LEGAL MEDICINE

Medical Malpractice - is professional negligence by act or omission by a health care provider in

which the treatment provided falls below the accepted standard of practice in the medical
community and causes injury or death to the patient, with most cases involving medical error.
Illegal Practice of Medicine
Case: People vs Hatani
That on or about the 6th day of July, 1979, in Quezon City, Philippines the above named accused,
knowing fully well that he has not satisfactorily passed the corresponding Board Examination,
neither is he a holder of a valid Certificate of Registration duly issued by the Board of Medical
Examiners, as in fact he does not even appear to have taken or completed the course leading to
a medical degree, did, then and there, willfully, unlawfully and feloniously for compensation, fee
and salary, paid to him directly, physically examined Priscila (sic) Borja Y Loquero and Wilma Borja
Y Loquero, diagnosed, treated and administer injections on the persons of Prescila (sic) Borja Y
Loquero and Wilma Borja Y Loquero, in Violation of Section 10, in relation to Section 28, Republic
Act No. 2382 (Records, Vol. I, p. 1).
That on or about the 6th day of July, 1979, in Quezon City, Philippines, the above-named accused,
with lewd designs, and while she was deprived of reason or unconscious after having been
drugged or administered medicine, did, then and there, willfully, unlawfully and feloniously have
sexual intercourse with the undersigned PRECILA BORJA Y LOQUERO without her consent and
against her will, to her damage and prejudice in such amount as may be awarded under the
provisions of the Civil Code (Records, Vol. II, p. 1).
The four elements of medical malpractice that must be satisfied before filing anything are:
Duty.
Breach of Duty.
Damages.
Causation.
Standard of Care:
The National Standard of Care: requires a doctor to use the degree of skill and care of a
reasonably competent practitioner in his field under same or similar circumstances
The Locality Rule: requires a doctor to have the reasonable caliber of skill and knowledge that is
generally possessed by surgeons and physicians in the locality where he or she practices.
In a personal injury case, the cause in fact is the condition, action, or object that caused the
plaintiff's injuries. The cause in fact may have caused the entire injury or only a part of it. If the
defendant's behavior created the cause in fact, the defendant may be liable for negligence.
But For Definition: A test in tort law linking the tort and the damages (aka causation), which are
stated as: "but for" the defendant's negligence, the plaintiff would not have been injured.
Negligence

The prima facie case for negligence requires:

Duty is owed to the plaintiff by the defendant

Breach of the Duty
Causation: The defendant caused the harm to occur.
Damages: The plaintiff suffers harm.

Duty
In order to hold a defendant liable for negligence, the defendant must owe a duty of reasonable
care to the plaintiff. Two issues arise in terms of duty of reasonable care:

Foreseeability
Standard of Care
Foreseeability
The duty of care must be toward a foreseeable plaintiff.

Test for foreseeability: A plaintiff is foreseeable if he was in the zone of danger created by the
defendant.

Standard of Care
The Standard of care that the defendant must exercise towards the plaintiff is that of a reasonable,
ordinary and prudent person in the same or similar circumstances.

Factors to consider that may or may not modify the circumstances include:

Physical characteristics
A person who has great physical strength will be judged according to an ordinary person of great
physical strength. Likewise, a weak person will be judged according to a standard of what an
ordinary weak person would do.

Average Mental Ability

Everyone is judged as being of average mental ability and no accommodation is made for being
extraordinarily intelligent.

Same knowledge as an average member of community

Presumed to have common knowledge about known dangers in the community.

Professionals
Professionals are judged according to other professionals in same community.

Children
Children are judged according to children of same age, education, intelligence and experience.

Breach of the Duty

In order to be held liable for negligence the action by plaintiff must fall below standard of care.

The primary issue is where to draw the line as to the standard of care. Factors to consider in
drawing the line are:

Custom in the community

Violation of statute (negligence per se)

Violating a statute creates a rebuttable presumption of negligence. Defendant is presumed to be
liable for negligence if he breaks a law and cause harm to the plaintiff but he can rebut that
presumption by showing that there was a custom to break the law.

