478 SUPREME COURT REPORTS ANNOTATED
Ampil did not inform Natividad
Professional Services, Inc. vs. Agana
G.R. No. 126297. January 31, 2007. *
PROFESSIONAL SERVICES, INC., petitioner, vs.
NATIVIDAD and ENRIQUE AGANA, respondents.
G.R. No. 126467. January 31, 2007. *
NATIVIDAD and ENRIQUE AGANA, respondents.
NATIVIDAD (Substituted by her children MARCELINO
AGANA III, ENRIQUE AGANA, JR., EMMA AGANA
ANDAYA, JESUS AGANA, and RAYMUND AGANA) and
ENRIQUE AGANA, petitioners, vs. JUAN FUENTES,
respondent.
G.R. No. 127590. January 31, 2007. *
MIGUEL AMPIL, petitioner, vs. NATIVIDAD AGANA and
ENRIQUE AGANA, respondents.
_______________
* FIRST DIVISION.
479
VOL. 513, JANUARY 31, 2007 479
Professional Services, Inc. vs. Agana
Civil Law; Damages; Negligence; 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.— 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 an inference of negligence. There are even legions of
authorities to the effect that such act is negligence per se.
Same; Same; Same; To the mind of the Court, what was initially an act of
negligence by Dr. Ampil has ripened into a deliberate wrongful act of
deceiving his patient.—Here, Dr.
about the missing two pieces of gauze. Worse, he even misled her that
the pain she was experiencing was the ordinary consequence of her
operation. Had he been more candid, Natividad could have taken
the immediate and appropriate medical remedy to remove the
gauzes from her body. To our mind, what was initially an act of
negligence by Dr. Ampil has ripened into a deliberate wrongful act
of deceiving his patient.
Same; Same; Same; Doctrine of Res Ipsa Loquitur; Requisites for the
Applicability of the Doctrine.—Literally, res ipsa loquitur means “the
thing speaks for itself.” It is the rule that the fact of the occurrence
of an injury, taken with the surrounding circumstances, may permit
an inference or raise a presumption of negligence, or make out a
plaintiff’s prima facie case, and present a question of fact for
defendant to meet with an explanation. Stated differently, where
the thing which caused the injury, without the fault of the injured,
is under the exclusive control of the defendant and the injury is
such that it should not have occurred if he, having such control
used proper care, it affords reasonable evidence, in the absence of
explanation that the injury arose from the defendant’s want of care,
and the burden of proof is shifted to him to establish that he has
observed due care and diligence. From the foregoing statements of
the rule, the requisites for the applicability of the doctrine of res ipsa
loquitur are: (1) the occurrence of an injury; (2) the thing which
caused the injury was under the control and management of the
defendant; (3) the occurrence was such that in the ordinary course
of things, would
480
480 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
not have happened if those who had control or management used
proper care; and (4) the absence of explanation by the defendant.
Of the foregoing requisites, the most instrumental is the “control and
management of the thing which caused the injury.”
Same; Same; Same; Same; Res ipsa loquitur is not a rule of substantive
law, hence, does not per se create or constitute an independent or separate
ground of liability, being a mere evidentiary rule.—In this jurisdiction,
res ipsa loquitur is not a rule of substantive law, hence, does not per
se create or constitute an independent or separate ground of
liability, being a mere evidentiary rule. In other words, mere
invocation and application of the doctrine does not dispense with
the requirement of proof of negligence. Here, the negligence was
proven to have been committed by Dr. Ampil and not by Dr.
Fuentes.
Same; Same; Same; Professionals are considered personally liable for the
fault or negligence they commit in the discharge of their duties and their
employer cannot be held liable for such fault or negligence.—A
prominent civilist commented that professionals engaged by an
employer, such as physicians, dentists, and pharmacists, are not
“employees” under this article because the manner in which they
perform their work is not within the control of the latter (employer).
In other words, professionals are considered personally liable for the fault
or negligence they commit in the discharge of their duties, and their
employer cannot be held liable for such fault or negligence. In the context
of the present case, “a hospital cannot be held liable for the fault or
negligence of a physician or surgeon in the treatment or operation
of patients.”
Same; Same; Same; In this jurisdiction, the nature of the relationship
between the hospital and the physicians is rendered inconsequential in
view of the pronouncement in Ramos vs. Court of Appeals, 321 SCRA 584
(1999), that for purposes of apportioning responsibility in medical
negligence cases, an employer-employee relationship in effect exists
between hospitals and their attending and visiting physicians.—In our
shores, the nature of the relationship between the hospital and the
physicians is rendered inconsequential in view of our categorical
pronouncement in Ramos v. Court of Appeals, 321 SCRA 584 (1999),
that for purposes of apportioning responsibility in
481
VOL. 513, JANUARY 31, 2007 481
Professional Services, Inc. vs. Agana
medical negligence cases, an employer-employee relationship in effect
exists between hospitals and their attending and visiting physicians.
Same;Same; Same; PSI’s liability is also anchored upon the agency
principle of apparent authority or agency by estoppel and the doctrine of
corporate negligence.—But the Ramos pronouncement is not our only
basis in sustaining PSI’s liability. Its liability is also anchored upon
the agency principle of apparent authority or agency by estoppel and
the doctrine of corporate negligence which have gained acceptance in
the determination of a hospital’s liability for negligent acts of health
professionals. The present case serves as a perfect platform to test
the applicability of these doctrines, thus, enriching our
jurisprudence. Apparent authority, or what is sometimes referred
to as the “holding out” theory, or doctrine of ostensible agency or
agency by estoppel, has its origin from the law of agency. It imposes
liability, not as the result of the reality of a contractual relationship,
but rather because of the actions of a principal or an employer in
somehow misleading the public into believing that the relationship
or the authority exists. The concept is essentially one of estoppel
and has been explained in this manner: “The principal is bound by
the acts of his agent with the apparent authority which he
knowingly permits the agent to assume, or which he holds the
agent out to the public as possessing. The question in every case is
whether the principal has by his voluntary act placed the agent in
such a situation that a person of ordinary prudence, conversant
with business usages and the nature of the particular business, is
justified in presuming that such agent has authority to perform the
particular act in question.
Same; Same; Same; In cases where it can be shown that a hospital, by its
actions, has held out a particular physician as its agent and/or employee
and that a patient has accepted treatment from that physician in the
reasonable belief that it is being rendered in behalf of the hospital, then the
hospital will be liable for the physician’s negligence.—The applicability
of apparent authority in the field of hospital liability was upheld
long time ago in Irving v. Doctor Hospital of Lake Worth, Inc., 415 So.
