Jarcia vs.

People; torts- medical malpractice

7/1/2013

1 Comment

G.R. No. 187926; February 15, 2012

Facts:
Private complainant Belinda Santiago lodged a complaint with the National Bureau of Investigation
against the petitioners, Dr. Emmanuel Jarcia, Jr. and Dr. Marilou Bastan, for their alleged neglect of
professional duty which caused her son, Roy Alfonso Santiago, 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 victim’s ankle was ordered;
that the X-ray result showed no fracture as read by Dr. Jarcia; that Dr. Bastan entered the emergency
room and, after conducting her own examination of the victim, informed Mrs. Santiago that since it was
only the ankle that was hit, there was no need to examine the upper leg. despite Mrs. Santiago's protest
the doctors did not examine the upper portion of the leg of Roy. 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.

After trial and applying the doctrine of res ipsa loquitor the RTC found petitioners to be guilty of simple
negligence. The decision was affirmed in toto by the CA.
Issues:
(1) Whether or not res ipsa loquitor is applicable in this case.
(2) Whether of not the petitioner physicians are negligent, hence liable for damages.

Ruling:
As to the first issue: 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 requisites for the application of the doctrine of res ipsa loquitur are:
(1) the accident was of a kind which does not ordinarily occur unless someone is
negligent;
(2) the instrumentality or agency which caused the injury was under the exclusive control of the
person in charge; and
(3) the injury suffered must not have been due to any voluntary action or contribution of the
person injured.

However, 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. Ergo, the doctrine can be invoked when and only when, under
the circumstances involved, direct evidence is absent and not readily available.

Relative to the case, res ipsa loquitor does not apply since 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

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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. 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 patient’s mother, but by the
unquestionable knowledge of expert witness/es. As to whether the petitioners have exercised the
requisite degree of skill and care in treating patient Roy, Jr. is generally a matter of expert opinion.

As to the second issue: Petitioners were negligent in their obligation. It was proven that a
thorough examination was not performed on Roy Jr since 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.

Thus, simple negligence is resent if: (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.

Dr. Jarcia and Dr. Bastan, explained the court, 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.

Moreover, the contention of petitioners that they cannot be held liable since Roy is not their patient,
since they are not the attending physicians but merely requested by the ER does not hold water.

Physician-patient relationship exists when a patient engages the services of a physician, a physician-
patient relationship is generated. And in accepting a case, the physician, for all intents and purposes,
represents that he has the needed training and skill possessed by physicians and surgeons practicing in
the same field; and that he will employ such training, care, and skill in the treatment of the patient. Thus,
in treating his patient, a physician is under a duty to exercise that degree of care, skill and diligence
which physicians in the same general neighborhood and in the same general line of practice ordinarily
possess and exercise in like cases. Stated otherwise, the physician has the obligation to use at least the
same level of care that any other reasonably competent physician would use to treat the condition under
similar circumstances.”
There is a physician-patient relationship in this case since the petitioner obliged themselves and
examined the victim, and later assured the mother that everything was fine and that they could go home.
Their assurance that everything is fine deprived the victim of seeking medical help.

Petitioners were absolved in the criminal charge for the reason that a reasonable doubt existed but the
are liable for damages. There is no direct evidence proving that it was their negligence that caused the
suffering of Roy.

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LI VS SOLIMAN (GR NO. 165279 JUNE 7, 2011)
Li vs Spouses Soliman
GR No. 165279 June 7, 2011

Facts: On July 7, 1993, respondents 11 year old daughter, Angelica Soliman underwent a biopsy of the mass located
in her lower extremity at the St. Lukes Medical Center (SLMC). Results showed that Angelica was suffering from
osteosaucoma, ostiobiostic type, a high-grade (highly malignant) cancer of the bone which usually affects teenage
children. Following this diagnosis, Angelica’s right leg was amputated by Dr. Tamayo in order to remove the tumor.
As a adjuvant treatment to eliminate any remaining cancer cells, and hence minimizing the chances of recurrence
and prevent the decease from spreading to other parts of the patient’s body, chemotherapy was suggested by Dr.
Tamayo and referred Angelica to another doctor at SLMC, herein petitioner Dr. Rubi Li, a medical oncologist.

On July 23, 1993, petitioner saw the respondents at the hospital after Angelica’s surgery and discussed with them
Angelica’s condition. Petitioner told respondents that Angelica should be given 2-3 weeks to recover from the
operation before starting the chemotherapy. Respondents were apprehensive due to financial constraints as Reynaldo
earns only from P70,000-150,000 a year from his jewelry and watching repair business. Petitioner, however, assured
them not to worry about her professional fee and told them to just save up for medicines to be used.

As the chemotherapy session started, day by day, Angelica experience worsening condition and other physical effect
on the body such as discoloration, nausea, and vomiting.

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

Issue: Whether or not petitioner committed medical malpractice.

Held: No. The type of lawsuit which has been called medical malpractice or more appropriately, medical
negligence, is that type of claim which a victim has available to him or her to redress a wrong committed by a
medical professional which has caused bodily harm. In order to successfully pursue such claim, a patient must prove
that a health care provider in most cases a physician, either failed to do something which a reasonably prudent health
care provider would have done or that he or she did something that a reasonably health care provider would not have
done; and that failure or action caused injury to the patient.

Medical negligence cases are best proved by opinions of expert witnesses belonging in the same general
neighborhood and in the same general line of practice as defendant physician or surgeon. The deference of courts to
the expert opinion of qualified physicians stems from the former’s realization that the latter possess unusual
technical skills which layman in most instances are incapable of intelligently evaluating, hence the indispensability
of expert testimonies.

The doctrine of informed consent within the context of physician-patient relationships goes as far back into english
common law. As early as 1767, doctors were charged with the tort of battery if they have not gained the consent of
their patients prior to performing a surgery or procedure. In the United States, the seminal case was Schoendorff vs
Society of New York Hospital which involved unwanted treatment performed by a doctor. Justice Bejamin Cardozo

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oft-quoted opinion upheld the basic right of a patient to give consent to any medical procedure or treatment; every
human being of adult year and sound mind has a right to determine what shall be done with his own body; and a
surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in
damages. From a purely ethical norm, informed consent evolved into a general principle of law that a physician has
a duty to disclose what a reasonably prudent physician in the medical community in the exercise of reasonable care
would disclose to his patient as to whatever grave risk of injury might be incurred from a proposed course of
treatment, so that a patient, exercising ordinary care for her own welfare and faced with a choice of undergoing the
proposed treatment, as alternative treatment, or none at all, may intelligently exercise his judgement by reasonably
balancing the probable risk against the probable benefits.

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

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

ROSIT VS DAVAO DOCTORS

VELASCO JR., J.:

The Case
This is a petition filed under Rule 45 of the Rules of Court assailing the Decision and Resolution dated January 22,
2013[1] and November 7, 2013,[2] respectively, of the Court of Appeals, Cagayan De Oro City (CA), in CA-G.R. CV
No. 00911-MIN. The CA Decision reversed the Decision dated September 14, 2004 [3] of the Regional Trial Court,
Branch 33 in Davao City-(RTC) in Civil Case No. 27,354-99, a suit for damages thereat which Nilo B. Rosit (Rosit)
commenced against Dr. Rolando Gestuvo (Dr. Gestuvo).