Res Ipsa Loquitur

Latin for "The thing speaks for itself." This doctrine draws an inference of liability because the thing
that caused the accident was in the exclusive control of the defendant. In other words, it couldn't
be anyone but the defendant who caused the harm.

Causation
The defendant caused the harm to occur. There are two types of causation:

Actual Causation

and Proximate Causation.

Actual Causation: Did the defendant actually cause the harm to occur? There are two different
tests you can use.

"But for" Test: Ask yourself the question: "But for the defendant's actions, would the plaintiff's harm
have occurred?"

Substantial Factor Test: If several causes could have caused the harm, then any cause that was a
substantial factor is held to be liable.

Proximate Causation: This sometimes difficult to grasp concept is actually very simple on most
exams. Be sure to check with your professor but if in doubt, use the following generally accepted
test:

Foreseeability Test: If harm is unforeseeable, then defendant is not held liable by reason that there
is no proximate causation.

Famous Proximate Cause Case: Palsgraf v. Long Island RR. Judge Cardoza. Railroad guard pushes
man who drops package. Package contains hidden fireworks that explode and cause scales to
fall harming plaintiff. Illustrates that harm was not foreseeable by guard as to plaintiff so no
proximate cause.

Damages
The plaintiff must suffer some harm. Two issues arise:

Was there actual harm?

Did plaintiff attempt to mitigate the harm?

Actual harm or injury: Can be shown by the following:

Personal Injury

Property Damage
Plaintiff gets Cost of repair OR fair market value

Punitive Damages
Extra damages beyond actual damage is available if the defendant's behavior was wanton and
willful, reckless or malicious

Duty to mitigate: Plaintiff must not act in a manner that makes damages worse - i.e. not going to
the doctor to get well. Defendant is not liable for damages where plaintiff did not mitigate.

Defenses to Negligence

Even if a defendant is found liable for negligence, he can argue to be relieved of or share liability
because of a valid defense. Defenses include:

Contributory Negligence
In these circumstance, the plaintiff contributed to the negligent act. The defendant must prove
the plaintiff was negligent using the negligence test above.

Under common law, if both parties are negligent, then the one with the last clear chance to
prevent the accident is liable; otherwise both plaintiff and defendant share liability.

Assumption of Risk
If plaintiff knew the risk and voluntarily assumed the risk by engaging in the behavior then the
plaintiff will be denied recovery.

Emergency Doctrine
Allows defendant to lower standard of care because an emergency required them to act rashly
in order to avoid a greater harm from occurring.

Custom
Custom can be used to show that behavior was in line with the behavior of everyone else, thus
resulting in no breach. E.g. Everyone drives at 50 MPH on that particular stretch of the highway
even though it is posted at 30 MPH.
Urbano vs IAC

Facts: Urbano had a dispute with Javier due to latters opening of irrigation system which flooded
farmers palay storage. Urbano hacked Javier with a bolo but they had amicable settlement later
on. 22 days after incident, Javier died due to tetanus.
Issue: WON Urbano is criminally liable?
Held: No. Civil liabilities only. Death wasnt directly due to the hacking. Proximate cause is that
cause, w/c, in natural & continuous sequence, unbroken by any efficient intervening cause,
produces injury & w/o w/c the result wouldnt have occurred. The rule is that the death of the
victim must be the direct, natural, & logical consequence of the wound inflicted upon him by the
accused to be proven beyond reasonable doubt (because this is a criminal conviction). Infection
of wound was efficient intervening cause between wounding & hacking w/c was distinct &
foreign to the crime. The petitioner at the very least is guilty of slight physical injury. But because
Urbano & Javier used the facilities of barangay mediators to effect a compromise agreement,
the criminal liability is wiped out by virtue of PD 1508, 2(3) w/c allows sePhoenix Construction v.
IAC
Facts:

At about 1:30 a.m. on November 15, 1975, private respondent Leonardo Dionisio was on his way
home from cocktails and dinner meeting with his boss. He was proceeding down General Lacuna
Street when he saw a Ford dump truck parked askew, partly blocking the way of oncoming traffic,
with no lights or early warning reflector devices. The truck was driven earlier by Armando Carbonel,
a regular driver of the petitioner company. Dionisio tried to swerve his car to the left, but it was too
late. He suffered some physical injuries and nervous breakdown. Dionision filed an action for
damages against Carbonel and Phoenix Insurance. Petitioners countered the claim by imputing
the accident to respondents own negligence in driving at high speed without curfew pass and
headlights, and while intoxicated. The trial court and the Court of Appeals ruled in favor of private
respondent.

Issue:

Whether the collision was brought about by the way the truck was parked, or by respondents
own negligence

Held: The distinctions between "cause" and "condition" which the 'petitioners would have us adopt
have already been "almost entirely discredited. If the defendant has created only a passive static
condition which made the damage possible, the defendant is said not to be liable. But so far as
the fact of causation is concerned, in the sense of necessary antecedents which have played an
important part in producing the result it is quite impossible to distinguish between active forces
and passive situations, particularly since, as is invariably the case, the latter are the result of other
active forces which have gone before. Even the lapse of a considerable time during which the
"condition" remains static will not necessarily affect liability. "Cause" and "condition" still find
occasional mention in the decisions; but the distinction is now almost entirely discredited. So far
as it has any validity at all, it must refer to the type of case where the forces set in operation by
the defendant have come to rest in a position of apparent safety, and some new force intervenes.
But even in such cases, it is not the distinction between "cause" and "condition" which is important
but the nature of the risk and the character of the intervening cause.

Lyons v. Midnight Sun Transp. Servs

Brief Fact Summary. Esther Hunter-Lyons (Hunter-Lyons) was killed in a collision with a truck owned
by Midnight Sun Transportation Services Incorporated (Defendant). The jury was given instructions
concerning the sudden emergency doctrine and found that while the driver of the truck was
negligent. His negligence was not the legal cause of the accident. Hunter-Lyons appealed,
asserting that the instruction was improper.
Synopsis of Rule of Law. The sudden emergency doctrine is a rule of law which states that a person
confronted with a sudden and unexpected peril, not resulting from that persons own negligence,
is not expected to exercise the same judgment and prudence the law requires of a person in
calmer and more deliberate moments. The person confronted with the imminent peril must,
however, act as a reasonable person would under the same conditions.

Facts. Hunter-Lyons was killed when her Volkswagen van was struck broadside by a truck driven
by David Jette (Jette) and owned by Defendant. When the accident occurred, Jette was driving
south in the right-hand lane of a thoroughfare in Anchorage, Alaska. Hunter-Lyons pulled out of a
parking lot in front of him. Jette braked and steered to the left, but Hunter-Lyons continued to pull
out further into the traffic lane. Jettes truck collided with Hunter-Lyonss vehicle. David Lyons, the
deceaseds husband, (Plaintiff) filed suit, asserting that Jette had been speeding and driving
negligently.

Issue. Was the jury instruction concerning the sudden emergency doctrine improper?

Perkins v. Texas and New Orleans Railroad Co

Brief Fact Summary. The husband of the Plaintiff, Ms. Perkins (Plaintiff), was a passenger in a car
when a train at a railway crossing struck the car. The Plaintiffs husband was killed.
Synopsis of Rule of Law. The defendants negligence must be a substantial factor in the cause of
the harm for liability to attach.
Facts. The Plaintiffs husband was killed in a collision between the car he was a passenger in and
a freight train operated by the Defendant, New Orleans Railroad Co. At the intersection of the
road and rail crossing where the accident occurred, a large warehouse obstructed the view of
both the cars driver and the trains engineer and brakeman. The trains engineer and brakeman
were aware of the obstruction and while approaching the intersection rang the trains bell and
whistle and put its headlights on. The intersection also had warning signals to warn drivers of
approaching trains. These signals were operating at the time of the accident. Of the three railway
employees in the forward engine of the train only two, the brakeman and a fireman saw the car
emerge from the intersection. The third, the engineer did not see the car due to the obstructed
view, but applied the emergency brakes when his companions alerted him to the presence of
the car. At the time of the accident the train was between 30 to 60 feet from the car. Both parties
have conceded that the driver of the car, who was also killed, was negligent in driving upon the
train track with the signal lights on. The parties have also conceded that the train was traveling at
37 miles per hour when the self-imposed speed limit for the intersection was 25 miles per hour.
Issue. Whether the negligence of the Defendant was a substantial factor in causing the accident.

