Republic of the Philippines

SUPREME COURT
Manila
EN BANC
G.R. No. 165279

June 7, 2011

DR. RUBI LI, Petitioner,

vs.
SPOUSES REYNALDO and LINA SOLIMAN, as parents/heirs of deceased Angelica
Soliman, Respondents.
DECISION
VILLARAMA, JR., J.:
Challenged in this petition for review on certiorari is the Decision1 dated June 15, 2004 as well as the
Resolution2dated September 1, 2004 of the Court of Appeals (CA) in CA-G.R. CV No. 58013 which
modified the Decision3dated September 5, 1997 of the Regional Trial Court of Legazpi City, Branch 8
in Civil Case No. 8904.
The factual antecedents:
On July 7, 1993, respondents 11-year old daughter, Angelica Soliman, underwent a biopsy of the
mass located in her lower extremity at the St. Lukes Medical Center (SLMC). Results showed that
Angelica was suffering from osteosarcoma, osteoblastic type, 4 a high-grade (highly malignant)
cancer of the bone which usually afflicts teenage children. Following this diagnosis and as primary
intervention, Angelicas right leg was amputated by Dr. Jaime Tamayo in order to remove the tumor.
As adjuvant treatment to eliminate any remaining cancer cells, and hence minimize the chances of
recurrence and prevent the disease from spreading to other parts of the patients body (metastasis),
chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo referred Angelica to another doctor at
SLMC, herein petitioner Dr. Rubi Li, a medical oncologist.
On August 18, 1993, Angelica was admitted to SLMC. However, she died on September 1, 1993,
just eleven (11) days after the (intravenous) administration of the first cycle of the chemotherapy
regimen. Because SLMC refused to release a death certificate without full payment of their hospital
bill, respondents brought the cadaver of Angelica to the Philippine National Police (PNP) Crime
Laboratory at Camp Crame for post-mortem examination. The Medico-Legal Report issued by said
institution indicated the cause of death as "Hypovolemic shock secondary to multiple organ
hemorrhages and Disseminated Intravascular Coagulation." 5
On the other hand, the Certificate of Death6 issued by SLMC stated the cause of death as follows:
Immediate cause : a. Osteosarcoma, Status Post AKA
Antecedent cause : b. (above knee amputation)
Underlying cause : c. Status Post Chemotherapy

On February 21, 1994, respondents filed a damage suit 7 against petitioner, Dr. Leo Marbella, Mr.
Jose Ledesma, a certain Dr. Arriete and SLMC. Respondents charged them with negligence and
disregard of Angelicas safety, health and welfare by their careless administration of the
chemotherapy drugs, their failure to observe the essential precautions in detecting early the
symptoms of fatal blood platelet decrease and stopping early on the chemotherapy, which bleeding
led to hypovolemic shock that caused Angelicas untimely demise. Further, it was specifically
averred that petitioner assured the respondents that Angelica would recover in view of 95% chance
of healing with chemotherapy ("Magiging normal na ang anak nyo basta ma-chemo. 95% ang
healing") and when asked regarding the side effects, petitioner mentioned only slight vomiting, hair
loss and weakness ("Magsusuka ng kaunti. Malulugas ang buhok. Manghihina"). Respondents thus
claimed that they would not have given their consent to chemotherapy had petitioner not falsely
assured them of its side effects.
In her answer,8 petitioner denied having been negligent in administering the chemotherapy drugs to
Angelica and asserted that she had fully explained to respondents how the chemotherapy will affect
not only the cancer cells but also the patients normal body parts, including the lowering of white and
red blood cells and platelets. She claimed that what happened to Angelica can be attributed to
malignant tumor cells possibly left behind after surgery. Few as they may be, these have the
capacity to compete for nutrients such that the body becomes so weak structurally (cachexia) and
functionally in the form of lower resistance of the body to combat infection. Such infection becomes
uncontrollable and triggers a chain of events (sepsis or septicemia) that may lead to bleeding in the
form of Disseminated Intravascular Coagulation (DIC), as what the autopsy report showed in the
case of Angelica.
Since the medical records of Angelica were not produced in court, the trial and appellate courts had
to rely on testimonial evidence, principally the declarations of petitioner and respondents
themselves. The following chronology of events was gathered:
On July 23, 1993, petitioner saw the respondents at the hospital after Angelicas surgery and
discussed with them Angelicas condition. Petitioner told respondents that Angelica should be given
two to three weeks to recover from the operation before starting chemotherapy. Respondents were
apprehensive due to financial constraints as Reynaldo earns only from P70,000.00 to P150,000.00 a
year from his jewelry and watch repairing business.9Petitioner, however, assured them not to worry
about her professional fee and told them to just save up for the medicines to be used.
Petitioner claimed that she explained to respondents that even when a tumor is removed, there are
still small lesions undetectable to the naked eye, and that adjuvant chemotherapy is needed to clean
out the small lesions in order to lessen the chance of the cancer to recur. She did not give the
respondents any assurance that chemotherapy will cure Angelicas cancer. During these
consultations with respondents, she explained the following side effects of chemotherapy treatment
to respondents: (1) falling hair; (2) nausea and vomiting; (3) loss of appetite; (4) low count of white
blood cells [WBC], red blood cells [RBC] and platelets; (5) possible sterility due to the effects on
Angelicas ovary; (6) damage to the heart and kidneys; and (7) darkening of the skin especially when
exposed to sunlight. She actually talked with respondents four times, once at the hospital after the
surgery, twice at her clinic and the fourth time when Angelicas mother called her through long
distance.10 This was disputed by respondents who countered that petitioner gave them assurance
that there is 95% chance of healing for Angelica if she undergoes chemotherapy and that the only
side effects were nausea, vomiting and hair loss.11Those were the only side-effects of chemotherapy
treatment mentioned by petitioner.12
On July 27, 1993, SLMC discharged Angelica, with instruction from petitioner that she be readmitted
after two or three weeks for the chemotherapy.

On August 18, 1993, respondents brought Angelica to SLMC for chemotherapy, bringing with them
the results of the laboratory tests requested by petitioner: Angelicas chest x-ray, ultrasound of the
liver, creatinine and complete liver function tests.13 Petitioner proceeded with the chemotherapy by
first administering hydration fluids to Angelica. 14
The following day, August 19, petitioner began administering three chemotherapy drugs
Cisplatin,15Doxorubicin16 and Cosmegen17 intravenously. Petitioner was supposedly assisted by her
trainees Dr. Leo Marbella18 and Dr. Grace Arriete.19 In his testimony, Dr. Marbella denied having any
participation in administering the said chemotherapy drugs.20
On the second day of chemotherapy, August 20, respondents noticed reddish discoloration on
Angelicas face.21They asked petitioner about it, but she merely quipped, "Wala yan. Epekto ng
gamot."22 Petitioner recalled noticing the skin rashes on the nose and cheek area of Angelica. At that
moment, she entertained the possibility that Angelica also had systemic lupus and consulted Dr.
Victoria Abesamis on the matter.23
On the third day of chemotherapy, August 21, Angelica had difficulty breathing and was thus
provided with oxygen inhalation apparatus. This time, the reddish discoloration on Angelicas face
had extended to her neck, but petitioner dismissed it again as merely the effect of
medicines.24 Petitioner testified that she did not see any discoloration on Angelicas face, nor did she
notice any difficulty in the childs breathing. She claimed that Angelica merely complained of nausea
and was given ice chips.25
1avvphi1

On August 22, 1993, at around ten oclock in the morning, upon seeing that their child could not
anymore bear the pain, respondents pleaded with petitioner to stop the chemotherapy. Petitioner
supposedly replied: "Dapat 15 Cosmegen pa iyan. Okay, lets observe. If pwede na, bigyan uli ng
chemo." At this point, respondents asked petitioners permission to bring their child home. Later in
the evening, Angelica passed black stool and reddish urine. 26 Petitioner countered that there was no
record of blackening of stools but only an episode of loose bowel movement (LBM). Petitioner also
testified that what Angelica complained of was carpo-pedal spasm, not convulsion or epileptic attack,
as respondents call it (petitioner described it in the vernacular as "naninigas ang kamay at paa").
She then requested for a serum calcium determination and stopped the chemotherapy. When
Angelica was given calcium gluconate, the spasm and numbness subsided. 27
The following day, August 23, petitioner yielded to respondents request to take Angelica home. But
prior to discharging Angelica, petitioner requested for a repeat serum calcium determination and
explained to respondents that the chemotherapy will be temporarily stopped while she observes
Angelicas muscle twitching and serum calcium level. Take-home medicines were also prescribed for
Angelica, with instructions to respondents that the serum calcium test will have to be repeated after
seven days. Petitioner told respondents that she will see Angelica again after two weeks, but
respondents can see her anytime if any immediate problem arises. 28
However, Angelica remained in confinement because while still in the premises of SLMC, her
"convulsions" returned and she also had LBM. Angelica was given oxygen and administration of
calcium continued.29
The next day, August 24, respondents claimed that Angelica still suffered from convulsions. They
also noticed that she had a fever and had difficulty breathing. 30 Petitioner insisted it was carpo-pedal
spasm, not convulsions. She verified that at around 4:50 that afternoon, Angelica developed difficulty
in breathing and had fever. She then requested for an electrocardiogram analysis, and infused
calcium gluconate on the patient at a "stat dose." She further ordered that Angelica be given
Bactrim,31 a synthetic antibacterial combination drug, 32 to combat any infection on the childs body. 33

By August 26, Angelica was bleeding through the mouth. Respondents also saw blood on her anus
and urine. When Lina asked petitioner what was happening to her daughter, petitioner replied,
"Bagsak ang platelets ng anak mo." Four units of platelet concentrates were then transfused to
Angelica. Petitioner prescribed Solucortef. Considering that Angelicas fever was high and her white
blood cell count was low, petitioner prescribed Leucomax. About four to eight bags of blood,
consisting of packed red blood cells, fresh whole blood, or platelet concentrate, were transfused to
Angelica. For two days (August 27 to 28), Angelica continued bleeding, but petitioner claimed it was
lesser in amount and in frequency. Petitioner also denied that there were gadgets attached to
Angelica at that time.34
On August 29, Angelica developed ulcers in her mouth, which petitioner said were blood clots that
should not be removed. Respondents claimed that Angelica passed about half a liter of blood
through her anus at around seven oclock that evening, which petitioner likewise denied.
On August 30, Angelica continued bleeding. She was restless as endotracheal and nasogastric
tubes were inserted into her weakened body. An aspiration of the nasogastric tube inserted to
Angelica also revealed a bloody content. Angelica was given more platelet concentrate and fresh
whole blood, which petitioner claimed improved her condition. Petitioner told Angelica not to remove
the endotracheal tube because this may induce further bleeding. 35 She was also transferred to the
intensive care unit to avoid infection.
The next day, respondents claimed that Angelica became hysterical, vomited blood and her body
turned black. Part of Angelicas skin was also noted to be shredding by just rubbing cotton on it.
Angelica was so restless she removed those gadgets attached to her, saying "Ayaw ko na"; there
were tears in her eyes and she kept turning her head. Observing her daughter to be at the point of
death, Lina asked for a doctor but the latter could not answer her anymore. 36 At this time, the
attending physician was Dr. Marbella who was shaking his head saying that Angelicas platelets
were down and respondents should pray for their daughter. Reynaldo claimed that he was
introduced to a pediatrician who took over his daughters case, Dr. Abesamis who also told him to
pray for his daughter. Angelica continued to have difficulty in her breathing and blood was being
suctioned from her stomach. A nurse was posted inside Angelicas room to assist her breathing and
at one point they had to revive Angelica by pumping her chest. Thereafter, Reynaldo claimed that
Angelica already experienced difficulty in urinating and her bowel consisted of blood-like fluid.
Angelica requested for an electric fan as she was in pain. Hospital staff attempted to take blood
samples from Angelica but were unsuccessful because they could not even locate her vein. Angelica
asked for a fruit but when it was given to her, she only smelled it. At this time, Reynaldo claimed he
could not find either petitioner or Dr. Marbella. That night, Angelica became hysterical and started
removing those gadgets attached to her. At three oclock in the morning of September 1, a priest
came and they prayed before Angelica expired. Petitioner finally came back and supposedly told
respondents that there was "malfunction" or bogged-down machine.37
By petitioners own account, Angelica was merely irritable that day (August 31). Petitioner noted
though that Angelicas skin was indeed sloughing off. 38 She stressed that at 9:30 in the evening,
Angelica pulled out her endotracheal tube. 39 On September 1, exactly two weeks after being
admitted at SLMC for chemotherapy, Angelica died. 40 The cause of death, according to petitioner,
was septicemia, or overwhelming infection, which caused Angelicas other organs to fail. 41 Petitioner
attributed this to the patients poor defense mechanism brought about by the cancer itself. 42
While he was seeking the release of Angelicas cadaver from SLMC, Reynaldo claimed that
petitioner acted arrogantly and called him names. He was asked to sign a promissory note as he did
not have cash to pay the hospital bill. 43

Respondents also presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-Legal Officer of the
PNP-Crime Laboratory who conducted the autopsy on Angelicas cadaver, and Dr. Melinda Vergara
Balmaceda who is a Medical Specialist employed at the Department of Health (DOH) Operations
and Management Services.
Testifying on the findings stated in her medico-legal report, Dr. Vergara noted the following: (1) there
were fluids recovered from the abdominal cavity, which is not normal, and was due to hemorrhagic
shock secondary to bleeding; (2) there was hemorrhage at the left side of the heart; (3) bleeding at
the upper portion of and areas adjacent to, the esophagus; (4) lungs were heavy with bleeding at the
back and lower portion, due to accumulation of fluids; (4) yellowish discoloration of the liver; (5)
kidneys showed appearance of facial shock on account of hemorrhages; and (6) reddishness on
external surface of the spleen. All these were the end result of "hypovolemic shock secondary to
multiple organ hemorrhages and disseminated intravascular coagulation." Dr. Vergara opined that
this can be attributed to the chemical agents in the drugs given to the victim, which caused platelet
reduction resulting to bleeding sufficient to cause the victims death. The time lapse for the
production of DIC in the case of Angelica (from the time of diagnosis of sarcoma) was too short,
considering the survival rate of about 3 years. The witness conceded that the victim will also die of
osteosarcoma even with amputation or chemotherapy, but in this case Angelicas death was not
caused by osteosarcoma. Dr. Vergara admitted that she is not a pathologist but her statements were
based on the opinion of an oncologist whom she had interviewed. This oncologist supposedly said
that if the victim already had DIC prior to the chemotherapy, the hospital staff could have detected
it.44
On her part, Dr. Balmaceda declared that it is the physicians duty to inform and explain to the
patient or his relatives every known side effect of the procedure or therapeutic agents to be
administered, before securing the consent of the patient or his relatives to such procedure or
therapy. The physician thus bases his assurance to the patient on his personal assessment of the
patients condition and his knowledge of the general effects of the agents or procedure that will be
allowed on the patient. Dr. Balmaceda stressed that the patient or relatives must be informed of all
known side effects based on studies and observations, even if such will aggravate the patients
condition.45
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelicas lower extremity, testified for
the defendants. He explained that in case of malignant tumors, there is no guarantee that the
ablation or removal of the amputated part will completely cure the cancer. Thus, surgery is not
enough. The mortality rate of osteosarcoma at the time of modern chemotherapy and early
diagnosis still remains at 80% to 90%. Usually, deaths occur from metastasis, or spread of the
cancer to other vital organs like the liver, causing systemic complications. The modes of therapy
available are the removal of the primary source of the cancerous growth and then the residual
cancer cells or metastasis should be treated with chemotherapy. Dr. Tamayo further explained that
patients with osteosarcoma have poor defense mechanism due to the cancer cells in the blood
stream. In the case of Angelica, he had previously explained to her parents that after the surgical
procedure, chemotherapy is imperative so that metastasis of these cancer cells will hopefully be
addressed. He referred the patient to petitioner because he felt that petitioner is a competent
oncologist. Considering that this type of cancer is very aggressive and will metastasize early, it will
cause the demise of the patient should there be no early intervention (in this case, the patient
developed sepsis which caused her death). Cancer cells in the blood cannot be seen by the naked
eye nor detected through bone scan. On cross-examination, Dr. Tamayo stated that of the more
than 50 child patients who had osteogenic sarcoma he had handled, he thought that probably all of
them died within six months from amputation because he did not see them anymore after follow-up;
it is either they died or had seen another doctor. 46

In dismissing the complaint, the trial court held that petitioner was not liable for damages as she
observed the best known procedures and employed her highest skill and knowledge in the
administration of chemotherapy drugs on Angelica but despite all efforts said patient died. It cited the
testimony of Dr. Tamayo who testified that he considered petitioner one of the most proficient in the
treatment of cancer and that the patient in this case was afflicted with a very aggressive type of
cancer necessitating chemotherapy as adjuvant treatment. Using the standard of negligence laid
down in Picart v. Smith,47 the trial court declared that petitioner has taken the necessary precaution
against the adverse effect of chemotherapy on the patient, adding that a wrong decision is not by
itself negligence. Respondents were ordered to pay their unpaid hospital bill in the amount
ofP139,064.43.48
Respondents appealed to the CA which, while concurring with the trial courts finding that there was
no negligence committed by the petitioner in the administration of chemotherapy treatment to
Angelica, found that petitioner as her attending physician failed to fully explain to the respondents all
the known side effects of chemotherapy. The appellate court stressed that since the respondents
have been told of only three side effects of chemotherapy, they readily consented thereto. Had
petitioner made known to respondents those other side effects which gravely affected their child -such as carpo-pedal spasm, sepsis, decrease in the blood platelet count, bleeding, infections and
eventual death -- respondents could have decided differently or adopted a different course of action
which could have delayed or prevented the early death of their child.
The CA thus declared:
Plaintiffs-appellants child was suffering from a malignant disease. The attending physician
recommended that she undergo chemotherapy treatment after surgery in order to increase her
chances of survival. Appellants consented to the chemotherapy treatment because they believed in
Dr. Rubi Lis representation that the deceased would have a strong chance of survival after
chemotherapy and also because of the representation of appellee Dr. Rubi Li that there were only
three possible side-effects of the treatment. However, all sorts of painful side-effects resulted from
the treatment including the premature death of Angelica. The appellants were clearly and totally
unaware of these other side-effects which manifested only during the chemotherapy treatment. This
was shown by the fact that every time a problem would take place regarding Angelicas condition
(like an unexpected side-effect manifesting itself), they would immediately seek explanation from Dr.
Rubi Li. Surely, those unexpected side-effects culminating in the loss of a love[d] one caused the
appellants so much trouble, pain and suffering.
On this point therefore, [w]e find defendant-appellee Dr. Rubi Li negligent which would entitle
plaintiffs-appellants to their claim for damages.
xxxx
WHEREFORE, the instant appeal is hereby GRANTED. Accordingly, the assailed decision is hereby
modified to the extent that defendant-appellee Dr. Rubi Li is ordered to pay the plaintiffs-appellants
the following amounts:
1. Actual damages of P139,064.43, plus P9,828.00 for funeral expenses;
2. Moral damages of P200,000.00;
3. Exemplary damages of P50,000.00;
4. Attorneys fee of P30,000.00.

SO ORDERED.49 (Emphasis supplied.)

Petitioner filed a motion for partial reconsideration which the appellate court denied.
Hence, this petition.
Petitioner assails the CA in finding her guilty of negligence in not explaining to the respondents all
the possible side effects of the chemotherapy on their child, and in holding her liable for actual,
moral and exemplary damages and attorneys fees. Petitioner emphasized that she was not
negligent in the pre-chemotherapy procedures and in the administration of chemotherapy treatment
to Angelica.
On her supposed non-disclosure of all possible side effects of chemotherapy, including death,
petitioner argues that it was foolhardy to imagine her to be all-knowing/omnipotent. While the
theoretical side effects of chemotherapy were explained by her to the respondents, as these should
be known to a competent doctor, petitioner cannot possibly predict how a particular patients genetic
make-up, state of mind, general health and body constitution would respond to the treatment. These
are obviously dependent on too many known, unknown and immeasurable variables, thus requiring
that Angelica be, as she was, constantly and closely monitored during the treatment. Petitioner
asserts that she did everything within her professional competence to attend to the medical needs of
Angelica.
Citing numerous trainings, distinctions and achievements in her field and her current position as codirector for clinical affairs of the Medical Oncology, Department of Medicine of SLMC, petitioner
contends that in the absence of any clear showing or proof, she cannot be charged with negligence
in not informing the respondents all the side effects of chemotherapy or in the pre-treatment
procedures done on Angelica.
As to the cause of death, petitioner insists that Angelica did not die of platelet depletion but of sepsis
which is a complication of the cancer itself. Sepsis itself leads to bleeding and death. She explains
that the response rate to chemotherapy of patients with osteosarcoma is high, so much so that
survival rate is favorable to the patient. Petitioner then points to some probable consequences if
Angelica had not undergone chemotherapy. Thus, without chemotherapy, other medicines and
supportive treatment, the patient might have died the next day because of massive infection, or the
cancer cells might have spread to the brain and brought the patient into a coma, or into the lungs
that the patient could have been hooked to a respirator, or into her kidneys that she would have to
undergo dialysis. Indeed, respondents could have spent as much because of these complications.
The patient would have been deprived of the chance to survive the ailment, of any hope for life and
her "quality of life" surely compromised. Since she had not been shown to be at fault, petitioner
maintains that the CA erred in holding her liable for the damages suffered by the respondents. 50
The issue to be resolved is whether the petitioner can be held liable for failure to fully disclose
serious side effects to the parents of the child patient who died while undergoing chemotherapy,
despite the absence of finding that petitioner was negligent in administering the said treatment.
The petition is meritorious.
The type of lawsuit which has been called medical malpractice or, more appropriately, medical
negligence, is that type of claim which a victim has available to him or her to redress a wrong
committed by a medical professional which has caused bodily harm. In order to successfully pursue
such a claim, a patient must prove that a health care provider, in most cases a physician, either
failed to do something which a reasonably prudent health care provider would have done, or that he

or she did something that a reasonably prudent provider would not have done; and that that failure
or action caused injury to the patient. 51
This Court has recognized that medical negligence cases are best proved by opinions of expert
witnesses belonging in the same general neighborhood and in the same general line of practice as
defendant physician or surgeon. The deference of courts to the expert opinion of qualified physicians
stems from the formers realization that the latter possess unusual technical skills which laymen in
most instances are incapable of intelligently evaluating, hence the indispensability of expert
testimonies.52
In this case, both the trial and appellate courts concurred in finding that the alleged negligence of
petitioner in the administration of chemotherapy drugs to respondents child was not proven
considering that Drs. Vergara and Balmaceda, not being oncologists or cancer specialists, were not
qualified to give expert opinion as to whether petitioners lack of skill, knowledge and professional
competence in failing to observe the standard of care in her line of practice was the proximate cause
of the patients death. Furthermore, respondents case was not at all helped by the non-production of
medical records by the hospital (only the biopsy result and medical bills were submitted to the court).
Nevertheless, the CA found petitioner liable for her failure to inform the respondents on all possible
side effects of chemotherapy before securing their consent to the said treatment.
The doctrine of informed consent within the context of physician-patient relationships goes far back
into English common law. As early as 1767, doctors were charged with the tort of "battery" (i.e., an
unauthorized physical contact with a patient) if they had not gained the consent of their patients prior
to performing a surgery or procedure. In the United States, the seminal case was Schoendorff v.
Society of New York Hospital53 which involved unwanted treatment performed by a doctor. Justice
Benjamin Cardozos oft-quoted opinion upheld the basic right of a patient to give consent to any
medical procedure or treatment: "Every human being of adult years and sound mind has a right to
determine what shall be done with his own body; and a surgeon who performs an operation without
his patients consent, commits an assault, for which he is liable in damages." 54 From a purely ethical
norm, informed consent evolved into a general principle of law that a physician has a duty to
disclose what a reasonably prudent physician in the medical community in the exercise of
reasonable care would disclose to his patient as to whatever grave risks of injury might be incurred
from a proposed course of treatment, so that a patient, exercising ordinary care for his own welfare,
and faced with a choice of undergoing the proposed treatment, or alternative treatment, or none at
all, may intelligently exercise his judgment by reasonably balancing the probable risks against the
probable benefits.55
Subsequently, in Canterbury v. Spence56 the court observed that the duty to disclose should not be
limited to medical usage as to arrogate the decision on revelation to the physician alone. Thus,
respect for the patients right of self-determination on particular therapy demands a standard set by
law for physicians rather than one which physicians may or may not impose upon themselves. 57 The
scope of disclosure is premised on the fact that patients ordinarily are persons unlearned in the
medical sciences. Proficiency in diagnosis and therapy is not the full measure of a physicians
responsibility. It is also his duty to warn of the dangers lurking in the proposed treatment and to
impart information which the patient has every right to expect. Indeed, the patients reliance upon the
physician is a trust of the kind which traditionally has exacted obligations beyond those associated
with armslength transactions.58 The physician is not expected to give the patient a short medical
education, the disclosure rule only requires of him a reasonable explanation, which means generally
informing the patient in nontechnical terms as to what is at stake; the therapy alternatives open to
him, the goals expectably to be achieved, and the risks that may ensue from particular treatment or
no treatment.59 As to the issue of demonstrating what risks are considered material necessitating
disclosure, it was held that experts are unnecessary to a showing of the materiality of a risk to a
patients decision on treatment, or to the reasonably, expectable effect of risk disclosure on the

decision. Such unrevealed risk that should have been made known must further materialize, for
otherwise the omission, however unpardonable, is without legal consequence. And, as in
malpractice actions generally, there must be a causal relationship between the physicians failure to
divulge and damage to the patient.60
Reiterating the foregoing considerations, Cobbs v. Grant61 deemed it as integral part of physicians
overall obligation to patient, the duty of reasonable disclosure of available choices with respect to
proposed therapy and of dangers inherently and potentially involved in each. However, the physician
is not obliged to discuss relatively minor risks inherent in common procedures when it is common
knowledge that such risks inherent in procedure of very low incidence. Cited as exceptions to the
rule that the patient should not be denied the opportunity to weigh the risks of surgery or treatment
are emergency cases where it is evident he cannot evaluate data, and where the patient is a child or
incompetent.62 The court thus concluded that the patients right of self-decision can only be
effectively exercised if the patient possesses adequate information to enable him in making an
intelligent choice. The scope of the physicians communications to the patient, then must be
measured by the patients need, and that need is whatever information is material to the decision.
The test therefore for determining whether a potential peril must be divulged is its materiality to the
patients decision.63
Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that for liability of the
physician for failure to inform patient, there must be causal relationship between physicians failure
to inform and the injury to patient and such connection arises only if it is established that, had
revelation been made, consent to treatment would not have been given.
There are four essential elements a plaintiff must prove in a malpractice action based upon the
doctrine of informed consent: "(1) the physician had a duty to disclose material risks; (2) he failed to
disclose or inadequately disclosed those risks; (3) as a direct and proximate result of the failure to
disclose, the patient consented to treatment she otherwise would not have consented to; and (4)
plaintiff was injured by the proposed treatment." The gravamen in an informed consent case requires
the plaintiff to "point to significant undisclosed information relating to the treatment which would have
altered her decision to undergo it.64
Examining the evidence on record, we hold that there was adequate disclosure of material risks
inherent in the chemotherapy procedure performed with the consent of Angelicas parents.
Respondents could not have been unaware in the course of initial treatment and amputation of
Angelicas lower extremity, that her immune system was already weak on account of the malignant
tumor in her knee. When petitioner informed the respondents beforehand of the side effects of
chemotherapy which includes lowered counts of white and red blood cells, decrease in blood
platelets, possible kidney or heart damage and skin darkening, there is reasonable expectation on
the part of the doctor that the respondents understood very well that the severity of these side
effects will not be the same for all patients undergoing the procedure. In other words, by the nature
of the disease itself, each patients reaction to the chemical agents even with pre-treatment
laboratory tests cannot be precisely determined by the physician. That death can possibly result
from complications of the treatment or the underlying cancer itself, immediately or sometime after
the administration of chemotherapy drugs, is a risk that cannot be ruled out, as with most other
major medical procedures, but such conclusion can be reasonably drawn from the general side
effects of chemotherapy already disclosed.
As a physician, petitioner can reasonably expect the respondents to have considered the variables
in the recommended treatment for their daughter afflicted with a life-threatening illness. On the other
hand, it is difficult to give credence to respondents claim that petitioner told them of 95% chance of
recovery for their daughter, as it was unlikely for doctors like petitioner who were dealing with grave

conditions such as cancer to have falsely assured patients of chemotherapys success rate. Besides,
informed consent laws in other countries generally require only a reasonable explanation of potential
harms, so specific disclosures such as statistical data, may not be legally necessary. 65
The element of ethical duty to disclose material risks in the proposed medical treatment cannot thus
be reduced to one simplistic formula applicable in all instances. Further, in a medical malpractice
action based on lack of informed consent, "the plaintiff must prove both the duty and the breach of
that duty through expert testimony.66Such expert testimony must show the customary standard of
care of physicians in the same practice as that of the defendant doctor. 67
In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medical Specialist of the
DOHs Operational and Management Services charged with receiving complaints against hospitals,
does not qualify as expert testimony to establish the standard of care in obtaining consent for
chemotherapy treatment. In the absence of expert testimony in this regard, the Court feels hesitant
in defining the scope of mandatory disclosure in cases of malpractice based on lack of informed
consent, much less set a standard of disclosure that, even in foreign jurisdictions, has been noted to
be an evolving one.
As society has grappled with the juxtaposition between personal autonomy and the medical
profession's intrinsic impetus to cure, the law defining "adequate" disclosure has undergone a
dynamic evolution. A standard once guided solely by the ruminations of physicians is now
dependent on what a reasonable person in the patients position regards as significant. This change
in perspective is especially important as medical breakthroughs move practitioners to the cutting
edge of technology, ever encountering new and heretofore unimagined treatments for currently
incurable diseases or ailments. An adaptable standard is needed to account for this constant
progression. Reasonableness analyses permeate our legal system for the very reason that they are
determined by social norms, expanding and contracting with the ebb and flow of societal evolution.
As we progress toward the twenty-first century, we now realize that the legal standard of disclosure
is not subject to construction as a categorical imperative. Whatever formulae or processes we adopt
are only useful as a foundational starting point; the particular quality or quantity of disclosure will
remain inextricably bound by the facts of each case. Nevertheless, juries that ultimately determine
whether a physician properly informed a patient are inevitably guided by what they perceive as the
common expectation of the medical consumer"a reasonable person in the patients position when
deciding to accept or reject a recommended medical procedure." 68(Emphasis supplied.)
WHEREFORE, the petition for review on certiorari is GRANTED. The Decision dated June 15, 2004
and the Resolution dated September 1, 2004 of the Court of Appeals in CA-G.R. CV No. 58013 are
SET ASIDE.
The Decision dated September 5, 1997 of the Regional Trial Court of Legazpi City, Branch 8, in Civil
Case No. 8904 is REINSTATED and UPHELD.
No costs.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
FIRST DIVISION
G.R. No. 126297

January 31, 2007

PROFESSIONAL SERVICES, INC., Petitioner,

vs.
NATIVIDAD and ENRIQUE AGANA, Respondents.
x-----------------------x
G.R. No. 126467

January 31, 2007

NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE AGANA, JR.,
EMMA AGANA ANDAYA, JESUS AGANA, and RAYMUND AGANA) and ENRIQUE
AGANA, Petitioners,
vs.
JUAN FUENTES, Respondent.
x- - - - - - - - - - - - - - - - - - - -- - - - x
G.R. No. 127590

January 31, 2007

MIGUEL AMPIL, Petitioner,

vs.
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
DECISION
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankinds most important and delicate endeavors, must
assume the grave responsibility of pursuing it with appropriate care. The care and service dispensed
through this high trust, however technical, complex and esoteric its character may be, must meet
standards of responsibility commensurate with the undertaking to preserve and protect the health,
and indeed, the very lives of those placed in the hospitals keeping. 1
Assailed in these three consolidated petitions for review on certiorari is the Court of Appeals
Decision2 dated September 6, 1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198 affirming
with modification the Decision3 dated March 17, 1993 of the Regional Trial Court (RTC), Branch 96,
Quezon City in Civil Case No. Q-43322 and nullifying its Order dated September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital (Medical City
Hospital) because of difficulty of bowel movement and bloody anal discharge. After a series of
medical examinations, Dr. Miguel Ampil, petitioner in G.R. No. 127590, diagnosed her to be suffering
from "cancer of the sigmoid."

On April 11, 1984, Dr. Ampil, assisted by the medical staff4 of the Medical City Hospital, performed
an anterior resection surgery on Natividad. He found that the malignancy in her sigmoid area had
spread on her left ovary, necessitating the removal of certain portions of it. Thus, Dr. Ampil obtained
the consent of Natividads husband, Enrique Agana, to permit Dr. Juan Fuentes, respondent in G.R.
No. 126467, to perform hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation
and closed the incision.
However, the operation appeared to be flawed. In the corresponding Record of Operation dated April
11, 1984, the attending nurses entered these remarks:
"sponge count lacking 2
"announced to surgeon searched (sic) done but to no avail continue for closure."
On April 24, 1984, Natividad was released from the hospital. Her hospital and medical bills, including
the doctors fees, amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating pain in her anal region. She consulted
both Dr. Ampil and Dr. Fuentes about it. They told her that the pain was the natural consequence of
the surgery. Dr. Ampil then recommended that she consult an oncologist to examine the cancerous
nodes which were not removed during the operation.
On May 9, 1984, Natividad, accompanied by her husband, went to the United States to seek further
treatment. After four months of consultations and laboratory examinations, Natividad was told she
was free of cancer. Hence, she was advised to return to the Philippines.
On August 31, 1984, Natividad flew back to the Philippines, still suffering from pains. Two weeks
thereafter, her daughter found a piece of gauze protruding from her vagina. Upon being informed
about it, Dr. Ampil proceeded to her house where he managed to extract by hand a piece of gauze
measuring 1.5 inches in width. He then assured her that the pains would soon vanish.
Dr. Ampils assurance did not come true. Instead, the pains intensified, prompting Natividad to seek
treatment at the Polymedic General Hospital. While confined there, Dr. Ramon Gutierrez detected
the presence of another foreign object in her vagina -- a foul-smelling gauze measuring 1.5 inches in
width which badly infected her vaginal vault. A recto-vaginal fistula had formed in her reproductive
organs which forced stool to excrete through the vagina. Another surgical operation was needed to
remedy the damage. Thus, in October 1984, Natividad underwent another surgery.
On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, Quezon City a
complaint for damages against the Professional Services, Inc. (PSI), owner of the Medical City
Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil Case No. Q-43322. They alleged that the
latter are liable for negligence for leaving two pieces of gauze inside Natividads body and
malpractice for concealing their acts of negligence.
Meanwhile, Enrique Agana also filed with the Professional Regulation Commission (PRC) an
administrative complaint for gross negligence and malpractice against Dr. Ampil and Dr. Fuentes,
docketed as Administrative Case No. 1690. The PRC Board of Medicine heard the case only with
respect to Dr. Fuentes because it failed to acquire jurisdiction over Dr. Ampil who was then in the
United States.

On February 16, 1986, pending the outcome of the above cases, Natividad died and was duly
substituted by her above-named children (the Aganas).
On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and
Dr. Fuentes liable for negligence and malpractice, 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. As actual damages, the following amounts:
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;
b. The sum of P4,800.00 as travel taxes of plaintiffs and their physician daughter;
c. The total sum of P45,802.50, representing the cost of hospitalization at Polymedic
Hospital, medical fees, and cost of the saline solution;
2. As moral damages, the sum of P2,000,000.00;
3. As exemplary damages, the sum of P300,000.00;
4. As attorneys fees, the sum of P250,000.00;
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
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 them for P451,275.00 and delivered the amount to the
Aganas.
Following their receipt of the money, the Aganas entered into an agreement with PSI and Dr.
Fuentes to indefinitely suspend any further execution of the RTC Decision. However, not long
thereafter, the Aganas again filed a motion for an alias writ of execution against the properties of PSI
and Dr. Fuentes. On September 21, 1993, the RTC granted the motion and issued the
corresponding writ, prompting Dr. Fuentes to file with the Court of Appeals a petition for certiorari
and prohibition, with prayer for preliminary injunction, docketed as CA-G.R. SP No. 32198. During its
pendency, the Court of Appeals issued a Resolution5 dated October 29, 1993 granting Dr. Fuentes
prayer for injunctive relief.

On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No. 42062.
Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision6 in
Administrative Case No. 1690 dismissing the case against Dr. Fuentes. The Board held that the
prosecution failed to show that Dr. Fuentes was the one who left the two pieces of gauze inside
Natividads body; and that he concealed such fact from Natividad.
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
AFFIRMED and the instant appeal DISMISSED.
Concomitant with the above, the petition for certiorari and prohibition filed by herein defendantappellant 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 Resolution7 dated December
19, 1996.
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.
In G.R. No. 126467, the Aganas maintain that the Court of Appeals erred in finding that Dr. Fuentes
is not guilty of negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. They
contend that the pieces of gauze are prima facie proofs that the operating surgeons have been
negligent.
Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of Appeals erred in finding him liable for
negligence and malpractice sans evidence that he left the two pieces of gauze in Natividads vagina.
He pointed to other probable causes, such as: (1) it was Dr. Fuentes who used gauzes in performing
the hysterectomy; (2) the attending nurses failure to properly count the gauzes used during surgery;
and (3) the medical intervention of the American doctors who examined Natividad in the United
States of America.

For our resolution are these three vital issues: first, whether the Court of Appeals erred in holding Dr.
Ampil liable for negligence and malpractice; second, whether the Court of Appeals erred in absolving
Dr. Fuentes of any liability; and third, whether PSI may be held solidarily liable for the negligence of
Dr. Ampil.
I - G.R. No. 127590
Whether the Court of Appeals Erred in Holding Dr. Ampil
Liable for Negligence and Malpractice.
Dr. Ampil, in an attempt to absolve himself, gears the Courts attention to other possible causes of
Natividads detriment. He argues that the Court should not discount either of the following
possibilities: first, Dr. Fuentes left the gauzes in Natividads body after performing hysterectomy;
second, the attending nurses erred in counting the gauzes; and third, the American doctors were the
ones who placed the gauzes in Natividads body.
Dr. Ampils arguments are purely conjectural and without basis. Records show that he did not
present any evidence to prove that the American doctors were the ones who put or left the gauzes in
Natividads body. Neither did he submit evidence to rebut the correctness of the record of operation,
particularly the number of gauzes used. As to the alleged negligence of Dr. Fuentes, we are mindful
that Dr. Ampil examined his (Dr. Fuentes) work and found it in order.
The glaring truth is that all the major circumstances, taken together, as specified by the Court of
Appeals, directly point to Dr. Ampil as the negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges to control the bleeding of
the patient during the surgical operation.
Second, immediately after the operation, the nurses who assisted in the surgery noted in
their report that the sponge count (was) lacking 2; that such anomaly was announced to
surgeon and that a search was done but to no avail prompting Dr. Ampil to continue for
closure x x x.
Third, after the operation, two (2) gauzes were extracted from the same spot of the body of
Mrs. Agana where the surgery was performed.
An operation requiring the placing of sponges in the incision is not complete until the sponges are
properly removed, and it is settled that the leaving of sponges or other foreign substances in the
wound after the incision has been closed is at least prima facie negligence by the operating
surgeon.8 To put it simply, such act is considered so inconsistent with due care as to raise an
inference of negligence. There are even legions of authorities to the effect that such act is
negligence per se.9
Of course, the Court is not blind to the reality that there are times when danger to a patients life
precludes a surgeon from further searching missing sponges or foreign objects left in the body. But
this does not leave him free from any obligation. Even if it has been shown that a surgeon was
required by the urgent necessities of the case to leave a sponge in his patients abdomen, because
of the dangers attendant upon delay, still, it is his legal duty to so inform his patient within a
reasonable time thereafter by advising her of what he had been compelled to do. This is in order that

she might seek relief from the effects of the foreign object left in her body as her condition might
permit. The ruling in Smith v. Zeagler 10 is explicit, thus:
The removal of all sponges used is part of a surgical operation, and when a physician or surgeon
fails to remove a sponge he has placed in his patients body that should be removed as part of the
operation, he thereby leaves his operation uncompleted and creates a new condition which imposes
upon him the legal duty of calling the new condition to his patients attention, and endeavoring with
the means he has at hand to minimize and avoid untoward results likely to ensue therefrom.
Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even
misled her that the pain she was experiencing was the ordinary consequence of her operation. Had
he been more candid, Natividad could have taken the immediate and appropriate medical remedy to
remove the gauzes from her body. To our mind, what was initially an act of negligence by Dr. Ampil
has ripened into a deliberate wrongful act of deceiving his patient.
This is a clear case of medical malpractice or more appropriately, medical negligence. To
successfully pursue this kind of case, a patient must only prove that a health care provider either
failed to do something which a reasonably prudent health care provider would have done, or that he
did something that a reasonably prudent provider would not have done; and that failure or action
caused injury to the patient.11 Simply put, the elements are duty, breach, injury and proximate
causation. Dr, Ampil, as the lead surgeon, had the duty to remove all foreign objects, such as
gauzes, from Natividads body before closure of the incision. When he failed to do so, it was his duty
to inform Natividad about it. Dr. Ampil breached both duties. Such breach caused injury to Natividad,
necessitating her further examination by American doctors and another surgery. That Dr. Ampils
negligence is the proximate cause12 of Natividads injury could be traced from his act of closing the
incision despite the information given by the attending nurses that two pieces of gauze were still
missing. That they were later on extracted from Natividads vagina established the causal link
between Dr. Ampils negligence and the injury. And what further aggravated such injury was his
deliberate concealment of the missing gauzes from the knowledge of Natividad and her family.
II - G.R. No. 126467
Whether the Court of Appeals Erred in Absolving
Dr. Fuentes of any Liability
The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes on the ground
that it is contrary to the doctrine of res ipsa loquitur. According to them, the fact that the two pieces
of gauze were left inside Natividads body is a prima facie evidence of Dr. Fuentes negligence.
We are not convinced.
Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule that the fact of the
occurrence of an injury, taken with the surrounding circumstances, may permit an inference or raise
a presumption of negligence, or make out a plaintiffs prima facie case, and present a question of
fact for defendant to meet with an explanation.13 Stated differently, where the thing which caused the
injury, without the fault of the injured, is under the exclusive control of the defendant and the injury is
such that it should not have occurred if he, having such control used proper care, it affords
reasonable evidence, in the absence of explanation that the injury arose from the defendants want
of care, and the burden of proof is shifted to him to establish that he has observed due care and
diligence.14

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

hospital vicarious liability under the theories of respondeat superior, apparent authority, ostensible
authority, or agency by estoppel. 20
In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of the Civil Code,
which reads:
Art. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is
obliged to pay for the damage done. Such fault or negligence, if there is no pre-existing contractual
relation between the parties, is called a quasi-delict and is governed by the provisions of this
Chapter.
A derivative of this provision is Article 2180, the rule governing vicarious liability under the doctrine of
respondeat superior, thus:
ART. 2180. The obligation imposed by Article 2176 is demandable not only for ones own acts or
omissions, but also for those of persons for whom one is responsible.
x x x

x x x

The owners and managers of an establishment or enterprise are likewise responsible for damages
caused by their employees in the service of the branches in which the latter are employed or on the
occasion of their functions.
Employers shall be liable for the damages caused by their employees and household helpers acting
within the scope of their assigned tasks even though the former are not engaged in any business or
industry.
x x x

