EN BANC

DR. RUBI LI,

G.R. No. 165279
Petitioner,
Present:
CORONA, C.J.,
CARPIO,
CARPIO MORALES,
VELASCO, JR.,
NACHURA,
LEONARDO-DE CASTRO,
BRION,
PERALTA,
- versus BERSAMIN,
DEL CASTILLO,
ABAD,
VILLARAMA, JR.,
PEREZ,
MENDOZA, and
SERENO, JJ.
SPOUSES REYNALDO and LINA
SOLIMAN, as parents/heirs of deceased
Angelica Soliman,
Promulgated:
Respondents.
June 7, 2011
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DECISION
VILLARAMA, JR., J.:
Challenged in this petition for review on certiorari is the Decision1[1] dated J
une 15, 2004 as well as the
Resolution2[2] dated September 1, 2004 of the Court of Appeals (CA) in CA-G.R. C
V No. 58013 which modified the
Decision3[3] dated September 5, 1997 of the Regional Trial Court of Legazpi City
, Branch 8 in Civil Case No. 8904.
The factual antecedents:
On July 7, 1993, respondents 11-year old daughter, Angelica Soliman, underwent a
biopsy of the mass located in
her lower extremity at the St. Lukes Medical Center (SLMC). Results showed that
Angelica was suffering from
osteosarcoma, osteoblastic type,4[4] a high-grade (highly malignant) cancer of t
he bone which usually afflicts teenage
children. Following this diagnosis and as primary intervention, Angelicas right
leg was amputated by Dr. Jaime Tamayo in
order to remove the tumor. As adjuvant treatment to eliminate any remaining canc
er cells, and hence minimize the
chances of recurrence and prevent the disease from spreading to other parts of t
he patients body (metastasis),
chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo referred Angelica to anothe
r doctor at SLMC, herein petitioner
Dr. Rubi Li, a medical oncologist.
On August 18, 1993, Angelica was admitted to SLMC. However, she died on Septembe
r 1, 1993, just eleven (11)
days after the (intravenous) administration of the first cycle of the chemothera
py regimen. Because SLMC refused to
release a death certificate without full payment of their hospital bill, respond
ents brought the cadaver of Angelica to the
Philippine National Police (PNP) Crime Laboratory at Camp Crame for post-mortem
examination. The Medico-Legal
Report issued by said institution indicated the cause of death as Hypovolemic sh
ock secondary to multiple organ
hemorrhages and Disseminated Intravascular Coagulation.5[5]
On the other hand, the Certificate of Death6[6] issued by SLMC stated the cause
of death as follows:
Immediate cause
Antecedent cause
: a. Osteosarcoma, Status Post AKA
: b. (above knee amputation)

Underlying cause
: c.
Status Post Chemotherapy
On February 21, 1994, respondents filed a damage suit7[7] against petitioner, Dr
. Leo Marbella, Mr. Jose
Ledesma, a certain Dr. Arriete and SLMC. Respondents charged them with negligenc
e and disregard of Angelicas safety,
health and welfare by their careless administration of the chemotherapy drugs, t
heir failure to observe the essential
precautions in detecting early the symptoms of fatal blood platelet decrease and
stopping early on the chemotherapy,
which bleeding led to hypovolemic shock that caused Angelicas untimely demise. F
urther, it was specifically averred that
petitioner assured the respondents that Angelica would recover in view of 95% ch
ance of healing with chemotherapy
(Magiging normal na ang anak nyo basta ma-chemo. 95% ang healing) and when asked
regarding the side effects,
petitioner mentioned only slight vomiting, hair loss and weakness (Magsusuka ng
kaunti. Malulugas ang buhok.
Manghihina). Respondents thus claimed that they would not have given their conse
nt to chemotherapy had petitioner not
falsely assured them of its side effects.
In her answer,8[8] petitioner denied having been negligent in administering the
chemotherapy drugs to Angelica
and asserted that she had fully explained to respondents how the chemotherapy wi
ll affect not only the cancer cells but
also the patients normal body parts, including the lowering of white and red blo
od cells and platelets. She claimed that
what happened to Angelica can be attributed to malignant tumor cells possibly le
ft behind after surgery. Few as they may
be, these have the capacity to compete for nutrients such that the body becomes
so weak structurally (cachexia) and
functionally in the form of lower resistance of the body to combat infection. Su
ch infection becomes uncontrollable and
triggers a chain of events (sepsis or septicemia) that may lead to bleeding in t
he form of Disseminated Intravascular
Coagulation (DIC), as what the autopsy report showed in the case of Angelica.
Since the medical records of Angelica were not produced in court, the trial and
appellate courts had to rely on
testimonial evidence, principally the declarations of petitioner and respondents
themselves. The following chronology of
events was gathered:
On July 23, 1993, petitioner saw the respondents at the hospital after Angelicas
surgery and discussed with them
Angelicas condition. Petitioner told respondents that Angelica should be given t
wo to three weeks to recover from the
operation before starting chemotherapy. Respondents were apprehensive due to fin
ancial constraints as Reynaldo earns
only from P70,000.00 to P150,000.00 a year from his jewelry and watch repairing
business.9[9] Petitioner, however,
assured them not to worry about her professional fee and told them to just save
up for the medicines to be used.
Petitioner claimed that she explained to respondents that even when a tumor is r
emoved, there are still small
lesions undetectable to the naked eye, and that adjuvant chemotherapy is needed
to clean out the small lesions in order to
lessen the chance of the cancer to recur. She did not give the respondents any a

ssurance that chemotherapy will cure

Angelicas cancer. During these consultations with respondents, she explained the
following side effects of chemotherapy
treatment to respondents: (1) falling hair; (2) nausea and vomiting; (3) loss of
appetite; (4) low count of white blood cells

[WBC], red blood cells [RBC] and platelets; (5) possible sterility due to the ef
fects on Angelicas ovary; (6) damage to the
heart and kidneys; and (7) darkening of the skin especially when exposed to sunl
ight. She actually talked with respondents
four times, once at the hospital after the surgery, twice at her clinic and the
fourth time when Angelicas mother called her
through long distance.10[10] This was disputed by respondents who countered that
petitioner gave them assurance that
there is 95% chance of healing for Angelica if she undergoes chemotherapy and th
at the only side effects were nausea,
vomiting and hair loss.11[11] Those were the only side-effects of chemotherapy t
reatment mentioned by petitioner.12[12]
On July 27, 1993, SLMC discharged Angelica, with instruction from petitioner tha
t she be readmitted after two or
three weeks for the chemotherapy.
On August 18, 1993, respondents brought Angelica to SLMC for chemotherapy, bring
ing with them the results of
the laboratory tests requested by petitioner: Angelicas chest x-ray, ultrasound
of the liver, creatinine and complete liver
function tests.13[13] Petitioner proceeded with the chemotherapy by first admini
stering hydration fluids to
Angelica.14[14]
The following day, August 19, petitioner began administering three chemotherapy
drugs Cisplatin,15[15]
Doxorubicin16[16] and Cosmegen17[17] intravenously. Petitioner was supposedly as
sisted by her trainees Dr. Leo
Marbella18[18] and Dr. Grace Arriete.19[19] In his testimony, Dr. Marbella denie
d having any participation in
administering the said chemotherapy drugs.20[20]
On the second day of chemotherapy, August 20, respondents noticed reddish discol
oration on Angelicas
face.21[21] They asked petitioner about it, but she merely quipped, Wala yan. Ep
ekto ng gamot.22[22] Petitioner

recalled noticing the skin rashes on the nose and cheek area of Angelica. At tha
t moment, she entertained the possibility
that Angelica also had systemic lupus and consulted Dr. Victoria Abesamis on the
matter.23[23]
On the third day of chemotherapy, August 21, Angelica had difficulty breathing a
nd was thus provided with
oxygen inhalation apparatus. This time, the reddish discoloration on Angelicas f
ace had extended to her neck, but
petitioner dismissed it again as merely the effect of medicines.24[24] Petitione
r testified that she did not see any
discoloration on Angelicas face, nor did she notice any difficulty in the childs
breathing. She claimed that Angelica merely
complained of nausea and was given ice chips.25[25]
On August 22, 1993, at around ten oclock in the morning, upon seeing that their
child could not anymore bear the
pain, respondents pleaded with petitioner to stop the chemotherapy. Petitioner s
upposedly replied: Dapat 15 Cosmegen
pa iyan. Okay, lets observe. If pwede na, bigyan uli ng chemo. At this point, re
spondents asked petitioners permission to
bring their child home. Later in the evening, Angelica passed black stool and re
ddish urine.26[26] Petitioner countered
that there was no record of blackening of stools but only an episode of loose bo
wel movement (LBM). Petitioner also
testified that what Angelica complained of was carpo-pedal spasm, not convulsion
or epileptic attack, as respondents call
it (petitioner described it in the vernacular as naninigas ang kamay at paa). Sh
e then requested for a serum calcium
determination and stopped the chemotherapy. When Angelica was given calcium gluc
onate, the spasm and numbness
subsided.27[27]
The following day, August 23, petitioner yielded to respondents request to take
Angelica home. But prior to
discharging Angelica, petitioner requested for a repeat serum calcium determinat
ion and explained to respondents that
the chemotherapy will be temporarily stopped while she observes Angelicas muscle
twitching and serum calcium level.
Take-home medicines were also prescribed for Angelica, with instructions to resp
ondents that the serum calcium test will
have to be repeated after seven days. Petitioner told respondents that she will
see Angelica again after two weeks, but
respondents can see her anytime if any immediate problem arises.28[28]
However, Angelica remained in confinement because while still in the premises of
SLMC, her convulsions
returned and she also had LBM. Angelica was given oxygen and administration of c
alcium continued.29[29]
The next day, August 24, respondents claimed that Angelica still suffered from c
onvulsions. They also noticed that
she had a fever and had difficulty breathing.30[30] Petitioner insisted it was c
arpo-pedal spasm, not convulsions. She

verified that at around 4:50 that afternoon, Angelica developed difficulty in br

eathing and had fever. She then requested for
an electrocardiogram analysis, and infused calcium gluconate on the patient at a
stat dose. She further ordered that Angelica
be given Bactrim,31[31] a synthetic antibacterial combination drug,32[32] to com
bat any infection on the childs
body.33[33]
By August 26, Angelica was bleeding through the mouth. Respondents also saw bloo
d on her anus and urine.
When Lina asked petitioner what was happening to her daughter, petitioner replie
d, Bagsak ang platelets ng anak mo.
Four units of platelet concentrates were then transfused to Angelica. Petitioner
prescribed Solucortef. Considering that
Angelicas fever was high and her white blood cell count was low, petitioner pres
cribed Leucomax. About four to eight bags
of blood, consisting of packed red blood cells, fresh whole blood, or platelet c
oncentrate, were transfused to Angelica. For
two days (August 27 to 28), Angelica continued bleeding, but petitioner claimed
it was lesser in amount and in frequency.
Petitioner also denied that there were gadgets attached to Angelica at that time
.34[34]
On August 29, Angelica developed ulcers in her mouth, which petitioner said were
blood clots that should not be
removed. Respondents claimed that Angelica passed about half a liter of blood th
rough her anus at around seven oclock
that evening, which petitioner likewise denied.
On August 30, Angelica continued bleeding. She was restless as endotracheal and
nasogastric tubes were inserted
into her weakened body. An aspiration of the nasogastric tube inserted to Angeli
ca also revealed a bloody content.
Angelica was given more platelet concentrate and fresh whole blood, which petiti
oner claimed improved her condition.
Petitioner told Angelica not to remove the endotracheal tube because this may in
duce further bleeding.35[35] She was
also transferred to the intensive care unit to avoid infection.
The next day, respondents claimed that Angelica became hysterical, vomited blood
and her body turned black.
Part of Angelicas skin was also noted to be shredding by just rubbing cotton on
it. Angelica was so restless she removed
those gadgets attached to her, saying Ayaw ko na; there were tears in her eyes a
nd she kept turning her head. Observing
her daughter to be at the point of death, Lina asked for a doctor but the latter
could not answer her anymore.36[36] At
this time, the attending physician was Dr. Marbella who was shaking his head say
ing that Angelicas platelets were down
and respondents should pray for their daughter. Reynaldo claimed that he was int
roduced to a pediatrician who took over
his daughters case, Dr. Abesamis who also told him to pray for his daughter. Ang
elica continued to have difficulty in her
breathing and blood was being suctioned from her stomach. A nurse was posted ins
ide Angelicas room to assist her

