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LEGAL MEDICINE MEDICAL NEGLIGENCE

Dr. Rubi Li vs. Sps. Reynaldo Cancer of the Bone, Chemotherapy, St. Lukes
Medical Center

Facts: Respondents daughter, Angelica, was suffering from osteosarcoma, a highly malignant
cancer of the bone which usually afflicts teenage children. Her right leg was amputated by Dr.
Tamayo in St. Lukes Medical Center in order to remove the tumor. To minimize the chances of
recurrence and prevent the disease from spreading to other parts of the patients body,
chemotherapy was suggested by Dr. Tamayo. He referred Angelica to Dr. Rubi Li, a medical
oncologist. On August 18, 1993, Angelica was admitted to SLMC. However, she died on
September 1, 1993, just 11 days after the intravenous administration of the first cycle of the
chemotherapy regimen. The Medico-Legal Report issued by PNP Crime Laboratory indicated
the cause of death as Hypovolemic shock secondary to multiple organ hemorrhages and
Disseminated Intravascular Coagulation. The Certificate of Death issued by SLMC stated that
the immediate cause of death is Osteosarcoma, and the underlying cause is Status Post
Chemotherapy.

Respondents filed a damage suit against petitioner, 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.
Respondents thus claimed that they would not have given their consent to chemotherapy had
petitioner not falsely assured them of its side effects. 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.

The RTC dismissed the complaint and 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. 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.

On appeal, 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. Had petitioner made known to
respondents those other side effects they could have decided differently or adopted a different
course of action which could have delayed or prevented the early death of their child.

Issue: W/N petitioner can be held liable for failure to fully disclose serious side effects to the
parents.

Held: No. There was adequate disclosure of material risks in this case.

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.
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.

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.

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.

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.

Doctrine of Informed Consent. It is 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. 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.

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. 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.

Cited as exceptions to the rule are emergency cases where it is evident he cannot evaluate
data, and where the patient is a child or incompetent. 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.
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. In
this case, respondents failed to prove both the duty and the breach of that duty through expert
testimony.

Professional Services vs. Agana Gauze, Medical City

Facts: Natividad Agana was rushed to the Medical City because of difficulty of bowel
movement and bloody anal discharge. After a series of medical examinations, Dr. Ampil,
diagnosed her to be suffering from "cancer of the sigmoid." Dr. Ampil, assisted by the medical
staff of the Medical City Hospital, performed a surgery on her. He found that the malignancy
had spread on her left ovary, necessitating the removal of certain portions of it. Thus, he
obtained the consent of Natividads husband, Enrique Agana, to permit Dr. Fuentes, to perform
hysterectomy on her. After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over,
completed the operation and closed the incision. In the corresponding Record of Operation, the
attending nurses stated that 2 sponges are missing, announced it to surgeon, search was
done but to no avail continue for closure. 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. Natividad and Enrique went to US to seek further treatment.
After 4 months, Natividad was told she was free of cancer. Hence, she was advised to return to
the Philippines. 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. But the pains intensified, prompting Natividad to seek treatment at the Polymedic
General Hospital. While confined there, Dr. 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. Natividad underwent another surgery.

Natividad and Enrique filed a complaint for damages with the RTC against petitioners. The RTC
ruled in favor of the Agana This was affirmed by the CA on appeal with the modification
dismissing the case against Dr. Fuentes.

Enrique filed an administrative complaint for gross negligence and malpractice against Drs.
Ampil and Fuentes before the PRC. The case proceeded only as to Dr. Fuentes, as jurisdiction
over Dr. Ampil, who was then in US, was not acquired by PRC. Dr. Fuentes was absolved since
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.

The Aganas maintain that the CA erred in finding that Dr. Fuentes is not guilty of negligence or
medical malpractice, invoking the doctrine of res ipsa loquitur. 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 US. 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.

Issues:
W/N Dr. Ampil is liable for negligence and malpractice;
W/N Dr. Fuentes should be absolved from liability; and
W/N PSI may be held solidarily liable for the negligence of Dr. Ampil.