The responsibility treated of in this article shall cease when the persons herein mentioned prove that
they observed all the diligence of a good father of a family to prevent damage.
A prominent civilist commented that professionals engaged by an employer, such as physicians,
dentists, and pharmacists, are not "employees" under this article because the manner in which they
perform their work is not within the control of the latter (employer). In other words, professionals are
considered personally liable for the fault or negligence they commit in the discharge of their duties,
and their employer cannot be held liable for such fault or negligence. In the context of the present
case, "a hospital cannot be held liable for the fault or negligence of a physician or surgeon in the
treatment or operation of patients."21
The foregoing view is grounded on the traditional notion that the professional status and the very
nature of the physicians calling preclude him from being classed as an agent or employee of a
hospital, whenever he acts in a professional capacity. 22 It has been said that medical practice strictly
involves highly developed and specialized knowledge, 23 such that physicians are generally free to
exercise their own skill and judgment in rendering medical services sans interference. 24 Hence, when
a doctor practices medicine in a hospital setting, the hospital and its employees are deemed to
subserve him in his ministrations to the patient and his actions are of his own responsibility. 25
The case of Schloendorff v. Society of New York Hospital26 was then considered an authority for this
view. The "Schloendorff doctrine" regards a physician, even if employed by a hospital, as an
independent contractor because of the skill he exercises and the lack of control exerted over his

work. Under this doctrine, hospitals are exempt from the application of the respondeat superior
principle for fault or negligence committed by physicians in the discharge of their profession.
However, the efficacy of the foregoing doctrine has weakened with the significant developments in
medical care. Courts came to realize that modern hospitals are increasingly taking active role in
supplying and regulating medical care to patients. No longer were a hospitals functions limited to
furnishing room, food, facilities for treatment and operation, and attendants for its patients. Thus, in
Bing v. Thunig,27 the New York Court of Appeals deviated from the Schloendorff doctrine, noting that
modern hospitals actually do far more than provide facilities for treatment. Rather, they regularly
employ, on a salaried basis, a large staff of physicians, interns, nurses, administrative and manual
workers. They charge patients for medical care and treatment, even collecting for such services
through legal action, if necessary. The court then concluded that there is no reason to exempt
hospitals from the universal rule of respondeat superior.
In our shores, the nature of the relationship between the hospital and the physicians is rendered
inconsequential in view of our categorical pronouncement in Ramos v. Court of Appeals 28 that for
purposes of apportioning responsibility in medical negligence cases, an employer-employee
relationship in effect exists between hospitals and their attending and visiting physicians. This Court
held:
"We now discuss the responsibility of the hospital in this particular incident. The unique practice
(among private hospitals) of filling up specialist staff with attending and visiting "consultants," who
are allegedly not hospital employees, presents problems in apportioning responsibility for negligence
in medical malpractice cases. However, the difficulty is more apparent than real.
In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the
conduct of their work within the hospital premises. Doctors who apply for consultant slots, visiting or
attending, are required to submit proof of completion of residency, their educational qualifications,
generally, evidence of accreditation by the appropriate board (diplomate), evidence of fellowship in
most cases, and references. These requirements are carefully scrutinized by members of the
hospital administration or by a review committee set up by the hospital who either accept or reject
the application. x x x.
After a physician is accepted, either as a visiting or attending consultant, he is normally required to
attend clinico-pathological conferences, conduct bedside rounds for clerks, interns and residents,
moderate grand rounds and patient audits and perform other tasks and responsibilities, for the
privilege of being able to maintain a clinic in the hospital, and/or for the privilege of admitting patients
into the hospital. In addition to these, the physicians performance as a specialist is generally
evaluated by a peer review committee on the basis of mortality and morbidity statistics, and
feedback from patients, nurses, interns and residents. A consultant remiss in his duties, or a
consultant who regularly falls short of the minimum standards acceptable to the hospital or its peer
review committee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and visiting
consultant staff. While consultants are not, technically employees, x x x, the control exercised, the
hiring, and the right to terminate consultants all fulfill the important hallmarks of an employeremployee 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 PSIs liability. Its liability is also
anchored upon the agency principle of apparent authority or agency by estoppel and the doctrine of
corporate negligence which have gained acceptance in the determination of a hospitals liability for
negligent acts of health professionals. The present case serves as a perfect platform to test the
applicability of these doctrines, thus, enriching our jurisprudence.
Apparent authority, or what is sometimes referred to as the "holding
out" theory, or doctrine of ostensible agency or agency by estoppel, 29 has its origin from the law of
agency. It imposes liability, not as the result of the reality of a contractual relationship, but rather
because of the actions of a principal or an employer in somehow misleading the public into believing
that the relationship or the authority exists.30 The concept is essentially one of estoppel and has
been explained in this manner:
"The principal is bound by the acts of his agent with the apparent authority which he knowingly
permits the agent to assume, or which he holds the agent out to the public as possessing. The
question in every case is whether the principal has by his voluntary act placed the agent in such a
situation that a person of ordinary prudence, conversant with business usages and the nature of the
particular business, is justified in presuming that such agent has authority to perform the particular
act in question.31
The applicability of apparent authority in the field of hospital liability was upheld long time ago in
Irving v. Doctor Hospital of Lake Worth, Inc.32 There, it was explicitly stated that "there does not
appear to be any rational basis for excluding the concept of apparent authority from the field of
hospital liability." Thus, in cases where it can be shown that a hospital, by its actions, has held out a
particular physician as its agent and/or employee and that a patient has accepted treatment from
that physician in the reasonable belief that it is being rendered in behalf of the hospital, then the
hospital will be liable for the physicians negligence.
Our jurisdiction recognizes the concept of an agency by implication or estoppel. Article 1869 of the
Civil Code reads:
ART. 1869. Agency may be express, or implied from the acts of the principal, from his silence or lack
of action, or his failure to repudiate the agency, knowing that another person is acting on his behalf
without authority.
In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and
specializations of the physicians associated or accredited by it, including those of Dr. Ampil and Dr.
Fuentes. We concur with the Court of Appeals conclusion that it "is now estopped from passing all
the blame to the physicians whose names it proudly paraded in the public directory leading the
public to believe that it vouched for their skill and competence." Indeed, PSIs act is tantamount to
holding out to the public that Medical City Hospital, through its accredited physicians, offers quality
health care services. By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their
qualifications, the hospital created the impression that they were its agents, authorized to perform
medical or surgical services for its patients. As expected, these patients, Natividad being one of
them, accepted the services on the reasonable belief that such were being rendered by the hospital
or its employees, agents, or servants. The trial court correctly pointed out:
x x x regardless of the education and status in life of the patient, he ought not be burdened with the
defense of absence of employer-employee relationship between the hospital and the independent
physician whose name and competence are certainly certified to the general public by the hospitals
act of listing him and his specialty in its lobby directory, as in the case herein. The high costs of

todays medical and health care should at least exact on the hospital greater, if not broader, legal
responsibility for the conduct of treatment and surgery within its facility by its accredited physician or
surgeon, regardless of whether he is independent or employed." 33
The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like PSI, are capable
of acting only through other individuals, such as physicians. If these accredited physicians do their
job well, the hospital succeeds in its mission of offering quality medical services and thus profits
financially. Logically, where negligence mars the quality of its services, the hospital should not be
allowed to escape liability for the acts of its ostensible agents.
We now proceed to the doctrine of corporate negligence or corporate responsibility.
One allegation in the complaint in Civil Case No. Q-43332 for negligence and malpractice is that PSI
as owner, operator and manager of Medical City Hospital, "did not perform the necessary
supervision nor exercise diligent efforts in the supervision of Drs. Ampil and Fuentes and its nursing
staff, resident doctors, and medical interns who assisted Drs. Ampil and Fuentes in the performance
of their duties as surgeons."34 Premised on the doctrine of corporate negligence, the trial court held
that PSI is directly liable for such breach of duty.
We agree with the trial court.
Recent years have seen the doctrine of corporate negligence as the judicial answer to the problem
of allocating hospitals liability for the negligent acts of health practitioners, absent facts to support
the application of respondeat superior or apparent authority. Its formulation proceeds from the
judiciarys acknowledgment that in these modern times, the duty of providing quality medical service
is no longer the sole prerogative and responsibility of the physician. The modern hospitals have
changed structure. Hospitals now tend to organize a highly professional medical staff whose
competence and performance need to be monitored by the hospitals commensurate with their
inherent responsibility to provide quality medical care. 35
The doctrine has its genesis in Darling v. Charleston Community Hospital.36 There, the Supreme
Court of Illinois held that "the jury could have found a hospital negligent, inter alia, in failing to have a
sufficient number of trained nurses attending the patient; failing to require a consultation with or
examination by members of the hospital staff; and failing to review the treatment rendered to the
patient." On the basis of Darling, other jurisdictions held that a hospitals corporate negligence
extends to permitting a physician known to be incompetent to practice at the hospital. 37 With the
passage of time, more duties were expected from hospitals, among them: (1) the use of reasonable
care in the maintenance of safe and adequate facilities and equipment; (2) the selection and
retention of competent physicians; (3) the overseeing or supervision of all persons who practice
medicine within its walls; and (4) the formulation, adoption and enforcement of adequate rules and
policies that ensure quality care for its patients. 38 Thus, in Tucson Medical Center, Inc. v.
Misevich,39 it was held that a hospital, following the doctrine of corporate responsibility, has the duty
to see that it meets the standards of responsibilities for the care of patients. Such duty includes the
proper supervision of the members of its medical staff. And in Bost v. Riley, 40 the court concluded
that a patient who enters a hospital does so with the reasonable expectation that it will attempt to
cure him. The hospital accordingly has the duty to make a reasonable effort to monitor and oversee
the treatment prescribed and administered by the physicians practicing in its premises.
In the present case, it was duly established that PSI operates the Medical City Hospital for the
purpose and under the concept of providing comprehensive medical services to the public.
Accordingly, it has the duty to exercise reasonable care to protect from harm all patients admitted

into its facility for medical treatment. Unfortunately, PSI failed to perform such duty. The findings of
the trial court are convincing, thus:
x x x PSIs liability is traceable to its failure to conduct an investigation of the matter reported in the
nota bene of the count nurse. Such failure established PSIs part in the dark conspiracy of silence
and concealment about the gauzes. Ethical considerations, if not also legal, dictated the holding of
an immediate inquiry into the events, if not for the benefit of the patient to whom the duty is primarily
owed, then in the interest of arriving at the truth. The Court cannot accept that the medical and the
healing professions, through their members like defendant surgeons, and their institutions like PSIs
hospital facility, can callously turn their backs on and disregard even a mere probability of mistake or
negligence by refusing or failing to investigate a report of such seriousness as the one in Natividads
case.
It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the assistance of the
Medical City Hospitals staff, composed of resident doctors, nurses, and interns. As such, it is
reasonable to conclude that PSI, as the operator of the hospital, has actual or constructive
knowledge of the procedures carried out, particularly the report of the attending nurses that the two
pieces of gauze were missing. In Fridena v. Evans, 41 it was held that a corporation is bound by the
knowledge acquired by or notice given to its agents or officers within the scope of their authority and
in reference to a matter to which their authority extends. This means that the knowledge of any of
the staff of Medical City Hospital constitutes knowledge of PSI. Now, the failure of PSI, despite the
attending nurses report, to investigate and inform Natividad regarding the missing gauzes amounts
to callous negligence. Not only did PSI breach its duties to oversee or supervise all persons who
practice medicine within its walls, it also failed to take an active step in fixing the negligence
committed. This renders PSI, not only vicariously liable for the negligence of Dr. Ampil under Article
2180 of the Civil Code, but also directly liable for its own negligence under Article 2176. In Fridena,
the Supreme Court of Arizona held:
x x x In recent years, however, the duty of care owed to the patient by the hospital has expanded.
The emerging trend is to hold the hospital responsible where the hospital has failed to monitor and
review medical services being provided within its walls. See Kahn Hospital Malpractice Prevention,
27 De Paul . Rev. 23 (1977).
Among the cases indicative of the emerging trend is Purcell v. Zimbelman, 18 Ariz. App. 75,500 P.
2d 335 (1972). In Purcell, the hospital argued that it could not be held liable for the malpractice of a
medical practitioner because he was an independent contractor within the hospital. The Court of
Appeals pointed out that the hospital had created a professional staff whose competence and
performance was to be monitored and reviewed by the governing body of the hospital, and the court
held that a hospital would be negligent where it had knowledge or reason to believe that a doctor
using the facilities was employing a method of treatment or care which fell below the recognized
standard of care.
Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hospital has certain
inherent responsibilities regarding the quality of medical care furnished to patients within its walls
and it must meet the standards of responsibility commensurate with this undertaking. Beeck v.
Tucson General Hospital, 18 Ariz. App. 165, 500 P. 2d 1153 (1972). This court has confirmed the
rulings of the Court of Appeals that a hospital has the duty of supervising the competence of the
doctors on its staff. x x x.
x

In the amended complaint, the plaintiffs did plead that the operation was performed at the hospital
with its knowledge, aid, and assistance, and that the negligence of the defendants was the
proximate cause of the patients injuries. We find that such general allegations of negligence, along
with the evidence produced at the trial of this case, are sufficient to support the hospitals liability
based on the theory of negligent supervision."
Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for damages, let it be
emphasized that PSI, apart from a general denial of its responsibility, failed to adduce evidence
showing that it exercised the diligence of a good father of a family in the accreditation and
supervision of the latter. In neglecting to offer such proof, PSI failed to discharge its burden under
the last paragraph of Article 2180 cited earlier, and, therefore, must be adjudged solidarily liable with
Dr. Ampil. Moreover, as we have discussed, PSI is also directly liable to the Aganas.
One final word. Once a physician undertakes the treatment and care of a patient, the law imposes
on him certain obligations. In order to escape liability, he must possess that reasonable degree of
learning, skill and experience required by his profession. At the same time, he must apply
reasonable care and diligence in the exercise of his skill and the application of his knowledge, and
exert his best judgment.
WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of the Court of
Appeals in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198.
Costs against petitioners PSI and Dr. Miguel Ampil.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
THIRD DIVISION

G.R. No. 122445 November 18, 1997

DR. NINEVETCH CRUZ, petitioner,
vs.
COURT OF APPEALS and LYDIA UMALI, respondents.

FRANCISCO, J.:
Doctors are protected by a special rule of law. They are not guarantors of care. They do not even
warrant a good result. They are not insurers against mishaps or unusual consequences.
Furthermore they are not liable for honest mistakes of judgment . . . 1
The present case against petitioner is in the nature of a medical malpractice suit, which in simplest
terms is the type of claim which a victim has available to him or her to redress a wrong committed by
a medical professional which has caused bodily harm. 2 In this jurisdiction, however, such claims are
most often brought as a civil action for damages under Article 2176 of the Civil Code, 3 and in some
instances, as a criminal case under Article 365 of the Revised Penal Code 4 with which the civil action for
damages is impliedly instituted. It is via the latter type of action that the heirs of the deceased sought
redress for the petitioner's alleged imprudence and negligence in treating the deceased thereby causing
her death. The petitioner and one Dr. Lina Ercillo who was the attending anaesthesiologist during the
operation of the deceased were charged with "reckless imprudence and negligence resulting to (sic)
homicide" in an information which reads:

That on or about March 23, 1991, in the City of San Pablo, Republic of the
Philippines and within the jurisdiction of this Honorable Court, the accused above
named, being then the attending anaesthesiologist and surgeon, respectively, did
then and there, in a negligence (sic), careless, imprudent, and incompetent manner,
and failing to supply or store sufficient provisions and facilities necessary to meet any
and all exigencies apt to arise before, during and/or after a surgical operation
causing by such negligence, carelessness, imprudence, and incompetence, and
causing by such failure, including the lack of preparation and foresight needed to
avert a tragedy, the untimely death of said Lydia Umali on the day following said
surgical operation. 5
Trial ensued after both the petitioner and Dr. Lina Ercillo pleaded not guilty to the above-mentioned
charge. On March 4, 1994, the Municipal Trial Court in Cities (MTCC) of San Pablo City rendered a
decision, the dispositive portion of which is hereunder quoted as follows:
WHEREFORE, the court finds the accused Dra. Lina Ercillo not guilty of the offense
charged for insufficiency of evidence while her co-accused Dra. Ninevetch Cruz is
hereby held responsible for the death of Lydia Umali on March 24, 1991, and
therefore guilty under Art. 365 of the Revised Penal Code, and she is hereby

sentenced to suffer the penalty of 2 months and 1 day imprisonment of arresto mayor
with costs. 6
The petitioner appealed her conviction to the Regional Trial Court (RTC) which affirmed in
toto the decision of the MTCC 7 prompting the petitioner to file a petition for review with the
Court of Appeals but to no avail. Hence this petition for review on certiorari assailing the decision
promulgated by the Court of Appeals on October 24, 1995 affirming petitioner's conviction with
modification that she is further directed to pay the heirs of Lydia Umali P50,000.00 as indemnity
for her death. 8

In substance, the petition brought before this Court raises the issue of whether or not
petitioner's conviction of the crime of reckless imprudence resulting in homicide, arising from
an alleged medical malpractice, is supported by the evidence on record.
First the antecedent facts.
On March 22, 1991, prosecution witness, Rowena Umali De Ocampo, accompanied her mother to
the Perpetual Help Clinic and General Hospital situated in Balagtas Street, San Pablo City, Laguna.
They arrived at the said hospital at around 4:30 in the afternoon of the same day. 9 Prior to
March 22, 1991, Lydia was examined by the petitioner who found a "myoma" 10 in her uterus, and
scheduled her for a hysterectomy operation on March 23,
1991. 11 Rowena and her mother slept in the clinic on the evening of March 22, 1991 as the latter was to
be operated on the next day at 1:00 o'clock in the afternoon. 12 According to Rowena, she noticed that the
clinic was untidy and the window and the floor were very dusty prompting her to ask the attendant for a
rag to wipe the window and the floor with. 13 Because of the untidy state of the clinic, Rowena tried to
persuade her mother not to proceed with the operation. 14 The following day, before her mother was
wheeled into the operating room, Rowena asked the petitioner if the operation could be postponed. The
petitioner called Lydia into her office and the two had a conversation. Lydia then informed Rowena that
the petitioner told her that she must be operated on as scheduled. 15

Rowena and her other relatives, namely her husband, her sister and two aunts waited outside the
operating room while Lydia underwent operation. While they were waiting, Dr. Ercillo went out of the
operating room and instructed them to buy tagamet ampules which Rowena's sister immediately
bought. About one hour had passed when Dr. Ercillo came out again this time to ask them to buy
blood for Lydia. They bought type "A" blood from the St. Gerald Blood Bank and the same was
brought by the attendant into the operating room. After the lapse of a few hours, the petitioner
informed them that the operation was finished. The operating staff then went inside the petitioner's
clinic to take their snacks. Some thirty minutes after, Lydia was brought out of the operating room in
a stretcher and the petitioner asked Rowena and the other relatives to buy additional blood for Lydia.
Unfortunately, they were not able to comply with petitioner's order as there was no more type "A"
blood available in the blood bank. Thereafter, a person arrived to donate blood which was later
transfused to Lydia. Rowena then noticed her mother, who was attached to an oxygen tank, gasping
for breath. Apparently the oxygen supply had run out and Rowena's husband together with the driver
of the accused had to go to the San Pablo District Hospital to get oxygen. Lydia was given the fresh
supply of oxygen as soon as it arrived. 16 But at around 10:00 o'clock P.M. she went into shock and her
blood pressure dropped to 60/50. Lydia's unstable condition necessitated her transfer to the San Pablo
District Hospital so she could be connected to a respirator and further examined. 17 The transfer to the
San Pablo District Hospital was without the prior consent of Rowena nor of the other relatives present
who found out about the intended transfer only when an ambulance arrived to take Lydia to the San
Pablo District Hospital. Rowena and her other relatives then boarded a tricycle and followed the
ambulance. 18

Upon Lydia's arrival at the San Pablo District Hospital, she was wheeled into the operating room and
the petitioner and Dr. Ercillo re-operated on her because there was blood oozing from the abdominal
incision. 19 The attending physicians summoned Dr. Bartolome Angeles, head of the Obstetrics and
Gynecology Department of the San Pablo District Hospital. However, when Dr. Angeles arrived, Lydia
was already in shock and possibly dead as her blood pressure was already 0/0. Dr. Angeles then
informed petitioner and Dr. Ercillo that there was nothing he could do to help save the patient. 20 While the
petitioner was closing the abdominal wall, the patient died. 21 Thus, on March 24, 1991, at 3:00 o'clock in
the morning, Lydia Umali was pronounced dead. Her death certificate states "shock" as the immediate
cause of death and "Disseminated Intravascular Coagulation (DIC)" as the antecedent cause. 22

In convicting the petitioner, the MTCC found the following circumstances as sufficient basis to
conclude that she was indeed negligent in the performance of the operation:
. . . , the clinic was untidy, there was lack of provision like blood and oxygen to
prepare for any contingency that might happen during the operation. The manner
and the fact that the patient was brought to the San Pablo District Hospital for
reoperation indicates that there was something wrong in the manner in which Dra.
Cruz conducted the operation. There was no showing that before the operation,
accused Dra. Cruz had conducted a cardio pulmonary clearance or any typing of the
blood of the patient. It was (sic) said in medical parlance that the "the abdomen of the
person is a temple of surprises" because you do not know the whole thing the
moment it was open (sic) and surgeon must be prepared for any eventuality thereof.
The patient (sic) chart which is a public document was not presented because it is
only there that we could determine the condition of the patient before the surgery.
The court also noticed in Exh. "F-1" that the sister of the deceased wished to
postpone the operation but the patient was prevailed upon by Dra. Cruz to proceed
with the surgery. The court finds that Lydia Umali died because of the negligence
and carelessness of the surgeon Dra. Ninevetch Cruz because of loss of blood
during the operation of the deceased for evident unpreparedness and for lack of skill,
the reason why the patient was brought for operation at the San Pablo City District
Hospital. As such, the surgeon should answer for such negligence. With respect to
Dra. Lina Ercillo, the anaesthesiologist, there is no evidence to indicate that she
should be held jointly liable with Dra. Cruz who actually did the operation. 23
The RTC reiterated the abovementioned findings of the MTCC and upheld the latter's declaration of
"incompetency, negligence and lack of foresight and skill of appellant (herein petitioner) in handling
the subject patient before and after the operation." 24 And likewise affirming the petitioner's conviction,
the Court of Appeals echoed similar observations, thus:

. . . While we may grant that the untidiness and filthiness of the clinic may not by
itself indicate negligence, it nevertheless shows the absence of due care and
supervision over her subordinate employees. Did this unsanitary condition permeate
the operating room? Were the surgical instruments properly sterilized? Could the
conditions in the OR have contributed to the infection of the patient? Only the
petitioner could answer these, but she opted not to testify. This could only give rise to
the presumption that she has nothing good to testify on her defense. Anyway, the
alleged "unverified statement of the prosecution witness" remains unchallenged and
unrebutted.
Likewise undisputed is the prosecution's version indicating the following facts: that
the accused asked the patient's relatives to buy Tagamet capsules while the
operation was already in progress; that after an hour, they were also asked to buy
type "A" blood for the patient; that after the surgery, they were again asked to

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

Immediately apparent from a review of the records of this case is the absence of any expert
testimony on the matter of the standard of care employed by other physicians of good standing in
the conduct of similar operations. The prosecution's expert witnesses in the persons of Dr. Floresto
Arizala and Dr. Nieto Salvador, Jr. of the National Bureau of Investigation (NBI) only testified as to
the possible cause of death but did not venture to illuminate the court on the matter of the standard
of care that petitioner should have exercised.

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

Even granting arguendo that the inadequacy of the facilities and untidiness of the clinic; the lack of
provisions; the failure to conduct pre-operation tests on the patient; and the subsequent transfer of
Lydia to the San Pablo Hospital and the reoperation performed on her by the petitioner do indicate,
even without expert testimony, that petitioner was recklessly imprudent in the exercise of her duties
as a surgeon, no cogent proof exists that any of these circumstances caused petitioner's death.
Thus, the absence of the fourth element of reckless imprudence: that the injury to the person or
property was a consequence of the reckless imprudence.
In litigations involving medical negligence, the plaintiff has the burden of establishing appellant's
negligence and for a reasonable conclusion of negligence, there must be proof of breach of duty on
the part of the surgeon as well as a causal connection of such breach and the resulting death of his
patient. 33 In Chan Lugay v. St. Luke's Hospital, Inc., 34 where the attending physician was absolved of
liability for the death of the complainant's wife and newborn baby, this Court held that:

In order that there may be a recovery for an injury, however, it must be shown that
the "injury for which recovery is sought must be the legitimate consequence of the
wrong done; the connection between the negligence and the injury must be a direct
and natural sequence of events, unbroken by intervening efficient causes." In other
words, the negligence must be the proximate cause of the injury. For, "negligence,
no matter in what it consists, cannot create a right of action unless it is the proximate
cause of the injury complained of ." And "the proximate cause of an injury is that
cause, which, in natural and continuous sequence, unbroken by any efficient
intervening cause, produces the injury, and without which the result would not have
occurred." 35 (Emphasis supplied.)
Dr. Arizala who conducted an autopsy on the body of the deceased summarized his findings as
follows:
Atty. Cachero:
Q. You mentioned about your Autopsy Report which has been
marked as Exh. "A-1-b". There appears here a signature above the
typewritten name Floresto Arizala, Jr., whose signature is that?

A. That is my signature, sir.

Q. Do you affirm the truth of all the contents of Exh. "A-1-b"?
A. Only as to the autopsy report no. 91-09, the time and place and
everything after the post mortem findings, sir.
Q. You mentioned on your "Post Mortem Findings" about surgical
incision, 14:0 cm., infraumbilical area, anterior abdominal area,
midline, will you please explain that in your own language?
A. There was incision wound (sic) the area just below the navel, sir.
Q. And the last paragraph of the postmortem findings which I read:
Uterus, pear-shaped and pale measuring 7.5 x 5.5 x 5.0 cm. with
some surface nodulation of the fundic area posteriorly. Cut-section
shows diffusely pale myometrium with areas of streak induration. The
ovaries and adnexal structures are missing with the raw surfaces
patched with clotted blood. Surgical sutures were noted on the
operative site.
Intestines and mesenteries are pale with blood clots noted between
the mesentric folds.
Hemoperitoneum: 300 s.s.,
right paracolic gutter,
50 c.c., left paracolic gutter
200 c.c., mesentric area,
100 c.c., right pelvic gutter
stomach empty.
Other visceral organs, pale.,
will you please explain that on (sic) your own language or in ordinary. . . . . . . . . . . .
A. There was a uterus which was not attached to the adnexal
structures namely ovaries which were not present and also sign of
previous surgical operation and there were (sic) clotted blood, sir.
Q. How about the ovaries and adnexal structures?
A. They are missing, sir.
Q. You mean to say there are no ovaries?
A. During that time there are no ovaries, sir.
Q. And there were likewise sign of surgical sutures?
A. Yes, sir.

Q. How about the intestines and mesenteries are place (sic) with
blood clots noted between the mesenteric folds, will you please
explain on (sic) this?
A. In the peritoneal cavity, they are mostly perritonial blood . . . . . . . .
Q. And what could have caused this blood?
A. Well, ordinarily blood is found inside the blood vessel. Blood were
(sic) outside as a result of the injuries which destroyed the integrity of
the vessel allowing blood to sip (sic) out, sir.
Q. By the nature of the postmortem findings indicated in Exh. A-1-B,
can you tell the court the cause of death?
A. Yes, sir. The cause of death is: Gross findings are compatible with
hemorrhagic shock.
Q. Can you tell the us what could have caused this hemorrhagic
shock?
A. Well hemorrhagic shock is the result of blood loss.
Q. What could have the effect of that loss of blood?
A. Unattended hemorrhage, sir. 36 (Emphasis supplied.)
The foregoing was corroborated by Dr. Nieto Salvador:
Q. And were you able to determine the cause of death by virtue of the
examination of the specimen submitted by Dr. Arizala?
A. Without knowledge of the autopsy findings it would be difficult for
me to determine the cause of death, sir.
Q. Have you also examined the post mortem of Dr. Arizala?
A. Yes, sir, and by virtue of the autopsy report in connection with your
pathology report.
Q. What could have caused the death of the victim?
A. This pathologic examination are (sic) compatible with the person
who died, sir.
Q. Will you explain to us the meaning of hemorrhagic compatible?
A. It means that a person died of blood loss. Meaning a person died
of non-replacement of blood and so the victim before she died there

was shock of diminish of blood of the circulation. She died most

probably before the actual complete blood loss, sir.
Court: Is it possible doctor that the loss of the blood was due on (sic)
operation?
A. Based on my pathologist finding, sir.
Q. What could have caused this loss of blood?
A. Many, sir. A patient who have undergone surgery. Another may be
a blood vessel may be cut while on operation and this cause (sic)
bleeding, or may be set in the course of operation, or may be (sic) he
died after the operation. Of course there are other cause (sic).
Atty. Cachero:
Q. Especially so doctor when there was no blood replacement?
A. Yes, sir. 37 (Emphasis supplied.)
The testimonies of both doctors establish hemorrhage or hemorrhagic shock as the cause of death.
However, as likewise testified to by the expert witnesses in open court, hemorrhage or hemorrhagic
shock during surgery may be caused by several different factors. Thus, Dr. Salvador's elaboration on
the matter:
Atty. Pascual:
Q. Doctor, among the causes of hemorrhage that you mentioned you
said that it could be at the moment of operation when one losses (sic)
control of the presence, is that correct? During the operation there is
lost (sic) of control of the cut vessel?
A. Yes, sir.
Q. Or there is a failure to ligate a vessel of considerable size?
A. Yes, sir.
Q. Or even if the vessel were ligated the knot may have slipped later
on?
A. Yes, sir.
Q. And you also mentioned that it may be possible also to some
clotting defect, is that correct?
A. May be (sic). 38 (Emphasis supplied).
Defense witness, Dr. Bu C. Castro also gave the following expert opinion:

Q. Doctor even a patient after an operations (sic) would suffer

hemorrage what would be the possible causes of such hemorrage
(sic)?
A. Among those would be what we call Intravascular Coagulation and
this is the reason for the bleeding, sir, which cannot be prevented by
anyone, it will happen to anyone, anytime and to any persons (sic),
sir.
COURT:
What do you think of the cause of the bleeding, the cutting or the
operations done in the body?
A. Not related to this one, the bleeding here is not related to any
cutting or operation that I (sic) have done.
Q. Aside from the DIC what could another causes (sic) that could be
the cause for the hemorrhage or bleeding in a patient by an
operations (sic)?
A. In general sir, if there was an operations (sic) and it is possible that
the ligature in the suture was (sic) become (sic) loose, it is (sic)
becomes loose if proven..
xxx xxx xxx
Q. If the person who performed an autopsy does not find any untight
(sic) clot (sic) blood vessel or any suture that become (sic) loose the
cause of the bleeding could not be attributed to the fault of the
subject?
A. Definitely, sir. 39 (Emphasis supplied.)
According to both doctors, the possible causes of hemorrhage during an operation are: (1) the failure
of the surgeon to tie or suture a cut blood vessel; (2) allowing a cut blood vessel to get out of control;
(3) the subsequent loosening of the tie or suture applied to a cut blood vessel; and (4) and a clotting
defect known as DIC. It is significant to state at this juncture that the autopsy conducted by Dr.
Arizala on the body of Lydia did not reveal any untied or unsutured cut blood vessel nor was there
any indication that the tie or suture of a cut blood vessel had become loose thereby causing the
hemorrhage. 40 Hence the following pertinent portion of Dr. Arizala's testimony:
Q: Doctor, in examining these structures did you know whether these
were sutured ligature or plain ligature
A: Ligature, sir.
Q: We will explain that later on. Did you recall if the cut structures
were tied by first suturing it and then tying a knot or the tie was
merely placed around the cut structure and tied?

A: I cannot recall, sir.

Q: As a matter of fact, you cannot recall because you did not even
bothered (sic) to examine, is that correct?
A: Well, I bothered enough to know that they were sutured, sir.
Q: So, therefore, Doctor, you would not know whether any of the cut
structures were not sutured or tied neither were you able to determine
whether any loose suture was found in the peritoneal cavity?
A: I could not recall any loose sutured (sic), sir. 41
On the other hand, the findings of all three doctors do not preclude the probability that DIC caused
the hemorrhage and consequently, Lydia's death. DIC which is a clotting defect creates a serious
bleeding tendency and when massive DIC occurs as a complication of surgery leaving raw surface,
major hemorrhage occurs. 42And as testified to by defense witness, Dr. Bu C. Castro, hemorrhage due
to DIC "cannot be prevented, it will happen to anyone,
anytime." 43 He testified further:

Q. Now, under that circumstance one of the possibility as you

mentioned in (sic) DIC?
A. Yes, sir.
Q. And you mentioned that this cannot be prevented?
A. Yes, sir.
Q. Can you even predict if it really happen (sic)?
A. Possible, sir.
Q. Are there any specific findings of autopsy that will tell you whether
this patient suffered among such things as DIC?
A. Well, I did reserve because of the condition of the patient.
Q. Now, Doctor you said that you went through the record of the
deceased Lydia Umali looking for the chart, the operated (sic)
records, the post mortem findings on the histophanic (sic)
examination based on your examination of record, doctor, can you
more or less says (sic) what part are (sic) concerned could have been
the caused (sic) of death of this Lydia Umali?
A. As far as the medical record is concern (sic) the caused (sic) of
death is dessimulated (sic) Intra Vascular Coagulation or the DIC
which resulted to hemorrhage or bleedings, sir.
Q. Doctor based on your findings then there is knowing (sic) the
doctor would say whether the doctor her (sic) has been (sic) fault?

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

WHEREFORE, premises considered, petitioner DR. NINEVETCH CRUZ is hereby ACQUITTED of

the crime of reckless imprudence resulting in homicide but is ordered to pay the heirs of the
deceased Lydia Umali the amount of FIFTY THOUSAND PESOS (P50,000.00) as civil liability, ONE
HUNDRED THOUSAND PESOS (P100,000.00) as moral damages, and FIFTY THOUSAND
PESOS (P50,000.00) as exemplary damages.

Let a copy of this decision be furnished to the Professional Regulation Commission (PRC) for
appropriate action.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
SECOND DIVISION
G.R. No. 158996

November 14, 2008

SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA FLORES, petitioners,

vs.
SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO, and FLORENCIO, CANDIDA,
MARTA, GODOFREDO, BALTAZAR and LUCENA, all surnamed PINEDA, as heirs of the
deceased TERESITA S. PINEDA, and UNITED DOCTORS MEDICAL CENTER,
INC., respondents.
DECISION
BRION, J.:
This petition involves a medical negligence case that was elevated to this Court through an
appeal bycertiorari under Rule 45 of the Rules of Court. The petition assails the Decision 1 of the
Court of Appeals (CA) in CA G.R. CV No. 63234, which affirmed with modification the
Decision2 of the Regional Trial Court (RTC) of Nueva Ecija, Branch 37 in Civil Case No. SD1233. The dispositive portion of the assailed CA decision states:
WHEREFORE, premises considered, the assailed Decision of the Regional Trial Court
of Baloc, Sto. Domingo, Nueva Ecija, Branch 37 is hereby AFFIRMED but with
modifications as follows:
1) Ordering defendant-appellants Dr. and Dra. Fredelicto A. Flores and the
United Doctors Medical Center, Inc. to jointly and severally pay the plaintiffappellees - heirs of Teresita Pineda, namely, Spouses Dominador Pineda and
Virginia Saclolo and Florencio, Candida, Marta, Godofredo, Baltazar and Lucena,
all surnamed Pineda, the sum of P400,000.00 by way of moral damages;
2) Ordering the above-named defendant-appellants to jointly and severally pay
the above-named plaintiff-appellees the sum of P100,000.00 by way of
exemplary damages;
3) Ordering the above-named defendant-appellants to jointly and severally pay
the above-named plaintiff-appellees the sum of P36,000.00 by way of actual and
compensatory damages; and
4) Deleting the award of attorney's fees and costs of suit.
SO ORDERED.

While this case essentially involves questions of facts, we opted for the requested review in light
of questions we have on the findings of negligence below, on the awarded damages and costs,
and on the importance of this type of ruling on medical practice.3
BACKGROUND FACTS
Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto. Domingo, Nueva
Ecija. She consulted on April 17, 1987 her townmate, Dr. Fredelicto Flores, regarding her
medical condition. She complained of general body weakness, loss of appetite, frequent
urination and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto initially interviewed the
patient and asked for the history of her monthly period to analyze the probable cause of the
vaginal bleeding. He advised her to return the following week or to go to the United Doctors
Medical Center (UDMC) in Quezon City for a general check-up. As for her other symptoms, he
suspected that Teresita might be suffering from diabetes and told her to continue her
medications.4
Teresita did not return the next week as advised. However, when her condition persisted, she
went to further consult Dr. Flores at his UDMC clinic on April 28, 1987, travelling for at least two
hours from Nueva Ecija to Quezon City with her sister, Lucena Pineda. They arrived at UDMC
at around 11:15 a.m.. Lucena later testified that her sister was then so weak that she had to lie
down on the couch of the clinic while they waited for the doctor. When Dr. Fredelicto arrived, he
did a routine check-up and ordered Teresita's admission to the hospital. In the admission slip,
he directed the hospital staff to prepare the patient for an "on call" D&C5 operation to be
performed by his wife, Dr. Felicisima Flores (Dr. Felicisima). Teresita was brought to her
hospital room at around 12 noon; the hospital staff forthwith took her blood and urine samples
for the laboratory tests6 which Dr. Fredelicto ordered.
At 2:40 p.m. of that same day, Teresita was taken to the operating room. It was only then that
she met Dr. Felicisima, an obstetrician and gynecologist. The two doctors - Dr. Felicisima and
Dr. Fredelicto, conferred on the patient's medical condition, while the resident physician and the
medical intern gave Dr. Felicisima their own briefings. She also interviewed and conducted an
internal vaginal examination of the patient which lasted for about 15 minutes. Dr. Felicisima
thereafter called up the laboratory for the results of the tests. At that time, only the results for the
blood sugar (BS), uric acid determination, cholesterol determination, and complete blood count
(CBC) were available. Teresita's BS count was 10.67mmol/l7 and her CBC was 109g/l.8
Based on these preparations, Dr. Felicisima proceeded with the D&C operation with Dr.
Fredelicto administering the general anesthesia. The D&C operation lasted for about 10 to 15
minutes. By 3:40 p.m., Teresita was wheeled back to her room.
A day after the operation (or on April 29, 1987), Teresita was subjected to an ultrasound
examination as a confirmatory procedure. The results showed that she had an enlarged uterus
and myoma uteri.9Dr. Felicisima, however, advised Teresita that she could spend her recovery
period at home. Still feeling weak, Teresita opted for hospital confinement.
Teresita's complete laboratory examination results came only on that day (April 29, 1987).
Teresita's urinalysis showed a three plus sign (+++) indicating that the sugar in her urine was
very high. She was then placed under the care of Dr. Amado Jorge, an internist.

By April 30, 1987, Teresita's condition had worsened. She experienced difficulty in breathing
and was rushed to the intensive care unit. Further tests confirmed that she was suffering
from Diabetes Mellitus Type II.10 Insulin was administered on the patient, but the medication
might have arrived too late. Due to complications induced by diabetes, Teresita died in the
morning of May 6, 1987.11
Believing that Teresita's death resulted from the negligent handling of her medical needs, her
family (respondents) instituted an action for damages against Dr. Fredelicto Flores and Dr.
Felicisima Flores (collectively referred to as the petitioner spouses) before the RTC of Nueva
Ecija.
The RTC ruled in favor of Teresita's family and awarded actual, moral, and exemplary damages,
plus attorney's fees and costs.12 The CA affirmed the judgment, but modified the amount of
damages awarded and deleted the award for attorney's fees and costs of suit.13
Through this petition for review on certiorari, the petitioner spouses -Dr. Fredelicto (now
deceased) and Dr. Felicisima Flores - allege that the RTC and CA committed a reversible error
in finding them liable through negligence for the death of Teresita Pineda.
ASSIGNMENT OF ERRORS
The petitioner spouses contend that they exercised due care and prudence in the performance
of their duties as medical professionals. They had attended to the patient to the best of their
abilities and undertook the management of her case based on her complaint of an on-and-off
vaginal bleeding. In addition, they claim that nothing on record shows that the death of Teresita
could have been averted had they employed means other than what they had adopted in the
ministration of the patient.
THE COURT'S RULING
We do not find the petition meritorious.
The respondents' claim for damages is predicated on their allegation that the decision of the
petitioner spouses to proceed with the D&C operation, notwithstanding Teresita's condition and
the laboratory test results, amounted to negligence. On the other hand, the petitioner spouses
contend that a D&C operation is the proper and accepted procedure to address vaginal bleeding
- the medical problem presented to them. Given that the patient died after the D&C, the core
issue is whether the decision to proceed with the D&C operation was an honest mistake of
judgment or one amounting to negligence.
Elements of a Medical Negligence Case
A medical negligence case is a type of claim to redress a wrong committed by a medical
professional, that has caused bodily harm to or the death of a patient. There are four elements
involved in a medical negligence case, namely: duty, breach, injury, and proximate causation.14
Duty refers to the standard of behavior which imposes restrictions on one's conduct.15 The
standard in turn refers to the amount of competence associated with the proper discharge of the
profession. A physician is expected to use at least the same level of care that any other
reasonably competent doctor would use under the same circumstances. Breach of duty occurs

when the physician fails to comply with these professional standards. If injury results to the
patient as a result of this breach, the physician is answerable for negligence. 16
As in any civil action, the burden to prove the existence of the necessary elements rests with the
plaintiff.17 To successfully pursue a claim, the plaintiff must prove by preponderance of evidence
that,one, the physician either failed to do something which a reasonably prudent health care
provider would have done, or that he did something that a reasonably prudent provider would
not have done; and two, the failure or action caused injury to the patient.18 Expert testimony is
therefore essential since the factual issue of whether a physician or surgeon has exercised the
requisite degree of skill and care in the treatment of his patient is generally a matter of expert
opinion.19
Standard of Care and Breach of Duty
D&C is the classic gynecologic procedure for the evaluation and possible therapeutic treatment
for abnormal vaginal bleeding.20 That this is the recognized procedure is confirmed by Drs.
Salvador Nieto (Dr. Nieto) and Joselito Mercado (Dr. Mercado), the expert witnesses presented
by the respondents:
DR. NIETO: [W]hat I know among obstetricians, if there is bleeding, they perform what
we call D&C for diagnostic purposes.
xxx xxx xxx
Q: So are you trying to tell the Court that D&C can be a diagnostic treatment?
A: Yes, sir. Any doctor knows this.21
Dr. Mercado, however, objected with respect to the time the D&C operation should have been
conducted in Teresita's case. He opined that given the blood sugar level of Teresita, her
diabetic condition should have been addressed first:
Q: Why do you consider the time of performance of the D&C not appropriate?
A: Because I have read the record and I have seen the urinalysis, [there is] spillage in
the urine, and blood sugar was 10.67
Q: What is the significance of the spillage in the urine?
A: It is a sign that the blood sugar is very high.
Q: Does it indicate sickness?
A: 80 to 95% it means diabetes mellitus. The blood sugar was 10.67.
xxx xxx xxx
COURT: In other words, the operation conducted on the patient, your opinion, that it is
inappropriate?

A: The timing of [when] the D&C [was] done, based on the record, in my personal
opinion, that D&C should be postponed a day or two.22
The petitioner spouses countered that, at the time of the operation, there was nothing to indicate
that Teresita was afflicted with diabetes: a blood sugar level of 10.67mmol/l did not necessarily
mean that she was a diabetic considering that this was random blood sugar;23 there were
other factors that might have caused Teresita's blood sugar to rise such as the taking of blood
samples during lunchtime and while patient was being given intra-venous
dextrose.24 Furthermore, they claim that their principal concern was to determine the cause of
and to stop the vaginal bleeding.
The petitioner spouses' contentions, in our view, miss several points. First, as early as April 17,
1987, Teresita was already suspected to be suffering from diabetes.25 This suspicion again
arose rightbefore the D&C operation on April 28, 1987 when the laboratory result revealed
Teresita's increased blood sugar level.26 Unfortunately, the petitioner spouses did not wait for
the full medical laboratory results before proceeding with the D&C, a fact that was never
considered in the courts below.Second, the petitioner spouses were duly advised that the
patient was experiencing general body weakness, loss of appetite, frequent urination, and thirst
- all of which are classic symptoms of diabetes.27 When a patient exhibits symptoms typical of a
particular disease, these symptoms should, at the very least, alert the physician of the possibility
that the patient may be afflicted with the suspected disease:
Expert testimony for the plaintiff showed that] tests should have been ordered immediately on admission to the hospital in view of the
symptoms presented, and that failure to recognize the existence of diabetes constitutes negligence.28

Third, the petitioner spouses cannot claim that their principal concern was the vaginal bleeding
and should not therefore be held accountable for complications coming from other sources. This
is a very narrow and self-serving view that even reflects on their competence.
Taken together, we find that reasonable prudence would have shown that diabetes and its
complications were foreseeable harm that should have been taken into consideration by the
petitioner spouses. If a patient suffers from some disability that increases the magnitude
of risk to him, that disability must be taken into account so long as it is or should have
been known to the physician.29 And when the patient is exposed to an increased risk, it is
incumbent upon the physician to take commensurate and adequate precautions.
Taking into account Teresita's high blood sugar,30 Dr. Mendoza opined that the attending
physician should have postponed the D&C operation in order to conduct a confirmatory test to
make a conclusive diagnosis of diabetes and to refer the case to an internist or diabetologist.
This was corroborated by Dr. Delfin Tan (Dr. Tan), an obstetrician and gynecologist, who stated
that the patient's diabetes should have been managed by an internist prior to, during, and
after the operation.31
Apart from bleeding as a complication of pregnancy, vaginal bleeding is only rarely so heavy
and life-threatening that urgent first-aid measures are required.32 Indeed, the expert witnesses
declared that a D&C operation on a hyperglycemic patient may be justified only when it is an
emergency case - when there is profuse vaginal bleeding. In this case, we choose not to rely on
the assertions of the petitioner spouses that there was profuse bleeding, not only because the
statements were self-serving, but also because the petitioner spouses were inconsistent in their
testimonies. Dr. Fredelicto testified earlier that on April 28, he personally saw the bleeding, 33 but

later on said that he did not see it and relied only on Teresita's statement that she was
bleeding.34 He went on to state that he scheduled the D&C operation without conducting any
physical examination on the patient.
The likely story is that although Teresita experienced vaginal bleeding on April 28, it was not
sufficiently profuse to necessitate an immediate emergency D&C operation. Dr. Tan 35 and Dr.
Mendoza36 both testified that the medical records of Teresita failed to indicate that there was
profuse vaginal bleeding. The claim that there was profuse vaginal bleeding although this was
not reflected in the medical records strikes us as odd since the main complaint is vaginal
bleeding. A medical record is the only document that maintains a long-term transcription of
patient care and as such, its maintenance is considered a priority in hospital practice. Optimal
record-keeping includes all patient inter-actions. The records should always be clear, objective,
and up-to-date.37 Thus, a medical record that does not indicate profuse medical bleeding
speaks loudly and clearly of what it does not contain.
That the D&C operation was conducted principally to diagnose the cause of the vaginal bleeding
further leads us to conclude that it was merely an elective procedure, not an emergency case. In
an elective procedure, the physician must conduct a thorough pre-operative evaluation of the
patient in order to adequately prepare her for the operation and minimize possible risks and
complications. The internist is responsible for generating a comprehensive evaluation of all
medical problems during the pre-operative evaluation.38
The aim of pre-operative evaluation is not to screen broadly for undiagnosed disease,
but rather to identify and quantify comorbidity that may impact on the operative outcome.
This evaluation is driven by findings on history and physical examination suggestive of
organ system dysfunctionThe goal is to uncover problem areas that may require
further investigation or be amenable to preoperative optimization.
If the preoperative evaluation uncovers significant comorbidity or evidence of poor
control of an underlying disease process, consultation with an internist or medical
specialist may be required to facilitate the work-up and direct management. In this
process, communication between the surgeons and the consultants is essential to define
realistic goals for this optimization process and to expedite surgical
management.39 [Emphasis supplied.]
Significantly, the evidence strongly suggests that the pre-operative evaluation was less than
complete as the laboratory results were fully reported only on the day following the D&C
operation. Dr. Felicisima only secured a telephone report of the preliminary laboratory result
prior to the D&C. This preliminary report did not include the 3+ status of sugar in the patient's
urine40 - a result highly confirmatory of diabetes.
Because the D&C was merely an elective procedure, the patient's uncontrolled hyperglycemia
presented a far greater risk than her on-and-off vaginal bleeding. The presence of
hyperglycemia in a surgical patient is associated with poor clinical outcomes, and aggressive
glycemic control positively impacts on morbidity and mortality. 41 Elective surgery in people with
uncontrolled diabetes should preferably be scheduled after acceptable glycemic control has
been achieved.42 According to Dr. Mercado, this is done by administering insulin on the
patient.43

The management approach in this kind of patients always includes insulin therapy in
combination with dextrose and potassium infusion. Insulin xxx promotes glucose uptake
by the muscle and fat cells while decreasing glucose production by the liver xxx. The net
effect is to lower blood glucose levels.44
The prudent move is to address the patient's hyperglycemic state immediately and promptly
before any other procedure is undertaken. In this case, there was no evidence that insulin was
administered on Teresita prior to or during the D&C operation. Insulin was only administered
two days after the operation.
As Dr. Tan testified, the patient's hyperglycemic condition should have been managed not only
before and during the operation, but also immediately after. Despite the possibility that Teresita
was afflicted with diabetes, the possibility was casually ignored even in the post-operative
evaluation of the patient; the concern, as the petitioner spouses expressly admitted, was limited
to the complaint of vaginal bleeding. Interestingly, while the ultrasound test confirmed that
Teresita had a myoma in her uterus, she was advised that she could be discharged a day after
the operation and that her recovery could take place at home. This advice implied that a day
after the operation and even after the complete laboratory results were submitted, the petitioner
spouses still did not recognize any post-operative concern that would require the monitoring of
Teresita's condition in the hospital.
The above facts, point only to one conclusion - that the petitioner spouses failed, as medical
professionals, to comply with their duty to observe the standard of care to be given to
hyperglycemic/diabetic patients undergoing surgery. Whether this breach of duty was the
proximate cause of Teresita's death is a matter we shall next determine.
Injury and Causation
As previously mentioned, the critical and clinching factor in a medical negligence case is proof
of thecausal connection between the negligence which the evidence established and the
plaintiff's injuries;45 the plaintiff must plead and prove not only that he had been injured and
defendant has been at fault, but also that the defendant's fault caused the injury. A verdict in a
malpractice action cannot be based on speculation or conjecture. Causation must be proven
within a reasonable medical probability based upon competent expert testimony. 46
The respondents contend that unnecessarily subjecting Teresita to a D&C operation without
adequately preparing her, aggravated her hyperglycemic state and caused her untimely demise.
The death certificate of Teresita lists down the following causes of death:
Immediate cause:

Cardiorespiratory arrest

Antecedent cause:

Septicemic shock,ketoacidocis

Underlying cause:

Diabetes Mellitus II

Other significant conditions

contributing to death:

Renal Failure - Acute47

Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C operation
is a form of physical stress. Dr. Mendoza explained how surgical stress can aggravate the
patient's hyperglycemia: when stress occurs, the diabetic's body, especially the autonomic
system, reacts by secreting hormones which are counter-regulatory; she can have prolonged
hyperglycemia which, if unchecked, could lead to death.48 Medical literature further explains that
if the blood sugar has become very high, the patient becomes comatose (diabetic coma). When
this happens over several days, the body uses its own fat to produce energy, and the result is
high levels of waste products (called ketones) in the blood and urine (called diabetic
ketoacidiosis, a medical emergency with a significant mortality). 49 This was apparently what
happened in Teresita's case; in fact, after she had been referred to the internist Dr. Jorge,
laboratory test showed that her blood sugar level shot up to 14.0mmol/l, way above the normal
blood sugar range. Thus, between the D&C and death was the diabetic complication that could
have been prevented with the observance of standard medical precautions. The D&C operation
and Teresita's death due to aggravated diabetic condition is therefore sufficiently established.
The trial court and the appellate court pinned the liability for Teresita's death on both the
petitioner spouses and this Court finds no reason to rule otherwise. However, we clarify that Dr.
Fredelicto's negligence is not solely the act of ordering an "on call" D&C operation when he was
mainly ananaesthesiologist who had made a very cursory examination of the patient's vaginal
bleeding complaint. Rather, it was his failure from the very start to identify and confirm, despite
the patient's complaints and his own suspicions, that diabetes was a risk factor that should be
guarded against, and his participation in the imprudent decision to proceed with the D&C
operation despite his early suspicion and the confirmatory early laboratory results. The latter
point comes out clearly from the following exchange during the trial:
Q: On what aspect did you and your wife consult [with] each other?
A: We discussed on the finding of the laboratory [results] because the hemoglobin was
below normal, the blood sugar was elevated, so that we have to evaluate these
laboratory results - what it means.
Q: So it was you and your wife who made the evaluation when it was phoned in?
A: Yes, sir.
Q: Did your wife, before performing D&C ask your opinion whether or not she can
proceed?
A: Yes, anyway, she asked me whether we can do D&C based on my experience.
Q: And your answer was in the positive notwithstanding the elevation of blood
sugar?
A: Yes, sir, it was both our disposition to do the D&C. [Emphasis supplied.]50
If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not being an internist
or a diabetologist (for which reason he referred Teresita to Dr. Jorge),51 he should have likewise
refrained from making a decision to proceed with the D&C operation since he was niether an
obstetrician nor a gynecologist.