The elements of reckless imprudence are: (1) that the offender does or fails to do an act; (2) that
the doing or the failure to do that act is voluntary; (3) that it be without malice; (4) that material
damage results from the reckless imprudence; and (5) that there is inexcusable lack of precaution
on the part of the offender, taking into consideration his employment or occupation, degree of
intelligence, physical condition, and other circumstances regarding persons, time and place.

The elements of simple imprudence are (1) that there is lack of precaution on the part of the
offender; and (2) that the damage impending to be caused is not immediate or the danger is not
clearly manifest.

Highest degree of diligence (reyes vs sisters of mary)

SPS Santos vs Pizardo

Facts: Dionisio M. Sibayan was charged with reckless imprudence resulting to multiple homicide
and multiple physical injuries due to the vehicle collision between Viron Transit bus driven by
Sibayan and a Lite Van Ace. However the municipal circuit trial court was no pronouncement of
civil liability. The petitioners filed a complaint for damages to the respondents pursuant to their

to dismiss by the Viron Transit. The petitioners opposed and contends that the motion to dismiss
that be ten (10) years from the judgment of criminal action is the prescription and therefore it is
within the period since it was just barely two (2)years had elapse.
Issues: Whether or not the dismissal of the action was based on culpa aquiliana is a bar to the
enforcement of the subsidiary liability of the employer?
Held: The dismissal of the action based on culpa aquiliana is not a bar to the subsidiary liability of
the employer. Because the Article 103 of the R.P.C. operates with controlling force to obviate
thepossibility of the aggrieved party being deprived of indemnity even after the rendition of a
final judgment convicting the employee. The trial court should not have dismissed the complaint
on the ground of prescription, but instead allowed the complaint for damages ex delicto to be
prosecuted on the merits, this does not offend the policy that the reservation or institution of a
separate civil waives the other civil actions but this is merely an avoidance of multiple suits. The
action for damages based on quasi- delict should be considered waived no occasion for
petitioners to file multiple suits against private respondents as available to them is to pursue
damages ex delicto

CASUPANAN VS LAROYA CASE DIGEST G.R. No. 145391 August 26, 2002
FACTS: As a result of a vehicular accident between two vehicles, one driven by Mario Llavore
Laroya and the other owned by Roberto Capitulo and driven by Avelino Casupanan, two cases
were filed before the MCTC of Capas, Tarlac.
ISSUE/HELD: WON an accused in a pending criminal case for reckless imprudence can validly file,
simultaneously and independently, a separate civil action for quasi-delict against the private
complainant in the criminal case. AFFIRMATIVE
Since the present Rules require the accused in a criminal action to file his counterclaim in a
separate civil action, there can be no forum-shopping if the accused files such separate civil
action.

Under the present Rule 111, the offended party is still given the option to file a separate civil action
to recover civil liability ex-delicto by reserving such right in the criminal action before the
prosecution presents its evidence. Also, the offended party is deemed to make such reservation
if he files a separate civil action before filing the criminal action. If the civil action to recover civil
liability ex-delicto is filed separately but its trial has not yet commenced, the civil action may be
consolidated with the criminal action. The consolidation under this Rule does not apply to
separate civil actions arising from the same act or omission filed under Articles 32, 33, 34 and 2176
of the Civil Code.