Held:
Yes. Dr. Ampils arguments are purely conjectural and without basis.
All the major circumstances taken together directly point to Dr. Ampil as the negligent party.
Leaving of sponges or other foreign substances in the wound after the incision has been closed
is at least prima facie negligence by the operating surgeon. To put it simply, such act is
considered so inconsistent with due care as to raise an inference of negligence. There are even
legions of authorities to the effect that such act is negligence per se.

Elements of Medical Malpractice. A patient must only prove that a health care provider
either failed to do something which a reasonably prudent health care provider would have
done, or that he did something that a reasonably prudent provider would not have done; and
that failure or action caused injury to the patient. Simply 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 cause 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.

No. The negligence was proven to be committed by Dr. Ampil and not Dr. Fuentes. Dr.
Fuentes has no control and management of the thing which caused the injury.

Res Ipsa Loquitur. It literally means "the thing speaks for itself." 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.

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."

Captain of the Ship. Under this doctrine 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.

In this case, Dr. Ampil order the closure of the incision notwithstanding that two pieces of
gauze remained unaccounted for. This 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.

Yes. 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 Ramos v. Court of Appeals, we held that for purposes of apportioning responsibility in

medical negligence cases, an employer-employee relationship in effect exists between
hospitals and their attending and visiting physicians.

In 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.

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.

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.

Doctrine of Apparent Authority. ("Holding Out" Theory, or Doctrine of Ostensible Agency or

Agency by Estoppel) 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. 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.

PSI "is now estopped from passing all the blame to the physicians whose names it proudly
paraded in the public directory leading the public to believe that it vouched for their skill and
competence." 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.

Doctrine of Corporate Negligence. 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.

PSIs liability is traceable to its failure to conduct an investigation of the matter reported in the
nota bene of the count nurse. 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. 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.

3. Dr. Cruz vs. CA Untidy

Facts: Lydia was examined by the petitioner who found a "myoma" in her uterus, and
scheduled her for a hysterectomy operation on March 23, 1991 at Perpetual Help Clinic and
General Hospital. Lydia was accompanied by her daughter who noticed that the clinic was
untidy and dusty. Before the operation, Rowena tried to persuade her mother and asked
petitioner to postpone the operation, but the latter prevailed upon Lydia to continue with it.
During the operation, Lydias relatives were asked to buy Tagamet capsules, and later type A
blood. After the operation, they were further asked to buy type A blood, but since there were
no more type A blood available in the bank, a person arrived to donate blood which was
transfused to Lydia. Later, Rowena found that her mother is gasping for breath. They found out
that the oxygen tank was already empty, they had to rush to San Pablo District Hospital to get
her a fresh supply of oxygen. Lydias unstable condition necessitated her transfer to the San
Pablo District Hospital, but this was discovered by her relatives when an ambulance arrived to
take Lydia. Upon her arrival at San Pablo District Hospital petitioner re-operated on her
because there was blood oozing from the abdominal incision. When the head of the Ob-Gyn
Section of the hospital arrived, Lydia was already in shock and dead as her blood pressure was
already 0/0.

The MTCC found that Lydia Umali died because of the negligence and carelessness of the
surgeon Dra. Cruz because of loss of blood during the operation of the deceased for evident
unpreparedness and for lack of skill. This was affirmed by the RTC and the CA.

Issues: W/N petitioner's conviction of the crime of reckless imprudence resulting in homicide,
arising from an alleged medical malpractice, is supported by the evidence on record.

Held: No. The circumstances are 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.

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.

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 only testified
as to the possible cause of death but not on the matter of the standard of care that petitioner
should have exercised. 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. 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. 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. This presumption is rebuttable by expert
opinion which is so sadly lacking in the case at bench.

Even granting that the clinic was untidy and there was inadequate facilities, lack of provisions,
and failure to conduct pre-operation tests on the patient, still 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.

"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.''

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. According to the
doctor witnesses, 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. 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.
As testified to by defense witness, hemorrhage due to DIC "cannot be prevented, it will happen
to anyone, anytime." 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.

