At6:15a.m.,Dr.Estradaorderedtheinjectionoftengramsofmagnesiumsulfate.However,Dr.
142625December19,2006
ElyVillaflor("Dr. Villaflor"), who was assisting Dr. Estrada, administered only 2.5gramsof
magnesiumsulfate.
At6:22a.m.,Dr.Estrada,assistedbyDr.Villaflor,appliedlowforcepstoextractCorazon'sbaby.
Intheprocess,a1.0x2.5cm.pieceofcervicaltissuewasallegedlytorn.Thebabycameoutinan vs.
apnic, cyanotic, weak and injured condition. Consequently, the baby had to be intubated and
resuscitatedbyDr.EnriquezandDr.Payumo.
At6:27a.m.,Corazonbegantomanifestmoderatevaginalbleedingwhichrapidlybecameprofuse.
Corazon'sbloodpressuredroppedfrom130/80to60/40withinfiveminutes.Therewascontinuous
profusevaginalbleeding.Theassistingnurseadministeredhemacelthroughagauge19needleasa
sidedriptotheongoingintravenousinjectionofdextrose.
At7:45a.m.,Dr.Estradaorderedbloodtypingandcrossmatchingwithbottledblood.Ittook
approximately30minutesfortheCMClaboratory,headedbyDr.PerpetuaLacson("Dr.Lacson"),
tocomplywithDr.Estrada'sorderanddelivertheblood.
At8:00a.m.,Dr.NoeEspinola("Dr.Espinola"),headoftheObstetricsGynecologyDepartmentof
theCMC,wasapprisedofCorazon'sconditionbytelephone.UponbeinginformedthatCorazon
wasbleedingprofusely,Dr.Espinolaorderedimmediatehysterectomy.Rogeliowasmadetosigna
"ConsenttoOperation."13
Due to the inclement weather then, Dr. Espinola, who was fetched from his residence by an
ambulance,arrivedattheCMCaboutanhourlaterorat9:00a.m.Heexaminedthepatientand
orderedsomeresuscitativemeasurestobeadministered.DespiteDr.Espinola'sefforts,Corazon
diedat9:15a.m.Thecauseofdeathwas"hemorrhage,postpartum."14
On14May1980,petitionersfiledacomplaintfordamages 15 withtheRegionalTrialCourt16 of
ManilaagainstCMC,Dr.Estrada,Dr.Villaflor,Dr.Uy,Dr.Enriquez,Dr.Lacson,Dr.Espinola,
and a certain Nurse J. Dumlao for the death of Corazon. Petitioners mainly contended that
defendantphysiciansandCMCpersonnelwerenegligentinthetreatmentandmanagementof
Corazon'scondition.PetitionerschargedCMCwithnegligenceintheselectionandsupervisionof
defendantphysiciansandhospitalstaff.
Forfailingtofiletheiranswertothecomplaintdespiteserviceofsummons,thetrialcourtdeclared
Dr. Estrada, Dr. Enriquez, and Nurse Dumlao in default. 17 CMC, Dr. Villaflor, Dr. Uy, Dr.
Espinola,andDr.Lacsonfiledtheirrespectiveanswersdenyingandopposingtheallegationsinthe
complaint.Subsequently,trialensued.
Aftermorethan11yearsoftrial,thetrialcourtrenderedjudgmenton22November1993finding
Dr.Estradasolelyliablefordamages.Thetrialcourtruledasfollows:
The victim was under his prenatal care, apparently, his fault began from his incorrect and
inadequatemanagementandlackoftreatmentofthepreeclampticconditionofhispatient.Itisnot
disputed that he misapplied the forceps in causing the delivery because it resulted in a large
cervical tear which had caused the profuse bleeding which he also failed to control with the
applicationofinadequateinjectionofmagnesiumsulfatebyhisassistantDra.ElyVillaflor.Dr.
EstradaevenfailedtonoticetheerroneousadministrationbynurseDumlaoofhemacelbywayof
sidedrip,insteadofdirectintravenousinjection,andhisfailuretoconsultaseniorobstetricianat
anearlystageoftheproblem.
OntheparthoweverofDra. ElyVillaflor,Dra.RosaUy, Dr. JoelEnriquez,Dr.Lacson,Dr.
Espinola,nurseJ.DumlaoandCMC,theCourtfindsnolegaljustificationtofindthemcivilly
liable.
G.R.No.
ROGELIOP.NOGALES,forhimselfandonbehalfoftheminors,ROGERANTHONY,
ANGELICA, NANCY, and MICHAEL CHRISTOPHER, all surnamed NOGALES,
petitioners,
CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR. ELY VILLAFLOR, DR.
ROSAUY,DR.JOELENRIQUEZ,DR.PERPETUALACSON,DR.NOEESPINOLA,and
NURSEJ.DUMLAO,respondents.
DECISION
CARPIO,J.:
TheCase
Thispetitionforreview1assailsthe6February1998Decision2and21March2000Resolution3of
theCourtofAppealsinCAG.R.CVNo.45641.TheCourtofAppealsaffirmed intoto the22
November1993Decision4 oftheRegionalTrialCourtofManila,Branch33,findingDr.Oscar
Estradasolelyliablefordamagesforthedeathofhispatient,CorazonNogales,whileabsolvingthe
remaining respondents of any liability. The Court of Appeals denied petitioners' motion for
reconsideration.
TheFacts
Pregnantwithherfourthchild,CorazonNogales("Corazon"),whowasthen37yearsold,was
undertheexclusiveprenatalcareofDr.OscarEstrada("Dr.Estrada")beginningonherfourth
monthofpregnancyorasearlyasDecember1975.WhileCorazonwasonherlasttrimesterof
pregnancy,Dr.Estradanotedanincreaseinherbloodpressureanddevelopmentoflegedema 5
indicatingpreeclampsia,6whichisadangerouscomplicationofpregnancy.7
Around midnight of 25 May 1976, Corazon started to experience mild labor pains prompting
CorazonandRogelioNogales("SpousesNogales")toseeDr.Estradaathishome.Afterexamining
Corazon,Dr.EstradaadvisedherimmediateadmissiontotheCapitolMedicalCenter("CMC").
On26May1976,Corazonwasadmittedat2:30a.m.attheCMCafterthestaffnursenotedthe
writtenadmissionrequest8ofDr.Estrada.UponCorazon'sadmissionattheCMC,RogelioNogales
("Rogelio")executedandsignedthe"ConsentonAdmissionandAgreement" 9 and"Admission
Agreement."10CorazonwasthenbroughttothelaborroomoftheCMC.
Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an internal
examinationofCorazon.Dr.UythencalledupDr.Estradatonotifyhimofherfindings.