Factual Antecedents

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

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

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

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

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

In Cebu, Dr. Pangan removed the plate and screws thus installed by Dr. Gestuvo and replaced them with smaller
titanium plate and screws. Dr. Pangan also extracted Rosit's molar that was hit with a screw and some bone
fragments. Three days after the operation, Rosit was able to eat and speak well and could open and close his mouth
normally.[7]

On his return to Davao, Rosit demanded that Dr. Gestuvo reimburse him for the cost of the operation and the
expenses he incurred in Cebu amounting to P140,000, as well as for the P50,000 that Rosit would have to spend for
the removal of the plate and screws that Dr. Pangan installed. Dr. Gestuvo refused to pay.[8]

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

The Ruling of the Regional Trial Court

The RTC freed DDH from liability on the ground that it exercised the proper diligence in the selection and
supervision of Dr. Gestuvo, but adjudged Dr. Gestuvo negligent and ruled, thus:

FOR ALL THE FOREGOING, finding the plaintiff Nilo B. Rosit to have preponderantly established his cause of
action in the complaint against defendant Dr. Rolando G. Gestuvo only, judgment is hereby rendered for the plaintiff
and against said defendant, ordering the defendant DR. ROLANDO G. GESTUVO to pay unto plaintiff NILO B.
ROSIT the following:

the sum of ONE HUNDRED FORTY THOUSAND ONE HUNDRED NINETY NINE PESOS and 13/100
a) (P140,199.13) representing reimbursement of actual expenses incurred by plaintiff in the operation and re-
operation of his mandible;
the sum of TWENTY NINE THOUSAND AND SIXTY EIGHT PESOS (P29,068.00) representing
b)
reimbursement of the filing fees and appearance fees;
c) the sum of ONE HUNDRED FIFTY THOUSAND PESOS (P150,000.00) as and for attorney's fees;
d) the amount of FIFTY THOUSAND PESOS (P50,000.00) as moral damages;
e) the amount of TEN THOUSAND PESOS (P10,000.00) as exemplary damages; and
f) the costs of the suit.

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

Cost against Dr. Rolando G. Gestuvo.

SO ORDERED.

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

Therefrom, both parties appealed to the CA.

The Ruling of the Court of Appeals

In its January 22, 2013 Decision, the CA modified the appealed judgment by deleting the awards made by the trial
court, disposing as follows:

WHEREFORE, the appeal filed by Gestuvo is GRANTED. The Decision dated September 14, 2004 of the Regional
Trial Court, Branch 33, Davao City, rendered in Civil Case No. 27,354-99 is hereby MODIFIED. The monetary
awards adjudged in favor of Nilo B. Rosit are hereby DELETED for lack of basis.

SO ORDERED.

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

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

Hence, the instant appeal.

The Issue
The ultimate issue for our resolution is whether the appellate court correctly absolved Dr. Gestuvo from liability.

The Court's Ruling

The petition is impressed with merit.

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

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

Duty refers to the standard of behavior which imposes restrictions on one's conduct. The standard in turn refers to
the amount of competence associated with the proper discharge of the profession. A physician is expected to use at
least the same level of care that any other reasonably competent doctor would use under the same circumstances.

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Breach of duty occurs when the physician fails to comply with these professional standards. If injury results to the
patient as a result of this breach, the physician is answerable for negligence. (emphasis supplied)

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

To establish medical negligence, this Court has held that an expert testimony is generally required to define the
standard of behavior by which the court may determine whether the physician has properly performed the requisite
duty toward the patient. This is so considering that the requisite degree of skill and care in the treatment of a patient
is usually a matter of expert opinion.[10]

Solidum v. People of the Philippines[11] provides an exception. There, the Court explained that where the application
of the principle of res ipsa loquitur is warranted, an expert testimony may be dispensed with in medical negligence
cases:

Although generally, expert medical testimony is relied upon in malpractice suits to prove that a physician has
done a negligent act or that he has deviated from the standard medical procedure, when the doctrine of res
ipsa loquitur is availed by the plaintiff, the need for expert medical testimony is dispensed with because the
injury itself provides the proof of negligence. The reason is that the general rule on the necessity of expert
testimony applies only to such matters clearly within the domain of medical science, and not to matters that are
within the common knowledge of mankind which may be testified to by anyone familiar with the facts. x x x

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

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

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

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

The first element was sufficiently established when Rosit proved that one of the screws installed by Dr. Gestuvo
struck his molar. It was for this issue that Dr. Gestuvo himself referred Rosit to Dr. Pangan. In fact, the affidavit of
Dr. Pangan presented by Dr. Gestuvo himself before the trial court narrated that the same molar struck with the
screw installed by Dr. Gestuvo was examined and eventually operated on by Dr. Pangan. Dr. Gestuvo cannot now
go back and say that Dr. Pangan treated a molar different from that which was affected by the first operation.

Clearly, had Dr. Gestuvo used the proper size and length of screws and placed the same in the proper locations,
these would not have struck Rosit's teeth causing him pain and requiring him to undergo a corrective surgery.

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

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

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

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

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

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

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

What is more damning for Dr. Gestuvo is his failure to inform Rosit that such smaller screws were available in
Manila, albeit at a higher price.[16] As testified to by Dr. Gestuvo himself:

Court This titanium materials according to you were already available in the Philippines since the time of
Alright. Rosit's accident?
Witness Yes, your Honor.
xxxx
Did you inform Rosit about the existence of titanium screws and plates which according to you is the
Court
screws and plates of choice?
Witness No, your Honor.
xxxx
The reason I did not inform him anymore Judge because what I thought he was already hard up with the
Witness down payment. And if I will further introduce him this screws, the more he will not be able to afford the
operation.
xxxx
This titanium screws and plates were available then it is up to Rosit to decide whether to use it or not
Court
because after all the material you are using is paid by the patient himscll, is it not?
Witness Yes, that is true.

Li v. Soliman[17] made the following disquisition on the relevant Doctrine of Informed Consent in relation to medical
negligence cases, to wit:

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

xxxx

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

The four adverted essential elements above are present here.

First, Dr. Gestuvo clearly had the duty of disclosing to Rosit the risks of using the larger screws for the operation.
This was his obligation as the physician undertaking the operation.

Second, Dr. Gestuvo failed to disclose these risks to Rosit, deciding by himself that Rosit could not afford to get the
more expensive titanium screws.

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

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

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

Dr. Pangan's Affidavit is not admissible

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

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

Moreover, even if such affidavit is considered as admissible and the testimony of an expert witness, the Court is not

9
bound by such testimony. As ruled in Ilao-Quianay v. Mapile:[20]

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

Thus, the belief of Dr. Pangan whether Dr. Gestuvo is guilty of negligence or not will not bind the Court. The Court
must weigh and examine such testimony and decide for itself the merits thereof.

As discussed above, Dr. Gestuvo's negligence is clearly demonstrable by the doctrines of res ipsa loquitur and
informed consent.

Damages

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

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

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

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

As to the award of exemplary damages, the same too has to be affirmed. In Mendoza,[24] the Court enumerated the
requisites for the award of exemplary damages:

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

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

WHEREFORE, the instant petition is GRANTED. The CA Decision dated January 22, 2013 and Resolution dated
November 7, 2013 in CA-G.R. CV No. 00911-MIN are hereby REVERSED and SET ASIDE. Further, the

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Decision dated September 14, 2004 of the Regional Trial Court, Branch 33 in Davao City in Civil Case No. 27,345-
99 is hereby REINSTATED and AFFIRMED.

FLORES VS PINEDA (GR NO. 158996 NOVEMBER 14, 2008)

Spouses Flores vs Spouses Pineda
GR No. 158996 November 14, 2008

Facts: Teresita Pineda consulted her townmate Dr. Fredelicto Flores regarding her medical condition, complaining
about general body weakness, loss of appetite, frequent urination and thirst, and on-and-off vaginal bleeding. After
interviewing Teresita, Dr. Fredelicto advised her to go to United Doctors Medical Center (UDMC) in Quezon City
for a general check-up the following week but the former did not. As for her other symptoms, he suspected that
Teresita might be suffering from diabetes and told her to continue her medications. When her conditions persisted,
she went to UDMC where Dr. Fredelictor check-up her and ordered her admission and further indicate on call D&C
operation to be performed by his wife, Dra. Felicisima Flores, an Ob-Gyne. Laboratory tests were done on Teresita
including internal vaginal examination, however, only the blood sugar and CBC results came out prior to operation
which indicated of diabetes. D&C operations were still done and thereafter, Dra. Felicisima advised her that she can
go home and continue to rest at home but Teresita opted otherwise. Two days after the operation, her condition
worsened prompting further test to be done which resulted that Teresita have diabetes melitus type II. Insulin was
administered but it might arrived late, she died.