2d 55 (1982). There, it was explicitly stated that “there does not appear
to be any rational basis for excluding the concept of apparent authority
from the field of hospital liability.” Thus, in cases where it can be
shown that a hospital, by its actions, has held out a particular
physician as its agent and/or employee and
482
482 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
that a patient has accepted treatment from that physician in the
reasonable belief that it is being rendered in behalf of the hospital,
then the hospital will be liable for the physician’s negligence.
Same; Same; Same; By accrediting Dr. Ampil and Dr. Fuentes and
publicly advertising their qualifications, the hospital created the
impression that they were its agents, authorized to perform medical or
surgical services for its patients.—In this case, PSI publicly displays in
the lobby of the Medical City Hospital the names and
specializations of the physicians associated or accredited by it,
including those of Dr. Ampil and Dr. Fuentes. We concur with the
Court of Appeals’ conclusion that it “is now estopped from passing all
the blame to the physicians whose names it proudly paraded in the public
directory leading the public to believe that it vouched for their skill and
competence.” Indeed, PSI’s act is tantamount to holding out to the
public that Medical City Hospital, through its accredited physicians,
offers quality health care services. By accrediting Dr. Ampil and Dr.
Fuentes and publicly advertising their qualifications, the hospital
created the impression that they were its agents, authorized to
perform medical or surgical services for its patients. As expected,
these patients, Natividad being one of them, accepted the services
on the reasonable belief that such were being rendered by the
hospital or its employees, agents, or servants.
PETITION for review on certiorari of the decisions of the
Court of Appeals.
The facts are stated in the opinion of the Court.
Bengzon, Narciso, Cudala, Pecson, Bengzon & Jimenez for
petitioner Professional Services, Inc.
Enrique Agana & Associates for petitioners Natividad and
Enrique Agana.
The Law Firm of Raymundo M. Armovit for petitioner Miguel
Ampil.
Agcaoili Law Offices collaborating counsel for Heirs of
Natividad Agana.
Benjamin M. Tongol for Juan Fuentes.
483
VOL. 513, JANUARY 31, 2007 483
Professional Services, Inc. vs. Agana
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankind’s most
important and delicate endeavors, must assume the grave
responsibility of pursuing it with appropriate care. The care
and service dispensed through this high trust, however
technical, complex and esoteric its character may be, must
meet standards of responsibility commensurate with the
undertaking to preserve and protect the health, and indeed,
the very lives of those placed in the hospital’s keeping.
1
Assailed in these three consolidated petitions for review on
certiorari is the Court of Appeals’ Decision dated September
2
6, 1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198
affirming with modification the Decision dated March 17,
3
1993 of the Regional Trial Court (RTC), Branch 96, Quezon
City in Civil Case No. Q-43322 and nullifying its Order
dated September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the
Medical City General Hospital (Medical City Hospital)
because of difficulty of bowel movement and bloody anal
discharge. After a series of medical examinations, Dr. Miguel
Ampil, petitioner in G.R. No. 127590, diagnosed her to be
suffering from “cancer of the sigmoid.”
_______________
1Beeck v. Tucson General Hospital, 500 P. 2d 1153 (1972), citing
Darling v. Charleston Community Memorial Hospital, 33 Ill. 2d 326, 211
N.E. 2d 253.
2 Penned by Associate Justice Cancio C. Garcia (now a member of
the Supreme Court) and concurred in by Associate Justices Eugenio
S. Labitoria and Artemio G. Tuquero (both retired), Rollo, G.R. No.
126297, pp. 36-51; 126467, pp. 27-42; 127590, pp. 23-38.
3 Penned by Judge Lucas P. Bersamin (now Justice of the Court of
Appeals), Rollo, G.R. No. 126647, pp. 69-83.
484
484 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
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 in her
sigmoid area had spread on her left ovary, necessitating the
removal of certain portions of it. Thus, Dr. Ampil obtained the
consent of Natividad’s husband, Enrique Agana, to permit
Dr. Juan Fuentes, respondent in G.R. No. 126467, to perform
hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil
took over, completed the operation and closed the incision.
However, the operation appeared to be flawed. In the
corresponding Record of Operation dated April 11, 1984, the
attending nurses entered these remarks:
“sponge count lacking 2
“announced to surgeon searched (sic) done but to no avail
continue for closure.”
On April 24, 1984, Natividad was released from the hospital.
Her hospital and medical bills, including the doctors’ fees,
amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating
pain in her anal region. She consulted both Dr. Ampil and Dr.
Fuentes about it. They told her that the pain was the natural
consequence of the surgery. Dr. Ampil then recommended
that she consult an oncologist to examine the cancerous nodes
which were not removed during the operation.
On May 9, 1984, Natividad, accompanied by her husband,
went to the United States to seek further treatment. After four
months of consultations and laboratory examinations,
Natividad was told she was free of cancer. Hence, she was
advised to return to the Philippines.
_______________
4The medical staff was composed of physicians, both residents and
interns, as well as nurses.
4 485
VOL. 513, JANUARY 31, 2007 485
Professional Services, Inc. vs. Agana
On August 31, 1984, Natividad flew back to the Philippines,
still suffering from pains. Two weeks thereafter, her daughter
found a piece of gauze protruding from her vagina. Upon
being informed about it, Dr. Ampil proceeded to her house
where he managed to extract by hand a piece of gauze
measuring 1.5 inches in width. He then assured her that the
pains would soon vanish.
Dr. Ampil’s assurance did not come true. Instead, the pains
intensified, prompting Natividad to seek treatment at the
Polymedic General Hospital. While confined there, Dr.
Ramon Gutierrez detected the presence of another foreign
object in her vagina—a foul-smelling gauze measuring 1.5
inches in width which badly infected her vaginal vault. A
recto-vaginal fistula had formed in her reproductive organs
which forced stool to excrete through the vagina. Another
surgical operation was needed to remedy the damage. Thus,
in October 1984, Natividad underwent another surgery.
On November 12, 1984, Natividad and her husband filed with
the RTC, Branch 96, Quezon City a complaint for damages
against the Professional Services, Inc. (PSI), owner of the
Medical City Hospital, Dr. Ampil, and Dr. Fuentes, docketed
as Civil Case No. Q-43322. They alleged that the latter are
liable for negligence for leaving two pieces of gauze inside
Natividad’s body and malpractice for concealing their acts of
negligence.
Meanwhile, Enrique Agana also filed with the Professional
Regulation Commission (PRC) an administrative complaint
for gross negligence and malpractice against Dr. Ampil and
Dr. Fuentes, docketed as Administrative Case No. 1690. The
PRC Board of Medicine heard the case only with respect to
Dr. Fuentes because it failed to acquire jurisdiction over Dr.
Ampil who was then in the United States.
On February 16, 1986, pending the outcome of the above
cases, Natividad died and was duly substituted by her
abovenamed children (the Aganas).