Sps. Flores vs. Heirs of Teresita Pineda Diabetes, UDMC

Facts: Teresita consulted Dr. Fredelicto Flores and complained of general body weakness, loss
of appetite, frequent urination and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto
advised her to return the following week or to go to the United Doctors Medical Center in
Quezon City for a general check-up. He suspected that she might be suffering from diabetes
and told her to continue her medications. 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, travelling for at least two hours from Nueva Ecija to Quezon City with her sister, Lucena.
Teresita was then so weak was admitted to the hospital. In the admission slip, Dr. Fredelicto
directed the hospital staff to prepare the patient for an on call D&C operation to be performed
by his wife, Dr. Felicisima. The hospital staff took her blood and urine samples for the
laboratory tests. The two doctors Dr. Felicisima and Dr. Fredelicto, conferred on the patients
medical condition, and called up the laboratory for the results of the tests. At that time, only
the blood sugar, uric acid and cholesterol determination, and blood count was available. Dr.
Felicisima proceeded with the D&C operation with Dr. Fredelicto administering the general
anesthesia. A day after the operation, Teresita was subjected to an ultrasound examination as
a confirmatory procedure. The results showed that she had an enlarged uterus and myoma
uteri. Dr. Felicisima, however, advised Teresita that she could spend her recovery period at
home. Still feeling weak, Teresita opted for hospital confinement. When Teresitas complete
laboratory examination results came, her 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. Jorge, an
internist. Teresitas condition had worsened. She experienced difficulty in breathing and was
rushed to ICU. Further tests confirmed that she was suffering from Diabetes Mellitus Type II.
Insulin was administered, but the medication might have arrived too late. Due to complications
induced by diabetes, Teresita died the next morning.

Teresitas family filed a complaint for damages before the RTC which ruled in their favor. This
was affirmed by the CA.

The petitioner spouses countered that, at the time of the operation, there was nothing to
indicate that Teresita was afflicted with diabetes. There were other factors that might have
caused Teresitas blood sugar to rise such as the taking of blood samples during lunchtime and
while patient was being given intra-venous dextrose. Furthermore, they claim that their
principal concern was to determine the cause of and to stop the vaginal bleeding.
Issue: Whether the decision to proceed with the D&C operation was an honest mistake of
judgment or one amounting to negligence.

Held: 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. The decision to proceed with the D&C operation, notwithstanding Teresitas
hyperglycemia and without adequately preparing her for the procedure, was contrary to the
standards observed by the medical profession.

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. 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.

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. 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.

In his testimony, Dr. Mercado, the expert witness, objected with respect to the time the D&C
operation should have been conducted in Teresitas case. He opined that given the blood sugar
level of Teresita, her diabetic condition should have been addressed first. A D&C operation on a
hyperglycemic patient may be justified only when it is an emergency case when there is
profuse vaginal bleeding. The medical records of Teresita failed to indicate that there was
profuse 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. 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 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. The prudent move is to address the patients 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.

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 Teresitas condition in the hospital.
The critical and clinching factor in a medical negligence case is proof of the causal
connection between the negligence which the evidence established and the
plaintiffs injuries.

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
patients hyperglycemia. 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 Teresitas death due to aggravated diabetic condition is therefore sufficiently
established.

However, we clarify that Dr. Fredelictos negligence is not solely the act of ordering an on call
D&C operation when he was mainly an anaesthesiologist who had made a very cursory
examination of the patients vaginal bleeding complaint. Rather, it was his failure from the very
start to identify and confirm, despite the patients 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.

5. Solidum vs. People, 718 SCRA 263, G.R. No. 192123 March 10, 2014

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
nonexpert 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
 Cayao-Lasam vs. Sps. Ramolete Raspa

Facts: Editha Ramolete, three months pregnant was brought to the Lorma Medical Center
(LMC) in San Fernando, La Union due to vaginal bleeding. A pelvic sonogram was then
conducted on Editha revealing the fetus weak cardiac pulsation. The following day, Edithas
repeat pelvic sonogram 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. Editha was
discharged from the hospital the following day. Forty five days thereafter, Editha was once
again brought at the LMC, as she was suffering from vomiting and severe abdominal pains. Dr.
Mayo allegedly informed Editha that there was a dead fetus in the latters womb. After, Editha
underwent laparotomy, she was found to have a massive intra-abdominal hemorrhage and a
ruptured uterus. Thus, Editha had to undergo a procedure for hysterectomy and as a result,
she has no more chance to bear a child.