Issue: Whether or not spouses petitioners are liable for medical negligence.

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

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

If a patient suffers from some disability that increases the magnitude of risk to him, that disability must be taken into
account as long as it is or should have been known to the physician.

Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C operation is a form of physical
stress. Dr. Mendoza explained how surgical stress can aggravate the patient’s hyperglycemia: when stress occurs,
the diabetic’s body, especially the autonomic system, reacts by secreting hormones which are counter-regulatory;
she can have prolonged hyperglycemia which, if unchecked, could lead to death. Medical lecture further explains
that if the blood sugar has become very high, the patient becomes comatose (diabetic coma). When this happens
over several days, the body uses its own fats to produce energy, and the result is high level of waste products in the
blood and urine.

These findings leads us to the conclusion that the decision to proceed with the D&C operation notwithstanding
Teresita’s hyperglycemia and without adequately preparing her for the procedure, was contrary to the standards
observed by the medical profession. Deviation from this standard amounted to a breach of duty which resulted in the
patient’s death. Due to this negligent conduct, liability must attach to the petitioner spouses.

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SOLIDUM VS PEOPLE (GR NO. 192123 MARCH 10, 2014)
Solidum vs People of the Philippines
GR No. 192123 March 10, 2014

Facts: Gerald Albert Gercayo was born on June 2, 1992 with an imperforate anus. Two days after his birth, Gerald
under went colostomy, a surgical procedure to bring one end of the large intestine out through the abdominal walls,
enabling him to excrete through a colostomy bag attached to the side of his body. On May 17, 1995, Gerald was
admitted at the Ospital ng Maynila for a pull-through operation. Dr. Leandro Resurreccionheaded the surgical team,
and was assisted by Dr. Joselito Lucerio, Dr.Donatella Valeria and Dr. Joseph Tibio. The anesthesiologist included
Drs. Abella, Razon and Solidum. During the operation, Gerald experienced bradycardia and went into a coma. His
coma lasted for two weeks , but he regained consciousness only after a month. He could no longer see, hear, or
move. A complaint for reckless imprudence resulting in serious physical injuries were filed by Gerald’s parents
against the team of doctors alleging that there was failure in monitoring the anesthesia administered to Gerald.

Issues: Whether or not petitioner is liable for medical negligence.

Whether or not res ipsa liquitor can be resorted to in medical negligence cases.

Held: No. Negligence is defined as the failure to observe for the protection of the interests of another person that
degree of care, precaution, and vigilance that the circumstances justly demand, whereby such other person suffers
injury. Reckless imprudence, on the other hand, consists of voluntarily doing or failing to do, without malice, an act
from which material damage results by reason of an inexcusable lack of precaution on the part of the person to
perform or failing to perform such act.

The negligence must be the proximate cause of the injury. For, negligence no matter in what it consists, cannot
create a right of action unless it is the proximate cause of the injury complained of. And the proximate cause of an
injury is that cause, which, in natural and continuous sequence and unbroken by any efficient intervening cause,
produces the injury, and without which the result would not have occurred.

An action upon medical negligence – whether criminal, civil or administrative – calls for the plaintiff to prove by
competent evidence each of the following four elements namely: a.) the duty owed by the physician to the patient, as
created by the physician-patient relationship, to act in accordance with the specific norms or standards established
by his profession; b.) the breach of the duty by the physician’s failing to act in accordance with the applicable
standard of care; c.) the causation, is, there must be a reasonably close and casual connection between the negligent
act or omission and the resulting injury; and d.) the damages suffered by the patient.

In the medical profession, specific norms on standard of care to protect the patient against unreasonable risk,
commonly referred to as standards of care, set the duty of the physician in respect of the patient. The standard of
care is an objective standard which conduct of a physician sued for negligence or malpractice may be measured, and
it does not depend therefore, on any individual’s physician’s own knowledge either. In attempting to fix a standard
by which a court may determine whether the physician has properly performed the requisite duty toward the patient,
expert medical testimony from both plaintiff and defense experts is required.

The doctrine of res ipsa liquitor means that where the thing which causes injury is shown to be under the
management of the defendant, and the accident is such as in ordinary course of things does not happen if those who
have management use proper care, it affords reasonable evidence, in the absence of an explanation by defendant that
the accident arose from want of care.

Nevertheless, despite the fact that the scope of res ipsa liquitor has been measurably enlarged, it does not
automatically apply to all cases of medical negligence as to mechanically shift the burden of proof to the defendant
to show that he is not guilty of the ascribed negligence. Res ipsa liquitor is not a rigid or ordinary doctrine to be

12
perfunctorily used but a rule to be cautiously applied, depending upon the circumstances of each case. It is generally
restricted to situations in malpractice cases where a layman is able to say, as a matter of common knowledge and
observation, that the consequences of professional care were not as such as would ordinarily have followed if due
care had been exercised. A distinction must be made between the failure to secure results, and the occurrence of
something more unusual and not ordinarily found if the service or treatment rendered followed the usual procedure
of those skilled in that particular practice. It must be conceded that the doctrine of res ipsa liquitor can have no
application in a suit against a physician or surgeon which involves the merits of a diagnosis or of a scientific
treatment. The physician or surgeon is not required at his peril to explain why any particular diagnosis was not
correct, or why any particular scientific treatment did not produce the desired results. Thus, res ipsa liquitor is not
available in a malpractice suit if the only showing is that the desired result of an operation or treatment was not
accomplished. The real question, therefore, is whether or not in the process of the operation any extraordinary
incident or unusual event outside the routine performance occurred which is beyond the regular scope of customary
professional activity in such operations, which if unexplained would themselves reasonably speak to the average
man as the negligent case or causes of the untoward consequence. If there was such extraneous intervention, the
doctrine of res ipsa liquitor may be utilized and the dependent is called upon to explain the matter, by evidence of
exculpation, if he could.

Rico Rommel Atienza

vs.

Board of Medicine and Editha Sioson

G.R. No. 177407

February 9. 2011

Facts:

Private respondent went to Rizal Medical Center to submit for a check up due to her lumbar pains. Her diagnostic
laboratory test results revealed that her right kidney was normal while her left kidney was non-functioning and non-
visualizing. Hence, she underwent kidney operation under the care of the four physicians namely: Dr. Judd dela
Vega, Dr. Pedro Lantin III, Dr. Gerardo Antonio and petitioner Dr. Rico Rommel Atienza.

The said physicians removed her fully functioning right kidney instead of the left non-functioning and non-
visualizing kidney. Due to their gross negligence and incompetence, private respondent filed a complaint against the
four doctors before the Board of Medicine. Private respondent therein offered four certified photocopies as her
documentary evidence to prove that her kidneys were both in their proper anatomical locations at the time that she
was operated.

The Board of Medicine admitted the formal offer despite the objection of herein petitioner. Petitioner contends that
the documentary evidence offered were inadmissible as it were incompetent. Further, he alleged that the same
documents were not properly identified and authenticated, violate the best evidence rule and his substantive rights,
and are completely hearsay.

Issues:

1. Whether the exhibits are inadmissible evidence on the ground that it violates the best evidence rule.

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2. Whether the exhibits are inadmissible evidence on the ground that they have not been properly identified and
authenticated.

3. Whether the exhibits are inadmissible evidence on the ground that it is completely hearsay.

4. Whether the admission of the documents violated the substantive rights of the petitioner.

Ruling:

1. No. The subject of the inquiry in this case is whether the doctors are liable for gross negligence in removing
the right functioning kidney of Editha instead of the left non-functioning kidney, not the proper anatomical locations
of Editha’s kidneys. The proper anatomical locations of Editha’s kidneys at the time of her operation at the RMC
may be established not only through the exhibits offered in evidence

In fact, the introduction of secondary evidence is allowed. Section 3, Rule 130 provides that when the subject of the
inquiry is the contents of the document, no evidence shall be admissible other than the original document itself,
except when the original has been lost or destroyed, or cannot be produced in court without bad faith on the offeror.
Since the original documents cannot be produced based on the testimony of Dr. Aquino BOM properly admitted
Editha’s formal offer of evidence, and thereafter, the BOM shall determine the probative value thereof when it
decides the case.