486
486 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
On March 17, 1993, the RTC rendered its Decision in favor of
the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable for
negligence and malpractice, the decretal part of which reads:
“WHEREFORE, judgment is hereby rendered for the plaintiffs
ordering the defendants PROFESSIONAL SERVICES, INC., DR.
MIGUEL AMPIL and DR. JUAN FUENTES to pay to the plaintiffs,
jointly and severally, except in respect of the award for exemplary
damages and the interest thereon which are the liabilities of
defendants Dr. Ampil and Dr. Fuentes only, as follows:
1 1.
As actual damages, the following amounts:
1 a.
The equivalent in Philippine Currency of the total of
US$19,900.00 at the rate of P21.60-US$1.00, as
reimbursement of actual expenses incurred in the United
States of America;
2 b.
The sum of P4,800.00 as travel taxes of plaintiffs and their
physician daughter;
3 c.
The total sum of P45,802.50, representing the cost of
hospitalization at Polymedic Hospital, medical fees, and
cost of the saline solution;
1 2.
As moral damages, the sum of P2,000,000.00;
2 3.
As exemplary damages, the sum of P300,000.00;
3 4.
As attorney’s fees, the sum of P250,000.00;
4 5.
Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove,
from date of filing of the complaint until full payment; and
5 6.
Costs of suit.
SO ORDERED.”
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an
appeal to the Court of Appeals, docketed as CA-G.R. CV No.
42062.
Incidentally, on April 3, 1993, the Aganas filed with the RTC
a motion for a partial execution of its Decision, which was
granted in an Order dated May 11, 1993. Thereafter, the
sheriff levied upon certain properties of Dr. Ampil and sold
487
VOL. 513, JANUARY 31, 2007 487
Professional Services, Inc. vs. Agana
them for P451,275.00 and delivered the amount to the Aganas.
Following their receipt of the money, the Aganas entered into
an agreement with PSI and Dr. Fuentes to indefinitely
suspend any further execution of the RTC Decision. However,
not long thereafter, the Aganas again filed a motion for an
alias writ of execution against the properties of PSI and Dr.
Fuentes. On September 21, 1993, the RTC granted the motion
and issued the corresponding writ, prompting Dr. Fuentes to
file with the Court of Appeals a petition for certiorari and
prohibition, with prayer for preliminary injunction, docketed
as CA-G.R. SP No. 32198. During its pendency, the Court of
Appeals issued a Resolution dated October 29, 1993 granting
5 AFFIRMED and the instant appeal DISMISSED.
Dr. Fuentes’ prayer for injunctive relief.
On January 24, 1994, CA-G.R. SP No. 32198 was consolidated
with CA-G.R. CV No. 42062.
Meanwhile, on January 23, 1995, the PRC Board of Medicine
rendered its Decision in Administrative Case No. 1690
6
dismissing the case against Dr. Fuentes. The Board held that
the prosecution failed to show that Dr. Fuentes was the one
who left the two pieces of gauze inside Natividad’s body; and
that he concealed such fact from Natividad.
_______________
5 The dispositive portion reads:
“WHEREFORE, let a writ of preliminary injunction be issued upon
petitioner’s posting of bond in the amount of P20,000.00, ENJOINING
public respondents from implementing the questioned order dated
September 21, 1993 and from further taking any action in Civil Case
No. Q-43322 entitled ‘Natividad G. Agana, et al., plaintiffs, versus
Professional Services, Inc., et al., defendants’ pending resolution of the
instant petition.
SO ORDERED.” See Rollo, G.R. No. 126297, p. 42.
6 Rollo of G.R. No. 126467, pp. 84-89.
488
488 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
On September 6, 1996, the Court of Appeals rendered its
Decision jointly disposing of CA-G.R. CV No. 42062 and CA-
G.R. SP No. 32198, thus:
“WHEREFORE, except for the modification that the case against
defendant-appellant Dr. Juan Fuentes is hereby DISMISSED, and
with the pronouncement that defendant-appellant Dr. Miguel
Ampil is liable to reimburse defendant-appellant Professional
Services, Inc., whatever amount the latter will pay or had paid to
the plaintiffs-appellees, the decision appealed from is hereby
Concomitant with the above, the petition for certiorari and
prohibition filed by herein defendant-appellant Dr. Juan Fuentes in
CA-G.R. SP No. 32198 is hereby GRANTED and the challenged
order of the respondent judge dated September 21, 1993, as well as
the alias writ of execution issued pursuant thereto are hereby
NULLIFIED and SET ASIDE. The bond posted by the petitioner in
connection with the writ of preliminary injunction issued by this
Court on November 29, 1993 is hereby cancelled.
Costs against defendants-appellants Dr. Miguel Ampil and
Professional Services, Inc.
SO ORDERED.”
Only Dr. Ampil filed a motion for reconsideration, but it was
denied in a Resolution dated December 19, 1996.
7
Hence, the instant consolidated petitions.
In G.R. No. 126297, PSI alleged in its petition that the Court of
Appeals erred in holding that: (1) it is estopped from raising
the defense that Dr. Ampil is not its employee; (2) it is
solidarily liable with Dr. Ampil; and (3) it is not entitled to its
counterclaim against the Aganas. PSI contends that Dr. Ampil
is not its employee, but a mere consultant or independent
contractor. As such, he alone should answer for his
negligence.
_______________
7 Rollo of G.R. No. 127590, p. 40.
489
VOL. 513, JANUARY 31, 2007 489
Professional Services, Inc. vs. Agana
In G.R. No. 126467, the Aganas maintain that the Court of
Appeals erred in finding that Dr. Fuentes is not guilty of
negligence or medical malpractice, invoking the doctrine of
res ipsa loquitur. They contend that the pieces of gauze are
prima facie proofs that the operating surgeons have been
negligent.
Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of
Appeals erred in finding him liable for negligence and
malpractice sans evidence that he left the two pieces of gauze
in Natividad’s vagina. He pointed to other probable causes,
such as: (1) it was Dr. Fuentes who used gauzes in performing
the hysterectomy; (2) the attending nurses’ failure to properly
count the gauzes used during surgery; and (3) the medical
intervention of the American doctors who examined
Natividad in the United States of America.
For our resolution are these three vital issues: first, whether
the Court of Appeals erred in holding Dr. Ampil liable for
negligence and malpractice; second, whether the Court of
Appeals erred in absolving Dr. Fuentes of any liability; and
third, whether PSI may be held solidarily liable for the
negligence of Dr. Ampil.
I—G.R. No. 127590
Whether the Court of Appeals Erred in Holding Dr. Ampil Liable
for Negligence and Malpractice.
Dr. Ampil, in an attempt to absolve himself, gears the Court’s
attention to other possible causes of Natividad’s detriment.