breathing and at one point they had to revive Angelica by pumping her chest. The
reafter, Reynaldo claimed that Angelica
already experienced difficulty in urinating and her bowel consisted of blood-lik
e fluid. Angelica requested for an electric
fan as she was in pain. Hospital staff attempted to take blood samples from Ange
lica but were unsuccessful because they
could not even locate her vein. Angelica asked for a fruit but when it was given
to her, she only smelled it. At this time,
Reynaldo claimed he could not find either petitioner or Dr. Marbella. That night
, Angelica became hysterical and started
removing those gadgets attached to her. At three oclock in the morning of Septem
ber 1, a priest came and they prayed
before Angelica expired. Petitioner finally came back and supposedly told respon
dents that there was malfunction or
bogged-down machine.37[37]
By petitioners own account, Angelica was merely irritable that day (August 31).
Petitioner noted though that
Angelicas skin was indeed sloughing off.38[38] She stressed that at 9:30 in the
evening, Angelica pulled out her
endotracheal tube.39[39] On September 1, exactly two weeks after being admitted
at SLMC for chemotherapy, Angelica
died.40[40] The cause of death, according to petitioner, was septicemia, or over
whelming infection, which caused
Angelicas other organs to fail.41[41] Petitioner attributed this to the patients
poor defense mechanism brought about by
the cancer itself.42[42]
While he was seeking the release of Angelicas cadaver from SLMC, Reynaldo claime
d that petitioner acted
arrogantly and called him names. He was asked to sign a promissory note as he di
d not have cash to pay the hospital
bill.43[43]
Respondents also presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-Legal
Officer of the PNP-Crime
Laboratory who conducted the autopsy on Angelicas cadaver, and Dr. Melinda Verga
ra Balmaceda who is a Medical
Specialist employed at the Department of Health (DOH) Operations and Management
Services.
Testifying on the findings stated in her medico-legal report, Dr. Vergara noted
the following: (1) there were fluids
recovered from the abdominal cavity, which is not normal, and was due to hemorrh
agic shock secondary to bleeding; (2)
there was hemorrhage at the left side of the heart; (3) bleeding at the upper po
rtion of and areas adjacent to, the
esophagus; (4) lungs were heavy with bleeding at the back and lower portion, due
to accumulation of fluids; (4) yellowish
discoloration of the liver; (5) kidneys showed appearance of facial shock on acc
ount of hemorrhages; and (6) reddishness
on external surface of the spleen. All these were the end result of hypovolemic
shock secondary to multiple organ
hemorrhages and disseminated intravascular coagulation. Dr. Vergara opined that
this can be attributed to the chemical

agents in the drugs given to the victim, which caused platelet reduction resulti
ng to bleeding sufficient to cause the victims
death. The time lapse for the production of DIC in the case of Angelica (from th
e time of diagnosis of sarcoma) was too
short, considering the survival rate of about 3 years. The witness conceded that
the victim will also die of osteosarcoma
even with amputation or chemotherapy, but in this case Angelicas death was not c
aused by osteosarcoma. Dr. Vergara
admitted that she is not a pathologist but her statements were based on the opin
ion of an oncologist whom she had
interviewed. This oncologist supposedly said that if the victim already had DIC
prior to the chemotherapy, the hospital
staff could have detected it.44[44]
On her part, Dr. Balmaceda declared that it is the physicians duty to inform and
explain to the patient or his
relatives every known side effect of the procedure or therapeutic agents to be a
dministered, before securing the consent of
the patient or his relatives to such procedure or therapy. The physician thus ba
ses his assurance to the patient on his
personal assessment of the patients condition and his knowledge of the general e
ffects of the agents or procedure that will
be allowed on the patient. Dr. Balmaceda stressed that the patient or relatives
must be informed of all known side effects
based on studies and observations, even if such will aggravate the patients cond
ition.45[45]
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelicas lower extrem
ity, testified for the
defendants. He explained that in case of malignant tumors, there is no guarantee
that the ablation or removal of the
amputated part will completely cure the cancer. Thus, surgery is not enough. The
mortality rate of osteosarcoma at the
time of modern chemotherapy and early diagnosis still remains at 80% to 90%. Usu
ally, deaths occur from metastasis, or
spread of the cancer to other vital organs like the liver, causing systemic comp
lications. The modes of therapy available are
the removal of the primary source of the cancerous growth and then the residual
cancer cells or metastasis should be
treated with chemotherapy. Dr. Tamayo further explained that patients with osteo
sarcoma have poor defense mechanism
due to the cancer cells in the blood stream. In the case of Angelica, he had pre
viously explained to her parents that after
the surgical procedure, chemotherapy is imperative so that metastasis of these c
ancer cells will hopefully be addressed. He
referred the patient to petitioner because he felt that petitioner is a competen
t oncologist. Considering that this type of
cancer is very aggressive and will metastasize early, it will cause the demise o
f the patient should there be no early
intervention (in this case, the patient developed sepsis which caused her death)
. Cancer cells in the blood
cannot be seen by the naked eye nor detected through bone scan. On cross-examina
tion, Dr. Tamayo stated that of the
more than 50 child patients who had osteogenic sarcoma he had handled, he though
t that probably all of them died within
six months from amputation because he did not see them anymore after follow-up;
it is either they died or had seen
another doctor.46[46]
In dismissing the complaint, the trial court held that petitioner was not liable
for damages as she observed the
best known procedures and employed her highest skill and knowledge in the admini
stration of chemotherapy drugs on

Angelica but despite all efforts said patient died. It cited the testimony of Dr
. Tamayo who testified that he considered
petitioner one of the most proficient in the treatment of cancer and that the pa
tient in this case was afflicted with a very
aggressive type of cancer necessitating chemotherapy as adjuvant treatment. Usin
g the standard of negligence laid down

in Picart v. Smith,47[47] the trial court declared that petitioner has taken the
necessary precaution against the adverse
effect of chemotherapy on the patient, adding that a wrong decision is not by it
self negligence. Respondents were ordered
to pay their unpaid hospital bill in the amount of P139,064.43.48[48]
Respondents appealed to the CA which, while concurring with the trial courts fin
ding that there was no negligence
committed by the petitioner in the administration of chemotherapy treatment to A
ngelica, found that petitioner as her
attending physician failed to fully explain to the respondents all the known sid
e effects of chemotherapy. The appellate
court stressed that since the respondents have been told of only three side effe
cts of chemotherapy, they readily consented
thereto. Had petitioner made known to respondents those other side effects which
gravely affected their child -- such as
carpo-pedal spasm, sepsis, decrease in the blood platelet count, bleeding, infec
tions and eventual death -- respondents
could have decided differently or adopted a different course of action which cou
ld have delayed or prevented the early
death of their child.
The CA thus declared:
Plaintiffs-appellants child was suffering from a malignant disease. The attendin
g physician
recommended that she undergo chemotherapy treatment after surgery in order to in
crease her chances of
survival. Appellants consented to the chemotherapy treatment because they believ
ed in Dr. Rubi Lis
representation that the deceased would have a strong chance of survival after ch
emotherapy and also
because of the representation of appellee Dr. Rubi Li that there were only three
possible side-effects of the
treatment. However, all sorts of painful side-effects resulted from the treatmen
t including the premature
death of Angelica. The appellants were clearly and totally unaware of these othe
r side-effects
which manifested only during the chemotherapy treatment. This was shown by the f
act
that every time a problem would take place regarding Angelicas condition (like a
n
unexpected side-effect manifesting itself), they would immediately seek explanat
ion from
Dr. Rubi Li. Surely, those unexpected side-effects culminating in the loss of a
love[d] one caused the
appellants so much trouble, pain and suffering.
On this point therefore, [w]e find defendant-appellee Dr. Rubi Li negligent whic
h would entitle
plaintiffs-appellants to their claim for damages.
xxxx
WHEREFORE, the instant appeal is hereby GRANTED. Accordingly, the assailed decis
ion is
hereby modified to the extent that defendant-appellee Dr. Rubi Li is ordered to
pay the plaintiffsappellants the following amounts:
1.
Actual damages of P139,064.43, plus P9,828.00 for funeral expenses;
2.
Moral damages of P200,000.00;

3.
Exemplary damages of P50,000.00;
4.
Attorneys fee of P30,000.00.
SO ORDERED.49[49] (Emphasis supplied.)

Petitioner filed a motion for partial reconsideration which the appellate court
denied.
Hence, this petition.
Petitioner assails the CA in finding her guilty of negligence in not explaining
to the respondents all the possible
side effects of the chemotherapy on their child, and in holding her liable for a
ctual, moral and exemplary damages and
attorneys fees. Petitioner emphasized that she was not negligent in the pre-chem
otherapy procedures and in the
administration of chemotherapy treatment to Angelica.
On her supposed non-disclosure of all possible side effects of chemotherapy, inc
luding death, petitioner argues
that it was foolhardy to imagine her to be all-knowing/omnipotent. While the the
oretical side effects of chemotherapy
were explained by her to the respondents, as these should be known to a competen
t doctor, petitioner cannot possibly
predict how a particular patients genetic make-up, state of mind, general health
and body constitution would respond to
the treatment. These are obviously dependent on too many known, unknown and imme
asurable variables, thus requiring
that Angelica be, as she was, constantly and closely monitored during the treatm
ent. Petitioner asserts that she did
everything within her professional competence to attend to the medical needs of
Angelica.
Citing numerous trainings, distinctions and achievements in her field and her cu
rrent position as co-director for
clinical affairs of the Medical Oncology, Department of Medicine of SLMC, petiti
oner contends that in the absence of any
clear showing or proof, she cannot be charged with negligence in not informing t
he respondents all the side effects of
chemotherapy or in the pre-treatment procedures done on Angelica.
As to the cause of death, petitioner insists that Angelica did not die of platel
et depletion but of sepsis which is a
complication of the cancer itself. Sepsis itself leads to bleeding and death. Sh
e explains that the response rate to
chemotherapy of patients with osteosarcoma is high, so much so that survival rat
e is favorable to the patient. Petitioner
then points to some probable consequences if Angelica had not undergone chemothe
rapy. Thus, without chemotherapy,
other medicines and supportive treatment, the patient might have died the next d
ay because of massive infection, or the
cancer cells might have spread to the brain and brought the patient into a coma,
or into the lungs that the patient could
have been hooked to a respirator, or into her kidneys that she would have to und
ergo dialysis. Indeed, respondents could
have spent as much because of these complications. The patient would have been d
eprived of the chance to survive the
ailment, of any hope for life and her quality of life surely compromised. Since
she had not been shown to be at fault,
petitioner maintains that the CA erred in holding her liable for the damages suf
fered by the respondents.50[50]
The issue to be resolved is whether the petitioner can be held liable for failur
e to fully disclose serious side effects
to the parents of the child patient who died while undergoing chemotherapy, desp
ite the absence of finding that petitioner
was negligent in administering the said treatment.
The petition is meritorious.

The type of lawsuit which has been called medical malpractice or, more appropria
tely, medical negligence, is that
type of claim which a victim has available to him or her to redress a wrong comm
itted by a medical professional which has
caused bodily harm. In order to successfully pursue such a claim, a patient must
prove that a health care provider, in most
cases a physician, either failed to do something which a reasonably prudent heal
th care provider would have done, or that
he or she did something that a reasonably prudent provider would not have done;
and that that failure or action caused
injury to the patient.51[51]
This Court has recognized that medical negligence cases are best proved by opini
ons of expert witnesses belonging
in the same general neighborhood and in the same general line of practice as def
endant physician or surgeon. The
deference of courts to the expert opinion of qualified physicians stems from the
formers realization that the latter possess
unusual technical skills which laymen in most instances are incapable of intelli
gently evaluating, hence the
indispensability of expert testimonies.52[52]
In this case, both the trial and appellate courts concurred in finding that the
alleged negligence of petitioner in the
administration of chemotherapy drugs to respondents child was not proven conside
ring that Drs. Vergara and Balmaceda,
not being oncologists or cancer specialists, were not qualified to give expert o
pinion as to whether petitioners lack of skill,
knowledge and professional competence in failing to observe the standard of care
in her line of practice was the proximate
cause of the patients death. Furthermore, respondents case was not at all helped
by the non-production of medical records
by the hospital (only the biopsy result and medical bills were submitted to the
court). Nevertheless, the CA found
petitioner liable for her failure to inform the respondents on all possible side
effects of chemotherapy before securing their
consent to the said treatment.
The doctrine of informed consent within the context of physician-patient relatio
nships goes far back into English
common law. As early as 1767, doctors were charged with the tort of battery (i.e
., an unauthorized physical contact with a
patient) if they had not gained the consent of their patients prior to performin
g a surgery or procedure. In the United
States, the seminal case was Schoendorff v. Society of New York Hospital53[53] w
hich involved unwanted treatment
performed by a doctor. Justice Benjamin Cardozos oft-quoted opinion upheld the b
asic right of a patient to give consent to
any medical procedure or treatment: Every human being of adult years and sound m
ind has a right to determine what
shall be done with his own body; and a surgeon who performs an operation without
his patients consent, commits an
assault, for which he is liable in damages.54[54] From a purely ethical norm, in
formed consent evolved into a general
principle of law that a physician has a duty to disclose what a reasonably prude
nt physician in the medical community in
the exercise of reasonable care would disclose to his patient as to whatever gra
ve risks of injury might be incurred from a
proposed course of treatment, so that a patient, exercising ordinary care for hi
s own welfare, and faced with a choice of