These findings lead us to the conclusion that the decision to proceed with the D&C operation,
notwithstanding Teresita's hyperglycemia and without adequately preparing her for the
procedure, was contrary to the standards observed by the medical profession. Deviation from
this standard amounted to a breach of duty which resulted in the patient's death. Due to this
negligent conduct, liability must attach to the petitioner spouses.
Liability of the Hospital
In the proceedings below, UDMC was the spouses Flores' co-defendant. The RTC found the
hospital jointly and severally liable with the petitioner spouses, which decision the CA affirmed.
In a Resolution dated August 28, 2006, this Court however denied UDMC's petition for review
on certiorari. Since UDMC's appeal has been denied and they are not parties to this case, we
find it unnecessary to delve on the matter. Consequently, the RTC's decision, as affirmed by the
CA, stands.
Award of Damages
Both the trial and the appellate court awarded actual damages as compensation for the
pecuniary loss the respondents suffered. The loss was presented in terms of the hospital bills
and expenses the respondents incurred on account of Teresita's confinement and death. The
settled rule is that a plaintiff is entitled to be compensated for proven pecuniary loss. 52 This
proof the respondents successfully presented. Thus, we affirm the award of actual
damages of P36,000.00 representing the hospital expenses the patient incurred.
In addition to the award for actual damages, the respondent heirs of Teresita are likewise
entitled toP50,000.00 as death indemnity pursuant to Article 2206 of the Civil Code, which
states that "the amount of damages for death caused by a xxx quasi-delict shall be at least
three thousand pesos,53even though there may have been mitigating circumstances xxx." This
is a question of law that the CA missed in its decision and which we now decide in the
respondents' favor.
The same article allows the recovery of moral damages in case of death caused by a quasidelict and enumerates the spouse, legitimate or illegitimate ascendants or descendants as the
persons entitled thereto. Moral damages are designed to compensate the claimant for the injury
suffered, that is, for the mental anguish, serious anxiety, wounded feelings which the
respondents herein must have surely felt with the unexpected loss of their daughter. We affirm
the appellate court's award ofP400,000.00 by way of moral damages to the respondents.
We similarly affirm the grant of exemplary damages. Exemplary damages are imposed by way
of example or correction for the public good.54 Because of the petitioner spouses' negligence in
subjecting Teresita to an operation without first recognizing and addressing her diabetic
condition, the appellate court awarded exemplary damages to the respondents in the amount
of P100,000.00. Public policy requires such imposition to suppress the wanton acts of an
offender.55 We therefore affirm the CA's award as an example to the medical profession and to
stress that the public good requires stricter measures to avoid the repetition of the type of
medical malpractice that happened in this case.
With the award of exemplary damages, the grant of attorney's fees is legally in order.56 We
therefore reverse the CA decision deleting these awards, and grant the respondents the amount
ofP100,000.00 as attorney's fees taking into consideration the legal route this case has taken.

WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003 in CA G.R. CV No.
63234 finding petitioner spouses liable for negligent medical practice. We likewise AFFIRM the
awards of actual and compensatory damages of P36,000.00; moral damages of P400,000.00;
and exemplary damages of P100,000.00.
We MODIFY the CA Decision by additionally granting an award of P50,000.00 as death
indemnity and by reversing the deletion of the award of attorney's fees and costs and restoring
the award ofP100,000.00 as attorney's fees. Costs of litigation are adjudged against petitioner
spouses.
To summarize, the following awards shall be paid to the family of the late Teresita Pineda:
1. The sum of P36,000.00 by way of actual and compensatory damages;
2. The sum of P50,000.00 by way of death indemnity;
3. The sum of P400,000.00 by way of moral damages;
4. The sum of P100,000.00 by way of exemplary damages;
5. The sum of P100,000.00 by way of attorney's fees; and
6. Costs.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
FIRST DIVISION
G.R. No. 192123

March 10, 2014

DR. FERNANDO P. SOLIDUM, Petitioner,

vs.
PEOPLE OF THE PHILIPPINES, Respondent.
DECISION
BERSAMIN, J.:
This appeal is taken by a physician-anesthesiologist who has been pronounced guilty of reckless
imprudence resulting in serious physical injuries by the Regional Trial Court (RTC) and the Court of
Appeals (CA). He had been part of the team of anesthesiologists during the surgical pull-through
operation conducted on a three-year old patient born with an imperforate anus. 1
The antecedents are as follows:
Gerald Albert Gercayo (Gerald) was born on June 2, 19922 with an imperforate anus. Two days after
his birth, Gerald underwent colostomy, a surgical procedure to bring one end of the large intestine
out through the abdominal wall,3 enabling him to excrete through a colostomy bag attached to the
side of his body.4
On May 17, 1995, Gerald, then three years old, was admitted at the Ospital ng Maynila for a pullthrough operation.5 Dr. Leandro Resurreccion headed the surgical team, and was assisted by Dr.
Joselito Luceo, Dr. Donatella Valea and Dr. Joseph Tibio. The anesthesiologists included Dr.
Marichu Abella, Dr. Arnel Razon and petitioner Dr. Fernando Solidum (Dr. Solidum). 6 During the
operation, Gerald experienced bradycardia,7 and went into a coma.8 His coma lasted for two
weeks,9 but he regained consciousness only after a month. 10 He could no longer see, hear or move.11
Agitated by her sons helpless and unexpected condition, Ma. Luz Gercayo (Luz) lodged a complaint
for reckless imprudence resulting in serious physical injuries with the City Prosecutors Office of
Manila against the attending physicians. 12
Upon a finding of probable cause, the City Prosecutors Office filed an information solely against Dr.
Solidum,13alleging:
That on or about May 17, 1995, in the City of Manila, Philippines, the said accused, being then an
anesthesiologist at the Ospital ng Maynila, Malate, this City, and as such was tasked to administer
the anesthesia on three-year old baby boy GERALD ALBERT GERCAYO, represented by his
mother, MA. LUZ GERCAYO, the former having been born with an imperforate anus [no anal
opening] and was to undergo an operation for anal opening [pull through operation], did then and
there willfully, unlawfully and feloniously fail and neglect to use the care and diligence as the best of
his judgment would dictate under said circumstance, by failing to monitor and regulate properly the
levels of anesthesia administered to said GERALD ALBERT GERCAYO and using 100% halothane
and other anesthetic medications, causing as a consequence of his said carelessness and

negligence, said GERALD ALBERT GERCAYO suffered a cardiac arrest and consequently a defect
called hypoxic encephalopathy meaning insufficient oxygen supply in the brain, thereby rendering
said GERALD ALBERT GERCAYO incapable of moving his body, seeing, speaking or hearing, to
his damage and prejudice.
Contrary to law.14
The case was initially filed in the Metropolitan Trial Court of Manila, but was transferred to the RTC
pursuant to Section 5 of Republic Act No. 8369 (The Family Courts Act of 1997),15 where it was
docketed as Criminal Case No. 01-190889.
Judgment of the RTC
On July 19, 2004, the RTC rendered its judgment finding Dr. Solidum guilty beyond reasonable
doubt of reckless imprudence resulting to serious physical injuries, 16 decreeing:
WHEREFORE, premises considered, the Court finds accused DR. FERNANDO P. SOLIDUM
GUILTY beyond reasonable doubt as principal of the crime charged and is hereby sentenced to
suffer the indeterminate penalty of TWO (2) MONTHS and ONE (1) DAY of arresto mayor as
minimum to ONE (1) YEAR, ONE (1) MONTH and TEN (10) DAYS of prision correccional as
maximum and to indemnify, jointly and severally with the Ospital ng Maynila, Dr. Anita So and Dr.
Marichu Abella, private complainant Luz Gercayo, the amount of P500,000.00 as moral damages
and P100,000.00 as exemplary damages and to pay the costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby CANCELLED.
SO ORDERED.17
Upon motion of Dr. Anita So and Dr. Marichu Abella to reconsider their solidary liability, 18 the RTC
excluded them from solidary liability as to the damages, modifying its decision as follows:
WHEREFORE, premises considered, the Court finds accused Dr. Fernando Solidum, guilty beyond
reasonable doubt as principal of the crime charged and is hereby sentenced to suffer the
indeterminate penalty of two (2) months and one (1) day of arresto mayor as minimum to one (1)
year, one (1) month and ten (10) days of prision correccional as maximum and to indemnify jointly
and severally with Ospital ng Maynila, private complainant Luz Gercayo the amount of P500,000.00
as moral damages and P100,000 as exemplary damages and to pay the costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby cancelled. 19
Decision of the CA
On January 20, 2010, the CA affirmed the conviction of Dr. Solidum, 20 pertinently stating and ruling:
The case appears to be a textbook example of res ipsa loquitur.
xxxx
x x x [P]rior to the operation, the child was evaluated and found fit to undergo a major operation. As
noted by the OSG, the accused himself testified that pre-operation tests were conducted to ensure
that the child could withstand the surgery. Except for his imperforate anus, the child was healthy.

The tests and other procedures failed to reveal that he was suffering from any known ailment or
disability that could turn into a significant risk. There was not a hint that the nature of the operation
itself was a causative factor in the events that finally led to hypoxia.
In short, the lower court has been left with no reasonable hypothesis except to attribute the accident
to a failure in the proper administration of anesthesia, the gravamen of the charge in this case. The
High Court elucidates in Ramos vs. Court of Appeals 321 SCRA 584
In cases where the res ipsa loquitur is applicable, the court is permitted to find a physician negligent
upon proper proof of injury to the patient, without the aid of expert testimony, where the court from its
fund of common knowledge can determine the proper standard of care.
Where common knowledge and experience teach that a resulting injury would not have occurred to
the patient if due care had been exercised, an inference of negligence may be drawn giving rise to
an application of the doctrine of res ipsa loquitur without medical evidence, which is ordinarily
required to show not only what occurred but how and why it occurred. When the doctrine is
appropriate, all that the patient must do is prove a nexus between the particular act or omission
complained of and the injury sustained while under the custody and management of the defendant
without need to produce expert medical testimony to establish the standard of care. Resort to res
ipsa loquitur is allowed because there is no other way, under usual and ordinary conditions, by which
the patient can obtain redress for injury suffered by him.
The lower court has found that such a nexus exists between the act complained of and the injury
sustained, and in line with the hornbook rules on evidence, we will afford the factual findings of a trial
court the respect they deserve in the absence of a showing of arbitrariness or disregard of material
facts that might affect the disposition of the case. People v. Paraiso 349 SCRA 335.
The res ipsa loquitur test has been known to be applied in criminal cases. Although it creates a
presumption of negligence, it need not offend due process, as long as the accused is afforded the
opportunity to go forward with his own evidence and prove that he has no criminal intent. It is in this
light not inconsistent with the constitutional presumption of innocence of an accused.
IN VIEW OF THE FOREGOING, the modified decision of the lower court is affirmed.
SO ORDERED.21
Dr. Solidum filed a motion for reconsideration, but the CA denied his motion on May 7, 2010. 22
Hence, this appeal.
Issues
Dr. Solidum avers that:
I.
THE HONORABLE COURT OF APPEALS ERRED IN AFFIRMING THE DECISION OF THE
LOWER COURT IN UPHOLDING THE PETITIONERS CONVICTION FOR THE CRIME
CHARGED BASED ON THE TRIAL COURTS OPINION, AND NOT ON THE BASIS OF
THE FACTS ESTABLISHED DURING THE TRIAL. ALSO, THERE IS A CLEAR
MISAPPREHENSION OF FACTS WHICH IF CORRECTED, WILL RESULT TO THE

ACQUITTAL OF THE PETITIONER. FURTHER, THE HONORABLE COURT ERRED IN

AFFIRMING THE SAID DECISION OF THE LOWER COURT, AS THIS BREACHES THE
CRIMINAL LAW PRINCIPLE THAT THE PROSECUTION MUST PROVE THE
ALLEGATIONS OF THE INFORMATION BEYOND REASONABLE DOUBT, AND NOT ON
THE BASIS OF ITS PRESUMPTIVE CONCLUSION.
II.
THE HONORABLE COURT OF APPEALS ERRED IN APPLYING THE PRINCIPLE OF RES
IPSA LOQUITOR (sic) WHEN THE DEFENSE WAS ABLE TO PROVE THAT THERE IS NO
NEGLIGENCE ON THE PART OF THE PETITIONER, AND NO OVERDOSING IN THE
APPLICATION OF THE ANESTHETIC AGENT BECAUSE THERE WAS NO 100%
HALOTHANE ADMINISTERED TO THE CHILD, BUT ONLY ONE (1%) PERCENT AND
THE APPLICATION THEREOF, WAS REGULATED BY AN ANESTHESIA MACHINE.
THUS, THE APPLICATION OF THE PRINCIPLE OF RES IPSA LOQUITOR (sic)
CONTRADICTED THE ESTABLISHED FACTS AND THE LAW APPLICABLE IN THE
CASE.
III.
THE AWARD OF MORAL DAMAGES AND EXEMPLARY DAMAGES IS NOT JUSTIFIED
THERE BEING NO NEGLIGENCE ON THE PART OF THE PETITIONER. ASSUMING
THAT THE CHILD IS ENTITLED TO FINANCIAL CONSIDERATION, IT SHOULD BE ONLY
AS A FINANCIAL ASSISTANCE, BECAUSE THERE WAS NO NEGLIGENCE, AND NO
OVERDOSING OF ANESTHETIC AGENT AND AS SUCH, THE AWARD IS SO
EXCESSIVE, AND NO FACTUAL AND LEGAL BASIS.23
To simplify, the following are the issues for resolution, namely: (a) whether or not the doctrine of res
ipsa loquitur was applicable herein; and (b) whether or not Dr. Solidum was liable for criminal
negligence.
Ruling
The appeal is meritorious.
Applicability of the Doctrine of Res Ipsa Loquitur
Res ipsa loquitur is literally translated as "the thing or the transaction speaks for itself." The doctrine
res ipsa loquitur means that "where the thing which causes injury is shown to be under the
management of the defendant, and the accident is such as in the ordinary course of things does not
happen if those who have the management use proper care, it affords reasonable evidence, in the
absence of an explanation by the defendant, that the accident arose from want of care." 24 It is simply
"a recognition of the postulate that, as a matter of common knowledge and experience, the very
nature of certain types of occurrences may justify an inference of negligence on the part of the
person who controls the instrumentality causing the injury in the absence of some explanation by the
defendant who is charged with negligence. It is grounded in the superior logic of ordinary human
experience and on the basis of such experience or common knowledge, negligence may be
deduced from the mere occurrence of the accident itself.
Hence, res ipsa loquitur is applied in conjunction with the doctrine of common knowledge." 25

Jarcia, Jr. v. People26 has underscored that the doctrine is not a rule of substantive law, but merely a
mode of proof or a mere procedural convenience. The doctrine, when applicable to the facts and
circumstances of a given case, is not meant to and does not dispense with the requirement of proof
of culpable negligence against the party charged. It merely determines and regulates what shall be
prima facie evidence thereof, and helps the plaintiff in proving a breach of the duty. The doctrine can
be invoked when and only when, under the circumstances involved, direct evidence is absent and
not readily available.27
The applicability of the doctrine of res ipsa loquitur in medical negligence cases was significantly and
exhaustively explained in Ramos v. Court of Appeals, 28 where the Court said
Medical malpractice cases do not escape the application of this doctrine. Thus, res ipsa loquitur has
been applied when the circumstances attendant upon the harm are themselves of such a character
as to justify an inference of negligence as the cause of that harm. The application of res ipsa loquitur
in medical negligence cases presents a question of law since it is a judicial function to determine
whether a certain set of circumstances does, as a matter of law, permit a given inference.
Although generally, expert medical testimony is relied upon in malpractice suits to prove that a
physician has done a negligent act or that he has deviated from the standard medical procedure,
when the doctrine of res ipsa loquitur is availed by the plaintiff, the need for expert medical testimony
is dispensed with because the injury itself provides the proof of negligence. The reason is that the
general rule on the necessity of expert testimony applies only to such matters clearly within the
domain of medical science, and not to matters that are within the common knowledge of mankind
which may be testified to by anyone familiar with the facts. Ordinarily, only physicians and surgeons
of skill and experience are competent to testify as to whether a patient has been treated or operated
upon with a reasonable degree of skill and care. However, testimony as to the statements and acts
of physicians and surgeons, external appearances, and manifest conditions which are observable by
any one may be given by non-expert witnesses. Hence, in cases where the res ipsa loquitur is
applicable, the court is permitted to find a physician negligent upon proper proof of injury to the
patient, without the aid of expert testimony, where the court from its fund of common knowledge can
determine the proper standard of care. Where common knowledge and experience teach that a
resulting injury would not have occurred to the patient if due care had been exercised, an inference
of negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur without
medical evidence, which is ordinarily required to show not only what occurred but how and why it
occurred. When the doctrine is appropriate, all that the patient must do is prove a nexus between the
particular act or omission complained of and the injury sustained while under the custody and
management of the defendant without need to produce expert medical testimony to establish the
standard of care. Resort to res ipsa loquitur is allowed because there is no other way, under usual
and ordinary conditions, by which the patient can obtain redress for injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following situations: leaving of a
foreign object in the body of the patient after an operation, injuries sustained on a healthy part of the
body which was not under, or in the area, of treatment, removal of the wrong part of the body when
another part was intended, knocking out a tooth while a patients jaw was under anesthetic for the
removal of his tonsils, and loss of an eye while the patient plaintiff was under the influence of
anesthetic, during or following an operation for appendicitis, among others.
Nevertheless, despite the fact that the scope of res ipsa loquitur has been measurably enlarged, it
does not automatically apply to all cases of medical negligence as to mechanically shift the burden
of proof to the defendant to show that he is not guilty of the ascribed negligence. Res ipsa loquitur is
not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied, depending
upon the circumstances of each case. It is generally restricted to situations in malpractice cases

where a layman is able to say, as a matter of common knowledge and observation, that the
consequences of professional care were not as such as would ordinarily have followed if due care
had been exercised. A distinction must be made between the failure to secure results, and the
occurrence of something more unusual and not ordinarily found if the service or treatment rendered
followed the usual procedure of those skilled in that particular practice. It must be conceded that the
doctrine of res ipsa loquitur can have no application in a suit against a physician or surgeon which
involves the merits of a diagnosis or of a scientific treatment. The physician or surgeon is not
required at his peril to explain why any particular diagnosis was not correct, or why any particular
scientific treatment did not produce the desired result. Thus, res ipsa loquitur is not available in a
malpractice suit if the only showing is that the desired result of an operation or treatment was not
accomplished. The real question, therefore, is whether or not in the process of the operation any
extraordinary incident or unusual event outside of the routine performance occurred which is beyond
the regular scope of customary professional activity in such operations, which, if unexplained would
themselves reasonably speak to the average man as the negligent cause or causes of the untoward
consequence. If there was such extraneous intervention, the doctrine of res ipsa loquitur may be
utilized and the defendant is called upon to explain the matter, by evidence of exculpation, if he
could.
In order to allow resort to the doctrine, therefore, the following essential requisites must first be
satisfied, to wit: (1) the accident was of a kind that does not ordinarily occur unless someone is
negligent; (2) the instrumentality or agency that caused the injury was under the exclusive control of
the person charged; and (3) the injury suffered must not have been due to any voluntary action or
contribution of the person injured. 29
The Court considers the application here of the doctrine of res ipsa loquitur inappropriate. Although it
should be conceded without difficulty that the second and third elements were present, considering
that the anesthetic agent and the instruments were exclusively within the control of Dr. Solidum, and
that the patient, being then unconscious during the operation, could not have been guilty of
contributory negligence, the first element was undeniably wanting. Luz delivered Gerald to the care,
custody and control of his physicians for a pull-through operation. Except for the imperforate anus,
Gerald was then of sound body and mind at the time of his submission to the physicians. Yet, he
experienced bradycardia during the operation, causing loss of his senses and rendering him
immobile. Hypoxia, or the insufficiency of oxygen supply to the brain that caused the slowing of the
heart rate, scientifically termed as bradycardia, would not ordinarily occur in the process of a pullthrough operation, or during the administration of anesthesia to the patient, but such fact alone did
not prove that the negligence of any of his attending physicians, including the anesthesiologists, had
caused the injury. In fact, the anesthesiologists attending to him had sensed in the course of the
operation that the lack of oxygen could have been triggered by the vago-vagal reflex, prompting
them to administer atropine to the patient. 30
This conclusion is not unprecedented. It was similarly reached in Swanson v. Brigham, 31 relevant
portions of the decision therein being as follows:
On January 7, 1973, Dr. Brigham admitted 15-year-old Randall Swanson to a hospital for the
treatment of infectious mononucleosis. The patient's symptoms had included a swollen throat and
some breathing difficulty. Early in the morning of January 9 the patient was restless, and at 1:30 a.m.
Dr. Brigham examined the patient. His inspection of the patient's air passage revealed that it was in
satisfactory condition. At 4:15 a.m. Dr. Brigham received a telephone call from the hospital, advising
him that the patient was having respiratory difficulty. The doctor ordered that oxygen be
administered and he prepared to leave for the hospital. Ten minutes later, 4:25 a.m., the hospital
called a second time to advise the doctor that the patient was not responding. The doctor ordered
that a medicine be administered, and he departed for the hospital. When he arrived, the physician

who had been on call at the hospital had begun attempts to revive the patient. Dr. Brigham joined
him in the effort, but the patient died.
The doctor who performed the autopsy concluded that the patient died between 4:25 a.m. and 4:30
a.m. of asphyxia, as a result of a sudden, acute closing of the air passage. He also found that the air
passage had been adequate to maintain life up to 2 or 3 minutes prior to death. He did not know
what caused the air passage to suddenly close.
xxxx
It is a rare occurrence when someone admitted to a hospital for the treatment of infectious
mononucleosis dies of asphyxiation. But that is not sufficient to invoke res ipsa loquitur. The fact that
the injury rarely occurs does not in itself prove that the injury was probably caused by someone's
negligence. Mason v. Ellsworth, 3 Wn. App. 298, 474 P.2d 909 (1970). Nor is a bad result by itself
enough to warrant the application of the doctrine. Nelson v. Murphy, 42 Wn.2d 737, 258 P.2d 472
(1953). See 2 S. Speiser, The Negligence Case Res Ipsa Loquitur 24:10 (1972). The evidence
presented is insufficient to establish the first element necessary for application of res ipsa loquitur
doctrine. The acute closing of the patients air passage and his resultant asphyxiation took place
over a very short period of time. Under these circumstances it would not be reasonable to infer that
the physician was negligent. There was no palpably negligent act. The common experience of
mankind does not suggest that death would not be expected without negligence. And there is no
expert medical testimony to create an inference that negligence caused the injury.
Negligence of Dr. Solidum
In view of the inapplicability of the doctrine of res ipsa loquitur, the Court next determines whether
the CA correctly affirmed the conviction of Dr. Solidum for criminal negligence.
Negligence is defined as the failure to observe for the protection of the interests of another person
that degree of care, precaution, and vigilance that the circumstances justly demand, whereby such
other person suffers injury.32Reckless imprudence, on the other hand, consists of voluntarily doing or
failing to do, without malice, an act from which material damage results by reason of an inexcusable
lack of precaution on the part of the person performing or failing to perform such act. 33
Dr. Solidums conviction by the RTC was primarily based on his failure to monitor and properly
regulate the level of anesthetic agent administered on Gerald by overdosing at 100% halothane. In
affirming the conviction, the CA observed:
On the witness stand, Dr. Vertido made a significant turnaround. He affirmed the findings and
conclusions in his report except for an observation which, to all intents and purposes, has become
the storm center of this dispute. He wanted to correct one piece of information regarding the dosage
of the anesthetic agent administered to the child. He declared that he made a mistake in reporting a
100% halothane and said that based on the records it should have been 100% oxygen.
The records he was relying on, as he explains, are the following:
(a) the anesthesia record A portion of the chart in the record was marked as Exhibit 1-A
and 1-B to indicate the administration at intervals of the anesthetic agent.
(b) the clinical abstract A portion of this record that reads as follows was marked Exhibit
3A. 3B Approximately 1 hour and 45 minutes through the operation, patient was noted to

have bradycardia (CR = 70) and ATSO4 0.2 mg was immediately administered. However,
the bradycardia persisted, the inhalational agent was shut off, and the patient was ventilated
with 100% oxygen and another dose of ATSO4 0.2 mg was given. However, the patient did
not respond until no cardiac rate can be auscultated and the surgeons were immediately told
to stop the operation. The patient was put on a supine position and CPR was initiated.
Patient was given 1 amp of epinephrine initially while continuously doing cardiac massage
still with no cardiac rate appreciated; another ampule of epinephrine was given and after 45
secs, patients vital signs returned to normal. The entire resuscitation lasted approximately 35 mins. The surgeons were then told to proceed to the closure and the childs vital signs
throughout and until the end of surgery were: BP = 110/70; CR = 116/min and RR = 20-22
cycles/min (on assisted ventilation).
Dr. Vertido points to the crucial passage in the clinical abstract that the patient was ventilated with
100% oxygen and another dose of ATSO4 when the bradycardia persisted, but for one reason or
another, he read it as 100% halothane. He was asked to read the anesthesia record on the
percentage of the dosage indicated, but he could only sheepishly note I cant understand the
number. There are no clues in the clinical abstract on the quantity of the anesthetic agent used. It
only contains the information that the anesthetic plan was to put the patient under general
anesthesia using a nonrebreathing system with halothane as the sole anesthetic agent and that 1
hour and 45 minutes after the operation began, bradycardia occurred after which the inhalational
agent was shut off and the patient administered with 100% oxygen. It would be apparent that the
100% oxygen that Dr. Vertido said should be read in lieu of 100% halothane was the pure oxygen
introduced after something went amiss in the operation and the halothane itself was reduced or shut
off.
The key question remains what was the quantity of halothane used before bradycardia set in?
The implication of Dr. Vertidos admission is that there was no overdose of the anesthetic agent, and
the accused Dr. Solidum stakes his liberty and reputation on this conclusion. He made the
assurance that he gave his patient the utmost medical care, never leaving the operating room except
for a few minutes to answer the call of nature but leaving behind the other members of his team Drs.
Abella and Razon to monitor the operation. He insisted that he administered only a point 1% not
100% halothane, receiving corroboration from Dr. Abella whose initial MA in the record should be
enough to show that she assisted in the operation and was therefore conversant of the things that
happened. She revealed that they were using a machine that closely monitored the concentration of
the agent during the operation.
But most compelling is Dr. Solidums interpretation of the anesthesia record itself, as he takes the
bull by the horns, so to speak. In his affidavit, he says, reading from the record, that the quantity of
halothane used in the operation is one percent (1%) delivered at time intervals of 15 minutes. He
studiedly mentions the concentration of halothane as reflected in the anesthesia record (Annex D
of the complaint-affidavit) is only one percent (1%) The numbers indicated in 15 minute increments
for halothane is an indication that only 1% halothane is being delivered to the patient Gerard
Gercayo for his entire operation; The amount of halothane delivered in this case which is only one
percent cannot be summated because halothane is constantly being rapidly eliminated by the body
during the entire operation.
xxxx
In finding the accused guilty, despite these explanations, the RTC argued that the volte-face of Dr.
Vertido on the question of the dosage of the anesthetic used on the child would not really validate
the non-guilt of the anesthesiologist. Led to agree that the halothane used was not 100% as initially

believed, he was nonetheless unaware of the implications of the change in his testimony. The court
observed that Dr. Vertido had described the condition of the child as hypoxia which is deprivation of
oxygen, a diagnosis supported by the results of the CT Scan. All the symptoms attributed to a failing
central nervous system such as stupor, loss of consciousness, decrease in heart rate, loss of usual
acuity and abnormal motor function, are manifestations of this condition or syndrome. But why would
there be deprivation of oxygen if 100% oxygen to 1% halothane was used? Ultimately, to the court,
whether oxygen or halothane was the object of mistake, the detrimental effects of the operation are
incontestable, and they can only be led to one conclusion if the application of anesthesia was
really closely monitored, the event could not have happened. 34
The Prosecution did not prove the elements of reckless imprudence beyond reasonable doubt
because the circumstances cited by the CA were insufficient to establish that Dr. Solidum had been
guilty of inexcusable lack of precaution in monitoring the administration of the anesthetic agent to
Gerald. The Court aptly explained in Cruz v. Court of Appeals 35 that:
Whether or not a physician has committed an "inexcusable lack of precaution" in the treatment of his
patient is to be determined according to the standard of care observed by other members of the
profession in good standing under similar circumstances bearing in mind the advanced state of the
profession at the time of treatment or the present state of medical science. In the recent case of
Leonila Garcia-Rueda v. Wilfred L. Pacasio, et. al., this Court stated that in accepting a case, a
doctor in effect represents that, having the needed training and skill possessed by physicians and
surgeons practicing in the same field, he will employ such training, care and skill in the treatment of
his patients. He therefore has a duty to use at least the same level of care that any other reasonably
competent doctor would use to treat a condition under the same circumstances. It is in this aspect of
medical malpractice that expert testimony is essential to establish not only the standard of care of
the profession but also that the physician's conduct in the treatment and care falls below such
standard. Further, inasmuch as the causes of the injuries involved in malpractice actions are
determinable only in the light of scientific knowledge, it has been recognized that expert testimony is
usually necessary to support the conclusion as to causation.
xxxx
In litigations involving medical negligence, the plaintiff has the burden of establishing appellant's
negligence and for a reasonable conclusion of negligence, there must be proof of breach of duty on
the part of the surgeon as well as a causal connection of such breach and the resulting death of his
patient. In Chan Lugay v. St Luke's Hospital, Inc., where the attending physician was absolved of
liability for the death of the complainants wife and newborn baby, this Court held that:
"In order that there may be a recovery for an injury, however, it must be shown that the injury for
which recovery is sought must be the legitimate consequence of the wrong done; the connection
between the negligence and the injury must be a direct and natural sequence of events, unbroken by
intervening efficient causes. In other words, the negligence must be the proximate cause of the
injury. For, negligence, no matter in what it consists, cannot create a right of action unless it is the
proximate cause of the injury complained of. And the proximate cause of an injury is that cause,
which, in natural and continuous sequence, unbroken by any efficient intervening cause, produces
the injury, and without which the result would not have occurred."
An action upon medical negligence whether criminal, civil or administrative calls for the plaintiff to
prove by competent evidence each of the following four elements, namely: (a) the duty owed by the
physician to the patient, as created by the physician-patient relationship, to act in accordance with
the specific norms or standards established by his profession; (b) the breach of the duty by the
physicians failing to act in accordance with the applicable standard of care; (3) the causation, i.e.,

there must be a reasonably close and causal connection between the negligent act or omission and
the resulting injury; and (4) the damages suffered by the patient. 36
In the medical profession, specific norms or standards to protect the patient against unreasonable
risk, commonly referred to as standards of care, set the duty of the physician to act in respect of the
patient. Unfortunately, no clear definition of the duty of a particular physician in a particular case
exists. Because most medical malpractice cases are highly technical, witnesses with special medical
qualifications must provide guidance by giving the knowledge necessary to render a fair and just
verdict. As a result, the standard of medical care of a prudent physician must be determined from
expert testimony in most cases; and in the case of a specialist (like an anesthesiologist), the
standard of care by which the specialist is judged is the care and skill commonly possessed and
exercised by similar specialists under similar circumstances. The specialty standard of care may be
higher than that required of the general practitioner. 37
The standard of care is an objective standard by which the conduct of a physician sued for
negligence or malpractice may be measured, and it does not depend, therefore, on any individual
physicians own knowledge either. In attempting to fix a standard by which a court may determine
whether the physician has properly performed the requisite duty toward the patient, expert medical
testimony from both plaintiff and defense experts is required. The judge, as the trier of fact,
ultimately determines the standard of care, after listening to the testimony of all medical experts. 38
Here, the Prosecution presented no witnesses with special medical qualifications in anesthesia to
provide guidance to the trial court on what standard of care was applicable. It would consequently be
truly difficult, if not impossible, to determine whether the first three elements of a negligence and
malpractice action were attendant.
Although the Prosecution presented Dr. Benigno Sulit, Jr., an anesthesiologist himself who served
as the Chairman of the Committee on Ethics and Malpractice of the Philippine Society of
Anesthesiologists that investigated the complaint against Dr. Solidum, his testimony mainly focused
on how his Committee had conducted the investigation. 39 Even then, the report of his Committee was
favorable to Dr. Solidum,40 to wit:
Presented for review by this committee is the case of a 3 year old male who underwent a pull-thru
operation and was administered general anesthesia by a team of anesthesia residents. The patient,
at the time when the surgeons was manipulating the recto-sigmoid and pulling it down in preparation
for the anastomosis, had bradycardia. The anesthesiologists, sensing that the cause thereof was the
triggering of the vago-vagal reflex, administered atropine to block it but despite the administration of
the drug in two doses, cardiac arrest ensued. As the records show, prompt resuscitative measures
were administered and spontaneous cardiac function re-established in less than five (5) minutes and
that oxygen was continuously being administered throughout, unfortunately, as later become
manifest, patient suffered permanent irreversible brain damage.
In view of the actuations of the anaesthesiologists and the administration of anaesthesia, the
committee find that the same were all in accordance with the universally accepted standards of
medical care and there is no evidence of any fault or negligence on the part of the
anaesthesiologists.
Dr. Antonio Vertido, a Senior Medico-Legal Officer of the National Bureau of Investigation, was also
presented as a Prosecution witness, but his testimony concentrated on the results of the physical
examination he had conducted on Gerald, as borne out by the following portions of his direct
examination, to wit:

FISCAL CABARON Doctor, what do you mean by General Anesthetic Agent?

WITNESS General Anesthetic Agent is a substance used in the conduction of Anesthesia and in this
case, halothane was used as a sole anesthetic agent.
xxxx
Q Now under paragraph two of page 1 of your report you mentioned that after one hour and 45
minutes after the operation, the patient experienced a bradycardia or slowing of heart rate, now as a
doctor, would you be able to tell this Honorable Court as to what cause of the slowing of heart rate
as to Gerald Gercayo?
WITNESS Well honestly sir, I cannot give you the reason why there was a bradycardia of time
because is some reason one way or another that might caused bradycardia.
FISCAL CABARON What could be the possible reason?
A Well bradycardia can be caused by anesthetic agent itself and that is a possibility, were talking
about possibility here.
Q What other possibility do you have in mind, doctor?
A Well, because it was an operation, anything can happen within that situation.
FISCAL CABARON Now, this representation would like to ask you about the slowing of heart rate,
now what is the immediate cause of the slowing of the heart rate of a person?
WITNESS Well, one of the more practical reason why there is slowing of the heart rate is when you
do a vagal reflex in the neck wherein the vagal receptors are located at the lateral part of the neck,
when you press that, you produce the slowing of the heart rate that produce bradycardia.
Q I am pro[p]ounding to you another question doctor, what about the deficiency in the supply of
oxygen by the patient, would that also cause the slowing of the heart rate?
A Well that is a possibility sir, I mean not as slowing of the heart rate, if there is a hypoxia or there is
a low oxygen level in the blood, the normal thing for the heart is to pump or to do not a bradycardia
but a to counter act the Hypoxia that is being experienced by the patient
(sic).
xxxx
Q Now, you made mention also doctor that the use of general anesthesia using 100% halothane and
other anesthetic medications probably were contributory to the production of hypoxia.
A Yes, sir in general sir.41
On cross-examination, Dr. Vertido expounded more specifically on his interpretation of the
anesthesia record and the factors that could have caused Gerald to experience bradycardia, viz:

ATTY. COMIA I noticed in, may I see your report Doctor, page 3, will you kindly read to this
Honorable court your last paragraph and if you will affirm that as if it is correct?
A "The use of General Anesthesia, that is using 100% Halothane probably will be contributory to the
production of Hypoxia and - - - -"
ATTY COMIA And do you affirm the figure you mentioned in this Court Doctor?
WITNESS Based on the records, I know the - - Q 100%?
A 100% based on the records.
Q I will show you doctor a clinical record. I am a lawyer I am not a doctor but will you kindly look at
this and tell me where is 100%, the word "one hundred" or 1-0-0, will you kindly look at this Doctor,
this Xerox copy if you can show to this Honorable Court and even to this representation the word
"one hundred" or 1-0-0 and then call me.
xxxx
ATTY. COMIA Doctor tell this Honorable Court where is that 100, 1-0-0 and if there is, you just call
me and even the attention of the Presiding Judge of this Court. Okay, you read one by one.
WITNESS Well, are you only asking 100%, sir?
ATTY. COMIA Im asking you, just answer my question, did you see there 100% and 100 figures, tell
me, yes or no?
WITNESS Im trying to look at the 100%, there is no 100% there sir.
ATTY. COMIA Okay, that was good, so you Honor please, may we request also temporarily,
because this is just a xerox copy presented by the fiscal, that the percentage here that the
Halothane administered by Dr. Solidum to the patient is 1% only so may we request that this portion,
temporarily your Honor, we are marking this anesthesia record as our Exhibit 1 and then this 1%
Halothane also be bracketed and the same be marked as our Exhibit "1-A".
xxxx
ATTY. COMIA Doctor, my attention was called also when you said that there are so many factors
that contributed to Hypoxia is that correct?
WITNESS Yes, sir.
Q I remember doctor, according to you there are so many factors that contributed to what you call
hypoxia and according to you, when this Gerald suffered hypoxia, there are other factors that might
lead to this Hypoxia at the time of this operation is that correct?
WITNESS The possibility is there, sir.

Q And according to you, it might also be the result of such other, some or it might be due to
operations being conducted by the doctor at the time when the operation is being done might also
contribute to that hypoxia is that correct?
A That is a possibility also.
xxxx
ATTY. COMIA How will you classify now the operation conducted to this Gerald, Doctor?
WITNESS Well, that is a major operation sir.
Q In other words, when you say major operation conducted to this Gerald, there is a possibility that
this Gerald might [be] exposed to some risk is that correct?
A That is a possibility sir.
Q And which according to you that Gerald suffered hypoxia is that correct?
A Yes, sir.
Q And that is one of the risk of that major operation is that correct?
A That is the risk sir.42
At the continuation of his cross-examination, Dr. Vertido maintained that Geralds operation for his
imperforate anus, considered a major operation, had exposed him to the risk of suffering the same
condition.43 He then corrected his earlier finding that 100% halothane had been administered on
Gerald by saying that it should be 100% oxygen. 44
Dr. Solidum was criminally charged for "failing to monitor and regulate properly the levels of
anesthesia administered to said Gerald Albert Gercayo and using 100% halothane and other
anesthetic medications."45However, the foregoing circumstances, taken together, did not prove
beyond reasonable doubt that Dr. Solidum had been recklessly imprudent in administering the
anesthetic agent to Gerald. Indeed, Dr. Vertidos findings did not preclude the probability that other
factors related to Geralds major operation, which could or could not necessarily be attributed to the
administration of the anesthesia, had caused the hypoxia and had then led Gerald to experience
bradycardia. Dr. Vertido revealingly concluded in his report, instead, that "although the
anesthesiologist followed the normal routine and precautionary procedures, still hypoxia and its
corresponding side effects did occur."46
The existence of the probability about other factors causing the hypoxia has engendered in the mind
of the Court a reasonable doubt as to Dr. Solidums guilt, and moves us to acquit him of the crime of
reckless imprudence resulting to serious physical injuries. "A reasonable doubt of guilt," according to
United States v. Youthsey:47
x x x is a doubt growing reasonably out of evidence or the lack of it. It is not a captious doubt; not a
doubt engendered merely by sympathy for the unfortunate position of the defendant, or a dislike to
accept the responsibility of convicting a fellow man. If, having weighed the evidence on both sides,
you reach the conclusion that the defendant is guilty, to that degree of certainty as would lead you to
act on the faith of it in the most important and crucial affairs of your life, you may properly convict

him. Proof beyond reasonable doubt is not proof to a mathematical demonstration. It is not proof
beyond the possibility of mistake.
We have to clarify that the acquittal of Dr. Solidum would not immediately exempt him from civil
liability. But we cannot now find and declare him civilly liable because the circumstances that have
been established here do not present the factual and legal bases for validly doing so. His acquittal
did not derive only from reasonable doubt. There was really no firm and competent showing how the
injury to Gerard had been caused. That meant that the manner of administration of the anesthesia
by Dr. Solidum was not necessarily the cause of the hypoxia that caused the bradycardia
experienced by Gerard. Consequently, to adjudge Dr. Solidum civilly liable would be to speculate on
the cause of the hypoxia. We are not allowed to do so, for civil liability must not rest on speculation
but on competent evidence.
1wphi1

Liability of Ospital ng Maynila

Although the result now reached has resolved the issue of civil liability, we have to address the
unusual decree of the RTC, as affirmed by the CA, of expressly holding Ospital ng Maynila civilly
liable jointly and severally with Dr. Solidum. The decree was flawed in logic and in law.
In criminal prosecutions, the civil action for the recovery of civil liability that is deemed instituted with
the criminal action refers only to that arising from the offense charged. 48 It is puzzling, therefore, how
the RTC and the CA could have adjudged Ospital ng Maynila jointly and severally liable with Dr.
Solidum for the damages despite the obvious fact that Ospital ng Maynila, being an artificial entity,
had not been charged along with Dr. Solidum. The lower courts thereby acted capriciously and
whimsically, which rendered their judgment against Ospital ng Maynila void as the product of grave
abuse of discretion amounting to lack of jurisdiction.
Not surprisingly, the flawed decree raises other material concerns that the RTC and the CA
overlooked. We deem it important, then, to express the following observations for the instruction of
the Bench and Bar.
For one, Ospital ng Maynila was not at all a party in the proceedings. Hence, its fundamental right to
be heard was not respected from the outset. The R TC and the CA should have been alert to this
fundamental defect. Verily, no person can be prejudiced by a ruling rendered in an action or
proceeding in which he was not made a party. Such a rule would enforce the constitutional
guarantee of due process of law.
Moreover, Ospital ng Maynila could be held civilly liable only when subsidiary liability would be
properly enforceable pursuant to Article 103 of the Revised Penal Code. But the subsidiary liability
seems far-fetched here. The conditions for subsidiary liability to attach to Ospital ng Maynila should
first be complied with. Firstly, pursuant to Article 103 of the Revised Penal Code, Ospital ng Maynila
must be shown to be a corporation "engaged in any kind of industry." The term industry means any
department or branch of art, occupation or business, especially one that employs labor and capital,
and is engaged in industry.49 However, Ospital ng Maynila, being a public hospital, was not engaged
in industry conducted for profit but purely in charitable and humanitarian work.50Secondly, assuming
that Ospital ng Maynila was engaged in industry for profit, Dr. Solidum must be shown to be an
employee of Ospital ng Maynila acting in the discharge of his duties during the operation on Gerald.
Yet, he definitely was not such employee but a consultant of the hospital. And, thirdly, assuming that
civil liability was adjudged against Dr. Solidum as an employee (which did not happen here), the
execution against him was unsatisfied due to his being insolvent.