2. No, the documentary evidence were properly identified and authenticated. The records show that the exhibits
offered by private respondent were the same evidence attached in Doctor Lantin's counter-affidavit filed before the
Office of the City Prosecutor in answer to the criminal complaint of the respondent. To lay the predicate for her
case, private respondent offered the exhibits in evidence to prove that her kidneys were both in their proper
anatomical locations at the time of her operation

3. No, these exhibits do not constitute hearsay evidence. The anatomical positions whether left or right, of
Editha’s kidneys, and the removal of one or both, may still be established through a belated ultrasound or x-ray of
her abdominal area.

4. No, petitioner’s substantive rights were not violated when the documentary evidence were admitted. The fact
sought to be proved by the exhibits that the two kidneys of Editha were in their proper anatomical locations at the
time she was operated on is presumed under Section 3 of Rule 131 of the Rules of Court which provides that things
have happened according to the ordinary course of nature and the ordinary habits of life.

The fact sought to be established by the admission of the respondent’s exhibit need not be proved as it is covered by
mandatory judicial notice. Laws of nature involving the physical science, specifically biology include the structural
make-up and composition of living things such as human beings in which the court may take judicial notice.

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 DR. PEDRO DENNIS CERENO, and DR. SANTOS ZAFE, Petitioners,
vs.
COURT OF APPEALS, SPOUSES DIOGENES S. OLAVERE and FE R.
SERRANO, Respondents

G.R. No. 167366

September 26, 2012

Facts:

At about 9:15 in the evening of 16 September 1995, Raymond S. Olavere,a victim of a stabbing
incident, was rushed to the emergency room of the Bicol Regional Medical Center. Dr. Realuyo
— the emergency room resident physician, recommended that the patient undergo "emergency
exploratory laparotomy." Dr. Realuyo then requested the parents of Raymond to procure 500 cc
of type "O" blood needed for the operation.

At 10:30 P.M., Raymond was wheeled inside the operating room. During that time, the hospital
surgeons, Drs. Zafe and Cereno, were busy operating on gunshot victim Charles Maluluy-on.
Assisting them in the said operation was Dr. Tatad, who was the only senior anesthesiologist on
duty at BRMC that night.Just before the operation on Maluluy-on was finished, another
emergency case involving Lilia Aguila, a woman who was giving birth to triplets, was brought to
the operating room.

At 10:59 P.M., the operation on the gunshot victom was finished. By that time, however, Dr.
Tatadis still engaged in another operation and there being no other available anesthesiologist to
assist them, Drs. Zafe and Cereno decided to defer the operation on Raymond. The petitioners, in
the meantime, proceeded to examine Raymond and they found that the latter’s blood pressure
was normal and "nothing in him was significant." Dr. Cereno reported that based on the xray
result he interpreted, the fluid inside the thoracic cavity of Raymond was minimal at around 200-
300 cc.

At 11:15 P.M, the relatives of Raymond brought the bag of blood to be used for blood
transfusion. Dr. Cereno and Dr. Zafe immediately started the operation around 12:15 AM of 17
September 1995. Upon opening of Raymond’s thoracic cavity, they found that 3,200 cc of blood
was stocked therein. The blood was evacuated and petitioners found a puncture at the inferior
pole of the left lung.Dr. Cereno did not immediately transfuse blood because he had to control
the bleeders first.Blood was finally transfused on Raymond at 1:40 A.M. While the operation
was on-going, Raymond suffered a cardiac arrest. The operation ended at 1:50 A.M. and
Raymond was pronounced dead at 2:30 A.M.Raymond’s death certificate indicated that the
immediate cause of death was "hypovolemic shock".

The parents of Raymondfiled a case for damages against the attending surgeons claiming that
there was negligence on the part of those who attended to their son.

15
The trial court found petitioners negligent in not immediately conducting surgery on Raymond
and that that the non-availability of Dr. Tatad after the operation on the gunshot victim was not a
sufficient excuse for the petitioners to not immediately operate on Raymond. Lastly, the trial
court faulted petitioners for the delay in the transfusion of blood on Raymond.

On appeal, the CA affirmed the decision rendered by the RTC finding herein petitioners guilty of
gross negligence in the performance of their duties and awarding damages to private
respondents, prompting the petitoners to file a petition for review on certiorari before the
Supreme Court.

Issue:

Whether Dr. Cereno and Dr. Zafe are guilty of gross negligence in the performance of
their duties.

Held:

Petition GRANTED.

The Supreme Court held that the petitioners are not guilty of gross negligence.The type of
lawsuit which has been called medical malpractice or medical negligence, is that type of claim
which the complainant must prove: (1) that the health care provider, either by his act or
omission, had been negligent, and (2) that such act or omission proximately caused the injury
complained of.

The best approach to prove these is through the opinions of expert witnesses belonging in the
same general line of practice as defendant surgeon. The deference of courts to the expert opinion
of qualified physicians stems from the former’s realization that the latter possess unusual
technical skills which laymen in most instances are incapable of intelligently evaluating, hence,
the indispensability of expert testimonies.

In the case at bar, there were no expert witnesses presented to testify norwas there any testimony
offered, except that of Dr. Tatad’s, on which it may be inferred that petitioners failed to exercise
the standard of care, diligence, learning and skill expected from practitioners of their profession.
Dr. Tatad is not an expert witness in this case as her expertise is in the administration of
anesthesia and not in the determination of whether surgery ought or not ought to be performed.

In medical negligence cases, it is established that the complainant has the burden of establishing
breach of duty on the part of the doctors or surgeons. It must be proven that such breach of duty
has a causal connection to the death of the patient.Aside from their failure to prove negligence on
the part of the petitioners, they also failed to prove that it was petitioners’ fault that caused the
injury.

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BATIQUIN V CA (Villegas)
258 SCRA 334 DAVIDE; July 5, 1996

NATURE:
Petition for review of the decision of the Court of Appeals
FACTS
- Mrs. Villegas submitted to Dr. Batiquin for prenatal care as the latter's private patient
sometime before September 21,1988. In the morning of September 21, 1988 Dr. Batiquin, along
with other physicians and nurses, performed a caesarean operation on Mrs. Villegas and
successfully delivered the latter’s baby. After leaving the hospital, Mrs. Villegas began to
suffer abdominal pains and complained of being feverish. She also gradually lost her appetite, so
she consulted Dr. Batiquin at the latter's polyclinic who prescribed for her certain medicines.
However, the pains still kept recurring. She then consulted Dr.Ma. Salud Kho. After examining
her, Dr Kho suggested that Mrs.Villegas submit to another surgery.- When Dr. Kho opened the
abdomen of Mrs. Villegas she found whitish-yellow discharge inside, an ovarian cyst on each of
the left and right ovaries which gave out pus, dirt and pus behind the uterus, and a piece of
rubber material on the right side of the uterus, embedded on the ovarian cyst. The piece of rubber
appeared to be a part of a rubber glove. This was the cause of all of the infection of the ovaries
and consequently of all the discomfort suffered by Mrs. Villegas. The piece of rubber allegedly
found was not presented in court, and Dr. Kho testified that she sent it to a pathologist in Cebu
City for examination. Aside from Dr. Kho's testimony, the evidence which mentioned the piece
of rubber are a Medical Certificate, a Progress Record, an Anaesthesia Record, a Nurse's Record,
and a Physician's Discharge Summary. The trial court, however, regarded these documentary
evidence as mere hearsay, "there being no showing that the person or persons who prepared them
are deceased or unable to testify on the facts therein stated- There was also doubts as to the
whereabouts of the piece of rubber, as 2 versions arose from Dr. Kho’s testimony: 1) that it was
sent to the Pathologist in Cebu as testified to in Court by Dr. Kho and (2) that Dr. Kho threw it
away as told by her to Defendant. The failure of the Plaintiffs to reconcile these two different
versions served only to weaken their claim against Defendant Batiquin. The trial court ruled in
favor of the defendants. The CA reversed the decision.