He argues that the Court should not discount either of the
following possibilities: first, Dr. Fuentes left the gauzes in
Natividad’s body after performing hysterectomy; second, the
attending nurses erred in counting the gauzes; and third, the
American doctors were the ones who placed the gauzes in
Natividad’s body.
Dr. Ampil’s arguments are purely conjectural and without
basis. Records show that he did not present any evidence to
prove that the American doctors were the ones who put or left
490
490 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
the gauzes in Natividad’s body. Neither did he submit
evidence to rebut the correctness of the record of operation,
particularly the number of gauzes used. As to the alleged
negligence of Dr. Fuentes, we are mindful that Dr. Ampil
examined his (Dr. Fuentes’) work and found it in order.
The glaring truth is that all the major circumstances, taken
together, as specified by the Court of Appeals, directly point
to Dr. Ampil as the negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges to
control the bleeding of the patient during the surgical operation.
Second, immediately after the operation, the nurses who
assisted in the surgery noted in their report that the ‘sponge count
(was) lacking 2’; that such anomaly was ‘announced to surgeon’
and that a ‘search was done but to no avail’ prompting Dr. Ampil
to ‘continue for closure’ x x x.
Third, after the operation, two (2) gauzes were extracted from
the same spot of the body of Mrs. Agana where the surgery was
performed.
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 8
put it simply, such act is considered so inconsistent with due
care as to raise an inference of negligence. There are even
legions of authorities to the effect that such act is negligence per
se. 9
_______________
8Rule v. Cheeseman, 317 P. 2d 472 (1957), citing Russel v. Newman,
116 Kan. 268 P. 752; Bernsden v. Johnson, 174 Kan. 230, 255 P. 2d 1033.
9 Smith v. Zeagler, 157 So. 328 Fla. (1934), citing Ruth v. Johnson,
(C.C.A.) 172 F. 191; Reeves v. Lutz, 179 Mo. App. 61, 162 S.W. 280;
Rayburn v. Day, 126 Or. 135, 68 P. 1002, 59 A.L.R. 1062; Wynne v.
Harvey, 96 Wash. 379, 165 P. 67; Harris v. Fall (C.C.A.), 177 F. 79,
491
VOL. 513, JANUARY 31, 2007 491
Professional Services, Inc. vs. Agana
Of course, the Court is not blind to the reality that there are
times when danger to a patient’s life precludes a surgeon from
further searching missing sponges or foreign objects left in the
body. But this does not leave him free from any obligation. Even if
it has been shown that a surgeon was required by the urgent
necessities of the case to leave a sponge in his patient’s
abdomen, because of the dangers attendant upon delay, still,
it is his legal duty to so inform his patient within a reasonable time
thereafter by advising her of what he had been compelled to do. This
is in order that she might seek relief from the effects of the
foreign object left in her body as her condition might permit.
The ruling in Smith v. Zeagler is explicit, thus:
10
“The removal of all sponges used is part of a surgical operation, and
when a physician or surgeon fails to remove a sponge he has placed
in his patient’s body that should be removed as part of the
operation, he thereby leaves his operation uncompleted and creates
a new condition which imposes upon him the legal duty of calling
the new condition to his patient’s attention, and endeavoring with
the means he has at hand to minimize and avoid untoward results
likely to ensue therefrom.”
Here, Dr. Ampil did not inform Natividad about the missing
two pieces of gauze. Worse, he even misled her that the pain she
was experiencing was the ordinary consequence of her operation.
Had he been more candid, Natividad could have taken the
immediate and appropriate medical remedy to remove the
gauzes from her body. To our mind, what was initially an act
of negligence by Dr. Ampil has ripened into a deliberate
wrongful act of deceiving his patient.
This is a clear case of medical malpractice or more
appropriately, medical negligence. To successfully pursue
this kind of case, a patient must only prove that a health care
provider
_______________
27 L.R.A. (N.S.) 1174; Moore v. Ivey, (Tex. Civ. App.) 264 S.W. 283;
21 R.C. L. 388.
10 157 So. 328 Fla. (1934)
492
492 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
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 put, the elements are duty, breach, injury and
11
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
12
be traced from his act of closing the incision despite the
information given by the attending nurses that two pieces of gauze
were still missing. That they were later on extracted from
Natividad’s vagina established the causal link between Dr.
Ampil’s negligence and the injury. And what further
aggravated such injury was
_______________
11 Garcia-Rueda v. Pascasio, G.R. No. 118141, September 5, 1997, 278
SCRA 769.
12 In the leading case of Vda. de Bataclan v. Medina, (102 Phil. 181
[1957]), this Court laid down the following definition of proximate
cause in this jurisdiction as follows:
[T]hat cause, which, in natural and continuous sequence unbroken by
any efficient intervening cause, produces the injury and without which
the result would not have occurred. And more comprehensively, the
proximate cause is that acting first and producing the injury, either
immediately or by setting other events in motion, all constituting a
natural and continuous chain of events, each having a close causal
connection with the immediate predecessor, the final event in the chain
immediately effecting the injury as a natural and probable result of the
cause which first acted, under which circumstances that the person
responsible for the first event should, as an ordinarily prudent and
intelligent person, have reasonable ground to expect at the moment of
his act or default that an injury to some person might probably result
therefrom.
493
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Professional Services, Inc. vs. Agana
his deliberate concealment of the missing gauzes from the
knowledge of Natividad and her family.
II—G.R. No. 126467
Whether the Court of Appeals Erred in Absolving Dr. Fuentes of
any Liability
The Aganas assailed the dismissal by the trial court of the case
against Dr. Fuentes on the ground that it is contrary to the
doctrine of res ipsa loquitur. According to them, the fact that
the two pieces of gauze were left inside Natividad’s body is a
prima facie evidence of Dr. Fuentes’ negligence.
We are not convinced.
Literally, res ipsa loquitur means “the thing speaks for itself.”
It is the rule that the fact of the occurrence of an injury, taken
with the surrounding circumstances, may permit an inference
or raise a presumption of negligence, or make out a plaintiff’s
prima facie case, and present a question of fact for defendant
to meet with an explanation. Stated differently, where the
13
thing which caused the injury, without the fault of the injured,
is under the exclusive control of the defendant and the injury
is such that it should not have occurred if he, having such
control used proper care, it affords reasonable evidence, in the
absence of explanation that the injury arose from the
defendant’s want of care, and the burden of proof is shifted to
him to establish that he has observed due care and diligence. 14
From the foregoing statements of the rule, the requisites for
the applicability of the doctrine of res ipsa loquitur are: (1) the
occurrence of an injury; (2) the thing which caused the injury
was under the control and management of the defen-
_______________
13 Ramos v. Court of Appeals, G.R. No. 124354, December 29, 1999, 321
SCRA 584.