WHEREFORE, the Court GRANTS the petition for review on certiorari; REVERSES AND SETS
ASIDE the decision promulgated on January 20, 2010; ACQUITS Dr. Fernando P. Solidum of the
crime of reckless imprudence resulting to serious physical injuries; and MAKES no pronouncement
on costs of suit.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 159132

December 18, 2008

FE CAYAO-LASAM, petitioner,
vs.
SPOUSES CLARO and EDITHA RAMOLETE, respondents.*
DECISION
AUSTRIA-MARTINEZ, J.:
Before the Court is a Petition for Review on Certiorari under Rule 45 of the Rules of Court filed by
Dr. Fe Cayao-Lasam (petitioner) seeking to annul the Decision1 dated July 4, 2003 of the Court of
Appeals (CA) in CA-G.R. SP No. 62206.
The antecedent facts:
On July 28, 1994, respondent, three months pregnant Editha Ramolete (Editha) was brought to the
Lorma Medical Center (LMC) in San Fernando, La Union due to vaginal bleeding. Upon advice of
petitioner relayed viatelephone, Editha was admitted to the LMC on the same day. A pelvic
sonogram2 was then conducted on Editha revealing the fetus weak cardiac pulsation. 3 The following
day, Edithas repeat pelvic sonogram 4 showed that aside from the fetus weak cardiac pulsation, no
fetal movement was also appreciated. Due to persistent and profuse vaginal bleeding, petitioner
advised Editha to undergo a Dilatation and Curettage Procedure (D&C) or "raspa."
On July 30, 1994, petitioner performed the D&C procedure. Editha was discharged from the hospital
the following day.
On September 16, 1994, Editha was once again brought at the LMC, as she was suffering from
vomiting and severe abdominal pains. Editha was attended by Dr. Beatriz de la Cruz, Dr. Victor B.
Mayo and Dr. Juan V. Komiya. Dr. Mayo allegedly informed Editha that there was a dead fetus in the
latters womb. After, Editha underwent laparotomy, 5 she was found to have a massive intraabdominal hemorrhage and a ruptured uterus. Thus, Editha had to undergo a procedure for
hysterectomy6 and as a result, she has no more chance to bear a child.
On November 7, 1994, Editha and her husband Claro Ramolete (respondents) filed a Complaint 7 for
Gross Negligence and Malpractice against petitioner before the Professional Regulations
Commission (PRC).
Respondents alleged that Edithas hysterectomy was caused by petitioners unmitigated negligence
and professional incompetence in conducting the D&C procedure and the petitioners failure to
remove the fetus inside Edithas womb. 8 Among the alleged acts of negligence were: first,
petitioners failure to check up, visit or administer medication on Editha during her first day of
confinement at the LMC;9 second, petitioner recommended that a D&C procedure be performed on
Editha without conducting any internal examination prior to the procedure; 10 third, petitioner

immediately suggested a D&C procedure instead of closely monitoring the state of pregnancy of
Editha.11
In her Answer,12 petitioner denied the allegations of negligence and incompetence with the following
explanations: upon Edithas confirmation that she would seek admission at the LMC, petitioner
immediately called the hospital to anticipate the arrival of Editha and ordered through the telephone
the medicines Editha needed to take, which the nurses carried out; petitioner visited Editha on the
morning of July 28, 1994 during her rounds; on July 29, 1994, she performed an internal
examination on Editha and she discovered that the latters cervix was already open, thus, petitioner
discussed the possible D&C procedure, should the bleeding become more profuse; on July 30 1994,
she conducted another internal examination on Editha, which revealed that the latters cervix was
still open; Editha persistently complained of her vaginal bleeding and her passing out of some meaty
mass in the process of urination and bowel movement; thus, petitioner advised Editha to undergo
D&C procedure which the respondents consented to; petitioner was very vocal in the operating room
about not being able to see an abortus; 13 taking the words of Editha to mean that she was passing
out some meaty mass and clotted blood, she assumed that the abortus must have been expelled in
the process of bleeding; it was Editha who insisted that she wanted to be discharged; petitioner
agreed, but she advised Editha to return for check-up on August 5, 1994, which the latter failed to
do.
Petitioner contended that it was Edithas gross negligence and/or omission in insisting to be
discharged on July 31, 1994 against doctors advice and her unjustified failure to return for check-up
as directed by petitioner that contributed to her life-threatening condition on September 16, 1994;
that Edithas hysterectomy was brought about by her very abnormal pregnancy known as placenta
increta, which was an extremely rare and very unusual case of abdominal placental implantation.
Petitioner argued that whether or not a D&C procedure was done by her or any other doctor, there
would be no difference at all because at any stage of gestation before term, the uterus would rupture
just the same.
On March 4, 1999, the Board of Medicine (the Board) of the PRC rendered a Decision,14 exonerating
petitioner from the charges filed against her. The Board held:
Based on the findings of the doctors who conducted the laparotomy on Editha, hers is a case
of Ectopic Pregnancy Interstitial. This type of ectopic pregnancy is one that is being
protected by the uterine muscles and manifestations may take later than four (4) months and
only attributes to two percent (2%) of ectopic pregnancy cases.
When complainant Editha was admitted at Lorma Medical Center on July 28, 1994 due to
vaginal bleeding, an ultra-sound was performed upon her and the result of the Sonogram
Test reveals a morbid fetus but did not specify where the fetus was located. Obstetricians will
assume that the pregnancy is within the uterus unless so specified by the Sonologist who
conducted the ultra-sound. Respondent (Dr. Lasam) cannot be faulted if she was not able to
determine that complainant Editha is having an ectopic pregnancy interstitial. The D&C
conducted on Editha is necessary considering that her cervix is already open and so as to
stop the profuse bleeding. Simple curettage cannot remove a fetus if the patient is having an
ectopic pregnancy, since ectopic pregnancy is pregnancy conceived outside the uterus and
curettage is done only within the uterus. Therefore, a more extensive operation needed in
this case of pregnancy in order to remove the fetus. 15
Feeling aggrieved, respondents went to the PRC on appeal. On November 22, 2000, the PRC
rendered a Decision16 reversing the findings of the Board and revoking petitioners authority or
license to practice her profession as a physician. 17

Petitioner brought the matter to the CA in a Petition for Review under Rule 43 of the Rules of Court.
Petitioner also dubbed her petition as one for certiorari18 under Rule 65 of the Rules of Court.
In the Decision dated July 4, 2003, the CA held that the Petition for Review under Rule 43 of the
Rules of Court was an improper remedy, as the enumeration of the quasi-judicial agencies in Rule
43 is exclusive.19 PRC is not among the quasi-judicial bodies whose judgment or final orders are
subject of a petition for review to the CA, thus, the petition for review of the PRC Decision, filed at
the CA, was improper. The CA further held that should the petition be treated as a petition
for certiorari under Rule 65, the same would still be dismissed for being improper and premature.
Citing Section 2620 of Republic Act (R.A.) No. 2382 or the Medical Act of 1959, the CA held that the
plain, speedy and adequate remedy under the ordinary course of law which petitioner should have
availed herself of was to appeal to the Office of the President. 21
Hence, herein petition, assailing the decision of the CA on the following grounds:
1. THE COURT OF APPEALS ERRED ON A QUESTION OF LAW IN HOLDING THAT THE
PROFESSIONAL REGULATION[S] COMMISSION (PRC) WAS EXCLUDED AMONG THE
QUASI-JUDICIAL AGENCIES CONTEMPLATED UNDER RULE 43 OF THE RULES OF
CIVIL PROCEDURE;
2. EVEN ASSUMING, ARGUENDO, THAT PRC WAS EXCLUDED FROM THE PURVIEW
OF RULE 43 OF THE RULES OF CIVIL PROCEDURE, THE PETITIONER WAS NOT
PRECLUDED FROM FILING A PETITION FOR CERTIORARI WHERE THE DECISION
WAS ALSO ISSUED IN EXCESS OF OR WITHOUT JURISDICTION, OR WHERE THE
DECISION WAS A PATENT NULLITY;
3. HEREIN RESPONDENTS-SPOUSES ARE NOT ALLOWED BY LAW TO APPEAL FROM
THE DECISION OF THE BOARD OF MEDICINE TO THE PROFESSIONAL
REGULATION[S] COMMISSION;
4. THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF DISCRETION IN
DENYING FOR IMPROPER FORUM THE PETITION FOR REVIEW/PETITION FOR
CERTIORARI WITHOUT GOING OVER THE MERITS OF THE GROUNDS RELIED UPON
BY THE PETITIONER;
5. PRCS GRAVE OMISSION TO AFFORD HEREIN PETITONER A CHANCE TO BE
HEARD ON APPEAL IS A CLEAR VIOLATION OF HER CONSTITUTIONAL RIGHT TO
DUE PROCESS AND HAS THE EFFECT OF RENDERING THE JUDGMENT NULL AND
VOID;
6. COROLLARY TO THE FOURTH ASSIGNED ERROR, PRC COMMITTED GRAVE
ABUSE OF DISCRETION, AMOUNTING TO LACK OF JURISDICTION, IN ACCEPTING
AND CONSIDERING THE MEMORANDUM ON APPEAL WITHOUT PROOF OF SERVICE
TO HEREIN PETITIONER, AND IN VIOLATION OF ART. IV, SEC. 35 OF THE RULES AND
REGULATIONS GOVERNING THE REGULATION AND PRACTICE OF PROFESSIONALS;
7. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN REVOKING PETITIONERS
LICENSE TO PRACTICE MEDICINE WITHOUT AN EXPERT TESTIMONY TO SUPPORT
ITS CONCLUSION AS TO THE CAUSE OF RESPONDENT EDITHAT [SIC] RAMOLETES
INJURY;

8. PRC COMMITTED AN EVEN GRAVER ABUSE OF DISCRETION IN TOTALLY

DISREGARDING THE FINDING OF THE BOARD OF MEDICINE, WHICH HAD THE
NECESSARY COMPETENCE AND EXPERTISE TO ESTABLISH THE CAUSE OF
RESPONDENT EDITHAS INJURY, AS WELL AS THE TESTIMONY OF THE EXPERT
WITNESS AUGUSTO MANALO, M.D. ;[and]
9. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN MAKING CONCLUSIONS OF
FACTS THAT WERE NOT ONLY UNSUPPORTED BY EVIDENCE BUT WERE ACTUALLY
CONTRARY TO EVIDENCE ON RECORD.22
The Court will first deal with the procedural issues.
Petitioner claims that the law does not allow complainants to appeal to the PRC from the decision of
the Board. She invokes Article IV, Section 35 of the Rules and Regulations Governing the
Regulation and Practice of Professionals, which provides:
Sec. 35. The respondent may appeal the decision of the Board within thirty days from receipt
thereof to the Commission whose decision shall be final. Complainant, when allowed by
law, may interpose an appeal from the Decision of the Board within the same
period. (Emphasis supplied)
Petitioner asserts that a careful reading of the above law indicates that while the respondent, as a
matter of right, may appeal the Decision of the Board to the Commission, the complainant may
interpose an appeal from the decision of the Board only when so allowed by law. 23 Petitioner cited
Section 26 of Republic Act No. 2382 or "The Medical Act of 1959," to wit:
Section 26. Appeal from judgment. The decision of the Board of Medical Examiners (now
Medical Board) shall automatically become final thirty days after the date of its promulgation
unless the respondent, during the same period, has appealed to the Commissioner of Civil
Service (now Professional Regulations Commission) and later to the Office of the President
of the Philippines. If the final decision is not satisfactory, the respondent may ask for a review
of the case, or may file in court a petition for certiorari.
Petitioner posits that the reason why the Medical Act of 1959 allows only the respondent in an
administrative case to file an appeal with the Commission while the complainant is not allowed to do
so is double jeopardy. Petitioner is of the belief that the revocation of license to practice a profession
is penal in nature.24
The Court does not agree.
For one, the principle of double jeopardy finds no application in administrative cases. Double
jeopardy attaches only: (1) upon a valid indictment; (2) before a competent court; (3) after
arraignment; (4) when a valid plea has been entered; and (5) when the defendant was acquitted or
convicted, or the case was dismissed or otherwise terminated without the express consent of the
accused.25 These elements were not present in the proceedings before the Board of Medicine, as
the proceedings involved in the instant case were administrative and not criminal in nature. The
Court has already held that double jeopardy does not lie in administrative cases.26
Moreover, Section 35 of the Rules and Regulations Governing the Regulation and Practice of
Professionals cited by petitioner was subsequently amended to read:

Sec. 35. The complainant/respondent may appeal the order, the resolution or the decision
of the Board within thirty (30) days from receipt thereof to the Commission whose decision
shall be final and executory. Interlocutory order shall not be appealable to the Commission.
(Amended by Res. 174, Series of 1990).27(Emphasis supplied)
Whatever doubt was created by the previous provision was settled with said amendment. It is
axiomatic that the right to appeal is not a natural right or a part of due process, but a mere statutory
privilege that may be exercised only in the manner prescribed by law. 28 In this case, the clear intent
of the amendment is to render the right to appeal from a decision of the Board available to both
complainants and respondents.
Such conclusion is bolstered by the fact that in 2006, the PRC issued Resolution No. 06-342(A), or
the New Rules of Procedure in Administrative Investigations in the Professional Regulations
Commission and the Professional Regulatory Boards, which provides for the method of appeal, to
wit:
Sec. 1. Appeal; Period Non-Extendible.- The decision, order or resolution of the Board
shall be final and executory after the lapse of fifteen (15) days from receipt of the decision,
order or resolution without an appeal being perfected or taken by either the respondent or
the complainant. A party aggrieved by the decision, order or resolution may file a
notice of appeal from the decision, order or resolution of the Board to the
Commission within fifteen (15) days from receipt thereof, and serving upon the adverse
party a notice of appeal together with the appellants brief or memorandum on appeal, and
paying the appeal and legal research fees. x x x29
The above-stated provision does not qualify whether only the complainant or respondent may file an
appeal; rather, the new rules provide that "a party aggrieved" may file a notice of appeal. Thus,
either the complainant or the respondent who has been aggrieved by the decision, order or
resolution of the Board may appeal to the Commission. It is an elementary rule that when the law
speaks in clear and categorical language, there is no need, in the absence of legislative intent to the
contrary, for any interpretation.30 Words and phrases used in the statute should be given their plain,
ordinary, and common usage or meaning. 31
Petitioner also submits that appeals from the decisions of the PRC should be with the CA, as Rule
4332 of the Rules of Court was precisely formulated and adopted to provide for a uniform rule of
appellate procedure for quasi-judicial agencies.33 Petitioner further contends that a quasi-judicial
body is not excluded from the purview of Rule 43 just because it is not mentioned therein. 34
On this point, the Court agrees with the petitioner.
Sec. 1, Rule 43 of the Rules of Court provides:
Section 1. Scope. - This Rule shall apply to appeals from judgments or final orders of the
Court of Tax Appeals, and from awards, judgments, final orders or resolutions of or
authorized by any quasi-judicial agency in the exercise of its quasi-judicial functions.
Among these agencies are the Civil Service Commission, Central Board of Assessment
Appeals, Securities and Exchange Commission, Office of the President, Land Registration
Authority, Social Security Commission, Civil Aeronautics Board, Bureau of Patents,
Trademarks and Technology Transfer, National Electrification Administration, Energy
Regulatory Board, National Telecommunications Commission, Department of Agrarian
Reform under Republic Act No. 6657, Government Service Insurance System, Employees
Compensation Commission, Agricultural Inventions Board, Insurance Commission,

Philippine Atomic Energy Commission, Board of Investments, Construction Industry

Arbitration Commission, and voluntary arbitrators authorized by law. (Emphasis supplied)
Indeed, the PRC is not expressly mentioned as one of the agencies which are expressly enumerated
under Section 1, Rule 43 of the Rules of Court. However, its absence from the enumeration does
not, by this fact alone, imply its exclusion from the coverage of said Rule. 35 The Rule expressly
provides that it should be applied to appeals from awards, judgments final orders or resolutions of
any quasi-judicial agency in the exercise of its quasi-judicial functions. The phrase "among these
agencies" confirms that the enumeration made in the Rule is not exclusive to the agencies therein
listed.36
Specifically, the Court, in Yang v. Court of Appeals,37 ruled
that Batas Pambansa (B.P.) Blg. 12938 conferred upon the CA exclusive appellate jurisdiction over
appeals from decisions of the PRC. The Court held:
The law has since been changed, however, at least in the matter of the particular court to
which appeals from the Commission should be taken. On August 14, 1981, Batas Pambansa
Bilang 129 became effective and in its Section 29, conferred on the Court of Appeals
"exclusive appellate jurisdiction over all final judgments, decisions, resolutions, orders or
awards of Regional Trial Courts and quasi-judicial agencies, instrumentalities, boards or
commissions except those falling under the appellate jurisdiction of the Supreme Court. x x
x." In virtue of BP 129, appeals from the Professional Regulations Commission are
now exclusively cognizable by the Court of Appeals. 39 (Emphasis supplied)
Clearly, the enactment of B.P. Blg. 129, the precursor of the present Rules of Civil
Procedure,40 lodged with the CA such jurisdiction over the appeals of decisions made by the PRC.
Anent the substantive merits of the case, petitioner questions the PRC decision for being without an
expert testimony to support its conclusion and to establish the cause of Edithas injury. Petitioner
avers that in cases of medical malpractice, expert testimony is necessary to support the conclusion
as to the cause of the injury.41
Medical malpractice is a particular form of negligence which consists in the failure of a physician or
surgeon to apply to his practice of medicine that degree of care and skill which is ordinarily
employed by the profession generally, under similar conditions, and in like surrounding
circumstances.42 In order to successfully pursue such a claim, a patient must prove that the
physician or surgeon either failed to do something which a reasonably prudent physician or surgeon
would not have done, and that the failure or action caused injury to the patient. 43
There are four elements involved in medical negligence cases: duty, breach, injury and proximate
causation.44
A physician-patient relationship was created when Editha employed the services of the petitioner. As
Edithas physician, petitioner was duty-bound to use at least the same level of care that any
reasonably competent doctor would use to treat a condition under the same circumstances. 45 The
breach of these professional duties of skill and care, or their improper performance by a physician
surgeon, whereby the patient is injured in body or in health, constitutes actionable malpractice. 46 As
to this aspect of medical malpractice, the determination of the reasonable level of care and the
breach thereof, expert testimony is essential. 47 Further, inasmuch as the causes of the injuries
involved in malpractice actions are determinable only in the light of scientific knowledge, it has been
recognized that expert testimony is usually necessary to support the conclusion as to causation.48

In the present case, respondents did not present any expert testimony to support their claim that
petitioner failed to do something which a reasonably prudent physician or surgeon would have done.
Petitioner, on the other hand, presented the testimony of Dr. Augusto M. Manalo, who was clearly an
expert on the subject.
Generally, to qualify as an expert witness, one must have acquired special knowledge of the subject
matter about which he or she is to testify, either by the study of recognized authorities on the subject
or by practical experience.49
Dr. Manalo specializes in gynecology and obstetrics, authored and co-authored various publications
on the subject, and is a professor at the University of the Philippines. 50 According to him, his
diagnosis of Edithas case was "Ectopic Pregnancy Interstitial (also referred to as Cornual),
Ruptured."51 In stating that the D&C procedure was not the proximate cause of the rupture of
Edithas uterus resulting in her hysterectomy, Dr. Manalo testified as follows:
Atty. Hidalgo:
Q: Doctor, we want to be clarified on this matter. The complainant had testified here that
the D&C was the proximate cause of the rupture of the uterus. The condition which she
found herself in on the second admission. Will you please tell us whether that is true or not?
A: Yah, I do not think so for two reasons. One, as I have said earlier, the instrument
cannot reach the site of the pregnancy, for it to further push the pregnancy outside the
uterus. And, No. 2, I was thinking a while ago about another reason- well, why I dont think
so, because it is the triggering factor for the rupture, it could havethe rupture could have
occurred much earlier, right after the D&C or a few days after the D&C.
Q: In this particular case, doctor, the rupture occurred to have happened minutes prior to
the hysterectomy or right upon admission on September 15, 1994 which is about 1 months
after the patient was discharged, after the D&C was conducted. Would you tell us whether
there is any relation at all of the D&C and the rupture in this particular instance?
A: I dont think so for the two reasons that I have just mentioned- that it would not
be possible for the instrument to reach the site of pregnancy. And, No. 2, if it is because
of the D&C that rupture could have occurred earlier. 52 (Emphases supplied)
Clearly, from the testimony of the expert witness and the reasons given by him, it is evident that the
D&C procedure was not the proximate cause of the rupture of Edithas uterus.
During his cross-examination, Dr. Manalo testified on how he would have addressed Edithas
condition should he be placed in a similar circumstance as the petitioner. He stated:
Atty. Ragonton:
Q: Doctor, as a practicing OB-Gyne, when do you consider that you have done a good,
correct and ideal dilatation and curettage procedure?
A: Well, if the patient recovers. If the patient gets well. Because even after the procedure,
even after the procedure you may feel that you have scraped everything, the patient stops

bleeding, she feels well, I think you should still have some reservations, and wait a little more
time.
Q: If you were the OB-Gyne who performed the procedure on patient Editha Ramolete,
would it be your standard practice to check the fetal parts or fetal tissues that were allegedly
removed?
A: From what I have removed, yes. But in this particular case, I think it was assumed that
it was part of the meaty mass which was expelled at the time she was urinating and flushed
in the toilet. So theres no way.
Q:

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

A:

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

Q:

And you would not mind checking those scant or those little parts that were removed?

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

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

A: Sometimes yes, depending on how familiar I am with the patient. We are on the
question of telephone orders. I am not saying that that is the idle [sic] thing to do, but I think
the reality of present day practice somehow justifies telephone orders. I have patients
whom I have justified and then all of a sudden, late in the afternoon or late in the evening,
would suddenly call they have decided that they will go home inasmuch as they anticipated
that I will discharge them the following day. So, I just call and ask our resident on duty or the
nurse to allow them to go because I have seen that patient and I think I have full grasp of her
problems. So, thats when I make this telephone orders. And, of course before giving that
order I ask about how she feels.53 (Emphases supplied)
From the foregoing testimony, it is clear that the D&C procedure was conducted in accordance with
the standard practice, with the same level of care that any reasonably competent doctor would use

to treat a condition under the same circumstances, and that there was nothing irregular in the way
the petitioner dealt with Editha.
Medical malpractice, in our jurisdiction, is often brought as a civil action for damages under Article
217654 of the Civil Code. The defenses in an action for damages, provided for under Article 2179 of
the Civil Code are:
Art. 2179. When the plaintiffs own negligence was the immediate and proximate cause
of his injury, he cannot recover damages. But if his negligence was only contributory, the
immediate and proximate cause of the injury being the defendants lack of due care, the
plaintiff may recover damages, but the courts shall mitigate the damages to be awarded.
Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by
any efficient intervening cause, produces injury, and without which the result would not have
occurred.55 An injury or damage is proximately caused by an act or a failure to act, whenever it
appears from the evidence in the case that the act or omission played a substantial part in bringing
about or actually causing the injury or damage; and that the injury or damage was either a direct
result or a reasonably probable consequence of the act or omission. 56
In the present case, the Court notes the findings of the Board of Medicine:
When complainant was discharged on July 31, 1994, herein respondent advised her to
return on August 4, 1994 or four (4) days after the D&C. This advise was clear in
complainants Discharge Sheet. However, complainant failed to do so. This being the
case, the chain of continuity as required in order that the doctrine of proximate cause can be
validly invoked was interrupted. Had she returned, the respondent could have examined
her thoroughly.57 x x x (Emphases supplied)
Also, in the testimony of Dr. Manalo, he stated further that assuming that there was in fact a
misdiagnosis, the same would have been rectified if Editha followed the petitioners order to return
for a check-up on August 4, 1994. Dr. Manalo stated:
Granting that the obstetrician-gynecologist has been misled (justifiably) up to thus
point that there would have been ample opportunity to rectify the misdiagnosis, had
the patient returned, as instructed for her follow-up evaluation. It was one and a half
months later that the patient sought consultation with another doctor. The continued
growth of an ectopic pregnancy, until its eventual rupture, is a dynamic process. Much
change in physical findings could be expected in 1 months, including the emergence of
suggestive ones.58
It is undisputed that Editha did not return for a follow-up evaluation, in defiance of the petitioners
advise. Editha omitted the diligence required by the circumstances which could have avoided the
injury. The omission in not returning for a follow-up evaluation played a substantial part in bringing
about Edithas own injury. Had Editha returned, petitioner could have conducted the proper medical
tests and procedure necessary to determine Edithas health condition and applied the corresponding
treatment which could have prevented the rupture of Edithas uterus. The D&C procedure having
been conducted in accordance with the standard medical practice, it is clear that Edithas omission
was the proximate cause of her own injury and not merely a contributory negligence on her part.
Contributory negligence is the act or omission amounting to want of ordinary care on the part of the
person injured, which, concurring with the defendants negligence, is the proximate cause of the
injury.59 Difficulty seems to be apprehended in deciding which acts of the injured party shall be

considered immediate causes of the accident. 60 Where the immediate cause of an accident resulting
in an injury is the plaintiffs own act, which contributed to the principal occurrence as one of its
determining factors, he cannot recover damages for the injury. 61 Again, based on the evidence
presented in the present case under review, in which no negligence can be attributed to the
petitioner, the immediate cause of the accident resulting in Edithas injury was her own
omission when she did not return for a follow-up check up, in defiance of petitioners orders.
The immediate cause of Edithas injury was her own act; thus, she cannot recover damages
from the injury.
Lastly, petitioner asserts that her right to due process was violated because she was never informed
by either respondents or by the PRC that an appeal was pending before the PRC. 62 Petitioner claims
that a verification with the records section of the PRC revealed that on April 15, 1999, respondents
filed a Memorandum on Appeal before the PRC, which did not attach the actual registry receipt but
was merely indicated therein.63
Respondents, on the other hand avers that if the original registry receipt was not attached to the
Memorandum on Appeal, PRC would not have entertained the appeal or accepted such pleading for
lack of notice or proof of service on the other party. 64 Also, the registry receipt could not be
appended to the copy furnished to petitioners former counsel, because the registry receipt was
already appended to the original copy of the Memorandum of Appeal filed with PRC. 65
It is a well-settled rule that when service of notice is an issue, the rule is that the person alleging that
the notice was served must prove the fact of service. The burden of proving notice rests upon the
party asserting its existence.66 In the present case, respondents did not present any proof that
petitioner was served a copy of the Memorandum on Appeal. Thus, respondents were not able to
satisfy the burden of proving that they had in fact informed the petitioner of the appeal proceedings
before the PRC.
In EDI-Staffbuilders International, Inc. v. National Labor Relations Commission,67 in which the
National Labor Relations Commission failed to order the private respondent to furnish the petitioner
a copy of the Appeal Memorandum, the Court held that said failure deprived the petitioner of
procedural due process guaranteed by the Constitution, which could have served as basis for the
nullification of the proceedings in the appeal. The same holds true in the case at bar. The Court finds
that the failure of the respondents to furnish the petitioner a copy of the Memorandum of Appeal
submitted to the PRC constitutes a violation of due process. Thus, the proceedings before the PRC
were null and void.
All told, doctors are protected by a special rule of law. They are not guarantors of care. They are not
insurers against mishaps or unusual consequences 68 specially so if the patient herself did not
exercise the proper diligence required to avoid the injury.
WHEREFORE, the petition is GRANTED. The assailed Decision of the Court of Appeals dated July
4, 2003 in CA-GR SP No. 62206 is hereby REVERSED and SET ASIDE. The Decision of the Board
of Medicine dated March 4, 1999 exonerating petitioner is AFFIRMED. No pronouncement as to
costs.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 142625

December 19, 2006

ROGELIO P. NOGALES, for himself and on behalf of the minors, ROGER ANTHONY,
ANGELICA, NANCY, and MICHAEL CHRISTOPHER, all surnamed NOGALES, petitioners,
vs.
CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR. ELY VILLAFLOR, DR. ROSA UY,
DR. JOEL ENRIQUEZ, DR. PERPETUA LACSON, DR. NOE ESPINOLA, and NURSE J.
DUMLAO, respondents.

DECISION

CARPIO, J.:
The Case
This petition for review1 assails the 6 February 1998 Decision2 and 21 March 2000 Resolution3 of the
Court of Appeals in CA-G.R. CV No. 45641. The Court of Appeals affirmed in toto the 22 November
1993 Decision4 of the Regional Trial Court of Manila, Branch 33, finding Dr. Oscar Estrada solely
liable for damages for the death of his patient, Corazon Nogales, while absolving the remaining
respondents of any liability. The Court of Appeals denied petitioners' motion for reconsideration.
The Facts
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 years old, was under
the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada") beginning on her fourth month of
pregnancy or as early as December 1975. While Corazon was on her last trimester of pregnancy,
Dr. Estrada noted an increase in her blood pressure and development of leg edema5 indicating
preeclampsia,6 which is a dangerous complication of pregnancy. 7
Around midnight of 25 May 1976, Corazon started to experience mild labor pains prompting Corazon
and Rogelio Nogales ("Spouses Nogales") to see Dr. Estrada at his home. After examining Corazon,
Dr. Estrada advised her immediate admission to the Capitol Medical Center ("CMC").
On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the staff nurse noted the
written admission request8 of Dr. Estrada. Upon Corazon's admission at the CMC, Rogelio Nogales
("Rogelio") executed and signed the "Consent on Admission and Agreement" 9 and "Admission
Agreement."10 Corazon was then brought to the labor room of the CMC.

Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an internal
examination of Corazon. Dr. Uy then called up Dr. Estrada to notify him of her findings.
Based on the Doctor's Order Sheet,11 around 3:00 a.m., Dr. Estrada ordered for 10 mg. of valium to
be administered immediately by intramuscular injection. Dr. Estrada later ordered the start of
intravenous administration of syntocinon admixed with dextrose, 5%, in lactated Ringers' solution, at
the rate of eight to ten micro-drops per minute.
According to the Nurse's Observation Notes, 12 Dr. Joel Enriquez ("Dr. Enriquez"), an
anesthesiologist at CMC, was notified at 4:15 a.m. of Corazon's admission. Subsequently, when
asked if he needed the services of an anesthesiologist, Dr. Estrada refused. Despite Dr. Estrada's
refusal, Dr. Enriquez stayed to observe Corazon's condition.
At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10 a.m., Corazon's
bag of water ruptured spontaneously. At 6:12 a.m., Corazon's cervix was fully dilated. At 6:13 a.m.,
Corazon started to experience convulsions.
At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfate. However, Dr. Ely
Villaflor ("Dr. Villaflor"), who was assisting Dr. Estrada, administered only 2.5 grams of magnesium
sulfate.
At 6:22 a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract Corazon's baby. In
the process, a 1.0 x 2.5 cm. piece of cervical tissue was allegedly torn. The baby came out in an
apnic, cyanotic, weak and injured condition. Consequently, the baby had to be intubated and
resuscitated by Dr. Enriquez and Dr. Payumo.
At 6:27 a.m., Corazon began to manifest moderate vaginal bleeding which rapidly became profuse.
Corazon's blood pressure dropped from 130/80 to 60/40 within five minutes. There was continuous
profuse vaginal bleeding. The assisting nurse administered hemacel through a gauge 19 needle as a
side drip to the ongoing intravenous injection of dextrose.
At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with bottled blood. It took
approximately 30 minutes for the CMC laboratory, headed by Dr. Perpetua Lacson ("Dr. Lacson"), to
comply with Dr. Estrada's order and deliver the blood.
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-Gynecology Department of
the CMC, was apprised of Corazon's condition by telephone. Upon being informed that Corazon was
bleeding profusely, Dr. Espinola ordered immediate hysterectomy. Rogelio was made to sign a
"Consent to Operation."13
Due to the inclement weather then, Dr. Espinola, who was fetched from his residence by an
ambulance, arrived at the CMC about an hour later or at 9:00 a.m. He examined the patient and
ordered some resuscitative measures to be administered. Despite Dr. Espinola's efforts, Corazon
died at 9:15 a.m. The cause of death was "hemorrhage, post partum."14
On 14 May 1980, petitioners filed a complaint for damages 15 with the Regional Trial Court16 of Manila
against CMC, Dr. Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr. Lacson, Dr. Espinola, and a certain
Nurse J. Dumlao for the death of Corazon. Petitioners mainly contended that defendant physicians
and CMC personnel were negligent in the treatment and management of Corazon's condition.
Petitioners charged CMC with negligence in the selection and supervision of defendant physicians
and hospital staff.

For failing to file their answer to the complaint despite service of summons, the trial court declared
Dr. Estrada, Dr. Enriquez, and Nurse Dumlao in default. 17 CMC, Dr. Villaflor, Dr. Uy, Dr. Espinola,
and Dr. Lacson filed their respective answers denying and opposing the allegations in the complaint.
Subsequently, trial ensued.
After more than 11 years of trial, the trial court rendered judgment on 22 November 1993 finding Dr.
Estrada solely liable for damages. The trial court ruled as follows:
The victim was under his pre-natal care, apparently, his fault began from his incorrect and
inadequate management and lack of treatment of the pre-eclamptic condition of his patient. It
is not disputed that he misapplied the forceps in causing the delivery because it resulted in a
large cervical tear which had caused the profuse bleeding which he also failed to control with
the application of inadequate injection of magnesium sulfate by his assistant Dra. Ely
Villaflor. Dr. Estrada even failed to notice the erroneous administration by nurse Dumlao of
hemacel by way of side drip, instead of direct intravenous injection, and his failure to consult
a senior obstetrician at an early stage of the problem.
On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr. Joel Enriquez, Dr. Lacson, Dr.
Espinola, nurse J. Dumlao and CMC, the Court finds no legal justification to find them civilly
liable.
On the part of Dra. Ely Villaflor, she was only taking orders from Dr. Estrada, the principal
physician of Corazon Nogales. She can only make suggestions in the manner the patient
maybe treated but she cannot impose her will as to do so would be to substitute her good
judgment to that of Dr. Estrada. If she failed to correctly diagnose the true cause of the
bleeding which in this case appears to be a cervical laceration, it cannot be safely concluded
by the Court that Dra. Villaflor had the correct diagnosis and she failed to inform Dr. Estrada.
No evidence was introduced to show that indeed Dra. Villaflor had discovered that there was
laceration at the cervical area of the patient's internal organ.
On the part of nurse Dumlao, there is no showing that when she administered the hemacel
as a side drip, she did it on her own. If the correct procedure was directly thru the veins, it
could only be because this was what was probably the orders of Dr. Estrada.
While the evidence of the plaintiffs shows that Dr. Noe Espinola, who was the Chief of the
Department of Obstetrics and Gynecology who attended to the patient Mrs. Nogales, it was
only at 9:00 a.m. That he was able to reach the hospital because of typhoon Didang (Exhibit
2). While he was able to give prescription in the manner Corazon Nogales may be treated,
the prescription was based on the information given to him by phone and he acted on the
basis of facts as presented to him, believing in good faith that such is the correct remedy. He
was not with Dr. Estrada when the patient was brought to the hospital at 2:30 o'clock a.m.
So, whatever errors that Dr. Estrada committed on the patient before 9:00 o'clock a.m. are
certainly the errors of Dr. Estrada and cannot be the mistake of Dr. Noe Espinola. His failure
to come to the hospital on time was due to fortuitous event.
On the part of Dr. Joel Enriquez, while he was present in the delivery room, it is not
incumbent upon him to call the attention of Dr. Estrada, Dra. Villaflor and also of Nurse
Dumlao on the alleged errors committed by them. Besides, as anesthesiologist, he has no
authority to control the actuations of Dr. Estrada and Dra. Villaflor. For the Court to assume
that there were errors being committed in the presence of Dr. Enriquez would be to dwell on
conjectures and speculations.

On the civil liability of Dr. Perpetua Lacson, [s]he is a hematologist and in-charge of the
blood bank of the CMC. The Court cannot accept the theory of the plaintiffs that there was
delay in delivering the blood needed by the patient. It was testified, that in order that this
blood will be made available, a laboratory test has to be conducted to determine the type of
blood, cross matching and other matters consistent with medical science so, the lapse of 30
minutes maybe considered a reasonable time to do all of these things, and not a delay as the
plaintiffs would want the Court to believe.
Admittedly, Dra. Rosa Uy is a resident physician of the Capitol Medical Center. She was
sued because of her alleged failure to notice the incompetence and negligence of Dr.
Estrada. However, there is no evidence to support such theory. No evidence was adduced to
show that Dra. Rosa Uy as a resident physician of Capitol Medical Center, had knowledge of
the mismanagement of the patient Corazon Nogales, and that notwithstanding such
knowledge, she tolerated the same to happen.
In the pre-trial order, plaintiffs and CMC agreed that defendant CMC did not have any hand
or participation in the selection or hiring of Dr. Estrada or his assistant Dra. Ely Villaflor as
attending physician[s] of the deceased. In other words, the two (2) doctors were not
employees of the hospital and therefore the hospital did not have control over their
professional conduct. When Mrs. Nogales was brought to the hospital, it was an emergency
case and defendant CMC had no choice but to admit her. Such being the case, there is
therefore no legal ground to apply the provisions of Article 2176 and 2180 of the New Civil
Code referring to the vicarious liability of an employer for the negligence of its employees. If
ever in this case there is fault or negligence in the treatment of the deceased on the part of
the attending physicians who were employed by the family of the deceased, such civil liability
should be borne by the attending physicians under the principle of "respondeat superior".
WHEREFORE, premises considered, judgment is hereby rendered finding defendant Dr.
Estrada of Number 13 Pitimini St. San Francisco del Monte, Quezon City civilly liable to pay
plaintiffs: 1) By way of actual damages in the amount of P105,000.00; 2) By way of moral
damages in the amount of P700,000.00; 3) Attorney's fees in the amount of P100,000.00
and to pay the costs of suit.
For failure of the plaintiffs to adduce evidence to support its [sic] allegations against the other
defendants, the complaint is hereby ordered dismissed. While the Court looks with disfavor
the filing of the present complaint against the other defendants by the herein plaintiffs, as in a
way it has caused them personal inconvenience and slight damage on their name and
reputation, the Court cannot accepts [sic] however, the theory of the remaining defendants
that plaintiffs were motivated in bad faith in the filing of this complaint. For this reason
defendants' counterclaims are hereby ordered dismissed.
SO ORDERED.18
Petitioners appealed the trial court's decision. Petitioners claimed that aside from Dr. Estrada, the
remaining respondents should be held equally liable for negligence. Petitioners pointed out the
extent of each respondent's alleged liability.
On 6 February 1998, the Court of Appeals affirmed the decision of the trial court.19 Petitioners filed a
motion for reconsideration which the Court of Appeals denied in its Resolution of 21 March 2000. 20
Hence, this petition.

Meanwhile, petitioners filed a Manifestation dated 12 April 200221 stating that respondents Dr.
Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao "need no longer be notified of the petition
because they are absolutely not involved in the issue raised before the [Court], regarding the liability
of [CMC]."22 Petitioners stressed that the subject matter of this petition is the liability of CMC for the
negligence of Dr. Estrada.23
The Court issued a Resolution dated 9 September 200224 dispensing with the requirement to submit
the correct and present addresses of respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse
Dumlao. The Court stated that with the filing of petitioners' Manifestation, it should be understood
that they are claiming only against respondents CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy who
have filed their respective comments. Petitioners are foregoing further claims against respondents
Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao.
The Court noted that Dr. Estrada did not appeal the decision of the Court of Appeals affirming the
decision of the Regional Trial Court. Accordingly, the decision of the Court of Appeals, affirming the
trial court's judgment, is already final as against Dr. Oscar Estrada.
Petitioners filed a motion for reconsideration25 of the Court's 9 September 2002 Resolution claiming
that Dr. Enriquez, Dr. Villaflor and Nurse Dumlao were notified of the petition at their counsels' last
known addresses. Petitioners reiterated their imputation of negligence on these respondents. The
Court denied petitioners' Motion for Reconsideration in its 18 February 2004 Resolution. 26
The Court of Appeals' Ruling
In its Decision of 6 February 1998, the Court of Appeals upheld the trial court's ruling. The Court of
Appeals rejected petitioners' view that the doctrine in Darling v. Charleston Community Memorial
Hospital27 applies to this case. According to the Court of Appeals, the present case differs from
the Darling case since Dr. Estrada is an independent contractor-physician whereas the Darling case
involved a physician and a nurse who were employees of the hospital.
Citing other American cases, the Court of Appeals further held that the mere fact that a hospital
permitted a physician to practice medicine and use its facilities is not sufficient to render the hospital
liable for the physician's negligence.28 A hospital is not responsible for the negligence of a physician
who is an independent contractor.29
The Court of Appeals found the cases of Davidson v. Conole30 and Campbell v. Emma Laing
Stevens Hospital31applicable to this case. Quoting Campbell, the Court of Appeals stated that where
there is no proof that defendant physician was an employee of defendant hospital or that defendant
hospital had reason to know that any acts of malpractice would take place, defendant hospital could
not be held liable for its failure to intervene in the relationship of physician-patient between
defendant physician and plaintiff.
On the liability of the other respondents, the Court of Appeals applied the "borrowed servant"
doctrine considering that Dr. Estrada was an independent contractor who was merely exercising
hospital privileges. This doctrine provides that once the surgeon enters the operating room and
takes charge of the proceedings, the acts or omissions of operating room personnel, and any
negligence associated with such acts or omissions, are imputable to the surgeon.32 While the
assisting physicians and nurses may be employed by the hospital, or engaged by the patient, they
normally become the temporary servants or agents of the surgeon in charge while the operation is in
progress, and liability may be imposed upon the surgeon for their negligent acts under the doctrine
of respondeat superior.33

The Court of Appeals concluded that since Rogelio engaged Dr. Estrada as the attending physician
of his wife, any liability for malpractice must be Dr. Estrada's sole responsibility.
While it found the amount of damages fair and reasonable, the Court of Appeals held that no interest
could be imposed on unliquidated claims or damages.
The Issue
Basically, the issue in this case is whether CMC is vicariously liable for the negligence of Dr.
Estrada. The resolution of this issue rests, on the other hand, on the ascertainment of the
relationship between Dr. Estrada and CMC. The Court also believes that a determination of the
extent of liability of the other respondents is inevitable to finally and completely dispose of the
present controversy.
The Ruling of the Court
The petition is partly meritorious.
On the Liability of CMC
Dr. Estrada's negligence in handling the treatment and management of Corazon's condition which
ultimately resulted in Corazon's death is no longer in issue. Dr. Estrada did not appeal the decision
of the Court of Appeals which affirmed the ruling of the trial court finding Dr. Estrada solely liable for
damages. Accordingly, the finding of the trial court on Dr. Estrada's negligence is already final.
Petitioners maintain that CMC is vicariously liable for Dr. Estrada's negligence based on Article 2180
in relation to Article 2176 of the Civil Code. These provisions pertinently state:
Art. 2180. The obligation imposed by article 2176 is demandable not only for one's own acts
or omissions, but also for those of persons for whom one is responsible.
xxxx
Employers shall be liable for the damages caused by their employees and household helpers
acting within the scope of their assigned tasks, even though the former are not engaged in
any business or industry.
xxxx
The responsibility treated of in this article shall cease when the persons herein mentioned
prove that they observed all the diligence of a good father of a family to prevent damage.
Art. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done. Such fault or negligence, if there is no
pre-existing contractual relation between the parties, is called a quasi-delict and is governed
by the provisions of this Chapter.
Similarly, in the United States, a hospital which is the employer, master, or principal of a physician
employee, servant, or agent, may be held liable for the physician's negligence under the doctrine
of respondeat superior.34

In the present case, petitioners maintain that CMC, in allowing Dr. Estrada to practice and admit
patients at CMC, should be liable for Dr. Estrada's malpractice. Rogelio claims that he knew Dr.
Estrada as an accredited physician of CMC, though he discovered later that Dr. Estrada was not a
salaried employee of the CMC.35 Rogelio further claims that he was dealing with CMC, whose
primary concern was the treatment and management of his wife's condition. Dr. Estrada just
happened to be the specific person he talked to representing CMC. 36 Moreover, the fact that CMC
made Rogelio sign a Consent on Admission and Admission Agreement 37 and a Consent to
Operation printed on the letterhead of CMC indicates that CMC considered Dr. Estrada as a member
of its medical staff.
On the other hand, CMC disclaims liability by asserting that Dr. Estrada was a mere visiting
physician and that it admitted Corazon because her physical condition then was classified an
emergency obstetrics case.38
CMC alleges that Dr. Estrada is an independent contractor "for whose actuations CMC would be a
total stranger." CMC maintains that it had no control or supervision over Dr. Estrada in the exercise
of his medical profession.
The Court had the occasion to determine the relationship between a hospital and a consultant or
visiting physician and the liability of such hospital for that physician's negligence in Ramos v. Court
of Appeals,39 to wit:
In the first place, hospitals exercise significant control in the hiring and firing of consultants
and in the conduct of their work within the hospital premises. Doctors who apply for
"consultant" slots, visiting or attending, are required to submit proof of completion of
residency, their educational qualifications; generally, evidence of accreditation by the
appropriate board (diplomate), evidence of fellowship in most cases, and references. These
requirements are carefully scrutinized by members of the hospital administration or by a
review committee set up by the hospital who either accept or reject the application. This is
particularly true with respondent hospital.
After a physician is accepted, either as a visiting or attending consultant, he is normally
required to attend clinico-pathological conferences, conduct bedside rounds for clerks,
interns and residents, moderate grand rounds and patient audits and perform other tasks
and responsibilities, for the privilege of being able to maintain a clinic in the hospital, and/or
for the privilege of admitting patients into the hospital. In addition to these, the physician's
performance as a specialist is generally evaluated by a peer review committee on the basis
of mortality and morbidity statistics, and feedback from patients, nurses, interns and
residents. A consultant remiss in his duties, or a consultant who regularly falls short of the
minimum standards acceptable to the hospital or its peer review committee, is normally
politely terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and
visiting "consultant" staff. While "consultants" are not, technically employees, a point
which respondent hospital asserts in denying all responsibility for the patient's
condition, the control exercised, the hiring, and the right to terminate consultants all
fulfill the important hallmarks of an employer-employee relationship, with the
exception of the payment of wages. In assessing whether such a relationship in fact
exists, the control test is determining. Accordingly, on the basis of the foregoing, we
rule that for the purpose of allocating responsibility in medical negligence cases, an
employer-employee relationship in effect exists between hospitals and their attending

and visiting physicians. This being the case, the question now arises as to whether or not
respondent hospital is solidarily liable with respondent doctors for petitioner's condition.
The basis for holding an employer solidarily responsible for the negligence of its employee is
found in Article 2180 of the Civil Code which considers a person accountable not only for his
own acts but also for those of others based on the former's responsibility under a relationship
of patria potestas. x x x40(Emphasis supplied)
While the Court in Ramos did not expound on the control test, such test essentially determines
whether an employment relationship exists between a physician and a hospital based on the
exercise of control over the physician as to details. Specifically, the employer (or the hospital) must
have the right to control both the means and the details of the process by which the employee (or
the physician) is to accomplish his task. 41
After a thorough examination of the voluminous records of this case, the Court finds no single
evidence pointing to CMC's exercise of control over Dr. Estrada's treatment and management of
Corazon's condition. It is undisputed that throughout Corazon's pregnancy, she was under the
exclusive prenatal care of Dr. Estrada. At the time of Corazon's admission at CMC and during her
delivery, it was Dr. Estrada, assisted by Dr. Villaflor, who attended to Corazon. There was no
showing that CMC had a part in diagnosing Corazon's condition. While Dr. Estrada enjoyed staff
privileges at CMC, such fact alone did not make him an employee of CMC. 42 CMC merely allowed
Dr. Estrada to use its facilities43 when Corazon was about to give birth, which CMC considered an
emergency. Considering these circumstances, Dr. Estrada is not an employee of CMC, but an
independent contractor.
The question now is whether CMC is automatically exempt from liability considering that Dr. Estrada
is an independent contractor-physician.
In general, a hospital is not liable for the negligence of an independent contractor-physician. There
is, however, an exception to this principle. The hospital may be liable if the physician is the
"ostensible" agent of the hospital.44This exception is also known as the "doctrine of apparent
authority."45 In Gilbert v. Sycamore Municipal Hospital,46 the Illinois Supreme Court explained the
doctrine of apparent authority in this wise:
[U]nder the doctrine of apparent authority a hospital can be held vicariously liable for the
negligent acts of a physician providing care at the hospital, regardless of whether the
physician is an independent contractor, unless the patient knows, or should have known, that
the physician is an independent contractor. The elements of the action have been set out as
follows:
"For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show
that: (1) the hospital, or its agent, acted in a manner that would lead a reasonable person to
conclude that the individual who was alleged to be negligent was an employee or agent of
the hospital; (2) where the acts of the agent create the appearance of authority, the plaintiff
must also prove that the hospital had knowledge of and acquiesced in them; and (3) the
plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with
ordinary care and prudence."
The element of "holding out" on the part of the hospital does not require an express
representation by the hospital that the person alleged to be negligent is an employee.
Rather, the element is satisfied if the hospital holds itself out as a provider of emergency
room care without informing the patient that the care is provided by independent contractors.