ISSUES

Procedural:
WON the court can review questions of fact

Substantive:
WON Dr. Batiquin is liable

HELD
Procedural:
YES

- While the rule is that only questions of law may be raised in a petition for review on

17
certiorari , there are exceptions, among which are when the factual findings of the trial court and
the appellate court conflict, when the appealed decision is clearly contradicted by the evidence
on record, or when the appellate court misapprehended the facts
Substantive
- The focal point of the appeal is Dr. Kho’s testimony. There were inconsistencies within her
own testimony, which led to the different decision of the RTC and CA. The CA was correct in
saying that the trial court erred when it isolated the disputed portion of Dr. Kho’s testimony and
did not consider it with other portions of Dr. Kho’s testimony. Also, the phrase relied upon by
the trial court does not negate the fact that Dr. Kho saw a piece of rubber in private respondent
Villegas' abdomen, and that she sent it to a laboratory and then to Cebu City for examination by
a pathologist. Furthermore, Dr. Kho's knowledge of the piece of rubber could not be based on
other than first hand knowledge for, as she asserted before the trial court.

BATIQUIN vs. COURT OF APPEALS

“At present, the primary objective of the medical profession is the preservation of life and maintenance
of the health of the people.”

FACTS

Dr. Batiquin was a Resident Physician at the Negros Oriental Provincial Hospital, Dumaguete City. She
was also the Actg. Head of the Department of Obstetrics and Gynecology at the said Hospital. Mrs.
Villegas, a married woman, submitted herself to Dr. Batiquin for prenatal care as the latter's private
patient. One morning, Dr. Batiquin, with the assistance of Dr. Doris Teresita Sy, also a Resident Physician
at the same Hospital, C.I. and O.R. Nurse Arlene Diones and some student nurses performed a simple
cesarean section on Mrs. Villegas and after 45 minutes Mrs. Villegas delivered her first child, Rachel
Acogido. Thereafter, Plaintiff remained confined at the Hospital during which she was regularly visited by
Dr. Batiquin. Soon after leaving the Hospital Mrs. Villegas began to suffer abdominal pains and
complained of being feverish. She also gradually lost her appetite, so she consulted Dr. Batiquin at the
latter's polyclinic who prescribed for her certain medicines. The abdominal pains and fever kept on
recurring despite the medications administered by Dr. Batiquin. When the pains become unbearable and
she was rapidly losing weight she consulted Dr. Ma. Salud Kho at the Holy Child's Hospital in Dumaguete
City. Dr. Ma. Salud Kho found Mrs. Villegas to be feverish, pale and was breathing fast. Upon examination
she felt an abdominal mass one finger below the umbilicus which she suspected to be either a tumor of
the uterus or an ovarian cyst, either of which could be cancerous. She had an x-ray taken of Mrs.
Villegas' chest, abdomen and kidney. She also took blood tests of Plaintiff. A blood count showed that
Mrs. Villegas had an infection inside her abdominal cavity. The result of all those examinations impelled
Dr. Kho to suggest that Mrs. Villegas submit to another surgery to which the latter agreed. Legal

18
Medicine – Medical Negligence Digest by Bianca Beltran 2 When Dr. Kho opened the abdomen of Mrs.
Villegas she found whitish-yellow discharge inside, an ovarian cyst on each of the left and right ovaries
which gave out pus, dirt and pus behind the uterus, and a piece of rubber materials on the right side of
the uterus embedded on the ovarian cyst, 2 inches by 3/4 inch in size. This piece of rubber material
which Dr. Kho described as a "foreign body" looked like a piece of a "rubber glove" and which is also
"rubber-drain like”. It could have been a torn section of a surgeon's gloves or could have come from
other sources. And this foreign body was the cause of the infection of the ovaries and consequently of all
the discomfort suffered by Mrs. Villegas after her delivery. The piece of rubber allegedly found near
private respondent Flotilde Villegas' uterus was not presented in court, and although Dr. Ma. Salud Kho
testified that she sent it to a pathologist in Cebu City for examination, it was not mentioned in the
pathologist's Surgical Pathology Report. Aside from Dr. Kho's testimony, the evidence which mentioned
the piece of rubber are a Medical Certificate, a Progress Record, an Anesthesia Record, a Nurse's Record,
and a Physician's Discharge Summary. The trial court, however, regarded these documentary evidence as
mere hearsay. The trial court deemed vital Dr. Victoria Batiquin's testimony that when she confronted Dr.
Kho regarding the piece of rubber, "Dr. Kho answered that there was rubber indeed but that she threw it
away." This statement, the trial court noted, was never denied nor disputed by Dr. Kho, leading it to
conclude: There are now two different versions on the whereabouts of that offending "rubber" — (1) that
it was sent to the Pathologist in Cebu as testified to in Court by Dr. Kho and (2) that Dr. Kho threw it
away as told by her to Defendant. The failure of the Plaintiffs to reconcile these two different versions
serve only to weaken their claim against Defendant Batiquin. RTC - held in favor of the petitioners herein.
CA – reversed the decision. It deemed Dr. Kho’s positive testimony to definitely establish that a piece of
rubber was found near private respondent Villegas’ uterus. It further noted the fact that Villegas can no
longer bear children because her uterus and ovaries were removed by Dr. Kho is not taken into
consideration as it not shown that the removal of said organs were the direct result of the rubber left by
the appellee Dr. Batiquin near the uterus. What is establishe is that the rubber Legal Medicine – Medical
Negligence Digest by Bianca Beltran 3 left by appellee cause infection, placed the life of appellant Flotilde
in jeopardy ad caused appelants fear, worry and anxiety.

ISSUE

Whether or not the testimony of Dr. Kho should be given credence

Ruling

We agree with the Court of Appeals. The phrase relied upon by the trial court does not negate the fact
that Dr. Kho saw a piece of rubber in private respondent Villegas' abdomen, and that she sent it to a
laboratory and then to Cebu City for examination by a pathologist. Not even the Pathologist's Report,
although devoid of any mention of a piece of rubber, could alter what Dr. Kho saw. Furthermore, Dr.
Kho's knowledge of the piece of rubber could not be based on other than first hand. Although hearsay,
Dr. Batiquin's claim was not objected to, and hence, the same is admissible but it carries no probative
value. Nevertheless, assuming otherwise, Dr. Batiquin's statement cannot belie the fact that Dr. Kho
found a piece of rubber near private respondent Villegas' uterus. And even if we were to doubt Dr. Kho
as to what she did to the piece of rubber. On this score, it is perfectly reasonable to believe the testimony
of a witness with respect to some facts and disbelieve his testimony with respect to other facts. And it
has been aptly said that even when a witness is found to have deliberately falsified in some material
particulars, it is not required that the whole of his uncorroborated testimony be rejected, but such
portions thereof deemed worthy of belief may be credited. Considering that we have assessed Dr. Kho to
be a credible witness, her positive testimony [that a piece of rubber was indeed found in private
respondent Villegas' abdomen] prevails over the negative testimony in favor of the petitioners. As such,
the rule of res ipsa loquitur comes to fore. This Court has had occasion to delve into the nature and
operation of this doctrine: Res ipsa loquitur. The thing speaks for itself. Rebuttable presumption or