BasedontheDoctor'sOrderSheet,11around3:00a.m.,Dr.Estradaorderedfor10mg.ofvaliumto
be administered immediately by intramuscular injection. Dr. Estrada later ordered the start of
intravenousadministrationofsyntocinonadmixedwithdextrose,5%,inlactatedRingers'solution,
attherateofeighttotenmicrodropsperminute.
According to the Nurse's Observation Notes,12 Dr. Joel Enriquez ("Dr. Enriquez"), an
anesthesiologistatCMC,wasnotifiedat4:15a.m.ofCorazon'sadmission.Subsequently,when
askedifheneededtheservicesofananesthesiologist,Dr.Estradarefused.DespiteDr.Estrada's
refusal,Dr.EnriquezstayedtoobserveCorazon'scondition.
At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10 a.m.,
Corazon'sbagofwaterrupturedspontaneously.At6:12a.m.,Corazon'scervixwasfullydilated.
At6:13a.m.,Corazonstartedtoexperienceconvulsions.
thenegligenceofitsemployees.Ifeverinthiscasethereisfaultornegligenceinthetreatmentof
thedeceasedonthepartoftheattendingphysicianswhowereemployedbythefamilyofthe
deceased,suchcivilliabilityshouldbebornebytheattendingphysiciansundertheprincipleof
"respondeatsuperior".
WHEREFORE,premisesconsidered,judgmentisherebyrenderedfindingdefendantDr.Estradaof
Number13PitiminiSt.SanFranciscodelMonte,QuezonCitycivillyliabletopayplaintiffs:1)By
wayofactualdamagesintheamountofP105,000.00;2)Bywayofmoraldamagesintheamount
ofP700,000.00;3)Attorney'sfeesintheamountofP100,000.00andtopaythecostsofsuit.
Forfailureoftheplaintiffstoadduceevidencetosupportits[sic]allegationsagainsttheother
defendants,thecomplaintisherebyordereddismissed.WhiletheCourtlookswithdisfavorthe
filingofthepresentcomplaintagainsttheotherdefendantsbythehereinplaintiffs,asinawayit
hascausedthempersonalinconvenienceandslightdamageontheirnameandreputation,theCourt
cannotaccepts[sic]however,thetheoryoftheremainingdefendantsthatplaintiffsweremotivated
inbadfaithinthefilingofthiscomplaint.Forthisreasondefendants'counterclaimsarehereby
ordereddismissed.
SOORDERED.18
Petitionersappealedthetrialcourt'sdecision.PetitionersclaimedthatasidefromDr.Estrada,the
remainingrespondentsshouldbeheldequallyliablefornegligence.Petitionerspointedoutthe
extentofeachrespondent'sallegedliability.
On6February1998,theCourtofAppealsaffirmedthedecisionofthetrialcourt. 19Petitionersfiled
amotionforreconsiderationwhichtheCourtofAppealsdeniedinitsResolutionof21March
2000.20
Hence,thispetition.
Meanwhile,petitionersfiledaManifestationdated12April2002 21 statingthatrespondentsDr.
Estrada,Dr.Enriquez,Dr.Villaflor,andNurseDumlao"neednolongerbenotifiedofthepetition
because they are absolutely not involved in the issue raised before the [Court], regarding the
liabilityof[CMC]."22Petitionersstressedthatthesubjectmatterofthispetitionistheliabilityof
CMCforthenegligenceofDr.Estrada.23
TheCourtissuedaResolutiondated9September200224dispensingwiththerequirementtosubmit
thecorrectandpresentaddressesofrespondentsDr.Estrada,Dr.Enriquez,Dr.Villaflor,andNurse
Dumlao.TheCourtstatedthatwiththefilingofpetitioners'Manifestation,itshouldbeunderstood
thattheyareclaimingonlyagainstrespondentsCMC,Dr.Espinola,Dr.Lacson,andDr.Uywho
havefiledtheirrespectivecomments.Petitionersareforegoingfurtherclaimsagainstrespondents
Dr.Estrada,Dr.Enriquez,Dr.Villaflor,andNurseDumlao.
TheCourtnotedthatDr.EstradadidnotappealthedecisionoftheCourtofAppealsaffirmingthe
decisionoftheRegionalTrialCourt.Accordingly,thedecisionoftheCourtofAppeals,affirming
thetrialcourt'sjudgment,isalreadyfinalasagainstDr.OscarEstrada.
Petitioners filed a motion for reconsideration 25 of the Court's 9 September 2002 Resolution
claimingthatDr.Enriquez,Dr.VillaflorandNurseDumlaowerenotifiedofthepetitionattheir
counsels' last known addresses. Petitioners reiterated their imputation of negligence on these
respondents.TheCourtdeniedpetitioners'MotionforReconsiderationinits18February2004
Resolution.26
TheCourtofAppeals'Ruling
InitsDecisionof6February1998,theCourtofAppealsupheldthetrialcourt'sruling.TheCourt
of Appeals rejected petitioners' view that the doctrine in Darling v. Charleston Community
MemorialHospital27 appliestothiscase. AccordingtotheCourtofAppeals,thepresentcase
On the part of Dra. Ely Villaflor, she was only taking orders from Dr. Estrada, the principal
physicianofCorazonNogales.Shecanonlymakesuggestionsinthemannerthepatientmaybe
treatedbutshecannotimposeherwillastodosowouldbetosubstitutehergoodjudgmenttothat
ofDr.Estrada.Ifshefailedtocorrectlydiagnosethetruecauseofthebleedingwhichinthiscase
appearstobeacervicallaceration,itcannotbesafelyconcludedbytheCourtthatDra.Villaflor
hadthecorrectdiagnosisandshefailedtoinformDr.Estrada.Noevidencewasintroducedtoshow
that indeed Dra. Villaflor had discovered that there was laceration at the cervical area of the
patient'sinternalorgan.
OnthepartofnurseDumlao,thereisnoshowingthatwhensheadministeredthehemacelasaside
drip,shediditonherown.Ifthecorrectprocedurewasdirectlythrutheveins,itcouldonlybe
becausethiswaswhatwasprobablytheordersofDr.Estrada.
While the evidence of the plaintiffs shows that Dr. Noe Espinola, who was the Chief of the
DepartmentofObstetricsandGynecologywhoattendedtothepatientMrs.Nogales,itwasonlyat
9:00a.m.ThathewasabletoreachthehospitalbecauseoftyphoonDidang(Exhibit2).Whilehe
wasabletogiveprescriptioninthemannerCorazonNogalesmaybetreated,theprescriptionwas
basedontheinformationgiventohimbyphoneandheactedonthebasisoffactsaspresentedto
him,believingingoodfaiththatsuchisthecorrectremedy.HewasnotwithDr.Estradawhenthe
patient was brought to the hospital at 2:30 o'clock a.m. So, whatever errors that Dr. Estrada
committedonthepatientbefore9:00o'clocka.m.arecertainlytheerrorsofDr.Estradaandcannot
be the mistake of Dr. Noe Espinola. His failure to come to the hospital on time was due to
fortuitousevent.