undergoing the proposed treatment, or alternative treatment, or none at all, may

intelligently exercise his judgment by
reasonably balancing the probable risks against the probable benefits.55[55]
Subsequently, in Canterbury v. Spence56[56] the court observed that the duty to
disclose should not be limited
to medical usage as to arrogate the decision on revelation to the physician alon
e. Thus, respect for the patients right of
self-determination on particular therapy demands a standard set by law for physi
cians rather than one which physicians
may or may not impose upon themselves.57[57] The scope of disclosure is premised
on the fact that patients ordinarily
are persons unlearned in the medical sciences. Proficiency in diagnosis and ther
apy is not the full measure of a physicians
responsibility. It is also his duty to warn of the dangers lurking in the propos
ed treatment and to impart information
which the patient has every right to expect. Indeed, the patients reliance upon
the physician is a trust of the kind which
traditionally has exacted obligations beyond those associated with armslength tr
ansactions.58[58] The physician is not
expected to give the patient a short medical education, the disclosure rule only
requires of him a reasonable explanation,
which means generally informing the patient in nontechnical terms as to what is
at stake; the therapy alternatives open to
him, the goals expectably to be achieved, and the risks that may ensue from part
icular treatment or no treatment.59[59]
As to the issue of demonstrating what risks are considered material necessitatin
g disclosure, it was held that experts are
unnecessary to a showing of the materiality of a risk to a patients decision on
treatment, or to the reasonably, expectable
effect of risk disclosure on the decision. Such unrevealed risk that should have
been made known must further materialize,
for otherwise the omission, however unpardonable, is without legal consequence.
And, as in malpractice actions generally,
there must be a causal relationship between the physicians failure to divulge an
d damage to the patient.60[60]
Reiterating the foregoing considerations, Cobbs v. Grant61[61] deemed it as inte
gral part of physicians overall
obligation to patient, the duty of reasonable disclosure of available choices wi
th respect to proposed therapy and of
dangers inherently and potentially involved in each. However, the physician is n
ot obliged to discuss relatively minor risks
inherent in common procedures when it is common knowledge that such risks inhere
nt in procedure of very low
incidence. Cited as exceptions to the rule that the patient should not be denied
the opportunity to weigh the risks of
surgery or treatment are emergency cases where it is evident he cannot evaluate
data, and where the patient is a child or
incompetent.62[62] The court thus concluded that the patients right of self-deci
sion can only be effectively exercised if
the patient possesses adequate information to enable him in making an intelligen
t choice. The scope of the physicians
communications to the patient, then must be measured by the patients need, and t
hat need is whatever information is

material to the decision. The test therefore for determining whether a potential
peril must be divulged is its materiality to
the patients decision.63[63]
Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that
for liability of the physician
for failure to inform patient, there must be causal relationship between physici
ans failure to inform and the injury to
patient and such connection arises only if it is established that, had revelatio
n been made, consent to treatment would not
have been given.
There are four essential elements a plaintiff must prove in a malpractice action
based upon the doctrine of
informed consent: (1) the physician had a duty to disclose material risks; (2) h
e failed to disclose or inadequately disclosed
those risks; (3) as a direct and proximate result of the failure to disclose, th
e patient consented to treatment she otherwise
would not have consented to; and (4) plaintiff was injured by the proposed treat
ment. The gravamen in an informed
consent case requires the plaintiff to point to significant undisclosed informat
ion relating to the treatment which would
have altered her decision to undergo it.64[64]
Examining the evidence on record, we hold that there was adequate disclosure of
material risks inherent in the
chemotherapy procedure performed with the consent of Angelicas parents. Responde
nts could not have been unaware in
the course of initial treatment and amputation of Angelicas lower extremity, tha
t her immune system was already weak on
account of the malignant tumor in her knee. When petitioner informed the respond
ents beforehand of the side effects of
chemotherapy which includes lowered counts of white and red blood cells, decreas
e in blood platelets, possible kidney or
heart damage and skin darkening, there is reasonable expectation on the part of
the doctor that the respondents
understood very well that the severity of these side effects will not be the sam
e for all patients undergoing the procedure.
In other words, by the nature of the disease itself, each patients reaction to t
he chemical agents even with pre-treatment
laboratory tests cannot be precisely determined by the physician. That death can
possibly result from complications of the
treatment or the underlying cancer itself, immediately or sometime after the adm
inistration of chemotherapy drugs, is a
risk that cannot be ruled out, as with most other major medical procedures, but
such conclusion can be reasonably drawn
from the general side effects of chemotherapy already disclosed.
As a physician, petitioner can reasonably expect the respondents to have conside
red the variables in the
recommended treatment for their daughter afflicted with a life-threatening illne
ss. On the other hand, it is difficult to give
credence to respondents claim that petitioner told them of 95% chance of recover
y for their daughter, as it was unlikely for
doctors like petitioner who were dealing with grave conditions such as cancer to
have falsely assured patients of
chemotherapys success rate. Besides, informed consent laws in other countries ge
nerally require only a reasonable
explanation of potential harms, so specific disclosures such as statistical data
, may not be legally necessary.65[65]
The element of ethical duty to disclose material risks in the proposed medical t
reatment cannot thus be reduced to
one simplistic formula applicable in all instances. Further, in a medical malpra
ctice action based on lack of informed

consent, the plaintiff must prove both the duty and the breach of that duty thro
ugh expert testimony.66[66] Such expert
testimony must show the customary standard of care of physicians in the same pra
ctice as that of the defendant
doctor.67[67]
In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medi
cal Specialist of the DOHs
Operational and Management Services charged with receiving complaints against ho
spitals, does not qualify as expert
testimony to establish the standard of care in obtaining consent for chemotherap
y treatment. In the absence of expert
testimony in this regard, the Court feels hesitant in defining the scope of mand
atory disclosure in cases of malpractice
based on lack of informed consent, much less set a standard of disclosure that,
even in foreign jurisdictions, has been
noted to be an evolving one.
As society has grappled with the juxtaposition between personal autonomy and the
medical
profession's intrinsic impetus to cure, the law defining adequate disclosure has
undergone a dynamic
evolution. A standard once guided solely by the ruminations of physicians is now
dependent on what a
reasonable person in the patients position regards as significant. This change i
n perspective is especially
important as medical breakthroughs move practitioners to the cutting edge of tec
hnology, ever
encountering new and heretofore unimagined treatments for currently incurable di
seases or ailments. An
adaptable standard is needed to account for this constant progression. Reasonabl
eness analyses permeate
our legal system for the very reason that they are determined by social norms, e
xpanding and contracting
with the ebb and flow of societal evolution.
As we progress toward the twenty-first century, we now realize that the legal st
andard of
disclosure is not subject to construction as a categorical imperative. Whatever
formulae or
processes we adopt are only useful as a foundational starting point; the particu
lar quality or quantity
of disclosure will remain inextricably bound by the facts of each case. Neverthe
less, juries that
ultimately determine whether a physician properly informed a patient are inevita
bly guided by what they
perceive as the common expectation of the medical consumera reasonable person in
the patients position
when deciding to accept or reject a recommended medical procedure.68[68] (Emphas
is supplied.)
WHEREFORE, the petition for review on certiorari is GRANTED. The Decision dated
June 15, 2004 and the
Resolution dated September 1, 2004 of the Court of Appeals in CA-G.R. CV No. 580
13 are SET ASIDE.
The Decision dated September 5, 1997 of the Regional Trial Court of Legazpi City
, Branch 8, in Civil Case No.
8904 is REINSTATED and UPHELD.
No costs.
SO ORDERED.

MARTIN S. VILLARAMA, JR.

Associate Justice
WE CONCUR:
RENATO C. CORONA
Chief Justice
See Dissenting Opinion
ANTONIO T. CARPIO
I join the dissent of J. Carpio
CONCHITA CARPIO MORALES
Associate Justice
Associate Justice
I join dissent of J. Carpio
PRESBITERO J. VELASCO, JR.
I join J. Brions Separate Opinion
ANTONIO EDUARDO B. NACHURA
Associate Justice
Associate Justice
I join the separate opinion of Justice Brion
TERESITA J. LEONARDO-DE CASTRO
In the result: See Separate Opinion
ARTURO D. BRION
Associate Justice
Associate Justice
I join the dissent opinion of Jus. Carpio
DIOSDADO M. PERALTA
Concur in the result, and I join the
Separate Opinion of J. Brion
LUCAS P. BERSAMIN
Associate Justice

Associate Justice
(No Part)
MARIANO C. DEL CASTILLO
Please see my concurring opinion
ROBERTO A. ABAD
Associate Justice
Associate Justice
JOSE PORTUGAL PEREZ
I join J. Brion in his concurrence
JOSE CATRAL MENDOZA
Associate Justice
Associate Justice
I dissent. Evidence was provided by the doctor-petitioner herself.
I join J. Antonio Carpio
MARIA LOURDES P. A. SERENO
Associate Justice
CERTIFICATION
Pursuant to Section 13, Article VIII of the 1987 Constitution, I certify that th
e conclusions in the above Decision
had been reached in consultation before the case was assigned to the writer of t
he opinion of the Court.
RENATO C. CORONA
Chief Justice
Republic of the Philippines
SUPREME COURT
Manila

FIRST DIVISION
G.R. No. 126297
January 31, 2007
PROFESSIONAL SERVICES, INC., Petitioner,
vs.
NATIVIDAD and ENRIQUE AGANA, Respondents.
x-----------------------x
G.R. No. 126467
January 31, 2007
NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE AGANA, JR.,
EMMA
AGANA ANDAYA, JESUS AGANA, and RAYMUND AGANA) and ENRIQUE AGANA, Petitioners,
vs.
JUAN FUENTES, Respondent.
x- - - - - - - - - - - - - - - - - - - -- - - - x
G.R. No. 127590
January 31, 2007
MIGUEL AMPIL, Petitioner,
vs.
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
DECISION
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankinds most important and delicate endeavor
s, must assume the grave
responsibility of pursuing it with appropriate care. The care and service dispen
sed through this high trust, however
technical, complex and esoteric its character may be, must meet standards of res
ponsibility commensurate with the
undertaking to preserve and protect the health, and indeed, the very lives of th
ose placed in the hospitals keeping. 1
Assailed in these three consolidated petitions for review on certiorari is the C
ourt of Appeals Decision 2 dated September
6, 1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198 affirming with modifica
tion the Decision3 dated March 17,
1993 of the Regional Trial Court (RTC), Branch 96, Quezon City in Civil Case No.
Q-43322 and nullifying its Order dated
September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospita
l (Medical City Hospital) because of
difficulty of bowel movement and bloody anal discharge. After a series of medica
l examinations, Dr. Miguel Ampil,
petitioner in G.R. No. 127590, diagnosed her to be suffering from "cancer of the
sigmoid."
On April 11, 1984, Dr. Ampil, assisted by the medical staff4 of the Medical City
Hospital, performed an anterior resection
surgery on Natividad. He found that the malignancy in her sigmoid area had sprea
d on her left ovary, necessitating the
removal of certain portions of it. Thus, Dr. Ampil obtained the consent of Nativ
idads husband, Enrique Agana, to permit
Dr. Juan Fuentes, respondent in G.R. No. 126467, to perform hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed
the operation and closed the incision.
However, the operation appeared to be flawed. In the corresponding Record of Ope

ration dated April 11, 1984, the

attending nurses entered these remarks:
"sponge count lacking 2
"announced to surgeon searched (sic) done but to no avail continue for closure."