The element of justifiable reliance on the part of the plaintiff is satisfied if the plaintiff relies
upon the hospital to provide complete emergency room care, rather than upon a specific
physician.
The doctrine of apparent authority essentially involves two factors to determine the liability of an
independent-contractor physician.
The first factor focuses on the hospital's manifestations and is sometimes described as an inquiry
whether the hospital acted in a manner which would lead a reasonable person to conclude that the
individual who was alleged to be negligent was an employee or agent of the hospital. 47 In this
regard, the hospital need not make express representations to the patient that the treating
physician is an employee of the hospital; rather a representation may be general and
implied.48
The doctrine of apparent authority is a species of the doctrine of estoppel. Article 1431 of the Civil
Code provides that "[t]hrough estoppel, an admission or representation is rendered conclusive upon
the person making it, and cannot be denied or disproved as against the person relying thereon."
Estoppel rests on this rule: "Whenever a party has, by his own declaration, act, or omission,
intentionally and deliberately led another to believe a particular thing true, and to act upon such
belief, he cannot, in any litigation arising out of such declaration, act or omission, be permitted to
falsify it."49
In the instant case, CMC impliedly held out Dr. Estrada as a member of its medical staff. Through
CMC's acts, CMC clothed Dr. Estrada with apparent authority thereby leading the Spouses Nogales
to believe that Dr. Estrada was an employee or agent of CMC. CMC cannot now repudiate such
authority.
First, CMC granted staff privileges to Dr. Estrada. CMC extended its medical staff and facilities to Dr.
Estrada. Upon Dr. Estrada's request for Corazon's admission, CMC, through its personnel, readily
accommodated Corazon and updated Dr. Estrada of her condition.
Second, CMC made Rogelio sign consent forms printed on CMC letterhead. Prior to Corazon's
admission and supposed hysterectomy, CMC asked Rogelio to sign release forms, the contents of
which reinforced Rogelio's belief that Dr. Estrada was a member of CMC's medical staff. 50 The
Consent on Admission and Agreement explicitly provides:
KNOW ALL MEN BY THESE PRESENTS:
I, Rogelio Nogales, of legal age, a resident of 1974 M. H. Del Pilar St., Malate Mla., being the
father/mother/brother/sister/spouse/relative/ guardian/or person in custody of Ma. Corazon,
and representing his/her family, of my own volition and free will, do consent and submit said
Ma. Corazon to Dr. Oscar Estrada (hereinafter referred to as Physician) for cure, treatment,
retreatment, or emergency measures, that the Physician, personally or by and through
the Capitol Medical Center and/or its staff, may use, adapt, or employ such means,
forms or methods of cure, treatment, retreatment, or emergency measures as he may
see best and most expedient; that Ma. Corazon and I will comply with any and all
rules, regulations, directions, and instructions of the Physician, the Capitol Medical
Center and/or its staff; and, that I will not hold liable or responsible and hereby waive and
forever discharge and hold free the Physician, the Capitol Medical Center and/or its staff,
from any and all claims of whatever kind of nature, arising from directly or indirectly, or by
reason of said cure, treatment, or retreatment, or emergency measures or intervention of
said physician, the Capitol Medical Center and/or its staff.

x x x x51 (Emphasis supplied)

While the Consent to Operation pertinently reads, thus:
I, ROGELIO NOGALES, x x x, of my own volition and free will, do consent and submit said
CORAZON NOGALES to Hysterectomy, by the Surgical Staff and Anesthesiologists of
Capitol Medical Centerand/or whatever succeeding operations, treatment, or emergency
measures as may be necessary and most expedient; and, that I will not hold liable or
responsible and hereby waive and forever discharge and hold free the Surgeon, his
assistants, anesthesiologists, the Capitol Medical Center and/or its staff, from any and all
claims of whatever kind of nature, arising from directly or indirectly, or by reason of said
operation or operations, treatment, or emergency measures, or intervention of the Surgeon,
his assistants, anesthesiologists, the Capitol Medical Center and/or its staff. 52 (Emphasis
supplied)
Without any indication in these consent forms that Dr. Estrada was an independent contractorphysician, the Spouses Nogales could not have known that Dr. Estrada was an independent
contractor. Significantly, no one from CMC informed the Spouses Nogales that Dr. Estrada was an
independent contractor. On the contrary, Dr. Atencio, who was then a member of CMC Board of
Directors, testified that Dr. Estrada was part of CMC's surgical staff. 53
Third, Dr. Estrada's referral of Corazon's profuse vaginal bleeding to Dr. Espinola, who was then the
Head of the Obstetrics and Gynecology Department of CMC, gave the impression that Dr. Estrada
as a member of CMC's medical staff was collaborating with other CMC-employed specialists in
treating Corazon.
The second factor focuses on the patient's reliance. It is sometimes characterized as an inquiry on
whether the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with
ordinary care and prudence.54
The records show that the Spouses Nogales relied upon a perceived employment relationship with
CMC in accepting Dr. Estrada's services. Rogelio testified that he and his wife specifically chose Dr.
Estrada to handle Corazon's delivery not only because of their friend's recommendation, but more
importantly because of Dr. Estrada's "connection with a reputable hospital, the [CMC]." 55 In other
words, Dr. Estrada's relationship with CMC played a significant role in the Spouses Nogales'
decision in accepting Dr. Estrada's services as the obstetrician-gynecologist for Corazon's delivery.
Moreover, as earlier stated, there is no showing that before and during Corazon's confinement at
CMC, the Spouses Nogales knew or should have known that Dr. Estrada was not an employee of
CMC.
Further, the Spouses Nogales looked to CMC to provide the best medical care and support services
for Corazon's delivery. The Court notes that prior to Corazon's fourth pregnancy, she used to give
birth inside a clinic. Considering Corazon's age then, the Spouses Nogales decided to have their
fourth child delivered at CMC, which Rogelio regarded one of the best hospitals at the time. 56 This is
precisely because the Spouses Nogales feared that Corazon might experience complications during
her delivery which would be better addressed and treated in a modern and big hospital such as
CMC. Moreover, Rogelio's consent in Corazon's hysterectomy to be performed by a different
physician, namely Dr. Espinola, is a clear indication of Rogelio's confidence in CMC's surgical staff.
CMC's defense that all it did was "to extend to [Corazon] its facilities" is untenable. The Court cannot
close its eyes to the reality that hospitals, such as CMC, are in the business of treatment. In this

regard, the Court agrees with the observation made by the Court of Appeals of North Carolina in
Diggs v. Novant Health, Inc.,57 to wit:
"The conception that the hospital does not undertake to treat the patient, does not undertake
to act through its doctors and nurses, but undertakes instead simply to procure them to act
upon their own responsibility, no longer reflects the fact. Present day hospitals, as their
manner of operation plainly demonstrates, do far more than furnish facilities for
treatment. They regularly employ on a salary basis a large staff of physicians, nurses
and internes [sic], as well as administrative and manual workers, and they charge
patients for medical care and treatment, collecting for such services, if necessary, by
legal action. Certainly, the person who avails himself of 'hospital facilities' expects
that the hospital will attempt to cure him, not that its nurses or other employees will
act on their own responsibility." x x x (Emphasis supplied)
Likewise unconvincing is CMC's argument that petitioners are estopped from claiming damages
based on the Consent on Admission and Consent to Operation. Both release forms consist of two
parts. The first part gave CMC permission to administer to Corazon any form of recognized medical
treatment which the CMC medical staff deemed advisable. The second part of the documents, which
may properly be described as the releasing part, releases CMC and its employees "from any and all
claims" arising from or by reason of the treatment and operation.
The documents do not expressly release CMC from liability for injury to Corazon due to negligence
during her treatment or operation. Neither do the consent forms expressly exempt CMC from liability
for Corazon's death due to negligence during such treatment or operation. Such release forms,
being in the nature of contracts of adhesion, are construed strictly against hospitals. Besides, a
blanket release in favor of hospitals "from any and all claims," which includes claims due to bad faith
or gross negligence, would be contrary to public policy and thus void.
Even simple negligence is not subject to blanket release in favor of establishments like hospitals but
may only mitigate liability depending on the circumstances.58 When a person needing urgent medical
attention rushes to a hospital, he cannot bargain on equal footing with the hospital on the terms of
admission and operation. Such a person is literally at the mercy of the hospital. There can be no
clearer example of a contract of adhesion than one arising from such a dire situation. Thus, the
release forms of CMC cannot relieve CMC from liability for the negligent medical treatment of
Corazon.
On the Liability of the Other Respondents
Despite this Court's pronouncement in its 9 September 200259 Resolution that the filing of petitioners'
Manifestation confined petitioners' claim only against CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy,
who have filed their comments, the Court deems it proper to resolve the individual liability of the
remaining respondents to put an end finally to this more than two-decade old controversy.
a) Dr. Ely Villaflor
Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause of Corazon's bleeding and to
suggest the correct remedy to Dr. Estrada. 60 Petitioners assert that it was Dr. Villaflor's duty to
correct the error of Nurse Dumlao in the administration of hemacel.
The Court is not persuaded. Dr. Villaflor admitted administering a lower dosage of magnesium
sulfate. However, this was after informing Dr. Estrada that Corazon was no longer in convulsion and
that her blood pressure went down to a dangerous level. 61 At that moment, Dr. Estrada instructed Dr.

Villaflor to reduce the dosage of magnesium sulfate from 10 to 2.5 grams. Since petitioners did not
dispute Dr. Villaflor's allegation, Dr. Villaflor's defense remains uncontroverted. Dr. Villaflor's act of
administering a lower dosage of magnesium sulfate was not out of her own volition or was in
contravention of Dr. Estrada's order.
b) Dr. Rosa Uy
Dr. Rosa Uy's alleged negligence consisted of her failure (1) to call the attention of Dr. Estrada on
the incorrect dosage of magnesium sulfate administered by Dr. Villaflor; (2) to take corrective
measures; and (3) to correct Nurse Dumlao's wrong method of hemacel administration.
The Court believes Dr. Uy's claim that as a second year resident physician then at CMC, she was
merely authorized to take the clinical history and physical examination of Corazon. 62 However, that
routine internal examination did not ipso facto make Dr. Uy liable for the errors committed by Dr.
Estrada. Further, petitioners' imputation of negligence rests on their baseless assumption that Dr. Uy
was present at the delivery room. Nothing shows that Dr. Uy participated in delivering Corazon's
baby. Further, it is unexpected from Dr. Uy, a mere resident physician at that time, to call the
attention of a more experienced specialist, if ever she was present at the delivery room.
c) Dr. Joel Enriquez
Petitioners fault Dr. Joel Enriquez also for not calling the attention of Dr. Estrada, Dr. Villaflor, and
Nurse Dumlao about their errors.63 Petitioners insist that Dr. Enriquez should have taken, or at least
suggested, corrective measures to rectify such errors.
The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field of expertise is definitely
not obstetrics and gynecology. As such, Dr. Enriquez was not expected to correct Dr. Estrada's
errors. Besides, there was no evidence of Dr. Enriquez's knowledge of any error committed by Dr.
Estrada and his failure to act upon such observation.
d) Dr. Perpetua Lacson
Petitioners fault Dr. Perpetua Lacson for her purported delay in the delivery of blood Corazon
needed.64Petitioners claim that Dr. Lacson was remiss in her duty of supervising the blood bank
staff.
As found by the trial court, there was no unreasonable delay in the delivery of blood from the time of
the request until the transfusion to Corazon. Dr. Lacson competently explained the procedure before
blood could be given to the patient.65 Taking into account the bleeding time, clotting time and crossmatching, Dr. Lacson stated that it would take approximately 45-60 minutes before blood could be
ready for transfusion.66 Further, no evidence exists that Dr. Lacson neglected her duties as head of
the blood bank.
e) Dr. Noe Espinola
Petitioners argue that Dr. Espinola should not have ordered immediate hysterectomy without
determining the underlying cause of Corazon's bleeding. Dr. Espinola should have first considered
the possibility of cervical injury, and advised a thorough examination of the cervix, instead of
believing outright Dr. Estrada's diagnosis that the cause of bleeding was uterine atony.

Dr. Espinola's order to do hysterectomy which was based on the information he received by phone is
not negligence. The Court agrees with the trial court's observation that Dr. Espinola, upon hearing
such information about Corazon's condition, believed in good faith that hysterectomy was the correct
remedy. At any rate, the hysterectomy did not push through because upon Dr. Espinola's arrival, it
was already too late. At the time, Corazon was practically dead.
f) Nurse J. Dumlao
In Moore v. Guthrie Hospital Inc.,67 the US Court of Appeals, Fourth Circuit, held that to recover, a
patient complaining of injuries allegedly resulting when the nurse negligently injected medicine to
him intravenously instead of intramuscularly had to show that (1) an intravenous injection constituted
a lack of reasonable and ordinary care; (2) the nurse injected medicine intravenously; and (3) such
injection was the proximate cause of his injury.
In the present case, there is no evidence of Nurse Dumlao's alleged failure to follow Dr. Estrada's
specific instructions. Even assuming Nurse Dumlao defied Dr. Estrada's order, there is no showing
that side-drip administration of hemacel proximately caused Corazon's death. No evidence linking
Corazon's death and the alleged wrongful hemacel administration was introduced. Therefore, there
is no basis to hold Nurse Dumlao liable for negligence.
On the Award of Interest on Damages
The award of interest on damages is proper and allowed under Article 2211 of the Civil Code, which
states that in crimes and quasi-delicts, interest as a part of the damages may, in a proper case, be
adjudicated in the discretion of the court.68
WHEREFORE, the Court PARTLY GRANTS the petition. The Court finds respondent Capitol
Medical Center vicariously liable for the negligence of Dr. Oscar Estrada. The amounts of P105,000
as actual damages andP700,000 as moral damages should each earn legal interest at the rate of six
percent (6%) per annum computed from the date of the judgment of the trial court. The Court affirms
the rest of the Decision dated 6 February 1998 and Resolution dated 21 March 2000 of the Court of
Appeals in CA-G.R. CV No. 45641.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
SECOND DIVISION
G.R. No. 160889

April 27, 2007

DR. MILAGROS L. CANTRE, Petitioner,

vs.
SPS. JOHN DAVID Z. GO and NORA S. GO, Respondents.
DECISION
QUISUMBING, J.:
For review on certiorari are the Decision1 dated October 3, 2002 and Resolution2 dated November
19, 2003 of the Court of Appeals in CA-G.R. CV No. 58184, which affirmed with modification the
Decision3 dated March 3, 1997 of the Regional Trial Court of Quezon City, Branch 98, in Civil Case
No. Q-93-16562.
The facts, culled from the records, are as follows:
Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and Gynecology at the Dr. Jesus
Delgado Memorial Hospital. She was the attending physician of respondent Nora S. Go, who was
admitted at the said hospital on April 19, 1992.
At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy. However, at around
3:30 a.m., Nora suffered profuse bleeding inside her womb due to some parts of the placenta which
were not completely expelled from her womb after delivery. Consequently, Nora suffered
hypovolemic shock, resulting in a drop in her blood pressure to "40" over "0." Petitioner and the
assisting resident physician performed various medical procedures to stop the bleeding and to
restore Noras blood pressure. Her blood pressure was frequently monitored with the use of a
sphygmomanometer. While petitioner was massaging Noras uterus for it to contract and stop
bleeding, she ordered a droplight to warm Nora and her baby. 4 Nora remained unconscious until she
recovered.
While in the recovery room, her husband, respondent John David Z. Go noticed a fresh gaping
wound two and a half (2 ) by three and a half (3 ) inches in the inner portion of her left arm, close
to the armpit.5 He asked the nurses what caused the injury. He was informed it was a burn.
Forthwith, on April 22, 1992, John David filed a request for investigation.6 In response, Dr. Rainerio
S. Abad, the medical director of the hospital, called petitioner and the assisting resident physician to
explain what happened. Petitioner said the blood pressure cuff caused the injury.
On May 7, 1992, John David brought Nora to the National Bureau of Investigation for a physical
examination, which was conducted by medico-legal officer Dr. Floresto Arizala, Jr.7 The medico-legal
officer later testified that Noras injury appeared to be a burn and that a droplight when placed near
the skin for about 10 minutes could cause such burn.8 He dismissed the likelihood that the wound
was caused by a blood pressure cuff as the scar was not around the arm, but just on one side of the
arm.9

On May 22, 1992, Noras injury was referred to a plastic surgeon at the Dr. Jesus Delgado Memorial
Hospital for skin grafting.10 Her wound was covered with skin sourced from her abdomen, which
consequently bore a scar as well. About a year after, on April 30, 1993, scar revision had to be
performed at the same hospital.11 The surgical operation left a healed linear scar in Noras left arm
about three inches in length, the thickest portion rising about one-fourth (1/4) of an inch from the
surface of the skin. The costs of the skin grafting and the scar revision were shouldered by the
hospital.12
Unfortunately, Noras arm would never be the same. Aside from the unsightly mark, the pain in her
left arm remains. When sleeping, she has to cradle her wounded arm. Her movements now are also
restricted. Her children cannot play with the left side of her body as they might accidentally bump the
injured arm, which aches at the slightest touch.
1a\^/phi1.net

Thus, on June 21, 1993, respondent spouses filed a complaint 13 for damages against petitioner, Dr.
Abad, and the hospital. Finding in favor of respondent spouses, the trial court decreed:
In view of the foregoing consideration, judgment is hereby rendered in favor of the plaintiffs and
against the defendants, directing the latters, (sic) jointly and severally
(a) to pay the sum of Five Hundred Thousand Pesos (P500,000.00) in moral damages;
(b) to pay the sum of One Hundred Fifty Thousand Pesos (P150,000.00) exemplary
damages;
(c) to pay the sum of Eighty Thousand Pesos (P80,000.00) nominal damages;
(d) to pay Fifty Thousand Pesos (P50,000.00) for and as attorneys fees; and
(e) to pay Six Thousand Pesos (P6,000.00) litigation expenses.
SO ORDERED.14
Petitioner, Dr. Abad, and the hospital all appealed to the Court of Appeals, which affirmed with
modification the trial court decision, thus:
WHEREFORE, in view of all the foregoing, and finding no reversible error in the appealed Decision
dated March 3, 1997 of Branch 98 of the Regional Trial Court of Quezon City in Civil Case No. Q-9316562, the same is hereby AFFIRMED, with the following MODIFICATIONS:
1. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay plaintiffs-appellees
John David Go and Nora S. Go the sum of P200,000.00 as moral damages;
2. Deleting the award [of] exemplary damages, attorneys fees and expenses of litigation;

1awphi1.nt

3. Dismissing the complaint with respect to defendants-appellants Dr. Rainerio S. Abad and
Delgado Clinic, Inc.;
4. Dismissing the counterclaims of defendants-appellants for lack of merit; and
5. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay the costs.

SO ORDERED.15
Petitioners motion for reconsideration was denied by the Court of Appeals. Hence, the instant
petition assigning the following as errors and issues:
I.
WHETHER OR NOT, THE LOWER COURT, AND THE COURT OF APPEALS COMMITTED
GRAVE ABUSE OF THEIR DISCRETION WHEN, NOTWITHSTANDING THAT BOTH PARTIES
HAVE RESTED THEIR RESPECTIVE CASES, THE LOWER COURT ADMITTED THE
ADDITIONAL EXHIBITS FURTHER OFFERED BY RESPONDENTS NOT TESTIFIED TO BY ANY
WITNESS AND THIS DECISION OF THE LOWER COURT WAS UPHELD BY THE COURT OF
APPEALS LIKEWISE COMMITTING GRAVE ABUSE OF DISCRETION;
II.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION
WHEN, CONTRARY TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE PETITIONER,
IT RULED THAT THE PETITIONER HAS NOT AMPLY SHOWED THAT THE DROPLIGHT DID
NOT TOUCH THE BODY OF MRS. NORA GO, AND THIS DECISION OF THE LOWER COURT
WAS UPHELD BY THE COURT OF APPEALS LIKEWISE COMMITTING GRAVE ABUSE OF
DISCRETION;
III.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION
WHEN, CONTRARY TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE PETITIONER,
IT RULED THAT PETITIONER DRA. CANTRE WAS NOT ABLE TO AMPLY EXPLAIN HOW THE
INJURY (BLISTERS) IN THE LEFT INNER ARM OF RESPONDENT MRS. GO CAME ABOUT;
IV.
WHETHER OR NOT THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF ITS
DISCRETION WHEN IT MADE A RULING ON THE RESPONDENTS INJURY QUOTING THE
TESTIMONY OF SOMEONE WHO WAS NOT PRESENT AND HAS NOT SEEN THE ORIGINAL,
FRESH INJURY OF RESPONDENT MRS. NORA GO;
V.
WHETHER OR NOT THE COURT OF APPEALS GRAVELY ABUSING ITS DISCRETION RULED
THAT PETITIONER DRA. CANTRE SHOULD HAVE INTENDED TO INFLICT THE INJURY TO
SAVE THE LIFE OF RESPONDENT MRS. GO;
VI.
WHETHER OR NOT THE LOWER COURT AND THE COURT [OF] APPEALS COMMITTED
GRAVE ABUSE OF DISCRETION WHEN, CONTRARY TO THE DETAILED PROCEDURES DONE
BY PETITIONER, BOTH RULED THAT THE RESPONDENT WAS LEFT TO THE CARE OF THE
NURSING STAFF;
VII.

WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF DISCRETION

WHEN, CONTRARY TO THE MEDICAL PURPOSES OF COSMETIC SURGERY, IT RULED THAT
THE COSMETIC SURGERY MADE THE SCARS EVEN MORE UGLY AND DECLARED THE
COSMETIC SURGERY A FAILURE;
VIII.
WHETHER OR NOT THE LOWER COURT GRAVELY ABUSE OF (SIC) DISCRETION WHEN,
CONTRARY TO RESPONDENTS CONTRARY TESTIMONIES AND THE ABSENCE OF ANY
TESTIMONY, IT RULED THAT THEY ARE ENTITLED TO DAMAGES AND WHICH WAS UPHELD,
ALTHOUGH MODIFIED, BY THE COURT OF APPEALS LIKEWISE ABUSING ITS DISCRETION. 16
Petitioner contends that additional documentary exhibits not testified to by any witness are
inadmissible in evidence because they deprived her of her constitutional right to confront the
witnesses against her. Petitioner insists the droplight could not have touched Noras body. She
maintains the injury was due to the constant taking of Noras blood pressure. Petitioner also
insinuates the Court of Appeals was misled by the testimony of the medico-legal officer who never
saw the original injury before plastic surgery was performed. Finally, petitioner stresses that plastic
surgery was not intended to restore respondents injury to its original state but rather to prevent
further complication.
Respondents, however, counter that the genuineness and due execution of the additional
documentary exhibits were duly admitted by petitioners counsel. Respondents point out that
petitioners blood pressure cuff theory is highly improbable, being unprecedented in medical history
and that the injury was definitely caused by the droplight. At any rate, they argue, even if the injury
was brought about by the blood pressure cuff, petitioner was still negligent in her duties as Noras
attending physician.
Simply put, the threshold issues for resolution are: (1) Are the questioned additional exhibits
admissible in evidence? (2) Is petitioner liable for the injury suffered by respondent Nora Go?
Thereafter, the inquiry is whether the appellate court committed grave abuse of discretion in its
assailed issuances.
As to the first issue, we agree with the Court of Appeals that said exhibits are admissible in
evidence. We note that the questioned exhibits consist mostly of Noras medical records, which were
produced by the hospital during trial pursuant to a subpoena duces tecum. Petitioners counsel
admitted the existence of the same when they were formally offered for admission by the trial court.
In any case, given the particular circumstances of this case, a ruling on the negligence of petitioner
may be made based on the res ipsa loquitur doctrine even in the absence of such additional exhibits.
Petitioners contention that the medico-legal officer who conducted Noras physical examination
never saw her original injury before plastic surgery was performed is without basis and contradicted
by the records. Records show that the medico-legal officer conducted the physical examination on
May 7, 1992, while the skin grafting and the scar revision were performed on Nora on May 22, 1992
and April 30, 1993, respectively.
Coming now to the substantive matter, is petitioner liable for the injury suffered by respondent Nora
Go?
The Hippocratic Oath mandates physicians to give primordial consideration to the well-being of their
patients. If a doctor fails to live up to this precept, he is accountable for his acts. This
notwithstanding, courts face a unique restraint in adjudicating medical negligence cases because

physicians are not guarantors of care and, they never set out to intentionally cause injury to their
patients. However, intent is immaterial in negligence cases because where negligence exists and is
proven, it automatically gives the injured a right to reparation for the damage caused. 17
In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere existence of
an injury to justify a presumption of negligence on the part of the person who controls the instrument
causing the injury, provided that the following requisites concur:
1. The accident is of a kind which ordinarily does not occur in the absence of someones
negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or
defendants; and
3. The possibility of contributing conduct which would make the plaintiff responsible is
eliminated.18
As to the first requirement, the gaping wound on Noras arm is certainly not an ordinary occurrence
in the act of delivering a baby, far removed as the arm is from the organs involved in the process of
giving birth. Such injury could not have happened unless negligence had set in somewhere.
Second, whether the injury was caused by the droplight or by the blood pressure cuff is of no
moment. Both instruments are deemed within the exclusive control of the physician in charge under
the "captain of the ship" doctrine. This doctrine holds the surgeon in charge of an operation liable for
the negligence of his assistants during the time when those assistants are under the surgeons
control.19 In this particular case, it can be logically inferred that petitioner, the senior consultant in
charge during the delivery of Noras baby, exercised control over the assistants assigned to both the
use of the droplight and the taking of Noras blood pressure. Hence, the use of the droplight and the
blood pressure cuff is also within petitioners exclusive control.
Third, the gaping wound on Noras left arm, by its very nature and considering her condition, could
only be caused by something external to her and outside her control as she was unconscious while
in hypovolemic shock. Hence, Nora could not, by any stretch of the imagination, have contributed to
her own injury.
Petitioners defense that Noras wound was caused not by the droplight but by the constant taking of
her blood pressure, even if the latter was necessary given her condition, does not absolve her from
liability. As testified to by the medico-legal officer, Dr. Arizala, Jr., the medical practice is to deflate
the blood pressure cuff immediately after each use. Otherwise, the inflated band can cause injury to
the patient similar to what could have happened in this case. Thus, if Noras wound was caused by
the blood pressure cuff, then the taking of Noras blood pressure must have been done so
negligently as to have inflicted a gaping wound on her arm,20 for which petitioner cannot escape
liability under the "captain of the ship" doctrine.
Further, petitioners argument that the failed plastic surgery was not intended as a cosmetic
procedure, but rather as a measure to prevent complication does not help her case. It does not
negate negligence on her part.
Based on the foregoing, the presumption that petitioner was negligent in the exercise of her
profession stands unrebutted. In this connection, the Civil Code provides:

ART. 2176. Whoever by act or omission causes damage to another, there being fault or negligence,
is obliged to pay for the damage done.
ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious anxiety,
besmirched reputation, wounded feelings, moral shock, social humiliation, and similar injury. Though
incapable of pecuniary computation, moral damages may be recovered if they are the proximate
result of the defendants wrongful act or omission.
Clearly, under the law, petitioner is obliged to pay Nora for moral damages suffered by the latter as a
proximate result of petitioners negligence.
We note, however, that petitioner has served well as Noras obstetrician for her past three
successful deliveries. This is the first time petitioner is being held liable for damages due to
negligence in the practice of her profession. The fact that petitioner promptly took care of Noras
wound before infection and other complications set in is also indicative of petitioners good
intentions. We also take note of the fact that Nora was suffering from a critical condition when the
injury happened, such that saving her life became petitioners elemental concern. Nonetheless, it
should be stressed that all these could not justify negligence on the part of petitioner.
Hence, considering the specific circumstances in the instant case, we find no grave abuse of
discretion in the assailed decision and resolution of the Court of Appeals. Further, we rule that the
Court of Appeals award of Two Hundred Thousand Pesos (P200,000) as moral damages in favor of
respondents and against petitioner is just and equitable. 21
WHEREFORE, the petition is DENIED. The Decision dated October 3, 2002 and Resolution dated
November 19, 2003 of the Court of Appeals in CA-G.R. CV No. 58184 are AFFIRMED.
No pronouncement as to costs.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
FIRST DIVISION

G.R. No. 124354 December 29, 1999

ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural guardians of
the minors, ROMMEL RAMOS, ROY RODERICK RAMOS and RON RAYMOND
RAMOS, petitioners,
vs.
COURT OF APPEALS, DELOS SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and DRA.
PERFECTA GUTIERREZ, respondents.

KAPUNAN, J.:
The Hippocratic Oath mandates physicians to give primordial consideration to the health and welfare
of their patients. If a doctor fails to live up to this precept, he is made accountable for his acts. A
mistake, through gross negligence or incompetence or plain human error, may spell the difference
between life and death. In this sense, the doctor plays God on his patient's fate. 1
In the case at bar, the Court is called upon to rule whether a surgeon, an anesthesiologist and a
hospital should be made liable for the unfortunate comatose condition of a patient scheduled for
cholecystectomy. 2
Petitioners seek the reversal of the decision 3 of the Court of Appeals, dated 29 May 1995, which
overturned the decision 4 of the Regional Trial Court, dated 30 January 1992, finding private respondents
liable for damages arising from negligence in the performance of their professional duties towards
petitioner Erlinda Ramos resulting in her comatose condition.

The antecedent facts as summarized by the trial court are reproduced hereunder:
Plaintiff Erlinda Ramos was, until the afternoon of June 17, 1985, a 47-year old (Exh.
"A") robust woman (TSN, October 19, 1989, p. 10). Except for occasional complaints
of discomfort due to pains allegedly caused by the presence of a stone in her gall
bladder (TSN, January 13, 1988, pp. 4-5), she was as normal as any other woman.
Married to Rogelio E. Ramos, an executive of Philippine Long Distance Telephone
Company, she has three children whose names are Rommel Ramos, Roy Roderick
Ramos and Ron Raymond Ramos (TSN, October 19, 1989, pp. 5-6).
Because the discomforts somehow interfered with her normal ways, she sought
professional advice. She was advised to undergo an operation for the removal of a
stone in her gall bladder (TSN, January 13, 1988, p. 5). She underwent a series of
examinations which included blood and urine tests (Exhs. "A" and "C") which
indicated she was fit for surgery.

Through the intercession of a mutual friend, Dr. Buenviaje (TSN, January 13, 1988,
p. 7), she and her husband Rogelio met for the first time Dr. Orlino Hozaka (should
be Hosaka; see TSN, February 20, 1990, p. 3), one of the defendants in this case, on
June 10, 1985. They agreed that their date at the operating table at the DLSMC
(another defendant), would be on June 17, 1985 at 9:00 A.M.. Dr. Hosaka decided
that she should undergo a "cholecystectomy" operation after examining the
documents (findings from the Capitol Medical Center, FEU Hospital and DLSMC)
presented to him. Rogelio E. Ramos, however, asked Dr. Hosaka to look for a good
anesthesiologist. Dr. Hosaka, in turn, assured Rogelio that he will get a good
anesthesiologist. Dr. Hosaka charged a fee of P16,000.00, which was to include the
anesthesiologist's fee and which was to be paid after the operation (TSN, October
19, 1989, pp. 14-15, 22-23, 31-33; TSN, February 27, 1990, p. 13; and TSN,
November 9, 1989, pp. 3-4, 10, 17).
A day before the scheduled date of operation, she was admitted at one of the rooms
of the DLSMC, located along E. Rodriguez Avenue, Quezon City (TSN, October
19,1989, p. 11).
At around 7:30 A.M. of June 17, 1985 and while still in her room, she was prepared
for the operation by the hospital staff. Her sister-in-law, Herminda Cruz, who was the
Dean of the College of Nursing at the Capitol Medical Center, was also there for
moral support. She reiterated her previous request for Herminda to be with her even
during the operation. After praying, she was given injections. Her hands were held by
Herminda as they went down from her room to the operating room (TSN, January 13,
1988, pp. 9-11). Her husband, Rogelio, was also with her (TSN, October 19, 1989, p.
18). At the operating room, Herminda saw about two or three nurses and Dr.
Perfecta Gutierrez, the other defendant, who was to administer anesthesia. Although
not a member of the hospital staff, Herminda introduced herself as Dean of the
College of Nursing at the Capitol Medical Center who was to provide moral support
to the patient, to them. Herminda was allowed to stay inside the operating room.
At around 9:30 A.M., Dr. Gutierrez reached a nearby phone to look for Dr. Hosaka
who was not yet in (TSN, January 13, 1988, pp. 11-12). Dr. Gutierrez thereafter
informed Herminda Cruz about the prospect of a delay in the arrival of Dr. Hosaka.
Herminda then went back to the patient who asked, "Mindy, wala pa ba ang Doctor"?
The former replied, "Huwag kang mag-alaala, darating na iyon" (Ibid.).
Thereafter, Herminda went out of the operating room and informed the patient's
husband, Rogelio, that the doctor was not yet around (id., p. 13). When she returned
to the operating room, the patient told her, "Mindy, inip na inip na ako, ikuha mo ako
ng ibang Doctor." So, she went out again and told Rogelio about what the patient
said (id., p. 15). Thereafter, she returned to the operating room.
At around 10:00 A.M., Rogelio E. Ramos was "already dying [and] waiting for the
arrival of the doctor" even as he did his best to find somebody who will allow him to
pull out his wife from the operating room (TSN, October 19, 1989, pp. 19-20). He
also thought of the feeling of his wife, who was inside the operating room waiting for
the doctor to arrive (ibid.). At almost 12:00 noon, he met Dr. Garcia who remarked
that he (Dr. Garcia) was also tired of waiting for Dr. Hosaka to arrive (id., p. 21).
While talking to Dr. Garcia at around 12:10 P.M., he came to know that Dr. Hosaka
arrived as a nurse remarked, "Nandiyan na si Dr. Hosaka, dumating na raw." Upon

hearing those words, he went down to the lobby and waited for the operation to be
completed (id., pp. 16, 29-30).
At about 12:15 P.M., Herminda Cruz, who was inside the operating room with the
patient, heard somebody say that "Dr. Hosaka is already here." She then saw people
inside the operating room "moving, doing this and that, [and] preparing the patient for
the operation" (TSN, January 13, 1988, p. 16). As she held the hand of Erlinda
Ramos, she then saw Dr. Gutierrez intubating the hapless patient. She thereafter
heard Dr. Gutierrez say, "ang hirap ma-intubate nito, mali yata ang pagkakapasok. O
lumalaki ang tiyan" (id., p. 17). Because of the remarks of Dra. Gutierrez, she
focused her attention on what Dr. Gutierrez was doing. She thereafter noticed bluish
discoloration of the nailbeds of the left hand of the hapless Erlinda even as Dr.
Hosaka approached her. She then heard Dr. Hosaka issue an order for someone to
call Dr. Calderon, another anesthesiologist (id., p. 19). After Dr. Calderon arrived at
the operating room, she saw this anesthesiologist trying to intubate the patient. The
patient's nailbed became bluish and the patient was placed in a trendelenburg
position a position where the head of the patient is placed in a position lower than
her feet which is an indication that there is a decrease of blood supply to the patient's
brain (Id., pp. 19-20). Immediately thereafter, she went out of the operating room,
and she told Rogelio E. Ramos "that something wrong was . . . happening" (Ibid.).
Dr. Calderon was then able to intubate the patient (TSN, July 25, 1991, p. 9).
Meanwhile, Rogelio, who was outside the operating room, saw a respiratory machine
being rushed towards the door of the operating room. He also saw several doctors
rushing towards the operating room. When informed by Herminda Cruz that
something wrong was happening, he told her (Herminda) to be back with the patient
inside the operating room (TSN, October 19, 1989, pp. 25-28).
Herminda Cruz immediately rushed back, and saw that the patient was still in
trendelenburg position (TSN, January 13, 1988, p. 20). At almost 3:00 P.M. of that
fateful day, she saw the patient taken to the Intensive Care Unit (ICU).
About two days thereafter, Rogelio E. Ramos was able to talk to Dr. Hosaka. The
latter informed the former that something went wrong during the intubation. Reacting
to what was told to him, Rogelio reminded the doctor that the condition of his wife
would not have happened, had he (Dr. Hosaka) looked for a good anesthesiologist
(TSN, October 19, 1989, p. 31).
Doctors Gutierrez and Hosaka were also asked by the hospital to explain what
happened to the patient. The doctors explained that the patient had bronchospasm
(TSN, November 15, 1990, pp. 26-27).
Erlinda Ramos stayed at the ICU for a month. About four months thereafter or on
November 15, 1985, the patient was released from the hospital.
During the whole period of her confinement, she incurred hospital bills amounting to
P93,542.25 which is the subject of a promissory note and affidavit of undertaking
executed by Rogelio E. Ramos in favor of DLSMC. Since that fateful afternoon of
June 17, 1985, she has been in a comatose condition. She cannot do anything. She
cannot move any part of her body. She cannot see or hear. She is living on
mechanical means. She suffered brain damage as a result of the absence of oxygen
in her brain for four to five minutes (TSN, November 9, 1989, pp. 21-22). After being

discharged from the hospital, she has been staying in their residence, still needing
constant medical attention, with her husband Rogelio incurring a monthly expense
ranging from P8,000.00 to P10,000.00 (TSN, October 19, 1989, pp. 32-34). She was
also diagnosed to be suffering from "diffuse cerebral parenchymal damage" (Exh.
"G"; see also TSN, December 21, 1989,
p. 6). 5
Thus, on 8 January 1986, petitioners filed a civil case 6 for damages with the Regional Trial Court of
Quezon City against herein private respondents alleging negligence in the management and care of
Erlinda Ramos.

During the trial, both parties presented evidence as to the possible cause of Erlinda's injury. Plaintiff
presented the testimonies of Dean Herminda Cruz and Dr. Mariano Gavino to prove that the
sustained by Erlinda was due to lack of oxygen in her brain caused by the faulty management of her
airway by private respondents during the anesthesia phase. On the other hand, private respondents
primarily relied on the expert testimony of Dr. Eduardo Jamora, a pulmonologist, to the effect that the
cause of brain damage was Erlinda's allergic reaction to the anesthetic agent, Thiopental Sodium
(Pentothal).
After considering the evidence from both sides, the Regional Trial Court rendered judgment in favor
of petitioners, to wit:
After evaluating the evidence as shown in the finding of facts set forth earlier, and
applying the aforecited provisions of law and jurisprudence to the case at bar, this
Court finds and so holds that defendants are liable to plaintiffs for damages. The
defendants were guilty of, at the very least, negligence in the performance of their
duty to plaintiff-patient Erlinda Ramos.
On the part of Dr. Perfecta Gutierrez, this Court finds that she omitted to exercise
reasonable care in not only intubating the patient, but also in not repeating the
administration of atropine (TSN, August 20, 1991, pp. 5-10), without due regard to
the fact that the patient was inside the operating room for almost three (3) hours. For
after she committed a mistake in intubating [the] patient, the patient's nailbed
became bluish and the patient, thereafter, was placed in trendelenburg position,
because of the decrease of blood supply to the patient's brain. The evidence further
shows that the hapless patient suffered brain damage because of the absence of
oxygen in her (patient's) brain for approximately four to five minutes which, in turn,
caused the patient to become comatose.
On the part of Dr. Orlino Hosaka, this Court finds that he is liable for the acts of Dr.
Perfecta Gutierrez whom he had chosen to administer anesthesia on the patient as
part of his obligation to provide the patient a good anesthesiologist', and for arriving
for the scheduled operation almost three (3) hours late.
On the part of DLSMC (the hospital), this Court finds that it is liable for the acts of
negligence of the doctors in their "practice of medicine" in the operating room.
Moreover, the hospital is liable for failing through its responsible officials, to cancel
the scheduled operation after Dr. Hosaka inexcusably failed to arrive on time.
In having held thus, this Court rejects the defense raised by defendants that they
have acted with due care and prudence in rendering medical services to plaintiffpatient. For if the patient was properly intubated as claimed by them, the patient

would not have become comatose. And, the fact that another anesthesiologist was
called to try to intubate the patient after her (the patient's) nailbed turned bluish, belie
their claim. Furthermore, the defendants should have rescheduled the operation to a
later date. This, they should have done, if defendants acted with due care and
prudence as the patient's case was an elective, not an emergency case.
xxx xxx xxx
WHEREFORE, and in view of the foregoing, judgment is rendered in favor of the
plaintiffs and against the defendants. Accordingly, the latter are ordered to pay,
jointly and severally, the former the following sums of money, to wit:
1) the sum of P8,000.00 as actual monthly expenses for the plaintiff
Erlinda Ramos reckoned from November 15, 1985 or in the total sum
of P632,000.00 as of April 15, 1992, subject to its being updated;
2) the sum of P100,000.00 as reasonable attorney's fees;
3) the sum of P800,000.00 by way of moral damages and the further
sum of P200,000,00 by way of exemplary damages; and,
4) the costs of the suit.
SO ORDERED. 7
Private respondents seasonably interposed an appeal to the Court of Appeals. The appellate court
rendered a Decision, dated 29 May 1995, reversing the findings of the trial court. The decretal
portion of the decision of the appellate court reads:
WHEREFORE, for the foregoing premises the appealed decision is hereby
REVERSED, and the complaint below against the appellants is hereby ordered
DISMISSED. The counterclaim of appellant De Los Santos Medical Center is
GRANTED but only insofar as appellees are hereby ordered to pay the unpaid
hospital bills amounting to P93,542.25, plus legal interest for justice must be
tempered with mercy.
SO ORDERED. 8
The decision of the Court of Appeals was received on 9 June 1995 by petitioner Rogelio Ramos who
was mistakenly addressed as "Atty. Rogelio Ramos." No copy of the decision, however, was sent
nor received by the Coronel Law Office, then counsel on record of petitioners. Rogelio referred the
decision of the appellate court to a new lawyer, Atty. Ligsay, only on 20 June 1995, or four (4) days
before the expiration of the reglementary period for filing a motion for reconsideration. On the same
day, Atty. Ligsay, filed with the appellate court a motion for extension of time to file a motion for
reconsideration. The motion for reconsideration was submitted on 4 July 1995. However, the
appellate court denied the motion for extension of time in its Resolution dated 25 July
1995. 9Meanwhile, petitioners engaged the services of another counsel, Atty. Sillano, to replace Atty.
Ligsay. Atty. Sillano filed on 7 August 1995 a motion to admit the motion for reconsideration contending
that the period to file the appropriate pleading on the assailed decision had not yet commenced to run as
the Division Clerk of Court of the Court of Appeals had not yet served a copy thereof to the counsel on
record. Despite this explanation, the appellate court still denied the motion to admit the motion for

reconsideration of petitioners in its Resolution, dated 29 March 1996, primarily on the ground that the
fifteen-day (15) period for filing a motion for reconsideration had already expired, to wit:

We said in our Resolution on July 25, 1995, that the filing of a Motion for
Reconsideration cannot be extended; precisely, the Motion for Extension (Rollo, p.
12) was denied. It is, on the other hand, admitted in the latter Motion that
plaintiffs/appellees received a copy of the decision as early as June 9, 1995.
Computation wise, the period to file a Motion for Reconsideration expired on June
24. The Motion for Reconsideration, in turn, was received by the Court of Appeals
already on July 4, necessarily, the 15-day period already passed. For that alone, the
latter should be denied.
Even assuming admissibility of the Motion for the Reconsideration, but after
considering the Comment/Opposition, the former, for lack of merit, is hereby
DENIED.
SO ORDERED. 10
A copy of the above resolution was received by Atty. Sillano on 11 April 1996. The next day, or on
12 April 1996, Atty. Sillano filed before this Court a motion for extension of time to file the present
petition for certiorari under Rule 45. The Court granted the motion for extension of time and gave
petitioners additional thirty (30) days after the expiration of the fifteen-day (15) period counted from
the receipt of the resolution of the Court of Appeals within which to submit the petition. The due date
fell on 27 May 1996. The petition was filed on 9 May 1996, well within the extended period given by
the Court.
Petitioners assail the decision of the Court of Appeals on the following grounds:
I
IN PUTTING MUCH RELIANCE ON THE TESTIMONIES OF RESPONDENTS DRA.
GUTIERREZ, DRA. CALDERON AND DR. JAMORA;
II
IN FINDING THAT THE NEGLIGENCE OF THE RESPONDENTS DID NOT CAUSE
THE UNFORTUNATE COMATOSE CONDITION OF PETITIONER ERLINDA
RAMOS;
III
IN NOT APPLYING THE DOCTRINE OF RES IPSA LOQUITUR. 11
Before we discuss the merits of the case, we shall first dispose of the procedural issue on the
timeliness of the petition in relation to the motion for reconsideration filed by petitioners with the
Court of Appeals. In their
Comment, 12 private respondents contend that the petition should not be given due course since the
motion for reconsideration of the petitioners on the decision of the Court of Appeals was validly dismissed
by the appellate court for having been filed beyond the reglementary period. We do not agree.

A careful review of the records reveals that the reason behind the delay in filing the motion for
reconsideration is attributable to the fact that the decision of the Court of Appeals was not sent to
then counsel on record of petitioners, the Coronel Law Office. In fact, a copy of the decision of the
appellate court was instead sent to and received by petitioner Rogelio Ramos on 9 June 1995
wherein he was mistakenly addressed as Atty. Rogelio Ramos. Based on the other communications
received by petitioner Rogelio Ramos, the appellate court apparently mistook him for the counsel on
record. Thus, no copy of the decision of the counsel on record. Petitioner, not being a lawyer and
unaware of the prescriptive period for filing a motion for reconsideration, referred the same to a legal
counsel only on 20 June 1995.
It is elementary that when a party is represented by counsel, all notices should be sent to the party's
lawyer at his given address. With a few exceptions, notice to a litigant without notice to his counsel
on record is no notice at all. In the present case, since a copy of the decision of the appellate court
was not sent to the counsel on record of petitioner, there can be no sufficient notice to speak of.
Hence, the delay in the filing of the motion for reconsideration cannot be taken against petitioner.
Moreover, since the Court of Appeals already issued a second Resolution, dated 29 March 1996,
which superseded the earlier resolution issued on 25 July 1995, and denied the motion for
reconsideration of petitioner, we believed that the receipt of the former should be considered in
determining the timeliness of the filing of the present petition. Based on this, the petition before us
was submitted on time.
After resolving the foregoing procedural issue, we shall now look into the merits of the case. For a
more logical presentation of the discussion we shall first consider the issue on the applicability of the
doctrine of res ipsa loquitur to the instant case. Thereafter, the first two assigned errors shall be
tackled in relation to the res ipsa loquitur doctrine.
Res ipsa loquitur is a Latin phrase which literally means "the thing or the transaction speaks for
itself." The phrase "res ipsa loquitur'' is a maxim for the rule that the fact of the occurrence of an
injury, taken with the surrounding circumstances, may permit an inference or raise a presumption of
negligence, or make out a plaintiff's prima faciecase, and present a question of fact for defendant to
meet with an explanation. 13 Where the thing which caused the injury complained of is shown to be
under the management of the defendant or his servants and the accident is such as in ordinary course of
things does not happen if those who have its management or control use proper care, it affords
reasonable evidence, in the absence of explanation by the defendant, that the accident arose from or was
caused by the defendant's want of care. 14

The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a matter of common
knowledge and experience, the very nature of certain types of occurrences may justify an inference
of negligence on the part of the person who controls the instrumentality causing the injury in the
absence of some explanation by the defendant who is charged with negligence. 15 It is grounded in
the superior logic of ordinary human experience and on the basis of such experience or common
knowledge, negligence may be deduced from the mere occurrence of the accident itself. 16 Hence, res
ipsa loquitur is applied in conjunction with the doctrine of common knowledge.

However, much has been said that res ipsa loquitur is not a rule of substantive law and, as such,
does not create or constitute an independent or separate ground of liability. 17 Instead, it is considered
as merely evidentiary or in the nature of a procedural rule. 18 It is regarded as a mode of proof, or a mere
procedural of convenience since it furnishes a substitute for, and relieves a plaintiff of, the burden of
producing specific proof of negligence. 19 In other words, mere invocation and application of the doctrine
does not dispense with the requirement of proof of negligence. It is simply a step in the process of such
proof, permitting the plaintiff to present along with the proof of the accident, enough of the attending
circumstances to invoke the doctrine, creating an inference or presumption of negligence, and to thereby

place on the defendant the burden of going forward with the proof. 20 Still, before resort to the doctrine
may be allowed, the following requisites must be satisfactorily shown:

1. The accident is of a kind which ordinarily does not occur in the

absence of someone's negligence;
2. It is caused by an instrumentality within the exclusive control of the
defendant or defendants; and
3. The possibility of contributing conduct which would make the
plaintiff responsible is eliminated. 21
In the above requisites, the fundamental element is the "control of instrumentality" which caused the
damage. 22Such element of control must be shown to be within the dominion of the defendant. In order to
have the benefit of the rule, a plaintiff, in addition to proving injury or damage, must show a situation
where it is applicable, and must establish that the essential elements of the doctrine were present in a
particular incident. 23

Medical malpractice 24 cases do not escape the application of this doctrine. Thus, res ipsa loquitur has
been applied when the circumstances attendant upon the harm are themselves of such a character as to
justify an inference of negligence as the cause of that harm. 25 The application of res ipsa loquitur in
medical negligence cases presents a question of law since it is a judicial function to determine whether a
certain set of circumstances does, as a matter of law, permit a given inference. 26

Although generally, expert medical testimony is relied upon in malpractice suits to prove that a
physician has done a negligent act or that he has deviated from the standard medical procedure,
when the doctrine of res ipsa loquitur is availed by the plaintiff, the need for expert medical testimony
is dispensed with because the injury itself provides the proof of negligence. 27 The reason is that the
general rule on the necessity of expert testimony applies only to such matters clearly within the domain of
medical science, and not to matters that are within the common knowledge of mankind which may be
testified to by anyone familiar with the facts. 28 Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has been treated or operated upon with a
reasonable degree of skill and care. However, testimony as to the statements and acts of physicians and
surgeons, external appearances, and manifest conditions which are observable by any one may be given
by non-expert witnesses. 29 Hence, in cases where theres ipsa loquitur is applicable, the court is
permitted to find a physician negligent upon proper proof of injury to the patient, without the aid of expert
testimony, where the court from its fund of common knowledge can determine the proper standard of
care. 30 Where common knowledge and experience teach that a resulting injury would not have occurred
to the patient if due care had been exercised, an inference of negligence may be drawn giving rise to an
application of the doctrine of res ipsa loquitur without medical evidence, which is ordinarily required to
show not only what occurred but how and why it occurred. 31 When the doctrine is appropriate, all that the
patient must do is prove a nexus between the particular act or omission complained of and the injury
sustained while under the custody and management of the defendant without need to produce expert
medical testimony to establish the standard of care. Resort to res ipsa loquitur is allowed because there is
no other way, under usual and ordinary conditions, by which the patient can obtain redress for injury
suffered by him.

Thus, courts of other jurisdictions have applied the doctrine in the following situations: leaving of a
foreign object in the body of the patient after an operation, 32 injuries sustained on a healthy part of the
body which was not under, or in the area, of treatment, 33 removal of the wrong part of the body when
another part was intended, 34 knocking out a tooth while a patient's jaw was under anesthetic for the
removal of his tonsils, 35 and loss of an eye while the patient plaintiff was under the influence of
anesthetic, during or following an operation for appendicitis, 36 among others.