Respondents filed a Complaint for Gross Negligence and Malpractice against petitioner before
the PRC. They 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. 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; second, petitioner recommended that a D&C
procedure be performed on Editha without conducting any internal examination prior to the
procedure; third, petitioner immediately suggested a D&C procedure instead of closely
monitoring the state of pregnancy of Editha. Petitioner denied the allegations and alleged that
petitioner immediately called the hospital to anticipate the arrival of Editha and ordered
through the telephone the medicines Editha needed to take. She conducted various internal
examination on Editha. She 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 her to undergo D&C procedure which the respondents consented to. 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, which the latter failed to do. Edithas hysterectomy was brought about by her very
abnormal pregnancy known as placenta increta. 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.

The Board of Medicine ruled in petitioners favor. This was reversed by PRC, revoking her
authority or license to practice as a physician. Petitioner brought the matter to the CA in a
Petition for Review under Rule 43, which she dubbed as petition for certiorari. 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. Even if the petition be
treated as a petition for certiorari under Rule 65, the same would still be dismissed for being
improper and premature. It held that the the plain, speedy and adequate remedy under the
ordinary course of law which petitioner should have availed herself of was to appeal to the OP.

Issues:
Whether the appeal by respondents is already precluded by double jeopardy;
Whether the proper remedy is a petition for review with the CA via Rule 43;
Whether petitioner is guilty of negligence; and
Whether 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.

Held:
 No.

Double jeopardy has 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.
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.

Petitioner invokes Article IV, Section 35 of the Rules and Regulations Governing the Regulation
and Practice of Professionals which she interprets as giving the respondent the option to
appeal as a matter of right, but as to complainant, only when so allowed by law. But this was
already amended by Res. 174, Series of 1990 and in 2006 when PRC issued 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 giving either the
complainant or the respondent who has been aggrieved by the decision, order or resolution of
the Board may appeal to the Commission within 15 days from receipt thereof.

Yes.

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. In
Yang v. CA, it was declared that BP 129 conferred upon the CA exclusive appellate
jurisdiction over appeals from decisions of the PRC.

No. based on the evidence presented, 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 checkup, in defiance of petitioners
orders. The immediate cause of Edithas injury was her own act; thus, she cannot
recover damages from the injury.

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. 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. There are four elements involved in medical negligence cases: duty, breach, injury
and proximate causation. As to this aspect of medical malpractice, the determination of the
reasonable level of care and the breach thereof, expert testimony is essential. 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.

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.
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. He stated
that the D&C procedure was not the proximate cause of the rupture of Edithas uterus resulting
in her hysterectomy. Further, 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.

Art. 2179 states that when the plaintiffs own negligence was the immediate and proximate
cause of his injury, he cannot recover damages. 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. 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.

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. 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.

Yes. 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.

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. Respondents failed to overcome this burden.

