Module 13 MEDICAL MALPRACTICE
applicable. (NO)
By the end of the module, the student should be able to:
1. Define medical malpractice and its basic elements.
2. Define the nature of physician-patient relationship.
3. Relate the legal bases of medical malpractice and the
major doctrines on medical malpractice as defined in
court cases.
4. Define the circumstances and doctrines relating to
liability of hospitals.
injury, and proximate causation. As to the determination
1. DEFINITION
Reyes v. Sisters of Mercy Hospital, GR No. 13047, Oct. 3,
2000.
Reyes vs. Sisters of Mercy Hospital (2000)
FACTS:
1. Lea Reyes, wife of late Jorge Reyes filed a complaint
for damages against Sisters of Mercy, Sister Rose
Palacio, Dr. Blanes, Dr. Rico and Mercy Community
Clinic. The allegations in her complaint are as follows:
- Jorge has been having recurring fever with chills
for five days before he was taken to Mercy
Community Clinic by his wife
- He was attended to by Dr. Rico who performed a
physical examination on Jorge
- During that time, typhoid fever was prevalent
- Suspecting that Jorge could be suffering from
typhoid fever, Dr. Rico ordered a Widal Test, a
standard test for typhoid fever, to be performed
on Jorge. Jorge tested positive.
- Dr. Rico then indorsed Jorge to Dr. Blanes.
o Antibiotics being the accepted treatment for
typhoid fever, Dr. Blanes ordered that a
compatibility test with the antibiotic
chloromycetin be done on Jorge. No
adverse reaction was observed so Dr. Blanes
ordered the first five miligrams of said
antibiotic to be administered around 9 pm
and a second dose about three hours later
- At around 1 am, Jorges temperature rose to 41C
- Emergency measures were taken but Jorge
eventually died at around 2 am. The cause of
death was Ventricular Arrythemia Secondary to
Hyperpyrexia and typhoid fever
2. Leah contends that Jorge did not die of typhoid
fever but instead due to the wrongful administration
of chloromycetin. She contends that had respondent
doctors exercised due care and diligence, they
would not have recommended and rushed the
performance of the Widal Test, hastily concluded
that Jorge had typhoid fever and administered
chloromycetin without first conducting sufficient tests
RTC: dismissed the complaint
CA: affirmed RTC
Whether or not the doctrine of res ipsa loquitur is
Whether or not the doctors are negligent. (NO)
Ratio
The court first discussed the action of the petitioners:
medical malpractice. This is the failure of a physician
/surgeon to apply to his practice that degree of care and
skill which is ordinarily employed by the profession
generally, under similar conditions, and in like surrounding
circumstances. The four elements are: duty, breach,
of the reasonable level of care required and the breach
thereof, expert testimony is essential. This is because the
causes of the injuries involved in malpractice actions are
determinable only in the light of scientific knowledge. But
there is an exceptionwhen the doctrine of res ipsa
loquitur is applicable.
Res ipsa loquitur. Expert testimony may be dispensed
with under the doctrine. This is because the injury itself
provides the proof of negligence. Where common
knowledge and experience (a layman knows it) 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. (e.g. tool left inside the body)
Petitioners: This doctrine is applicable because Jorge
was just suffering a fever when he went to the clinic, but
he died 10 hours later.
SC: Wrong. This doctrine is not applicable since there
is really nothing unusual or extraordinary about his death.
Prior to his admission, the patient already had recurring
fevers and chills for five days unrelieved by the medicine
given to him by his wife. This shows that he had been
suffering from a serious illness and professional medical
help came too late for him. When a diagnosis or medical
treatment is in question, the doctrine is not applicable.
Specific acts of negligence. Petitioners presented Dr.
Vacalares, who did an autopsy on the body, as expert
witness. He did not open the skull to examine the brain,
but his findings show that the gastrointestinal tract was
normalwithout any ulceration or enlargement of
nodules. According to him, Jorge did not die of typhoid
fever, and that he had not seen a patient die of typhoid
fever within five days from the onset of the disease.
SC: NOT AN EXPERT WITNESS. He is not a specialist on
infectious diseases like typhoid fever. In fact, he had yet
to do one on the body of a typhoid victim at the time he
conducted the postmortem on Jorge Reyes. His testimony
also states that he has only treated 3 cases of typhoid
fever as a doctor. Thus, he is not qualified to prove that
Dr. Rico erred in her diagnosis.
Respondents expert witnesses, Dr. Gotiong
(specialized in infectious diseases, testified that he had
already treated over a thousand cases of typhoid fever)
and Dr. Panopio (chief pathologist of a hospital), were
clearly experts on the subjects. Dr. Gotiong testified that,
when typhoid fever is suspected, the Widal Test is
normally used, and chloromycetin was the drug of
choice. He said that if he was presented the case of
Jorge Reyes, he wouldve suspected he had typhoid
fever too. He also averred that the autopsy done by
Vacalares was incomplete, since the toxic effect of
typhoid fever can lead to meningitis, and that he
shouldve examined the brain too. He laso said, that
while hyperplasia in the payers aptches or layers of the
small intestine is present in typhoid fever, the same may
not be grossly visible and may be microscopic. Dr. Ibarra
concurred in all these statements.
(IMPORTANT) The standard contemplated for due
care and diligence is not what is actually the average
merit among all known practitioners from the best to the
worst and from the most to the leased experienced, but
the reasonable average merit among the ordinarily good
physicians. Dr. Rico did not depart from the reasonable
standard recommended by the experts. Though the
Widal Test is not conclusive, it remains a standard
diagnostic test for typhoid fever and, in the present case,
greater accuracy through repeated testing was
rendered unobtainable by the early death of the patient.
All that the law requires of them is that they perform the
standard tests and perform standard procedures. The law
cannot require them to predict every possible reaction to
all drugs administered.
Huling hirit ng petitioners: The medical profession, like
the business of common carriers, is affected with public
interest. Hence, extraordinary diligence is required of
them.
SC: The practice of medicine is a profession engaged
in only by qualified individuals. It is earned through years
of education, obtaining a license through board exams,
which can be revoked by the government at any time for
cause. There is no need to expressly require doctors to
observe extraordinary diligence. As it is now, the
practice of medicine is already conditioned upon the
highest degree of diligence.
2. ASSUMPTIONS
2.1. Engaged in the practice of medicine
2.1.1.Sections 10 & 11 of the Medical Act of 1959
2.2. Doctors representation in accepting a case
Garcia-Rueda v. Pascasio, GR No. 118141, Sep. 5, 1997
3. NATURE OF PHYSICIAN-PATIENT RELATIONSHIP
3.1. Cayao-Lasam v. Ramolete, GR No.159132, Dec. 18,
2008
Fe Cayao-Lasam vs Sps. Ramolete (2008)
Brief Facts: Mrs. Ramolete underwent a hysterectomy
after the bleeding continued even after a D&C
procedure. She later sued the doctor who performed the
D&C procedure for medical malpractice.
Doctrine: Expert testimony is needed in a medical
malpractice suits to prove the existence of the elements
of breach of duty, injury suffered, and proximate
causation.
FACTS:
1. Editha was 3 months pregnant was brought to
the hospital due to vaginal bleeding. 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."
Cayao-Lasam performed the D&C and
Editha was discharged the following day
2. About a month after, 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.
3. Thus, Sps. filed a case against petitioner for Gross
Negligence and Malpractice before the PRC.
4. As a defense, Petitioner contended that it was
Edithas gross negligence and/or omission in
insisting to be discharged the following against
doctors advice and her unjustified failure to
return for check-up as directed by petitioner that
contributed to her life-threatening condition. In
addition, the hysterectomy was brought about
by her very abnormal pregnancy known as
placenta increta, which was an extremely rare
and very unusual case of abdominal placental
implantation.
5. The Board of Medicine of the PRC exonerated
petitioner. The decision states that:
When complainant Editha was admitted
at Lorma Medical Center on July 28,
1994 due to vaginal bleeding, an ultra-
sound was performed upon her and the
result of the Sonogram Test reveals a
morbid fetus but did not specify where
the fetus was located. Obstetricians will
assume that the pregnancy is within the
uterus unless so specified by the
Sonologist who conducted the ultra-
sound. Respondent (Dr. Lasam) cannot
be faulted if she was not able to
determine that complainant Editha is
having an ectopic pregnancy interstitial.
The D&C conducted on Editha is
necessary considering that her cervix is
already open and so as to stop the
profuse bleeding. Simple curettage
cannot remove a fetus if the patient is
having an ectopic pregnancy, since
ectopic pregnancy is pregnancy
conceived outside the uterus and
curettage is done only within the uterus.
Therefore, a more extensive operation
needed in this case of pregnancy in
order to remove the fetus.
 6. On appeal to the CA, CA ruled that Rule 43 was
inapplicable since such mode of appeal is
exclusive to the list of quasi-judicial agencies, of
which the PRC is not included. Rule 65 is also not
proper as it would be premature. The proper
remedy would have been to appeal to the Office
of the President pursuant to the Medical Act of
1969.
7. Petitioners main argument: PRC decision was
baseless as no expert testimony was presented to
support its conclusion.
ISSUE: WON Rule 43 was the proper mode of appeal (YES)
RATIO:
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. The
Rule expressly provides that it should be applied
to appeals from awards, judgments final orders or
resolutions of any quasi-judicial agency in the
exercise of its quasi-judicial functions. The phrase
"among these agencies" confirms that the
enumeration made in the Rule is not exclusive to
the agencies therein listed.
Citing Yang vs. CA: BP 129 conferred upon the
CA exclusive appellate jurisdiction over appeals
from decisions of the PRC
ISSUE: WON expert testimony is necessary to support
decisions in medical malpractice suits (YES)
RATIO:
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.
4 elements: duty, breach, injury, and proximate
causation
The breach of these professional duties of skill
and care, or their improper performance by a
physician surgeon, whereby the patient is injured
in body or in health, constitutes actionable
malpractice. 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.
o However, 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.
On the other hand, petitioner presented Dr.
Manalo who specializes in gynecology and
obstetrics. He testified that the D&C procedure
was not the proximate cause of the rupture of
Edithas uterus.
o From the foregoing testimony, it is clear
that the D&C procedure was conducted
in accordance with the standard
practice, with the same level of care
that any reasonably competent doctor
would use to treat a condition under the
same circumstances, and that there was
nothing irregular in the way the petitioner
dealt with Editha.
PRC noted that the proximate cause of the injury
is respondents own negligence in neglecting the
doctors advice to return 4 days after the
procedure for a check-up. Had she done so, the
doctor could have examined her thoroughly.
o 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.
3.2. Article II, Physicians Code of Ethics
3.3. Republic Act No. 8344, August 25, 1997
3.4. Osborne v. Frazor, 58 Tenn. App. 15
Osborne v Frazer
FACTS:
1. In December, 1952 Effie Frazor suffered a broken hip
and was taken to the office of Dr. Osborne who sent
her to the hospital for surgery which was performed
by a specialist, assisted by Osborne.
2. Approximately twelve months later, deceased was
readmitted to the hospital for additional hip surgery
during which a surgical sponge was left in
deceased's hip without her knowledge.
3. The incision failed to heal and produced pain, foul
odor and drainage until May, 1961 when a few
threads began to protrude from the wound, and the
sponge was discovered and removed. The wound
healed promptly thereafter.
4. During the entire period from surgery until discovery
and removal of the sponge, the deceased was
under the professional care of the defendant.
ISSUES:
1. WON there was a contractual relationship between the
parties (YES)
2. WON there was evidence of negligence to support
Osbornes conviction (YES)
RATIO:
1. The voluntary acceptance of the physician-patient
relationship by the affected parties certainly creates a
prima facie presumption of a contractual relationship.
- The relationship of physician or surgeon and patient is
one arising out of a contract, express or implied. The
relation of "physician and patient" is created when
the professional services of a physician are accepted
for a purpose of medical or surgical treatment, the
relation being a contractual one, wherein patient
knowingly seeks assistance of a physician and
physician knowingly accepts him as a patient.
2. Where a physician sets his own standard of professional
competence and testifies that he measured up to that
standard, but the jury finds from other evidence that the
physician failed to do that which he himself considers
proper and necessary, the physician cannot complain
that the plaintiff has not proven negligence.
- The defendant and his witnesses, Drs. Eyler, Troutt,
and Wallace were agreed that the condition of an
unhealed and draining wound following orthopaedic
surgical procedure would be beyond the capacity of
a general practitioner and ought to be referred back
to the orthopaedic surgeon for specialized diagnosis
and treatment
- In 132 A.L.R. 392 is found the following general
statement: "It may be stated as a general rule that, as
a part of the requirements which the law exacts of
general practitioners of medicine and surgery, or
other schools of healing, if, in the exercise of the care
and skill demanded by those requirements, such a
practitioner discovers, or should know or discover,
that the patient's ailment is beyond his knowledge or
technical skill, or ability or capacity to treat with a
likelihood of reasonable success, he is under a duty
to disclose the situation to his patient, or advise him of
the necessity of other or different treatment."
- The many cases analyzed under this annotation
support the insistence of the plaintiff, the admission of
the defendant, and the testimony of the defendant's
witnesses that the chronic, persistent condition of the
patient in this case required the defendant to
recommend treatment by specialist.
- Since defendant's duty to refer his patient to more
competent specialized medical authority was clearly
established, the question remains, did the defendant
perform that duty? He insists that he did. Repeatedly,
he testified, he urged both the patient and various
members of her family to submit the problem to Dr.
Eyler. Several times, he says, he discussed the matter
with Dr. Eyler.
- Norman Frazor and his wife, Herman Frazor and his
wife, and Mrs. Mary Elizabeth Frazor Tillman each
testified that defendant had never made any
suggestion of reference to Dr. Eyler, but assured them
that the condition of deceased was hopeless,
permanent and incurable. They testified in effect that
one or more of them were present whenever the
defendant visited deceased, and defendant himself
testified that one or more of them were present on
most if not all occasions when he insisted that the
patient be taken to Dr. Eyler.