On April 24, 1984, Natividad was released from the hospital. Her hospital and me
dical bills, including the doctors fees,
amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating pain in her anal re
gion. She consulted both Dr. Ampil and Dr.
Fuentes about it. They told her that the pain was the natural consequence of the
surgery. Dr. Ampil then recommended
that she consult an oncologist to examine the cancerous nodes which were not rem
oved during the operation.
On May 9, 1984, Natividad, accompanied by her husband, went to the United States
to seek further treatment. After four
months of consultations and laboratory examinations, Natividad was told she was
free of cancer. Hence, she was advised
to return to the Philippines.
On August 31, 1984, Natividad flew back to the Philippines, still suffering from
pains. Two weeks thereafter, her daughter
found a piece of gauze protruding from her vagina. Upon being informed about it,
Dr. Ampil proceeded to her house
where he managed to extract by hand a piece of gauze measuring 1.5 inches in wid
th. He then assured her that the pains
would soon vanish.
Dr. Ampils assurance did not come true. Instead, the pains intensified, prompting
Natividad to seek treatment at the
Polymedic General Hospital. While confined there, Dr. Ramon Gutierrez detected t
he presence of another foreign object in
her vagina -- a foul-smelling gauze measuring 1.5 inches in width which badly in
fected her vaginal vault. A recto-vaginal
fistula had formed in her reproductive organs which forced stool to excrete thro
ugh the vagina. Another surgical operation
was needed to remedy the damage. Thus, in October 1984, Natividad underwent anot
her surgery.
On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, Q
uezon City a complaint for damages
against the Professional Services, Inc. (PSI), owner of the Medical City Hospita
l, Dr. Ampil, and Dr. Fuentes, docketed as
Civil Case No. Q-43322. They alleged that the latter are liable for negligence f
or leaving two pieces of gauze inside
Natividads body and malpractice for concealing their acts of negligence.
Meanwhile, Enrique Agana also filed with the Professional Regulation Commission
(PRC) an administrative complaint for
gross negligence and malpractice against Dr. Ampil and Dr. Fuentes, docketed as
Administrative Case No. 1690. The PRC
Board of Medicine heard the case only with respect to Dr. Fuentes because it fai
led to acquire jurisdiction over Dr. Ampil
who was then in the United States.
On February 16, 1986, pending the outcome of the above cases, Natividad died and
was duly substituted by her abovenamed children (the Aganas).
On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding
PSI, Dr. Ampil and Dr. Fuentes liable for
negligence and malpractice, the decretal part of which reads:
WHEREFORE, judgment is hereby rendered for the plaintiffs ordering the defendant
s PROFESSIONAL SERVICES, INC.,
DR. MIGUEL AMPIL and DR. JUAN FUENTES to pay to the plaintiffs, jointly and seve
rally, except in respect of the
award for exemplary damages and the interest thereon which are the liabilities o
f defendants Dr. Ampil and Dr. Fuentes
only, as follows:
1. As actual damages, the following amounts:
a. The equivalent in Philippine Currency of the total of US$19,900.00 at the rat
e of P21.60-US$1.00, as

reimbursement of actual expenses incurred in the United States of America;

b. The sum of P4,800.00 as travel taxes of plaintiffs and their physician daught
er;
c. The total sum of P45,802.50, representing the cost of hospitalization at Poly
medic Hospital, medical
fees, and cost of the saline solution;
2. As moral damages, the sum of P2,000,000.00;
3. As exemplary damages, the sum of P300,000.00;
4. As attorneys fees, the sum of P250,000.00;

5. Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove, from date
of filing of the complaint until full
payment; and
6. Costs of suit.
SO ORDERED.
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of A
ppeals, docketed as CA-G.R. CV No.
42062.
Incidentally, on April 3, 1993, the Aganas filed with the RTC a motion for a par
tial execution of its Decision, which was
granted in an Order dated May 11, 1993. Thereafter, the sheriff levied upon cert
ain properties of Dr. Ampil and sold them
for P451,275.00 and delivered the amount to the Aganas.
Following their receipt of the money, the Aganas entered into an agreement with
PSI and Dr. Fuentes to indefinitely
suspend any further execution of the RTC Decision. However, not long thereafter,
the Aganas again filed a motion for an
alias writ of execution against the properties of PSI and Dr. Fuentes. On Septem
ber 21, 1993, the RTC granted the motion
and issued the corresponding writ, prompting Dr. Fuentes to file with the Court
of Appeals a petition for certiorari and
prohibition, with prayer for preliminary injunction, docketed as CA-G.R. SP No.
32198. During its pendency, the Court of
Appeals issued a Resolution5 dated October 29, 1993 granting Dr. Fuentes prayer f
or injunctive relief.
On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No. 4
2062.
Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision
6 in Administrative Case No. 1690
dismissing the case against Dr. Fuentes. The Board held that the prosecution fai
led to show that Dr. Fuentes was the one
who left the two pieces of gauze inside Natividads body; and that he concealed su
ch fact from Natividad.
On September 6, 1996, the Court of Appeals rendered its Decision jointly disposi
ng of CA-G.R. CV No. 42062 and CA-G.R.
SP No. 32198, thus:
WHEREFORE, except for the modification that the case against defendant-appellant
Dr. Juan Fuentes is hereby
DISMISSED, and with the pronouncement that defendant-appellant Dr. Miguel Ampil
is liable to reimburse defendantappellant Professional Services, Inc., whatever
amount the latter will pay or had paid to the plaintiffs-appellees, the
decision appealed from is hereby AFFIRMED and the instant appeal DISMISSED.
Concomitant with the above, the petition for certiorari and prohibition filed by
herein defendant-appellant Dr. Juan
Fuentes in CA-G.R. SP No. 32198 is hereby GRANTED and the challenged order of th
e respondent judge dated September
21, 1993, as well as the alias writ of execution issued pursuant thereto are her
eby NULLIFIED and SET ASIDE. The bond
posted by the petitioner in connection with the writ of preliminary injunction i
ssued by this Court on November 29, 1993
is hereby cancelled.
Costs against defendants-appellants Dr. Miguel Ampil and Professional Services,
Inc.
SO ORDERED.
Only Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolu
tion 7 dated December 19, 1996.
Hence, the instant consolidated petitions.
In G.R. No. 126297, PSI alleged in its petition that the Court of Appeals erred
in holding that: (1) it is estopped from
raising the defense that Dr. Ampil is not its employee; (2) it is solidarily lia

ble with Dr. Ampil; and (3) it is not entitled to

its counterclaim against the Aganas. PSI contends that Dr. Ampil is not its empl
oyee, but a mere consultant or
independent contractor. As such, he alone should answer for his negligence.
In G.R. No. 126467, the Aganas maintain that the Court of Appeals erred in findi
ng that Dr. Fuentes is not guilty of
negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. T
hey contend that the pieces of gauze are
prima facie proofs that the operating surgeons have been negligent.

Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of Appeals erred i
n finding him liable for negligence and
malpractice sans evidence that he left the two pieces of gauze in Natividads vagi
na. He pointed to other probable causes,
such as: (1) it was Dr. Fuentes who used gauzes in performing the hysterectomy;
(2) the attending nurses failure to
properly count the gauzes used during surgery; and (3) the medical intervention
of the American doctors who examined
Natividad in the United States of America.
For our resolution are these three vital issues: first, whether the Court of App
eals erred in holding Dr. Ampil liable for
negligence and malpractice; second, whether the Court of Appeals erred in absolv
ing Dr. Fuentes of any liability; and
third, whether PSI may be held solidarily liable for the negligence of Dr. Ampil
.
I - G.R. No. 127590
Whether the Court of Appeals Erred in Holding Dr. Ampil
Liable for Negligence and Malpractice.
Dr. Ampil, in an attempt to absolve himself, gears the Courts attention to other
possible causes of Natividads detriment.
He argues that the Court should not discount either of the following possibiliti
es: first, Dr. Fuentes left the gauzes in
Natividads body after performing hysterectomy; second, the attending nurses erred
in counting the gauzes; and third, the
American doctors were the ones who placed the gauzes in Natividads body.
Dr. Ampils arguments are purely conjectural and without basis. Records show that
he did not present any evidence to
prove that the American doctors were the ones who put or left the gauzes in Nati
vidads body. Neither did he submit
evidence to rebut the correctness of the record of operation, particularly the n
umber of gauzes used. As to the alleged
negligence of Dr. Fuentes, we are mindful that Dr. Ampil examined his (Dr. Fuent
es) work and found it in order.
The glaring truth is that all the major circumstances, taken together, as specif
ied by the Court of Appeals, directly point to
Dr. Ampil as the negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges to control th
e bleeding of the patient during the
surgical operation.
Second, immediately after the operation, the nurses who assisted in the surgery
noted in their report that the
sponge count (was) lacking 2; that such anomaly was announced to surgeon and that a s
earch was done but to
no avail prompting Dr. Ampil to continue for closure x x x.
Third, after the operation, two (2) gauzes were extracted from the same spot of
the body of Mrs. Agana where the
surgery was performed.
An operation requiring the placing of sponges in the incision is not complete un
til the sponges are properly removed, and
it is settled that the leaving of sponges or other foreign substances in the wou
nd after the incision has been closed is at
least prima facie negligence by the operating surgeon.8 To put it simply, such a
ct is considered so inconsistent with due
care as to raise an inference of negligence. There are even legions of authoriti
es to the effect that such act is negligence per
se.9
Of course, the Court is not blind to the reality that there are times when dange
r to a patients life precludes a surgeon from
further searching missing sponges or foreign objects left in the body. But this
does not leave him free from any obligation.

Even if it has been shown that a surgeon was required by the urgent necessities
of the case to leave a sponge in his
patients abdomen, because of the dangers attendant upon delay, still, it is his l
egal duty to so inform his patient within a
reasonable time thereafter by advising her of what he had been compelled to do.
This is in order that she might seek relief
from the effects of the foreign object left in her body as her condition might p
ermit. The ruling in Smith v. Zeagler 10 is
explicit, thus:
The removal of all sponges used is part of a surgical operation, and when a phys
ician or surgeon fails to remove a sponge
he has placed in his patients body that should be removed as part of the operatio
n, he thereby leaves his operation
uncompleted and creates a new condition which imposes upon him the legal duty of
calling the new condition to his
patients attention, and endeavoring with the means he has at hand to minimize and
avoid untoward results likely to ensue
therefrom.

Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze.
Worse, he even misled her that the pain
she was experiencing was the ordinary consequence of her operation. Had he been
more candid, Natividad could have
taken the immediate and appropriate medical remedy to remove the gauzes from her
body. To our mind, what was initially
an act of negligence by Dr. Ampil has ripened into a deliberate wrongful act of
deceiving his patient.
This is a clear case of medical malpractice or more appropriately, medical negli
gence. To successfully pursue this kind of
case, a patient must only prove that a health care provider either failed to do
something which a reasonably prudent health
care provider would have done, or that he did something that a reasonably pruden
t provider would not have done; and
that failure or action caused injury to the patient.11 Simply put, the elements
are duty, breach, injury and proximate
causation. Dr, Ampil, as the lead surgeon, had the duty to remove all foreign ob
jects, such as gauzes, from Natividads
body before closure of the incision. When he failed to do so, it was his duty to
inform Natividad about it. Dr. Ampil
breached both duties. Such breach caused injury to Natividad, necessitating her
further examination by American doctors
and another surgery. That Dr. Ampils negligence is the proximate cause 12 of Nati
vidads injury could be traced from his
act of closing the incision despite the information given by the attending nurse
s that two pieces of gauze were still missing.
That they were later on extracted from Natividads vagina established the causal l
ink between Dr. Ampils negligence and
the injury. And what further aggravated such injury was his deliberate concealme
nt of the missing gauzes from the
knowledge of Natividad and her family.
II - G.R. No. 126467
Whether the Court of Appeals Erred in Absolving
Dr. Fuentes of any Liability
The Aganas assailed the dismissal by the trial court of the case against Dr. Fue
ntes on the ground that it is contrary to the
doctrine of res ipsa loquitur. According to them, the fact that the two pieces o
f gauze were left inside Natividads body is a
prima facie evidence of Dr. Fuentes negligence.
We are not convinced.
Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule
that the fact of the occurrence of an injury,
taken with the surrounding circumstances, may permit an inference or raise a pre
sumption of negligence, or make out a
plaintiffs prima facie case, and present a question of fact for defendant to meet
with an explanation.13 Stated differently,
where the thing which caused the injury, without the fault of the injured, is un
der the exclusive control of the defendant
and the injury is such that it should not have occurred if he, having such contr
ol used proper care, it affords reasonable
evidence, in the absence of explanation that the injury arose from the defendants
want of care, and the burden of proof is
shifted to him to establish that he has observed due care and diligence.14
From the foregoing statements of the rule, the requisites for the applicability
of the doctrine of res ipsa loquitur are: (1) the
occurrence of an injury; (2) the thing which caused the injury was under the con
trol and management of the defendant;
(3) the occurrence was such that in the ordinary course of things, would not hav
e happened if those who had control or
management used proper care; and (4) the absence of explanation by the defendant