14 Africa v. Caltex (Phils.) Inc., 123 Phil. 280; 16 SCRA 448 (1966).
494
494 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
dant; (3) the occurrence was such that in the ordinary course
of things, would not have happened if those who had control
or management used proper care; and (4) the absence of
explanation by the defendant. Of the foregoing requisites, the
most instrumental is the “control and management of the thing
which caused the injury.” 15
We find the element of “control and management of the thing
which caused the injury” to be wanting. Hence, the doctrine
of res ipsa loquitur will not lie.
It was duly established that Dr. Ampil was the lead surgeon
during the operation of Natividad. He requested the
assistance of Dr. Fuentes only to perform hysterectomy when
he (Dr. Ampil) found that the malignancy in her sigmoid area
had spread to her left ovary. Dr. Fuentes performed the
surgery and thereafter reported and showed his work to Dr.
Ampil. The latter examined it and finding everything to be in order,
allowed Dr. Fuentes to leave the operating room. Dr. Ampil then
resumed operating on Natividad. He was about to finish the
procedure when the attending nurses informed him that two
pieces of gauze were missing. A “diligent search” was
conducted, but the misplaced gauzes were not found. Dr.
Ampil then directed that the incision be closed. During this entire
period, Dr. Fuentes was no longer in the operating room and
had, in fact, left the hospital.
Under the “Captain of the Ship” rule, the operating surgeon is
the person in complete charge of the surgery room and all
personnel connected with the operation. Their duty is to obey
his orders. As stated before, Dr. Ampil was the lead surgeon. In
16
other words, he was the “Captain of the Ship.” That he
discharged such role is evident from his following
_______________
15 Ranos v. Court of Appeals, supra. In Ramos, the phrase used is
“control of the instrumentality which caused the damage,” citing
St. John’s Hospital and School of Nursing v. Chapman, 434 P2d 160
(1967).
16Rural Educational Assn v. Bush, 42 Tenn. App. 34, 298 S.W. 2d 761
(1956).
495
VOL. 513, JANUARY 31, 2007 495
Professional Services, Inc. vs. Agana
conduct: (1) calling Dr. Fuentes to perform a hysterectomy; (2)
examining the work of Dr. Fuentes and finding it in order; (3)
granting Dr. Fuentes’ permission to leave; and (4) ordering
the closure of the incision. To our mind, it was this act of ordering
the closure of the incision notwithstanding that two pieces of gauze
remained unaccounted for, that caused injury to Natividad’s body.
Clearly, the control and management of the thing which
caused the injury was in the hands of Dr. Ampil, not Dr.
Fuentes.
In this jurisdiction, res ipsa loquitur is not a rule of substantive
law, hence, does not per se create or constitute an independent
or separate ground of liability, being a mere evidentiary rule. 17
In other words, mere invocation and application of the
doctrine does not dispense with the requirement of proof of
negligence. Here, the negligence was proven to have been
committed by Dr. Ampil and not by Dr. Fuentes.
III—G.R. No. 126297
Whether PSI Is Liable for the Negligence of Dr. Ampil
The third issue necessitates a glimpse at the historical
development of hospitals and the resulting theories
concerning their liability for the negligence of physicians.
Until the mid-nineteenth century, hospitals were generally
charitable institutions, providing medical services to the
lowest classes of society, without regard for a patient’s ability
to pay. Those who could afford medical treatment were
18
usually treated at home by their doctors. However, the days
19
of house calls and philanthropic health care are over. The
modern health care industry continues to distance itself from
its
_______________
17 Ramos v. Court of Appeals, supra at footnote 13.
18Levin, Hospital Vicarious Liability for Negligence by Independent
Contractor Physicians: A New Rule for New Times, October 17, 2005.
19 Id.
496
496 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
charitable past and has experienced a significant conversion
from a not-for-profit health care to for-profit hospital
businesses. Consequently, significant changes in health law
have accompanied the business-related changes in the
hospital industry. One important legal change is an increase
in hospital liability for medical malpractice. Many courts now
allow claims for hospital vicarious liability under the theories
of respondeat superior, apparent authority, ostensible
authority, or agency by estoppel. 20
In this jurisdiction, the statute governing liability for
negligent acts is Article 2176 of the Civil Code, which reads:
Art. 2176. Whoever by act or omission causes damage to another,
there being fault or negligence, is obliged to pay for the damage
done. Such fault or negligence, if there is no pre-existing contractual
relation between the parties, is called a quasi-delict and is governed
by the provisions of this Chapter.
A derivative of this provision is Article 2180, the rule
governing vicarious liability under the doctrine of respondeat
superior, thus:
ART. 2180. The obligation imposed by Article 2176 is demandable
not only for one’s own acts or omissions, but also for those of
persons for whom one is responsible.
xxx xxx
The owners and managers of an establishment or enterprise are
likewise responsible for damages caused by their employees in the
service of the branches in which the latter are employed or on the
occasion of their functions.
Employers shall be liable for the damages caused by their
employees and household helpers acting within the scope of their
assigned tasks even though the former are not engaged in any
business or industry.
xxx xxx
_______________
20 Id.
497
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Professional Services, Inc. vs. Agana
The responsibility treated of in this article shall cease when the
persons herein mentioned prove that they observed all the
diligence of a good father of a family to prevent damage.
A prominent civilist commented that professionals engaged
by an employer, such as physicians, dentists, and
pharmacists, are not “employees” under this article because
the manner in which they perform their work is not within the
control of the latter (employer). In other words, professionals are
considered personally liable for the fault or negligence they commit
in the discharge of their duties, and their employer cannot be held
liable for such fault or negligence. In the context of the present
case, “a hospital cannot be held liable for the fault or
negligence of a physician or surgeon in the treatment or
operation of patients.” 21
The foregoing view is grounded on the traditional notion that
the professional status and the very nature of the physician’s
calling preclude him from being classed as an agent or
employee of a hospital, whenever he acts in a professional
capacity. It has been said that medical practice strictly
22
involves highly developed and specialized knowledge, such 23
that physicians are generally free to exercise their own skill
_______________
21Tolentino, The Civil Code of the Philippines, Volume V, 1992 Ed., p.
616.
22 Arkansas M.R. Co. v. Pearson, 98 Ark. 442, 153 SW 595 (1911);
Runyan v. Goodrum, 147 Ark. 281, 228 SW 397, 13 ALR 1403 (1921);
Rosane v. Senger, 112 Colo. 363, 149 P. 2d 372 (superseded by statute
on other grounds); Moon v. Mercy Hosp., 150 Col. 430, 373 P. 2d 944
(1962); Austin v. Litvak, 682 P. 2d 41, 50 ALR 4th 225 (1984); Western
Ins. Co. v. Brochner, 682 P. 2d 1213 (1983); Rodriguez v. Denver, 702 P.
2d 1349 (1984).
