligence. The doctrine, however, is not a rule of
substantive law, but merely a mode of proof or a mere procedural convenience. The rule,
when applicable to the facts and circumstances of a given case, is not meant to and does
not dispense with the requirement of proof of culpable negligence on the party charged. It
merely determines and regulates what shall be prima facie evidence thereof and helps the
plaintiff in proving a breach of the duty. The doctrine can be invoked when and only when,
under the circumstances involved, direct evidence is absent and not readily available. 11
The requisites for the application of the doctrine of res ipsa loquitur are: (1) the accident was
of a kind which does not ordinarily occur unless someone is negligent; (2) the

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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.
On the 2nd Issue:
As to Dr. Jarcia and Dr. Bastans negligence
The totality of the evidence on record clearly points to the negligence of the petitioners. At
the risk of being repetitious, the Court, however, is not satisfied that Dr. Jarcia and Dr.
Bastan are criminally negligent in this case.
Negligence is defined as the failure to observe for the protection of the interests of another
person that degree of care, precaution, and vigilance which the circumstances justly
demand, whereby such other person suffers injury. 14
Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act
from which material damage results by reason of an inexcusable lack of precaution on the
part of the person performing or failing to perform such act.15
The elements of simple negligence are: (1) that there is lack of precaution on the part of the
offender, and (2) that the damage impending to be caused is not immediate or the danger is
not clearly manifest.16
In this case, the Court is not convinced with moral certainty that the petitioners are guilty of
reckless imprudence or simple negligence. The elements thereof were not proved by the
prosecution beyond reasonable doubt.
The testimony of Dr. Cirilo R. Tacata (Dr. Tacata), a specialist in pediatric orthopedic,
although pointing to some medical procedures that could have been done by Dr. Jarcia and
Dr. Bastan, as physicians on duty, was not clear as to whether the injuries suffered by
patient Roy Jr. were indeed aggravated by the petitioners judgment call and their diagnosis
or appreciation of the condition of the victim at the time they assessed him.
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-

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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.
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.
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.

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