OnthepartofDr.JoelEnriquez,whilehewaspresentinthedeliveryroom,itisnotincumbent
uponhimtocalltheattentionofDr.Estrada,Dra.VillaflorandalsoofNurseDumlaoonthe
allegederrorscommittedbythem.Besides,asanesthesiologist,hehasnoauthoritytocontrolthe
actuationsofDr.EstradaandDra.Villaflor.FortheCourttoassumethattherewereerrorsbeing
committedinthepresenceofDr.Enriquezwouldbetodwellonconjecturesandspeculations.
OnthecivilliabilityofDr.PerpetuaLacson,[s]heisahematologistandinchargeoftheblood
bankoftheCMC.TheCourtcannotacceptthetheoryoftheplaintiffsthattherewasdelayin
deliveringthebloodneededbythepatient.Itwastestified,thatinorderthatthisbloodwillbe
made available, a laboratory test has to be conducted to determine the type of blood, cross
matchingandothermattersconsistentwithmedicalscienceso,thelapseof30minutesmaybe
consideredareasonabletimetodoallofthesethings,andnotadelayastheplaintiffswouldwant
theCourttobelieve.
Admittedly,Dra.RosaUyisaresidentphysicianoftheCapitolMedicalCenter.Shewassued
becauseofherallegedfailuretonoticetheincompetenceandnegligenceofDr.Estrada.However,
thereisnoevidencetosupportsuchtheory.NoevidencewasadducedtoshowthatDra.RosaUy
asaresidentphysicianofCapitolMedicalCenter,hadknowledgeofthemismanagementofthe
patient Corazon Nogales, and that notwithstanding such knowledge, she tolerated the same to
happen.
Inthepretrialorder,plaintiffsandCMCagreedthatdefendantCMCdidnothaveanyhandor
participationintheselectionorhiringofDr.EstradaorhisassistantDra.ElyVillaflorasattending
physician[s] of the deceased. In other words, the two (2) doctors were not employees of the
hospitalandthereforethehospitaldidnothavecontrolovertheirprofessionalconduct.WhenMrs.
Nogaleswasbroughttothehospital,itwasanemergencycaseanddefendantCMChadnochoice
buttoadmither.Suchbeingthecase,thereisthereforenolegalgroundtoapplytheprovisionsof
Article2176and2180oftheNewCivilCodereferringtothevicariousliabilityofanemployerfor
xxxx
Theresponsibilitytreatedofinthisarticleshallceasewhenthepersonshereinmentionedprove
thattheyobservedallthediligenceofagoodfatherofafamilytopreventdamage.
Art.2176.Whoeverbyactoromissioncausesdamagetoanother,therebeingfaultornegligence,
is obliged to pay for the damage done. Such fault or negligence, if there is no preexisting hospitalliableforthephysician'snegligence.28Ahospitalisnotresponsibleforthenegligenceofa
contractualrelationbetweentheparties,iscalledaquasidelictandisgovernedbytheprovisions
ofthisChapter.
Similarly,intheUnitedStates,ahospitalwhichistheemployer,master,orprincipalofaphysician
employee,servant,oragent,maybeheldliableforthephysician'snegligenceunderthedoctrineof
respondeatsuperior.34
Inthepresentcase,petitionersmaintainthatCMC,inallowingDr.Estradatopracticeandadmit
patientsatCMC,shouldbeliableforDr.Estrada'smalpractice.RogelioclaimsthatheknewDr.
EstradaasanaccreditedphysicianofCMC,thoughhediscoveredlaterthatDr.Estradawasnota
salariedemployeeoftheCMC.35 RogeliofurtherclaimsthathewasdealingwithCMC,whose
primary concern was the treatment and management of his wife's condition. Dr. Estrada just
happenedtobethespecificpersonhetalkedtorepresentingCMC. 36Moreover,thefactthatCMC
made Rogelio sign a Consent on Admission and Admission Agreement 37 and a Consent to
Operation printed on the letterhead of CMC indicates that CMC considered Dr. Estrada as a
memberofitsmedicalstaff.
Ontheotherhand, CMC disclaims liability by asserting that Dr. Estradawasamerevisiting
physician and that it admitted Corazon because her physical condition then was classified an
emergencyobstetricscase.38
CMCallegesthatDr.Estradaisanindependentcontractor"forwhoseactuationsCMCwouldbea
total stranger." CMC maintains that it had no control or supervision over Dr. Estrada in the
exerciseofhismedicalprofession.
TheCourthadtheoccasiontodeterminetherelationshipbetweenahospitalandaconsultantor
visitingphysicianandtheliabilityofsuchhospitalforthatphysician'snegligencein Ramosv.
CourtofAppeals,39towit:
Inthefirstplace,hospitalsexercisesignificantcontrolinthehiringandfiringofconsultantsandin
theconductoftheirworkwithinthehospitalpremises.Doctorswhoapplyfor"consultant"slots,
visitingorattending,arerequiredtosubmitproofofcompletionofresidency,theireducational
qualifications;generally,evidenceofaccreditationbytheappropriateboard(diplomate),evidence
of fellowship in most cases, and references. These requirements are carefully scrutinized by
membersofthehospitaladministrationorbyareviewcommitteesetupbythehospitalwhoeither
acceptorrejecttheapplication.Thisisparticularlytruewithrespondenthospital.
Afteraphysicianisaccepted,eitherasavisitingorattendingconsultant,heisnormallyrequiredto
attendclinicopathologicalconferences,conductbedsideroundsforclerks,internsandresidents,
moderategrandroundsandpatientauditsandperformothertasksandresponsibilities, forthe
privilegeofbeingabletomaintainaclinicinthehospital,and/orfortheprivilegeofadmitting
patients into the hospital. In addition to these, the physician's performance as a specialist is
generallyevaluatedbyapeerreviewcommitteeonthebasisofmortalityandmorbiditystatistics,
andfeedbackfrompatients,nurses,internsandresidents.Aconsultantremissinhisduties,ora
consultantwhoregularlyfallsshortoftheminimumstandardsacceptabletothehospitaloritspeer
reviewcommittee,isnormallypolitelyterminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and
visiting"consultant"staff. While"consultants"arenot,technicallyemployees,apointwhich
differsfromtheDarlingcasesinceDr.Estradaisanindependentcontractorphysicianwhereasthe
Darlingcaseinvolvedaphysicianandanursewhowereemployeesofthehospital.