23 Arkansas M.R. Co. v. Pearson, Id.; Nieto v. State, 952 P. 2d 834 (1997).
But see Beeck v. Tucson General Hosp., 18 Ariz. App. 165, 500 P. 2d
1153 (1972); Paintsville Hosp. Co., 683 SW 2d 255 (1985); Kelley v.
Rossi, 395 Mass. 659, 481 NE 2d 1340 (1985) which held that a
physician’s professional status does not prevent him or her from
being a servant or agent of the hospital.
498
498 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
and judgment in rendering medical services sans interference. 24
Hence, when a doctor practices medicine in a hospital setting,
the hospital and its employees are deemed to subserve him in
his ministrations to the patient and his actions are of his own
responsibility. 25
The case of Schloendorff v. Society of New York Hospital was 26
then considered an authority for this view. The “Schloendorff
doctrine” regards a physician, even if employed by a hospital,
as an independent contractor because of the skill he exercises
and the lack of control exerted over his work. Under this
doctrine, hospitals are exempt from the application of the
respondeat superior principle for fault or negligence committed
by physicians in the discharge of their profession.
However, the efficacy of the foregoing doctrine has weakened
with the significant developments in medical care. Courts
came to realize that modern hospitals are increasingly taking
active role in supplying and regulating medical care to
patients. No longer were a hospital’s functions limited to
furnishing room, food, facilities for treatment and operation,
and attendants for its patients. Thus, in Bing v. Thunig, the 27
New York Court of Appeals deviated from the Schloendorff
doctrine, noting that modern hospitals actually do far more
than provide facilities for treatment. Rather, they regularly
_______________
24 Fridena v. Evans, 127 Ariz. 516, 522 P. 2d 463 (1980).
25 Kitto v. Gilbert, 39 Colo App 374, 570 P. 2d 544 (1977).
26 211 N.Y. 125, 105 N.E. 92, 52 L.R.A., N.S., 505 (1914). The court in
Schloendorff opined that a hospital does not act through physicians
but merely procures them to act on their own initiative and
responsibility. For subsequent application of the doctrine, see for
instance, Hendrickson v. Hodkin, 250 App. Div 649, 294 NYS 982,
revd on other grounds, 276 NY 252, 11 NE 2d 899 (1937); Necolayff
v. Genesee Hosp., 270 App. Div. 648, 61 NYS 2d 832, affd 296 NY 936,
73 NE2d 117 (1946); Davie v. Lenox Hill Hosp., Inc., 81 NYS 2d 583
(1948); Roth v. Beth El Hosp., Inc., 279 App. Div 917, 110 NYS 2d 583
(1952); Rufino v. US, 126 F. Supp. 132 (1954); Mrachek v. Sunshine
Biscuit, Inc., 308 NY 116, 123 N.E. 2d 801 (1954).
27 2 NY 2d 656, 163 NYS 2d 3, 143 N.E. 2d 3 (1957).
499
VOL. 513, JANUARY 31, 2007 499
Professional Services, Inc. vs. Agana
employ, on a salaried basis, a large staff of physicians, interns,
nurses, administrative and manual workers. They charge
patients for medical care and treatment, even collecting for
such services through legal action, if necessary. The court then
concluded that there is no reason to exempt hospitals from the
universal rule of respondeat superior.
In our shores, the nature of the relationship between the
hospital and the physicians is rendered inconsequential in
view of our categorical pronouncement in Ramos v. Court of
Appeals that for purposes of apportioning responsibility in
28
medical negligence cases, an employer-employee relationship in
effect exists between hospitals and their attending and visiting
physicians. This Court held:
“We now discuss the responsibility of the hospital in this particular
incident. The unique practice (among private hospitals) of filling up
specialist staff with attending and visiting “consultants,” who are
allegedly not hospital employees, presents problems in
apportioning responsibility for negligence in medical malpractice
cases. However, the difficulty is more apparent than real.
In the first place, hospitals exercise significant control in the
hiring and firing of consultants and in the conduct of their work
within the hospital premises. Doctors who apply for ‘consultant’
slots, visiting or attending, are required to submit proof of
completion of residency, their educational qualifications, generally,
evidence of accreditation by the appropriate board (diplomate),
evidence of fellowship in most cases, and references. These
requirements are carefully scrutinized by members of the hospital
administration or by a review committee set up by the hospital who
either accept or reject the application. x x x.
After a physician is accepted, either as a visiting or attending
consultant, he is normally required to attend clinicopathological
conferences, conduct bedside rounds for clerks, interns and
residents, moderate grand rounds and patient audits and perform
other tasks and responsibilities, for the
_______________
28 Supra at footnote 13.
500
500 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
privilege of being able to maintain a clinic in the hospital, and/or
for the privilege of admitting patients into the hospital. In addition
to these, the physician’s performance as a specialist is generally
evaluated by a peer review committee on the basis of mortality and
morbidity statistics, and feedback from patients, nurses, interns
and residents. A consultant remiss in his duties, or a consultant
who regularly falls short of the minimum standards acceptable to
the hospital or its peer review committee, is normally politely
terminated.
In other words, private hospitals, hire, fire and exercise real
control over their attending and visiting ‘consultant’ staff. While
‘consultants’ are not, technically employees, x x x, the control
exercised, the hiring, and the right to terminate consultants all
fulfill the important hallmarks of an employer-employee
relationship, with the exception of the payment of wages. In
assessing whether such a relationship in fact exists, the control test
is determining. Accordingly, on the basis of the foregoing, we rule
that for the purpose of allocating responsibility in medical
negligence cases, an employeremployee relationship in effect exists
between hospitals and their attending and visiting physicians.”
But the Ramos pronouncement is not our only basis in
sustaining PSI’s liability. Its liability is also anchored upon the
agency principle of apparent authority or agency by estoppel and
the doctrine of corporate negligence which have gained
acceptance in the determination of a hospital’s liability for
negligent acts of health professionals. The present case serves
as a perfect platform to test the applicability of these
doctrines, thus, enriching our jurisprudence.