. Of the foregoing requisites, the most

instrumental is the "control and management of the thing which caused the injury
." 15
We find the element of "control and management of the thing which caused the inj
ury" to be wanting. Hence, the doctrine
of res ipsa loquitur will not lie.
It was duly established that Dr. Ampil was the lead surgeon during the operation
of Natividad. He requested the assistance
of Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil) found that the m
alignancy in her sigmoid area had
spread to her left ovary. Dr. Fuentes performed the surgery and thereafter repor
ted and showed his work to Dr. Ampil.
The latter examined it and finding everything to be in order, allowed Dr. Fuente
s to leave the operating room. Dr. Ampil
then resumed operating on Natividad. He was about to finish the procedure when t
he attending nurses informed him that
two pieces of gauze were missing. A "diligent search" was conducted, but the mis
placed gauzes were not found. Dr. Ampil
then directed that the incision be closed. During this entire period, Dr. Fuente
s was no longer in the operating room and
had, in fact, left the hospital.
Under the "Captain of the Ship" rule, the operating surgeon is the person in com
plete charge of the surgery room and all
personnel connected with the operation. Their duty is to obey his orders. 16 As
stated before, Dr. Ampil was the lead
surgeon. In other words, he was the "Captain of the Ship." That he discharged su
ch role is evident from his following
conduct: (1) calling Dr. Fuentes to perform a hysterectomy; (2) examining the wo
rk of Dr. Fuentes and finding it in order;

(3) granting Dr. Fuentes permission to leave; and (4) ordering the closure of the
incision. To our mind, it was this act of
ordering the closure of the incision notwithstanding that two pieces of gauze re
mained unaccounted for, that caused injury
to Natividads body. Clearly, the control and management of the thing which caused
the injury was in the hands of Dr.
Ampil, not Dr. Fuentes.
In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence,
does not per se create or constitute an
independent or separate ground of liability, being a mere evidentiary rule. 17 I
n other words, mere invocation and
application of the doctrine does not dispense with the requirement of proof of n
egligence. Here, the negligence was proven
to have been committed by Dr. Ampil and not by Dr. Fuentes.
III - G.R. No. 126297
Whether PSI Is Liable for the Negligence of Dr. Ampil
The third issue necessitates a glimpse at the historical development of hospital
s and the resulting theories concerning
their liability for the negligence of physicians.
Until the mid-nineteenth century, hospitals were generally charitable institutio
ns, providing medical services to the lowest
classes of society, without regard for a patients ability to pay.18 Those who cou
ld afford medical treatment were usually
treated at home by their doctors.19 However, the days of house calls and philant
hropic health care are over. The modern
health care industry continues to distance itself from its charitable past and h
as experienced a significant conversion from
a not-for-profit health care to for-profit hospital businesses. Consequently, si
gnificant changes in health law have
accompanied the business-related changes in the hospital industry. One important
legal change is an increase in hospital
liability for medical malpractice. Many courts now allow claims for hospital vic
arious liability under the theories of
respondeat superior, apparent authority, ostensible authority, or agency by esto
ppel. 20
In this jurisdiction, the statute governing liability for negligent acts is Arti
cle 2176 of the Civil Code, which reads:
Art. 2176. Whoever by act or omission causes damage to another, there being faul
t or negligence, is obliged to pay for the
damage done. Such fault or negligence, if there is no pre-existing contractual r
elation between the parties, is called a
quasi-delict and is governed by the provisions of this Chapter.
A derivative of this provision is Article 2180, the rule governing vicarious lia
bility under the doctrine of respondeat
superior, thus:
ART. 2180. The obligation imposed by Article 2176 is demandable not only for ones
own acts or omissions, but also for
those of persons for whom one is responsible.
x x x
x x x
The owners and managers of an establishment or enterprise are likewise responsib
le for damages caused by their
employees in the service of the branches in which the latter are employed or on
the occasion of their functions.
Employers shall be liable for the damages caused by their employees and househol
d helpers acting within the scope of
their assigned tasks even though the former are not engaged in any business or i
ndustry.

x x x
x x x
The responsibility treated of in this article shall cease when the persons herei
n mentioned prove that they observed all the
diligence of a good father of a family to prevent damage.
A prominent civilist commented that professionals engaged by an employer, such a
s physicians, dentists, and pharmacists,
are not "employees" under this article because the manner in which they perform
their work is not within the control of
the latter (employer). In other words, professionals are considered personally l
iable for the fault or negligence they
commit in the discharge of their duties, and their employer cannot be held liabl
e for such fault or negligence. In the
context of the present case, "a hospital cannot be held liable for the fault or
negligence of a physician or surgeon in the
treatment or operation of patients."21

The foregoing view is grounded on the traditional notion that the professional s
tatus and the very nature of the physicians
calling preclude him from being classed as an agent or employee of a hospital, w
henever he acts in a professional
capacity.22 It has been said that medical practice strictly involves highly deve
loped and specialized knowledge, 23 such that
physicians are generally free to exercise their own skill and judgment in render
ing medical services sans interference.24
Hence, when a doctor practices medicine in a hospital setting, the hospital and
its employees are deemed to subserve him
in his ministrations to the patient and his actions are of his own responsibilit
y. 25
The case of Schloendorff v. Society of New York Hospital26 was then considered a
n authority for this view. The
"Schloendorff doctrine" regards a physician, even if employed by a hospital, as
an independent contractor because of the
skill he exercises and the lack of control exerted over his work. Under this doc
trine, hospitals are exempt from the
application of the respondeat superior principle for fault or negligence committ
ed by physicians in the discharge of their
profession.
However, the efficacy of the foregoing doctrine has weakened with the significan
t developments in medical care. Courts
came to realize that modern hospitals are increasingly taking active role in sup
plying and regulating medical care to
patients. No longer were a hospitals functions limited to furnishing room, food,
facilities for treatment and operation, and
attendants for its patients. Thus, in Bing v. Thunig,27 the New York Court of Ap
peals deviated from the Schloendorff
doctrine, noting that modern hospitals actually do far more than provide facilit
ies for treatment. Rather, they regularly
employ, on a salaried basis, a large staff of physicians, interns, nurses, admin
istrative and manual workers. They charge
patients for medical care and treatment, even collecting for such services throu
gh legal action, if necessary. The court then
concluded that there is no reason to exempt hospitals from the universal rule of
respondeat superior.
In our shores, the nature of the relationship between the hospital and the physi
cians is rendered inconsequential in view
of our categorical pronouncement in Ramos v. Court of Appeals 28 that for purpos
es of apportioning responsibility in
medical negligence cases, an employer-employee relationship in effect exists bet
ween hospitals and their attending and
visiting physicians. This Court held:
"We now discuss the responsibility of the hospital in this particular incident.
The unique practice (among private
hospitals) of filling up specialist staff with attending and visiting "consultan
ts," who are allegedly not hospital employees,
presents problems in apportioning responsibility for negligence in medical malpr
actice cases. However, the difficulty is
more apparent than real.
In the first place, hospitals exercise significant control in the hiring and fir
ing of consultants and in the conduct of their
work within the hospital premises. Doctors who apply for consultant slots, visitin
g or attending, are required to submit
proof of completion of residency, their educational qualifications, generally, e
vidence of accreditation by the appropriate
board (diplomate), evidence of fellowship in most cases, and references. These r
equirements are carefully scrutinized by
members of the hospital administration or by a review committee set up by the ho

spital who either accept or reject the

application. x x x.
After a physician is accepted, either as a visiting or attending consultant, he
is normally required to attend clinicopathological conferences, conduct bedside
rounds for clerks, interns and residents, moderate grand rounds and patient
audits and perform other tasks and responsibilities, for the privilege of being
able to maintain a clinic in the hospital,
and/or for the privilege of admitting patients into the hospital. In addition to
these, the physicians performance as a
specialist is generally evaluated by a peer review committee on the basis of mor
tality and morbidity statistics, and
feedback from patients, nurses, interns and residents. A consultant remiss in hi
s duties, or a consultant who regularly falls
short of the minimum standards acceptable to the hospital or its peer review com
mittee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control over the
ir attending and visiting consultant staff.
While consultants are not, technically employees, x x x, the control exercised, th
e hiring, and the right to terminate
consultants all fulfill the important hallmarks of an employer-employee relation
ship, with the exception of the payment of
wages. In assessing whether such a relationship in fact exists, the control test
is determining. Accordingly, on the basis of
the foregoing, we rule that for the purpose of allocating responsibility in medi
cal negligence cases, an employer-employee
relationship in effect exists between hospitals and their attending and visiting
physicians. "
But the Ramos pronouncement is not our only basis in sustaining PSIs liability. I
ts liability is also anchored upon the
agency principle of apparent authority or agency by estoppel and the doctrine of
corporate negligence which have gained
acceptance in the determination of a hospitals liability for negligent acts of he
alth professionals. The present case serves
as a perfect platform to test the applicability of these doctrines, thus, enrich
ing our jurisprudence.
Apparent authority, or what is sometimes referred to as the "holding

out" theory, or doctrine of ostensible agency or agency by estoppel,29 has its o

rigin from the law of agency. It imposes
liability, not as the result of the reality of a contractual relationship, but r
ather because of the actions of a principal or an
employer in somehow misleading the public into believing that the relationship o
r the authority exists.30 The concept is
essentially one of estoppel and has been explained in this manner:
"The principal is bound by the acts of his agent with the apparent authority whi
ch he knowingly permits the agent to
assume, or which he holds the agent out to the public as possessing. The questio
n in every case is whether the principal
has by his voluntary act placed the agent in such a situation that a person of o
rdinary prudence, conversant with business
usages and the nature of the particular business, is justified in presuming that
such agent has authority to perform the
particular act in question.31
The applicability of apparent authority in the field of hospital liability was u
pheld long time ago in Irving v. Doctor
Hospital of Lake Worth, Inc.32 There, it was explicitly stated that "there does
not appear to be any rational basis for
excluding the concept of apparent authority from the field of hospital liability
." Thus, in cases where it can be shown that a
hospital, by its actions, has held out a particular physician as its agent and/o
r employee and that a patient has accepted
treatment from that physician in the reasonable belief that it is being rendered
in behalf of the hospital, then the hospital
will be liable for the physicians negligence.
Our jurisdiction recognizes the concept of an agency by implication or estoppel.
Article 1869 of the Civil Code reads:
ART. 1869. Agency may be express, or implied from the acts of the principal, fro
m his silence or lack of action, or his
failure to repudiate the agency, knowing that another person is acting on his be
half without authority.
In this case, PSI publicly displays in the lobby of the Medical City Hospital th
e names and specializations of the physicians
associated or accredited by it, including those of Dr. Ampil and Dr. Fuentes. We
concur with the Court of Appeals
conclusion that it "is now estopped from passing all the blame to the physicians
whose names it proudly paraded in the
public directory leading the public to believe that it vouched for their skill a
nd competence." Indeed, PSIs act is
tantamount to holding out to the public that Medical City Hospital, through its
accredited physicians, offers quality health
care services. By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising
their qualifications, the hospital created
the impression that they were its agents, authorized to perform medical or surgi
cal services for its patients. As expected,
these patients, Natividad being one of them, accepted the services on the reason
able belief that such were being rendered
by the hospital or its employees, agents, or servants. The trial court correctly
pointed out:
x x x regardless of the education and status in life of the patient, he ought no
t be burdened with the defense of absence of
employer-employee relationship between the hospital and the independent physicia
n whose name and competence are
certainly certified to the general public by the hospitals act of listing him and
his specialty in its lobby directory, as in the
case herein. The high costs of todays medical and health care should at least exa
ct on the hospital greater, if not broader,
legal responsibility for the conduct of treatment and surgery within its facilit

y by its accredited physician or surgeon,

regardless of whether he is independent or employed." 33
The wisdom of the foregoing ratiocination is easy to discern. Corporate entities
, like PSI, are capable of acting only
through other individuals, such as physicians. If these accredited physicians do
their job well, the hospital succeeds in its
mission of offering quality medical services and thus profits financially. Logic
ally, where negligence mars the quality of its
services, the hospital should not be allowed to escape liability for the acts of
its ostensible agents.
We now proceed to the doctrine of corporate negligence or corporate responsibili
ty.
One allegation in the complaint in Civil Case No. Q-43332 for negligence and mal
practice is that PSI as owner, operator
and manager of Medical City Hospital, "did not perform the necessary supervision
nor exercise diligent efforts in the
supervision of Drs. Ampil and Fuentes and its nursing staff, resident doctors, a
nd medical interns who assisted Drs. Ampil
and Fuentes in the performance of their duties as surgeons."34 Premised on the d
octrine of corporate negligence, the trial
court held that PSI is directly liable for such breach of duty.
We agree with the trial court.
Recent years have seen the doctrine of corporate negligence as the judicial answ
er to the problem of allocating hospitals
liability for the negligent acts of health practitioners, absent facts to suppor
t the application of respondeat superior or
apparent authority. Its formulation proceeds from the judiciarys acknowledgment t
hat in these modern times, the duty of
providing quality medical service is no longer the sole prerogative and responsi
bility of the physician. The modern
hospitals have changed structure. Hospitals now tend to organize a highly profes
sional medical staff whose competence