Cancio vs Isip
FACTS
The accused, EmerenciaIsip, was charged with 3 counts of violation of B.P. 22, also known as the
Bouncing Checks Law and 3 cases of Estafa. One of the B.P. 22 cases was dismissed due to it
being deposited before 90 days from the date written on the check. The other two cases of B.P.

22 were filed with the Regional Trial Court of Guagua, Pampanga and were then dismissed due
to the failure of the prosecution to prosecute the crime.

Meanwhile the three cases of Estafa were filed with the Regional Trial Court of Pampanga. After
failing to present its second witness, the prosecution dismissed the Estafa case. The prosecution
reserved its right to file a separate civil action from the said criminal cases. The court granted the
reservation. The criminal case of Estafa was then dismissed without prejudice to the civil action.
On December 15, 1997, petitioner filed the instant case for the collection of the sum of money,
seeking to recover the amount of the check subject to the Estafa cases. Respondent then filed a
motion to dismiss the complaint contending that the petition is already barred by the doctrine of
Res Judicata.

ISSUE
Whether or not the respondents can file a separate civil action regardless of the dismissal of the
criminal case of estafa.

RULING
The Supreme Court ruled that the civil action can prosper. The reservation for civil action was
made by the prosecution on time. According to Section 1, Rule 111 of the Rules on Criminal
Procedure states that civil liability is deemed instituted with the criminal case unless there is a
reservation of the right to file a separate civil action.

In the case at bar, the complaint is clearly based on culpa contractual. The cause of action was
the breach of the respondents breach of the contractual obligation. Evidently, the petitioner was
seeking to make good the value written on the checks in exchange for cash. The case was not
anchored the criminal aspect of estafa but on the civil aspect of culpa contractual. As such, it is
distinct and independent from the estafa case filed against the offender and may proceed
regardless of the result of the criminal proceedings.

Art. 1146. The following actions must be instituted within four years:
(1) Upon an injury to the rights of the plaintiff;

(2) Upon a quasi-delict;

However, when the action arises from or out of any act, activity, or conduct of any public officer
involving the exercise of powers or authority arising from Martial Law including the arrest, detention
and/or trial of the plaintiff, the same must be brought within one (1) year. (As amended by PD No.
1755, Dec. 24, 1980.)

The Discovery Rule

The more complicated part of the statute of limitations is generally called the discovery rule. The
discovery rule is an exception to the standard deadline. The purpose of the discovery rule is to
give victims of medical malpractice the right to file a medical malpractice lawsuit after the
standard statute of limitations expired, when they did not even know that they had a potential
medical malpractice claim.

The key to the discovery rule is that the malpractice victim did not know that he/she had a
potential medical malpractice case. Only patients who truly did not know -- and could not
reasonably have figured out -- of their doctor's medical negligence have the right to use the
discovery rule exception to file a medical malpractice lawsuit after the expiration of the standard
statute of limitations.

continuous treatment rule

A common law liability doctrine stating that if a physician has treated a patient over a period of
time, only one policy limit appliesthe one in force at the time the claim is made. This rule prevents
a "stacking of limits" situation where the total policy limits (that were available during the entire
course of treatment) could otherwise be applied to a claim of this type. The continuous treatment
rule can also be applied to other professionals, most frequently to lawyers and accountants,
whose services for a given case or engagement sometimes take place over several years.
Hospital liability is divided into two main types. The first type is the hospitals liability for the
negligence of its employees. According to the legal rule of vicarious liability, any employer
(including hospitals) is liable for its employees negligence. So, the hospital is legally liable for any
malpractice committed by a physician, nurse, or other health care providers who is employed by
the hospital.

The second type of hospital liability is the hospitals liability for its own mistakes and negligence,
such as negligence in hiring and supervising its employees and maintaining and repairing its
equipment.