- We are satisfied that there was evidence at that trial
which would have justified the jury in finding the facts
as insisted by the plaintiffs, that is, that the defendant
did not refer the patient to a specialist as it was his
duty to do.
3.5. Jarcia v. Court of Appeals, G.R. No. 187926, February
12, 2012
Jarcia v. CA (2012)
FACTS:
1. Belinda Santiago filed a complaint with the NBI
against petitioners, Dr. Jarcia and Dr. Bastan, for
their alleged neglect of professional duty which
caused her son, Roy Jr., to suffer serious physical
injuries.
2. Upon investigation, NBI found that Roy Jr. was hit
by a taxicab; that he was rushed to the Manila
Doctors Hospital for an emergency medical
treatment; that an X-ray of his ankle was ordered;
that the X-ray result showed no fracture as read
by Dr. Jarcia; that Dr. Bastan informed Mrs.
Santiago that since it was only the ankle that was
hit, there was no need to examine the upper leg;
that 11 days later, Roy Jr. developed fever,
swelling of the right leg and misalignment of the
right foot; that Mrs. Santiago brought him back to
the hospital; and that the X-ray revealed a right
mid-tibial fracture and a linear hairline fracture in
the shaft of the bone
3. A criminal case for reckless imprudence resulting
to serious physical injuries was filed against the
physicians
RTC: found petitioners guilty of the crime simple
imprudence resulting to serious physical injuries
CA: Affirmed RTC
4. Petitioners filed the instant petition which was
denied; they then filed a motion for
consideration raising the argument that there is
no causal connection between their failure to
diagnose the fracture and the injury sustained by
Roy.
ISSUES: circumstances justly demand, whereby such
1) WON the doctrine of res ipsa loquitur is other person suffers injury
applicable (NO) - Reckless imprudence consists of voluntarily
2) WON the physicians were negligent (YES) doing or failing to do, without malice, an act
from which material damage results by
reason of an inexcusable lack of precaution
RATIO:
on the part of the person performing or
1. No. The elements for the application of res ipsa
failing to perform such act
loquitur were not satisfied
- The elements of simple negligence are:
- The doctrine or res ipsa loquitur means
(1) That there is a lack of precaution on the
Where the thing which causes injury is
part of the offender
shown to be under the management of the
(2) That the damage impending to be
defendant, and the accident is such as in
caused is not immediate or the danger is
the ordinary course of things does not
not clearly manifest
happen if those who have the management
- The court is not convinced with moral
use proper care, it affords reasonable
certainty that the petitioners are guilty of
evidence, in the absence of an explanation
reckless imprudence or simple negligence
by the defendant, that the accident arose
- The testimony of Dr. Tacata, a specialist in
from want of care
pediatric orthopedic, revealed that it was
- Requisites for its application:
not clear whether the injuries of Roy Jr. were
(1) The accident was of a kind which does
indeed aggravated by the petitioners
not ordinarily occur unless someone is
judgment call and their diagnosis or
negligent
appreciation of the condition of the victim at
(2) The instrumentality or agency which
the time they assessed him. However,
caused the injury was under the
according to his testimony, a thorough
exclusive control of the person in charge
examination was not performed on Roy. As
(3) The injury suffered must not have been
residents on duty at the emergency room, Dr.
due to any voluntary action or
Jarcia and Dr. Bastan were expected to
contribution of the person injured
know the medical protocol in treating leg
- In the case at bar, the circumstances that
fractures and in attending to victims of car
caused Roy Jr.s injury and the series of tests
accidents. However, no precise evidence
that were supposed to be undergone by him
pointing to the fact that the delay in the
to determine the extent of the injury were not
application of the case to the patients
under the exclusive control of doctors Jarcia
fractured leg because of failure to
and Bastan. It was established that they are
immediately diagnose the specific injury of
mere residents of the hospital at that time.
the patient, prolonged the pain of the child
While it may be true that the circumstances
or aggravated his condition. Hence, there is
pointed out by the courts below seem
reasonable doubt as to the petitioners guilt
doubtless to constitute reckless imprudence
- However, they are civilly liable for failure to
on the part of the petitioners, this conclusion
sufficiently attend to Roys medical needs.
is still best achieved by the unquestionable
Preponderance of evidence suffices to
knowledge of expert witnesses and not
establish civil liability.
through the scholarly assumptions of a
o They were remiss of their duties as
layman like the patients mother.
members of the medical profession.
- As to whether the petitioners have exercised
Assuming that they did not have the
the requisite degree of skill and care in
capacity to make such thorough
treating Roy Jr. is generally a matter of expert
evaluation at that stage, they should
opinion
have referred the patient to another
doctor with sufficient training and
2. Yes, the physicians were negligent. However, experience instead of assuring him
they are not criminally negligent. They are only and his mother that everything was
held liable for damages. all right
- Negligence is defined as the failure to - Patient-physician relationship undoubtedly
observe the protection of the interests of existed. The petitioners obliged and
another person that degree of care, examined the patient, and later assured the
precaution, and vigilance which the mother that everything was fine. Clearly,
 such relationship was established between
the parties.
Dispositive: Petition partly granted. Dr. Jarcia and Bastan
are acquitted of the crime of reckless imprudence
resulting to serious physical injuries but are held civilly
liable for actual, moral and exemplary damages
4. ELEMENTS
Garcia-Rueda v. Pascasio, supra.
4.1. DUTY OF A PHYSICIAN
4.1.1.Section 1. of Art. II, Physicians Code of Ethics
4.1.2.Carillo v. People, GR No. 868890, Jan. 21 , 1994
4.1.3.Lucas v. Tuano, GR No. 178763, Apr. 21, 2009
4.1.4.Cruz v. Court of Appeals, GR No. 122445, Nov. 18,
1997
Cruz v CA
FACTS:
1. The petitioner and one Dr. Lina Ercillo who was
the attending anaesthesiologist during
operation of the deceased were charged with
"reckless imprudence and negligence resulting to
homicide for the untimely death of said Lydia
Umali on the day following her surgical operation.
2. Rowena Umali De Ocampo, accompanied her
mother, Lydia, to the Perpetual Help Clinic and
General Hospital. Lydia was examined by the
petitioner who found a "myoma" in her uterus,
and scheduled her for a hysterectomy operation
on March 23, 1991.
3. Because of the untidy state of the clinic, Rowena
tried to persuade her mother not to proceed with
the operation. The following day, before her
mother was wheeled into the operating room,
Rowena asked the petitioner if the operation
could be postponed.
4. Lydia then informed Rowena that the petitioner
told her that she must be operated on as
scheduled. Rowena and her other relatives
waited outside the operating room while Lydia
underwent operation. While they were waiting,
Dr. Ercillo went out of the operating room and
instructed them to buy tagamet ampules which
Rowena's sister immediately bought. About one
hour had passed when Dr. Ercillo came out again
this time to ask them to buy blood for Lydia.
5. After the lapse of a few hours, the petitioner
informed them that the operation was finished.
Some thirty minutes after, Lydia was brought out
of the operating room in a stretcher and the
petitioner asked Rowena and the other relatives
to buy additional blood for Lydia.
6. Unfortunately, they were not able to comply with
petitioner's order as there was no more type "A"
blood available in the blood bank. Thereafter, a
person arrived to donate blood which was later
transfused to Lydia.
7. Rowena then noticed her mother, who was
attached to an oxygen tank, gasping for breath.
Apparently the oxygen supply had run out and
Rowena's husband together with the driver of the
accused had to go to the San Pablo District
Hospital to get oxygen. Lydia was given the fresh
supply of oxygen as soon as it arrived. But at
around 10:00 o'clock P.M. she went into shock
and her blood pressure dropped to 60/50. Lydia's
unstable condition necessitated her transfer to
the San Pablo District Hospital so she could be
connected to a respirator and further examined.
8. Upon Lydia's arrival at the San Pablo District
Hospital, she was wheeled into the operating
the
room and the petitioner and Dr. Ercillo re-
operated on her because there was blood
oozing from the abdominal incision. While the
petitioner was closing the abdominal wall, the
patient died. Lydia Umali was pronounced dead.
Her death certificate states "shock" as the
immediate cause of death and "Disseminated
Intravascular Coagulation (DIC)" as the
antecedent cause.
9. Trial ensued after both the petitioner and Dr. Lina
Ercillo pleaded not guilty to the above-
mentioned charge. On March 4, 1994, the
Municipal Trial Court in Cities (MTCC) of San
Pablo City rendered a decision finding the
accused Dra. Lina Ercillo not guilty of the offense
charged for insufficiency of evidence while her
co-accused Dra. Ninevetch Cruz is hereby held
responsible for the death of Lydia Umali on
March 24, 1991, and therefore guilty under Art.
365 of the Revised Penal Code.
10. The RTC and the Court of Appeals affirmed the
MTCC in toto and further directed petitioner to
pay the heirs of Lydia Umali P50,000.00 as
indemnity for her death.

ISSUE: Won petitioner is guilty of reckless imprudence
resulting in homicide? (NO)
RATIO:
- This Court finds the foregoing circumstances
insufficient to sustain a judgment of conviction
against the petitioner for the crime of reckless
imprudence resulting in homicide. The elements of
reckless imprudence are: (1) that the offender does
or fails to do an act; (2) that the doing or the failure
to do that act is voluntary; (3) that it be without
malice; (4) that material damage results from the
reckless imprudence; and (5) that
inexcusable lack of precaution on the part of the
offender, taking into consideration his employment or
occupation, degree of intelligence,
condition, and other circumstances regarding
persons, time and place.
- Even granting arguendo that the inadequacy of the
facilities and untidiness of the clinic; the lack of
provisions; the failure to conduct pre-operation tests
on the patient; and the subsequent transfer of Lydia
to the San Pablo Hospital and the reoperation
performed on her by the petitioner do indicate, even
without expert testimony, that petitioner
recklessly imprudent in the exercise of her duties as a
surgeon, no cogent proof exists that any of these
circumstances caused petitioner's death. Thus, the
absence of the fourth element of
imprudence: that the injury to the person or property
was a consequence of the reckless imprudence.
- 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
circumstances bearing in mind the advanced state
of the profession at the time of treatment or the
present state of medical science.
- The prosecution's expert witnesses in the persons of
Dr. Floresto Arizala and Dr. Nieto Salvador, Jr. of the
National Bureau of Investigation (NBI) only testified as
to the possible cause of death but did not venture to
illuminate the court on the matter of the standard of
care that petitioner should have exercised. Expert
testimony should have been offered to prove that
the circumstances cited by the courts below are
constitutive of conduct falling below the standard of
care employed by other physicians in good standing
when performing the same operation. It must be
remembered that when the qualifications of a
physician are admitted, as in the instant case, there is
an inevitable presumption that in proper cases he
takes the necessary precaution and employs the best
of his knowledge and skill in attending to his clients,
unless the contrary is sufficiently established. This
presumption is rebuttable by expert opinion which is
so sadly lacking in the case at bench.
- 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
there is connection of such breach and the resulting death of
his patient. It is significant to state at this juncture that
the autopsy conducted by Dr. Arizala on the body of
physical 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.
- This Court has no recourse but to rely on the expert
testimonies rendered by both prosecution and
defense witnesses that substantiate rather than
contradict petitioner's allegation that thecause of
Lydia's death was DIC which, as attested to by an
was expert witness, cannot be attributed to the
petitioner's fault or negligence. The probability that
Lydia's death was caused by DIC was unrebutted
during trial and has engendered in the mind of this
reckless Court a reasonable doubt as to the petitioner's guilt.
Thus, her acquittal of the crime of reckless
imprudence resulting in homicide, but this Court finds
the petitioner civilly liable for the death of Lydia
Umali, for while a conviction of a crime requires proof
beyond reasonable doubt, only a preponderance of
evidence is required to establish civil liability.
similar DISPOSITIVE: WHEREFORE, premises considered,
petitioner DR. NINEVETCH CRUZ is hereby ACQUITTED
of the crime of reckless imprudence resulting in
homicide but is ordered to pay the heirs of the
deceased Lydia Umali the amount of FIFTY
THOUSAND PESOS (P50,000.00) as civil liability, ONE
HUNDRED THOUSAND PESOS (P100,000.00) as moral
damages, and FIFTY THOUSAND PESOS (P50,000.00) as
exemplary damage
4.1.5.Reyes v. Sisters of Mercy Hospital, supra.
4.1.6.Ramos v. CA, G.R. No. 124354. April 11, 2002)
RAMOS v. CA
Digest adapted from: B2015

FACTS:
1. Erlinda Ramos, 47 years old, has occasional
complaints of discomfort due to pains allegedly
caused by the presence of a stone in her gall
bladder. Since these discomforts interfered with her
normal ways, she sought professional advice. She
was advised to undergo an operation for the
removal of the gall stone.
2. Erlinda and her husband Rogelio met for the first time
with Dr. Orlino Hosaka. They agreed on a date and
time (9am) at the operating room of De Los Santos
Medical Clinic (DLSMC). Erlinda is to undergo a
cholecystectomy operation after Dr. Hosaka
examined the documents presented to him. Rogelio
asked Dr. Hosaka to look for a good anesthesiologist.
Dr. Hosaka assured Rogelio that he will provide the
same.
3. On the day of the operation, she was prepped for
surgery and was transported to the operating room.
Her sister-in-law, Herminda Cruz, Dean of the College
of Nursing at the Capitol Medical Center, decided to
be with her during the operation for moral support.
4. However, Dr. Hosaka did not arrive at the time of
operation (9am). Instead, he arrived at the hospital
at past 12nn.
5. Upon arrival of Dr. Hosaka, Dr. Perfecta Gutierrez, the
assigned anesthesiologist, started to intubate Erlinda.
Herminda heard Dr. Gutierrez remark that she has
difficulty in intubating the patient. Herminda then
noticed that the nail beds of Erlinda was turning blue.
6. Dr. Hosaka then issued an order for someone to call
Dr. Calderon, another anesthesiologist, to take over.
Erlinda was then placed in a trendelenburg position
(an indication that there is a decrease of blood
supply to the patients brain) and then Erlinda was
intubated.