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

We find the doctrine of res ipsa loquitur appropriate in the case at bar. As will hereinafter be
explained, the damage sustained by Erlinda in her brain prior to a scheduled gall bladder operation
presents a case for the application of res ipsa loquitur.
A case strikingly similar to the one before us is Voss vs. Bridwell, 43 where the Kansas Supreme Court
in applying theres ipsa loquitur stated:

The plaintiff herein submitted himself for a mastoid operation and delivered his
person over to the care, custody and control of his physician who had complete and
exclusive control over him, but the operation was never performed. At the time of
submission he was neurologically sound and physically fit in mind and body, but he
suffered irreparable damage and injury rendering him decerebrate and totally
incapacitated. The injury was one which does not ordinarily occur in the process of a
mastoid operation or in the absence of negligence in the administration of an
anesthetic, and in the use and employment of an endoctracheal tube. Ordinarily a
person being put under anesthesia is not rendered decerebrate as a consequence of
administering such anesthesia in the absence of negligence. Upon these facts and
under these circumstances a layman would be able to say, as a matter of common
knowledge and observation, that the consequences of professional treatment were
not as such as would ordinarily have followed if due care had been exercised.
Here the plaintiff could not have been guilty of contributory negligence because he
was under the influence of anesthetics and unconscious, and the circumstances are
such that the true explanation of event is more accessible to the defendants than to
the plaintiff for they had the exclusive control of the instrumentalities of anesthesia.
Upon all the facts, conditions and circumstances alleged in Count II it is held that a
cause of action is stated under the doctrine of res ipsa loquitur. 44

Indeed, the principles enunciated in the aforequoted case apply with equal force here. In the present
case, Erlinda submitted herself for cholecystectomy and expected a routine general surgery to be
performed on her gall bladder. On that fateful day she delivered her person over to the care, custody
and control of private respondents who exercised complete and exclusive control over her. At the
time of submission, Erlinda was neurologically sound and, except for a few minor discomforts, was
likewise physically fit in mind and body. However, during the administration of anesthesia and prior
to the performance of cholecystectomy she suffered irreparable damage to her brain. Thus, without
undergoing surgery, she went out of the operating room already decerebrate and totally
incapacitated. Obviously, brain damage, which Erlinda sustained, is an injury which does not
normally occur in the process of a gall bladder operation. In fact, this kind of situation does not in the
absence of negligence of someone in the administration of anesthesia and in the use of
endotracheal tube. Normally, a person being put under anesthesia is not rendered decerebrate as a
consequence of administering such anesthesia if the proper procedure was followed. Furthermore,
the instruments used in the administration of anesthesia, including the endotracheal tube, were all
under the exclusive control of private respondents, who are the physicians-in-charge. Likewise,
petitioner Erlinda could not have been guilty of contributory negligence because she was under the
influence of anesthetics which rendered her unconscious.
Considering that a sound and unaffected member of the body (the brain) is injured or destroyed
while the patient is unconscious and under the immediate and exclusive control of the physicians,
we hold that a practical administration of justice dictates the application of res ipsa loquitur. Upon
these facts and under these circumstances the Court would be able to say, as a matter of common
knowledge and observation, if negligence attended the management and care of the patient.
Moreover, the liability of the physicians and the hospital in this case is not predicated upon an
alleged failure to secure the desired results of an operation nor on an alleged lack of skill in the
diagnosis or treatment as in fact no operation or treatment was ever performed on Erlinda. Thus,
upon all these initial determination a case is made out for the application of the doctrine of res ipsa
loquitur.
Nonetheless, in holding that res ipsa loquitur is available to the present case we are not saying that
the doctrine is applicable in any and all cases where injury occurs to a patient while under
anesthesia, or to any and all anesthesia cases. Each case must be viewed in its own light and
scrutinized in order to be within the res ipsa loquitur coverage.
Having in mind the applicability of the res ipsa loquitur doctrine and the presumption of negligence
allowed therein, the Court now comes to the issue of whether the Court of Appeals erred in finding
that private respondents were not negligent in the care of Erlinda during the anesthesia phase of the
operation and, if in the affirmative, whether the alleged negligence was the proximate cause of
Erlinda's comatose condition. Corollary thereto, we shall also determine if the Court of Appeals erred
in relying on the testimonies of the witnesses for the private respondents.
In sustaining the position of private respondents, the Court of Appeals relied on the testimonies of
Dra. Gutierrez, Dra. Calderon and Dr. Jamora. In giving weight to the testimony of Dra. Gutierrez,
the Court of Appeals rationalized that she was candid enough to admit that she experienced some
difficulty in the endotracheal intubation 45 of the patient and thus, cannot be said to be covering her
negligence with falsehood. The appellate court likewise opined that private respondents were able to
show that the brain damage sustained by Erlinda was not caused by the alleged faulty intubation but was
due to the allergic reaction of the patient to the drug Thiopental Sodium (Pentothal), a short-acting
barbiturate, as testified on by their expert witness, Dr. Jamora. On the other hand, the appellate court
rejected the testimony of Dean Herminda Cruz offered in favor of petitioners that the cause of the brain
injury was traceable to the wrongful insertion of the tube since the latter, being a nurse, was allegedly not
knowledgeable in the process of intubation. In so holding, the appellate court returned a verdict in favor of
respondents physicians and hospital and absolved them of any liability towards Erlinda and her family.

We disagree with the findings of the Court of Appeals. We hold that private respondents were unable
to disprove the presumption of negligence on their part in the care of Erlinda and their negligence
was the proximate cause of her piteous condition.
In the instant case, the records are helpful in furnishing not only the logical scientific evidence of the
pathogenesis of the injury but also in providing the Court the legal nexus upon which liability is
based. As will be shown hereinafter, private respondents' own testimonies which are reflected in the
transcript of stenographic notes are replete of signposts indicative of their negligence in the care and
management of Erlinda.
With regard to Dra. Gutierrez, we find her negligent in the care of Erlinda during the anesthesia
phase. As borne by the records, respondent Dra. Gutierrez failed to properly intubate the patient.
This fact was attested to by Prof. Herminda Cruz, Dean of the Capitol Medical Center School of
Nursing and petitioner's sister-in-law, who was in the operating room right beside the patient when
the tragic event occurred. Witness Cruz testified to this effect:
ATTY. PAJARES:
Q: In particular, what did Dra. Perfecta Gutierrez do, if any on the
patient?
A: In particular, I could see that she was intubating the patient.
Q: Do you know what happened to that intubation process
administered by Dra. Gutierrez?
ATTY. ALCERA:
She will be incompetent Your Honor.
COURT:
Witness may answer if she knows.
A: As have said, I was with the patient, I was beside the stretcher
holding the left hand of the patient and all of a sudden heard some
remarks coming from Dra. Perfecta Gutierrez herself. She was saying
"Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki
ang tiyan.
xxx xxx xxx
ATTY. PAJARES:
Q: From whom did you hear those words "lumalaki ang tiyan"?
A: From Dra. Perfecta Gutierrez.
xxx xxx xxx

Q: After hearing the phrase "lumalaki ang tiyan," what did you notice
on the person of the patient?
A: I notice (sic) some bluish discoloration on the nailbeds of the left
hand where I was at.
Q: Where was Dr. Orlino Ho[s]aka then at that particular time?
A: I saw him approaching the patient during that time.
Q: When he approached the patient, what did he do, if any?
A: He made an order to call on the anesthesiologist in the person of
Dr. Calderon.
Q: Did Dr. Calderon, upon being called, arrive inside the operating
room?
A: Yes sir.
Q: What did [s]he do, if any?
A: [S]he tried to intubate the patient.
Q: What happened to the patient?
A: When Dr. Calderon try (sic) to intubate the patient, after a while the
patient's nailbed became bluish and I saw the patient was placed in
trendelenburg position.
xxx xxx xxx
Q: Do you know the reason why the patient was placed in that
trendelenburg position?
A: As far as I know, when a patient is in that position, there is a
decrease of blood supply to the brain. 46
xxx xxx xxx

The appellate court, however, disbelieved Dean Cruz's testimony in the trial court by declaring that:
A perusal of the standard nursing curriculum in our country will show that intubation
is not taught as part of nursing procedures and techniques. Indeed, we take judicial
notice of the fact that nurses do not, and cannot, intubate. Even on the assumption
that she is fully capable of determining whether or not a patient is properly intubated,
witness Herminda Cruz, admittedly, did not peep into the throat of the patient. (TSN,
July 25, 1991, p. 13). More importantly, there is no evidence that she ever
auscultated the patient or that she conducted any type of examination to check if the
endotracheal tube was in its proper place, and to determine the condition of the
heart, lungs, and other organs. Thus, witness Cruz's categorical statements that

appellant Dra. Gutierrez failed to intubate the appellee Erlinda Ramos and that it was
Dra. Calderon who succeeded in doing so clearly suffer from lack of sufficient factual
bases. 47
In other words, what the Court of Appeals is trying to impress is that being a nurse, and considered a
layman in the process of intubation, witness Cruz is not competent to testify on whether or not the
intubation was a success.
We do not agree with the above reasoning of the appellate court. Although witness Cruz is not an
anesthesiologist, she can very well testify upon matters on which she is capable of observing such
as, the statements and acts of the physician and surgeon, external appearances, and manifest
conditions which are observable by any one. 48 This is precisely allowed under the doctrine of res ipsa
loquitur where the testimony of expert witnesses is not required. It is the accepted rule that expert
testimony is not necessary for the proof of negligence in non-technical matters or those of which an
ordinary person may be expected to have knowledge, or where the lack of skill or want of care is so
obvious as to render expert testimony unnecessary. 49 We take judicial notice of the fact that anesthesia
procedures have become so common, that even an ordinary person can tell if it was administered
properly. As such, it would not be too difficult to tell if the tube was properly inserted. This kind of
observation, we believe, does not require a medical degree to be acceptable.

At any rate, without doubt, petitioner's witness, an experienced clinical nurse whose long experience
and scholarship led to her appointment as Dean of the Capitol Medical Center School at Nursing,
was fully capable of determining whether or not the intubation was a success. She had extensive
clinical experience starting as a staff nurse in Chicago, Illinois; staff nurse and clinical instructor in a
teaching hospital, the FEU-NRMF; Dean of the Laguna College of Nursing in San Pablo City; and
then Dean of the Capitol Medical Center School of Nursing. 50Reviewing witness Cruz' statements, we
find that the same were delivered in a straightforward manner, with the kind of detail, clarity, consistency
and spontaneity which would have been difficult to fabricate. With her clinical background as a nurse, the
Court is satisfied that she was able to demonstrate through her testimony what truly transpired on that
fateful day.

Most of all, her testimony was affirmed by no less than respondent Dra. Gutierrez who admitted that
she experienced difficulty in inserting the tube into Erlinda's trachea, to wit:
ATTY. LIGSAY:
Q: In this particular case, Doctora, while you were intubating at your
first attempt (sic), you did not immediately see the trachea?
DRA. GUTIERREZ:
A: Yes sir.
Q: Did you pull away the tube immediately?
A: You do not pull the . . .
Q: Did you or did you not?
A: I did not pull the tube.
Q: When you said "mahirap yata ito," what were you referring to?

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

Q: So, you found some difficulty in inserting the tube?
A: Yes, because of (sic) my first attempt, I did not see right away.

51

Curiously in the case at bar, respondent Dra. Gutierrez made the haphazard defense that she
encountered hardship in the insertion of the tube in the trachea of Erlinda because it was positioned
more anteriorly (slightly deviated from the normal anatomy of a person) 52 making it harder to locate
and, since Erlinda is obese and has a short neck and protruding teeth, it made intubation even more
difficult.

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

In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda for the first time on the
day of the operation itself, on 17 June 1985. Before this date, no prior consultations with, or preoperative evaluation of Erlinda was done by her. Until the day of the operation, respondent Dra.
Gutierrez was unaware of the physiological make-up and needs of Erlinda. She was likewise not
properly informed of the possible difficulties she would face during the administration of anesthesia
to Erlinda. Respondent Dra. Gutierrez' act of seeing her patient for the first time only an hour before
the scheduled operative procedure was, therefore, an act of exceptional negligence and professional
irresponsibility. The measures cautioning prudence and vigilance in dealing with human lives lie at
the core of the physician's centuries-old Hippocratic Oath. Her failure to follow this medical
procedure is, therefore, a clear indicia of her negligence.
Respondent Dra. Gutierrez, however, attempts to gloss over this omission by playing around with
the trial court's ignorance of clinical procedure, hoping that she could get away with it. Respondent
Dra. Gutierrez tried to muddle the difference between an elective surgery and an emergency surgery
just so her failure to perform the required pre-operative evaluation would escape unnoticed. In her
testimony she asserted:
ATTY. LIGSAY:

Q: Would you agree, Doctor, that it is good medical practice to see

the patient a day before so you can introduce yourself to establish
good doctor-patient relationship and gain the trust and confidence of
the patient?
DRA. GUTIERREZ:
A: As I said in my previous statement, it depends on the operative
procedure of the anesthesiologist and in my case, with elective cases
and normal cardio-pulmonary clearance like that, I usually don't do it
except on emergency and on cases that have an abnormalities
(sic). 58
However, the exact opposite is true. In an emergency procedure, there is hardly enough time
available for the fastidious demands of pre-operative procedure so that an anesthesiologist is able to
see the patient only a few minutes before surgery, if at all. Elective procedures, on the other hand,
are operative procedures that can wait for days, weeks or even months. Hence, in these cases, the
anesthesiologist possesses the luxury of time to be at the patient's beside to do a proper interview
and clinical evaluation. There is ample time to explain the method of anesthesia, the drugs to be
used, and their possible hazards for purposes of informed consent. Usually, the pre-operative
assessment is conducted at least one day before the intended surgery, when the patient is relaxed
and cooperative.
Erlinda's case was elective and this was known to respondent Dra. Gutierrez. Thus, she had all the
time to make a thorough evaluation of Erlinda's case prior to the operation and prepare her for
anesthesia. However, she never saw the patient at the bedside. She herself admitted that she had
seen petitioner only in the operating room, and only on the actual date of the cholecystectomy. She
negligently failed to take advantage of this important opportunity. As such, her attempt to exculpate
herself must fail.
Having established that respondent Dra. Gutierrez failed to perform pre-operative evaluation of the
patient which, in turn, resulted to a wrongful intubation, we now determine if the faulty intubation is
truly the proximate cause of Erlinda's comatose condition.
Private respondents repeatedly hammered the view that the cerebral anoxia which led to Erlinda's
coma was due to bronchospasm 59 mediated by her allergic response to the drug, Thiopental Sodium,
introduced into her system. Towards this end, they presented Dr. Jamora, a Fellow of the Philippine
College of Physicians and Diplomate of the Philippine Specialty Board of Internal Medicine, who
advanced private respondents' theory that the oxygen deprivation which led to anoxic
encephalopathy, 60 was due to an unpredictable drug reaction to the short-acting barbiturate. We find the
theory of private respondents unacceptable.

First of all, Dr. Jamora cannot be considered an authority in the field of anesthesiology simply
because he is not an anesthesiologist. Since Dr. Jamora is a pulmonologist, he could not have been
capable of properly enlightening the court about anesthesia practice and procedure and their
complications. Dr. Jamora is likewise not an allergologist and could not therefore properly advance
expert opinion on allergic-mediated processes. Moreover, he is not a pharmacologist and, as such,
could not have been capable, as an expert would, of explaining to the court the pharmacologic and
toxic effects of the supposed culprit, Thiopental Sodium (Pentothal).
The inappropriateness and absurdity of accepting Dr. Jamora's testimony as an expert witness in the
anesthetic practice of Pentothal administration is further supported by his own admission that he

formulated his opinions on the drug not from the practical experience gained by a specialist or expert
in the administration and use of Sodium Pentothal on patients, but only from reading certain
references, to wit:
ATTY. LIGSAY:
Q: In your line of expertise on pulmonology, did you have any
occasion to use pentothal as a method of management?
DR. JAMORA:
A: We do it in conjunction with the anesthesiologist when they have to
intubate our patient.
Q: But not in particular when you practice pulmonology?
A: No.
Q: In other words, your knowledge about pentothal is based only on
what you have read from books and not by your own personal
application of the medicine pentothal?
A: Based on my personal experience also on pentothal.
Q: How many times have you used pentothal?
A: They used it on me. I went into bronchospasm during my
appendectomy.
Q: And because they have used it on you and on account of your own
personal experience you feel that you can testify on pentothal here
with medical authority?
A: No. That is why I used references to support my claims. 61
An anesthetic accident caused by a rare drug-induced bronchospasm properly falls within the fields
of anesthesia, internal medicine-allergy, and clinical pharmacology. The resulting anoxic
encephalopathy belongs to the field of neurology. While admittedly, many bronchospastic-mediated
pulmonary diseases are within the expertise of pulmonary medicine, Dr. Jamora's field, the
anesthetic drug-induced, allergic mediated bronchospasm alleged in this case is within the
disciplines of anesthesiology, allergology and pharmacology. On the basis of the foregoing
transcript, in which the pulmonologist himself admitted that he could not testify about the drug with
medical authority, it is clear that the appellate court erred in giving weight to Dr. Jamora's testimony
as an expert in the administration of Thiopental Sodium.
The provision in the rules of evidence 62 regarding expert witnesses states:
Sec. 49. Opinion of expert witness. The opinion of a witness on a matter requiring
special knowledge, skill, experience or training which he is shown to possess, may
be received in evidence.

Generally, to qualify as an expert witness, one must have acquired special knowledge of the subject
matter about which he or she is to testify, either by the study of recognized authorities on the subject
or by practical experience.63 Clearly, Dr. Jamora does not qualify as an expert witness based on the
above standard since he lacks the necessary knowledge, skill, and training in the field of anesthesiology.
Oddly, apart from submitting testimony from a specialist in the wrong field, private respondents'
intentionally avoided providing testimony by competent and independent experts in the proper areas.

Moreover, private respondents' theory, that Thiopental Sodium may have produced Erlinda's coma
by triggering an allergic mediated response, has no support in evidence. No evidence of stridor, skin
reactions, or wheezing some of the more common accompanying signs of an allergic reaction
appears on record. No laboratory data were ever presented to the court.
In any case, private respondents themselves admit that Thiopental induced, allergic-mediated
bronchospasm happens only very rarely. If courts were to accept private respondents' hypothesis
without supporting medical proof, and against the weight of available evidence, then every
anesthetic accident would be an act of God. Evidently, the Thiopental-allergy theory vigorously
asserted by private respondents was a mere afterthought. Such an explanation was advanced in
order to advanced in order to absolve them of any and all responsibility for the patient's condition.
In view of the evidence at hand, we are inclined to believe petitioners' stand that it was the faulty
intubation which was the proximate cause of Erlinda's comatose condition.
Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by
any efficient intervening cause, produces injury, and without which the result would not have
occurred. 64 An injury or damage is proximately caused by an act or a failure to act, whenever it appears
from the evidence in the case, that the act or omission played a substantial part in bringing about or
actually causing the injury or damage; and that the injury or damage was either a direct result or a
reasonably probable consequence of the act or omission. 65 It is the dominant, moving or producing
cause.

Applying the above definition in relation to the evidence at hand, faulty intubation is undeniably the
proximate cause which triggered the chain of events leading to Erlinda's brain damage and,
ultimately, her comatosed condition.
Private respondents themselves admitted in their testimony that the first intubation was a failure.
This fact was likewise observed by witness Cruz when she heard respondent Dra. Gutierrez
remarked, "Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan."
Thereafter, witness Cruz noticed abdominal distention on the body of Erlinda. The development of
abdominal distention, together with respiratory embarrassment indicates that the endotracheal tube
entered the esophagus instead of the respiratory tree. In other words, instead of the intended
endotracheal intubation what actually took place was an esophageal intubation. During intubation,
such distention indicates that air has entered the gastrointestinal tract through the esophagus
instead of the lungs through the trachea. Entry into the esophagus would certainly cause some delay
in oxygen delivery into the lungs as the tube which carries oxygen is in the wrong place. That
abdominal distention had been observed during the first intubation suggests that the length of time
utilized in inserting the endotracheal tube (up to the time the tube was withdrawn for the second
attempt) was fairly significant. Due to the delay in the delivery of oxygen in her lungs Erlinda showed
signs of cyanosis. 66 As stated in the testimony of Dr. Hosaka, the lack of oxygen became apparent only
after he noticed that the nailbeds of Erlinda were already blue. 67 However, private respondents contend
that a second intubation was executed on Erlinda and this one was successfully done. We do not think
so. No evidence exists on record, beyond private respondents' bare claims, which supports the contention
that the second intubation was successful. Assuming that the endotracheal tube finally found its way into
the proper orifice of the trachea, the same gave no guarantee of oxygen delivery, the hallmark of a

successful intubation. In fact, cyanosis was again observed immediately after the second intubation.
Proceeding from this event (cyanosis), it could not be claimed, as private respondents insist, that the
second intubation was accomplished. Even granting that the tube was successfully inserted during the
second attempt, it was obviously too late. As aptly explained by the trial court, Erlinda already suffered
brain damage as a result of the inadequate oxygenation of her brain for about four to five minutes. 68

The above conclusion is not without basis. Scientific studies point out that intubation problems are
responsible for one-third (1/3) of deaths and serious injuries associated with
anesthesia. 69 Nevertheless, ninety-eight percent (98%) or the vast majority of difficult intubations may be
anticipated by performing a thorough evaluation of the patient's airway prior to the operation. 70 As stated
beforehand, respondent Dra. Gutierrez failed to observe the proper pre-operative protocol which could
have prevented this unfortunate incident. Had appropriate diligence and reasonable care been used in
the pre-operative evaluation, respondent physician could have been much more prepared to meet the
contingency brought about by the perceived anatomic variations in the patient's neck and oral area,
defects which would have been easily overcome by a prior knowledge of those variations together with a
change in technique. 71 In other words, an experienced anesthesiologist, adequately alerted by a
thorough pre-operative evaluation, would have had little difficulty going around the short neck and
protruding teeth. 72 Having failed to observe common medical standards in pre-operative management
and intubation, respondent Dra. Gutierrez' negligence resulted in cerebral anoxia and eventual coma of
Erlinda.

We now determine the responsibility of respondent Dr. Orlino Hosaka as the head of the surgical
team. As the so-called "captain of the ship," 73 it is the surgeon's responsibility to see to it that those
under him perform their task in the proper manner. Respondent Dr. Hosaka's negligence can be found in
his failure to exercise the proper authority (as the "captain" of the operative team) in not determining if his
anesthesiologist observed proper anesthesia protocols. In fact, no evidence on record exists to show that
respondent Dr. Hosaka verified if respondent Dra. Gutierrez properly intubated the patient. Furthermore, it
does not escape us that respondent Dr. Hosaka had scheduled another procedure in a different hospital
at the same time as Erlinda's cholecystectomy, and was in fact over three hours late for the latter's
operation. Because of this, he had little or no time to confer with his anesthesiologist regarding the
anesthesia delivery. This indicates that he was remiss in his professional duties towards his patient. Thus,
he shares equal responsibility for the events which resulted in Erlinda's condition.

We now discuss the responsibility of the hospital in this particular incident. The unique practice
(among private hospitals) of filling up specialist staff with attending and visiting "consultants," 74 who
are allegedly not hospital employees, presents problems in apportioning responsibility for negligence in
medical malpractice cases. However, the difficulty is only more apparent than real.

In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the
conduct of their work within the hospital premises. Doctors who apply for "consultant" slots, visiting
or attending, are required to submit proof of completion of residency, their educational qualifications;
generally, evidence of accreditation by the appropriate board (diplomate), evidence of fellowship in
most cases, and references. These requirements are carefully scrutinized by members of the
hospital administration or by a review committee set up by the hospital who either accept or reject
the application. 75 This is particularly true with respondent hospital.
After a physician is accepted, either as a visiting or attending consultant, he is normally required to
attend clinico-pathological conferences, conduct bedside rounds for clerks, interns and residents,
moderate grand rounds and patient audits and perform other tasks and responsibilities, for the
privilege of being able to maintain a clinic in the hospital, and/or for the privilege of admitting patients
into the hospital. In addition to these, the physician's performance as a specialist is generally
evaluated by a peer review committee on the basis of mortality and morbidity statistics, and
feedback from patients, nurses, interns and residents. A consultant remiss in his duties, or a

consultant who regularly falls short of the minimum standards acceptable to the hospital or its peer
review committee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and visiting
"consultant" staff. While "consultants" are not, technically employees, a point which respondent
hospital asserts in denying all responsibility for the patient's condition, the control exercised, the
hiring, and the right to terminate consultants all fulfill the important hallmarks of an employeremployee 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.
This being the case, the question now arises as to whether or not respondent hospital is solidarily
liable with respondent doctors for petitioner's condition. 76
The basis for holding an employer solidarily responsible for the negligence of its employee is found
in Article 2180 of the Civil Code which considers a person accountable not only for his own acts but
also for those of others based on the former's responsibility under a relationship of patria
potestas. 77 Such responsibility ceases when the persons or entity concerned prove that they have
observed the diligence of a good father of the family to prevent damage. 78 In other words, while the
burden of proving negligence rests on the plaintiffs, once negligence is shown, the burden shifts to the
respondents (parent, guardian, teacher or employer) who should prove that they observed the diligence
of a good father of a family to prevent damage.

In the instant case, respondent hospital, apart from a general denial of its responsibility over
respondent physicians, failed to adduce evidence showing that it exercised the diligence of a good
father of a family in the hiring and supervision of the latter. It failed to adduce evidence with regard to
the degree of supervision which it exercised over its physicians. In neglecting to offer such proof, or
proof of a similar nature, respondent hospital thereby failed to discharge its burden under the last
paragraph of Article 2180. Having failed to do this, respondent hospital is consequently solidarily
responsible with its physicians for Erlinda's condition.
Based on the foregoing, we hold that the Court of Appeals erred in accepting and relying on the
testimonies of the witnesses for the private respondents. Indeed, as shown by the above
discussions, private respondents were unable to rebut the presumption of negligence. Upon these
disquisitions we hold that private respondents are solidarily liable for damages under Article
2176 79 of the Civil Code.
We now come to the amount of damages due petitioners. The trial court awarded a total of
P632,000.00 pesos (should be P616,000.00) in compensatory damages to the plaintiff, "subject to its
being updated" covering the period from 15 November 1985 up to 15 April 1992, based on monthly
expenses for the care of the patient estimated at P8,000.00.
At current levels, the P8000/monthly amount established by the trial court at the time of its decision
would be grossly inadequate to cover the actual costs of home-based care for a comatose individual.
The calculated amount was not even arrived at by looking at the actual cost of proper hospice care
for the patient. What it reflected were the actual expenses incurred and proved by the petitioners
after they were forced to bring home the patient to avoid mounting hospital bills.
And yet ideally, a comatose patient should remain in a hospital or be transferred to a hospice
specializing in the care of the chronically ill for the purpose of providing a proper milieu adequate to
meet minimum standards of care. In the instant case for instance, Erlinda has to be constantly
turned from side to side to prevent bedsores and hypostatic pneumonia. Feeding is done by

nasogastric tube. Food preparation should be normally made by a dietitian to provide her with the
correct daily caloric requirements and vitamin supplements. Furthermore, she has to be seen on a
regular basis by a physical therapist to avoid muscle atrophy, and by a pulmonary therapist to
prevent the accumulation of secretions which can lead to respiratory complications.
Given these considerations, the amount of actual damages recoverable in suits arising from
negligence should at least reflect the correct minimum cost of proper care, not the cost of the care
the family is usually compelled to undertake at home to avoid bankruptcy. However, the provisions of
the Civil Code on actual or compensatory damages present us with some difficulties.
Well-settled is the rule that actual damages which may be claimed by the plaintiff are those suffered
by him as he has duly proved. The Civil Code provides:
Art. 2199. Except as provided by law or by stipulation, one is entitled to an
adequate compensation only for such pecuniary loss suffered by him as he has duly
proved. Such compensation is referred to as actual or compensatory damages.
Our rules on actual or compensatory damages generally assume that at the time of litigation, the
injury suffered as a consequence of an act of negligence has been completed and that the cost can
be liquidated. However, these provisions neglect to take into account those situations, as in this
case, where the resulting injury might be continuing and possible future complications directly arising
from the injury, while certain to occur, are difficult to predict.
In these cases, the amount of damages which should be awarded, if they are to adequately and
correctly respond to the injury caused, should be one which compensates for pecuniary loss incurred
and proved, up to the time of trial; and one which would meet pecuniary loss certain to be suffered
but which could not, from the nature of the case, be made with certainty. 80 In other words, temperate
damages can and should be awarded on top of actual or compensatory damages in instances where the
injury is chronic and continuing. And because of the unique nature of such cases, no incompatibility
arises when both actual and temperate damages are provided for. The reason is that these damages
cover two distinct phases.

As it would not be equitable and certainly not in the best interests of the administration of justice
for the victim in such cases to constantly come before the courts and invoke their aid in seeking
adjustments to the compensatory damages previously awarded temperate damages are
appropriate. The amount given as temperate damages, though to a certain extent speculative,
should take into account the cost of proper care.
In the instant case, petitioners were able to provide only home-based nursing care for a comatose
patient who has remained in that condition for over a decade. Having premised our award for
compensatory damages on the amount provided by petitioners at the onset of litigation, it would be
now much more in step with the interests of justice if the value awarded for temperate damages
would allow petitioners to provide optimal care for their loved one in a facility which generally
specializes in such care. They should not be compelled by dire circumstances to provide
substandard care at home without the aid of professionals, for anything less would be grossly
inadequate. Under the circumstances, an award of P1,500,000.00 in temperate damages would
therefore be reasonable. 81
In Valenzuela vs. Court of Appeals, 82 this Court was confronted with a situation where the injury
suffered by the plaintiff would have led to expenses which were difficult to estimate because while they
would have been a direct result of the injury (amputation), and were certain to be incurred by the plaintiff,
they were likely to arise only in the future. We awarded P1,000,000.00 in moral damages in that case.

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

As a result of the accident, Ma. Lourdes Valenzuela underwent a traumatic
amputation of her left lower extremity at the distal left thigh just above the knee.
Because of this, Valenzuela will forever be deprived of the full ambulatory functions
of her left extremity, even with the use of state of the art prosthetic technology. Well
beyond the period of hospitalization (which was paid for by Li), she will be required to
undergo adjustments in her prosthetic devise due to the shrinkage of the stump from
the process of healing.
These adjustments entail costs, prosthetic replacements and months of physical and
occupational rehabilitation and therapy. During the lifetime, the prosthetic devise will
have to be replaced and readjusted to changes in the size of her lower limb effected
by the biological changes of middle-age, menopause and aging. Assuming she
reaches menopause, for example, the prosthetic will have to be adjusted to respond
to the changes in bone resulting from a precipitate decrease in calcium levels
observed in the bones of all post-menopausal women. In other words, the damage
done to her would not only be permanent and lasting, it would also be permanently
changing and adjusting to the physiologic changes which her body would normally
undergo through the years. The replacements, changes, and adjustments will require
corresponding adjustive physical and occupational therapy. All of these adjustments,
it has been documented, are painful.
xxx xxx xxx
A prosthetic devise, however technologically advanced, will only allow a reasonable
amount of functional restoration of the motor functions of the lower limb. The sensory
functions are forever lost. The resultant anxiety, sleeplessness, psychological injury,
mental and physical pain are inestimable. 83
The injury suffered by Erlinda as a consequence of private respondents' negligence is certainly
much more serious than the amputation in the Valenzuela case.
Petitioner Erlinda Ramos was in her mid-forties when the incident occurred. She has been in a
comatose state for over fourteen years now. The burden of care has so far been heroically
shouldered by her husband and children, who, in the intervening years have been deprived of the
love of a wife and a mother.
Meanwhile, the actual physical, emotional and financial cost of the care of petitioner would be
virtually impossible to quantify. Even the temperate damages herein awarded would be inadequate if
petitioner's condition remains unchanged for the next ten years.
We recognized, in Valenzuela that a discussion of the victim's actual injury would not even scratch
the surface of the resulting moral damage because it would be highly speculative to estimate the
amount of emotional and moral pain, psychological damage and injury suffered by the victim or
those actually affected by the victim's condition. 84The husband and the children, all petitioners in this
case, will have to live with the day to day uncertainty of the patient's illness, knowing any hope of
recovery is close to nil. They have fashioned their daily lives around the nursing care of petitioner, altering
their long term goals to take into account their life with a comatose patient. They, not the respondents, are
charged with the moral responsibility of the care of the victim. The family's moral injury and suffering in
this case is clearly a real one. For the foregoing reasons, an award of P2,000,000.00 in moral damages
would be appropriate.

Finally, by way of example, exemplary damages in the amount of P100,000.00 are hereby awarded.
Considering the length and nature of the instant suit we are of the opinion that attorney's fees valued
at P100,000.00 are likewise proper.
Our courts face unique difficulty in adjudicating medical negligence cases because physicians are
not insurers of life and, they rarely set out to intentionally cause injury or death to their patients.
However, intent is immaterial in negligence cases because where negligence exists and is proven,
the same automatically gives the injured a right to reparation for the damage caused.
Established medical procedures and practices, though in constant flux are devised for the purpose of
preventing complications. A physician's experience with his patients would sometimes tempt him to
deviate from established community practices, and he may end a distinguished career using
unorthodox methods without incident. However, when failure to follow established procedure results
in the evil precisely sought to be averted by observance of the procedure and a nexus is made
between the deviation and the injury or damage, the physician would necessarily be called to
account for it. In the case at bar, the failure to observe pre-operative assessment protocol which
would have influenced the intubation in a salutary way was fatal to private respondents' case.
WHEREFORE, the decision and resolution of the appellate court appealed from are hereby modified
so as to award in favor of petitioners, and solidarily against private respondents the following: 1)
P1,352,000.00 as actual damages computed as of the date of promulgation of this decision plus a
monthly payment of P8,000.00 up to the time that petitioner Erlinda Ramos expires or miraculously
survives; 2) P2,000,000.00 as moral damages, 3) P1,500,000.00 as temperate damages; 4)
P100,000.00 each as exemplary damages and attorney's fees; and, 5) the costs of the suit.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
G.R. No. 187926

February 15, 2012

Dr. EMMANUEL JARCIA, Jr. and Dr. MARILOU BASTAN, Petitioners,

vs.
PEOPLE OF THE PHILIPPINES, Respondent.
DECISION
MENDOZA, J.:
Even early on, patients have consigned their lives to the skill of their doctors. Time and again, it can
be said that the most important goal of the medical profession is the preservation of life and health of
the people. Corollarily, when a physician departs from his sacred duty and endangers instead the life
of his patient, he must be made liable for the resulting injury. This Court, as this case would show,
cannot and will not let the act go unpunished. 1
This is a petition for review under Rule 45 of the Rules of Court challenging the August 29, 2008
Decision2 of the Court of Appeals (CA), and its May 19, 2009 Resolution3 in CA-G.R. CR No. 29559,
dismissing the appeal and affirming in toto the June 14, 2005 Decision4 of the Regional Trial Court,
Branch 43, Manila (RTC), finding the accused guilty beyond reasonable doubt of simple imprudence
resulting to serious physical injuries.
THE FACTS
Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of
Investigation (NBI) against the petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou
Bastan (Dr. Bastan), for their alleged neglect of professional duty which caused her son, Roy
Alfonso Santiago (Roy Jr.), to suffer serious physical injuries. Upon investigation, the NBI found that
Roy Jr. was hit by a taxicab; that he was rushed to the Manila Doctors Hospital for an emergency
medical treatment; that an X-ray of the victims ankle was ordered; that the X-ray result showed no
fracture as read by Dr. Jarcia; that Dr. Bastan entered the emergency room (ER) and, after
conducting her own examination of the victim, informed Mrs. Santiago that since it was only the
ankle that was hit, there was no need to examine the upper leg; that eleven (11) days later, Roy Jr.
developed fever, swelling of the right leg and misalignment of the right foot; that Mrs. Santiago
brought him back to the hospital; and that the X-ray revealed a right mid-tibial fracture and a linear
hairline fracture in the shaft of the bone.
The NBI indorsed the matter to the Office of the City Prosecutor of Manila for preliminary
investigation. Probable cause was found and a criminal case for reckless imprudence resulting to
serious physical injuries, was filed against Dr. Jarcia, Dr. Bastan and Dr. Pamittan,5 before the RTC,
docketed as Criminal Case No. 01-196646.
On June 14, 2005, the RTC found the petitioners guilty beyond reasonable doubt of the crime
of Simple Imprudence Resulting to Serious Physical Injuries. The decretal portion of the RTC
decision reads:

WHEREFORE, premises considered, the Court finds accused DR. EMMANUEL JARCIA, JR. and
DR. MARILOU BASTAN GUILTY beyond reasonable doubt of the crime of SIMPLE IMPRUDENCE
RESULTING TO SERIOUS PHYSICAL INJURIES and are hereby sentenced to suffer the penalty of
ONE (1) MONTH and ONE (1) DAY to TWO (2) MONTHS and to indemnify MRS. BELINDA
SANTIAGO the amount of P 3,850.00 representing medical expenses without subsidiary
imprisonment in case of insolvency and to pay the costs.
It appearing that Dr. Pamittan has not been apprehended nor voluntarily surrendered despite
warrant issued for her arrest, let warrant be issued for her arrest and the case against her be
ARCHIVED, to be reinstated upon her apprehension.
SO ORDERED.6
The RTC explained:
After a thorough and in depth evaluation of the evidence adduced by the prosecution and the
defense, this court finds that the evidence of the prosecution is the more credible, concrete and
sufficient to create that moral certainty in the mind of the Court that accused herein [are] criminally
responsible. The Court believes that accused are negligent when both failed to exercise the
necessary and reasonable prudence in ascertaining the extent of injury of Alfonso Santiago, Jr.
However, the negligence exhibited by the two doctors does not approximate negligence of a
reckless nature but merely amounts to simple imprudence. Simple imprudence consists in the lack of
precaution displayed in those cases in which the damage impending to be caused is not the
immediate nor the danger clearly manifest. The elements of simple imprudence are as follows.
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 of the danger is not clearly
manifest.
Considering all the evidence on record, The Court finds the accused guilty for simple imprudence
resulting to physical injuries. Under Article 365 of the Revised Penal Code, the penalty provided for
is arresto mayor in its minimum period.7
Dissatisfied, the petitioners appealed to the CA.
As earlier stated, the CA affirmed the RTC decision in toto. The August 29, 2008 Decision of the CA
pertinently reads:
This Court holds concurrently and finds the foregoing circumstances sufficient to sustain a judgment
of conviction against the accused-appellants for the crime of simple imprudence resulting in serious
physical injuries. The elements of imprudence are: (1) that the offender does or fails to do an act; (2)
that the doing or the failure to do that act is voluntary; (3) that it be without malice; (4) that material
damage results from the imprudence; and (5) that there is inexcusable lack of precaution on the part
of the offender, taking into consideration his employment or occupation, degree of intelligence,
physical condition, and other circumstances regarding persons, time and place.
Whether or not Dr. Jarcia and Dr. Bastan had committed an "inexcusable lack of precaution" in the
treatment of their patient is to be determined according to the standard of care observed by other
members of the profession in good standing under similar circumstances, bearing in mind the

advanced state of the profession at the time of treatment or the present state of medical science. In
the case of Leonila Garcia-Rueda v. Pascasio, the Supreme Court stated that, in accepting a case, a
doctor in effect represents that, having the needed training and skill possessed by physicians and
surgeons practicing in the same field, he will employ such training, care and skill in the treatment of
his patients. He therefore has a duty to use at least the same level of care that any other reasonably
competent doctor would use to treat a condition under the same circumstances.
In litigations involving medical negligence, the plaintiff has the burden of establishing accusedappellants negligence, and for a reasonable conclusion of negligence, there must be proof of breach
of duty on the part of the physician as well as a causal connection of such breach and the resulting
injury of his patient. The connection between the negligence and the injury must be a direct and
natural sequence of events, unbroken by intervening efficient causes. In other words, the negligence
must be the proximate cause of the injury. Negligence, no matter in what it consists, cannot create a
right of action unless it is the proximate cause of the injury complained of. The proximate cause of
an injury is that cause which, in natural and continuous sequence, unbroken by any efficient
intervening cause, produces the injury and without which the result would not have occurred.
In the case at bench, the accused-appellants questioned the imputation against them and argued
that there is no causal connection between their failure to diagnose the fracture and the injury
sustained by Roy.
We are not convinced.
The prosecution is however after the cause which prolonged the pain and suffering of Roy and not
on the failure of the accused-appellants to correctly diagnose the extent of the injury sustained by
Roy.
For a more logical presentation of the discussion, we shall first consider the applicability of the
doctrine of res ipsa loquitur to the instant case. Res ipsa loquitur is a Latin phrase which literally
means "the thing or the transaction speaks for itself. The doctrine of res ipsa loquitur is simply a
recognition of the postulate that, as a matter of common knowledge and experience, the very nature
of certain types of occurrences may justify an inference of negligence on the part of the person who
controls the instrumentality causing the injury in the absence of some explanation by the accusedappellant who is charged with negligence. It is grounded in the superior logic of ordinary human
experience and, on the basis of such experience or common knowledge, negligence may be
deduced from the mere occurrence of the accident itself. Hence, res ipsa loquitur is applied in
conjunction with the doctrine of common knowledge.
The specific acts of negligence was narrated by Mrs. Santiago who accompanied her son during the
latters ordeal at the hospital. She testified as follows:
Fiscal Formoso:
Q: Now, he is an intern did you not consult the doctors, Dr. Jarcia or Dra. Pamittan to confirm
whether you should go home or not?
A: Dra. Pamittan was inside the cubicle of the nurses and I asked her, you let us go home and you
dont even clean the wounds of my son.
Q: And what did she [tell] you?

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

xxx

xxx

xxx

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

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

xxx

xxx

xxx

xxx

xxx

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

xxx

xxx

xxx

xxx

xxx

Q: And you were present when they were called?

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

Still, before resort to the doctrine may be allowed, the following requisites must be satisfactorily
shown:
1. The accident is of a kind which ordinarily does not occur in the absence of someones
negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or
defendants; and
3. The possibility of contributing conduct which would make the plaintiff responsible is
eliminated.
In the above requisites, the fundamental element is the "control of the instrumentality" which caused
the damage. Such element of control must be shown to be within the dominion of the accusedappellants. In order to have the benefit of the rule, a plaintiff, in addition to proving injury or damage,
must show a situation where it is applicable and must establish that the essential elements of the
doctrine were present in a particular incident. The early treatment of the leg of Roy would have
lessen his suffering if not entirely relieve him from the fracture. A boy of tender age whose leg was
hit by a vehicle would engender a well-founded belief that his condition may worsen without proper
medical attention. As junior residents who only practice general surgery and without specialization
with the case consulted before them, they should have referred the matter to a specialist. This
omission alone constitutes simple imprudence on their part. When Mrs. Santiago insisted on having
another x-ray of her child on the upper part of his leg, they refused to do so. The mother would not
have asked them if they had no exclusive control or prerogative to request an x-ray test. Such is a
fact because a radiologist would only conduct the x-ray test upon request of a physician.
The testimony of Mrs. Santiago was corroborated by a bone specialist Dr. Tacata. He further
testified based on his personal knowledge, and not as an expert, as he examined himself the child
Roy. He testified as follows:
Fiscal Macapagal:
Q: And was that the correct respon[se] to the medical problem that was presented to Dr. Jarcia and
Dra. Bastan?
A: I would say at that stage, yes. Because they have presented the patient and the history. "At sabi
nila, nadaanan lang po ito." And then, considering their year of residency they are still junior
residents, and they are not also orthopedic residents but general surgery residents, its entirely
different thing. Because if you are an orthopedic resident, I am not trying to saybut if I were an
orthopedic resident, there would be more precise and accurate decision compare to a general
surgery resident in so far as involved.
Q: You mean to say there is no supervisor attending the emergency room?
A: At the emergency room, at the Manila Doctors Hospital, the supervisor there is a consultant that
usually comes from a family medicine. They see where a certain patient have to go and then if they
cannot manage it, they refer it to the consultant on duty. Now at that time, I dont [know] why they
dont.Because at that time, I think, it is the decision. Since the x-rays.
Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to
whether a patient has been treated or operated upon with a reasonable degree of skill and care.