Apparent authority, or what is sometimes referred to as the
“holding out” theory, or doctrine of ostensible agency or agency
by estoppel, has its origin from the law of agency. It
29
_______________
29Black’s Law Dictionary (6th Ed. 1990) 1100. The terms “ostensible
agency,” “agency by estoppel,” “apparent authority,” and “holding
out” tend to be used interchangeably by the courts to refer to this
theory of liability. See for instance, Baker v. Werner, 654 P2d 263
(1982) and Adamski v. Tacoma Gen. Hosp., 20 Wash App. 98,
501
VOL. 513, JANUARY 31, 2007 501
Professional Services, Inc. vs. Agana
imposes liability, not as the result of the reality of a
contractual relationship, but rather because of the actions of a
principal or an employer in somehow misleading the public
into believing that the relationship or the authority exists. 30
The concept is essentially one of estoppel and has been
explained in this manner:
“The principal is bound by the acts of his agent with the apparent
authority which he knowingly permits the agent to assume, or
which he holds the agent out to the public as possessing. The
question in every case is whether the principal has by his voluntary
act placed the agent in such a situation that a person of ordinary
prudence, conversant with business usages and the nature of the
particular business, is justified in presuming that such agent has
authority to perform the particular act in question.31
The applicability of apparent authority in the field of hospital
liability was upheld long time ago in Irving v. Doctor Hos-
_______________
579 P2d 970 (1978). Agency by estoppel is defined as “one created by
operation of law and established by proof of such acts of the
principal as reasonably lead third persons to the conclusion of its
existence. Arises where principal by negligence in failing to
supervise agent’s affairs, allows agent to exercise powers not
granted to him, thus justifying others in believing the agent
possesses requisite authority.” Black’s, supra, p. 62. An ostensible
agency is “an implied or presumptive agency which exists where
one, either intentionally or from want of ordinary care, induces
another to believe that a third person is his agent, though he never
in fact, employed him. It is, strictly speaking, no agency at all, but
is in reality based entirely upon estoppel.” Apparent authority refers
to “the power to affect the legal relations of another person by
transactions with third persons, professedly as agent for the other,
arising from and in accordance with the other’s manifestations to
such third persons.” Supra, p. 96.
30 Irving v. Doctors Hospital of Lake Worth, Inc., 415 So. 2d 55 (1982),
quoting Arthur v. St. Peters Hospital, 169 N.J. 575, 405 A. 2d 443
(1979).
31Id., citing Hudson v. C., Loan Assn., Inc. v. Horowytz, 116 N.J.L. 605,
608, 186 A 437 (Sup. Ct. 1936).
502
502 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
pital of Lake Worth, Inc. There, it was explicitly stated that
32
“there does not appear to be any rational basis for excluding the
concept of apparent authority from the field of hospital liability.”
Thus, in cases where it can be shown that a hospital, by its
actions, has held out a particular physician as its agent and/or
employee and that a patient has accepted treatment from that
physician in the reasonable belief that it is being rendered in
behalf of the hospital, then the hospital will be liable for the
physician’s negligence.
Our jurisdiction recognizes the concept of an agency by
implication or estoppel. Article 1869 of the Civil Code reads:
ART. 1869. Agency may be express, or implied from the acts of the
principal, from his silence or lack of action, or his failure to
repudiate the agency, knowing that another person is acting on his
behalf without authority.
In this case, PSI publicly displays in the lobby of the Medical
City Hospital the names and specializations of the physicians
associated or accredited by it, including those of Dr. Ampil
and Dr. Fuentes. We concur with the Court of Appeals’
conclusion that it “is now estopped from passing all the blame to
the physicians whose names it proudly paraded in the public
directory leading the public to believe that it vouched for their skill
and competence.” Indeed, PSI’s act is tantamount to holding out
to the public that Medical City Hospital, through its accredited
physicians, offers quality health care services. By accrediting
Dr. Ampil and Dr. Fuentes and publicly advertising their
qualifications, the hospital created the impression that they
were its agents, authorized to perform medical or surgical
services for its patients. As expected, these patients,
Natividad being one of them, accepted the services on the
reasonable belief that such were being rendered by the
hospital or its employees, agents, or servants. The trial court
correctly pointed out:
_______________
32 Supra.
503
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Professional Services, Inc. vs. Agana
“x x x regardless of the education and status in life of the patient,
he ought not be burdened with the defense of absence of employer-
employee relationship between the hospital and the independent
physician whose name and competence are certainly certified to the
general public by the hospital’s act of listing him and his specialty
in its lobby directory, as in the case herein. The high costs of today’s
medical and health care should at least exact on the hospital greater,
if not broader, legal responsibility for the conduct of treatment and
surgery within its facility by its accredited physician or surgeon,
regardless of whether he is independent or employed.”33
The wisdom of the foregoing ratiocination is easy to discern.
Corporate entities, like PSI, are capable of acting only through
other individuals, such as physicians. If these accredited
physicians do their job well, the hospital succeeds in its
mission of offering quality medical services and thus profits
financially. Logically, where negligence mars the quality of its
services, the hospital should not be allowed to escape liability
for the acts of its ostensible agents.
We now proceed to the doctrine of corporate negligence or
corporate responsibility.
One allegation in the complaint in Civil Case No. Q-43332 for
negligence and malpractice is that PSI as owner, operator and
manager of Medical City Hospital, “did not perform the
necessary supervision nor exercise diligent efforts in the supervision
of Drs. Ampil and Fuentes and its nursing staff, resident doctors,
and medical interns who assisted Drs. Ampil and Fuentes in the
performance of their duties as surgeons.” Premised on the
34
doctrine of corporate negligence, the trial court held that PSI
is directly liable for such breach of duty.
We agree with the trial court.
_______________
33 RTC Decision, p. 9, Rollo of G.R. No. 126467, p. 127.
34 RTC Decision, p. 2, Rollo of G.R. No. 126467, p. 120.
504
504 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
Recent years have seen the doctrine of corporate negligence
as the judicial answer to the problem of allocating hospital’s
liability for the negligent acts of health practitioners, absent
facts to support the application of respondeat superior or
apparent authority. Its formulation proceeds from the
judiciary’s acknowledgment that in these modern times, the
duty of providing quality medical service is no longer the sole
prerogative and responsibility of the physician. The modern
hospitals have changed structure. Hospitals now tend to
organize a highly professional medical staff whose
competence and performance need to be monitored by the
hospitals commensurate with their inherent responsibility to
provide quality medical care. 35
The doctrine has its genesis in Darling v. Charleston Community
Hospital. There, the Supreme Court of Illinois held that “the
36
jury could have found a hospital negligent, inter alia, in failing to
have a sufficient number of trained nurses attending the patient;
failing to require a consultation with or examination by members of
the hospital staff; and failing to review the treatment rendered to the
patient.” On the basis of Darling, other jurisdictions held that
a hospital’s corporate negligence extends to permitting a physician
known to be incompetent to practice at the hospital. With the37
passage of time, more duties were expected from hospitals,
among them: (1) the use of reasonable care in the maintenance
of safe and adequate facilities and equipment; (2) the selection
and retention of competent physicians; (3) the overseeing or
supervision of all persons who practice medicine within its walls;
and (4) the formulation, adoption and enforcement of
adequate rules
_______________
35 Purcell v. Zimbelman, 18 Ariz. App. 75, 500 P2d 335 (1972).
36 Supra at footnote 1.
37 Corleto v. Hospital, 138 N.J. Super. 302, 350 A. 2d 534 (Super. Ct.
Law Div.1975); Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335
(1972); Hospital Authority v. Joiner, 229 Ga. 140,189 S.E. 2d 412 (1972).