7. At almost 3pm, Erlinda was taken to the ICU. Since
that afternoon, Erlinda has been in a comatose
condition since she suffered brain damage as a result
of the absence of oxygen in her brain for 4-5 minutes.
She was discharged after 4 months but is in constant
need of medical attention. She was also diagnosed
with diffuse cerebral parenchymal damage.
8. The Spouses Ramos and their children filed a civil
case for damages against DLSMC, Dr. Hosaka, and
Dr. Gutierrez, alleging negligence in the
management and care of Erlinda.
9. During trial, both parties presented evidence as to
the possible cause of Erlindas injury.
10. The plaintiffs presented testimonies of Dean Herminda
and Dr. Gavino to prove that damage sustained by
Erlinda was due to the lack of oxygen in her brain
caused by the faulty management of her airway by
the defendants during the anesthesia phase.
11. The defendants relied on the expert testimony of Dr.
Jamora, pulmonologist, to the effect that the cause
of brain damage was Erlindas allergic reaction to
the anesthetic agent.
RTC Decision:
It found in favor of the Ramoses. It held that the
defendants are liable for damages and were
guilty, at the very least, of negligence in the
performance of their duty to Erlinda.
Dr. Gutierrez was negligent for omitting to
exercise reasonable care in not only intubating
the patient but also in not repeating the
administration of atropine considering that
Erlinda was in the operating room for almost 3
hours. Because of her failure to intubate, Erlinda
suffered brain damage.
Dr. Hosaka is liable for the acts of Dr. Gutierrez
whom he had chosen to administer anesthesia as
part of his obligation to provide the patient a
good anesthesiologist and for arriving at the
scheduled operation, 3 hours late.
DLSMC is liable for the acts of negligence of the
doctors in their practice of medicine in the
operating room. It is liable for failing through its
responsible officials to cancel the operation after
Dr. Hosakas delay.
It rejected the contention that defendants acted
with due care and prudence. If they did, then
the patient would have been intubated on time
at would not have been in comatose and suffer
brain damage. They should have rescheduled
the operation.
CA Decision: It reversed the RTC decision and ordered
the dismissal of the complaint.
Issue: WON the CA erred in not applying res ipsa loquitur
and not finding the defendants negligent.
Held: YES
Courts discussion on Res Ipsa Loquitur
1. RIL The thing or the transaction speaks for itself
Maxim for the rule that the fact of the
occurrence of an injury, taken with the
surrounding circumstances, may permit an
inference or raise a presumption of negligence or
make out a plaintiffs prima facie case, and
present a question of fact for the defendant to
meet with an explanation
Where the thing which caused injury is shown to
be under the management of the defendant or
his servants, and the accident is such as in
ordinary course of things does not happen if
those who have its management or control use
proper care, it affords reasonable evidence, in
the absence of explanation by defendant, that
the accident arose from or was caused by
defendants want of care
It is grounded on the superior logic of ordinary
human experience and on the basis of such,
negligence may be deduced from the mere
occurrence of the accident itself
2. It is considered as merely evidentiary or a mode
of proof
It furnishes a substitute for, and relieves the
plaintiff of, the burden of producing specific
proof of negligence
Mere invocation and application of res ipsa does
not dispense with the requirement of proof of
negligence
1. It is simply a step in the process of such
proof
 2. Permitting the plaintiff to present, along
with the proof of the accident, enough of
the attending circumstances to invoke the
doctrine
3. Thereby placing on the defendant the
burden of going forward with the proof
3. But before RIL may be allowed, the following
requisites must be met: (in addition to proving
injury or damage)
The accident is of a kind which ordinarily does
not occur in the absence of someones
negligence
It is caused by an instrumentality within the
exclusive control of the defendant
The possibility of contributing conduct which
would make plaintiff responsible is eliminated
4. Fundamental element: Control of the
instrumentality which caused the damage
A. Must be shown to be within the dominion
of the defendant
5. Res ipsa in Medical Malpractice
Generally: expert 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
Exception: when doctrine of res ipsa is availed,
need for medical testimony is dispensed with
because the injury itself is the proof of negligence
1. Reason: general rule on necessity of expert
testimony only applies to matters clearly
within the domain of medical science, and
not to matters that are within the common
knowledge
In cases where res ipsa is applicable, court is
permitted to find a physician negligent upon
proper proof of injury to patient, without expert
testimony, where court from its fund of common
knowledge can determine the proper standard
of care
1. If common knowledge dictates that a
resulting injury would not have occurred if
due care had been exercised, inference of
negligence may be drawn
2. When res ipsa is appropriate, all the patient
needs to do is to prove a nexus between the
particular act or omission complained and
the injury sustained while under
management and control of defendant
without need to produce expert testimony in
establishing the standard of care
But res ipsa does not automatically apply to all
cases of malpractice
1. It is restricted to situations where
laymen are 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
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 customary professional activity
in such operations, which, if unexplained would
themselves reasonably speak to the average
man as the negligent cause or causes of the
untoward consequence.
If there was such extraneous interventions, res
ipsa may be utilized
Res ipsa is applicable in the case at bar.
On the merits of the case
1. Res ipsa applies in this case considering the following
circumstances:
Erlinda submitted herself for operation and
expected a routine general surgery to be
performed
She delivered her person over to the care and
custody and control of the defendants who
exercised complete and exclusive control over
her
Erlinda was neurologically sound and physically
fit, except for a few discomforts
During the anesthesia she suffered irreparable
damage to her brain
Without undergoing surgery, she went out of the
OR already decerebrate and totally
incapacitated
Brain damage is an injury which does not
normally occur in the process of a gall stone
removal
This situation does not happen in the absence of
negligence of someone in the administration of
anesthesia and in the use of tubing
The instruments used were all under the control of
the respondents
Erlinda could not be guilty of contributory
negligence because she was under anesthetics
2. From the facts and circumstances, it can be said, as
a matter of common knowledge and observation, if
negligence attended the management and care of
the patient
Note that there was no operation or treatment
that was performed on Erlinda
Respondents failed to disprove the presumption
of negligence
3. Dr. Gutierrez was negligent in the care of Erlinda
during the anesthesia phase for failing to properly
intubate the patient
CA disbelieved Hermindas testimony on the
ground that being a nurse, she is not competent
to testify on whether the intubation was a
success
1. Although Herminda is not an
anesthesiologist, she is allowed in res
ipsa where testimony of expert
witnesses is not required
a. Expert testimony is not necessary
for the proof of negligence in
non-technical matters or those
which an ordinary person may
be expected to have
knowledge
 b. Anesthesia procedures are so
common that even an ordinary
person can tell if it was
administered properly
2. Besides, Herminda is a very capable
nurse with extensive clinical experience
3. Her testimony was even affirmed by
Guttierez herself
Gutierrez makes a defense that she encountered
hardship in the insertion because of the physical
attributes of Erlinda
1. Respondents adduced no evidence
demonstrating that they proceeded to
make a thorough assessment of Erlindas
airway prior to the anesthesia
2. There was no pre-operative examination to
ascertain the condition of the patient to
avoid anesthesia-related complications
3. This was a clear indicia of her negligence
Dr. Jamora cannot be considered an authority in
the field of anesthesiology simply because he is
not an anesthesiologist. His testimony cannot be
given that much weight
4. It was the faulty intubation which was the proximate
cause of Erlindas comatose condition
The faulty intubation triggered the chain of
events leading to Erlindas brain damage
Respondents themselves admitted that the first
intubation was a failure
Having failed to observe common medical
standards in pre-operative management and
intubation, Gutierrezs negligence resulted in the
brain damage and coma of Erlinda
5. Dr. Hosaka is also negligent
Failure to exercise proper authority as head of
the surgical team in not determining if his
anesthesiologist observed proper protocols
No evidence on record exists to show that
Hosaka verified if Gutierrez properly intubated
the patient
He also had a surgery on the same date and
time in another hospital which was why he was
late for 3 hours
As such, he had little or no time to confer with the
anesthesiologist
He was remiss in his professional duties
He shares equal responsibility
6. The hospital should also be solidarily liable
Hospitals exercise significant control in the hiring
and firing of consultants and in the conduct of
their work within hospital premises
For the purpose of allocating responsibility in
medical negligence cases, an employer-
employee relationship exists between hospitals
and their attending and visiting physicians
Basis for liability: Art 2180
1. It failed to discharge the burden of proof; it
merely offered general denials of its
responsibility
2. No evidence to show that it complied with the
degree of diligence in the supervision and
selection of its employees
7. Respondents solidarily liable for damages.
4.2. BREACH OF DUTY
4.2.1.NEGLIGENCE PER SE DOCTRINE
4.2.1.1. Anonuevo v. Court of Appeals, G.R. No. 130003,
October 20, 2004
JONAS AONUEVO vs. HON. COURT OF APPEALS and
JEROME VILLAGRACIA
Facts:
The accident in question occurred on 8 February
1989, at around 9pm, at the intersection of Boni
Avenue and Barangka Drive in Mandaluyong,
Villagracia was traveling along Boni Avenue on his
bicycle, while Aonuevo, traversing the opposite
lane was driving his Lancer car, which is owned by
Procter and Gamble Inc., the employer of his brother,
Jonathan. Aonuevo was about to turn left towards
Libertad Street when the collision occurred.
Villagracia sustained serious injuries as a result, which
necessitated his hospitalization several times, and
forced him to undergo 4 operations.
Villagracia instituted an action for damages against
Procter and Gamble Phils., Inc. and Aonuevo
before the RTC. He had also filed a criminal
complaint against Aonuevo before the MTC of
Mandaluyong, but the latter was subsequently
acquitted of the criminal charge. RTC rendered
judgment against Procter and Gamble and
Aonuevo, ordering them to pay Villagracia the
amounts of P150,000 for actual damages, P10,000 for
moral damages, and P20,000.00 for attorneys fees, as
well as legal costs.
Both defendants appealed to the Court of Appeals.
CA affirmed the RTC decision, together with the ff
findings:
1. Aonuevos vehicle had struck Villagracia;
2. Aonuevos vehicle had actually hit Villagracias
left mid-thigh, thus causing a comminuted
fracture;
3. As testified by eyewitness Alfredo Sorsano, witness
for Villagracia, Aonuevo was speeding as he
made the left turn into Libertad;
4. Considering Aonuevos claim that a passenger
jeepney was obstructing his path as he made the
turn, Aonuevo had enough warning to control
his speed;
5. Aonuevo failed to exercise the ordinary
precaution, care and diligence required of him in
order that the accident could have been
avoided
6. Aonuevo before the CA, did not dispute the
findings of tortious conduct on his part made by
 the lower courts, hinging his appeal instead on
the alleged negligence of cyclist Villagracia.
ISSUE:
1. WON Article 2185 of the New Civil Code should apply
by analogy to non-motorized vehicles - NO
2. WON Villagracias own negligence serves to absolve
Aonuevo of any liability for damages - NO
RATIO:
1. ART 2185 ONLY COVERS MOTORIZED VEHICLES. THUS,
NO PRESUMPTION OF NEGLIGENCE
Aonuevo posits that Article 2185 of the New Civil
Code applies by analogy. The provision reads:
Article 2185. Unless there is proof to the contrary,
it is presumed that a person driving a motor
vehicle has been negligent if at the time of the
mishap he was violating any traffic regulation.
He points out that modern-day travel is more
complex now than when the Code was enacted, the
number and types of vehicles now in use far more
numerous than as of then. He even suggests that at
the time of the enactment of the Code, the
legislators must have seen that only motor vehicles
were of such public concern that they had to be
specifically mentioned, yet today, the interaction of
vehicles of all types and nature has inescapably
become matter of public concern so as to expand
the application of the law to be more responsive to
the times.
What Aonuevo seeks is for the Court to amend the
explicit command of the legislature, as embodied in
Article 2185, a task beyond the pale of judicial
power. The Court interprets and not creates the law.
At the time Article 2185 was formulated, there existed
a whole array of non-motorized vehicles ranging from
human-powered contraptions on wheels such as
bicycles, scooters, and animal-drawn carts such
as calesas and carromata. These modes of transport
were even more prevalent on the roads of the 1940s
and 1950s than they are today, yet the framers of the
New Civil Code chose then to exclude these
alternative modes from the scope of Article 2185 with
the use of the term motorized vehicles. The ratio of
motorized vehicles as to non-motorized vehicles, as it
stood in 1950, was significantly lower than as it stands
today. Aonuevos characterization of a vibrant intra-
road dynamic between motorized and non-
motorized vehicles is more apropos to the past than
to the present.
The more pertinent basis for the segregate
classification is the difference in type of these
vehicles. A motorized vehicle operates by reason of a
motor engine unlike a non-motorized vehicle, which
runs as a result of a direct exertion by man or beast of
burden of direct physical force. A motorized vehicle,
unimpeded by the limitations in physical exertion, is
capable of greater speeds and acceleration than
non-motorized vehicles. At the same time, motorized
vehicles are more capable in inflicting greater injury
or damage in the event of an accident or collision.
This is due to a combination of factors peculiar to the
motor vehicle, such as the greater speed, its relative
greater bulk of mass, and greater combustability due
to the fuels that they use.
o The machine is capable of greater
destruction, and furthermore, it is absolutely
under the power and control of the driver;
whereas, a horse or other animal can and
does to some extent aid in averting an
accident. It is not pleasant to be obliged to
slow down automobiles to accommodate
persons riding, driving, or walking. It is
probably more agreeable to send the
machine along and let the horse or person
get out of the way in the best manner
possible; but it is well to understand, if this
course is adopted and an accident occurs,
that the automobile driver will be called
upon to account for his acts.
o An automobile driver must at all times use all
the care and caution which a careful and
prudent driver would have exercised under
the circumstances.
o American jurisprudence: Motorists are
required to exercise ordinary or reasonable
care to avoid collision with bicyclists. While
the duty of using ordinary care falls alike on
the motorist and the rider or driver of a
bicycle, it is obvious that more is required
from the former to fully discharge the duty
than from the latter.
Art. 2185 was not formulated to compel or ensure
obeisance by all to traffic rules and regulations. If
such were indeed the evil sought to be remedied or
guarded against, then the framers of the Code
would have included non-motorized vehicles or for
that matter, pedestrians.