However, testimony as to the statements and acts of physicians, external appearances, and
manifest conditions which are observable by any one may be given by non-expert witnesses. Hence,
in cases where the res ipsa loquitur is applicable, the court is permitted to find a physician negligent
upon proper proof of injury to the patient, without the aid of expert testimony, where the court from its
fund of common knowledge can determine the proper standard of care. Where common knowledge
and experience teach that a resulting injury would not have occurred to the patient if due care had
been exercised, an inference of negligence may be drawn giving rise to an application of the
doctrine ofres ipsa loquitur without medical evidence, which is ordinarily required to show not only
what occurred but how and why it occurred. In the case at bench, we give credence to the testimony
of Mrs. Santiago by applying the doctrine of res ipsa loquitur.
Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously
applied, depending upon the circumstances of each case. It is generally restricted to situations in
malpractice cases where a layman is able to say, as a matter of common knowledge and
observation, that the consequences of professional care were not as such as would ordinarily have
followed if due care had been exercised. A distinction must be made between the failure to secure
results and the occurrence of something more unusual and not ordinarily found if the service or
treatment rendered followed the usual procedure of those skilled in that particular practice. The latter
circumstance is the primordial issue that confronted this Court and we find application of the doctrine
of res ipsa loquitur to be in order.
WHEREFORE, in view of the foregoing, the appeal in this case is hereby DISMISSED and the
assailed decision of the trial court finding accused-appellants guilty beyond reasonable doubt of
simple imprudence resulting in serious physical injuries is hereby AFFIRMED in toto.
SO ORDERED.8
The petitioners filed a motion for reconsideration, but it was denied by the CA in its May 19, 2009
Resolution.
Hence, this petition.
The petitioners pray for the reversal of the decision of both the RTC and the CA anchored on the
following
GROUNDS1. IN AFFIRMING ACCUSED-PETITIONERS CONVICTION, THE COURT OF APPEALS
ERRED IN NOT HOLDING THAT THE ACTUAL, DIRECT, IMMEDIATE, AND PROXIMATE
CAUSE OF THE PHYSICAL INJURY OF THE PATIENT (FRACTURE OF THE LEG BONE
OR TIBIA), WHICH REQUIRED MEDICAL ATTENDANCE FOR MORE THAN THIRTY (30)
DAYS AND INCAPACITATED HIM FROM PERFORMING HIS CUSTOMARY DUTY
DURING THE SAME PERIOD OF TIME, WAS THE VEHICULAR ACCIDENT WHERE THE
PATIENTS RIGHT LEG WAS HIT BY A TAXI, NOT THE FAILURE OF THE ACCUSEDPETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY
EXAMINATION.
2. THE COURT OF APPEALS ERRED IN DISREGARDING ESTABLISHED FACTS
CLEARLY NEGATING PETITIONERS ALLEGED NEGLIGENCE OR IMPRUDENCE.
SIGNIFICANTLY, THE COURT OF APPEALS UNJUSTIFIABLY DISREGARDED THE
OPINION OF THE PROSECUTIONS EXPERT WITNESS, DR. CIRILO TACATA, THAT

PETITIONERS WERE NOT GUILTY OF NEGLIGENCE OR IMPRUDENCE COMPLAINED

OF.
3. THE COURT OF APPEALS ERRED IN HOLDING THAT THE FAILURE OF
PETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY
EXAMINATION PROLONGED THE PAIN AND SUFFERING OF THE PATIENT, SUCH
CONCLUSION BEING UNSUPPORTED BY, AND EVEN CONTRARY TO, THE EVIDENCE
ON RECORD.
4. ASSUMING ARGUENDO THAT THE PATIENT EXPERIENCED PROLONGED PAIN
AND SUFFERING, THE COURT OF APPEALS ERRED IN NOT HOLDING THAT THE
ALLEGED PAIN AND SUFFERING WERE DUE TO THE UNJUSTIFIED FAILURE OF THE
PATIENTS MOTHER, A NURSE HERSELF, TO IMMEDIATELY BRING THE PATIENT
BACK TO THE HOSPITAL, AS ADVISED BY THE PETITIONERS, AFTER HE
COMPLAINED OF SEVERE PAIN IN HIS RIGHT LEG WHEN HE REACHED HOME
AFTER HE WAS SEEN BY PETITIONERS AT THE HOSPITAL. THUS, THE PATIENTS
ALLEGED INJURY (PROLONGED PAIN AND SUFFERING) WAS DUE TO HIS OWN
MOTHERS ACT OR OMISSION.
5. THE COURT OF APPEALS ERRED IN NOT HOLDING THAT NO PHYSICIAN-PATIENT
RELATIONSHIP EXISTED BETWEEN PETITIONERS AND PATIENT ALFONSO
SANTIAGO, JR., PETITIONERS NOT BEING THE LATTERS ATTENDING PHYSICIAN
AS THEY WERE MERELY REQUESTED BY THE EMERGENCY ROOM (ER) NURSE TO
SEE THE PATIENT WHILE THEY WERE PASSING BY THE ER FOR THEIR LUNCH.
6. THE COURT OF APPEALS GRAVELY ERRED IN NOT ACQUITTING ACCUSEDPETITIONERS OF THE CRIME CHARGED."9
The foregoing can be synthesized into two basic issues: [1] whether or not the doctrine of res ipsa
loquitur is applicable in this case; and [2] whether or not the petitioners are liable for criminal
negligence.
THE COURTS RULING
The CA is correct in finding that there was negligence on the part of the petitioners. After a perusal
of the records, however, the Court is not convinced that the petitioners are guilty of criminal
negligence complained of. The Court is also of the view that the CA erred in applying the doctrine of
res ipsa loquitur in this particular case.
As to the Application of The Doctrine of Res Ipsa Loquitur
This doctrine of res ipsa loquitur means "Where the thing which causes injury is shown to be under
the management of the defendant, and the accident is such as in the ordinary course of things does
not happen if those who have the management use proper care, it affords reasonable evidence, in
the absence of an explanation by the defendant, that the accident arose from want of care."
The Black's Law Dictionary defines the said doctrine. Thus:
The thing speaks for itself. Rebuttable presumption or inference that defendant was negligent, which
arises upon proof that the instrumentality causing injury was in defendant's exclusive control, and
that the accident was one which ordinarily does not happen in absence of negligence. Res ipsa
loquitur is a rule of evidence whereby negligence of the alleged wrongdoer may be inferred from the
mere fact that the accident happened provided the character of the accident and circumstances

attending it lead reasonably to belief that in the absence of negligence it would not have occurred
and that thing which caused injury is shown to have been under the management and control of the
alleged wrongdoer. Under this doctrine, the happening of an injury permits an inference of
negligence where plaintiff produces substantial evidence that the injury was caused by an agency or
instrumentality under the exclusive control and management of defendant, and that the occurrence
was such that in the ordinary course of things would not happen if reasonable care had been used. 10
The doctrine of res ipsa loquitur as a rule of evidence is unusual to the law of negligence which
recognizes thatprima facie negligence may be established without direct proof and furnishes a
substitute for specific proof of negligence. The doctrine, however, is not a rule of substantive law, but
merely a mode of proof or a mere procedural convenience. The rule, when applicable to the facts
and circumstances of a given case, is not meant to and does not dispense with the requirement of
proof of culpable negligence on the party charged. It merely determines and regulates what shall
be prima facie evidence thereof and helps the plaintiff in proving a breach of the duty. The doctrine
can be invoked when and only when, under the circumstances involved, direct evidence is absent
and not readily available.11
The requisites for the application of the doctrine of res ipsa loquitur are: (1) the accident was of a
kind which does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency
which caused the injury was under the exclusive control of the person in charge; and (3) the injury
suffered must not have been due to any voluntary action or contribution of the person injured. 12
In this case, the circumstances that caused patient Roy Jr.s injury and the series of tests that were
supposed to be undergone by him to determine the extent of the injury suffered were not under the
exclusive control of Drs. Jarcia and Bastan. It was established that they are mere residents of the
Manila Doctors Hospital at that time who attended to the victim at the emergency room. 13 While it
may be true that the circumstances pointed out by the courts below seem doubtless to constitute
reckless imprudence on the part of the petitioners, this conclusion is still best achieved, not through
the scholarly assumptions of a layman like the patients mother, but by the unquestionable
knowledge of expert witness/es. As to whether the petitioners have exercised the requisite degree of
skill and care in treating patient Roy, Jr. is generally a matter of expert opinion.
As to Dr. Jarcia and Dr. Bastans negligence
The totality of the evidence on record clearly points to the negligence of the petitioners. At the risk of
being repetitious, the Court, however, is not satisfied that Dr. Jarcia and Dr. Bastan are criminally
negligent in this case.
Negligence is defined as the failure to observe for the protection of the interests of another person
that degree of care, precaution, and vigilance which the circumstances justly demand, whereby such
other person suffers injury.14
Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act from which
material damage results by reason of an inexcusable lack of precaution on the part of the person
performing or failing to perform such act.15
The elements of simple negligence are: (1) that there is lack of precaution on the part of the
offender, and (2) that the damage impending to be caused is not immediate or the danger is not
clearly manifest.16

In this case, the Court is not convinced with moral certainty that the petitioners are guilty of reckless
imprudence or simple negligence. The elements thereof were not proved by the prosecution beyond
reasonable doubt.
The testimony of Dr. Cirilo R. Tacata (Dr. Tacata), a specialist in pediatric orthopedic, although
pointing to some medical procedures that could have been done by Dr. Jarcia and Dr. Bastan, as
physicians on duty, was not clear as to whether the injuries suffered by patient Roy Jr. were indeed
aggravated by the petitioners judgment call and their diagnosis or appreciation of the condition of
the victim at the time they assessed him. Thus:
Q: Will you please tell us, for the record, doctor, what is your specialization?
A: At present I am the chairman department of orthopedic in UP-PGH and I had special training in
pediatric orthopedic for two (2) years.
Q: In June 1998, doctor, what was your position and what was your specialization at that time?
A: Since 1980, I have been specialist in pediatric orthopedic.
Q: When Alfonso Santiago, Jr. was brought to you by his mother, what did you do by way of
physicians as first step?
A: As usual, I examined the patient physically and, at that time as I have said, the patient could not
walk so I [began] to suspect that probably he sustained a fracture as a result of a vehicular accident.
So I examined the patient at that time, the involved leg, I dont know if that is left or right, the
involved leg then was swollen and the patient could not walk, so I requested for the x-ray of [the]
lower leg.
Q: What part of the leg, doctor, did you request to be examined?
A: If we refer for an x-ray, usually, we suspect a fracture whether in approximal, middle or lebistal
tinial, we usually x-ray the entire extremity.
Q: And what was the result?
A: Well, I can say that it was a spiral fracture of the mid-tibial, it is the bigger bone of the leg.
Q: And when you say spiral, doctor, how long was this fracture?
A: When we say spiral, it is a sort of letter S, the length was about six (6) to eight (8) centimeters.
Q: Mid-tibial, will you please point to us, doctor, where the tibial is?
(Witness pointing to his lower leg)
A: The tibial is here, there are two bones here, the bigger one is the tibial and the smaller one is the
fibula. The bigger one is the one that get fractured.
Q: And in the course of your examination of Alfonso Santiago, Jr. did you ask for the history of such
injury?

A: Yes, actually, that was a routine part of our examination that once a patient comes in, before we
actually examine the patient, we request for a detailed history. If it is an accident, then, we request
for the exact mechanism of injuries.
Q: And as far as you can recall, Doctor, what was the history of that injury that was told to you?
A: The patient was sideswiped, I dont know if it is a car, but it is a vehicular accident.
Q: Who did you interview?
A: The mother.
Q: How about the child himself, Alfonso Santiago, Jr.?
A: Normally, we do not interview the child because, usually, at his age, the answers are not
accurate. So, it was the mother that I interviewed.
Q: And were you informed also of his early medication that was administered on Alfonso Santiago,
Jr.?
A: No, not actually medication. I was informed that this patient was seen initially at the emergency
room by the two (2) physicians that you just mentioned, Dr. Jarcia and Dra. Bastan, that time who
happened to be my residents who were [on] duty at the emergency room.
xxxx
A: At the emergency room, at the Manila Doctors Hospital, the supervisor there is a consultant that
usually comes from a family medicine. They see where a certain patient have to go and then if they
cannot manage it, they refer it to the consultant on duty. Now at that time, I dont why they dont
Because at that time, I think, it is the decision. Since the x-rays
xxx
Q: You also said, Doctor, that Dr. Jarcia and Dra. Bastan are not even an orthopedic specialist.
A: They are general surgeon residents. You have to man[x] the emergency room, including
neurology, orthopedic, general surgery, they see everything at the emergency room.
xxxx
Q: But if initially, Alfonso Santiago, Jr. and his case was presented to you at the emergency room,
you would have subjected the entire foot to x-ray even if the history that was given to Dr. Jarcia and
Dra. Bastan is the same?
A: I could not directly say yes, because it would still depend on my examination, we cannot subject
the whole body for x-ray if we think that the damaged was only the leg.
Q: Not the entire body but the entire leg?
A: I think, if my examination requires it, I would.

Q: So, you would conduct first an examination?

A: Yes, sir.
Q: And do you think that with that examination that you would have conducted you would discover
the necessity subjecting the entire foot for x-ray?
A: It is also possible but according to them, the foot and the ankle were swollen and not the leg,
which sometimes normally happens that the actual fractured bone do not get swollen.
xxxx
Q: Doctor, if you know that the patient sustained a fracture on the ankle and on the foot and
the history that was told to you is the region that was hit is the region of the foot, will the
doctor subject the entire leg for x-ray?
A: I am an orthopedic surgeon, you have to subject an x-ray of the leg. Because you have to
consider the kind of fracture that the patient sustained would you say the exact mechanism
of injury. For example spiral, "paikot yung bale nya," so it was possible that the leg was run
over, the patient fell, and it got twisted. Thats why the leg seems to be fractured.17 [Emphases
supplied]
It can be gleaned from the testimony of Dr. Tacata that a thorough examination was not performed
on Roy Jr. As residents on duty at the emergency room, Dr. Jarcia and Dr. Bastan were expected to
know the medical protocol in treating leg fractures and in attending to victims of car accidents. There
was, however, no precise evidence and scientific explanation pointing to the fact that the delay in the
application of the cast to the patients fractured leg because of failure to immediately diagnose the
specific injury of the patient, prolonged the pain of the child or aggravated his condition or even
caused further complications. Any person may opine that had patient Roy Jr. been treated properly
and given the extensive X-ray examination, the extent and severity of the injury, spiral fracture of the
mid-tibial part or the bigger bone of the leg, could have been detected early on and the prolonged
pain and suffering of Roy Jr. could have been prevented. But still, that opinion, even how logical it
may seem would not, and could not, be enough basis to hold one criminally liable; thus, a
reasonable doubt as to the petitioners guilt.
Although the Court sympathizes with the plight of the mother and the child in this case, the Court is
bound by the dictates of justice which hold inviolable the right of the accused to be presumed
innocent until proven guilty beyond reasonable doubt. The Court, nevertheless, finds the
petitioners civilly liable for their failure to sufficiently attend to Roy Jr.s medical needs when the latter
was rushed to the ER, for while a criminal conviction requires proof beyond reasonable doubt, only a
preponderance of evidence is required to establish civil liability. Taken into account also was the fact
that there was no bad faith on their part.
Dr. Jarcia and Dr. Bastan cannot pass on the liability to the taxi driver who hit the victim. It may be
true that the actual, direct, immediate, and proximate cause of the injury (fracture of the leg bone or
tibia) of Roy Jr. was the vehicular accident when he was hit by a taxi. The petitioners, however,
cannot simply invoke such fact alone to excuse themselves from any liability. If this would be so,
doctors would have a ready defense should they fail to do their job in attending to victims of hit-andrun, maltreatment, and other crimes of violence in which the actual, direct, immediate, and proximate
cause of the injury is indubitably the act of the perpetrator/s.

In failing to perform an extensive medical examination to determine the extent of Roy Jr.s injuries,
Dr. Jarcia and Dr. Bastan were remiss of their duties as members of the medical profession.
Assuming for the sake of argument that they did not have the capacity to make such thorough
evaluation at that stage, they should have referred the patient to another doctor with sufficient
training and experience instead of assuring him and his mother that everything was all right.
This Court cannot also stamp its imprimatur on the petitioners contention that no physician-patient
relationship existed between them and patient Roy Jr., since they were not his attending physicians
at that time. They claim that they were merely requested by the ER nurse to see the patient while
they were passing by the ER for their lunch. Firstly, this issue was never raised during the trial at the
RTC or even before the CA. The petitioners, therefore, raise the want of doctor-patient relationship
for the first time on appeal with this Court. It has been settled that "issues raised for the first time on
appeal cannot be considered because a party is not permitted to change his theory on appeal. To
allow him to do so is unfair to the other party and offensive to the rules of fair play, justice and due
process."18 Stated differently, basic considerations of due process dictate that theories, issues and
arguments not brought to the attention of the trial court need not be, and ordinarily will not be,
considered by a reviewing court.19
Assuming again for the sake of argument that the petitioners may still raise this issue of "no
physicianpatient relationship," the Court finds and so holds that there was a "physicianpatient"
relationship in this case.
In the case of Lucas v. Tuao,20 the Court wrote that "[w]hen a patient engages the services of a
physician, a physician-patient relationship is generated. And in accepting a case, the physician, for
all intents and purposes, represents that he has the needed training and skill possessed by
physicians and surgeons practicing in the same field; and that he will employ such training, care, and
skill in the treatment of the patient. Thus, in treating his patient, a physician is under a duty to
exercise that degree of care, skill and diligence which physicians in the same general neighborhood
and in the same general line of practice ordinarily possess and exercise in like cases. Stated
otherwise, the physician has the obligation to use at least the same level of care that any other
reasonably competent physician would use to treat the condition under similar circumstances."
Indubitably, a physician-patient relationship exists between the petitioners and patient Roy Jr.
Notably, the latter and his mother went to the ER for an immediate medical attention. The petitioners
allegedly passed by and were requested to attend to the victim (contrary to the testimony of Dr.
Tacata that they were, at that time, residents on duty at the ER).21 They obliged and examined the
victim, and later assured the mother that everything was fine and that they could go home. Clearly, a
physician-patient relationship was established between the petitioners and the patient Roy Jr.
To repeat for clarity and emphasis, if these doctors knew from the start that they were not in the
position to attend to Roy Jr., a vehicular accident victim, with the degree of diligence and
commitment expected of every doctor in a case like this, they should have not made a baseless
assurance that everything was all right. By doing so, they deprived Roy Jr. of adequate medical
attention that placed him in a more dangerous situation than he was already in. What petitioners
should have done, and could have done, was to refer Roy Jr. to another doctor who could
competently and thoroughly examine his injuries.
All told, the petitioners were, indeed, negligent but only civilly, and not criminally, liable as the facts
show.
Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in the Philippines states:

A physician should attend to his patients faithfully and conscientiously. He should secure for them all
possible benefits that may depend upon his professional skill and care. As the sole tribunal to
adjudge the physicians failure to fulfill his obligation to his patients is, in most cases, his own
conscience, violation of this rule on his part is discreditable and inexcusable.22
Established medical procedures and practices, though in constant instability, are devised for the
purpose of preventing complications. In this case, the petitioners failed to observe the most prudent
medical procedure under the circumstances to prevent the complications suffered by a child of
tender age.
As to the Award of Damages
While no criminal negligence was found in the petitioners failure to administer the necessary
medical attention to Roy Jr., the Court holds them civilly liable for the resulting damages to their
patient. While it was the taxi driver who ran over the foot or leg of Roy Jr., their negligence was
doubtless contributory.
It appears undisputed that the amount of P 3,850.00, as expenses incurred by patient Roy Jr., was
adequately supported by receipts. The Court, therefore, finds the petitioners liable to pay this
amount by way of actual damages.
The Court is aware that no amount of compassion can suffice to ease the sorrow felt by the family of
the child at that time. Certainly, the award of moral and exemplary damages in favor of Roy Jr. in the
amount of P 100,000.00 and P 50,000.00, respectively, is proper in this case.
It is settled that moral damages are not punitive in nature, but are designed to compensate and
alleviate in some way the physical suffering, mental anguish, fright, serious anxiety, besmirched
reputation, wounded feelings, moral shock, social humiliation, and similar injury unjustly inflicted on a
person. Intended for the restoration of the psychological or emotional status quo ante, the award of
moral damages is designed to compensate emotional injury suffered, not to impose a penalty on the
wrongdoer.23
The Court, likewise, finds the petitioners also liable for exemplary damages in the said
amount. Article 2229 of the Civil Code provides that exemplary damages may be imposed by way of
example or correction for the public good.
1wphi1

WHEREFORE, the petition is PARTLY GRANTED. The Decision of the Court of Appeals dated
August 29, 2008 isREVERSED and SET ASIDE. A new judgment is entered ACQUITTING Dr.
Emmanuel Jarcia, Jr. and Dr. Marilou Bastan of the crime of reckless imprudence resulting to
serious physical injuries but declaring them civilly liable in the amounts of:
(1) P 3,850.00 as actual damages;
(2) P 100,000.00 as moral damages;
(3) P 50,000.00 as exemplary damages; and
(4) Costs of the suit.
with interest at the rate of 6% per annum from the date of the filing of the Information. The rate shall
be 12% interest per annum from the finality of judgment until fully paid. SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
SECOND DIVISION
G.R. No. 177407

February 9, 2011

RICO ROMMEL ATIENZA, Petitioner,

vs.
BOARD OF MEDICINE and EDITHA SIOSON, Respondents.
DECISION
NACHURA, J.:
Before us is a petition for review on certiorari under Rule 45 of the Rules of Court, assailing the
Decision1 dated September 22, 2006 of the Court of Appeals (CA) in CA-G.R. SP No. 87755. The
CA dismissed the petition for certiorari filed by petitioner Rico Rommel Atienza (Atienza), which, in
turn, assailed the Orders2 issued by public respondent Board of Medicine (BOM) in Administrative
Case No. 1882.
The facts, fairly summarized by the appellate court, follow.
Due to her lumbar pains, private respondent Editha Sioson went to Rizal Medical Center (RMC) for
check-up on February 4, 1995. Sometime in 1999, due to the same problem, she was referred to Dr.
Pedro Lantin III of RMC who, accordingly, ordered several diagnostic laboratory tests. The tests
revealed that her right kidney is normal. It was ascertained, however, that her left kidney is nonfunctioning and non-visualizing. Thus, she underwent kidney operation in September, 1999.
On February 18, 2000, private respondents husband, Romeo Sioson (as complainant), filed a
complaint for gross negligence and/or incompetence before the [BOM] against the doctors who
allegedly participated in the fateful kidney operation, namely: Dr. Judd dela Vega, Dr. Pedro Lantin,
III, Dr. Gerardo Antonio Florendo and petitioner Rico Rommel Atienza.
It was alleged in the complaint that the gross negligence and/or incompetence committed by the said
doctors, including petitioner, consists of the removal of private respondents fully functional right
kidney, instead of the left non-functioning and non-visualizing kidney.
The complaint was heard by the [BOM]. After complainant Romeo Sioson presented his evidence,
private respondent Editha Sioson, also named as complainant there, filed her formal offer of
documentary evidence. Attached to the formal offer of documentary evidence are her Exhibits "A" to
"D," which she offered for the purpose of proving that her kidneys were both in their proper
anatomical locations at the time she was operated. She described her exhibits, as follows:
"EXHIBIT A the certified photocopy of the X-ray Request form dated December 12, 1996,
which is also marked as Annex 2 as it was actually originally the Annex to x x x Dr. Pedro
Lantin, IIIs counter affidavit filed with the City Prosecutor of Pasig City in connection with the
criminal complaint filed by [Romeo Sioson] with the said office, on which are handwritten
entries which are the interpretation of the results of the ultrasound examination. Incidentally,
this exhibit happens to be the same as or identical to the certified photocopy of the document

marked as Annex 2 to the Counter-Affidavit dated March 15, 2000, filed by x x x Dr. Pedro
Lantin, III, on May 4, 2000, with this Honorable Board in answer to this complaint;
"EXHIBIT B the certified photo copy of the X-ray request form dated January 30, 1997,
which is also marked as Annex 3 as it was actually likewise originally an Annex to x x x Dr.
Pedro Lantin, IIIs counter-affidavit filed with the Office of the City Prosecutor of Pasig City in
connection with the criminal complaint filed by the herein complainant with the said office, on
which are handwritten entries which are the interpretation of the results of the examination.
Incidentally, this exhibit happens to be also the same as or identical to the certified photo
copy of the document marked as Annex 3 which is likewise dated January 30, 1997, which
is appended as such Annex 3 to the counter-affidavit dated March 15, 2000, filed by x x x
Dr. Pedro Lantin, III on May 4, 2000, with this Honorable Board in answer to this complaint.
"EXHIBIT C the certified photocopy of the X-ray request form dated March 16, 1996,
which is also marked as Annex 4, on which are handwritten entries which are the
interpretation of the results of the examination.
"EXHIBIT D the certified photocopy of the X-ray request form dated May 20, 1999, which
is also marked as Annex 16, on which are handwritten entries which are the interpretation of
the results of the examination. Incidentally, this exhibit appears to be the draft of the
typewritten final report of the same examination which is the document appended as
Annexes 4 and 1 respectively to the counter-affidavits filed by x x x Dr. Judd dela Vega
and Dr. Pedro Lantin, III in answer to the complaint. In the case of Dr. dela Vega however,
the document which is marked as Annex 4 is not a certified photocopy, while in the case of
Dr. Lantin, the document marked as Annex 1 is a certified photocopy. Both documents are
of the same date and typewritten contents are the same as that which are written on Exhibit
D.
Petitioner filed his comments/objections to private respondents [Editha Siosons] formal offer of
exhibits. He alleged that said exhibits are inadmissible because the same are mere photocopies, not
properly identified and authenticated, and intended to establish matters which are hearsay. He
added that the exhibits are incompetent to prove the purpose for which they are offered.
Dispositions of the Board of Medicine
The formal offer of documentary exhibits of private respondent [Editha Sioson] was admitted by the
[BOM] per its Order dated May 26, 2004. It reads:
"The Formal Offer of Documentary Evidence of [Romeo Sioson], the Comments/Objections of
[herein petitioner] Atienza, [therein respondents] De la Vega and Lantin, and the Manifestation of
[therein] respondent Florendo are hereby ADMITTED by the [BOM] for whatever purpose they may
serve in the resolution of this case.
"Let the hearing be set on July 19, 2004 all at 1:30 p.m. for the reception of the evidence of the
respondents.
"SO ORDERED."
Petitioner moved for reconsideration of the abovementioned Order basically on the same reasons
stated in his comment/objections to the formal offer of exhibits.

The [BOM] denied the motion for reconsideration of petitioner in its Order dated October 8, 2004. It
concluded that it should first admit the evidence being offered so that it can determine its probative
value when it decides the case. According to the Board, it can determine whether the evidence is
relevant or not if it will take a look at it through the process of admission. x x x. 3
Disagreeing with the BOM, and as previously adverted to, Atienza filed a petition for certiorari with
the CA, assailing the BOMs Orders which admitted Editha Siosons (Edithas) Formal Offer of
Documentary Evidence. The CA dismissed the petition for certiorari for lack of merit.
Hence, this recourse positing the following issues:
I. PROCEDURAL ISSUE:
WHETHER PETITIONER ATIENZA AVAILED OF THE PROPER REMEDY WHEN HE
FILED THE PETITION FOR CERTIORARI DATED 06 DECEMBER 2004 WITH THE
COURT OF APPEALS UNDER RULE 65 OF THE RULES OF COURT TO ASSAIL THE
ORDERS DATED 26 MAY 2004 AND 08 OCTOBER 2004 OF RESPONDENT BOARD.
II. SUBSTANTIVE ISSUE:
WHETHER THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR AND
DECIDED A QUESTION OF SUBSTANCE IN A WAY NOT IN ACCORDANCE WITH LAW
AND THE APPLICABLE DECISIONS OF THE HONORABLE COURT WHEN IT UPHELD
THE ADMISSION OF INCOMPETENT AND INADMISSIBLE EVIDENCE BY RESPONDENT
BOARD, WHICH CAN RESULT IN THE DEPRIVATION OF PROFESSIONAL LICENSE A
PROPERTY RIGHT OR ONES LIVELIHOOD.4
We find no reason to depart from the ruling of the CA.
Petitioner is correct when he asserts that a petition for certiorari is the proper remedy to assail the
Orders of the BOM, admitting in evidence the exhibits of Editha. As the assailed Orders were
interlocutory, these cannot be the subject of an appeal separate from the judgment that completely
or finally disposes of the case.5 At that stage, where there is no appeal, or any plain, speedy, and
adequate remedy in the ordinary course of law, the only and remaining remedy left to petitioner is a
petition for certiorari under Rule 65 of the Rules of Court on the ground of grave abuse of discretion
amounting to lack or excess of jurisdiction.
However, the writ of certiorari will not issue absent a showing that the BOM has acted without or in
excess of jurisdiction or with grave abuse of discretion. Embedded in the CAs finding that the BOM
did not exceed its jurisdiction or act in grave abuse of discretion is the issue of whether the exhibits
of Editha contained in her Formal Offer of Documentary Evidence are inadmissible.
Petitioner argues that the exhibits formally offered in evidence by Editha: (1) violate the best
evidence rule; (2) have not been properly identified and authenticated; (3) are completely hearsay;
and (4) are incompetent to prove their purpose. Thus, petitioner contends that the exhibits are
inadmissible evidence.
We disagree.
To begin with, it is well-settled that the rules of evidence are not strictly applied in proceedings
before administrative bodies such as the BOM.6 Although trial courts are enjoined to observe strict

enforcement of the rules of evidence, 7 in connection with evidence which may appear to be of
doubtful relevancy, incompetency, or admissibility, we have held that:
[I]t is the safest policy to be liberal, not rejecting them on doubtful or technical grounds, but admitting
them unless plainly irrelevant, immaterial or incompetent, for the reason that their rejection places
them beyond the consideration of the court, if they are thereafter found relevant or competent; on the
other hand, their admission, if they turn out later to be irrelevant or incompetent, can easily be
remedied by completely discarding them or ignoring them. 8
From the foregoing, we emphasize the distinction between the admissibility of evidence and the
probative weight to be accorded the same pieces of evidence. PNOC Shipping and Transport
Corporation v. Court of Appeals9teaches:
Admissibility of evidence refers to the question of whether or not the circumstance (or evidence) is to
be considered at all. On the other hand, the probative value of evidence refers to the question of
whether or not it proves an issue.
Second, petitioners insistence that the admission of Edithas exhibits violated his substantive rights
leading to the loss of his medical license is misplaced. Petitioner mistakenly relies on Section 20,
Article I of the Professional Regulation Commission Rules of Procedure, which reads:
Section 20. Administrative investigation shall be conducted in accordance with these Rules. The
Rules of Court shall only apply in these proceedings by analogy or on a suppletory character and
whenever practicable and convenient. Technical errors in the admission of evidence which do not
prejudice the substantive rights of either party shall not vitiate the proceedings. 10
As pointed out by the appellate court, the admission of the exhibits did not prejudice the substantive
rights of petitioner because, at any rate, the fact sought to be proved thereby, that the two kidneys of
Editha were in their proper anatomical locations at the time she was operated on, is presumed under
Section 3, Rule 131 of the Rules of Court:
Sec. 3. Disputable presumptions. The following presumptions are satisfactory if uncontradicted,
but may be contradicted and overcome by other evidence:
xxxx
(y) That things have happened according to the ordinary course of nature and the ordinary habits of
life.
The exhibits are certified photocopies of X-ray Request Forms dated December 12, 1996, January
30, 1997, March 16, 1996, and May 20, 1999, filed in connection with Edithas medical case. The
documents contain handwritten entries interpreting the results of the examination. These exhibits
were actually attached as annexes to Dr. Pedro Lantin IIIs counter affidavit filed with the Office of
the City Prosecutor of Pasig City, which was investigating the criminal complaint for negligence filed
by Editha against the doctors of Rizal Medical Center (RMC) who handled her surgical procedure.
To lay the predicate for her case, Editha offered the exhibits in evidence to prove that her "kidneys
were both in their proper anatomical locations at the time" of her operation.
The fact sought to be established by the admission of Edithas exhibits, that her "kidneys were both
in their proper anatomical locations at the time" of her operation, need not be proved as it is covered
by mandatory judicial notice.11

Unquestionably, the rules of evidence are merely the means for ascertaining the truth respecting a
matter of fact.12 Thus, they likewise provide for some facts which are established and need not be
proved, such as those covered by judicial notice, both mandatory and discretionary. 13 Laws of nature
involving the physical sciences, specifically biology, 14 include the structural make-up and
composition of living things such as human beings. In this case, we may take judicial notice that
Edithas kidneys before, and at the time of, her operation, as with most human beings, were in their
proper anatomical locations.
Third, contrary to the assertion of petitioner, the best evidence rule is inapplicable. Section 3 of Rule
130 provides:
1awphil

1. Best Evidence Rule

Sec. 3. Original document must be produced; exceptions. When the subject of inquiry is the
contents of a document, no evidence shall be admissible other than the original document itself,
except in the following cases:
(a) When the original has been lost or destroyed, or cannot be produced in court, without bad
faith on the part of the offeror;
(b) When the original is in the custody or under the control of the party against whom the
evidence is offered, and the latter fails to produce it after reasonable notice;
(c) When the original consists of numerous accounts or other documents which cannot be
examined in court without great loss of time and the fact sought to be established from them
is only the general result of the whole; and
(d) When the original is a public record in the custody of a public officer or is recorded in a
public office.
The subject of inquiry in this case is whether respondent doctors before the BOM are liable for gross
negligence in removing the right functioning kidney of Editha instead of the left non-functioning
kidney, not the proper anatomical locations of Edithas kidneys. As previously discussed, the proper
anatomical locations of Edithas kidneys at the time of her operation at the RMC may be established
not only through the exhibits offered in evidence.
Finally, these exhibits do not constitute hearsay evidence of the anatomical locations of Edithas
kidneys. To further drive home the point, the anatomical positions, whether left or right, of Edithas
kidneys, and the removal of one or both, may still be established through a belated ultrasound or xray of her abdominal area.
In fact, the introduction of secondary evidence, such as copies of the exhibits, is allowed. 15 Witness
Dr. Nancy Aquino testified that the Records Office of RMC no longer had the originals of the exhibits
"because [it] transferred from the previous building, x x x to the new building." 16 Ultimately, since the
originals cannot be produced, the BOM properly admitted Edithas formal offer of evidence and,
thereafter, the BOM shall determine the probative value thereof when it decides the case.
WHEREFORE, the petition is DENIED. The Decision of the Court of Appeals in CA-G.R. SP No.
87755 is AFFIRMED. Costs against petitioner.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 192973

September 29, 2014

PEDRITO DELA TORRE, Petitioner,

vs.
DR. ARTURO IMBUIDO, DRA. NORMA IMBUIDO in their capacity as owners and operators of
DIVINE SPIRIT GENERAL HOSPITAL and/or DR. NESTOR PASAMBA, Respondents.
RESOLUTION
REYES, J.:
This resolves the petition for review on certiorari1 filed by petitioner Pedrito Dela Torre (Pedrito)
assailing the Decision2 dated December 15, 2009 and Resolution3 dated July 27, 2010 of the Court of
Appeals (CA) in CA-G.R. CV No. 78534.
The case stemmed from a complaint4 for damages filed by Pedrito against herein respondents Dr.
ArturoImbuido and Dr. Norma Imbuido (Dr. Norma), in their capacity as the ownersand operators of
the Divine Spirit General Hospital in Olongapo City, and Dr. Nestor Pasamba (Dr. Nestor)
(respondents). Pedrito alleged in his complaint that he was married to one Carmen Castillo Dela
Torre(Carmen), who died while admitted at the Divine Spirit General Hospital on February 13, 1992.
Carmen was due to give birth on February 2,1992 and was brought at around 11:30 p.m. on that day
by Pedrito to the Divine Spirit General Hospital. When Carmen still had not delivered her baby at the
expected time, Dr. Norma discussed with Pedrito the possibility of a caesarean section operation. 5
At around 3:00 p.m. on February 3, 1992, Carmen was brought to the hospitals operating room for
her caesarian section operation, which was to be performed by Dr. Nestor. By 5:30 p.m. of the same
day, Pedrito was informed of his wifes delivery of a baby boy. In the early morning of February 4,
1992, Carmen experienced abdominal pain and difficulty in urinating. She was diagnosed to be
suffering from urinary tract infection (UTI), and was prescribed medications by Dr. Norma. On
February 10, 1992, Pedrito noticed that Carmens stomach was getting bigger, but Dr. Norma
dismissed the patients condition as mere flatulence (kabag).6
When Carmens stomach still grewbigger despite medications, Dr. Norma advised Pedrito of the
possibility of a second operation on Carmen. Dr. Norma, however, provided no detailson its purpose
and the doctor who would perform it. At around 3:00 p.m. on February 12, 1992, Carmen had her
second operation. Later in the evening, Dr. Norma informed Pedrito that "everything was going on
fine with [his] wife."7
The condition of Carmen, however, did not improve. It instead worsened that on February 13, 1992,
she vomited dark red blood. At 9:30 p.m. on the same day, Carmen died.8 Per her certificate of death
upon information provided by the hospital,the immediate cause of Carmens death was "cardiorespiratory arrest secondary to cerebro vascular accident, hypertension and chronic nephritis
induced by pregnancy."9 An autopsy Report10prepared by Dr. Richard Patilano(Dr. Patilano), MedicoLegal Officer-Designate of Olongapo City, however, provided that the cause of Carmens death was
"shock due to peritonitis, severe, with multiple intestinal adhesions; Status post C[a]esarian Section
and Exploratory Laparotomy."

Pedrito claimed in his complaint that the respondents "failed to exercise the degree of diligence
required of them" as members of the medical profession, and were "negligent for practicing surgery
on [Carmen] in the most unskilled, ignorant and cruel manner, x x x[.]" 11
In their answer12 to the complaint, the respondents argued that they "observed the required standard
of medical care in attending to the needs of Carmen." 13 The respondents explained that Carmen was
admitted in Divine Spirit General Hospital for "pregnancy in labor and pre-eclampsia." Her condition
was closely monitored during her confinement. A caesarian section operation became necessary, as
she manifested no significant progress for the spontaneous delivery of her baby. 14 No unusual events
were observed during the course of Carmens caesarian section operation. The second surgery,
however, became necessary due to suspected intestinal obstruction and adhesions. This procedure
was fully explained to Carmen and Pedrito prior to its conduct. During the second operation, the
diagnosis of intestinal obstruction and adhesion was confirmed but resolved by her doctors. Despite
the observance of due care by the doctors, however, Carmen died on February 13, 1992. 15
The respondents included in their answer a counterclaim for P48,515.58 as unpaid hospital charges,
professional fees and medicines, P3,000,000.00 for moral damages, P1,500,000.00 for exemplary
damages, and attorneys fees.16
After the pre-trial conference, trial proper ensued. To support his claim, Pedrito presented the
testimony of Dr. Patilano, the medicolegal officer who conducted an autopsy on the body of Carmen
upon a telephone request made by the City Health Officer of Olongapo City, Dr. Generoso Espinosa.
Among Dr. Patilanos observations, as narrated in the lower courts decision, were as follows:
In the intestines, [Dr. Patilano] found outthat it was more reddish than the normal condition which is
supposed to bepinkish. There was presence of adhesions, meaning, it sticks to each other and these
areas were dilated. There were constricted areas. He concluded that there might have been foreign
organic matters in the intestines. He did not see any swelling but assuming that there was, it would
be concomitant to the enlargement. x x x He came to the conclusion that the cause of death was
peritonitis, with the multiple adhesions status in the post caesarian section. In connection with
peritonitis, this is the inflammation of the abdomen. This peritonitis in the abdominal cavity may be
caused by several conditions which are supposed to be infections, entrance of foreign bodies in the
intestines in connection with ruptured peptic ulcer or [may be] somewhere in the spleen. The
entrance of foreign object in the abdominal cavities may cause severe infections of the intraabdominal cavities resulting [in] multiple adhesions of the intestines. In cases of surgical operation, it
[may be] due to the conditions of the instruments used, the materials used in the operating room
being not aseptic and the ladies assisting the operation were not in uniform. x x x. 17
Dr. Patilano claimed that peritonitis could have been prevented through proper medical procedures
and medicines. He also stated that if the cause of Carmens death was actually cerebro-vascular
accident, there would have been ruptured blood vessels and blood clot in her head; but there were
none in Carmens case.18
Among those who testified to refutePedritos claim was Dr. Nestor. He claimed that when Carmen
was referred to him on February 3, 1992, she was in full term uterine pregnancy, with pre-eclampsia,
fetal distress and active labor pains. A caesarian section operation became necessary to terminate
the pregnancy for her safety. Carmen was ready to go home four days after giving birth, but was
advised by the doctors to stay more because of her persistent hypertension. 19
The second surgery performed on Carmen was necessary after she showed symptoms of intestinal
obstruction, which happens as the intestines get twisted due to adhesions and the normal flow of
intestinal contents are obstructed. For Dr. Nestor, this occurrence was not preventable since any

interference of the abdominal cavity would irritate the serosa of the intestines, inviting adhesions that
could cause obstruction. Surgery could remedy the adhesions and obstruction. 20 Both Carmen and
Pedrito gave their written consent to this second procedure. 21
Dr. Bienvenido G. Torres (Dr. Torres), Chief of the Medico-Legal Division of the Philippine National
Police (PNP) Crime Laboratory Service,22 also testified for the respondents.He claimed that based on
Dr. Patilanos report, vital internal organs of Carmen, such as her brain, lungs, kidneys, liver and
adrenal glands, were not examined during the autopsy. 23
On January 28, 2003, the Regional Trial Court (RTC) of Olongapo City, Branch 75, rendered its
Decision24 in favor of Pedrito. The trial court gave greater weight to the testimony of Dr. Patilano and
thus disposed of the case as follows:
WHEREFORE, premises considered, judgment is hereby rendered in favor of the plaintiff and
against the defendants, ordering the latter to pay jointly and severally, the former, the following sums
of money, to wit:
1.) the sum of Php 28,759.46 as actual damages;
2.) the sum of Fifty Thousand (Php 50,000.00) Pesos as indemnity for the death of Carmen
dela Torre;
3.) the sum of Fifty Thousand (Php 50,000.00) Pesos as moral damages and the further sum
of Twenty Thousand (Php 20,000.00) Pesos as exemplary damages;
4.) the sum of Twenty Thousand (Php 20,000.00) Pesos as attorneys fees; and
5.) the costs of [suit].
SO ORDERED.25
Dissatisfied with the RTC ruling, the respondents appealed to the CA. On December 15, 2009, the
CA rendered its Decision reversing and setting aside the decision of the RTC. For the appellate
court, it was not established that the respondents failed to exercisethe degree of diligence required
of them by their profession as doctors. The CA also granted the respondents counterclaim for the
amount of P48,515.58, as it held:
WHEREFORE, the Decision of the Regional Trial Court of Olongapo City dated January 28, 2003 in
Civil Case No. 165-0-92 is hereby REVERSED AND SET ASIDE.
Plaintiff-appellee is directed to pay the unpaid balance for hospital bills, professional fees and other
expenses in the amount of [P]48,515.58.
SO ORDERED.26
Hence, this petition for review on certiorariin which Pedrito insists that the respondents should be
held liable for the death of Carmen.
The petition is denied.

"[M]edical malpractice or, more appropriately, medical negligence, is that type of claim which a victim
has available to him or her to redress a wrong committed by a medical professionalwhich has
caused bodily harm." In order to successfully pursue such a claim, a patient, or his or her family as in
this case, "must prove that a health care provider, in most cases a physician, either failed to do
something which a reasonably prudent health care provider would have done, or that he or she did
something that a reasonably prudent provider would not have done; and that failure or action caused
injury to the patient."27
The Court emphasized in Lucas, et al. v. Tuao28 that in medical negligence cases, there is a
physician-patient relationship between the doctor and the victim, but just like in any other proceeding
for damages, four essential elements must be established by the plaintiff, namely: (1) duty; (2)
breach; (3) injury; and (4) proximate causation. All four elements must be present in order to find the
physician negligent and, thus, liable for damages.29
It is settled that a physicians duty tohis patient relates to his exercise of the degree of care, skill and
diligence which physicians in the same general neighborhood, and in the same general line of
practice, ordinarily possess and exercise in like cases. There is breach of this duty when the patient
is injured in body or in health. Proof of this breach rests upon the testimony of an expert witness that
the treatment accorded to the patient failed to meet the standard level of care, skill and diligence. To
justify an award of damages, the negligence of the doctor must be established to be the proximate
cause of the injury.30
Through the instant petition, Pedritoseeks the reinstatement of the decision of the RTC whose
finding of the respondents medical negligence depended mainly on the testimony of Dr. Patilano.
Upon review, however, the Court agrees with the CA that the report and testimony of Dr. Patilano
failed to justify Pedritos entitlement to the damages awarded by the RTC.
For the trial court to give weightto Dr. Patilanos report, it was necessary to show first Dr. Patilanos
specialization and competence to testify on the degree of care, skill and diligence needed for the
treatment of Carmens case. Considering that it was not duly established that Dr. Patilano practiced
and was an expert inthe fields that involved Carmens condition, he could not have accurately
identified the said degree of care, skill, diligence and the medical procedures that should have been
applied by her attending physicians.
Similarly, such duty, degree of care, skill and diligence were not sufficiently established in this case
because the testimony of Dr. Patilano was based solely on the results of his autopsy on the cadaver
of Carmen. His study and assessment were restrictedby limitations that denied his full evaluation of
Carmens case. He could have only deduced from the injuries apparent in Carmens body, and in the
condition when the body was examined. Judging from his testimony, Dr. Patilano did not even take
full consideration of the medical history of Carmen, her actual health condition at the time of hospital
admission, and her condition as it progressed while she was being monitored and treated by the
respondents. There was also no reference to the respondents defense that the emergency
caesarian section operation had to be performed in order to protect the lives and safety of Carmen
and her then unborn child. For lack of sufficient information on Carmens health condition while still
alive, Dr. Patilano could not have fully evaluated the suitability of the respondents decisions in
handling Carmens medical condition as it turned critical.
On the other hand, the CA pointed out that Dr. Nestor, a surgeon, possessed the reasonable degree
of learning, skill and experience required by his profession for the treatment ofCarmen. The
respondents also emphasized in their pleadings beforethe RTC that Dr. Nestor had his training and
experience in surgery and obstetrics since 1970. Without sufficient proof from the claimant on a
1wphi1

different degree of care, skill and diligence that should be expected from the respondents, it could
not be said with certainty that a breachwas actually committed.
Moreover, while Dr. Patilano opined that Carmen died of peritonitis which could be due to the poor
state of the hospital equipment and medical supplies used during her operation, there was no
sufficient proof that any such fault actually attended the surgery of Carmen, caused her illness and
resulted in her death. It is also significant that the Chief of the Medico-Legal Division of the PNP
Crime Laboratory Service, Dr. Torres, testified before the trial court that based on the autopsy report
issued by Dr. Patilano, the latter did not comply with the basic autopsy procedure when he examined
the cadaver of Carmen. Dr. Patilano did not appear to have thoroughly examined Carmens vital
organs such as her heart, lungs, uterus and brain during the autopsy. His findings were then
inconclusive on the issue of the actual cause of Carmen's death, and the claim of negligence
allegedly committed by the respondents.
As the Court held in Spouses Flores v. Spouses Pineda, et al., 31 the critical and clinching factor in a
medical negligence case is proof of the causal connection between the negligence and the injuries.
The claimant must prove not only the injury but also the defendant's fault, and that such fault caused
the injury. A verdict in a malpractice action cannot be based on speculation or conjecture. Causation
must be proven within a reasonable medical probability based upon competent expert
testimony,32 which the Court finds absent in the case at bar. As regards the respondents'
counterclaim, the CA's award of P48,515.58 is sustained, considering that among the parties'
stipulations during the pre-trial indicated:
5. That at the time of the death of the patient Carmen C. dela Torrell there was an unpaid balance
for hospital bills, professional fees and other expenses in the amount of P48,515.58, incurred by
plaintiff when the patient was confined at said hospital from February 3 to 13, 1992. 33
WHEREFORE, the petition is DENIED. The Decision dated December 15, 2009 and Resolution
dated July 27, 2010 of the Court of Appeals in CA-G.R. CV No. 78534 are AFFIRMED.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Baguio City
THIRD DIVISION
G.R. No. 175540

April 7, 2014

DR. FILOTEO A. ALANO, Petitioner,

vs.
ZENAIDA MAGUD-LOGMAO, Respondent.
DECISION
PERALTA, J.:
This deals with the Petition for Review on Certiorari under Rule 45 of the Rules of Court praying that
the Decision1of the Court of Appeals (CA), dated March 31, 2006, adjudging petitioner liable for
damages, and the Resolution2dated November 22, 2006, denying petitioner's motion for
reconsideration thereof, be reversed and set aside.
The CA's narration of facts is accurate, to wit:
Plaintiff-appellee Zenaida Magud-Logmao is the mother of deceased Arnelito Logmao. Defendantappellant Dr. Filoteo Alano is the Executive Director of the National Kidney Institute (NKI).
At around 9:50 in the evening of March 1, 1988, Arnelito Logmao, then eighteen (18) years old, was
brought to the East Avenue Medical Center (EAMC) in Quezon City by two sidewalk vendors, who
allegedly saw the former fall from the overpass near the Farmers Market in Cubao, Quezon City.
The patients data sheet identified the patient as Angelito Lugmoso of Boni Avenue, Mandaluyong.
However, the clinical abstract prepared by Dr. Paterno F. Cabrera, the surgical resident on-duty at
the Emergency Room of EAMC, stated that the patient is Angelito [Logmao].
Dr. Cabrera reported that [Logmao] was drowsy with alcoholic breath, was conscious and coherent;
that the skull x-ray showed no fracture; that at around 4:00 oclock in the morning of March 2, 1988,
[Logmao] developed generalized seizures and was managed by the neuro-surgery resident on-duty;
that the condition of [Logmao] progressively deteriorated and he was intubated and ambu-bagging
support was provided; that admission to the Intensive Care Unit (ICU) and mechanical ventilator
support became necessary, but there was no vacancy at the ICU and all the ventilator units were
being used by other patients; that a resident physician of NKI, who was rotating at EAMC, suggested
that [Logmao] be transferred to NKI; and that after arrangements were made, [Logmao] was
transferred to NKI at 10:10 in the morning.
At the NKI, the name Angelito [Logmao] was recorded as Angelito Lugmoso. Lugmoso was
immediately attended to and given the necessary medical treatment. As Lugmoso had no relatives
around, Jennifer B. Misa, Transplant Coordinator, was asked to locate his family by enlisting police
and media assistance. Dr. Enrique T. Ona, Chairman of the Department of Surgery, observed that
the severity of the brain injury of Lugmoso manifested symptoms of brain death. He requested the
Laboratory Section to conduct a tissue typing and tissue cross-matching examination, so that should
Lugmoso expire despite the necessary medical care and management and he would be found to be

a suitable organ donor and his family would consent to organ donation, the organs thus donated
could be detached and transplanted promptly to any compatible beneficiary.
Jennifer Misa verified on the same day, March 2, 1988, from EAMC the identity of Lugmoso and,
upon her request, she was furnished by EAMC a copy of the patients date sheet which bears the
name Angelito Lugmoso, with address at Boni Avenue, Mandaluyong. She then contacted several
radio and television stations to request for air time for the purpose of locating the family of Angelito
Lugmoso of Boni Avenue, Mandaluyong, who was confined at NKI for severe head injury after
allegedly falling from the Cubao overpass, as well as Police Station No. 5, Eastern Police District,
whose area of jurisdiction includes Boni Avenue, Mandaluyong, for assistance in locating the
relatives of Angelito Lugmoso. Certifications were issued by Channel 4, ABS-CBN and GMA
attesting that the request made by the NKI on March 2, 1988 to air its appeal to locate the family and
relatives of Angelito Lugmoso of Boni Avenue, Mandaluyong was accommodated. A Certification
was likewise issued by Police Station No. 5, Eastern Police District, Mandaluyong attesting to the
fact that on March 2, 1988, at about 6:00 p.m., Jennifer Misa requested for assistance to
immediately locate the family and relatives of Angelito Lugmoso and that she followed up her
request until March 9, 1988.
On March 3, 1988, at about 7:00 oclock in the morning, Dr. Ona was informed that Lugmoso had
been pronounced brain dead by Dr. Abdias V. Aquino, a neurologist, and by Dr. Antonio Rafael, a
neurosurgeon and attending physician of Lugmoso, and that a repeat electroencephalogram (EEG)
was in progress to confirm the diagnosis of brain death. Two hours later, Dr. Ona was informed that
the EEG recording exhibited a flat tracing, thereby confirming that Lugmoso was brain dead. Upon
learning that Lugmoso was a suitable organ donor and that some NKI patients awaiting organ
donation had blood and tissue types compatible with Lugmoso, Dr. Ona inquired from Jennifer Misa
whether the relatives of Lugmoso had been located so that the necessary consent for organ
donation could be obtained. As the extensive search for the relatives of Lugmoso yielded no positive
result and time being of the essence in the success of organ transplantation, Dr. Ona requested Dr.
Filoteo A. Alano, Executive Director of NKI, to authorize the removal of specific organs from the body
of Lugmoso for transplantation purposes. Dr. Ona likewise instructed Dr. Rose Marie Rosete-Liquete
to secure permission for the planned organ retrieval and transplantation from the Medico-Legal
Office of the National Bureau of Investigation (NBI), on the assumption that the incident which lead
to the brain injury and death of Lugmoso was a medico legal case.
On March 3, 1988, Dr. Alano issued to Dr. Ona a Memorandum, which reads as follows:
This is in connection with the use of the human organs or any portion or portions of the human body
of the deceased patient, identified as a certain Mr. Angelito Lugmoso who was brought to the
National Kidney Institute on March 2, 1988 from the East Avenue Medical Center.
As shown by the medical records, the said patient died on March 3, 1988 at 9:10 in the morning due
to craniocerebral injury. Please make certain that your Department has exerted all reasonable efforts
to locate the relatives or next of kin of the said deceased patient such as appeal through the radios
and television as well as through police and other government agencies and that the NBI [MedicoLegal] Section has been notified and is aware of the case.
If all the above has been complied with, in accordance with the provisions of Republic Act No. 349
as amended and P.D. 856, permission and/or authority is hereby given to the Department of Surgery
to retrieve and remove the kidneys, pancreas, liver and heart of the said deceased patient and to
transplant the said organs to any compatible patient who maybe in need of said organs to live and
survive.