Rogelio Nogales vs. Capitol Medical Center

Facts: Pregnant with her fourth child, Corazon, who was then 37 years old, was under the
exclusive prenatal care of Dr. Estrada beginning on her 4th month of pregnancy. While Corazon
was on her last trimester of pregnancy, Dr. Estrada noted an increase in her blood pressure
and development of leg edema, indicating preeclampsia, which is a dangerous complication of
pregnancy. The Spouses Nogales came to see Dr. Estrada at his home when Corazon
experienced mild labor pains. Dr. Estrada advised her immediate admission to CMC. 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. Dr. Enriquez, an anesthesiologist at
CMC, was notified at 4:15 a.m. of Corazons admission. Subsequently, when asked if he needed
the services of an anesthesiologist, Dr. Estrada refused. Despite Dr. Estradas refusal, Dr.
Enriquez stayed to observe Corazons condition. At 6:00 a.m., Corazon was transferred to
Delivery Room No. 1 of the CMC. At 6:10 a.m., Corazons bag of water ruptured spontaneously.
At 6:12 a.m., Corazons 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 10g of magnesium sulfate.
However, Dr. Villaflor, who was assisting Dr. Estrada, administered only 2.5g. At 6:22 a.m., Dr.
Estrada, assisted by Dr. Villaflor, applied low forceps to extract Corazons 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. Corazons blood pressure dropped
from 130/80 to 60/40 within 5 minutes. There was continuous profuse vaginal bleeding. The
assisting nurse administered hemacel 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 to order and deliver the blood. At 8:00
a.m., Dr. Espinola, head of the OB-GYN Department of the CMC, was apprised of Corazons
condition by telephone. Dr. Espinola ordered immediate hysterectomy. Rogelio was made to
sign a Consent to Operation. 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.
Despite Dr. Espinolas efforts, Corazon died at 9:15 a.m. The cause of death was hemorrhage,
post partum.

Petitioner filed a complaint for damages. The RTC rendered judgment finding Dr. Estrada solely
liable for damages. The CA affirmed the decision of the trial court, finding that Dr. Estrada is an
independent contractor. 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 physicians
negligence. It also discussed the borrowed servant doctrine which provides that once the
surgeon enters the operating room and takes charge of the proceedings, the acts or omissions
of operating room personnel, and any negligence associated with such acts or omissions, are
imputable to the surgeon. While the assisting physicians and nurses may be employed by the
hospital, or engaged by the patient, they normally become the temporary servants or agents
of the surgeon in charge while the operation is in progress, and liability may be imposed upon
the surgeon for their negligent acts under the doctrine of respondeat superior.

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. It 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.

Issue: Whether CMC is vicariously liable for the negligence of Dr. Estrada.

Held: Yes.

In Ramos vs. Court of Appeals, the Court discussed the relationship between a hospital
and a consultant or visiting physician and the liability of such hospital for that
physicians negligence. 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 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.

The control exercised, the hiring, and the right to terminate consultants all fulfill the important
hallmarks of an employer-employee relationship, with the exception of the payment of wages.
In assessing whether such a relationship in fact exists, the control test is determining.
Accordingly, on the basis of the foregoing, we rule that for the purpose of allocating
responsibility in medical negligence cases, an employer-employee relationship in
effect exists between hospitals and their attending and visiting physicians. The basis
for holding an employer solidarily responsible for the negligence of its employee is found in
Article 2180 of the Civil Code.

The control 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.

The Court finds no single evidence pointing to CMCs exercise of control over Dr. Estradas
treatment and management of Corazons condition. It is undisputed that throughout Corazons
pregnancy, she was under the exclusive prenatal care of Dr. Estrada. At the time of Corazons
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 Corazons
condition. While Dr. Estrada enjoyed staff privileges at CMC, such fact alone did not make him
an employee of CMC. CMC merely allowed Dr. Estrada to use its facilities 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.

But this does not automatically exempt CMC from liability considering that Dr. Estrada is an
independent contractor-physician. The hospital may be liable if the physician is the ostensible
agent of the hospital. This is the doctrine of apparent authority.

The doctrine of apparent authority involves two factors. The first factor focuses on the
hospitals manifestations and is sometimes described as an inquiry whether the hospital
acted in a manner which would lead a reasonable person to conclude that the
individual who was alleged to be negligent was an employee or agent of the
hospital. In this regard, the hospital need not make express representations to the
patient that the treating physician is an employee of the hospital; rather a representation
may be general and implied.
In the instant case, CMC impliedly held out Dr. Estrada as a member of its medical staff. CMC
extended its medical staff and facilities to Dr. Estrada. CMC extended its medical staff and
facilities to Dr. Estrada. Significantly, no one from CMC informed the Spouses Nogales that Dr.
Estrada was an independent contractor. Dr. Estradas referral of Corazons profuse vaginal
bleeding to Dr. Espinola, who was then the Head of the OB-GYN Department of CMC , gave the
impression that Dr. Estrada as a member of CMCs medical staff was collaborating with other
CMC-employed specialists in treating Corazon.