The fact that there has long existed a higher degree
of diligence and care imposed on motorized
vehicles, arising from the special nature of motor
vehicle, leads to the inescapable conclusion that the
qualification under Article 2185 exists precisely to
recognize such higher standard. Simply put, the
standards applicable to motor vehicle are not on
equal footing with other types of vehicles.
2. THERE IS NEGLIGENCE PER SE BUT NO CONTRIBUTORY
NEGLIGENCE
Aonuevo points out that Villagracias bicycle had
no safety gadgets such as a horn or bell, or
headlights, as invoked by a 1948 municipal
ordinance. Nor was it duly registered with the Office
of the Municipal Treasurer, as required by the same
ordinance. Finally, as admitted by Villagracia, his
bicycle did not have foot brakes.
The Civil Code characterizes negligence as the
omission of that diligence which is required by the
 nature of the obligation and corresponds with the
circumstances of the persons, of the time and of the
place. However, the existence of negligence in a
given case is not determined by the personal
judgment of the actor in a given situation, but rather,
it is the law which determines what would be reckless
or negligent.
The generally accepted view is that the violation of a
statutory duty constitutes negligence, negligence as
a matter of law, or negligence per se. The mere fact
of violation of a statute is not sufficient basis for an
inference that such violation was the proximate
cause of the injury complained. However, if the very
injury has happened which was intended to be
prevented by the statute, it has been held that
violation of the statute will be deemed to be the
proximate cause of the injury.
Non-observance of what the legislature has
prescribed as a suitable precaution is failure to
observe that care which an ordinarily prudent man
would observe, and, when the state regards certain
acts as so liable to injure others as to justify their
absolute prohibition, doing the forbidden act is a
breach of duty with respect to those who may be
injured thereby; or, as it has been otherwise
expressed, when the standard of care is fixed by law,
failure to conform to such standard is negligence,
negligence per se or negligence in and of itself, in
the absence of a legal excuse. It is immaterial, where
a statute has been violated, whether the act or
omission constituting such violation would have been
regarded as negligence in the absence of any
statute on the subject or whether there was, as a
matter of fact, any reason to anticipate that injury
would result from such violation.
The existence of an ordinance changes the situation.
If a driver causes an accident by exceeding the
speed limit, for example, we do not inquire whether
his prohibited conduct was unreasonably dangerous.
It is enough that it was prohibited. Violation of an
ordinance intended to promote safety is negligence.
The test is to be found not in the number of
intervening events or agents, but in their character
and in the natural and probable connection
between the wrong done and the injurious
consequence. The general principle is that the
violation of a statute or ordinance is not rendered
remote as the cause of an injury by the intervention
of another agency if the occurrence of the accident,
in the manner in which it happened, was the very
thing which the statute or ordinance was intended to
prevent.
The statutory purpose for requiring bicycles to be
equipped with headlights or horns is to promote road
safety and to minimize the occurrence of road
accidents involving bicycles. At face value,
Villagracias mishap was precisely the danger sought
to be guarded against by the ordinance he violated.
There is the fact that Aonuevo was speeding as he
made the left turn, and such negligent act was the
proximate cause of the accident. This reckless
behavior would have imperiled anyone unlucky
enough within the path of Anonuevos car as it turned
into the intersection. Villagracia would have avoided
injury had his bicycle been up to par with safety
regulations, especially considering that Anonuevo
was already speeding as he made the turn, or before
he had seen Villagracia. Even assuming that
Anonuevo had failed to see Villagracia because the
bicycle was not equipped with headlights, such lapse
on the cyclists part would not have acquitted the
driver of his duty to slow down as he proceeded to
make the left turn.
The bare fact that Villagracia was violating a
municipal ordinance at the time of the accident may
have sufficiently established some degree of
negligence on his part, but such negligence is
without legal consequence unless it is shown that it
was a contributing cause of the injury.
The rule on negligence per se must admit
qualifications that may arise from the logical
consequences of the facts leading to the mishap.
The doctrine (and Article 2185, for that matter) seeks
to impute culpability arising from the failure of the
actor to perform up to a standard established by a
legal fiat. But the doctrine should not be rendered
inflexible so as to deny relief when in fact there is no
causal relation between the statutory violation and
the injury sustained.
Presumptions in law, while convenient, are not
intractable so as to forbid rebuttal rooted in fact.
After all, tort law is remunerative in spirit, aiming to
provide compensation for the harm suffered by those
whose interests have been invaded owing to the
conduct of others
In the absence of statutory requirement, one is not
negligent as a matter of law for failing to equip a
horn, bell, or other warning devise onto a bicycle. In
most cases, the absence of proper lights on a bicycle
does not constitute negligence as a matter of law
but is a question for the jury whether the absence of
proper lights played a causal part in producing a
collision with a motorist. The absence of proper lights
on a bicycle at night, as required by statute or
ordinance, may constitute negligence barring or
diminishing recovery if the bicyclist is struck by a
motorist as long as the absence of such lights was a
proximate cause of the collision; however, the
absence of such lights will not preclude or diminish
recovery if the scene of the accident was well
illuminated by street lights, if substitute lights were
present which clearly rendered the bicyclist visible, if
the motorist saw the bicycle in spite of the absence
of lights thereon, or if the motorist would have been
unable to see the bicycle even if it had been
equipped with lights. A bicycle equipped with
defective or ineffective brakes may support a finding
of negligence barring or diminishing recovery by an
injured bicyclist where such condition was a
contributing cause of the accident.
On this point, the findings of the Court of Appeals are
well-worth citing:
 [As] admitted by appellant Anonuevo, he first saw
appellee Villagracia at a distance of about ten (10)
meters before the accident. Corrolarily, therefore, he
could have avoided the accident had he [stopped]
alongside with an earlier (sic) jeep which was already
at a full stop giving way to appellee. But according
to [eyewitness] Sorsano, he saw appellant Anonuevo
umaarangkada and hit the leg of Villagracia. This
earlier (sic) jeep at a full stop gave way to Villagracia
to proceed but Anonuevo at an unexpected motion
(umarangkada) came out hitting Villagracia.
Appellant Anonuevo admitted that he did not blow
his horn when he crossed Boni Avenue .
Had he been decelerating, as he should, as he made
the turn, Aonuevo would have had ample
opportunity to avoid hitting Villagracia. Moreover, the
fact that Aonuevo had sighted Villagracia before
the accident would negate any possibility that the
absence of lights on the bike contributed to the
cause of the accident.
Rakes v. Atlantic Gulf: Damages may be mitigated if
the claimant in conjunction with the occurrence,
[contributes] only to his injury. To hold a person as
having contributed to his injuries, it must be shown
that he performed an act that brought about his
injuries in disregard of warnings or signs of an
impending danger to health and body. To prove
contributory negligence, it is still necessary to
establish a causal link, although not proximate,
between the negligence of the party and the
succeeding injury. In a legal sense, negligence is
contributory only when it contributes proximately to
the injury, and not simply a condition for its
occurrence.
WHEREFORE, the Petition is DENIED. The Decision of the
Court of Appeals is AFFIRMED. Costs against petitioner.
4.2.1.2. Garcia, Jr., v. Salvador, G.R. No. 168512 , March
20, 2007
Garcia v. Salvador - Ynares- Santiago (2007)
Petitioner: Orlando Garcia, Jr.
Respondents: Ranida Salvador and Ramon Salvador
Topic: Negligence per se doctrine
Brief facts: Salvador underwent an HBs Ag test as part of
a physical examination for employment. During the first
test conducted by med tech Garcia, she was found to
be Reactive (suffering from Hep B) hence the Company
terminated her. Her father suffered a heart attack upon
hearing the news and was confined. Upon subsequent
tests, it was found out that Salvador was non-reactive.
The Company subsequently rehired her.
Doctrine: For health care providers, the test of the
existence of negligence is: did the health care provider
either fail to do something which a reasonably prudent
health care provider would have done, or that he or she
did something that a reasonably prudent health care
provider would not have done; and that failure or action
caused injury to the patient; if yes, then he is guilty of
negligence. Garcias failure to comply with the laws and
rules promulgated and issued for the protection of public
safety and interest is failure to observe that care which a
reasonably prudent health care provider would observe.
Thus, his act or omission constitutes a breach of duty.
FACTS:
1. October 1, 1993: Ranida D. Salvador started working as
a trainee in the Accounting Department of Limay Bulk
Handling Terminal, Inc. (the Company).
2. She underwent a medical examination at the
Community Diagnostic Center (CDC).
3. Garcia (med tech) conducted the HBs Ag test
4. CDC issued the test result indicating that Ranida was
HBs Ag: Reactive. The result bore the name and signature
of Garcia as examiner and the rubber stamp signature of
Castro as pathologist.
5. Dr. Sto. Domingo, the Company physician, apprised
her that the findings indicated that she is suffering from
Hepatitis B, a liver disease.
6. Thus, based on the medical report, the Company
terminated Ranidas employment for failing the physical
examination.
7. When Ranida informed her father, Ramon, he suffered
a heart attack and was confined at the Bataan Doctors
Hospital.
8. Ranida underwent another HBs Ag test at the said
hospital and the result indicated that she is non-reactive.
9. She informed Sto. Domingo of this development but
was told that the test conducted by CDC was more
reliable because it used the Micro-Elisa Method.
10. Ranida went back to CDC for confirmatory testing,
and this time, the Anti-HBs test conducted on her
indicated a Negative result.
11. Ranida also underwent another HBs Ag test at the
Bataan Doctors Hospital using the Micro-Elisa Method. The
result indicated that she was non-reactive.
12. Ranida submitted the test results from Bataan Doctors
Hospital and CDC to the Executive Officer of the
Company who requested her to undergo another similar
test before her re-employment would be considered.
13. CDC conducted another HBs Ag test on Ranida which
indicated a Negative result.
14. CDC issued a Certification correcting the initial result
and explaining that the examining medical technologist
(Garcia) interpreted the delayed reaction as positive or
reactive.
15. The Company rehired Ranida.
16. July 25, 1994: Ranida and Ramon filed a complaint for
damages against petitioner Garcia and Castro
17. Garcia denied the allegations of gross negligence
and incompetence and reiterated the scientific
explanation for the false positive result of the first HBs Ag
test in his December 7, 1993 letter to the respondents.
18. Castro claimed that as pathologist, he rarely went to
CDC and only when a case was referred to him; that he
did not examine Ranida; and that the test results bore
only his rubber-stamp signature.
19. RTC dismissed.
20. CA reversed and held Garcia liable. MR denied.
Hence, present petition.
ISSUE: WON Garcia is liable
RATIO:
- The issues raised are factual in nature. Whether a
person is negligent or not is a question of fact which SC
cannot pass upon in a petition for review on certiorari
which is limited to reviewing errors of law.
- Negligence is the failure to observe for the protection of
the interest of another person that degree of care,
precaution and vigilance which the circumstances justly
demand, whereby such other person suffers injury.
- For health care providers, the test of the existence of
negligence is: did the health care provider either fail to
do something which a reasonably prudent health care
provider would have done, or that he or she did
something that a reasonably prudent health care
provider would not have done; and that failure or action
caused injury to the patient; if yes, then he is guilty of
negligence.
- Thus, the elements of an actionable conduct are: 1)
duty, 2) breach, 3) injury, and 4) proximate causation. All
the elements are present in the case at bar.
- Owners and operators of clinical laboratories have the
duty to comply with statutes, as well as rules and
regulations, purposely promulgated to protect and
promote the health of the people by preventing the
operation of substandard, improperly managed and
inadequately supported clinical laboratories and by
improving the quality of performance of clinical
laboratory examinations. Their business is impressed with
public interest, as such, high standards of performance
are expected from them.
- Violation of a statutory duty is negligence. Where the
law imposes upon a person the duty to do something, his
omission or non-performance will render him liable to
whoever may be injured thereby.
- Section 2 of Republic Act (R.A.) No. 4688, otherwise
known as The Clinical Laboratory Law, provides:
Sec. 2. It shall be unlawful for any person to be
professionally in-charge of a registered clinical laboratory
unless he is a licensed physician duly qualified in
laboratory medicine and authorized by the Secretary of
Health, such authorization to be renewed annually.
No license shall be granted or renewed by the Secretary
of Health for the operation and maintenance of a clinical
laboratory unless such laboratory is under the
administration, direction and supervision of an authorized
physician, as provided for in the preceding paragraph.
- Sections 9(9.1)(1), 11 and 25(25.1)(1) of the DOH
Administrative Order No. 49-B Series of 1988, otherwise
known as the Revised Rules and Regulations Governing
the Registration, Operation and Maintenance of Clinical
Laboratories in the Philippines, read:
Sec. 9. Management of the Clinical Laboratory:
9.1 Head of the Clinical Laboratory: The head is that
person who assumes technical and administrative
supervision and control of the activities in the laboratory.
For all categories of clinical laboratories, the head shall
be a licensed physician certified by the Philippine Board
of Pathology in either Anatomic or Clinical Pathology or
both provided that:
(1) This shall be mandatory for all categories of free-
standing clinical laboratories; all tertiary category hospital
laboratories and for all secondary category hospital
laboratories located in areas with sufficient available
pathologist.
xxxx
Sec. 11. Reporting: All laboratory requests shall be
considered as consultations between the requesting
physician and pathologist of the laboratory. As such all
laboratory reports on various examinations of human
specimens shall be construed as consultation report and
shall bear the name of the pathologist or his associate.
No person in clinical laboratory shall issue a report, orally
or in writing, whole portions thereof without a directive
from the pathologist or his authorized associate and only
to the requesting physician or his authorized
representative except in emergencies when the results
may be released as authorized by the pathologist.
xxxx
Sec. 25. Violations:
25.1 The license to operate a clinical laboratory may be
suspended or revoked by the Undersecretary of Health
for Standards and Regulation upon violation of R.A. 4688
or the rules and regulations issued in pursuance thereto or
the commission of the following acts by the persons
owning or operating a clinical laboratory and the persons
under their authority.