505
VOL. 513, JANUARY 31, 2007 505
Professional Services, Inc. vs. Agana
and policies that ensure quality care for its patients. Thus, in
38
Tucson Medical Center, Inc. v. Misevich, it was held that a
39
hospital, following the doctrine of corporate responsibility,
has the duty to see that it meets the standards of
responsibilities for the care of patients. Such duty includes the
proper supervision of the members of its medical staff. And in Bost
v. Riley, the court concluded that a patient who enters a
40
hospital does so with the reasonable expectation that it will
attempt to cure him. The hospital accordingly has the duty to make
a reasonable effort to monitor and oversee the treatment prescribed
and administered by the physicians practicing in its premises.
In the present case, it was duly established that PSI operates
the Medical City Hospital for the purpose and under the
concept of providing comprehensive medical services to the
public. Accordingly, it has the duty to exercise reasonable care
to protect from harm all patients admitted into its facility for medical
treatment. Unfortunately, PSI failed to perform such duty. The
findings of the trial court are convincing, thus:
x x x PSI’s liability is traceable to its failure to conduct an
investigation of the matter reported in the nota bene of the count
nurse. Such failure established PSI’s part in the dark conspiracy of
silence and concealment about the gauzes. Ethical considerations,
if not also legal, dictated the holding of an immediate inquiry into
the events, if not for the benefit of the patient to whom the duty is
primarily owed, then in the interest of arriving at the truth. The
Court cannot accept that the medical and the healing professions,
through their members like defendant surgeons, and their
institutions like PSI’s hospital facility, can callously turn their backs
on and disregard even a mere probability of mistake or negligence
by refusing or failing to investigate a report of such seriousness as
the one in Natividad’s case.”
_______________
38 Welsh v. Bulger, 548 Pa. 504, 698 A.2d 581 (1997).
39 115 Ariz. 34, 545 P2d 958 (1976).
40 262 S.E. 2d 391, cert denied 300 NC 194, 269 S.E. 2d 621 (1980).
506
506 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
It is worthy to note that Dr. Ampil and Dr. Fuentes operated
on Natividad with the assistance of the Medical City
Hospital’s staff, composed of resident doctors, nurses, and
interns. As such, it is reasonable to conclude that PSI, as the
operator of the hospital, has actual or constructive knowledge
of the procedures carried out, particularly the report of the
attending nurses that the two pieces of gauze were missing. In
Fridena v. Evans, it was held that a corporation is bound by the
41
knowledge acquired by or notice given to its agents or officers
within the scope of their authority and in reference to a matter
to which their authority extends. This means that the
knowledge of any of the staff of Medical City Hospital
constitutes knowledge of PSI. Now, the failure of PSI, despite
the attending nurses’ report, to investigate and inform
Natividad regarding the missing gauzes amounts to callous
negligence. Not only did PSI breach its duties to oversee or
supervise all persons who practice medicine within its walls, it also
failed to take an active step in fixing the negligence committed. This
renders PSI, not only vicariously liable for the negligence of
Dr. Ampil under Article 2180 of the Civil Code, but also
directly liable for its own negligence under Article 2176. In
Fridena, the Supreme Court of Arizona held:
“x x x In recent years, however, the duty of care owed to the patient
by the hospital has expanded. The emerging trend is to hold the
hospital responsible where the hospital has failed to monitor and
review medical services being provided within its walls. See Kahn
Hospital Malpractice Prevention, 27 De Paul Rev. 23 (1977).
Among the cases indicative of the ‘emerging trend’ is Purcell v.
Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972). In Purcell, the
hospital argued that it could not be held liable for the malpractice
of a medical practitioner because he was an independent contractor
within the hospital. The Court of Appeals pointed out that the
hospital had created a professional staff whose competence
_______________
41 127 Ariz. 516, 622 P. 2d 463 (1980).
507
VOL. 513, JANUARY 31, 2007 507
Professional Services, Inc. vs. Agana
and performance was to be monitored and reviewed by the
governing body of the hospital, and the court held that a hospital
would be negligent where it had knowledge or reason to believe
that a doctor using the facilities was employing a method of
treatment or care which fell below the recognized standard of care.
Subsequent to the Purcell decision, the Arizona Court of
Appeals held that a hospital has certain inherent responsibilities
regarding the quality of medical care furnished to patients within
its walls and it must meet the standards of responsibility
commensurate with this undertaking. Beeck v. Tucson General
Hospital, 18 Ariz. App. 165, 500 P. 2d 1153 (1972). This court has
confirmed the rulings of the Court of Appeals that a hospital has
the duty of supervising the competence of the doctors on its staff. x
x x.
xxx xxx
In the amended complaint, the plaintiffs did plead that the
operation was performed at the hospital with its knowledge, aid,
and assistance, and that the negligence of the defendants was the
proximate cause of the patient’s injuries. We find that such general
allegations of negligence, along with the evidence produced at the
trial of this case, are sufficient to support the hospital’s liability
based on the theory of negligent supervision.”
Anent the corollary issue of whether PSI is solidarily liable
with Dr. Ampil for damages, let it be emphasized that PSI,
apart from a general denial of its responsibility, failed to
adduce evidence showing that it exercised the diligence of a
good father of a family in the accreditation and supervision of
the latter. In neglecting to offer such proof, PSI failed to
discharge its burden under the last paragraph of Article 2180
cited earlier, and, therefore, must be adjudged solidarily liable
with Dr. Ampil. Moreover, as we have discussed, PSI is also
directly liable to the Aganas.
One final word. Once a physician undertakes the treatment
and care of a patient, the law imposes on him certain
obligations. In order to escape liability, he must possess that
reasonable degree of learning, skill and experience required
by
508
508 SUPREME COURT REPORTS ANNOTATED
Professional Services, Inc. vs. Agana
his profession. At the same time, he must apply reasonable
care and diligence in the exercise of his skill and the
application of his knowledge, and exert his best judgment.
WHEREFORE, we DENY all the petitions and AFFIRM
the challenged Decision of the Court of Appeals in CA-G.R.
CV No. 42062 and CA-G.R. SP No. 32198.
Costs against petitioners PSI and Dr. Miguel Ampil.
SO ORDERED.
Puno (C.J., Chairperson), Corona and Azcuna, JJ., concur.
 Garcia, J., No part.
Petitions denied, challenged CA decision in CA-G.R. No. CV No.
42062 and CA-G.R. SP No. 32198 affirmed.
Note.—Under the Captain-of-the-Ship Doctrine, a
surgeon is likened to a captain of the ship in that it is his duty
to control everything going on in the operating room. (Ramos
vs. Court of Appeals, 380 SCRA 467 [2002])
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