The second factor focuses on the patients 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.

Rogelio testified that he and his wife specifically chose Dr. Estrada to handle Corazons delivery
not only because of their friends recommendation, but more importantly because of Dr.
Estradas connection with a reputable hospital, the CMC. Considering Corazons age then, the
Spouses Nogales looked to CMC to provide the best medical care and support services for
Corazons delivery.

CMCs defense that all it did was to extend to Corazon its facilities is untenable. 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, 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.

Likewise unconvincing is CMCs argument that petitioners are estopped from claiming damages
based on the Consent on Admission and Consent to 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. 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.

Liability of Other Respondents:

Dr. Villaflor - 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.
Dr. Uy The routine internal examination did not ipso facto make Dr. Uy liable for the
errors committed by Dr. Estrada. Further, nothing shows that Dr. Uy participated in
delivering Corazons 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.
Dr. Enriquez - 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.
Estradas errors. Besides, there was no evidence of Dr. Enriques knowledge of any
error committed by Dr. Estrada and his failure to act upon such observation.
Dr. Lacson - There was no unreasonable delay in the delivery of blood from the time of
the request until the transfusion to Corazon. Taking into account the bleeding time,
clotting time and cross-matching, Dr. Lacson stated that it would take approximately
45-60 minutes before blood could be ready for transfusion.
Dr. Espinola - Dr. Espinolas order to do hysterectomy which was based on the
 information he received by phone is not negligence. Dr. Espinola, upon hearing such
information about Corazons condition, believed in good faith that hysterectomy was
the correct remedy.
Nurse Dumlao - There is no evidence of Nurse Dumlaos alleged failure to follow Dr.
Estradas specific instructions. There is no showing that side-drip administration of
hemacel proximately caused Corazons death.

Dr. Cantre vs Sps. Go Arm Injury, Dr. Jesus Delgado Memorial Hospital

Facts: When Nora gave birth to her fourth child, petitioner was her attending physician at Dr.
Jesus Delgado Memorial Hospital. However, 2 hours later, 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. Nora remained unconscious until she recovered.

While in the recovery room, her husband, respondent John David noticed a fresh gaping wound
2.5 by 3.5 inches in the inner portion of her left arm, close to the armpit. He asked the nurses
and he was informed it was a burn. He requested for an investigation. Petitioner said the blood
pressure cuff caused the injury. He brought Nora to NBI for a physical examination. 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. 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. Skin grafting and scar revision was performed on Nora
that was shouldered by the hospital. Unfortunately, Noras arm will never be the same again as
the pain in her left arm remains.

Respondents filed a complaint for damages against petitioner, Dr. Abad, and the hospital. The
trial court ruled in their favor. This was affirmed by the CA, removing only the award of
exemplary damages.

Issue: Whether petitioner is liable for the injury suffered by Nora.

Held: Yes.

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.

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. 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.

The captain of the ship 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.

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, for which petitioner
cannot escape liability under the captain of the ship doctrine.

10. Jarcia, Jr. vs. People, 666 SCRA 336, G.R. No. 187926 February 15, 2012

Held:

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 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.

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.

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.

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.

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.

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.

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.

[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.

11. Atienza vs. Board of Medicine Kidney

Facts: Editha Sioson is suffering lumbar pains for quite a long time. When she got herself
checked up at Rizal Medical Center, several tests revealed that her right kidney is functioning,
but her left kidney is non-functioning and non-visualizing. She underwent a kidney operation.

Her husband filed a complaint for gross negligence and/or incompetence before the BOM
against the doctors who allegedly participated in the fateful kidney operation, wherein her
right kidney, instead of the left one, was removed. During the hearing, she offered Exhibits A to
D, consisting of photocopies of x-ray forms, for the purpose of proving that her kidneys were
both in their proper anatomical locations at the time she was operated. Petitioner objected
alleging that these are inadmissible because they are mere photocopies, not properly
identified and authenticated, and intended to establish matters which are hearsay. The BOM
admitted the evidence and denied petitioners motion for reconsideration. This was affirmed by
the CA.