(1) Operation of a Clinical Laboratory without a certified
pathologist or qualified licensed physician authorized by
the Undersecretary of Health or without employing a
registered medical technologist or a person not
registered as a medical technologist in such a position.
- Section 29(b) of R.A. No. 5527, otherwise known as The
Philippine Medical Technology Act of 1969, reads:
Section 29. Penal Provisions.- Without prejudice to the
provision of the Medical Act of 1959, as amended
relating to illegal practice of Medicine, the following shall
be punished by a fine of not less than two thousand
pesos nor more than five thousand pesos, or
imprisonment for not less than six months nor more than
two years, or both, in the discretion of the court:
xxxx
(b) Any medical technologist, even if duly registered, who
shall practice medical technology in the Philippines
without the necessary supervision of a qualified
pathologist or physician authorized by the Department of
Health;
- From the foregoing laws and rules, it is clear that a
clinical laboratory must be administered, directed and
supervised by a licensed physician authorized by the
Secretary of Health, like a pathologist who is specially
trained in methods of laboratory medicine; that the
medical technologist must be under the supervision of
the pathologist or a licensed physician; and that the
results of any examination may be released only to the
requesting physician or his authorized representative
upon the direction of the laboratory pathologist.
- SC: Garcia failed to comply with these standards.
- (1) First, CDC is not administered, directed and
supervised by a licensed physician as required by law,
but by Ma. Ruby C. Calderon, a licensed Medical
Technologist.
- Castros infrequent visit to the clinical laboratory barely
qualifies as an effective administrative supervision and
control over the activities in the laboratory. Supervision
and control means the authority to act directly whenever
a specific function is entrusted by law or regulation to a
subordinate; direct the performance of duty; restrain the
commission of acts; review, approve, revise or modify
acts and decisions of subordinate officials or units.
- (2) Second, Garcia conducted the HBsAG test of
respondent Ranida without the supervision of defendant-
appellee Castro,
- (3) Last, the disputed HBsAG test result was released to
respondent Ranida without the authorization of
defendant-appellee Castro.
- Garcia may not have intended to cause the
consequences which followed after the release of the
HBsAG test result. However, his failure to comply with the
laws and rules promulgated and issued for the protection
of public safety and interest is failure to observe that care
which a reasonably prudent health care provider would
observe. Thus, his act or omission constitutes a breach of
duty.
- Ranida suffered injury as a direct consequence of
Garcias failure to comply with the mandate of the laws
and rules aforequoted.
- Article 20 of the New Civil Code provides the legal basis
for the award of damages to a party who suffers
damage whenever one commits an act in violation of
some legal provision.
- Court of Appeals award of moral damages reasonable
under the circumstances bearing in mind the mental
trauma suffered by respondent Ranida who thought she
was afflicted by Hepatitis B, making her unfit or unsafe for
any type of employment.
DISPOSITIVE: CA decision affirmed. Garcia is guilty of gross
negligence and liable to bay damages.
4.2.1.3. Professional Services, Inc. v. Agana, GR No.
126927, Jan. 31, 2007
Professional Services v. Agana (2007)
Petitioner-Defendant: Professional Services Inc. (PSI)
Respondents-Plaintiff: Natividad and Enrique Agana
Concept: Basic Elements of Torts; Specific Cases
FACTS:
1. Natividad was rushed to the Medical City General
Hospital, as she was complaining of difficulty in bowel
movement and the presence of blood in her anal
discharge.
2. Dr. Miguel Ampil, after a series of medical
examinations, diagnosed her to be suffering from
cancer of the sigmoid. He later performed an
anterior resection surgery on Natividad and found
that the malignancy in her sigmoid area had spread
to her ovaries, requiring its removal via a
hysterectomy. Dr. Ampil acquired Enriques
(Natividads spouse) consent for him and Dr. Fuentes
to perform the procedure.
3. Apr 11, 1984: Dr. Fuentes first performed the
hysterectomy and then left the operation to be
continued and finished by Dr. Ampil. However, the
surgery did not end well as there were two sponges
that were left inside the body of Natividad. Both were
not found even after a search was conducted. The
surgery was concluded without their removal. This
fact was recorded by the nurses in the Record of
Operation.
4. Apr 24, 1984: Natividad was released from the
hospital. The medical bills amounted to P60,000.
5. However, after a couple of days, Natividad
complained of immense pain from her anal region
and consulted the two doctors. They told her it was a
natural consequence of the procedure. Dr. Ampil
further recommended that she see an oncologist
about the remaining cancerous nodes that were not
removed during her operation.
6. May 1984: Natividad and Enrique flew to the US for
further treatment. For four months, she underwent
examinations and consultations. She was told that
she was cancer-free and recommended her to go
back home.
7. August 1984: Natividad flew back home but was still
suffering from pains. Two weeks later, her daughter
found a piece of the sponge/gauze protruding from
her vagina. Dr. Ampil proceeded to her house and
removed it by hand. The gauze had a width of 1.5
inches. After this, he assured her that the pain would
vanish.
8. On the contrary, the pains intensified, forcing
Natividad to go to Polymedic General Hospital. Dr.
Ramon Gutierrez, the attending physician there,
detected another foreign object in her vagina: the
second sponge/gauze which badly infected her
vaginal vault, forming a recto-vaginal fistula in her
reproductive organs. Surgery was again required to
repair the damage, which Natividad underwent in
Oct 1984.
9. Nov 1984: Natividad and her spouse filed a complaint
for damages against PSI, Dr. Ampil and Dr. Fuentes.
They alleged that they were liable for negligence (for
leaving the two pieces of gauze inside Natividads
body) and for malpractice (for concealing this fact
against her).
Natividad also filed a complaint against the two
doctors in the Professional Regulation
Commission for gross negligence and
malpractice. However, only the case against Dr.
Fuentes proceeded as they were not able to
acquire jurisdiction over Dr. Ampil, who was in the
US at the time.
10. Pending the resolution of the cases, Natividad passed
away. She was substituted by her children.
RTC: Petitioner-defendants liable. Actual damages
($19,900 + P4,800 + P45,802), moral damages (P2 million),
exemplary damages (P300k) and attorneys fees (P250k)
were awarded, with legal interest.
The petitioner defendants appealed the RTC
decision.
Meanwhile, the Aganas filed for a motion for a partial
execution of the RTC decision, which the court
granted. The sheriff, in pursuance of the motion,
levied upon certain properties of Dr. Ampil and gave
the proceeds (P450k) to the Aganas.
After they received the money, the Aganas, and PSI
and Dr. Fuentes entered into an agreement to
suspend the execution of the RTC Decision. However,
not long after, the Aganas again filed for a motion for
execution of the RTC decision.
As a result, Dr. Fuentes filed with the CA a petition for
certiorari and prohibition, with a prayer for preliminary
 injunction. The CA later granted the prayer for
injunctive relief. The petition was consolidated with
the earlier appeal.
PRC: Case against Dr. Fuentes dismissed; prosecution was
unable to show that it was Dr. Fuentes who left the 2
pieces of gauze in Natividads body.
CA: PSI and Dr. Ampil liable while Dr. Fuentes is not liable.
The CA held that (a) PSI was vicariously liable for Dr.
Ampil and is estopped from raising the defense that
he is not their employee, (b) it is solidarily liable with
Dr. Ampil, and (c) PSI was not entitled counterclaim
against the Aganas.
Dr. Ampil filed for a motion for reconsideration but
was denied by the CA.
Thus the parties appealed:
o PSI: contended that Dr. Ampil was only an
independent contractor and hence, should be
held liable alone.
o Aganas: CA erred in absolving Dr. Fuentes,
invoking the res ipsa loquitur; the finding of the
pieces of gauze are prima facie proof that they
had been negligent
o Dr. Ampil: contended that he should not be held
liable for the finding of the pieces of gauze since
there could have been other probable causes:
(a) it was Dr. Fuentes who used the gauzes, (b)
the nurses failed to properly count the gauzes
used, and (c) it was the medical intervention of
the doctors in the US that caused it
ISSUE/S:
1. WON the CA erred in holding Dr. Ampil liable (NO)
2. WON the CA erred in absolving Dr. Fuentes of any
liability (NO)
3. WON PSI may be held solidarily liable with Dr. Ampil
(YES)
RATIO:
1. CA was correct; Dr. Ampil is liable
The arguments of Dr. Ampil are purely conjecture
and without factual basis. Moreover, he did not
submit any evidence as to the truthfulness of these
claims.
The fact is that Dr. Ampil finished the surgery without
the removal of the sponges/gauzes
o An operation that requires placing of the
sponges in the incision is not complete until they
have been removed, and it has been settled that
leaving them and other foreign substances in the
wound after the incision has been closed is at
least prima facie negligence by the operating
surgeon. Some legal authorities even consider
this as negligence per se.
o The Court recognizes that Dr. Ampil might have
been forced by the circumstances to finish the
surgeries without removing the gauzes. However,
this created an obligation for him to inform the
patient and to advise her of what should be
done to relieve the effects of such foreign
substance being in her body.
o However, Dr. Ampil did NOT inform Natividad
about the gauzes. What was worse is that he
even tried to mislead her as to the pain she
experienced from the foreign substance in her
body. To the Court, what was initially a negligent
act became a deliberate act of deception; it is
now a clear case of medical negligence as all
elements were present:
Duty: Dr. Ampil had the duty to remove the
gauzes from Natividads body
Breach: Dr. Ampil failed in removing the
gauzes
Injury: Natividad felt pain and required
further expense to remedy the problem
Proximate Cause: Natividads injury can be
traced back to Dr. Ampils decision to close
the incision despite the gauzes still being
inside of Natividad
Moreover, Dr. Ampils concealment
aggravated the injury to Natividad and her
family.
2. CA was correct; Dr. Fuentes is not liable.
The Aganas argue that under the doctrine of res ipsa
loquitur, Dr. Fuentes is clearly liable.
Res ipsa loquitur = the thing speaks for itself
o The fact of the occurrence of the injury, taken
with the surrounding circumstances, may permit
an inference of raise a presumption of
negligence OR make out a plaintiffs prima facie
case and present a question of fact for
defendant to meet with an explanation.
o Requisites: (a) occurrence of an injury, (b) the
thing which caused the injury was under the
control and management of the defendant, (c)
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 (d) the absence of an
explanation by the defendant
Of the element, the most instrumental is the third one,
the control and management of the thing, which
caused the injury. This element the Court found
missing for Dr. Fuentes to be held liable.
While Dr. Fuentes performed the hysterectomy first,
Dr. Ampil took over and had the opportunity to
review his work, which he found satisfactory and
allowed Dr. Fuentes to leave the operating room. Dr.
Ampil then resumed the operation. He was about to
finish but then the matter of the gauzes came up. A
search was conducted but they were not found. Dr.
Ampil then decided to close up the incision, despite
that fact.
Under the Captain of the Ship rule, the operating
surgeon is the person in the complete charge of the
surgery room and all personnel connected with the
operation; their duty is to obey his orders.
o Dr. Ampil was the lead surgeon in this case.
o As he was the one who had control, Dr. Fuentes
could not be held liable.
o Furthermore, it was the directive of Dr. Ampil to
close up the incision despite the missing gauzes
that was determined to be the proximate cause
of the injury.
Obiter: Under our jurisdiction, res ipsa loquitur is not a
part of substantial law and does not confer a
separate ground for liability but is only a rule in
 evidence. Mere invocation and application of the
doctrine will not dispense with the requirement of
proof of negligence.
3. Yes, PSI is solidarily liable with Dr. Ampils negligence
Historically, hospitals were charitable institutions. But
over time, this charitable nature became more
business and profit-oriented.
o Along with this change was the increase in a
hospitals liability. Many courts now allow claims
for a hospitals vicarious liability through the
related doctrines of respondeat superior,
apparent authority, ostensible authority and
agency by estoppel
o In our jurisdiction, this is embodied in NCC Art.
2180, the rule governing vicarious liability, under
which owners are held liable for damage caused
by their employees.
Even then, professionals (such as doctors, dentists
and pharmacists) do not fall under the ambit of the
word employees in Art. 2180.
o This is under the traditional notion that the very
nature of the field of medicine is so complex that
physicians are generally free to exercise their
own skill and judgment without interference from
the hospital.
o This was upheld in the case of Schloendorff v.
Society of New York Hospital.
However, this doctrine was overturned in Bing v.
Thunig, now making applicable the doctrine of
respondeat superior to hospitals.
In our jurisdiction, Ramos v. CA is the controlling
doctrine. In that case, it is held that an employer-
employee relationship, in effect, exists between the
hospital and visiting physicians. As PSI is considered
the employer of Dr. Ampil, it is solidarily liable. Hence,
NCC Art. 2180 applies.
Apart from Ramos, PSIs liability also rests on the basis
of agency by estoppel and corporate negligence.
o Agency by estoppel: liability is imposed not as a
result of a contractual relation but rather
because of the actions of a principal/employer
in somehow misleading the public into believing
that the relationship or principals /employers
authority over the agent/employee exists.
As PSI publicly displayed that Dr. Ampil and
Dr. Fuentes was one of their accredited
physicians. It is now estopped from passing
the blame to both of them.
o Corporate negligence: in the context of hospital
liability, there are certain duties expected of
hospitalsto monitor and review the medical
services being provided within its walls.
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.
4. Obiter: Once a physician undertakes the treatment
and care of a patient, the law imposes on him
certain obligations. In order to escape liability, he
must possess that reasonable degree of learning, skill
and experience required by his profession. At the
same time, he must apply reasonable care and
diligence in the exercise of his skill and the
application of his knowledge and exert his best
judgment.
DISPOSITIVE: CA affirmed.
4.2.2.CAPTAIN OF THE SHIP
4.2.2.1. McConnel v. Williams, 361 Pa. 355, 65 A.2d 243,
246 (1949)
McConnell v. Williams Stern, J.