CitingotherAmericancases,theCourtofAppealsfurtherheldthatthemerefactthatahospital
permittedaphysiciantopracticemedicineanduseitsfacilitiesisnotsufficienttorenderthe
physicianwhoisanindependentcontractor.29
TheCourtofAppealsfoundthecasesof Davidsonv.Conole30 and Campbellv.EmmaLaing
StevensHospital31 applicabletothiscase. Quoting Campbell, theCourtofAppealsstatedthat
wherethereisnoproofthatdefendantphysicianwasanemployeeofdefendanthospitalorthat
defendanthospitalhadreasontoknowthatanyactsofmalpracticewouldtakeplace,defendant
hospitalcouldnotbeheldliableforitsfailuretointerveneintherelationshipofphysicianpatient
betweendefendantphysicianandplaintiff.
Ontheliabilityoftheotherrespondents,theCourtofAppealsappliedthe"borrowedservant"
doctrineconsideringthatDr.Estradawasanindependentcontractorwhowasmerelyexercising
hospitalprivileges.Thisdoctrineprovidesthatoncethesurgeonenterstheoperatingroomand
takes charge of the proceedings, the acts or omissions of operating room personnel, and any
negligence associated with such acts or omissions, are imputable to the surgeon. 32 While the
assistingphysiciansandnursesmaybeemployedbythehospital,orengagedbythepatient,they
normallybecomethetemporaryservantsoragentsofthesurgeoninchargewhiletheoperationis
inprogress, and liability may be imposed upon the surgeon for their negligent acts under the
doctrineofrespondeatsuperior.33
TheCourtofAppealsconcludedthatsinceRogelioengagedDr.Estradaastheattendingphysician
ofhiswife,anyliabilityformalpracticemustbeDr.Estrada'ssoleresponsibility.
Whileitfoundtheamountofdamagesfairandreasonable,theCourtofAppealsheldthatno
interestcouldbeimposedonunliquidatedclaimsordamages.
TheIssue
Basically,theissueinthiscaseiswhetherCMCisvicariouslyliableforthenegligenceofDr.
Estrada. The resolution of this issue rests, on the other hand, on the ascertainment of the
relationshipbetweenDr.EstradaandCMC.TheCourtalsobelievesthatadeterminationofthe
extentofliabilityoftheotherrespondentsisinevitabletofinallyandcompletelydisposeofthe
presentcontroversy.
TheRulingoftheCourt
Thepetitionispartlymeritorious.
OntheLiabilityofCMC
Dr.Estrada'snegligenceinhandlingthetreatmentandmanagementofCorazon'sconditionwhich
ultimatelyresultedinCorazon'sdeathisnolongerinissue.Dr.Estradadidnotappealthedecision
oftheCourtofAppealswhichaffirmedtherulingofthetrialcourtfindingDr.Estradasolelyliable
fordamages.Accordingly,thefindingofthetrialcourtonDr.Estrada'snegligenceisalreadyfinal.
PetitionersmaintainthatCMCisvicariouslyliableforDr.Estrada'snegligencebasedonArticle
2180inrelationtoArticle2176oftheCivilCode.Theseprovisionspertinentlystate:
Art.2180.Theobligationimposedbyarticle2176isdemandablenotonlyforone'sownactsor
omissions,butalsoforthoseofpersonsforwhomoneisresponsible.
xxxx
Employersshallbeliableforthedamagescausedbytheiremployeesandhouseholdhelpersacting
withinthescopeoftheirassignedtasks,eventhoughtheformerarenotengagedinanybusinessor
industry.
Theelementof"holdingout"onthepartofthehospitaldoesnotrequireanexpressrepresentation
bythehospitalthatthepersonallegedtobenegligentisanemployee.Rather,theelementis
satisfiedifthehospitalholdsitselfoutasaproviderofemergencyroomcarewithoutinformingthe
patientthatthecareisprovidedbyindependentcontractors.
Theelementofjustifiablerelianceonthepartoftheplaintiffissatisfiediftheplaintiffreliesupon
thehospitaltoprovidecompleteemergencyroomcare,ratherthanuponaspecificphysician.
Thedoctrineofapparentauthorityessentiallyinvolvestwofactorstodeterminetheliabilityofan
independentcontractorphysician.
Thefirstfactorfocusesonthehospital'smanifestationsandissometimesdescribedasaninquiry
whetherthehospitalactedinamannerwhichwouldleadareasonablepersontoconcludethatthe
individualwhowasallegedtobenegligentwasanemployeeoragentofthehospital. 47 Inthis
regard,thehospitalneednotmakeexpressrepresentationstothepatientthatthetreating
physician is an employee of the hospital; rather a representation may be general and
implied.48
Thedoctrineofapparentauthorityisaspeciesofthedoctrineofestoppel.Article1431oftheCivil
Codeprovidesthat"[t]hroughestoppel,anadmissionorrepresentationisrenderedconclusiveupon
thepersonmakingit,andcannotbedeniedordisprovedasagainstthepersonrelyingthereon."
Estoppel rests on this rule: "Whenever a party has, by his own declaration, act, or omission,
intentionallyanddeliberatelyledanothertobelieveaparticularthingtrue,andtoactuponsuch
belief,hecannot,inanylitigationarisingoutofsuchdeclaration,actoromission,bepermittedto
falsifyit."49
Intheinstantcase,CMCimpliedlyheldoutDr.Estradaasamemberofitsmedicalstaff.Through
CMC'sacts,CMCclothedDr.EstradawithapparentauthoritytherebyleadingtheSpousesNogales
tobelievethatDr.EstradawasanemployeeoragentofCMC.CMCcannotnowrepudiatesuch
authority.
First,CMCgrantedstaffprivilegestoDr.Estrada.CMCextendeditsmedicalstaffandfacilitiesto
Dr.Estrada.UponDr. Estrada'srequestforCorazon'sadmission,CMC,throughitspersonnel,
readilyaccommodatedCorazonandupdatedDr.Estradaofhercondition.
Second,CMCmadeRogeliosignconsentformsprintedonCMCletterhead.PriortoCorazon's
admissionandsupposedhysterectomy,CMCaskedRogeliotosignreleaseforms,thecontentsof
whichreinforcedRogelio'sbeliefthatDr.EstradawasamemberofCMC'smedicalstaff. 50 The
ConsentonAdmissionandAgreementexplicitlyprovides:
KNOWALLMENBYTHESEPRESENTS:
I,RogelioNogales,oflegalage,aresidentof1974M.H.DelPilarSt.,MalateMla.,beingthe
father/mother/brother/sister/spouse/relative/ guardian/or person in custody of Ma. Corazon, and
representinghis/herfamily,ofmyownvolitionandfreewill,doconsentandsubmitsaidMa.