A Certification dated March 10, 1988 was issued by Dr. Maximo Reyes, Medico-Legal Officer of the
NBI, stating that he received a telephone call from Dr. Liquete on March 3, 1988 at 9:15 a.m.
regarding the case of Lugmoso, who was declared brain dead; that despite efforts to locate the
latters relatives, no one responded; that Dr. Liquete sought from him a second opinion for organ
retrieval for donation purposes even in the absence of consent from the family of the deceased; and
that he verbally agreed to organ retrieval.
At 3:45 in the afternoon of March 3, 1988, a medical team, composed of Dr. Enrique Ona, as
principal surgeon, Drs. Manuel Chua-Chiaco, Jr., Rose Marie Rosete-Liquete, Aurea Ambrosio,
Ludivino de Guzman, Mary Litonjua, Jaime Velasquez, Ricardo Fernando, and Myrna Mendoza,
removed the heart, kidneys, pancreas, liver and spleen of Lugmoso. The medical team then
transplanted a kidney and the pancreas of Lugmoso to Lee Tan Hoc and the other kidney of
Lugmoso to Alexis Ambustan. The transplant operation was completed at around 11:00 oclock in
the evening of March 3, 1988.
On March 4, 1988, Dr. Antonio R. Paraiso, Head of the Cadaver Organ Retrieval Effort (CORE)
program of NKI, made arrangements with La Funeraria Oro for the embalmment of the cadaver of
Lugmoso good for a period of fifteen (15) days to afford NKI more time to continue searching for the
relatives of the latter. On the same day, Roberto Ortega, Funeral Consultant of La Funeraria Oro,
sent a request for autopsy to the NBI. The Autopsy Report and Certification of Post-Mortem
Examination issued by the NBI stated that the cause of death of Lugmoso was intracranial
hemorrhage secondary to skull fracture.
On March 11, 1988, the NKI issued a press release announcing its successful double organ
transplantation. Aida Doromal, a cousin of plaintiff, heard the news aired on television that the donor
was an eighteen (18) year old boy whose remains were at La Funeraria Oro in Quezon City. As the
name of the donor sounded like Arnelito Logmao, Aida informed plaintiff of the news report.
It appears that on March 3, 1988, Arlen Logmao, a brother of Arnelito, who was then a resident of
17-C San Pedro Street, Mandaluyong, reported to Police Station No. 5, Eastern Police District,
Mandaluyong that the latter did not return home after seeing a movie in Cubao, Quezon City, as
evidenced by a Certification issued by said Station; and that the relatives of Arnelito were likewise
informed that the latter was missing. Upon receiving the news from Aida, plaintiff and her other
children went to La Funeraria Oro, where they saw Arnelito inside a cheap casket.
On April 29, 1988, plaintiff filed with the court a quo a complaint for damages against Dr. Emmanuel
Lenon, Taurean Protectors Agency, represented by its Proprietor, Celso Santiago, National Kidney
Institute, represented by its Director, Dr. Filoteo A. Alano, Jennifer Misa, Dr. Maximo Reyes, Dr.
Enrique T. Ona, Dr. Manuel Chua-Chiaco, Jr., Dr. Rose Marie O. Rosete-Liquete, Dr. Aurea Z.
Ambrosio, Dr. Ludivino de Guzman, Dr. Mary Litonjua, Dr. Jaime Velasquez, Dr. Ricardo Fernando,
Dr. Myrna Mendoza, Lee Tan Koc, Alexis Ambustan, Dr. Antonio R. Paraiso, La Funeraria Oro, Inc.,
represented by its President, German E. Ortega, Roberto Ortega alias Bobby Ortega, Dr. Mariano B.
Cueva, Jr., John Doe, Peter Doe, and Alex Doe in connection with the death of her son Arnelito.
Plaintiff alleged that defendants conspired to remove the organs of Arnelito while the latter was still
alive and that they concealed his true identity.
On January 17, 2000, the court a quo rendered judgment finding only Dr. Filoteo Alano liable for
damages to plaintiff and dismissing the complaint against the other defendants for lack of legal
basis.3
After finding petitioner liable for a quasi-delict, the Regional Trial Court of Quezon City (RTC)
ordered petitioner to pay respondent P188,740.90 as actual damages; P500,000.00 as moral

damages; P500,000.00 as exemplary damages; P300,000.00 as attorney's fees; and costs of suit.
Petitioner appealed to the CA.
On March 31, 2006, the CA issued its Decision, the dispositive portion of which reads as follows:
WHEREFORE, the Decision appealed from is AFFIRMED, with MODIFICATION by DELETING the
award ofP188,740.90 as actual damages and REDUCING the award of moral damages
to P250,000.00, the award of exemplary damages to P200,000.00 and the award of attorney's fees
to P100,000.00.
SO ORDERED.4
Petitioner then elevated the matter to this Court via a petition for review on certiorari, where the
following issues are presented for resolution:
A. WHETHER THE COURT OF APPEALS DISREGARDED EXISTING JURISPRUDENCE
PRONOUNCED BY THIS HONORABLE SUPREME COURT IN HOLDING PETITIONER
DR. FILOTEO ALANO LIABLE FOR MORAL AND EXEMPLARY DAMAGES AND
ATTORNEY'S FEES DESPITE THE FACT THAT THE ACT OF THE PETITIONER IS NOT
THE PROXIMATE CAUSE NOR IS THERE ANY FINDING THAT THE ACT OF THE
PETITIONER WAS THE PROXIMATE CAUSE OF THE INJURY OR DAMAGE ALLEGEDLY
SUSTAINED BY RESPONDENT ZENAIDA MAGUD-LOGMAO.
B. WHETHER THE COURT OF APPEALS GRAVELY ERRED IN REFUSING AND/OR
FAILING TO DECLARE THAT PETITIONER DR. ALANO ACTED IN GOOD FAITH AND
PURSUANT TO LAW WHEN HE ISSUED THE AUTHORIZATION TO REMOVE AND
RETRIEVE THE ORGANS OF ANGELITO LUGMOSO (LATER IDENTIFIED TO BE IN
FACT ARNELITO LOGMAO) CONSIDERING THAT NO NEGLIGENCE CAN BE
ATTRIBUTED OR IMPUTED ON HIM IN HIS PERFORMANCE OF AN ACT MANDATED BY
LAW.
C. WHETHER THE COURT OF APPEALS GRAVELY ERRED IN AWARDING
RESPONDENT ZENAIDA MAGUD-LOGMAO MORAL AND EXEMPLARY DAMAGES AND
ATTORNEY'S FEES THAT ARE NOT IN ACCORDANCE WITH AND ARE CONTRARY TO
ESTABLISHED JURISPRUDENCE.5
The first two issues boil down to the question of whether respondent's sufferings were brought about
by petitioner's alleged negligence in granting authorization for the removal or retrieval of the internal
organs of respondent's son who had been declared brain dead.
Petitioner maintains that when he gave authorization for the removal of some of the internal organs
to be transplanted to other patients, he did so in accordance with the letter of the law, Republic Act
(R.A.) No. 349, as amended by Presidential Decree (P.D.) 856, i.e., giving his subordinates
instructions to exert all reasonable efforts to locate the relatives or next of kin of respondent's son. In
fact, announcements were made through radio and television, the assistance of police authorities
was sought, and the NBI Medico-Legal Section was notified. Thus, petitioner insists that he should
not be held responsible for any damage allegedly suffered by respondent due to the death of her son
and the removal of her sons internal organs for transplant purposes.
The appellate court affirmed the trial court's finding that there was negligence on petitioner's part
when he failed to ensure that reasonable time had elapsed to locate the relatives of the deceased
before giving the authorization to remove said deceased's internal organs for transplant purposes.

However, a close examination of the records of this case would reveal that this case falls under one
of the exceptions to the general rule that factual findings of the trial court, when affirmed by the
appellate court, are binding on this Court. There are some important circumstances that the lower
courts failed to consider in ascertaining whether it was the actions of petitioner that brought about
the sufferings of respondent.6
The Memorandum dated March 3, 1988 issued by petitioner, stated thus:
As shown by the medical records, the said patient died on March 3, 1988 at 9:10 in the morning due
to craniocerebral injury. Please make certain that your Department has exerted all reasonable efforts
to locate the relatives or next-of-kin of the said deceased patient, such as appeal through the radios
and television, as well as through police and other government agencies and that the NBI [MedicoLegal] Section has been notified and is aware of the case.
If all the above has been complied with, in accordance with the provisions of Republic Act No. 349
as amended and P.D. 856, permission and/or authority is hereby given to the Department of Surgery
to retrieve and remove the kidneys, pancreas, liver and heart of the said deceased patient and to
transplant the said organs to any compatible patient who maybe in need of said organs to live and
survive.7
A careful reading of the above shows that petitioner instructed his subordinates to "make certain"
that "all reasonable efforts" are exerted to locate the patient's next of kin, even enumerating ways in
which to ensure that notices of the death of the patient would reach said relatives. It also clearly
stated that permission or authorization to retrieve and remove the internal organs of the deceased
was being given ONLY IF the provisions of the applicable law had been complied with. Such
instructions reveal that petitioner acted prudently by directing his subordinates to exhaust all
reasonable means of locating the relatives of the deceased. He could not have made his directives
any clearer. He even specifically mentioned that permission is only being granted IF the Department
of Surgery has complied with all the requirements of the law. Verily, petitioner could not have been
faulted for having full confidence in the ability of the doctors in the Department of Surgery to
comprehend the instructions, obeying all his directives, and acting only in accordance with the
requirements of the law.
Furthermore, as found by the lower courts from the records of the case, the doctors and personnel of
NKI disseminated notices of the death of respondent's son to the media and sought the assistance
of the appropriate police authorities as early as March 2, 1988, even before petitioner issued the
Memorandum. Prior to performing the procedure for retrieval of the deceased's internal organs, the
doctors concerned also the sought the opinion and approval of the Medico-Legal Officer of the NBI.
Thus, there can be no cavil that petitioner employed reasonable means to disseminate notifications
intended to reach the relatives of the deceased. The only question that remains pertains to the
sufficiency of time allowed for notices to reach the relatives of the deceased.
If respondent failed to immediately receive notice of her son's death because the notices did not
properly state the name or identity of the deceased, fault cannot be laid at petitioner's door. The trial
and appellate courts found that it was the EAMC, who had the opportunity to ascertain the name of
the deceased, who recorded the wrong information regarding the deceased's identity to NKI. The
NKI could not have obtained the information about his name from the patient, because as found by
the lower courts, the deceased was already unconscious by the time he was brought to the NKI.
Ultimately, it is respondent's failure to adduce adequate evidence that doomed this case. As stated
in Otero v. Tan,8 "[i]n civil cases, it is a basic rule that the party making allegations has the burden of
1wphi1

proving them by a preponderance of evidence. The parties must rely on the strength of their own
evidence and not upon the weakness of the defense offered by their opponent." 9 Here, there is to
proof that, indeed, the period of around 24 hours from the time notices were disseminated, cannot
be considered as reasonable under the circumstances. They failed to present any expert witness to
prove that given the medical technology and knowledge at that time in the 1980's, the doctors could
or should have waited longer before harvesting the internal organs for transplantation.
Verily, the Court cannot, in conscience, agree with the lower court. Finding petitioner liable for
damages is improper. It should be emphasized that the internal organs of the deceased were
removed only after he had been declared brain dead; thus, the emotional pain suffered by
respondent due to the death of her son cannot in any way be attributed to petitioner. Neither can the
Court find evidence on record to show that respondent's emotional suffering at the sight of the pitiful
state in which she found her son's lifeless body be categorically attributed to petitioner's conduct.
WHEREFORE, the petition is GRANTED. The Decision of the Court of Appeals, dated March 31,
2006, is REVERSED and SET ASIDE. The complaint against petitioner is hereby DISMISSED.
SO ORDERED.

Republic of the Philippines

SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 203080

November 12, 2014

DR. IDOL L. BONDOC, Petitioner,

vs.
MARILOU R. MANTALA, Respondent.
DECISION
VILLARAMA, JR., J.:
Before us is a petition for review on certiorari assailing the Decision1 dated May 24, 2012 and
Resolution2 dated August 14, 2012 of the Court of Appeals (CA) in CA-G.R. SP No. 120563. The CA
affirmed the Decision3 dated August 12, 2010 and Order4 dated February 28, 2011 of the Office of
the Deputy Ombudsman for Luzon in OMB-L-A-09-0681-K.
The Facts
On November 6, 2009, Marilou R. Mantala (respondent) filed a complaint for grave misconduct
against Dr. Idol L. Bondoc (petitioner), Medical Officer III at the Oriental Mindoro Provincial Hospital
(OMPH).
Respondent was admitted at the OMPH on April 3, 2009, at around 11 :00 in the morning, with
referral5 from the Bansud Municipal Health Office (BMHO). She was due to deliver her fifth child and
was advised by the BMHO for a cesarean section because her baby was big and there was
excessive amniotic fluid in her womb. She started to labor at 7:00 in the morning and was initially
brought tothe Bongabon Health Center. However, said health center also told her to proceed directly
to the hospital.
In her complaint-affidavit,6 respondent alleged that inside the delivery room of OMPH, she was
attended toby petitioner who instructed the midwife and two younger assistants topress down on
respondents abdomen and even demonstrated to them how to insert their fingers into her vagina.
Thereafter, petitioner went out of the delivery room and later, his assistants also left. As she labored
in pain, she felt the movement of her baby inside her womb and the intermittent stiffening of her
abdomen.
At about 4:00 in the afternoon, petitioner returned to the delivery room and asked her, "Hindi ka pa
nanganganak?" Since she could no longer bear the pain, she requested petitioner to perform a
cesarean section but this was not done. The midwife arrived and berated her for not yet sleeping
and holding on to the steelbar. The midwife and the younger assistants again pressed down on her
abdomen causing excruciating pain on her ribs and made her very weak. They repeatedly did this
pressing until the baby and placenta came out. When she regained consciousness, she was already
at the recovery room. She learned that an operation was performed on her by petitioner to
removeher ruptured uterus but what depressed her most was her stillborn baby and the loss of her
reproductive capacity. The next day, she was transferred to a ward. She noticedher very swollen
vulva and her surgical wound open with liquid squirting from it. Her wound was regularly cleaned by

a nurse. On April 9, 2009, she was discharged notwithstanding that the suture on her wound needs
to be fixed and she still has a cough. At home, she took the antibiotics, cough medicine and
multivitamins prescribed by petitioner.
After two days, the opening in her wound widened.Her husband brought her to the Bongabon
Community Hospital but they were advised to have her wound re-stitched by the samesurgeon
(petitioner) who operated on her. Thus, on April 14, 2009, theywent back to OMPH. She was
attended to by a certain Dr. Gonzales who cleaned her wound which now has a lot of pus, and the
said doctor commented that "problema ito ni Bondoc." On April 18, 2009, after she was given blood
transfusion, petitioner re-stitched her wound. Thereafter, it was Dr. Gonzales who regularly checked
on her condition.
On April 27, 2009, petitioner removed the sutures but still left open three of them. She wondered
then why petitioner suddenly showed kindness towards her. In the evening of April 28, 2009,
petitioner talked to her and said in a threatening tone "Ikaw ang sadyang ayaw magpa-cs" and also
told her that he just came from Pinamalayan and Bansud and already talked to Dr. Atienza and Dr.
Sales. Petitioner then told the nurse on duty, "Papirmahin mo si Mantala, pauuwiin ko na yan bukas.
Tanggalin mo na rin ang tahi." He further said, "huwag sana akong idemanda ni Mantala kasi kaya
ko siyang baligtarin." The following day, she was discharged after the nurse had removed the
remaining sutures. At home, it was her sister who cleaned the still open wound. Joel F. Mantala,
respondents husband, and her sisters Mylen R. Amistad and Lucia Rala, executed their respective
affidavits7 to corroborate her story. In addition, respondent submitted the affidavit of Dr. Rosinico F.
Fabon, the anesthesiologist on duty during the operation performed by petitioner on April 3, 2009.
Joel Mantala claimed that at the OMPH at around 2:30 in the afternoon when her wife was still
laboring, petitioner talked to him and told her that the baby is too big and if it comes out alive it will
probably be abnormal so that it would be better ifthe baby is stillborn. He further averred that despite
the pleas of her wife for a cesarean operation, petitioner insisted on a normal delivery during which
she almost died.8
On the other hand, Dr. Fabon narrated that in the afternoon of April 3, 2009, he was attending to a
patient being operated on by petitioner when he heard the latter saying that "meron pa nga kami sa
DR macrosomia, polyhydramnios pa, pero paanakin na lang yon, abnormal din naman ang bata
kahit mabuhay, kawawa lang siya." After the operation, petitioner went out of the Operating Room
(OR)and proceeded towards the direction of the OB ward. At 5:35 in the afternoon, a Request for
Surgery9 was forwarded to the OR for Emergency Pelvic Laparotomy of respondent with a diagnosis
of T/C Ruptured Uterus.
When respondent was brought to the OR at 8:15 p.m., Dr. Fabon found her conscious but very weak
and pale, with abdominal pain and tenderness on very slight palpation. He then heard from petitioner
himself that it was the same patient he was referring to earlier with a diagnosis of macrosomia,
polyhydramnios. Petitioner volunteered that respondent had just delivered her baby but that her
uterus probably ruptured in the process of childbirth. "Pinilit nong tatlong ungas, ayon lumusot pero
patay ang bata, tapos ito, mukhang pumutok," petitioner said.
Dr. Fabon immediately prepared respondent for General Anesthesia; respondent was inducted at
8:35 p.m. while surgery began at 8:45 p.m. He continued to narrate what transpired next and his
observations, as follows:
That right after induction when patient was asleep already and dont feel any pain at all her blood
pressure suddenly dropped to 70/40 mmHg;

That after opening the abdomen, I saw massive hemoperitonium and the ruptured uterus with
bleeding from various directions. I immediately requested for additional blood to be used intraoperatively while at the same time I established another intravenous lineso as to cope with on-going
surgical blood loss. I had now three big-bore fast-dripping IV lines.
That in spite of this measure,blood pressure dropped to 50/30 mmHg. There was an instance
wherein I cannot even appreciate the blood pressure of the patient, her pulse hardly noticeable on
palpation and she was very pale that necessitates turning the anesthetic gas off so as to keep her
alive. She was given a dose of Atropine after patientdid not respond to two 10mg doses of
Ephedrine. I prescribed Dobutamine and Dopamine drips to help improve her blood pressure and
maintain adequate urine output. Unfortunately, only Dopamine was available. I had to use 100%
Oxygen at 3L/minute without mixture ofvolatile gas for several minutes. She was maintained using
musclerelaxants alone on controlled ventilation.
That Dr. Bondoc operated on the patient all by himself without the help of a consultant or an
assistant surgeon. Nowhere in the patient chart will show that he referred this case tohis consultant;
one thing that I was wondering why he was doing the surgery alone. He utilized the scrub nurse to
assist him making a delicate and bloody surgery more bloody and difficult.
That after Dr. Bondoc had removed the ruptured uterus and the bleeding was controlled, he made
intra-operative referral to Dr. Ariel Tria, a resident surgeon, to check on the urinary bladder and the
ureters.
That the operation performed was Subtotal Hysterectomy with Unilateral Salpingooophorectomy. I
noticed that the operation technique was different from that which Dr. Bondoc had written in the
Surgical Memo and that the patient did nottolerate the procedure well.
That the patient was very pale after the procedure with low blood pressure due to massive blood
loss. That her blood pressure started to improve at the Recovery Room but the pulse rate remained
considerably high for several hours. Her urine outputwas inadequate and that it had to be maintained
using Dopamine.
That when Leo Reyes, the Recovery Room nurse, referred the patient to me and I checked the
urinary catheter, I noticed her vagina to be massively swollen with hematomas all over.
That the patient had to be referred to Internal Medicine for comanagement[.]
That Marilou Mantala stayed in the Recovery Room for almost eleven (11) hours. She was
transferred to Gyne Ward at 9:20 AM the following day. 10
In his counter-affidavit,11 petitioner averred thatwhen respondent was brought to OMPH with referral
form from BMHO, she had been in labor for more than twelve (12) hours at home. He submitted his
admitting diagnosis of the patient, "Gravida 5 Parity 4 (4004) Pregnancy Uterine 38 to 39 Weeks Age
of Gestation by Last Menstrual Period Cephalic in Labor; Macrosomia; Fetal Death in Utero."
Petitioner alleged that during his interview with respondent, the latter admitted to him that she
doesnt want tobe confined at any hospital because she was afraid to be handled by medical
doctors. Instead, she went to a traditional birth attendant (TBA) or "hilot" which she voluntarily
named as Apolonia Salcedo, residing at Dalapian, Labasan, Bongabon, Oriental Mindoro.
Respondent clearly defied the advice of Drs. Theresa Atienza and Mario Sales not to give birth at
home. As to her swollen vulvar hematoma which was noticed by Dr. Fabon, it was the result of
prolonged labor.

As to the charge that he abandoned the respondent to his assistants, petitioner claimed that
between 12 noonand 2:00 oclock in the afternoon, he was busy checking on pregnant patients at
the out-patient department (OPD) of OMPH until he was called for his first cesarean section (CS).
Later at 4:00 oclock, without resting and having lunch, he visited respondent and other admitted
patients atthe delivery room. Together with the nurse on duty, Mrs. Evelyn D. Morales, petitioner
said he explained to respondent her and her babys condition based on the referral from BMHO
(polyhydramnios)and initial findings that her abdomen and baby were big and the babys heartbeat is
not appreciated. He presented the respondent with two options: have a normal delivery or undergo
cesarean section, and the consequences of each choice. Respondent chose the former believing
that she can handle this childbirth at home, and petitioner respected her decision.
After seeing other patients at the delivery room, petitioner was called for his second CS that day.
Thus, he was obliged to proceed to the OR and left the respondent under the care of three
assistants, one of whom is an experienced midwife. That he was not the one who attended to the
respondent during her delivery is confirmed by the statements of respondent herself, Dr. Fabon and
Mrs. Morales. Further, petitioner claimed it has been a long-time practice at OMPH that whenever
the doctor is at the OR, the experienced midwives will take over the delivery of laboring patients.
Petitioner blamed respondent for risking her own life in not seeking immediately a higher level of
medical care and instead preferring a TBA who is prohibited under a 2006 provincial circular
tohandle deliveries at home. He emphasized that upon admission the fetal heart tone is no longer
appreciated and maintained that diligent care was extended to respondent during her stay at OMPH.
As to the complications like cough and wound dehiscence, he explained that these were the effects
of anesthesia and surgery (loss of blood, massive bloodtransfusion and intravenous fluid infusion),
and also poor compliance withprescribed medication. He further asserted that he had referred the
patient to other co-doctors on duty like Dr. Romy Lomio (Internal Medicine) for co-management.
On April 23, 2010, petitioner submitted a manifestation that he had resigned as Medical Officer of
OMPH effective March 5, 2010. He thus posited that the administrative case isnow rendered moot
and academic.
On August 12, 2010, the Office of the Deputy Ombudsman for Luzon rendered a Decision finding the
petitioner administratively liable. It held that by fully entrusting to his subordinates the task of
handling respondents complicated delivery, petitioner exhibited an improper or wrongful conduct
and dereliction of duty as medical practitioner. Being the most competent person who should have
rendered the appropriate medical service to respondent, petitioner should have personally attended
to the latter. Such action or inaction of his part amounts tointentional or willful neglect in discharging
his sworn duty as a government physician which is also equivalent to misconduct in office. The
administrative case filed against the respondent is also not rendered moot by his subsequent
resignation in office.
The Decision of the OMB thus decreed:
WHEREFORE, judgment is hereby rendered finding respondent Medical Officer Idol L. Bondoc of
Oriental Mindoro Provincial Hospital (OMPH), Barangay Ilaya, Calapan City, Oriental Mindoro, guilty
of Grave Misconduct.
Respondent Idol L. Bondocis hereby meted the penalty of DISMISSALin the Government Service
pursuant to Section 10, Rule III, Administrative Order No. 07, as amended by Administrative Order
No. 17, in relation to Section 25 of Republic Act No. 6770. The penalty of dismissal shall carry with it
that of cancellation of eligibility, forfeiture of the retirement benefits, and the perpetual disqualification

for reemployment in the government service pursuant to Section 58, Rule IV of the Uniform Rules on
Administrative Cases in the Civil Service.
The Honorable Governor of the Province of Oriental Mindoro, is hereby directed to implement this
DECISION immediately upon receipt thereof pursuant to Section 7, Rule III of Administrative Order
No. 7, as amended by Administrative Order No. 17 (Ombudsman Rules of Procedure) in relation to
Memorandum Circular No. 1, series of 2006 dated 11 April 2006 and to promptly inform this Office of
the action taken hereon.
SO DECIDED.12
The foregoing ruling was affirmedby the CA and petitioners motion for reconsideration was denied.
The CA concurred that petitioner should have chosen to stay in the delivery room and personally
attend to the patient as he is the most competent person to render medical service in view of
respondents critical condition. It likewise faulted the petitioner for deliberately leaving the laboring
and unstable respondent tothe care of his inexperienced subordinates at the time she was about to
give birth. As to petitioners excuse that he had to attend to an equally important cesarean operation,
the CA said there was no sufficient showing of the latters urgency and assuming it to be true, still,
petitioner should have exerted efforts to refer respondents case to another competent doctor or one
of his consultants.
Petitioner is now before this Court arguing that the CA erred in affirming the Ombudsmans ruling
that he is guilty of grave misconduct and imposing on him the penalty of dismissal from the service.
He reiterates that his failure to attend to respondent was not without justification and that in the
seven years he had been a medical officer of OMPH, he has dutifully observed the sworn duties of
the medical profession and would not neglect his responsibilities nor commit misconductat the risk of
his medical career which he had nurtured through the years.
The petition has no merit.
Misconduct is defined as a transgression of some established and definite rule of action, more
particularly, unlawful behavior or gross negligence by a public officer,13 a forbidden act, a dereliction
of duty, willful in character, and implies wrongful intent and not mere error in judgment. 14 It generally
means wrongful, improper or unlawful conduct motivated by a premeditated, obstinate or intentional
purpose. The term, however, does not necessarily imply corruption or criminal intent. To constitute
an administrative offense,misconduct should relate to or be connected with the performance of the
official functions and duties of a public officer. On the other hand, whenthe elements of corruption,
clear intent to violate the law or flagrant disregard of established rule are manifest, the public officer
shall be liable for grave misconduct.15
In this case, both the Ombudsman and CA found the petitioner guilty of grave misconduct in failing
to attend to respondent when she was having prolonged difficult labor and vaginal delivery after
being diagnosed with macrosamiaand polyhydramnios.
Polyhydramniosis an abnormal condition occurring in pregnancy, characterized by excessive
amniotic fluid (the fluid surrounding the baby in the uterus). Apart from protecting the baby from any
external impact by providing a cushioning effect, the clear or slightly yellowish fluid plays a vital role
in proper fetal development aswell. However, increased levels of the fluid can cause various
complications during different stages of pregnancy and childbirth.16Intra-amniotic pressureis markedly
elevated in most patients with severe hydramnios. The incidence of cesarean section is also
increased as a result of unstable lie and placental abruption, which may occur with the rapid

decrease in intrauterine pressure that accompanies membrane rupture. 17 One of the known causes
and risk factors of polyhydramniosis fetal macrosomia (having a baby too large for the gestational
age).18
According to medical authorities,a macrosomic infant poses a different set of complications. The
incidences of shoulder dystocia,19 birth injuries, perinatal death, and low Apgar scores are increased
in macrosomic infants.20 In these cases, careful attention to the patient, potential risk factors, clinical
progress, and fetal size should allow obstetricians to reduce the occurrence of maternaland neonatal
morbidity.21 Vaginal delivery of the macrosomic infant is associated with anincreased incidence of
birth trauma. The question whether to perform cesarean section thus arises. 22
If the estimated fetal weight is 4000 to 4500 g by ultrasonography and the patient has a clinically
adequate pelvis, labor may be allowed. If labor is protracted or the second stage is prolonged, a
cesarean section would avoid the possible trauma of a difficult vaginal delivery. Because of the
greater morbidity associated with infants who weigh more than 4500 g, elective cesarean section is
warranted.23
On the other hand, prolonged labormay culminate in obstructed labor, and is associated with
maternal infection, uterine rupture and postpartum hemorrhage. 24
As per the admitting diagnosis25 submitted by petitioner, the latter was aware of macrosomia and the
fetal heartbeat notappreciated. He also maintains that respondents baby was already dead due to
prolonged labor but she had insisted on having a normal delivery. However, this claim is belied by
the sworn statements of respondent, her husband and her sisters, all of whom averred that they
requested for a cesarean section as per the advice given by Dr. Atienza who examined her in March
2009, and as confirmed at the Bansud Health Center where she was told that it would be risky for
her to have a normal delivery.Moreover, Joel Mantala asserted that what petitioner said to him was
that the baby was too big and if born alive it would probably have abnormalities so it would be better
that the baby is stillborn.
The Court is more inclined to believe respondents version which was duly corroborated by Dr.
Fabon who heard petitioner saying that: "Meron pa nga kami sa DR macrosomnia, polyhydramnios
pa, pero paanakin na lang yon. Abnormal din namanang bata kahit mabuhay." This puts into doubt
petitioners supposed finding that the baby was already dead upon respondents admission at OMPH
and thatit was respondent who insisted on a normal delivery. Even assuming that petitioner had
actually confirmed intrauterine fetal death, this only aggravates the patients condition and it was
incumbent upon petitioner as the obstetrician on duty to personally attend to her and render
appropriate management or treatment.
In deliberately leaving the respondent to a midwife and two inexperienced assistants despite
knowing that she was under prolonged painful labor and about to give birth to a macrosomic baby by
vaginal delivery, petitioner clearly committed a dereliction of duty and a breach of his professional
obligations. The gravity of respondents condition is highlighted by the expected complications she
suffered her stillborn baby, a ruptured uterus that necessitated immediate surgery and blood
transfusion, and vulvar hematomas.
Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in the Philippines states:
A physician should attend to his patients faithfully and conscientiously. He should secure for them all
possible benefits that may depend upon his professional skill and care. As the sole tribunal to
adjudge the physicians failure to fulfill his obligation to his patients is, in most cases, his own
conscience, violation of this rule on his part is discreditable and inexcusable.26

A doctors duty to his patient is not required to be extraordinary. The standard contemplated for
doctors issimply the reasonable average merit among ordinarily good physicians, i.e.reasonable skill
and competence.27 Even by this standard, petitioner fell short when he routinely delegated an
important task that requires his professional skill and competence to his subordinates who have no
requisite training and capability to make crucial decisions in difficult childbirths.
Petitioners proffered excuse that it was the practice in OMPH to allow midwives to administer to
patients during deliveries, is unacceptable. No proof of such alleged hospital practice such as an
official written directive was presented. Besides, it is doubtful whether hospital administrators would
remedy personnel shortage by permitting inexperienced staff, by themselves, to handle laboring
patients with high-risk pregnancies and maternal/fetal complications.
As to the two other scheduled CS performed by petitioner on the same day, this will not exculpate
him from administrative liability. As correctly pointed out by the CA, there was no showing of similar
urgency in the said operations, and petitioner could have referred respondent to another competent
physician. He could have likewise arranged for adjustment in the operation schedules considering
that his personal attention and management is urgently needed in respondents difficult and
complicated delivery. But there is no indication in the records that petitioner duly informed or referred
the matter to the other doctors or the administrators of OMPH.
1wphi1

We therefore hold that the CA correctly affirmed the Ombudsman in finding the petitioner guilty of
grave misconduct. His violation of the sworn duty to attend to his patients faithfully and
conscientiously is inexcusable. Such flagrant disregard of established rule and improper conduct
were proven by substantial evidence.
Not only did petitioner routinely delegate his responsibility to his subordinates, he casually
instructedthem to press down repeatedly on respondents abdomen, unmindful of her critical
condition as borne out by his very own findings. Worse, petitioner haughtily and callously spoke of
respondents case to the other doctors and medical staff while performing a CS after he had briefly
attended to her at the delivery room "paanakin na lang yon, abnormal din naman ang bata kahit
mabuhay, kawawa lang siya." Such insensitive and derisive language was again heard from the
petitioner when he referred for the second time to respondents traumatic delivery, saying that:
"Pinilit nong tatlong ungas,ayon lumusot pero patay ang bata, tapos ito, mukhang pumutok." As a
government physician, petitioners demeanor is unbecoming and bespeaks of his indifference to the
well-being of his patients.
Petitioner thus not only committed a dereliction of duty, but also transgressed the ethical norms of
his profession when he failed to render competent medical care with compassion and respect for his
patients dignity.
A physician should be dedicated to provide competent medical care with full professional skill in
accordance with the current standards of care, compassion, independence and respect for human
dignity.28 (Italics supplied.)
Finally, we find no merit in petitioner's argument that the CA should have at least considered as
mitigating circumstances his being a first offender, 29 his 16 years in government service, and that he
had not acted in bad faith and with clear intent to violate the law and established rules.
Jurisprudence is replete with cases declaring that a grave offense cannot be mitigated by the fact
that the accused is a first time offender or by the length of service of the accused. 30 While in most
cases, length of service is considered in favor of the respondent, it is not considered where the
offense committed is found to be serious or grave.31 In Medina v. Commission on Audit,32the Court
stressed that dishonesty and grave misconduct have always been and should remain anathema in

the civil service. They inevitably reflect on the fitness of a civil servant to continue in office. When an
officer or employee is disciplined, the object sought is not the punishment of such officer or
employee but the improvement of the public service and the preservation of the public's faith and
confidence in the government. WHEREFORE, the petition is DENIED for lack of merit. The Decision
dated May 24, 2012 and Resolution dated August 14, 2012 of the Court of Appeals in CA-G.R. SP
No. 120563 are AFFIRMED and UPHELD.
With costs against the petitioner.
SO ORDERED.

THIRD DIVISION
[G.R. No. 176675 : September 15, 2010]
SPS. ALFREDO BONTILAO AND SHERLINA BONTILAO, PETITIONERS, VS. DR. CARLOS GERONA,
RESPONDENT.
DECISION
VILLARAMA, JR., J.:
Before us is a petition for review on certiorari [1] under Rule 45 of the 1997 Rules of Civil Procedure, as
amended, assailing the June 28, 2006 Decision[2] and January 19, 2007 Resolution[3] of the Court of
Appeals (CA) in CA-G.R. CV No, 00201. The CA had reversed the March 23, 2004 Decision[4] of the
Regional Trial Court (RTC) of Cebu City, Branch 6 and dismissed petitioners' complaint in Civil Case No.
CEB-17822.
The facts are as follows:
On December 28, 1991, respondent Dr. Carlos Gerona, an orthopedic surgeon at the Vicente Gullas
Memorial Hospital, treated petitioners' son, eight (8)-year-old Allen Key Bontilao (Allen), for a fractured
right wrist. Respondent administered a "U-splint" and immobilized Allen's wrist with a cast, then sent
Allen home. On June 4, 1992, Allen re-fractured the same wrist and was brought back to the
hospital. The x-ray examination showed a complete fracture and displacement of the bone, with the
fragments overlapping each other. Respondent performed a closed reduction procedure, with Dr.
Vicente Jabagat (Dr. Jabagat) as the anesthesiologist. Then he placed Allen's arm in a plaster cast to
immobilize it. He allowed Allen to go home after the post reduction x-ray showed that the bones were
properly aligned, but advised Allen's mother, petitioner Sherlina Bontilao (Sherlina), to bring Allen back
for re-tightening of the cast not later than June 15, 1992.
Allen, however, was brought back to the hospital only on June 1992. By then, because the cast had not
been re-tightened, a rotational deformity had developed in Allen's arm. The x-ray examination showed
that the deformity was caused by a re-displacement of the bone fragments, so it was agreed that an
open reduction surgery will be conducted on June 24, 1992 by respondent, again with Dr. Jabagat as the
anesthesiologist.
On the said date, Sherlina was allowed to observe the operation behind a glass panel. Dr. Jabagat failed
to intubate the patient after five (5) attempts so anesthesia was administered through a gas
mask. Respondent asked Dr. Jabagat if the operation should be postponed given the failure to intubate,
but Dr. Jabagat said that it was alright to proceed. Respondent verified that Allen was breathing
properly before proceeding with the surgery.[5] As respondent was about to finish the suturing, Sherlina
decided to go out of the operating
room to make a telephone call and wait for her son. Later, she was informed that her son had died on
the operating table. The cause of death was "asphyxia due to congestion and edema of the epiglottis."[6]
Aside from criminal and administrative cases, petitioners filed a complaint for damages against both
respondent and Dr. Jabagat in the RTC of Cebu City alleging negligence and incompetence on the part of

the doctors. The documentary evidence and testimonies of several witnesses presented in the criminal
proceedings were offered and admitted in evidence at the RTC.
On March 23, 2004, the RTC decided in favor of the petitioners. It held that the doctrine of res ipsa
loquitur was applicable in establishing respondent's liability. According to the RTC, asphyxia or cardiac
arrest does not normally occur in an operation on a fractured bone in the absence of negligence in the
administration of anesthesia and the use of an endotracheal tube. Also, the instruments used in the
administration of anesthesia were all under the exclusive control of respondent and Dr. Jabagat, and
neither Allen nor his mother could be said to be guilty of contributory negligence. Thus, the trial court
held that respondent and Dr. Jabagat were solidarity liable for they failed to prove that they were not
negligent. The trial court likewise said that respondent cannot shift the blame solely to Dr. Jabagat as
the fault of the latter is also the fault of the former, respondent being the attending physician and being
equally in care, custody and control of Allen.[7]
Aggrieved, respondent appealed the trial court's decision to the CA. Dr. Jabagat, for his part, no longer
appealed the decision.
On June 28, 2006, the CA reversed the RTC's ruling. It held that the doctrine of res ipsa loquitur does not
apply for it must be satisfactorily shown that (1) the accident is of a kind which ordinarily does not occur
in the absence of someone's negligence; (2) the plaintiff was not guilty of contributory conduct; and (3)
the instrumentality which caused the accident was within the control of the defendant.
The CA held that while it may be true that an Open Reduction and Internal Fixation or ORIF could not
possibly lead to a patient's death unless somebody was negligent, still what was involved in this case
was a surgical procedure with all risks attendant, including death. As explained by the expert testimony,
unexplained death and mal-occurrence is a possibility in surgical procedures especially those involving
the administration of general anesthesia. It had also been established in both the criminal and
administrative cases against respondent that Allen's death was the result of the anesthesiologist's
negligence and not his.[8]
The CA added that the trial court erred in applying the "captain of the ship" doctrine to make
respondent liable even though he was the lead surgeon. The CA noted that unlike in Ramos v. Court of
Appeals,[9] relied upon by the trial court, the anesthesiologist was chosen by petitioners and no specific
act of negligence was attributable to respondent. The alleged failure to perform a skin test and a
tracheotomy does not constitute negligence. Tracheotomy is an emergency procedure, and its
performance is a judgment call of the attending physician as it is another surgical procedure done during
instances of failure of intubation. On the other hand, a skin test for a patient's possible adverse reaction
to the anesthesia to be administered is the anesthesiologist's decision. The CA also noted that the same
anesthesia was previously administered to Allen and he did not manifest any allergic reaction to
it. Finally, unlike in the Ramos case, respondent arrived only a few minutes late for the surgery and he
was able to complete the procedure within the estimated time frame of less than an hour.
Petitioners filed the present petition on the following grounds:
[1] THE COURT OF APPEALS ERRED IN REVERSING THE DECISION OF THE REGIONAL TRIAL COURT BY
DISMISSING THE COMPLAINT IN SO FAR AS THE
SURGEON, DR. CARLOS GERONA IS CONCERNED [AFTER] CONCLUDING THAT HE IS NOT SOLIDARILY

LIABLE WITH HIS CO-DEFENDANT, DR. VICENTE JABAGAT, THE ANESTHESIOLOGIST, IN THE ABSENCE OF
ANY NEGLIGENT ACT ON HIS PART.
[2] THE COURT OF APPEALS ERRED WHEN IT MISAPPRECIATED ESSENTIAL FACTS OF THE CASE THAT LED
TO ITS FINDINGS THAT DOCTRINE OF RES IPSA LOQUITfUJR AS APPLIED IN THE RAMOS CASE IS NOT
APPLICABLE IN THE INSTANT CASE.[10]
Essentially, the issue before us is whether respondent is liable for damages for Allen's death.
Petitioners argued that the doctrine of res ipsa loquitur applies to the present case because Allen was
healthy, fully conscious, coherent, and ambulant when he went to the hospital to correct a deformed
arm. Yet, he did not survive the operation, which was not even an emergency surgery but a corrective
one. They contend that respondent, being the lead surgeon, should be held liable for the negligence of
the physicians and nurses working with him during the operation.
On the other hand, respondent posited that he should not be held solidarity liable with Dr. Jabagat as
they were employed independently from each other and their services were divided as their best
judgment dictated. He insisted that the captain-of-the-ship doctrine had long been abandoned
especially in this age of specialization. An anesthesiologist and a surgeon are specialists in their own
field and neither one (1) could dictate upon the other. The CA was correct in finding that the Ramoscase
does not apply to respondent. Dr. Jabagat was contracted separately from respondent and was chosen
by petitioner Sherlina. Respondent was only a few minutes late from the operation and he waited for
the signal of the anesthesiologist to start the procedure. He also determined the condition of Allen
before and after the operation.
We affirm the assailed CA decision.
The trial court erred in applying the doctrine of res ipsa loquitur to pin liability on respondent for Allen's
death. Res ipsa loquitur is a rebuttable presumption or inference that the defendant was negligent. The
presumption only arises upon proof that the instrumentality causing injury was in the defendant's
exclusive control, and that the accident was one (1) which ordinarily does not happen in the absence of
negligence. It is a rule of evidence whereby negligence of the alleged wrongdoer may be inferred from
the mere fact that the accident happened, provided that the character of the accident and
circumstances attending it lead reasonably to the belief that in the absence of negligence it would not
have occurred and that the thing which caused injury is shown to have been under the management and
control of the alleged wrongdoer.[11]
Under this doctrine, the happening of an injury permits an inference of negligence where the plaintiff
produces substantial evidence that the injury was caused by an agency or instrumentality under the
exclusive control and management of the defendant, and that the injury was such that in the ordinary
course of things would not happen if reasonable care had been used. [12]
However, res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be
cautiously applied, depending upon the circumstances of each case. [13] In malpractice cases, the
doctrine is generally restricted to situations where a layman is able to say, as a matter of common
knowledge and observation, that the consequences of professional care were not as such as would
ordinarily have followed if due care had been exercised. In other words, as held in Ramos v. Court of
Appeals,[14] the real question is whether or not in the process of the operation, any extraordinary

incident or unusual event outside of the routine performance occurred which is beyond the regular
scope of professional activity in such operations, and which, if unexplained, would
themselvesreasonably speak to the average man as the negligent cause or causes of the untoward
consequence.
Here, we find that the CA correctly found that petitioners failed to present substantial evidence of any
specific act of negligence on respondent's part or of the surrounding facts and circumstances which
would lead to the reasonable inference that the untoward consequence was caused by respondent's
negligence. In fact, under the established facts, respondent appears to have observed the proper
amount of care required under the circumstances. Having seen that Dr. Jabagat failed in the intubation,
respondent inquired from the latter, who was the expert on the matter of administering anesthesia,
whether the surgery should be postponed considering the failure to intubate. Respondent testified,
WITNESS:
A-

Actually sir, if I may cut short, I'm sorry. I don't know what is the term of this sir. But what
actually, what we had was that Dr. Jabagat failed in the intubation. He was not able to insert
the tube.

ATTY. PADILLA:
QA-

And you noticed that he failed?

Yes, sir.
xxxx

ATTY. PADILLA:
QA-

And you noticed that he failed and still you continued the surgery, Dr. Gerona?
Yes, I continued the surgery.
xxxx

COURT:
QA-

Did not Dr. Jabagat advise you not to proceed with the operation because the tube cannot be
inserted?
No, sir. In fact, I was the one who asked him, sir, the tube is not inserted, shall we postpone
this for another date? He said, it's alright.[15]

Respondent further verified that Allen was still breathing by looking at his chest to check that there was
excursion before proceeding with the surgery.[16] That respondent decided to continue with the surgery
even though there was a failure to intubate also does not tend to establish liability, contrary to the trial
court's ruling. Petitioners failed to present substantial proof that intubation was an indispensable
prerequisite for the operation and that it would be grave error for any surgeon to continue with the
operation under such circumstances. In fact, the testimony of the expert witness presented by the
prosecution in the criminal proceedings and admitted into evidence at the RTC, was even to the effect
that the anesthesia could be administered by alternative means such as a mask and that the operation
could proceed even without intubation.[17]

There was also no indication in the records that respondent saw or should have seen that something
was wrong as to prompt him to act differently than he did in this case. The anesthesia used in the
operation was the same anesthesia used in the previous closed reduction procedure, and Allen did not
register any adverse reaction to it. In fact, respondent knows the anesthesia Ketalar to be safe for
children. Dr. Jabagat was also a specialist and more competent than respondent to determine whether
the patient has been properly anesthetized for the operation, all things considered. Lastly, it appears
that Allen started experiencing difficulty in breathing only after the operation, when respondent was
already about to jot down his post-operation notes in the adjacent room. Respondent was called back
to the operating room after Dr. Jabagat failed to appreciate a heartbeat on the patient. [18] He acted
promptly and called for other doctors to assist and revive Allen, but to no avail.
Moreover, we note that in the instant case, the instrument which caused the damage or injury was not
even within respondent's exclusive management and control as Dr. Jabagat was exclusively in control
and management of the anesthesia and the endotracheal tube. The doctrine of res ipsa loquitur allows
the mere existence of an injury to justify a presumption of negligence on the part of the person who
controls the instrument causing the injury, provided that the following requisites concur:
1. The accident is of a kind which ordinarily does not occur in the absence of someone's negligence:
2. It is caused by an instrumentality within the exclusive control of the defendant or defendants; and
3. The possibility of contributing conduct which would make the plaintiff responsible is eliminated. [19]
Here, the respondent could only supervise Dr. Jabagat to make sure that he was performing his
duties. But respondent could not dictate upon Dr. Jabagat the particular anesthesia to administer, the
dosage thereof, or that it be administered in any particular way not deemed appropriate by Dr.
Jabagat. Respondent's specialization not being in the field of anesthesiology, it would be dangerous for
him to substitute his judgment for Dr. Jabagat's decisions in matters that fall appropriately within the
scope of Dr. Jabagat's expertise.
Under the above circumstances, although the Court commiserates with the petitioners on their infinitely
sorrowful loss, the Court cannot properly declare that respondent failed to exercise the required
standard of care as lead surgeon as to hold him liable for damages for Allen's death.
In civil cases, the burden of proof to be established by preponderance of evidence is on the plaintiff who
is asserting the affirmative of an issue.20 Unless the party asserting the affirmative of an issue sustains
the burden of proof, his or her cause will not succeed.
WHEREFORE, the petition is DENIED. The Decision dated June 28, 2006 and Resolution dated January
19, 2007 of the Court of Appeals in CA-G.R. CV No. 00201 are AFFIRMED.
No pronouncement as to costs.
SO ORDERED.