Vicarious Liability
When a hospital employee's malpractice injures a patient, the hospital itself may be held
vicariously liable under the legal doctrine of "respondeat superior." Under this doctrine, an
employer may be held liable for the negligent acts of its employee, if the employee was acting
within the scope of his or her employment when the negligent act or omission occurred. This
doctrine is very important to plaintiffs in medical malpractice cases, because it helps ensure there
will be a financially responsible party to compensate an injured plaintiff.

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 plaintiffs prima facie case, and present a question of fact for defendant to meet with
an explanation, where ordinarily in a medical 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 damagedres 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.
Nogales vs. Capitol Medical Center
[GR. No. 142625, Dec. 19, 2006]
Facts:

Dr. Estrada applied low forceps to extract Corazon's baby. In the process, a cervical tissue was
allegedly torn. The baby came out in an apnic, cyanotic, weak and injured condition. The baby
survived, but the mother died of profuse vaginal bleeding. The husband sued CMC and the
doctors.
Issues:
1) whether an employee-employer relationship existedbetween CMC and Dr. Estrada
2) whether CMC is vicariously liable for the negligence of Dr. Estrada
Held:
In Ramos vs. CA, weheld:
In other words, private hospitals, hire, fire and exercise real control over their attending and visiting
"consultant" staff. While "consultants" are not, technically employees, the control exercised, the
hiring,
and the right to terminate consultants all fulfill the important hallmarks of an employer-employee
relationship, with the exception of the payment of wages. In assessing whether such a relationship
in
fact exists, the control test is determining. Accordingly, on the basis of the foregoing, we rule that
for
the purpose of allocating responsibility in medical negligence cases, an employer-employee
relationship in effect exists between hospitals and their attending and visiting physicians.
Professional Services Inc. v. Agana

Professional Services Inc. (PSI) v. Natividad and Enrique Agana

Natividad and Enrique Agana v. Juan Fuentes
Miguel Ampil v. Natividad and Enrique Agana
2007 / Sandoval-Gutierrez / Petition for review on certiorari of CA decisions
Standard of conduct > Experts > Medical professionals

FACTS
Natividad Agana was rushed to Medical City because of difficulty of bowel movement and
bloody anal discharge. Dr. Ampil diagnosed her to be suffering from cancer of the sigmoid. Dr.
Ampil performed an anterior resection surgery on her, and finding that the malignancy spread on
her left ovary, he obtained the consent of her husband, Enrique, to permit Dr. Fuentes to perform
hysterectomy on her. After the hysterectomy, Dr. Fuentes showed his work to Dr. Ampil, who
examined it and found it in order, so he allowed Dr. Fuentes to leave the operating room. Dr. Ampil

was about to complete the procedure when the attending nurses made some remarks on the
Record of Operation: sponge count lacking 2; announced to surgeon search done but to no
avail continue for closure (two pieces of gauze were missing). A diligent search was conducted
but they could not be found. Dr. Ampil then directed that the incision be closed.
A couple of days after, she complained of pain in her anal region, but the doctors told her
that it was just a natural consequence of the surgery. Dr. Ampil recommended that she consult
an oncologist to examine the cancerous nodes which were not removed during the operation.
After months of consultations and examinations in the US, she was told that she was free of cancer.
Weeks after coming back, her daughter found a piece of gauze (1.5 in) protruding from her
vagina, so Dr. Ampil manually extracted this, assuring Natividad that the pains will go away.
However, the pain worsened, so she sought treatment at a hospital, where another 1.5 in piece
of gauze was found in her vagina. She underwent another surgery.
Sps. Agana filed a complaint for damages against PSI (owner of Medical City), Dr. Ampil,
and Dr. Fuentes, alleging that the latter are liable for negligence for leaving 2 pieces of gauze in
Natividads body, and malpractice for concealing their acts of negligence. Enrique Agana also
filed an administrative complaint for gross negligence and malpractice against the two doctors
with the PRC (although only the case against Dr. Fuentes was heard since Dr. Ampil was abroad).
Pending the outcome of the cases, Natividad died (now substituted by her children). RTC found
PSI and the two doctors liable for negligence and malpractice. PRC dismissed the case against
Dr. Fuentes. CA dismissed only the case against Fuentes.