CorazontoDr.OscarEstrada(hereinafterreferredtoasPhysician)forcure,treatment,retreatment,
oremergencymeasures,thatthePhysician,personallyorbyandthroughtheCapitolMedical
Centerand/oritsstaff,mayuse,adapt,oremploysuchmeans,formsormethodsofcure,
treatment,retreatment,oremergencymeasuresashemayseebestandmostexpedient;that
Ma. Corazon and I will comply with any and all rules, regulations, directions, and
instructionsofthePhysician,theCapitolMedicalCenterand/oritsstaff;and,thatIwillnot
holdliableorresponsibleandherebywaiveandforeverdischargeandholdfreethePhysician,the
CapitolMedicalCenterand/oritsstaff,fromanyandallclaimsofwhateverkindofnature,arising
respondent hospital asserts in denying all responsibility for the patient's condition, the
controlexercised,thehiring,andtherighttoterminateconsultantsallfulfilltheimportant
hallmarksofanemployeremployeerelationship,withtheexceptionofthepaymentofwages.
In assessing whether such a relationship in fact exists, the control test is determining.
Accordingly, on the basis of the foregoing, we rule that for the purpose of allocating
responsibilityinmedicalnegligencecases,anemployeremployeerelationshipineffectexists
betweenhospitalsandtheirattendingandvisitingphysicians.Thisbeingthecase,thequestion
nowarisesastowhetherornotrespondenthospitalissolidarilyliablewithrespondentdoctorsfor
petitioner'scondition.
Thebasisforholdinganemployersolidarilyresponsibleforthenegligenceofitsemployeeis
foundinArticle2180oftheCivilCodewhichconsidersapersonaccountablenotonlyforhisown
actsbutalsoforthoseofothersbasedontheformer'sresponsibilityunderarelationshipofpatria
potestas.xxx40(Emphasissupplied)
WhiletheCourtin Ramos didnotexpoundonthecontroltest,suchtestessentiallydetermines
whether an employment relationship exists between a physician and a hospital based on the
exerciseofcontroloverthephysicianastodetails.Specifically,theemployer(orthehospital)must
havetherighttocontrolboththemeansandthedetailsoftheprocessbywhichtheemployee(or
thephysician)istoaccomplishhistask.41
Afterathoroughexaminationofthevoluminousrecordsofthiscase,theCourtfindsnosingle
evidencepointingtoCMC'sexerciseofcontroloverDr.Estrada'streatmentandmanagementof
Corazon's condition. It is undisputed that throughout Corazon's pregnancy, she was under the
exclusiveprenatalcareofDr.Estrada.AtthetimeofCorazon'sadmissionatCMCandduringher
delivery,itwasDr.Estrada,assistedbyDr.Villaflor,whoattendedtoCorazon.Therewasno
showingthatCMChadapartindiagnosingCorazon'scondition.WhileDr.Estradaenjoyedstaff
privilegesatCMC,suchfactalonedidnotmakehimanemployeeofCMC.42CMCmerelyallowed
Dr.Estradatouseitsfacilities 43whenCorazonwasabouttogivebirth,whichCMCconsideredan
emergency. Considering these circumstances, Dr. Estrada is not an employee of CMC, butan
independentcontractor.
ThequestionnowiswhetherCMCisautomaticallyexemptfromliabilityconsideringthatDr.
Estradaisanindependentcontractorphysician.
Ingeneral,ahospitalisnotliableforthenegligenceofanindependentcontractorphysician.There
is, however, an exceptionto thisprinciple. The hospitalmay beliable ifthe physicianis the
"ostensible"agentofthehospital.44 Thisexceptionisalsoknownasthe"doctrineofapparent
authority."45InGilbertv.SycamoreMunicipalHospital,46theIllinoisSupremeCourtexplainedthe
doctrineofapparentauthorityinthiswise:
[U]nderthedoctrineofapparentauthorityahospitalcanbeheldvicariouslyliableforthenegligent
acts of a physician providing care at the hospital, regardless of whether the physician is an
independentcontractor,unlessthepatientknows,orshouldhaveknown,thatthephysicianisan
independentcontractor.Theelementsoftheactionhavebeensetoutasfollows:
"Forahospitaltobeliableunderthedoctrineofapparentauthority,aplaintiffmustshowthat:(1)
thehospital,oritsagent,actedinamannerthatwouldleadareasonablepersontoconcludethatthe
individualwhowasallegedtobenegligentwasanemployeeoragentofthehospital;(2)wherethe
actsoftheagentcreatetheappearanceofauthority,theplaintiffmustalsoprovethatthehospital
hadknowledgeofandacquiescedinthem;and(3)theplaintiffactedinrelianceupontheconduct
ofthehospitaloritsagent,consistentwithordinarycareandprudence."
thisregard,theCourtagreeswiththeobservationmadebytheCourtofAppealsofNorthCarolina
inDiggsv.NovantHealth,Inc.,57towit:
"Theconceptionthatthehospitaldoesnotundertaketotreatthepatient,doesnotundertaketoact
throughitsdoctorsandnurses,butundertakesinsteadsimplytoprocurethemtoactupontheirown
responsibility,nolongerreflectsthefact. Presentdayhospitals,astheirmannerofoperation
plainly demonstrates, do far more than furnish facilities for treatment. They regularly
employonasalarybasisalargestaffofphysicians, nursesandinternes[sic],aswellas
administrative and manual workers, and they charge patients for medical care and
treatment,collectingforsuchservices,ifnecessary,bylegalaction.Certainly,thepersonwho
availshimselfof'hospitalfacilities'expectsthatthehospitalwillattempttocurehim,notthat
itsnursesorotheremployeeswillactontheirownresponsibility."xxx(Emphasissupplied)
LikewiseunconvincingisCMC'sargumentthatpetitionersareestoppedfromclaimingdamages
basedontheConsentonAdmissionandConsenttoOperation.Bothreleaseformsconsistoftwo
parts. The first part gave CMC permission to administer to Corazon any form of recognized
medical treatment which the CMC medical staff deemed advisable. The second part of the
documents, which may properly be described as the releasing part, releases CMC and its
employees"fromanyandallclaims"arisingfromorbyreasonofthetreatmentandoperation.
The documents do not expressly release CMC from liability for injury to Corazon due to
negligenceduringhertreatmentoroperation.NeitherdotheconsentformsexpresslyexemptCMC
from liability for Corazon's death due to negligence during such treatment or operation. Such
releaseforms,beinginthenatureofcontractsofadhesion,areconstruedstrictlyagainsthospitals.