Issues: W/N Exhibits A to D are inadmissible as evidence.

Held: No. They are admissible.

The rules of evidence are not strictly applied in proceedings before administrative
bodies such as the BOM.
[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.

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.

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. Unquestionably,
the rules of evidence are merely the means for ascertaining the truth respecting a matter of
fact. 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. Laws of nature
involving the physical sciences, specifically biology, 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.

Best Evidence Rule. The best evidence rule is inapplicable. 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.

Hearsay Evidence. The exhibits do not constitute hearsay evidence 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 x-ray of her abdominal area. The introduction of
secondary evidence, such as copies of the exhibits, is allowed. 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.

12. Dela Torre vs. Dr. Imbuido Kabag

Facts: Pedritos wife, Carmen died while admitted at the Divine Spirit General Hospital on
February 13, 1992. Carmen was due to give birth on February 2, but when she had not
delivered her baby at the expected time, Dr. Nestor performed caesarian section operation on
her. After the successful delivery of a baby boy, she complained abdominal pain and difficulty
in urinating. She was found to be suffering UTI, and was prescribed medications by Dr. Norma.
Later on, Carmens stomach grew bigger, but Dr. Norma dismissed her condition as mere
kabag. When Carmens stomach still grew bigger despite medications, Dr. Norma advised
Pedrito of the possibility of a second operation on Carmen. Dr. Norma, however, provided no
details on its purpose and the doctor who would perform it. Carmen had her second operation
in the afternoon but the next day, after vomiting dark red blood, she died. Per her certificate of
death upon information provided by the hospital, the immediate cause of Carmens death was
"cardio-respiratory arrest secondary to cerebro vascular accident, hypertension and chronic
nephritis induced by pregnancy." An Autopsy Report prepared by Dr. Patilano, Medico-Legal
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[.]"

The RTC ruled in favor of Pedrito, but on appeal, this was reversed and set aside by the CA.

Issue: W/N respondents failed to exercise the degree of diligence required of them by their
profession as doctors.

Held: No.

"[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
professional which 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."

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.

It is settled that a physicians duty to his 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.

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.

The report of Dr. Patilano failed to justify Pedritos entitlement to the damages awarded by the
RTC. Considering that it was not duly established that Dr. Patilano practiced and was an expert
in the 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. The testimony of Dr. Patilano was based solely on the results of his
autopsy on the cadaver of Carmen. 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. 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.

Dr. Nestor, a surgeon, possessed the reasonable degree of learning, skill and experience
required by his profession for the treatment of Carmen. Without sufficient proof from the
claimant on a different degree of care, skill and diligence that should be expected from the
respondents, it could not be said with certainty that a breach was 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.

13. Dr. Alano vs. Logmao Organ Donation

Facts: Arnelito Logmao, then 18 years old, was brought to the East Avenue Medical Center by
two sidewalk vendors, who allegedly saw the former fall from the overpass near the Farmers
Market. As his condition deteriorated, he needed to be admitted to ICU and be given
mechanical ventilator support but none was available in EAMC. A resident physician of NKI,
who was rotating at EAMC, suggested that he be transferred to NKI. After arrangements were
made, he was transferred to NKI where he was immediately attended to and given the
necessary medical treatment. The severity of the brain injury of Logmao caused his brain
death. Officers of NKI resorted to media and police to seek help in locating the relatives of
Logmao. 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. Alano,
authorize the removal of specific organs from the body of Lugmoso for transplantation
purposes. They also secured permission for the planned organ retrieval and transplantation
from the Medico-Legal Office of the NBI. Dr. Alano issued a memorandum stating that
permission/authority will be given if all reasonable efforts are exerted 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 [Medico-Legal] Section
has been notified and is aware of the case. The next day, the medical team of NKI transplanted
Logmaos kidneys and pancreas to other patients. NKI made arrangements with La Funeraria
Oro for the embalmment of the cadaver of Lugmao good for a period of 15 days to afford more
time to continue searching for the relatives of the latter. The autopsy conducted by NBI show
that the cause of death of Lugmao was intracranial hemorrhage secondary to skull fracture.