19
inference that defendant was negligent, which arises upon proof that [the] Legal Medicine – Medical
Negligence Digest by Bianca Beltran 4 instrumentality causing injury was in defendant's exclusive control,
and that the accident was one which ordinary does not happen in absence of negligence. Res ipsa
loquitur is [a] rule of evidence whereby negligence of [the] alleged wrongdoer may be inferred from [the]
mere fact that [the] accident happened provided [the] character of [the] accident and circumstances
attending it lead reasonably to belief that in [the] absence of negligence it would not have occurred and
that thing which caused injury is shown to have been under [the] management and control of [the]
alleged wrongdoer . . . . Under [this] doctrine . . . the happening of an injury permits an inference of
negligence where plaintiff produces substantial evidence that [the] injury was caused by an agency or
instrumentality under [the] exclusive control and management of defendant, and that the occurrence
[sic] was such that in the ordinary course of things would not happen if reasonable care had been used.
xxx xxx xxx The doctrine of [r]es ipsa loquitur as a rule of evidence is peculiar to the law of negligence
which recognizes that prima facie negligence may be established without direct proof and furnishes a
substitute for specific proof of negligence. The doctrine is not a rule of substantive law, but merely a
mode of proof or a mere procedural convenience. The rule, when applicable to the facts and
circumstances of a particular case, is not intended to and does not dispense with the requirement of
proof of culpable negligence on the party charged. It merely determines and regulates what shall be
prima facie evidence thereof and facilitates the burden of plaintiff of proving a breach of the duty of due
care. The doctrine can be invoked when and only when, under the circumstances involved, direct
evidence is absent and not readily available. In the instant case, all the requisites for recourse to the
doctrine are present. First, the entire proceedings of the cesarean section were under the exclusive
control of Dr. Batiquin. In this light, the private respondents were bereft of direct evidence as to the
actual culprit or the exact cause of the foreign object finding its way into private respondent Villegas'
body, which, needless to say, does not occur unless through the intervention of negligence. Second,
since aside from the cesarean section, private respondent Villegas underwent no other operation which
could have caused the offending piece of rubber to appear in her uterus, it stands to reason that such
could only have been a by-product of the cesarean Legal Medicine – Medical Negligence Digest by Bianca
Beltran 5 section performed by Dr. Batiquin. The petitioners, in this regard, failed to overcome the
presumption of negligence arising from resort to the doctrine of res ipsa loquitur. Dr. Batiquin is therefore
liable for negligently leaving behind a piece of rubber in private respondent Villegas' abdomen and for all
the adverse effects thereof. As a final word, this Court reiterates its recognition of the vital role the
medical profession plays in the lives of the people, and State's compelling interest to enact measures to
protect the public from "the potentially deadly effects of incompetence and ignorance in those who would
undertake to treat our bodies and minds for disease or trauma." Indeed, a physician is bound to serve
the interest of his patients "with the greatest of solicitude, giving them always his best talent and skill."
Through her tortious conduct, the petitioner endangered the life of Flotilde Villegas, in violation of her
profession's rigid ethical code and in contravention of the legal standards set forth for professionals, in
the general, and members of the medical profession, in particular. WHEREFORE, the challenged decision
of 11 May 1994 of the Court of Appeals in CA-G.R. CV No. 30851 is hereby AFFIRMED in toto. Costs
against the petitioners. SO ORDERED.

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RAMOS vs. COURT OF APPEALS
G.R. No. 124354. December 29, 1999.

Ponente: Kapunan

FACTS:

Erlinda Ramos underwent a surgical procedure to remove stone from her gall bladder
(cholecystectomy). They hired Dr. Hosaka, a surgeon, to conduct the surgery at the De Los
Santos Medical Center (DLSMC). Hosaka assured them that he would find a good
anesthesiologist. But the operation did not go as planned, Dr. Hosaka arrived 3 hours late
for the operation, Dra. Gutierrez, the anesthesiologist “botched” the administration of the
anesthesia causing Erlinda to go into a coma and suffer brain damage. The botched
operation was witnessed by Herminda Cruz, sister in law of Erlinda and Dean of College of
Nursing of Capitol Medical Center.

The family of Ramos (petitioners) sued the hospital, the surgeon and the anesthesiologist
for damages. The petitioners showed expert testimony showing that Erlinda's condition was
caused by the anesthesiologist in not exercising reasonable care in “intubating” Erlinda.
Eyewitnesses heard the anesthesiologist saying “Ang hirap ma-intubate nito, mali yata ang
pagkakapasok. O lumalaki ang tiyan.”

Diagnostic tests prior to surgery showed that Erlinda was robust and fit to undergo surgery.

The RTC held that the anesthesiologist ommitted to exercise due care in intubating the
patient, the surgeon was remiss in his obligation to provide a “good anesthesiologist” and
for arriving 3 hours late and the hospital is liable for the negligence of the doctors and for
not cancelling the operation after the surgeon failed to arrive on time. The surgeon,
anesthesiologist and the DLSMC were all held jointly and severally liable for damages to
petitioners. The CA reversed the decision of the Trial Court.

ISSUES: Whether or not the private respondents were negligent and thereby caused the
comatose condition of Ramos.

HELD:

Yes, private respondents were all negligent and are solidarily liable for the damages.

RATIO:

Res ipsa loquitur – a procedural or evidentiary rule which means “the thing or the
transaction speaks for itself.” It 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, where ordinarily in a medical

21
malpractice case, the complaining party must present expert testimony to prove that the
attending physician was negligent.

This doctrine finds application in this case. On the day of the operation, Erlinda Ramos
already surrendered her person to the private respondents who had complete and exclusive
control over her. Apart from the gallstone problem, she was neurologically sound and fit.
Then, after the procedure, she was comatose and brain damaged—res ipsa loquitur!—the
thing speaks for itself!

Negligence – Private respondents were not able to disprove the presumption of negligence
on their part in the care of Erlinda and their negligence was the proximate cause of her
condition. One need not be an anesthesiologist in order to tell whether or not the intubation
was a success. [res ipsa loquitur applies here]. The Supreme Court also found that the
anesthesiologist only saw Erlinda for the first time on the day of the operation which
indicates unfamiliarity with the patient and which is an act of negligence and irresponsibility.

The head surgeon, Dr. Hosaka was also negligent. He failed to exercise the proper authority
as the “captain of the ship” in determining if the anesthesiologist observed the proper
protocols. Also, because he was late, he did not have time to confer with the
anesthesiologist regarding the anesthesia delivery.

The hospital failed to adduce evidence showing that it exercised the diligence of a good
father of the family in hiring and supervision of its doctors (Art. 2180). The hospital was
negligent since they are the one in control of the hiring and firing of their “consultants”.
While these consultants are not employees, hospitals still exert significant controls on the
selection and termination of doctors who work there which is one of the hallmarks of an
employer-employee reationship. Thus, the hospital was allocated a share in the liability.

Damages – temperate damages can and should be awarded on top of actual or

compensatory damages in instances where the injury is chronic and continuing.

CASUMPANG v. CORTEJO
G.R. No. 171127 | March 11, 2015

FACTS:

 On April 22, 1988, at about 11:30 in the morning, Mrs. Cortejo brought her 11-year old son, Edmer, to
the Emergency Room of the San Juan de Dios Hospital (SJDH) because of difficulty in breathing,
chest pain, stomach pain, and fever. Thereafter, she was referred and assigned to Dr. Casumpang, a
pediatrician. At 5:30 in the afternoon of the same day, Dr. Casumpang, upon examination using only
a stethoscope, confirmed the diagnosis of Bronchopneumonia. Mrs. Cortejo immediately advised Dr.
Casumpang that Edmer had a high fever, and had no colds or cough but Dr. Casumpang merely told
her that her son's bloodpressure is just being active and remarked that that's the usual
bronchopneumonia, no colds, no phlegm.

 Dr. Casumpang next visited the following day. Mrs. Cortejo again called Dr. Casumpang's attention
and stated that Edmer had a fever, throat irritation, as well as chest and stomach pain. Mrs. Cortejo
also alerted Dr. Casumpang about the traces of blood in Edmer's sputum. Despite these pieces of
information, however, Dr. Casumpang simply nodded and reassured Mrs. Cortejo that Edmer's illness
is bronchopneumonia.

22
 At around 11:30 in the morning of April 23, 1988, Edmer vomited phlegm with blood streak prompting
the Edmer's father to request for a doctor. Later, Miranda, one of the resident physicians of SJDH,
arrived. She claimed that although aware that Edmer had vomited phlegm with blood streak she failed
to examine the blood specimen. She then advised the respondent to preserve the specimen for
examination. Thereafter, Dr. Miranda conducted a check-up on Edmer and found that Edmer had a
low-grade fever and rashes.