Besides,ablanketreleaseinfavorofhospitals"fromanyandallclaims,"whichincludesclaims
duetobadfaithorgrossnegligence,wouldbecontrarytopublicpolicyandthusvoid.
Evensimplenegligenceisnotsubjecttoblanketreleaseinfavorofestablishmentslikehospitals
butmayonlymitigateliabilitydependingonthecircumstances.58 Whenapersonneedingurgent
medicalattentionrushestoahospital,hecannotbargainonequalfootingwiththehospitalonthe
termsofadmissionandoperation.Suchapersonisliterallyatthemercyofthehospital.Therecan
benoclearerexampleofacontractofadhesionthanonearisingfromsuchadiresituation.Thus,
thereleaseformsofCMCcannotrelieveCMCfromliabilityforthenegligentmedicaltreatmentof
Corazon.
OntheLiabilityoftheOtherRespondents
Despite this Court's pronouncement in its 9 September 2002 59 Resolution that the filing of
petitioners'Manifestationconfinedpetitioners'claimonlyagainstCMC,Dr.Espinola,Dr.Lacson,
andDr.Uy,whohavefiledtheircomments,theCourtdeemsitpropertoresolvetheindividual
liability of the remaining respondents to put an end finally to this more than twodecade old
controversy.
a)Dr.ElyVillaflor
PetitionersblameDr.ElyVillaflorforfailingtodiagnosethecauseofCorazon'sbleedingandto
suggestthecorrectremedytoDr.Estrada. 60 PetitionersassertthatitwasDr.Villaflor'sdutyto
correcttheerrorofNurseDumlaointheadministrationofhemacel.
TheCourtisnotpersuaded.Dr.Villafloradmittedadministeringalowerdosageofmagnesium
sulfate.However,thiswasafterinformingDr.EstradathatCorazonwasnolongerinconvulsion
and that her blood pressure went down to a dangerous level. 61 At that moment, Dr. Estrada
instructedDr.Villaflortoreducethedosageofmagnesiumsulfatefrom10to2.5grams.Since
petitionersdidnotdisputeDr.Villaflor'sallegation,Dr.Villaflor'sdefenseremainsuncontroverted.
fromdirectlyorindirectly, or by reason of said cure, treatment, or retreatment, oremergency
measuresorinterventionofsaidphysician,theCapitolMedicalCenterand/oritsstaff.
xxxx51(Emphasissupplied)
WhiletheConsenttoOperationpertinentlyreads,thus:
I,ROGELIONOGALES,xxx,ofmyownvolitionandfreewill,doconsentandsubmitsaid
CORAZONNOGALEStoHysterectomy,bytheSurgicalStaffandAnesthesiologistsofCapitol
MedicalCenterand/orwhateversucceedingoperations,treatment,oremergencymeasuresasmay
benecessaryandmostexpedient;and,thatIwillnotholdliableorresponsibleandherebywaive
and forever discharge and hold free the Surgeon, his assistants, anesthesiologists, the Capitol
MedicalCenterand/oritsstaff,fromanyandallclaimsofwhateverkindofnature,arisingfrom
directly or indirectly, or by reason of said operation or operations, treatment, or emergency
measures, or interventionof theSurgeon, his assistants, anesthesiologists, theCapitol Medical
Centerand/oritsstaff.52(Emphasissupplied)
WithoutanyindicationintheseconsentformsthatDr.Estradawasanindependentcontractor
physician, the Spouses Nogales could not have known that Dr. Estrada was an independent
contractor.Significantly,noonefromCMCinformedtheSpousesNogalesthatDr.Estradawasan
independentcontractor.Onthecontrary,Dr.Atencio,whowasthenamemberofCMCBoardof
Directors,testifiedthatDr.EstradawaspartofCMC'ssurgicalstaff.53
Third,Dr.Estrada'sreferralofCorazon'sprofusevaginalbleedingtoDr.Espinola,whowasthen
theHeadoftheObstetricsandGynecologyDepartmentofCMC,gavetheimpressionthatDr.
Estrada as a member of CMC's medical staff was collaborating with other CMCemployed
specialistsintreatingCorazon.
Thesecondfactorfocusesonthepatient'sreliance.Itissometimescharacterizedasaninquiryon
whethertheplaintiffactedinrelianceupontheconductofthehospitaloritsagent,consistentwith
ordinarycareandprudence.54
TherecordsshowthattheSpousesNogalesrelieduponaperceivedemploymentrelationshipwith
CMCinacceptingDr.Estrada'sservices.Rogeliotestifiedthatheandhiswifespecificallychose
Dr.EstradatohandleCorazon'sdeliverynotonlybecauseoftheirfriend'srecommendation,but
moreimportantlybecauseofDr.Estrada's"connectionwithareputablehospital,the[CMC]."55In
otherwords,Dr.Estrada'srelationshipwithCMCplayedasignificantroleintheSpousesNogales'
decisioninacceptingDr.Estrada'sservicesastheobstetriciangynecologistforCorazon'sdelivery.
Moreover,asearlierstated,thereisnoshowingthatbeforeandduringCorazon'sconfinementat
CMC,theSpousesNogaleskneworshouldhaveknownthatDr.Estradawasnotanemployeeof
CMC.
Further,theSpousesNogaleslookedtoCMCtoprovidethebestmedicalcareandsupportservices
forCorazon'sdelivery.TheCourtnotesthatpriortoCorazon'sfourthpregnancy,sheusedtogive
birthinsideaclinic.ConsideringCorazon'sagethen,theSpousesNogalesdecidedtohavetheir
fourthchilddeliveredatCMC,whichRogelioregardedoneofthebesthospitalsatthetime. 56This
is precisely because the Spouses Nogales feared that Corazon might experience complications
duringherdeliverywhichwouldbebetteraddressedandtreatedinamodernandbighospitalsuch
asCMC.Moreover,Rogelio'sconsentinCorazon'shysterectomytobeperformedbyadifferent
physician,namelyDr.Espinola,isaclearindicationofRogelio'sconfidenceinCMC'ssurgical
staff.
CMC'sdefensethatallitdidwas"toextendto[Corazon]itsfacilities"isuntenable.TheCourt
cannotcloseitseyestotherealitythathospitals,suchasCMC,areinthebusinessoftreatment.In
constitutedalackofreasonableandordinarycare;(2)thenurseinjectedmedicineintravenously;
and(3)suchinjectionwastheproximatecauseofhisinjury.