A relative of Logmao heard the press release of NKI announcing its successful double organ
transplantation, where the name of the donor sounded like Arnelito Logmao. Upon receiving
the news, plaintiff and her other children went to La Funeraria Oro, where they saw Arnelito
inside a cheap casket.

Plaintiff filed with the RTC a complaint for damages. She alleged that defendants conspired to
remove the organs of Arnelito while the latter was still alive and that they concealed his true
identity. The RTC rendered judgment finding only Dr. Alano liable for damages and dismissing
the complaint against the other defendants for lack of legal basis. This was affirmed by the CA
but deleted the award of actual damages, and reduced the award of moral and exemplary
damages, and attorneys fees.

Issues:
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; and
Whether sufficient time was allowed for notices to reach the relatives of the deceased.

Held:
No. 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.
Petitioner employed reasonable means to disseminate notifications intended to reach the
relatives of the deceased. 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. He could not have made his directives any clearer. 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.

Yes. Respondent failed to show proof that the doctors could or should have waited
longer before harvesting the internal organs for transplantation.

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. 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.

14. Bondoc vs. Mantala, 740 SCRA 311, G.R. No. 203080 November 12, 2014

Held:

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, a forbidden act, a
dereliction of duty, willful in character, and implies wrongful intent and not mere error in
judgment. 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, when the 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.

A doctors duty to his patient is not required to be extraordinary. The standard contemplated
for doctors is simply the reasonable average merit among ordinarily good physicians, i.e.,
reasonable skill and competence. 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.

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.

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. 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. In Medina vs. Commission on Audit, 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 publics:; faith and confidence in the government.

15. Sps. Bontilao vs. Dr. Gerona Wrist Fracture

Facts: In 1991, respondent, an orthopedic surgeon at the Vicente Gullas Memorial Hospital,
treated petitioners' son, 8-year-old Allen, for a fractured right wrist. Six months later, Allen re-
fractured the same wrist that needed a closed reduction procedure, which respondent
performed with Dr. Jabagat as the anesthesiologist. Respondent advised petitioner to come
back later for re-tightening of the cast, which petitioner failed to do. Because of this, a
rotational deformity had developed in Allen's arm, which required the conduct of an open
reduction surgery conducted by respondent, again with Dr. Jabagat as the anesthesiologist. In
this operation, Dr. Jabagat failed to intubate the patient after 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.
Later petitioner 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."

Petitioners filed a complaint for damages against both respondent and Dr. Jabagat in the RTC
alleging negligence and incompetence on the part of the doctors. The RTC decided in their
favor, holding that the doctrine of res ipsa loquitur was applicable. 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.
Neither Allen nor his mother could be said to be guilty of contributory negligence. 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.

On appeal solely by Dr. Gerona, the CA reversed the ruling of the RTC ruling that it was
established in both the criminal and administrative cases that Allen's death was the result of
the anesthesiologist's negligence and not the respondents. The trial court erred in applying
the "captain of the ship" doctrine to make respondent liable even though he was the lead
surgeon. 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. 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.

In the case before the SC, petitioner asserts that the doctrine of res ipsa loquitur applies
because Allen was healthy 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.

The respondent on the other hand 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. An anesthesiologist and a surgeon are specialists in their own
field and neither one could dictate upon the other.

Issue: Whether respondent is liable for damages for Allen's death.

Held: No. The doctrine of res ipsa loquitor is not applicable in this case.

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

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. As held in Ramos v. Court of Appeals, 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 themselves reasonably speak to the average man
as the negligent cause or causes of the untoward consequence.

No specific act of negligence. 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. 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, as shown by expert testimony,
anesthesia could be administered by alternative means such as a mask and that the operation
could proceed even without intubation. 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. 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.

No control over the instrumentality that caused death. 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.