and performance need to be monitored by the hospitals commensurate with their in

herent responsibility to provide
quality medical care.35
The doctrine has its genesis in Darling v. Charleston Community Hospital.36 Ther
e, the Supreme Court of Illinois held that
"the jury could have found a hospital negligent, inter alia, in failing to have
a sufficient number of trained nurses attending
the patient; failing to require a consultation with or examination by members of
the hospital staff; and failing to review the
treatment rendered to the patient." On the basis of Darling, other jurisdictions
held that a hospitals corporate negligence
extends to permitting a physician known to be incompetent to practice at the hos
pital. 37 With the passage of time, more
duties were expected from hospitals, among them: (1) the use of reasonable care
in the maintenance of safe and adequate
facilities and equipment; (2) the selection and retention of competent physician
s; (3) the overseeing or supervision of all
persons who practice medicine within its walls; and (4) the formulation, adoptio
n and enforcement of adequate rules and
policies that ensure quality care for its patients.38 Thus, in Tucson Medical Ce
nter, Inc. v. Misevich,39 it was held that a
hospital, following the doctrine of corporate responsibility, has the duty to se
e that it meets the standards of
responsibilities for the care of patients. Such duty includes the proper supervi
sion of the members of its medical staff. And
in Bost v. Riley,40 the court concluded that a patient who enters a hospital doe
s so with the reasonable expectation that it
will attempt to cure him. The hospital accordingly has the duty to make a reason
able effort to monitor and oversee the
treatment prescribed and administered by the physicians practicing in its premis
es.
In the present case, it was duly established that PSI operates the Medical City
Hospital for the purpose and under the
concept of providing comprehensive medical services to the public. Accordingly,
it has the duty to exercise reasonable care
to protect from harm all patients admitted into its facility for medical treatme
nt. Unfortunately, PSI failed to perform such
duty. The findings of the trial court are convincing, thus:
x x x PSIs liability is traceable to its failure to conduct an investigation of t
he matter reported in the nota bene of the count
nurse. Such failure established PSIs part in the dark conspiracy of silence and c
oncealment about the gauzes. Ethical
considerations, if not also legal, dictated the holding of an immediate inquiry
into the events, if not for the benefit of the
patient to whom the duty is primarily owed, then in the interest of arriving at
the truth. The Court cannot accept that the
medical and the healing professions, through their members like defendant surgeo
ns, and their institutions like PSIs
hospital facility, can callously turn their backs on and disregard even a mere p
robability of mistake or negligence by
refusing or failing to investigate a report of such seriousness as the one in Na
tividads case.
It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with t
he assistance of the Medical City
Hospitals staff, composed of resident doctors, nurses, and interns. As such, it i
s reasonable to conclude that PSI, as the
operator of the hospital, has actual or constructive knowledge of the procedures
carried out, particularly the report of the
attending nurses that the two pieces of gauze were missing. In Fridena v. Evans,
41 it was held that a corporation is bound

by the knowledge acquired by or notice given to its agents or officers within th

e scope of their authority and in reference to
a matter to which their authority extends. This means that the knowledge of any
of the staff of Medical City Hospital
constitutes knowledge of PSI. Now, the failure of PSI, despite the attending nur
ses report, to investigate and inform
Natividad regarding the missing gauzes amounts to callous negligence. Not only d
id PSI breach its duties to oversee or
supervise all persons who practice medicine within its walls, it also failed to
take an active step in fixing the negligence
committed. This renders PSI, not only vicariously liable for the negligence of D
r. Ampil under Article 2180 of the Civil
Code, but also directly liable for its own negligence under Article 2176. In Fri
dena, the Supreme Court of Arizona held:
x x x In recent years, however, the duty of care owed to the patient by the hosp
ital has expanded. The emerging trend is to
hold the hospital responsible where the hospital has failed to monitor and revie
w medical services being provided within
its walls. See Kahn Hospital Malpractice Prevention, 27 De Paul . Rev. 23 (1977)
.
Among the cases indicative of the emerging trend is Purcell v. Zimbelman, 18 Ariz.
App. 75,500 P. 2d 335 (1972). In
Purcell, the hospital argued that it could not be held liable for the malpractic
e of a medical practitioner because he was an
independent contractor within the hospital. The Court of Appeals pointed out tha
t the hospital had created a professional
staff whose competence and performance was to be monitored and reviewed by the g
overning body of the hospital, and
the court held that a hospital would be negligent where it had knowledge or reas
on to believe that a doctor using the
facilities was employing a method of treatment or care which fell below the reco
gnized standard of care.
Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hos
pital has certain inherent responsibilities
regarding the quality of medical care furnished to patients within its walls and
it must meet the standards of responsibility
commensurate with this undertaking. Beeck v. Tucson General Hospital, 18 Ariz. A
pp. 165, 500 P. 2d 1153 (1972). This
court has confirmed the rulings of the Court of Appeals that a hospital has the
duty of supervising the competence of the
doctors on its staff. x x x.
x
x
x
x
x x

In the amended complaint, the plaintiffs did plead that the operation was perfor
med at the hospital with its knowledge,
aid, and assistance, and that the negligence of the defendants was the proximate
cause of the patients injuries. We find
that such general allegations of negligence, along with the evidence produced at
the trial of this case, are sufficient to
support the hospitals liability based on the theory of negligent supervision."
Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for
damages, let it be emphasized that PSI,
apart from a general denial of its responsibility, failed to adduce evidence sho
wing that it exercised the diligence of a good
father of a family in the accreditation and supervision of the latter. In neglec
ting to offer such proof, PSI failed to discharge
its burden under the last paragraph of Article 2180 cited earlier, and, therefor
e, must be adjudged solidarily liable with Dr.
Ampil. Moreover, as we have discussed, PSI is also directly liable to the Aganas
.
One final word. Once a physician undertakes the treatment and care of a patient,
the law imposes on him certain
obligations. In order to escape liability, he must possess that reasonable degre
e of learning, skill and experience required
by his profession. At the same time, he must apply reasonable care and diligence
in the exercise of his skill and the
application of his knowledge, and exert his best judgment.
WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of the C
ourt of Appeals in CA-G.R. CV No.
42062 and CA-G.R. SP No. 32198.
Costs against petitioners PSI and Dr. Miguel Ampil.
SO ORDERED.
ANGELINA SANDOVAL-GUTIERREZ
Associate Justice
WE CONCUR:
REYNATO S. PUNO
Chief Justice
Chairperson
RENATO C. CORONA
Associate Justice
ADOLFO S. AZCUNA
Asscociate Justice
(No Part)
CANCIO C. GARCIA
Associate Justice
CERTIFICATION
Pursuant to Article VIII, Section 13 of the Constitution, it is hereby certified
that the conclusions in the above Decision
were reached in consultation before the case was assigned to the writer of the o
pinion of the Courts Division.
REYNATO S. PUNO
Chief Justice
Republic of the Philippines
SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 122445 November 18, 1997

DR. NINEVETCH CRUZ, petitioner,

vs.
COURT OF APPEALS and LYDIA UMALI, respondents.
FRANCISCO, J.:
Doctors are protected by a special rule of law. They are not guarantors of care.
They do not even warrant a good result.
They are not insurers against mishaps or unusual consequences. Furthermore they
are not liable for honest mistakes of
judgment . . . 1
The present case against petitioner is in the nature of a medical malpractice su
it, which in simplest terms is the type of
claim which a victim has available to him or her to redress a wrong committed by
a medical professional which has caused
bodily harm. 2 In this jurisdiction, however, such claims are most often brought
as a civil action for damages under Article
2176 of the Civil Code, 3 and in some instances, as a criminal case under Articl
e 365 of the Revised Penal Code 4 with
which the civil action for damages is impliedly instituted. It is via the latter
type of action that the heirs of the deceased
sought redress for the petitioner s alleged imprudence and negligence in treatin
g the deceased thereby causing her death.
The petitioner and one Dr. Lina Ercillo who was the attending anaesthesiologist
during the operation of the deceased were
charged with "reckless imprudence and negligence resulting to (sic) homicide" in
an information which reads:
That on or about March 23, 1991, in the City of San Pablo, Republic of the Phili
ppines and within the
jurisdiction of this Honorable Court, the accused above named, being then the at
tending anaesthesiologist
and surgeon, respectively, did then and there, in a negligence (sic), careless,
imprudent, and incompetent
manner, and failing to supply or store sufficient provisions and facilities nece
ssary to meet any and all
exigencies apt to arise before, during and/or after a surgical operation causing
by such negligence,
carelessness, imprudence, and incompetence, and causing by such failure, includi
ng the lack of
preparation and foresight needed to avert a tragedy, the untimely death of said
Lydia Umali on the day
following said surgical operation. 5
Trial ensued after both the petitioner and Dr. Lina Ercillo pleaded not guilty t
o the above-mentioned charge. On March 4,
1994, the Municipal Trial Court in Cities (MTCC) of San Pablo City rendered a de
cision, the dispositive portion of which is
hereunder quoted as follows:
WHEREFORE, the court finds the accused Dra. Lina Ercillo not guilty of the offen
se charged for
insufficiency of evidence while her co-accused Dra. Ninevetch Cruz is hereby hel
d responsible for the
death of Lydia Umali on March 24, 1991, and therefore guilty under Art. 365 of t
he Revised Penal Code,
and she is hereby sentenced to suffer the penalty of 2 months and 1 day imprison
ment of arresto mayor
with costs. 6
The petitioner appealed her conviction to the Regional Trial Court (RTC) which a
ffirmed in toto the decision of
the MTCC 7 prompting the petitioner to file a petition for review with the Court
of Appeals but to no avail. Hence
this petition for review on certiorari assailing the decision promulgated by the

Court of Appeals on October 24,

1995 affirming petitioner s conviction with modification that she is further dir
ected to pay the heirs of Lydia Umali
P50,000.00 as indemnity for her death. 8
In substance, the petition brought before this Court raises the issue of whether
or not petitioner s conviction of the
crime of reckless imprudence resulting in homicide, arising from an alleged medi
cal malpractice, is supported by
the evidence on record.
First the antecedent facts.
On March 22, 1991, prosecution witness, Rowena Umali De Ocampo, accompanied her
mother to the Perpetual Help
Clinic and General Hospital situated in Balagtas Street, San Pablo City, Laguna.
They arrived at the said hospital at around
4:30 in the afternoon of the same day. 9 Prior to
March 22, 1991, Lydia was examined by the petitioner who found a "myoma" 10 in h
er uterus, and scheduled her for a
hysterectomy operation on March 23,
1991. 11 Rowena and her mother slept in the clinic on the evening of March 22, 1
991 as the latter was to be operated on the
next day at 1:00 o clock in the afternoon. 12 According to Rowena, she noticed t
hat the clinic was untidy and the window
and the floor were very dusty prompting her to ask the attendant for a rag to wi
pe the window and the floor with. 13

Because of the untidy state of the clinic, Rowena tried to persuade her mother n
ot to proceed with the operation. 14 The
following day, before her mother was wheeled into the operating room, Rowena ask
ed the petitioner if the operation could
be postponed. The petitioner called Lydia into her office and the two had a conv
ersation. Lydia then informed Rowena
that the petitioner told her that she must be operated on as scheduled. 15
Rowena and her other relatives, namely her husband, her sister and two aunts wai
ted outside the operating room while
Lydia underwent operation. While they were waiting, Dr. Ercillo went out of the
operating room and instructed them to
buy tagamet ampules which Rowena s sister immediately bought. About one hour had
passed when Dr. Ercillo came out
again this time to ask them to buy blood for Lydia. They bought type "A" blood f
rom the St. Gerald Blood Bank and the
same was brought by the attendant into the operating room. After the lapse of a
few hours, the petitioner informed them
that the operation was finished. The operating staff then went inside the petiti
oner s clinic to take their snacks. Some
thirty minutes after, Lydia was brought out of the operating room in a stretcher
and the petitioner asked Rowena and the
other relatives to buy additional blood for Lydia. Unfortunately, they were not
able to comply with petitioner s order as
there was no more type "A" blood available in the blood bank. Thereafter, a pers
on arrived to donate blood which was later
transfused to Lydia. Rowena then noticed her mother, who was attached to an oxyg
en tank, gasping for breath. Apparently
the oxygen supply had run out and Rowena s husband together with the driver of t
he accused had to go to the San Pablo
District Hospital to get oxygen. Lydia was given the fresh supply of oxygen as s
oon as it arrived. 16 But at around 10:00
o clock P.M. she went into shock and her blood pressure dropped to 60/50. Lydia
s unstable condition necessitated her
transfer to the San Pablo District Hospital so she could be connected to a respi
rator and further examined. 17 The transfer
to the San Pablo District Hospital was without the prior consent of Rowena nor o
f the other relatives present who found
out about the intended transfer only when an ambulance arrived to take Lydia to
the San Pablo District Hospital. Rowena
and her other relatives then boarded a tricycle and followed the ambulance. 18
Upon Lydia s arrival at the San Pablo District Hospital, she was wheeled into th
e operating room and the petitioner and
Dr. Ercillo re-operated on her because there was blood oozing from the abdominal
incision. 19 The attending physicians
summoned Dr. Bartolome Angeles, head of the Obstetrics and Gynecology Department
of the San Pablo District Hospital.
However, when Dr. Angeles arrived, Lydia was already in shock and possibly dead
as her blood pressure was already 0/0.
Dr. Angeles then informed petitioner and Dr. Ercillo that there was nothing he c
ould do to help save the patient. 20 While
the petitioner was closing the abdominal wall, the patient died. 21 Thus, on Mar
ch 24, 1991, at 3:00 o clock in the morning,
Lydia Umali was pronounced dead. Her death certificate states "shock" as the imm
ediate cause of death and
"Disseminated Intravascular Coagulation (DIC)" as the antecedent cause. 22
In convicting the petitioner, the MTCC found the following circumstances as suff
icient basis to conclude that she was
indeed negligent in the performance of the operation:
. . . , the clinic was untidy, there was lack of provision like blood and oxygen
to prepare for any