Inthepresentcase,thereisnoevidenceofNurseDumlao'sallegedfailuretofollowDr.Estrada's
specificinstructions.EvenassumingNurseDumlaodefiedDr.Estrada'sorder,thereisnoshowing
thatsidedripadministrationofhemacelproximatelycausedCorazon'sdeath.Noevidencelinking
Corazon'sdeathandtheallegedwrongfulhemaceladministrationwasintroduced.Therefore,there
isnobasistoholdNurseDumlaoliablefornegligence.
OntheAwardofInterestonDamages
TheawardofinterestondamagesisproperandallowedunderArticle2211oftheCivilCode,
whichstatesthatincrimesandquasidelicts,interestasapartofthedamagesmay,inaproper
case,beadjudicatedinthediscretionofthecourt.68
WHEREFORE,theCourtPARTLYGRANTSthepetition.TheCourtfindsrespondentCapitol
Medical Center vicariously liable for the negligence of Dr. Oscar Estrada. The amounts of
P105,000asactualdamagesandP700,000asmoraldamagesshouldeachearnlegalinterestatthe
rateofsixpercent(6%)perannumcomputedfromthedateofthejudgmentofthetrialcourt.The
CourtaffirmstherestoftheDecisiondated6February1998andResolutiondated21March2000
oftheCourtofAppealsinCAG.R.CVNo.45641.
SOORDERED.
Casedigest:
Nogales vs. Capitol Medical Center
Carpio, J.:G.R. No. 142625, Dec. 19, 2006 | 511 SCRA 204
FACTS:
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 years old, was
under the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada") beginning on her fourth
month of pregnancy or as early as December 1975. While Corazon was on her last trimester of
pregnancy, Dr. Estrada noted an increase in her blood pressure and development of leg edema5
indicating preeclampsia, which is a dangerous complication of pregnancy.
Around midnight of 25 May 1976, Corazon started to experience mild labor painsprompting
Corazon and Rogelio Nogales ("Spouses Nogales") to see Dr. Estrada at his home. After examining
Corazon, Dr. Estrada advised her immediate admission to the Capitol Medical Center ("CMC").
On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the staff nurse noted the
written admission request8 of Dr. Estrada. Upon Corazon's admission at the CMC,
Rogelio Nogales ("Rogelio") executed and signed the "Consent on Admission Agreement and
Admission Agreement. Corazon was then bought to the labor room of the CMC.
Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an internal
examination of Corazon. Dr. Uy then called up Dr. Estrada to notify him of her findings.
Dr.Villaflor'sactofadministeringalowerdosageofmagnesiumsulfatewasnotoutofherown
volitionorwasincontraventionofDr.Estrada'sorder.
b)Dr.RosaUy
Dr.RosaUy'sallegednegligenceconsistedofherfailure(1)tocalltheattentionofDr.Estradaon
theincorrectdosageofmagnesiumsulfateadministeredbyDr.Villaflor;(2)totakecorrective
measures;and(3)tocorrectNurseDumlao'swrongmethodofhemaceladministration.
TheCourtbelievesDr.Uy'sclaimthatasasecondyearresidentphysicianthenatCMC,shewas
merelyauthorizedtotaketheclinicalhistoryandphysicalexaminationofCorazon.62However,that
routineinternalexaminationdidnotipsofactomakeDr.UyliablefortheerrorscommittedbyDr.
Estrada.Further,petitioners'imputationofnegligencerestsontheirbaselessassumptionthatDr.
Uy was present at the delivery room. Nothing shows that Dr. Uy participated in delivering
Corazon'sbaby.Further,itisunexpectedfromDr.Uy,amereresidentphysicianatthattime,to
calltheattentionofamoreexperiencedspecialist,ifevershewaspresentatthedeliveryroom.
c)Dr.JoelEnriquez
PetitionersfaultDr.JoelEnriquezalsofornotcallingtheattentionofDr.Estrada,Dr.Villaflor,
andNurseDumlaoabouttheirerrors. 63PetitionersinsistthatDr.Enriquezshouldhavetaken,orat
leastsuggested,correctivemeasurestorectifysucherrors.
The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field of expertise is
definitelynotobstetricsandgynecology.Assuch,Dr.EnriquezwasnotexpectedtocorrectDr.
Estrada's errors. Besides, there was no evidence of Dr. Enriquez's knowledge of any error
committedbyDr.Estradaandhisfailuretoactuponsuchobservation.
d)Dr.PerpetuaLacson
PetitionersfaultDr.PerpetuaLacsonforherpurporteddelayinthedeliveryofbloodCorazon
needed.64PetitionersclaimthatDr.Lacsonwasremissinherdutyofsupervisingthebloodbank
staff.
Asfoundbythetrialcourt,therewasnounreasonabledelayinthedeliveryofbloodfromthetime
oftherequestuntilthetransfusiontoCorazon.Dr.Lacsoncompetentlyexplainedtheprocedure
beforebloodcouldbegiventothepatient. 65Takingintoaccountthebleedingtime,clottingtime
and crossmatching, Dr. Lacson stated that it would take approximately 4560 minutes before
bloodcouldbereadyfortransfusion. 66 Further,noevidenceexiststhatDr.Lacsonneglectedher
dutiesasheadofthebloodbank.
e)Dr.NoeEspinola
Petitioners argue that Dr. Espinola should not have ordered immediate hysterectomy without
determiningtheunderlyingcauseofCorazon'sbleeding.Dr.Espinolashouldhavefirstconsidered
thepossibilityofcervicalinjury,andadvisedathoroughexaminationofthecervix,insteadof
believingoutrightDr.Estrada'sdiagnosisthatthecauseofbleedingwasuterineatony.
Dr.Espinola'sordertodohysterectomywhichwasbasedontheinformationhereceivedbyphone
is not negligence. The Court agrees with the trial court's observation that Dr. Espinola, upon
hearingsuchinformationaboutCorazon'scondition,believedingoodfaiththathysterectomywas
the correct remedy. At any rate, the hysterectomy did not push through because upon Dr.
Espinola'sarrival,itwasalreadytoolate.Atthetime,Corazonwaspracticallydead.
f)NurseJ.Dumlao
InMoorev.GuthrieHospitalInc.,67theUSCourtofAppeals,FourthCircuit,heldthattorecover,a
patientcomplainingofinjuriesallegedlyresultingwhenthenursenegligentlyinjectedmedicineto
him intravenously instead of intramuscularly had to show that (1) an intravenous injection
physicians and CMC personnel were negligent in the treatment and management of Corazon's
condition. Petitioners charged CMC with negligence in the selection and supervision of defendant
physicians and hospital staff.