Plaintiff-Appellant: Mary Jo McConnell, minor, by Joseph
McConnell, guardian and Joseph McConnell in his own
right
Defendant-Appellee: Philip Williams
Topic: Captain of the Ship
Facts:
1. Mrs. McConnell consulted Williams in his professional
capacity and engaged him to attend to her during
pregnancy and deliver her expected child
Williams found that a caesarian operation would
be necessary, so suggested that it be performed
at the Jewish Hospital in Philadelphia, where he
was one of the chiefs of the OB staff
The said hospital is a nonprofit, charitable
institution
2. Williams requested one of the interns at the hospital
to attend on the following day to be his assistant
and to take care of the baby at the time of the
operation
Said intern would not be on duty, so another was
requested
3. On the day of the delivery (Dec. 4):
The following were present: Defendant and
patient, nurse attached to the hospital, nurse
privately engaged by Mrs. McConnell, and the
designated intern
Operation was difficult and the patient suffered
profuse hemorrhages which required the
surgeons complete attention
Once delivered, he turned it over to the intern for
the purpose of tying the cord and applying a
solution of silver nitrate to the infants eyes
o Silver nitrate requires careful dosage and
proper technique calls for the application of
only 1 or 2 drops followed by prompt
irrigation
o The purpose is to prevent the disease known
as ophthalmia neonatorum
According to Mrs. McConnels nurse, the intern
squirted once into the left eye, twice into the
right, putting into the latter a great many drops
and failed to irrigate the eyes for 5-10 minutes
The baby lost sight in her right eye completely,
which was so badly burned that it had to be
excised later
o It necessitated a plastic operation and the
substitution of a glass eye which she will have
to wear throughout her life
o The left eye was also severely and
permanently scarred
 Defendant-surgeon testified that the insertion of
the silver nitrate drops was not a job which
required any special skill
4. Suit in trespass filed by Joseph McConnell, on behalf
of his injured child, and in his own right, to recover
damages was brought against Williams on behalf of
the injured
5. TC: Court entered non-suit
6. Appealed by plaintiffs, contending that the case
should have been submitted to the jury
They do not charge Williams personally with
negligence and concede that he is an
obstetrician of high repute and the operation
was entirely satisfactory
However, there was a prima facie case of
negligence against the intern
Issue:
WON a relationship of agency existed between the intern
and the surgeon (Williams) OR WON the intern was, in
view of the law, the servant or employee of the
defendant [YES]
Note: If so, the court should not have entered a non-suit
Ratio: YES. A relationship of agency existed between the
intern and the surgeon and the former was a servant or
employee of the latter.
Applicable principles to the situation:
1) In determining whether a person is the servant of
another, the essential test is whether he is subject
to the latters control or right of control with
regard not only to the work to be done but also
to the manner of performing it. The true criterion
is the existence of power to control the
employee at the time of the commission of the
negligent act.
2) A servant directed or permitted by his master to
perform services for another may become the
servant of such other in performing the services;
he may become the others servants as to some
acts and not as to others. The important question
is not whether he remains the servant of the
general employer as to matters generally, but
whether, as to the specific transaction in
question, he is acting in the business of, and
under the direction of, the one or the other:
Where one person lends his servant to another for
a special employment the test is whether, in the
particular service he is engaged to perform, he
continues liable to the direction and control of his
master or becomes subject to that of the party to
whom he is lent or hired.
3) A person may be the servant of two masters, not
joint employers, at one time as to one act,
provided that the service to one does not involve
abandonment of the service to the other. Such is
the case where an employee is transferred to
carry on work which is of mutual interest to both
of two employers and to effect their common
purpose.
4) When different inferences can fairly be drawn
from the evidence as to who is the controlling
master of the borrowed employee at the time of
the commission of the negligent act, it is for the
jury, not the court, to determine the question of
agency.
Here, defendants obligation under his contract with
Mrs. McConnell included not only her prenatal care
and the delivery of her child, but also the care of the
latter until it was turned over to the family physician
o Here, help was necessary to take care of the
new-born infant and the necessity of employing
assistants is one of the ordinary circumstances of
life; it is to regulate such situations that the law of
agency exists
o In selecting a person to aid him, Williams was free
to make his own choice; he even testified that it
would not have been necessary to use any
licensed physician at all
o What he did was to call for and borrow from the
hospital an intern who became his temporary
servant ot employee for the purpose for which he
was engaged
Defendant had complete control of the operating
room and of every person within it while the
operation was in progress
o In the course of an operation in the operating
room of a hospital, and until the surgeon leaves
that room at the conclusion of the operation
(operation includes the tying of the cord and
the insertion of the silver nitrate in the infants
eyes), he is in the same complete charge of
those who are present and assisting him as is the
captain of a ship over all on board
o Such degree of protection is essential in view of
the high degree of protection to which an
anaesthetized, unconscious patient is entitled
this type of protection is one which Mrs.
McConnell could justly claim
If it is true that Williams had supervisory control and
the right to give orders to the intern, it would follow,
according to the classical test of agency, that a jury
would be justified in concluding that the temporary
relationship between defendant and the intern was
that of master and servant, and that consequently
defendant was legally liable for the harm caused by
any negligence on the part of the intern
o As stated by J. Maxey: Responsibility is
commensurate with authority
It is not a tenable argument that Williams should be
relieved from legal responsibility because the hospital
furnished the services of an intern and the facilities
o The difference is that the interns becoming
subject to Williams control, he became
responsible for the proper performance of the
intern of all acts done in subordination to such
control, whether defendant actually exercised it
or not
o As far as the evidence discloses, it was illiams
who assigned the intern to the task of inserting
the solution. Even if he was also serving the
hospital, it would not change the fact that a
borrowed employee may, in the performance of
a given act, be serving the interests of both his
general employer and his termporary master
o When nurses and interns provide treatment in the
regular course, they would be clearly acting on
behalf of the hospital and not as assistants to the
surgeon; but for the period of the operation, the
 situtation is entirely different, and if operating
surgeons were not to be held liable for the
negligent performance of the duties of those
then working under them, the law would fail to
afford a means of redress for preventable injuries
sustained during such operations
Cited Ybarra v. Spangard: the court stated that In
this connection, it should be noted that 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 him for
their negligent acts under the doctrine of respondeat
superior. Thus a surgeon has been held liable for the
negligence of an assisting nurse who leaves a sponge
or other object inside a patient, and the fact that the
duty of seeing that such mistakes do not occur is
delegated to others does not absolve the doctor
from responsibility for their negligence.
SC: The Court erred in entering a nonsuit. It is for the
jury to determine whether the relationship between
defendant and the intern, at the time the childs eyes
were injured, was that of master and servant.
o If such was the relationship, defendant is legally
liable for the injury caused by the interns alleged
negligence
o In determining whether the intern was
defendants servant at the time, the mere fact
that he was in the general employ of the hospital
would not prevent the jury from finding that he
was also at the same time the servant of the
defendant if he was then subject to his orders in
respect to the treatment of the childs eyes with
the silver nitrate solution
Disp: Order reversed and record remanded with a
procedendo.
4.2.2.2. Cantre v. Sps. Go, G.R. No. 160889, April 27, 2007
Cantre v. Spouses Go (2007)
Petitioner: Milagros Cantre
Respondent: Sps. John David and Nora Go
FACTS:
1. Petitioner Dr. Milagros L. Cantre is a specialist in
Obstetrics and Gynecology at the Dr. Jesus Delgado
Memorial Hospital. She was the attending physician
of respondent Nora S. Go, who was admitted at the
said hospital on April 19, 1992.
2. At 1:30 a.m. of April 20, 1992, Nora gave birth to her
fourth child, a baby boy.
3. However, at around 3:30 a.m., Nora suffered profuse
bleeding inside her womb due to some parts of the
placenta which were not completely expelled from
her womb after delivery.
4. Consequently, Nora suffered hypovolemic shock,
resulting in a drop in her blood pressure to 40 over 0.
5. 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.
6. While in the recovery room, her husband, respondent
John David Z. Go noticed a fresh gaping wound two
and a half (2 ) by three and a half (3 ) inches in the
inner portion of her left arm, close to the armpit.
7. He asked the nurses what caused the injury. He was
informed it was a burn. Forthwith, on April 22, 1992,
John David filed a request for investigation.
8. In response, Dr. Rainerio S. Abad, the medical
director of the hospital, called petitioner and the
assisting resident physician to explain what
happened. Petitioner said the blood pressure cuff
caused the injury.
9. John David brought Nora to the National Bureau of
Investigation 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.
10. Noras injury was referred to a plastic for skin grafting.
Her wound was covered with skin sourced from her
abdomen, which consequently bore a scar as well.
11. About a year after, on April 30, 1993, scar revision had
to be performed at the same hospital. The surgical
operation left a healed linear scar in Noras left arm
about three inches in length, the thickest portion
rising about one-fourth (1/4) of an inch from the
surface of the skin. The costs of the skin grafting and
the scar revision were shouldered by the hospital.
12. respondent spouses filed a complaint for damages
against petitioner, Dr. Abad, and the hospital.
13. Unfortunately, Noras arm would never be the same.
Aside from the unsightly mark, the pain in her left arm
remains. When sleeping, she has to cradle her
wounded arm. Her movements now are also
restricted. Her children cannot play with the left side
of her body as they might accidentally bump the
injured arm, which aches at the slightest touch.
14. RTC Ruled in favour of the spouses.
15. Appeal to CA, CA Affirmed RTC.
Petitioner:
Petitioner contends that additional documentary
exhibits not testified to by any witness are
inadmissible in evidence because they deprived
her of her constitutional right to confront the
witnesses against her.
Petitioner insists the droplight could not have
touched Noras body. She maintains the injury
was due to the constant taking of Noras blood
pressure.
Petitioner also insinuates the Court of Appeals
was misled by the testimony of the medico-legal
officer who never saw the original injury before
plastic surgery was performed.
Finally, petitioner stresses that plastic surgery was
not intended to restore respondents injury to its
 original state but rather to prevent further
complication.
Repondents:
the genuineness and due execution of the
additional documentary exhibits were duly
admitted by petitioners counsel.
Respondents point out that petitioners blood
pressure cuff theory is highly improbable, being
unprecedented in medical history and that the
injury was definitely caused by the droplight.
At any rate, they argue, even if the injury was
brought about by the blood pressure cuff,
petitioner was still negligent in her duties as Noras
attending physician.
ISSUE: 1. WON the documents are admissible as
evidence? YES
2. WON Dr. Is liable for the injury suffered by Nora Go?
YES [RELEVANT]
RATIO
1, Petitioners counsel admitted the existence of the same
when they were formally offered for admission by the trial
court. In any case, given the particular circumstances of
this case, a ruling on the negligence of petitioner may be
made based on the res ipsa loquitur doctrine even in the
absence of such additional exhibits. Also, record show
the medico legal attended to her before the revision.
2. The Hippocratic Oath mandates physicians to give
primordial consideration to the well-being of their
patients. If a doctor fails to live up to this precept, he is
accountable for his acts. This notwithstanding, courts
face a unique restraint in adjudicating medical
negligence cases because physicians are not guarantors
of care and, they never set out to intentionally cause
injury to their patients.
In cases involving medical negligence, the doctrine of res
ipsa loquitur allows the mere existence of an injury to
justify a presumption of negligence on the part of the
person who controls the instrument causing the injury,
provided that the following requisites concur:
1. The accident is of a kind which ordinarily does
not occur in the absence of someones
negligence;
2. It is caused by an instrumentality within the
exclusive control of the defendant or
defendants; and
3. The possibility of contributing conduct which
would make the plaintiff responsible is eliminated.
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.
Third, the gaping wound on Noras left arm, by its very
nature and considering her condition, could only be
caused by something external to her and outside her
control as she was unconscious while in hypovolemic
shock. Hence, Nora could not, by any stretch of the
imagination, have contributed to her own injury.
Petitioners defense that Noras wound was caused not by
the droplight but by the constant taking of her blood
pressure, even if the latter was necessary given her
condition, does not absolve her from liability. 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.
Further, petitioners argument that the failed plastic
surgery was not intended as a cosmetic procedure, but
rather as a measure to prevent complication does not
help her case. It does not negate negligence on her part.
DISPOSITIVE: WHEREFORE, the petition is DENIED. The
Decision dated October 3, 2002 and Resolution dated
November 19, 2003 of the Court of Appeals in CA-G.R.
CV No. 58184 are AFFIRMED.
4.2.2.3. Ramos v. CA, supra.
4.2.3.BORROWED SERVANT DOCTRINE
4.2.3.1. Davis . Glaze, 182 GA.APP. 18, 354 S.E.2D 845, 849
(1987)
4.2.3.2. Nogales v. Capitol Medical Center, G.R. NO.
142625, December 19, 2006
Nogales v. Capitol Medical Center (2006); Carpio, J.
Digest writer: Dodot
Petitioners: Rogelio P. Nogales, for himself and on behalf
of the minors, Roger Anthony, Angelica, Nancy, and
Michael Christopher, all surnamed Nogales
Respondents: Capital Medical Center, Dr. Oscar Estrada,
Dr. Ely Villaflor, Dr. Rosa Uy, Dr. Joel Enriquez, Dr. Perpetua
Lacson, Dr. Noe Espinola, and Nurse J. Dumlao
Concept: Borrowed Servant Doctrine
Brief Facts: Pregnant with her 4th child, C. Nogales was
admitted to CMC upon Dr. Estradas advice. However,
her delivery was plagued with acts constituting fault or
negligence, most glaringly, the use by Dr. Estrada of
forceps led to tearing in her cervix. This led to her losing a
lot of blood, and eventually she died. Her surviving
husband filed a complaint for damages before the RTC,
impleading Dr. Estrada, CMC, and several other doctors
and a nurse. The RTC found Dr. Estrada solely liable; it
held that CMC could not be held vicariously liable. This
was affirmed by the CA. The surviving husband filed a
petition for review before the SC asserting among others
that CMC should be held vicariously liable.
The SC partially granted the petition and allowed CMC to
be held vicariously liable. The basis was not the existence
of an ER-EE rel., rather, vicarious liability was based on the
Doctrine of Apparent Authority.