 At 3:00 in the afternoon, Edmer once again vomited blood. Dr. Miranda then examined Edmer's
sputum with blood and noted that he was bleeding. Suspecting that he could be afflicted with dengue,
Dr. Miranda conducted a tourniquet test, which turned out to be negative. Dr. Miranda then called up
Dr. Casumpang at his clinic and told him about Edmer's condition. Upon being informed, Dr.
Casumpang ordered several procedures done. Dr. Miranda advised Edmer's parents that the blood
test results showed that Edmer was suffering from Dengue Hemorrhagic Fever. Dr. Casumpang
recommended Edmer’s transfer to the ICU, but since the ICU was then full, the respondent, insisted
on transferring his son to Makati Medical Center.

 At 12:00 midnight, Edmer, accompanied by his parents and by Dr. Casumpang, was transferred to
Makati Medical Center. Upon examination, the attending physician diagnosed Dengue Fever Stage IV
that was already in its irreversible stage. Edmer died at 4:00 in the morning of April 24, 1988. His
Death Certificate indicated the cause of death as Hypovolemic Shock/hemorrhagic shock/Dengue
Hemorrhagic Fever Stage IV.

 Believing that Edmer's death was caused by the negligent and erroneous diagnosis of his doctors, the
respondent instituted an action for damages against SJDH, and its attending physicians: Dr.
Casumpang and Dr. Miranda.

 Dr. Casumpang contends that he gave his patient medical treatment and care to the best of his
abilities, and within the proper standard of care required from physicians under similar circumstances.

 Dr. Miranda argued that the function of making the diagnosis and undertaking the medical treatment
devolved upon Dr. Casumpang, the doctor assigned to Edmer. Dr. Miranda also alleged that she
exercised prudence in performing her duties as a physician, underscoring that it was her professional
intervention that led to the correct diagnosis of Dengue Hemorrhagic Fever.

 SJDH, on the other hand, disclaims liability by asserting that Dr. Casumpang and Dr. Miranda are
mere independent contractors and consultants (not employees) of the hospital; hence, Article 2180 of
the Civil Code does not apply.

ISSUES:

1. W/N Casumpang had committed inexcusable lack of precaution in diagnosing and in treating the
patient

2. W/N Miranda had committed inexcusable lack of precaution in diagnosing and in treating the patient

3. W/N Whether or not the petitioner hospital is solidarity liable with the petitioner doctors

4. W/N or not there is a causal connection between the petitioners' negligent act/omission and the
patient's resulting death

HELD/RATIO:

1. YES, Casumpang was negligent.

 Even assuming that Edmer's symptoms completely coincided with the diagnosis of
bronchopneumonia, we still find Dr. Casumpang guilty of negligence. Wrong diagnosis is not by itself

23
 medical malpractice. Physicians are generally not liable for damages resulting from a bona fide error
of judgment and from acting according to acceptable medical practice standards. Nonetheless, when
the physician's erroneous diagnosis was the result of negligent conduct, it becomes an evidence of
medical malpractice.

 In the present case, evidence on record established that in confirming the diagnosis of
bronchopneumonia, Dr. Casumpang selectively appreciated some and not all of the symptoms
presented, and failed to promptly conduct the appropriate tests to confirm his findings. In sum, Dr.
Casumpang failed to timely detect dengue fever, which failure, especially when reasonable prudence
would have shown that indications of dengue were evident and/or foreseeable, constitutes
negligence. Apart from failing to promptly detect dengue fever, Dr. Casumpang also failed to promptly
undertake the proper medical management needed for this disease. Dr. Casumpang failed to
measure up to the acceptable medical standards in diagnosing and treating dengue fever.

 Dr. Casumpang's claim that he exercised prudence and due diligence in handling Edmer's case,
sside from being self-serving, is not supported by competent evidence. He failed, as a medical
professional, to observe the most prudent medical procedure under the circumstances in diagnosing
and treating Edmer.

2. No, Dr. Miranda is not liable for negligence.

 We find that Dr. Miranda was not independently negligent. Although she was subject to the same
standard of care applicable to attending physicians, as a resident physician, she merely operates as a
subordinate who usually refer to the attending physician on the decision to be made and on the action
to be taken. We also believe that a finding of negligence should also depend on several competing
factors. In this case, before Dr. Miranda attended to Edmer, Dr. Casumpang had diagnosed Edmer
with bronchopneumonia. There is also evidence supporting Dr. Miranda's claim that she extended
diligent care to Edmer. In fact, when she suspected, during Edmer's second episode of bleeding, that
Edmer could be suffering from dengue, she wasted no time in conducting the necessary tests, and
promptly notified Dr. Casumpang about the incident. Indubitably, her medical assistance led to the
finding of dengue fever. Dr. Miranda's error was merely an honest mistake of judgment; hence, she
should not be held liable for medical negligence.

3. Yes, causal connection between the petitioners' negligence and the patient's resulting death
was established

 Casumpang failed to timely diagnose Edmer with dengue fever despite the presence of its
characteristic symptoms; and as a consequence of the delayed diagnosis, he also failed to promptly
manage Edmer's illness. Had he immediately conducted confirmatory tests, and promptly
administered the proper care and management needed for dengue fever, the risk of complications or
even death, could have been substantially reduced. That Edmer later died of Dengue Hemorrhagic
Fever Stage IV, a severe and fatal form of dengue fever, established the causal link between Dr.
Casumpang's negligence and the injury. The element of causation is successfully proven.

4. YES, SJDH is solidarily liable.

 As a rule, hospitals are not liable for the negligence of its independent contractors. However, it may
be found liable if the physician or independent contractor acts as an ostensible agent of the hospital.
This exception is also known as the doctrine of apparent authority.

 SJDH impliedly held out and clothed Dr. Casumpang with apparent authority leading the respondent
to believe that he is an employee or agent of the hospital. Based on the records, the respondent
relied on SJDH rather than upon Dr. Casumpang, to care and treat his son Edmer. His testimony
during trial showed that he and his wife did not know any doctors at SJDH; they also did not know
that Dr. Casumpang was an independent contractor. They brought their son to SJDH for diagnosis

24
 because of their family doctor's referral. The referral did not specifically point to Dr. Casumpang or
even to Dr. Miranda, but to SJDH.

 Mrs. Cortejo accepted Dr. Casumpang's services on the reasonable belief that such were being
provided by SJDH or its employees, agents, or servants. By referring Dr. Casumpang to care and
treat for Edmer, SJDH impliedly held out Dr. Casumpang as a member of its medical staff. SJDH
cannot now disclaim liability since there is no showing that Mrs. Cortejo or the respondent knew, or
should have known, that Dr. Casumpang is only an independent contractor of the hospital. In this
case, estoppel has already set in.

Nogales v. Capitol Medical Center, et al., G.R. No. 142625, 19 December 2006.

20SEP

[CARPIO, J.]

FACTS:

Pregnant with her fourth child, Corazon Nogales (“Corazon”), who was then 37 years old, was under
the exclusive prenatal care of Dr. Oscar Estrada (“Dr. Estrada”) beginning on her fourth month of
pregnancy or as early as December 1975. While Corazon was on her last trimester of pregnancy, Dr.
Estrada noted an increase in her blood pressure and development of leg edema indicating
preeclampsia, which is a dangerous complication of pregnancy. 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”). The following day, Corazon was admitted at 2:30
a.m. at the CMC after the staff nurse noted the written admission request of Dr. Estrada. Upon
Corazon’s admission at the CMC, Rogelio Nogales (“Rogelio”) executed and signed the “Consent on
Admission and Agreement” and “Admission Agreement.” Corazon was then brought to the labor room of
the CMC. Corazon died at 9:15 a.m. The cause of death was “hemorrhage, post partum.”

Petitioners filed a complaint for damages with the Regional Trial Court of Manila against CMC, Dr.
Estrada, and the rest of CMC medical staff for the death of Corazon. In their defense, CMC pointed out
that Dr. Estrada was a consultant to be considered as an independent-contractor, and that no
employer-employee relationship existed between the former and the latter.