contingency that might happen during the operation. The manner and the fact that
the patient was
brought to the San Pablo District Hospital for reoperation indicates that there
was something wrong in
the manner in which Dra. Cruz conducted the operation. There was no showing that
before the operation,
accused Dra. Cruz had conducted a cardio pulmonary clearance or any typing of th
e blood of the patient.
It was (sic) said in medical parlance that the "the abdomen of the person is a t
emple of surprises" because
you do not know the whole thing the moment it was open (sic) and surgeon must be
prepared for any
eventuality thereof. The patient (sic) chart which is a public document was not
presented because it is
only there that we could determine the condition of the patient before the surge
ry. The court also noticed
in Exh. "F-1" that the sister of the deceased wished to postpone the operation b
ut the patient was
prevailed upon by Dra. Cruz to proceed with the surgery. The court finds that Ly
dia Umali died because of
the negligence and carelessness of the surgeon Dra. Ninevetch Cruz because of lo
ss of blood during the
operation of the deceased for evident unpreparedness and for lack of skill, the
reason why the patient was
brought for operation at the San Pablo City District Hospital. As such, the surg
eon should answer for such
negligence. With respect to Dra. Lina Ercillo, the anaesthesiologist, there is n
o evidence to indicate that
she should be held jointly liable with Dra. Cruz who actually did the operation.
23
The RTC reiterated the abovementioned findings of the MTCC and upheld the latter
s declaration of "incompetency,
negligence and lack of foresight and skill of appellant (herein petitioner) in h
andling the subject patient before and after
the operation." 24 And likewise affirming the petitioner s conviction, the Court
of Appeals echoed similar observations,
thus:
. . . While we may grant that the untidiness and filthiness of the clinic may no
t by itself indicate
negligence, it nevertheless shows the absence of due care and supervision over h
er subordinate
employees. Did this unsanitary condition permeate the operating room? Were the s
urgical instruments
properly sterilized? Could the conditions in the OR have contributed to the infe
ction of the patient? Only

the petitioner could answer these, but she opted not to testify. This could only
give rise to the presumption
that she has nothing good to testify on her defense. Anyway, the alleged "unveri
fied statement of the
prosecution witness" remains unchallenged and unrebutted.
Likewise undisputed is the prosecution s version indicating the following facts:
that the accused asked the
patient s relatives to buy Tagamet capsules while the operation was already in p
rogress; that after an hour,
they were also asked to buy type "A" blood for the patient; that after the surge
ry, they were again asked to
procure more type "A" blood, but such was not anymore available from the source;
that the oxygen given
to the patient was empty; and that the son-in-law of the patient, together with
a driver of the petitioner,
had to rush to the San Pablo City District Hospital to get the much-needed oxyge
n. All these conclusively
show that the petitioner had not prepared for any unforeseen circumstances befor
e going into the first
surgery, which was not emergency in nature, but was elective or pre-scheduled; s
he had no ready
antibiotics, no prepared blood, properly typed and cross-matched, and no suffici
ent oxygen supply.
Moreover, there are a lot of questions that keep nagging Us. Was the patient giv
en any cardio-pulmonary
clearance, or at least a clearance by an internist, which are standard requireme
nts before a patient is
subjected to surgery. Did the petitioner determine as part of the pre-operative
evaluation, the bleeding
parameters of the patient, such as bleeding time and clotting time? There is no
showing that these were
done. The petitioner just appears to have been in a hurry to perform the operati
on, even as the family
wanted a postponement to April 6, 1991. Obviously, she did not prepare the patie
nt; neither did she get
the family s consent to the operation. Moreover, she did not prepare a medical c
hart with instructions for
the patient s care. If she did all these, proof thereof should have been offered
. But there is none. Indeed,
these are overwhelming evidence of recklessness and imprudence. 25
This Court, however, holds differently and finds the foregoing circumstances ins
ufficient 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 d
oing or the failure to do that act is voluntary;
(3) that it be without malice; (4) that material damage results from the reckles
s imprudence; and (5) that there is
inexcusable lack of precaution on the part of the offender, taking into consider
ation his employment or occupation, degree
of intelligence, physical condition, and other circumstances regarding persons,
time and place.
Whether or not a physician has committed an "inexcusable lack of precaution" in
the treatment of his patient is to be
determined according to the standard of care observed by other members of the pr
ofession in good standing under similar
circumstances bearing in mind the advanced state of the profession at the time o
f treatment or the present state of medical
science. 26 In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pascasio, e
t al., 27 this Court stated that in accepting a

case, a doctor in effect represents that, having the needed training and skill p
ossessed by physicians and surgeons
practicing in the same field, he will employ such training, care and skill in th
e treatment of his patients. He therefore has a
duty to use at least the same level of care that any other reasonably competent
doctor would use to treat a condition under
the same circumstances. It is in this aspect of medical malpractice that expert
testimony is essential to establish not only
the standard of care of the profession but also that the physician s conduct in
the treatment and care falls below such
standard. 28 Further, inasmuch as the causes of the injuries involved in malprac
tice actions are determinable only in the
light of scientific knowledge, it has been recognized that expert testimony is u
sually necessary to support the conclusion as
to causation. 29
Immediately apparent from a review of the records of this case is the absence of
any expert testimony on the matter of the
standard of care employed by other physicians of good standing in the conduct of
similar operations. The prosecution s
expert witnesses in the persons of Dr. Floresto Arizala and Dr. Nieto Salvador,
Jr. of the National Bureau of Investigation
(NBI) only testified as to the possible cause of death but did not venture to il
luminate the court on the matter of the
standard of care that petitioner should have exercised.
All three courts below bewail the inadequacy of the facilities of the clinic and
its untidiness; the lack of provisions such as
blood, oxygen, and certain medicines; the failure to subject the patient to a ca
rdio-pulmonary test prior to the operation;
the omission of any form of blood typing before transfusion; and even the subseq
uent transfer of Lydia to the San Pablo
Hospital and the reoperation performed on her by the petitioner. But while it ma
y be true that the circumstances pointed
out by the courts below seemed beyond cavil to constitute reckless imprudence on
the part of the surgeon, this conclusion
is still best arrived at not through the educated surmises nor conjectures of la
ymen, including judges, but by the
unquestionable knowledge of expert witnesses. For whether a physician or surgeon
has exercised the requisite degree of
skill and care in the treatment of his patient is, in the generality of cases, a
matter of expert opinion. 30 The deference of
courts to the expert opinion of qualified physicians stems from its realization
that the latter possess unusual technical
skills which laymen in most instances are incapable of intelligently evaluating.
31 Expert testimony should have been
offered to prove that the circumstances cited by the courts below are constituti
ve of conduct falling below the standard of

care employed by other physicians in good standing when performing the same oper
ation. It must be remembered that
when the qualifications of a physician are admitted, as in the instant case, the
re is an inevitable presumption that in
proper cases he takes the necessary precaution and employs the best of his knowl
edge and skill in attending to his clients,
unless the contrary is sufficiently established. 32 This presumption is rebuttab
le by expert opinion which is so sadly lacking
in the case at bench.
Even granting arguendo that the inadequacy of the facilities and untidiness of t
he clinic; the lack of provisions; the failure
to conduct pre-operation tests on the patient; and the subsequent transfer of Ly
dia to the San Pablo Hospital and the
reoperation performed on her by the petitioner do indicate, even without expert
testimony, that petitioner was recklessly
imprudent in the exercise of her duties as a surgeon, no cogent proof exists tha
t any of these circumstances caused
petitioner s death. Thus, the absence of the fourth element of reckless impruden
ce: that the injury to the person or
property was a consequence of the reckless imprudence.
In litigations involving medical negligence, the plaintiff has the burden of est
ablishing appellant s negligence and for a
reasonable conclusion of negligence, there must be proof of breach of duty on th
e part of the surgeon as well as a causal
connection of such breach and the resulting death of his patient. 33 In Chan Lug
ay v. St. Luke s Hospital, Inc., 34 where
the attending physician was absolved of liability for the death of the complaina
nt s wife and newborn baby, this Court held
that:
In order that there may be a recovery for an injury, however, it must be shown t
hat the "injury for which
recovery is sought must be the legitimate consequence of the wrong done; the con
nection between the
negligence and the injury must be a direct and natural sequence of events, unbro
ken by intervening
efficient causes." In other words, the negligence must be the proximate cause of
the injury. For,
"negligence, no matter in what it consists, cannot create a right of action unle
ss it is the proximate cause
of the injury complained of ." And "the proximate cause of an injury is that cau
se, which, in natural and
continuous sequence, unbroken by any efficient intervening cause, produces the i
njury, and without
which the result would not have occurred." 35 (Emphasis supplied.)
Dr. Arizala who conducted an autopsy on the body of the deceased summarized his
findings as follows:
Atty. Cachero:
Q. You mentioned about your Autopsy Report which has been marked as Exh. "A-1-b"
.
There appears here a signature above the typewritten name Floresto Arizala, Jr.,
whose
signature is that?
A. That is my signature, sir.
Q. Do you affirm the truth of all the contents of Exh. "A-1-b"?
A. Only as to the autopsy report no. 91-09, the time and place and everything af
ter the
post mortem findings, sir.
Q. You mentioned on your "Post Mortem Findings" about surgical incision, 14:0 cm
.,
infraumbilical area, anterior abdominal area, midline, will you please explain t

hat in your
own language?
A. There was incision wound (sic) the area just below the navel, sir.
Q. And the last paragraph of the postmortem findings which I read: Uterus, pearshaped
and pale measuring 7.5 x 5.5 x 5.0 cm. with some surface nodulation of the fundi
c area
posteriorly. Cut-section shows diffusely pale myometrium with areas of streak in
duration.
The ovaries and adnexal structures are missing with the raw surfaces patched wit
h clotted
blood. Surgical sutures were noted on the operative site.
Intestines and mesenteries are pale with blood clots noted between the mesentric
folds.
Hemoperitoneum: 300 s.s.,
right paracolic gutter,
50 c.c., left paracolic gutter

200 c.c., mesentric area,

100 c.c., right pelvic gutter
stomach empty.
Other visceral organs, pale.,
will you please explain that on (sic) your own language or in ordinary. . . . .
. . . . . . .
A. There was a uterus which was not attached to the adnexal structures namely ov
aries
which were not present and also sign of previous surgical operation and there we
re (sic)
clotted blood, sir.
Q. How about the ovaries and adnexal structures?
A. They are missing, sir.
Q. You mean to say there are no ovaries?
A. During that time there are no ovaries, sir.
Q. And there were likewise sign of surgical sutures?
A. Yes, sir.
Q. How about the intestines and mesenteries are place (sic) with blood clots not
ed
between the mesenteric folds, will you please explain on (sic) this?
A. In the peritoneal cavity, they are mostly perritonial blood . . . . . . . .
Q. And what could have caused this blood?
A. Well, ordinarily blood is found inside the blood vessel. Blood were (sic) out
side as a
result of the injuries which destroyed the integrity of the vessel allowing bloo
d to sip (sic)
out, sir.
Q. By the nature of the postmortem findings indicated in Exh. A-1-B, can you tel
l the
court the cause of death?
A. Yes, sir. The cause of death is: Gross findings are compatible with hemorrhag
ic shock.
Q. Can you tell the us what could have caused this hemorrhagic shock?
A. Well hemorrhagic shock is the result of blood loss.
Q. What could have the effect of that loss of blood?
A. Unattended hemorrhage, sir. 36 (Emphasis supplied.)
The foregoing was corroborated by Dr. Nieto Salvador:
Q. And were you able to determine the cause of death by virtue of the examinatio
n of the
specimen submitted by Dr. Arizala?
A. Without knowledge of the autopsy findings it would be difficult for me to det
ermine
the cause of death, sir.
Q. Have you also examined the post mortem of Dr. Arizala?