Doctrine: The borrowed servant doctrine: once the
surgeon enters the operating room and takes charge of
the proceedings, the acts/omissions of operating room
personnel, and any negligence associated with such acts
or omissions are IMPUTABLE TO THE SURGEON. Assisting
physicians and nurses employed by the hospital or
engaged by the patient normally become TEMPORARY
SERVANTS/AGENTS of the surgeon in charge while the
operation is in progress. 11.4.1.1. Liability may be imposed
upon the surgeon for their negligent acts, under
respondeat superior. [NOTE: used by the CA, not the SC.)
FACTS:
Antecedents
1. Corazon Nogales (C. NOGALES) was pregnant with
her 4th child.
1.1. She was 37 years old.
1.2. Beginning her 4th mo. of pregnancy *around
Dec 1975), she was under the exclusive prenatal
care of Dr. Oscar Estrada (DR. ESTRADA).
1.3. During her last trimester, Dr. Estrada noted an
increase in C. Nogales blood pressure and the
development of leg edema indicating
preeclampsia, a dangerous complication of
pregnancy.
2. 12mn, 25 May 1976: C. Nogales started to experience
mild labor pains together with her husband Rogelio
Nogales (NOGALES), she went to see Dr. Estrada at
his home.
2.1. Dr. Estrada advised her immediate admission to
the Capitol Medical Center (CMC)
3. 2:30a, 26 May 1976: Corazon was admitted at the
CMC.
3.1. Documents signed by Nogales upon the
admission of his wife:
3.1.1. Consent on Admission and Agreement;
and,
3.1.2. Admission Agreement.
3.2. C. Nogales was brought to the Labor Room.
4. Note who did what.
4.1. Dr. Rosa Uy (DR. UY), a resident physician:
conducted internal examination of C. Nogales.
[Alleged negligence: failure to notice the
incompetence and negligence of Dr. Estrada.]
4.1.1. She then called up Dr. Estrada to notify him
of her findings.
4.2. Dr. Estrada (around 3a): ordered for 10 mg. of
valium to be administered by intramuscular
injection.
4.2.1. He later ordered the intravenous
administration of syntocinon admixed with
dextrose, 5%, in lactated Ringers solution
(at 8 to 10 microdrops/min.).
4.3. Dr. Joel Enriquez (DR. ENRIQUEZ), an
anesthesiologist: stayed to observe C. Nogales
condition notwithstanding Dr. Estradas refusal
when asked if the services of an anesthesiologist
was needed. [Alleged negligence: not calling
the attention of Dr. Estrada, Dr. Villaflor, and
Nurse Dumlao on the alleged errors committed
by them.]
5. At the Delivery Room note who did what.
5.1. 6a: C. Nogales was transferred to Delivery Room
No. 1.
5.2. 6:10a: Her bag of water ruptured.
5.3. 6:12a: Her cervix was fully dilated.
5.4. 6:13a: She started to experience convulsions.
5.5. 6:15a, Dr. Estrada: ordered the injection of 10
grams of magnesium sulfate.
5.5.1. Dr. Ely Villaflor (DR. VILLAFLOR), who assisted
Dr. Estrada: only administered 2.5 grams.
[Alleged negligence: administering below
what was required.]
5.6. 6:22a, Dr. Estrada (assisted by Dr. Villaflor):
applied low forceps to extract the baby.
5.6.1. 1.0 x 2.5 cm. piece of cervical tissue was
allegedly torn.
5.6.2. The baby had to be intubated and
resuscitated by Drs. Enriquez and Payumo.
5.6.2.1. It had come out in an apnic,
cyanoric, weak, and injured
condition.
5.7. 6:27a: C. Nogales manifested moderate vaginal
bleeding rapidly became profuse.
5.7.1. Blood pressure dropped from 130/80 to
60/40 w/in 5 mins.
5.7.2. Nurse J. Dumlao (NURSE DUMLAO):
administered hemacel as a side drip to the
ongoing intravenous injection of dextrose.
[Alleged negligence: not injecting directly
through the veins.]
5.8. 7:45a, Dr. Estrada: ordered blood typing and
cross matching with bottled blood.
5.8.1. It took around 30 mins. for the CMC
Laboratory, headed by Dr. Perpetua
Lacson (DR. LACSON) to deliver the blood.
[Alleged negligence: late delivery of the
blood.]
5.9. 8a, Dr. Noe Espinola (DR. ESPINOLA), head of the
Ob-Gyn Dept.: apprised of Corazons condition
by telephone.
5.9.1. Dr. Espinola ordered immediate
hysterectomy based on information that
 C. Nogales was bleeding profusely.
5.9.1.1. Nogales made to sign, Consent to
Operation).
5.9.2. Fetched by ambulance, but encountering
inclement weather Dr. Espinola arrived at
CMC about an hour later, at 9a. [Alleged
negligence: arriving late; negligence
related to recommendation regarding
hysterectomy, based on information
communicated over the phone.]
5.9.2.1. He examined C. Nogales and
ordered some resuscitative measures
to be administered.
5.10. 9:15a: C. Nogales died cause of death:
hemorrhage, post partum.
The Case
6. 14 May 1980: Nogales, et al. filed a complaint for
damages with the RTC of Manila
6.1. Contentions:
6.1.1. Defendant physicians and CMC personnel:
negligent in the treatment and
management of Corazons condition.
6.1.2. CMC negligent in the selection and
supervision of the defendant physicians
and the hospital staff.
7. Pre-trial order: Nogales and CMC agreed that CMC
did NOT have any hand or participation in the
selection or hiring of Dr. Estrada or his assistant, Dr.
Villaflor, as attending physicians.
7.1. Thus, the 2 were NOT employees of the hospital;
the hospital did NOT have control over their
professional conduct.
8. RTC declared Dr. Estrada, Dr. Enriquez, and Nurse
Dumlao in Default.
8.1. Only CMC, Dr. Villaflor, Dr. Uy, Dr. Espinola, and
Dr. Lacson filed their Answers.
9. 22 Nov 1993 (after more than 11 years of trial), RTC:
Dr. Estrada SOLELY LIABLE for damages.
9.1. Dr. Estradas negligence:
9.1.1. Incorrect and inadequate management
and lack of treatment of C. Nogales pre-
eclamptic condition.
9.1.2. Misapplied forceps, which caused a large
cervical tear that led to profuse bleeding.
9.1.3. Failed to control bleeding applied
inadequate injection of magnesium sulfate.
9.1.4. Failed to notice the erroneous
administration of hemacel by side drip,
instead of direct intravenous injection.
9.1.5. Failed to consult a senior obstetrician at an
early state of the problem.
9.2. No civil liability for the others.
9.2.1. Dr. Villaflor: only taking orders from the
principal physician (Dr. Estrada) can only
make suggestions; no evidence that Dr.
Villaflor had discovered that there was
laceration at the cervical area.
9.2.2. Nurse Dumlao: no showing that the
administration of hemacel as a side trip was
done on her own was probably through
the orders of Dr. Estrada.
9.2.3. Dr. Espinola: prescription based on
information given to him by phone he
had acted on the basis of the facts as
presented to him; whatever errors Dr.
Estrada committed on C. Nogales before
9a are his errors and cannot be the mistake
of Dr. Espinola; his failure to come to the
hospital on time was due to a fortuitous
event, Typhoon Didang.
9.2.4. Dr. Enriquez: he was present in the delivery
room but it was not incumbent upon him to
call Dr. Estrada, Dr. Villaflor, and Nurse
Dumlao on the errors allegedly committed
by them; as anesthesiologist, he had no
authority to control the actions of Dr.
Estrada and Dr. Villaflor.
9.2.5. Dr. Lacson: in order that blood may be
made available, a lab test has to be
conducted to determine the type of blood,
cross matching, and other matters the
lapse of 30 mins. may be considered a
reasonable time to do all of these things.
9.2.6. Dr. Uy: as resident physician, no evidence
to show that she had knowledge of the
mismanagement of C. Nogales and that,
notwithstanding such knowledge, she
tolerated the same to happen.
9.3. No legal ground to apply Arts. 2176 and 2180 of
the NCC (employers vicarious liability).
9.3.1. If there is fault or negligence in the
treatment of C. Nogales on the part of the
attending physicians such civil liability
should be borne by the attending
physicians under respondeat superior.
10. Nogales appealed the decision, contending that the
other respondents should be held equally liable.
11. 6 Feb 1998, CA: affirmed the decision of the RTC.
11.1. Citing American Cases, the CA held that the
mere fact that a hospital permitted a physician
to practice medicine and use its facilities is NOT
sufficient to render the hospital liable for the
Physicians negligence.
11.1.1. A hospital is NOT responsible for the
negligence of a physician who is an
independent contractor.
11.2. Darling v. Charleston Community Memorial
Hospital: NA in that case, the physician and
nurse were employees.
11.3. Davidson v. Conole, Campbell v. Emma Laing
Stevens Hospital: applicable.
11.3.1. Where there is (i) no proof that the
defendant physician was an employee, or
(ii) that defendant hospital had reason to
know that any acts of malpractice would
take place the defendant hospital could
NOT be liable for its failure to intervene in
the relationship of physician-patient.
11.4. On the liability of the other respondents: the CA
applied the borrowed servant doctrine once
the surgeon enters the operating room and
takes charge of the proceedings, the
acts/omissions of operating room personnel,
and any negligence associated with such acts
or omissions are IMPUTABLE TO THE SURGEON.
11.4.1. Assisting physicians and nurses employed
by the hospital or engaged by the patient
normally become TEMPORARY
 SERVANTS/AGENTS of the surgeon in charge
while the operation is in progress.
11.4.1.1. Liability may be imposed upon
the surgeon for their negligent acts,
under respondeat superior.
11.4.2. Since Nogales engaged Dr. Estrada as
the attending physician of his wife any
liability for malpractice must be Dr.
Estradas SOLE RESPONSIBILITY.
12. Thus this petition before the SC.
12.1. Nogales, et al. are claiming only against CMC,
Dr. Espinola, Dr. Lacson, and Dr. Uy.
12.1.1. Note that Dr. Estrada did NOT appeal the
decision of the CA.
12.2. According to Nogales, et al.: CMC is vicariously
liable for Dr. Estradas negligence. [Art. 2180, in
rel. to Art. 2176]
12.2.1. In allowing Dr. Estrada to practice and
admit patients at CMC CMC should be
liable.
12.3. According to CMC: CMC is NOT vicariously
liable Dr. Estrada was a mere visiting physician,
C. Nogales was admitted because her condition
was an emergency obstetrics case.
12.3.1. Dr. Estrada was an independent
contractor CMC exercised no control or
supervision over him in the exercise of his
medical profession.
ISSUE:
1. Was CMC liable? (YES.)
2. On the individual liability of the other respondents.
RATIO:
1. CMC liable, on the basis of the Doctrine of Apparent
Authority.
Jurisprudence on the relationship between Hospital-
Physician
Ramos v. CA:
While consultants are NOT technically
employees the control exercised, hiring, and
the right to terminate consultants all fulfill the
important hallmarks of an employer-employee
(ER-EE) relationship, with the exception of the
payment of wages.
For the purpose of allocating responsibility in
medical negligence cases an ER-EE rel. exists
between hospitals and their attending and
visiting physicians.
o If warranted, Art. 2180 would apply to
impose vicarious liability onto the
hospitals.
Clarification by the SC of Ramos v. CA, vis--vis the
Control Test:
The employer (hospital_ must have the right to
control both the means and the details of the
process by which the employee (physician) is to
accomplish his task.
Case at bar: no evidence pointing to CMCs exercise of
control over Dr. Estradas treatment and management of
Corazons Condition
There was no showing that CMC had a part in diagnosing
C. Nogales condition.
Undisputed that throughout the pregnancy, C.
Nogales was under the exclusive prenatal care
of Dr. Estrada.
At her admission at CMC and during her delivery,
it was Dr. Estrada, assisted by Dr. Villaflor, who
attended to Corazon.
That Dr. Estrada enjoyed staff privileges at CMC alone did
NOT make him an employee of CMC CMC merely
allowed Dr. Estrada to use its facilities.
THUS, Dr. Estrada was NOT an employee of CMC he was
an independent contractor.
Hospitals liability for the negligence of an independent
contractor physician
GR: hospital is NOT liable.
EXPN: hospital may be liable if the physician is the
ostensible agent of the hospital. (Doctrine of Apparent
Authority)
Gilbert v. Sycamore Municipal Hospital (Illinois
SC): a hospital can be held vicariously liable for
the negligent acts of a physician regardless of
whether he is an independent contractor
UNLESS the patient knows, or should have known,
that the physician is an independent contractor.
Elements:
o (SC: FIRST FACTOR) Hospital (or agent)
acted in a manner that would lead a
reasonable person to conclude that the
physician was an employee or agent of
the hospital;
NOTE: This element is satisfied if
the hospital holds itself out as a
provider of emergency room
care w/o informing the patient
that the care is provided by
independent contractors.
(SC: may be general and
implied.)
o Where the acts of the physician create
the appearance of authority, the plaintiff
must also prove that the hospital had
knowledge of AND acquiesced in them;
and,
o (SC: SECOND FACTOR) The plaintiff acted
in reliance upon the conduct of the
hospital (or agent), consistent with
ordinary care and prudence.
NOTE: satisfied If the plaintiff
relies upon the hospital to
provide complete emergency
room care, rather than upon a
specific physician.
SC on the two factors involved in determining the
liability of an independent contractor physician.
(SEE: first factor and second factor)
 SC noted that the Doctrine of Apparent Authority
is a species of the doctrine of estoppel. (See: Art.
1431, NCC)
FIRST FACTOR: present
CMC impliedly held out Dr. Estrada as a member of its
medical staff through CMCs acts, Dr. Estrada was
clothed with apparent authority, leading the Sps. Nogales
to believe that he was an employee/agent of CMC.
CMC granted staff privileges to Estrada
extending its medical staff and facilities to the
latter.
CMC made Nogales sign consent forms printed
on CMC letterhead. (Note the Consent on
Admission and Agreement1 and the Consent to
Operation2.)
o W/o any indication in these forms that Dr.
Estrada was an independent contractor
the Sps. Nogales could NOT have
known.