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 appeal, the Court of Appeals affirmed the trial court’s ruling and applied the “borrowed servant
doctrine” to release the liability of other medical staff. This doctrine provides that once the surgeon
enters the operating room and takes charge of the proceedings, the acts or omissions of operating room
personnel, and any negligence associated with such acts or omissions, are imputable to the surgeon.
While the assisting physicians and nurses may be employed by the hospital, or engaged by the patient,
they normally become the temporary servants or agents of the surgeon in charge while the operation is
in progress, and liability may be imposed upon the surgeon for their negligent acts under the doctrine
of respondeat superior.

25
ISSUE: Whether CMC is vicariously liable for the negligence of Dr. Estrada as its attending independent-
contractor physician considering that facts of the instant case.

HELD: YES.

In general, a hospital is not liable for the negligence of an independent contractor-physician. There is,
however, an exception to this principle. The hospital may be liable if the physician is the “ostensible”
agent of the hospital. This exception is also known as the “doctrine of apparent authority.”xxx 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. 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. xxx 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.

xxx

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
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].” 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. xxx 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.

xxx

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

26
PSI VS AGANA (GR NO. 126297 JANUARY 31, 2007)
Professional Services Inc. vs Agana
GR No. 126297 January 31, 2007

Facts: On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital because of difficulty of
bowel movement and bloody anal discharge. After a series of medical examinations, Dr. Miguel Ampil diagnosed
her to be suffering from Cancer of the sigmoid. On April 11, 1984, Dr. Ampil assisted by the medical staff of the
Medical City Hospital performed an Anterior resection surgery on Natividad. He found that the malignancy on her
sigmoid area had spread on her left ovary, necessitating the removal of certain portions of it. Thus, Dr. Ampil
obtained the consent of Natividad’s husband, Enrique Agana, to permit Dr. Juan Fuentes to perform hysterectomy
on her. After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and closed
the incision after searching for the missing 2 gauzes as indicated by the assisting nurses but failed to locate it. After
a couple of days, Natividad complained of excruciating pains in her anal region but Dr. Ampil said it is a natural
consequence of the operation/surgery and recommended that she consult an oncologist to examine the cancerous
nodes which were not removed during the operation. Natividad and her husband went to the US to seek further
treatment and she was declared free from cancer. A piece of gauze portruding from Natividad’s vagina was found by
her daughter which was then removed by hand by Dr. Ampil and assured that the pains will vanished. However, it
didn’t. The pains intensified prompting Natividad to seek treatment at the Polymedic General Hospital. While
confined there, Dr. Ramon Guttierez detected the presence of another foreign object in her vagina – a foul smelling
gauze measuring 1.5 inches in width which badly infected her vagina. A recto-vaginal fistula had forced stool to
excrete through her vagina. Another surgical operation was needed to remedy the damage.

Issue: Whether or not Dr. Ampil and Fuentes are liable for medical malpractice and the PSI for damages due to the
negligence of the said doctors.

Held: Yes. No. Yes. An operation requiring the placing of sponges in the incision is not complete until the sponges
are properly removed and it is settled that the leaving of sponges or other foreign substances in the wound after the
incision has been closed is at least prima facie negligence by the operating surgeon. To put it simply, such act is
considered so inconsistent with due care as to raise inference of negligence. There are even legions of authorities to
the effect that such act is negligence per se.

This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully pursue this
kind of case, a patient must only prove that a health care provider either failed to do something which a reasonably
prudent health care provider would have done, or that he did something that a reasonably prudent provider would
not have done; and that failure or action caused injury to the patient. Simply puts the elements are duty, breach,
injury, and proximate causation. Dr. Ampil, as the lead surgeon, had the duty to remove all foreign objects, such as
gauzes, from Natividad’s body before closure of the incision. When he failed to do so, it was his duty to inform
Natividad about it. Dr. Ampil breached both duties. Such breach caused injury to Natividad, necessitating her further
examination by American doctors and another surgery. That Dr. Ampil’s negligence is the proximate cause of
Natividad’s injury could be traced from his act of closing the incision despite the information given by the attending
nurses that 2 pieces of gauze were still missing. That they were later on extracted from Natividad’s vagina
established the causal link between Dr. Ampil’s negligence and the injury. And what further aggravated such injury
was his deliberate concealment of this missing gauzes from the knowledge of Natividad and her family.

The requisites for the applicability of the doctrine of res ipsa liquitor are:

1. Occurrence of an injury;
2. The thing which caused the injury was under the control and management of the defendant;
3. The occurrence was such that in the ordinary course of things would not have happened if those who had
control or management used proper care, and;
4. The absence of explanation by the defendant

27
Of the foregoing, the most instrumental is the “Control and management of the thing which caused the injury.”

Under the “Captain of the ship” rule, the operating surgeon is the person in complete charge of the surgery room and
all personnel connected with the operation.

The knowledge of any of the staff of Medical City constitutes knowledge of PSI.

The doctrine of corporate responsibility, has the duty to see that it meets the standards of responsibilities for the care
of patients. Such duty includes the proper supervision of the members of its medical staff. The hospital accordingly
has the duty to make a reasonable effort to monitor and over see the treatment prescribed and administered by the
physician practicing in its premises.

CANTRE VS GO (GR NO. 160889 APRIL 27, 2007)

Cantre vs Go
GR No. 160889 April 27, 2007

Facts: Petitioner Dr. Milagros L. Cantre is a specialist in obstetrics and gynecology at the Dr. Jesus Delgado
memorial Hospital. She was the attending physician of respondent Nora Go, who was admitted at the said hospital
on April 19, 1992. At 1:30am of April 20, 1992, Nora gave birth to her fourth child, a baby boy. However, at around
3:30am Nora suffered profuse bleeding insider her womb due to some parts of the placenta were not completely
expelled from her womb after delivery consequently, Nora suffered hypovolemic shock, resulting in a drop in her
blood pressure to 40/0. Petitioner said the assisting resident physician performed various medical procedures to stop
the bleeding and to restore Nora’s blood pressure. Her blood pressure was frequently monitored with the use of a
sphygmamometer. While petitioner was massaging Nora’s uterus for it to contract and stop bleeding, she ordered a
drop light to warm Nora and her baby. Nora remained unconscious until she recovered. While in the recovery room,
her husband, respondent John David Z. Go noticed a fresh gasping wound 2 1/2″ x 3 1/2″ in the inner portion of her
left arm, close to the armpit. He asked the nurses what caused the injury. He was informed, it was a burn. An
investigation was filed by Nora’s husband and found out from the petitioner that it was caused by the blood pressure
cuff, however, this was contrary to the findings from a medico-legal report which stated that it was indeed a burn
and that a drop light when placed near a skin for about 10mins could cause such burn. Nora was referred to a plastic
surgeon from the hospital and skin grafting was done on her and scar revision but both still left a mark on Nora’s
arm compelling the respondent spouse to file a complaint for damages against petitioner.

Issue: Whether or not petitioner is liable for the injury referred by Nora.

Held: Yes. The Hippocratic oath mandates physicians to give primordial consideration to the well-being of their
patients. If a doctor fails to live up to his precept, he is accountable for his acts. This is notwithstanding, courts face
a unique restraint in adjudicating medical negligence cases because physicians are not guardians of care and they
never set out to intentionally cause injury to their patients. However, intent is immaterial in negligence cases
because where negligence exist and is proven, it automatically gives the injured a right to reparation for the damage
caused.

In cases, involving medical negligence, the doctrine of res ipsa liquitor allows the mere existence of an injury to
justify a presumption of negligence on the part of the person who controls the instrument causing the injury,
provided that the following requisites concur:

28
 1. The accident is of a kind which ordinarily does not occur in the absence of someone’s negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or defendants;
3. The possibility of contributing conduct which would make the plaintiff responsible is eliminated.

All of these three requisites were present in the case at bar.

Under the the captain of the ship doctrine, the surgeon in charge of the operation is liable for the negligence of his
assistants during the time when those are under the surgeons control.

29