ISSUES & ARGUMENTS
W/N CMC should be held liable
HOLDING & RATIO DECIDENDI
YES
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 negligence of a physician who is an independent
contractor
o There is no proof that defendant physician was an employee of defendant hospital or
that the latter had reason to know that any acts of malpractice would take place
B o r r o w e d S e r v a n t D o c t r i n e
once the surgeon enters the operating room and takes charge of the proceedings, the acts or
omissions of operating room personnel, and any negligence associated with such acts or
omissions, are imputable to the surgeon.
o While the assisting physicians and nurses may be employed by thehospital, or engaged by
the patient, they normally become the temporary servants or agents of the surgeon in charge
while the operation is in progress, and liability may be imposed upon the surgeon for their
negligent acts under the doctrine of respondeat superior
A hospital is the employer, master, or principal of a physician employee, servant, or
agent, and may be held liable for the physicians negligence
While "consultants" are not, technically employees, a point which respondent hospital asserts in
denying all responsibility for the patient's condition, the control exercised, the hiring, and the right
to terminate consultants all fulfill the important hallmarks of an employer-employee relationship,
with the exception of the payment of wages.
O In assessing whether such a relationship in fact exists, the c o n t r o l t e s t is
determining. Accordingly, on the basis of the foregoing, we rule that for the purpose of
allocating responsibility in medical negligence cases, an employer-employee relationship in
effect exists between hospitals and their attending and visiting physicians.
After a thorough examination of the voluminous records of this case, the Court finds no single
evidence pointing to CMC's exercise of control over Dr.Estrada's treatment and management of
Corazon's condition.
o It is undisputed that throughout Corazon's pregnancy, she was under the exclusive prenatal
care of Dr. Estrada. At the time of Corazon's admission at CMC and during her delivery, it was
Dr. Estrada, assisted by Dr. Villaflor, who attended to Corazon.
o There was no showing that CMC had a part in diagnosing Corazon's condition.
o While Dr. Estrada enjoyed staff privileges at CMC, such fact alone did not make him an
employee of CMC.42 CMC merely allowed Dr.Estrada to use its facilities43 when Corazon was
Based on the Doctor's Order Sheet, around 3:00 a.m., Dr. Estrada ordered for 10 mg.of valium to
be administered immediately by intramuscular injection. Dr. Estrada later ordered the start of
intravenous administration of syntocinon admixed with dextrose,5%, in lactated Ringers' solution,
at the rate of eight to ten micro-drops per minute.
According to the Nurse's Observation Notes, Dr. Joel Enriquez ("Dr. Enriquez"), an anesthesiologist
at CMC, was notified at 4:15 a.m. of Corazon's admission. Subsequently, when asked if he
needed the services of an anesthesiologist, Dr. Estrada refused. Despite Dr. Estrada's refusal, Dr.
Enriquez stayed to observe Corazons condition.
At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10a.m., Corazon's
bag of water ruptured spontaneously. At 6:12 a.m., Corazon's cervix was fully dilated. At 6:13 a.m.,
Corazon started to experience convulsions.
At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfate. However, Dr. Ely
Villaflor ("Dr. Villaflor"), who was assisting Dr. Estrada, administered only 2.5 grams of magnesium
sulphate.
At 6:22 a.m. Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract Corazon's baby. In
the process, a 1.0 x 2.5 cm. piece of cervical tissue was allegedly torn. The baby came out in
an apnic, cyanotic, weak and injured condition. Consequently, the baby had to be intubated and
resuscitated by Dr. Enriquez and Dr. Payumo.
At 6:27 a.m., Corazon began to manifest moderate vaginal bleeding which rapidly became profuse.
Corazon's blood pressure dropped from 130/80 to 60/40 within five minutes. There was
continuous profuse vaginal bleeding. The assisting nurse administered hemacel through a gauge
19 needle as a side drip to the ongoing intravenous injection of dextrose.
At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with bottled blood. Ittook
approximately 30 minutes for the CMC laboratory, headed by Dr. Perpetua Lacson("Dr. Lacson"), to
comply with Dr. Estrada's order and deliver the blood.
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-Gynecology Department of
the CMC, was apprised of Corazon's condition by telephone. Upon being informed that Corazon
was bleeding profusely, Dr. Espinola ordered immediate hysterectomy. Rogelio was made to sign a
"Consent to Operation."13
Due to the inclement weather then, Dr. Espinola, who was fetched from his residence by an
ambulance, arrived at the CMC about an hour later or at 9:00 a.m. He examined the patient and
ordered some resuscitative measures to be administered. Despite Dr.Espinola's efforts, Corazon
died at 9:15 a.m. The cause of death was "hemorrhage, postpartum."14
On 14 May 1980, petitioners filed a complaint for damages15 with the Regional TrialCourt16 of
Manila against CMC, Dr. Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr.Lacson, Dr. Espinola, and a
certain Nurse J. Dumlao for the death of Corazon. Petitioners mainly contended that defendant
 about to give birth, which CMC considered an emergency. Considering thesecircumstances,
Dr. Estrada is not an employee of CMC, but an independent contractor
.
Question now is whether CMC is automatically exempt from liability considering that Dr. Estrada
is an independent contractor-physician.
o General Rule: Hospital is NOT liable for the negligence of an independent contractor-
physician
o Exception:
D o c t r i n e o f A p p a r e n t A u t h o r i t y ( D A A )
- a hospital can be held vicariously liable for the negligent acts of a physician providing
care at the hospital, regardless of whether the physician is an independent contractor,
unless the patient knows, or should have known, that the physician is an independent
contractor.

Elements:
Hospital, or its agent, acted in a manner that would lead a reasonable person to
conclude that the individual who was alleged to be negligent was an employee or agent
of the hospital
Where the acts of the agent create the appearance of authority, the plaintiff must
also prove that the hospital had knowledge of and acquiesced in them ;and
The plaintiff acted in reliance upon the conduct of the hospital or its agent,
consistent with ordinary care and prudence

o 2 Factors to determine liability of an independent contractor-physician:

Hospitals manifestations
Inquiry whether the hospital acted in a manner which would lead a
reasonable person to conclude that the individual who was alleged to be
negligent was an employee or agent of the hospital
Patients reliance
Inquiry on whether the plaintiff acted in reliance upon the conduct of the hospital
or its agent, consistent with ordinary care and prudence

o Circumstances of the cases showing application of DAA:

CMC granted Dr. Estrada staff privileges
Consent forms were printed on CMC letterhead
Dr. Estradas referral of Corazons case with other physicians of CMC gave the
impression that he, as a member of the CMCs medical staff, was collaborating with
other CMC-employed specialists
Spouses Nogales took Dr. Estrada as their physician inconsideration of his connection
with a reputable hospital(CMC)
Played a significant role in the Spouses decision

WHEREFORE, CMC is found liable to pay the corresponding damages