ISSUE AND HOLDING

WON CA erred in holding Dr. Ampil liable for negligence and malpractice. NO; DR. AMPIL IS GUILTY
WON CA erred in absolving Dr. Fuentes of any liability. NO
WON PSI may be held solidarily liable for Dr. Ampils negligence. YES
RATIO
DR. AMPIL IS LIABLE FOR NEGLIGENCE AND MALPRACTICE
His arguments are without basis [did not prove that the American doctors were the ones who put
/ left the gauzes; did not submit evidence to rebut the correctness of the operation record (re:
number of gauzes used); re: Dr. Fuentes alleged negligence, Dr. Ampil examined his work and
found it in order].
Leaving foreign substances in the wound after incision has been closed is at least prima
facie negligence by the operating surgeon. Even if it has been shown that a surgeon was required
to leave a sponge in his patients abdomen because of the dangers attendant upon delay, still,
it is his legal duty to inform his patient within a reasonable time by advising her of what he had
been compelled to do, so she can seek relief from the effects of the foreign object left in her body
as her condition might permit. Whats worse in this case is that he misled her by saying that the
pain was an ordinary consequence of her operation.

Medical negligence; standard of diligence

To successfully pursue this case of medical negligence, a patient must only prove that a health
care provider either failed to do something [or did something] which a reasonably prudent health
care provider would have done [or wouldnt have done], and that the failure or action caused
injury to the patient.
Duty to remove all foreign objects from the body before closure of the incision; if he fails to do
so, it was his duty to inform the patient about it
Breach failed to remove foreign objects; failed to inform patient
Injury suffered pain that necessitated examination and another surgery
Proximate Causation breach caused this injury; could be traced from his act of closing the
incision despite information given by the attendant nurses that 2 pieces of gauze were still missing;
what established causal link: gauze pieces later extracted from patients vagina
DR. FUENTES NOT LIABLE
The res ipsa loquitur [thing speaks for itself] argument of the Aganas does not convince the court.
Mere invocation and application of this doctrine does not dispense with the requirement of proof
of negligence.

Requisites for the applicability of res ipsa loquitur

Occurrence of injury
Thing which caused injury was under the control and management of the defendant [DR.
FUENTES] LACKING SINCE CTRL+MGT WAS WITH DR. AMPIL
Occurrence was such that in the ordinary course of things, would not have happened if those
who had control or management used proper care
Absence of explanation by defendant
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. That Dr. Ampil discharged such
role is evident from the following:
He called Dr. Fuentes to perform a hysterectomy
He examined Dr. Fuentes work and found it in order
He granted Dr. Fuentes permission to leave
He ordered the closure of the incision
HOSPITAL OWNER PSI SOLIDARILY LIABLE WITH DR. AMPIL [NCC 2180], AND DIRECTLY LIABLE TO SPS.
AGANAS [NCC 2176]
Previously, employers cannot be held liable for the fault or negligence of its professionals.
However, this doctrine has weakened since courts came to realize that modern hospitals are
taking a more active role in supplying and regulating medical care to its patients, by employing
staff of physicians, among others. Hence, there is no reason to exempt hospitals from the universal
rule of respondeat superior. Here are the Courts bases for sustaining PSIs liability:

Ramos v. CA doctrine on E-E relationship

For purposes of apportioning responsibility in medical negligence cases, an employer-employee
relationship in effect exists between hospitals and their attending and visiting physicians. [LABOR
LESSON: power to hire, fire, power of control]
Agency principle of apparent authority / agency by estoppel
Imposes liability because of the actions of a principal or employer in somehow misleading the
public into believing that the relationship or the authority exists [see NCC 1869]
PSI publicly displays in the Medical City lobby the names and specializations of their physicians.
Hence, PSI 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.
If doctors do well, hospital profits financially, so when negligence mars the quality of its services,
the hospital should not be allowed to escape liability for its agents acts.
Doctrine of corporate negligence / corporate responsibility
This is the judicial answer to the problem of allocating hospitals liability for the negligent acts of
health practitioners, absent facts to support the application of respondeat superior.
This provides for the duties expected [from hospitals]. In this case, PSI failed to perform the duty of
exercising reasonable care to protect from harm all patients admitted into its facility for medical
treatment. PSI failed to conduct an investigation of the matter reported in the note of the count
nurse, and this established PSIs part in the dark conspiracy of silence and concealment about the
gauzes.
PSI has actual / constructive knowledge of the matter, through the report of the attending nurses
+ the fact that the operation was carried on with the assistance of various hospital staff
It also breached its duties to oversee or supervise all persons who practice medicine within its walls
and take an active step in fixing the negligence committed
PSI also liable under NCC 2180
It failed to adduce evidence to show that it exercised the diligence of a good father of the family
in the accreditation and supervision of Dr. Ampil

borrowed servant doctrine

A principle under which the party usually liable for a persons actionse.g., a hospital which has
employed a particular nurseis absolved of responsibility when that 'borrowed servant' is asked
to do somethinge.g., by a surgeonwhich is outside of the bounds of hospital policy
Captain of the ship doctrine is the legal doctrine which holds that, during an operation in an
operating room, a surgeon of record is liable for all actions conducted in the course of the
operation.[1] The doctrine is a form of the "borrowed servant doctrine", in which a party usually
liable for his, her, its, or their actions is absolved of responsibility when that "borrowed servant" is
asked to do something that is outside of the bounds of policy.[2]

expert witness
a person who is permitted to testify at a trial because of special knowledge or proficiency in a
particular field that is relevant to the case.
net opinion rule. The rule requires trial courts to exclude expert opinions that have no factual or
evidentiary support and are based on nothing other than the experts own unsupported
conclusions.
HYPOTHETICAL QUESTIONS

1. The law requires that a physician who does not have personal knowledge regarding the patient
or the occurrence must give his or her opinions by hypothetical questions. A hypothetical question
is one that asks the doctor to assume certain hypothetical facts and express an opinion based
upon those facts contained in the question without specifically referring to a particular patient.

2. The law requires, with regard to answering hypothetical questions, that:

(1) The witness base his or her answer on the facts contained in the hypothetical question.

CROSS-EXAMINATION OF THE MEDICAL EXPERT

A. "YES" AND "NO" QUESTIONS

1. If a question is phrased so that only a yes or no answer is expected, the witness must answer the
question but has the right to explain the answer after answering. If the medical expert feels that
he or she cannot answer a question yes or no, the witness has a right to respond that the question
cannot be answered yes or no. If the witness feels a yes or no answer requires an explanation, the
witness has the right to ask the judge whether he or she might explain.

Direct Examination
The primary questioning of a witness during a trial that is conducted by the side for which that
person is acting as a witness.
During the course of a direct examination, the attorney who is conducting the interrogation
generally asks specific questions that provide the foundation of the case. After a witness is directly
examined, the opposing side conducts a cross-examination, the purpose of which is to impeach
or test the validity of the testimony.
90.706 Authoritativeness of literature for use in cross-examination.Statements of facts or opinions
on a subject of science, art, or specialized knowledge contained in a published treatise,

periodical, book, dissertation, pamphlet, or other writing may be used in cross-examination of an

expert witness if the expert witness recognizes the author or the treatise, periodical, book,
dissertation, pamphlet, or other writing to be authoritative, or, notwithstanding nonrecognition by
the expert witness, if the trial court finds the author or the treatise, periodical, book, dissertation,
pamphlet, or other writing to be authoritative and relevant to the subject matter.

The rule clearly sets out several methods for establishing literature as authoritative, thereby paving
the way for use in cross examination.11 The first method of establishing a particular publication as
authoritative12 relies upon the witness to concede that a particular work is authoritative. This rarely
happens.