Dr. Estradas referral of C. Nogales profuse
vaginal bleeding to Dr. Espinola then the Dead
of the Obstetrics and Gynecology Dept. of CMC
gave the impression that, as a member of
CMCs medical staff, Dr. Estrada was
collaborating with other CMC-employed
specialists.
SECOND FACTOR: present
Sps. Nogales relied upon a perceived employment
relationship with CMC in accepting Dr. Estradas services.
According to Nogales, he and his wife
specifically chose Dr. Estrada because of Dr.
Estradas connection with a reputable hospital,
the CMC.
No showing that before and during C. Nogales
confinement the Sps. Nogales KNEW or SHOULD
HAVE KNOWN that Dr. Estrada was NOT an
employee of CMC.
Sps. Nogales looked to CMC to provide the best
medical care and support services for C.
Nogales delivery.
o Note that the 3 previous deliveries
happened in a clinic (not a hospital).
Because of C. Nogales
advanced age and 4th delivery,
the Sps. Nogales decided to
have their child delivered at
CMC. (In view of possible
complications.)
1 xxx that the Physician, personally or by and through the Capitol
Medical Center and/or its staff, may use, adapt, or employ such
means, forms or methods of cure, treatment, retreatment, or
emergency measures as he may see best and most expedient; that Ma.
Corazon and I will comply with any and all rules, regulations,
directions, and instructions of the Physician, the Capitol Medical
Center and/or its staff xxx
2 I, ROGELIO NOGALES, x x x, of my own volition and free will,
do consent and submit said CORAZON NOGALES to Hysterectomy,
by the Surgical Staff and Anesthesiologists of Capitol Medical Center
xxx
On the defense forwarded by CMC that all it did was to
extend its facilities to C. Nogales
SC: this defense is untenable.
Hospitals are in the business of treatment.
Diggs v. Novant Health, Inc.: 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.
On the defense of estoppel (based on the Consent on
Admission and Consent to Operation)
SC: this defense is unconvincing.
Both release forms consist of two parts:
o FIRST: gave CMC permission to administer
to C. Nogales any form of recognized
medical treatment deemed advisable.
o SECOND: releases CMC and its
employees from any and all claims
arising from or by reason of the
treatment and operation.
The documents DO NOT expressly release CMC
from liability for injury DUE TO NEGLIGENCE during
treatment/operation.
They also DO NOT expressly exempt CMC from
liability for death due to negligence
Contracts of adhesion construed strictly against
the hospital.
Also, blanket release which includes claims due
to bad faith or gross negligence contrary to
public policy: VOID.
o Even simple negligence is NOT subject to
blanket release may only mitigate
liability, depending on the
circumstances.
o Note that a person needing urgent
medical attention is literally at the mercy
of the hospital.
2. None of the other respondents can be held liable.
Dr. Villaflor: not liable (not negligent)
Lower dosage of magnesium sulfate was after
informing Dr. Estrada that C. Nogales was no
longer in convulsion and that her blood pressure
went down to a dangerous level.
o Dr. Estrada instructed Dr. Villaflor to
reduce the dosage.
Defense: uncontroverted.
Dr. Uy: routine internal examination did not ipso facto
make Dr. Uy liable for errors committed by Dr. Estrada; no
showing that Dr. Uy participated in delivering the baby.
Dr. Uy was then a 2nd year resident physician who
was merely authorized to take the clinical history
and physical examination of C. Nogales.
No showing that she participated in delivering
the baby.
Unexpected for her to call the attention of a
more experienced specialist.
Dr. Enriquez: anesthesiologies not expert in obstetrics
and gynecology was not expected to correct Dr.
Estradas errors.
No evidence of Dr. Enriquezs knowledge of any
error committed by Dr. Estrada, nor his failure to
act upon such observation.
Dr. Lacson: given the procedure before blood could be
given to a patient no delay.
No evidence that Dr. Lacson neglected her
duties as head of the blood bank.
Dr. Espinola: order to to hysterectomy was based on info
received by phone not negligence, believed in good
faith that hysterectomy was the correct remedy.
In any case, hysterectomy did not push through
upon Dr. Espinolas arrival, C. Nogales was
practically dead.
Nurse Dumlao: no evidence of failure to follow Dr.
Estradas specific instructions; no showing that side-drip
administration of hemacel proximately caused C.
Nogales death, in any case.
Note Moore v. Guthries Hospital, which outlined requisites
to allow recovery for injuries allegedly resulting from a
negligent intravenous injection instead of intramuscular:
Intravenous injection constituted a lack of
reasonable and ordinary care;
Nurse injected medicine intravenously; and,
Injection was the proximate cause of the injury.
DISPOSITIVE: WHEREFORE, the Court PARTLY GRANTS the
petition. The Court finds respondent Capitol Medical
Center vicariously liable for the negligence of Dr. Oscar
Estrada. The amounts of P105,000 as actual damages
and P700,000 as moral damages should each earn legal
interest at the rate of six percent (6%) per annum
computed from the date of the judgment of the trial
court. The Court affirms the rest of the Decision dated 6
February 1998 and Resolution dated 21 March 2000 of the
Court of Appeals in CA-G.R. CV No. 45641.
4.2.3.3. Ybarra v. Spangard, 25 CAL.2D 486, 154 P.2D 687
(1944).
Ybarra v. Spangard
Petitioner: Joseph Roman Ybarra
Respondent: Lawrence Spangard et al.
Topic: Medical Malpractice; Borrowed Servants
FACTS:
- Ybarra was due for an appendectomy, to be
performed by Dr. Spangard, per the recommendation
of Dr. Tilley (defendant).
o The surgery was scheduled to be performed at the
hospital of Dr. Swift (also a defendant).
- To proceed with the surgery, Ybarra was given a
hypodermic injection and was induced to sleep.
When he woke up, he was taken to the operating
room by Nurse Gisler (also a defendant)
- Dr. Reser , the anesthesiologist (also a defendant),
prepped Ybarra for surgery by, according to Ybarra,
laying him back against two hard objects at the top of
his shoulders, about an inch below his neck.
- After the surgery and when Ybarra woke up, he
complained of a sharp pain, which he felt between
his neck and right shoulder.
o He testified that prior to the surgery, he has never
had any pain nor injury in that area.
- He immediately made his discomfort known to the
nurse. They responded by giving him diathermy
treatments
o (Merriam-Webster) diathermy a medical and
surgical technique involving the production of heat
in a part of the body by high-frequency electric
currents, to stimulate the circulation, relieve pain,
destroy unhealthy tissue, or cause bleeding vessels
to clot.
- The treatments did not work; the pain spread to the
lower part of his arm.
o It later resulted into his inability to rotate or lift his
right arm.
o The condition grew worse into paralysis and
atrophy of the muscles around the shoulder.
- Ybarra sought separate opinions from other doctors.
o Dr. Clark had x-rays showing that there had
already been atrophy and wasting away of the
muscles in his right shoulder. He opined that this
was die to trauma or injury by pressure or strain.
o Dr. Garduno also concurred in saying that the
condition was of a traumatic origin, and did not
arise from pathologic nor systemic causes (i.e.,
cause was external).
- Ybarra filed a suit and impleaded all the defendants.
The lower court, however, declared him to be
nonsuited. Hence the appeal.
- Ybarras argument:
o Circumstances of the case call for an application
of the res ipsa loquitur doctrine.
- Defense of respondents:
o Where there are several defendants, and there is a
division of responsibility in the use of an
instrumentality causing the injury, and the injury
might have resulted from the separate act of either
one of two or more persons, the rule of res ipsa
loquitur cannot be invoked
o Where there are several instrumentalities, and no
showing is made as to which caused the injury or
as to the particular defendant in control of it, the
doctrine cannot apply
-
ISSUE(S):
1. WON res ipsa loquitur applies in this case (YES)
RATIO:
1. Yes. The doctrine is applicable in this case.
- The doctrine of res ipsa loquitur has 3 conditions:
o (1) the accident must be of a kind which ordinarily
does not occur in the absence of someone's
negligence;
o (2) it must be caused by an agency or
instrumentality within the exclusive control of the
defendant;
 o (3) it must not have been due to any voluntary 4.2.5.2. Jarcia v. Court of Appeals, supra. 4.2.5.3. Cayao-
action or contribution on the part of the plaintiff. Lasam v. Ramolete, supra.
- It is difficult to see how the doctrine can, with any
justification, be so restricted in its statement as to
become inapplicable to a patient who submits himself 4.3. LIABILITY OF HOSPITALS
to the care and custody of doctors and nurses, is
rendered unconscious, and receives some injury from 4.3.1.Employer-employee relationship (Art. 2180, NCC)
instrumentalities used in his treatment.
o Without the application of the doctrine, a patient
rendered unconscious and receives an injury
following a medical procedure would be unable to 4.3.2.Control test
recover unless the hospital, the doctors and nurses
would be willing to disclose the negligent individual 4.3.2.1. Ramos vs. Court of Appeals, supra.
and the facts that will establish liability.
- Assisting nurses and physicians may be employed by
the hospital or engaged by the patients; during the 4.3.2.2. Nogales v. Capitol Medical Center, supra.
medical procedure, they become the temporary
agents of the surgeon in charge, meaning that liability
may be imposed upon the latter for the negligent acts 4.3.3.Independent contractors
of the former under the doctrine of respondeat
superior.
- Hence, even though the some of the defendants 4.3.4.Doctrine of apparent authority/ostensible agent
charged may be held liable while some might be
absolved, such should not preclude the application of 4.3.4.1. Ramos v. CA, supra.
res ipsa loquitur.
o The control, at one time or another, of one or
more of the various agencies or instrumentalities
which might have harmed the plaintiff was in the 4.3.4.2. Nogales v. Capitol Medical Center, supra.
hands of every defendant or of his employees or
temporary servants.
- As to the other aspect of respondents argument that 4.3.5.Hospital facilities
Ybarra cannot identify the particular instrumentality
that has caused the injury, the Court that again, this
should not preclude the application of the doctrine. 4.3.5.1. Manila Doctors Hospital v. So Un Chua, G.R. No.
o The trend is jurisprudence, the Court has examined, 150355, July 31, 2006.
has evolved from requiring actual exclusive control
of the instrumentality causing the injury to one that Manila Doctors Hospital v. So Un Chua
only requires that right of control of the Petitioner: Manila Doctors Hospital (MDH)
instrumentality be shown. Respondent: So Un Chua and Vicky Ty
o In the face of this liberalized doctrine, there can be Topic: Medical Malpractice; Hospital Facilities
no preclusion of the application of the doctrine.

HELD: Petition granted. FACTS:

- So Un Chua was admitted into MDH for hypertension
and diabetes.
- While So (mother) was still in confinement, Judith Chua
(daughter) had been confined as well for injuries
4.2.4.EXAMPLES OF BREACH OF DUTY sustained in a vehicular accident.
- Ty, the daughter of So and sister of Judith, made a
4.2.4.1. Cruz v. Court of Appeals, supra. partial payment for the hospital bills amounting to
P435,800.
o Judith was discharged, while So remained in
4.2.4.2. Professional Services, Inc. v. Agana, supra. confinement in MDH.
- Chua and Ty allege the ff:
o They were pressured by MDH to pay the balance
4.2.4.3. Jarcia v. Court of Appeals, supra. of the hospital bills.
o They kept sending So the correspondences
regarding the unpaid bills instead of sending them
4.2.5.PROXIMATE CAUSATION to Ty, despite an earlier request. They allege that
this aggravated Sos condition.
4.2.5.1. Ocean Builders Construction v. Cubacub, G.R. No. o They allegedly employed unethical, unpleasant
150898, April 13, 2011. and unlawful methods which worsened the
condition of So:
Cut off the telephone line, removed the aircon
unit, TV set, refrigeration
 Refused to render medical attendance, and o all things considered, and given the degree of
change the hospital gown and bed sheets diligence the petitioner duly exerted, not every
Barred the nurses and midwives from giving suppression of the things that one has grown
assistance accustomed to enjoy amounts to an actionable
- MDH specifically denied the allegations and put forth wrong, nor does every physical or emotional
its version of events: discomfort amount to the kind of anguish that
o Ty reneged on a commitment to pay the balance warrants the award of moral damages under the
of the unpaid bills general principles of tort.
o Ty signed a promissory note for the unpaid balance -
of P1,075,592.95, and issued postdated checks to
cover the same. HELD: Petition granted.
o The cutting of the telephone line and the removal
of some appliances were part of the cost-cutting
measures of non-critical amenities to minimize the
charges that were yet to be paid.
o That the case at bar was filed to counter the
criminal charges against her for violation of BP 22,
when the postdated checks she issued were found
to have bounced.
- RTC: MDH ordered to pay moral and exemplary
damages, with attorneys fees and costs.
- CA: RTC affirmed.

ISSUE(S):
2. WON there are actionable wrongs on the part of MDH
(NONE).

RATIO:
2. NO. There is no cause of action in favor of Chua and
Ty.
- Indeed the operation of private pay hospitals and
medical clinics is impressed with public interest and
imbued with a heavy social responsibility. But the
hospital is also a business, and, as a business, it has a
right to institute all measures of efficiency
commensurate to the ends for which it is designed,
especially to ensure its economic viability and
survival.
o The hospital has a right to reduce the facilities and
services that are deemed to be non-essential, in
the sense that their removal would not be
detrimental to the medical condition of the
patient.
- Corollary to this assessment would be whether the
hospital observed ordinary diligence in ascertaining
the effects of the removal of such non-essential
facilities, with a view to preventing injury to the
patient.
o Court: The lower courts drew their conclusions from
self-serving testimonies and uncorroborated
testimonies, which have highly questionable
probative value by their nature.
o MDH took steps to inform the relatives of So of the
removal of some of the non-essential facilities, and
to carry out certain measure to avoid deterioration
of her condition due to the removal of these
facilities.
o Dr. Sy, provided his expert testimony on the fact
that the removal of these facilities will not cause
any significant deterioration of a hypertensive and
diabetic patient.
- Court: The evidence on record demonstrates that So
was adequately attended to.