A. Yes, sir, and by virtue of the autopsy report in connection with your patholo
gy report.
Q. What could have caused the death of the victim?
A. This pathologic examination are (sic) compatible with the person who died, si
r.
Q. Will you explain to us the meaning of hemorrhagic compatible?
A. It means that a person died of blood loss. Meaning a person died of non-repla
cement
of blood and so the victim before she died there was shock of diminish of blood
of the
circulation. She died most probably before the actual complete blood loss, sir.
Court: Is it possible doctor that the loss of the blood was due on (sic) operati
on?
A. Based on my pathologist finding, sir.
Q. What could have caused this loss of blood?
A. Many, sir. A patient who have undergone surgery. Another may be a blood vesse
l
may be cut while on operation and this cause (sic) bleeding, or may be set in th
e course
of operation, or may be (sic) he died after the operation. Of course there are o
ther cause
(sic).
Atty. Cachero:
Q. Especially so doctor when there was no blood replacement?
A. Yes, sir. 37 (Emphasis supplied.)
The testimonies of both doctors establish hemorrhage or hemorrhagic shock as the
cause of death. However, as likewise
testified to by the expert witnesses in open court, hemorrhage or hemorrhagic sh
ock during surgery may be caused by
several different factors. Thus, Dr. Salvador s elaboration on the matter:
Atty. Pascual:
Q. Doctor, among the causes of hemorrhage that you mentioned you said that it co
uld be
at the moment of operation when one losses (sic) control of the presence, is tha
t correct?
During the operation there is lost (sic) of control of the cut vessel?
A. Yes, sir.
Q. Or there is a failure to ligate a vessel of considerable size?
A. Yes, sir.
Q. Or even if the vessel were ligated the knot may have slipped later on?
A. Yes, sir.
Q. And you also mentioned that it may be possible also to some clotting defect,
is that
correct?
A. May be (sic). 38 (Emphasis supplied).
Defense witness, Dr. Bu C. Castro also gave the following expert opinion:
Q. Doctor even a patient after an operations (sic) would suffer hemorrage what w
ould
be the possible causes of such hemorrage (sic)?

A. Among those would be what we call Intravascular Coagulation and this is the r
eason
for the bleeding, sir, which cannot be prevented by anyone, it will happen to an
yone,
anytime and to any persons (sic), sir.
COURT:
What do you think of the cause of the bleeding, the cutting or the operations do
ne in the
body?
A. Not related to this one, the bleeding here is not related to any cutting or o
peration that
I (sic) have done.
Q. Aside from the DIC what could another causes (sic) that could be the cause fo
r the
hemorrhage or bleeding in a patient by an operations (sic)?
A. In general sir, if there was an operations (sic) and it is possible that the
ligature in the
suture was (sic) become (sic) loose, it is (sic) becomes loose if proven..
xxx xxx xxx
Q. If the person who performed an autopsy does not find any untight (sic) clot (
sic) blood
vessel or any suture that become (sic) loose the cause of the bleeding could not
be
attributed to the fault of the subject?
A. Definitely, sir. 39 (Emphasis supplied.)
According to both doctors, the possible causes of hemorrhage during an operation
are: (1) the failure of the surgeon to tie
or suture a cut blood vessel; (2) allowing a cut blood vessel to get out of cont
rol; (3) the subsequent loosening of the tie or
suture applied to a cut blood vessel; and (4) and a clotting defect known as DIC
. It is significant to state at this juncture
that the autopsy conducted by Dr. Arizala on the body of Lydia did not reveal an
y untied or unsutured cut blood vessel nor
was there any indication that the tie or suture of a cut blood vessel had become
loose thereby causing the hemorrhage. 40
Hence the following pertinent portion of Dr. Arizala s testimony:
Q: Doctor, in examining these structures did you know whether these were sutured
ligature or plain ligature
A: Ligature, sir.
Q: We will explain that later on. Did you recall if the cut structures were tied
by first
suturing it and then tying a knot or the tie was merely placed around the cut st
ructure
and tied?
A: I cannot recall, sir.
Q: As a matter of fact, you cannot recall because you did not even bothered (sic
) to
examine, is that correct?
A: Well, I bothered enough to know that they were sutured, sir.
Q: So, therefore, Doctor, you would not know whether any of the cut structures w
ere not
sutured or tied neither were you able to determine whether any loose suture was
found in
the peritoneal cavity?
A: I could not recall any loose sutured (sic), sir. 41
On the other hand, the findings of all three doctors do not preclude the probabi
lity that DIC caused the hemorrhage and
consequently, Lydia s death. DIC which is a clotting defect creates a serious bl
eeding tendency and when massive DIC
occurs as a complication of surgery leaving raw surface, major hemorrhage occurs

. 42 And as testified to by defense

witness, Dr. Bu C. Castro, hemorrhage due to DIC "cannot be prevented, it will h

appen to anyone,
anytime." 43 He testified further:
Q. Now, under that circumstance one of the possibility as you mentioned in (sic)
DIC?
A. Yes, sir.
Q. And you mentioned that this cannot be prevented?
A. Yes, sir.
Q. Can you even predict if it really happen (sic)?
A. Possible, sir.
Q. Are there any specific findings of autopsy that will tell you whether this pa
tient
suffered among such things as DIC?
A. Well, I did reserve because of the condition of the patient.
Q. Now, Doctor you said that you went through the record of the deceased Lydia U
mali
looking for the chart, the operated (sic) records, the post mortem findings on t
he
histophanic (sic) examination based on your examination of record, doctor, can y
ou more
or less says (sic) what part are (sic) concerned could have been the caused (sic
) of death of
this Lydia Umali?
A. As far as the medical record is concern (sic) the caused (sic) of death is de
ssimulated
(sic) Intra Vascular Coagulation or the DIC which resulted to hemorrhage or blee
dings,
sir.
Q. Doctor based on your findings then there is knowing (sic) the doctor would sa
y
whether the doctor her (sic) has been (sic) fault?
ATTY. MALVEDA:
We will moved (sic) to strike out the (sic) based on finding they just read the
chart as well
as the other record.
ATTY. PASCUAL:
Precisely based on this examination.
ATTY. MALVEDA:
Not finding, there was no finding made.
COURT:
He is only reading the record.
ATTY. PASCUAL:
Yes, sir.
A. No, sir, there is no fault on the part of the surgeon, sir. 44
This Court has no recourse but to rely on the expert testimonies rendered by bot
h prosecution and defense witnesses that
substantiate rather than contradict petitioner s allegation that the cause of Ly
dia s death was DIC which, as attested to by

an expert witness, cannot be attributed to the petitioner s fault or negligence.

The probability that Lydia s death was
caused by DIC was unrebutted during trial and has engendered in the mind of this
Court a reasonable doubt as to the
petitioner s guilt. Thus, her acquittal of the crime of reckless imprudence resu
lting in homicide. While we condole with the
family of Lydia Umali, our hands are bound by the dictates of justice and fair d
ealing which hold inviolable the right of an
accused to be presumed innocent until proven guilty beyond reasonable doubt. Nev
ertheless, this Court finds the
petitioner civilly liable for the death of Lydia Umali, for while a conviction o
f a crime requires proof beyond reasonable
doubt, only a preponderance of evidence is required to establish civil liability
. 45
The petitioner is a doctor in whose hands a patient puts his life and limb. For
insufficiency of evidence this Court was not
able to render a sentence of conviction but it is not blind to the reckless and
imprudent manner in which the petitioner
carried out her duties. A precious life has been lost and the circumstances lead
ing thereto exacerbated the grief of those
left behind. The heirs of the deceased continue to feel the loss of their mother
up to the present time 46 and this Court is
aware that no amount of compassion and commiseration nor words of bereavement ca
n suffice to assuage the sorrow felt
for the loss of a loved one. Certainly, the award of moral and exemplary damages
in favor of the heirs of Lydia Umali are
proper in the instant case.
WHEREFORE, premises considered, petitioner DR. NINEVETCH CRUZ is hereby ACQUITTE
D of the crime of reckless
imprudence resulting in homicide but is ordered to pay the heirs of the deceased
Lydia Umali the amount of FIFTY
THOUSAND PESOS (P50,000.00) as civil liability, ONE HUNDRED THOUSAND PESOS (P100
,000.00) as moral
damages, and FIFTY THOUSAND PESOS (P50,000.00) as exemplary damages.
Let a copy of this decision be furnished to the Professional Regulation Commissi
on (PRC) for appropriate action.
SO ORDERED.
Romero, Melo and Panganiban, JJ., concur.
Narvasa, C.J., is on leave.
Republic of the Philippines
SUPREME COURT
Manila
SECOND DIVISION
G.R. No. 158996
November 14, 2008
SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA FLORES, petitioners,
vs.
SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO, and FLORENCIO, CANDIDA, MARTA,
GODOFREDO, BALTAZAR and LUCENA, all surnamed PINEDA, as heirs of the deceased TE
RESITA S.
PINEDA, and UNITED DOCTORS MEDICAL CENTER, INC., respondents.
DECISION
BRION, J.:
This petition involves a medical negligence case that was elevated to this Court
through an appeal by certiorari under Rule
45 of the Rules of Court. The petition assails the Decision1 of the Court of App
eals (CA) in CA G.R. CV No. 63234, which

affirmed with modification the Decision2 of the Regional Trial Court (RTC) of Nu
eva Ecija, Branch 37 in Civil Case No. SD1233. The dispositive portion of the as
sailed CA decision states:
WHEREFORE, premises considered, the assailed Decision of the Regional Trial Cour
t of Baloc, Sto. Domingo,
Nueva Ecija, Branch 37 is hereby AFFIRMED but with modifications as follows:
1) Ordering defendant-appellants Dr. and Dra. Fredelicto A. Flores and the Unite
d Doctors Medical
Center, Inc. to jointly and severally pay the plaintiff-appellees - heirs of Ter
esita Pineda, namely, Spouses

Dominador Pineda and Virginia Saclolo and Florencio, Candida, Marta, Godofredo,
Baltazar and Lucena,
all surnamed Pineda, the sum of P400,000.00 by way of moral damages;
2) Ordering the above-named defendant-appellants to jointly and severally pay th
e above-named
plaintiff-appellees the sum of P100,000.00 by way of exemplary damages;
3) Ordering the above-named defendant-appellants to jointly and severally pay th
e above-named plaintiffappellees the sum of P36,000.00 by way of actual and comp
ensatory damages; and
4) Deleting the award of attorney s fees and costs of suit.
SO ORDERED.
While this case essentially involves questions of facts, we opted for the reques
ted review in light of questions we have on
the findings of negligence below, on the awarded damages and costs, and on the i
mportance of this type of ruling on
medical practice.3
BACKGROUND FACTS
Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto. Domi
ngo, Nueva Ecija. She consulted on
April 17, 1987 her townmate, Dr. Fredelicto Flores, regarding her medical condit
ion. She complained of general body
weakness, loss of appetite, frequent urination and thirst, and on-and-off vagina
l bleeding. Dr. Fredelicto initially
interviewed the patient and asked for the history of her monthly period to analy
ze the probable cause of the vaginal
bleeding. He advised her to return the following week or to go to the United Doc
tors Medical Center (UDMC) in Quezon
City for a general check-up. As for her other symptoms, he suspected that Teresi
ta might be suffering from diabetes and
told her to continue her medications.4
Teresita did not return the next week as advised. However, when her condition pe
rsisted, she went to further consult Dr.
Flores at his UDMC clinic on April 28, 1987, travelling for at least two hours f
rom Nueva Ecija to Quezon City with her
sister, Lucena Pineda. They arrived at UDMC at around 11:15 a.m.. Lucena later t
estified that her sister was then so weak
that she had to lie down on the couch of the clinic while they waited for the do
ctor. When Dr. Fredelicto arrived, he did a
routine check-up and ordered Teresita s admission to the hospital. In the admiss
ion slip, he directed the hospital staff to
prepare the patient for an "on call" D&C5 operation to be performed by his wife,
Dr. Felicisima Flores (Dr. Felicisima).
Teresita was brought to her hospital room at around 12 noon; the hospital staff
forthwith took her blood and urine
samples for the laboratory tests6 which Dr. Fredelicto ordered.
At 2:40 p.m. of that same day, Teresita was taken to the operating room. It was
only then that she met Dr. Felicisima, an
obstetrician and gynecologist. The two doctors - Dr. Felicisima and Dr. Fredelic
to, conferred on the patient s medical
condition, while the resident physician and the medical intern gave Dr. Felicisi
ma their own briefings. She also
interviewed and conducted an internal vaginal examination of the patient which l
asted for about 15 minutes. Dr.
Felicisima thereafter called up the laboratory for the results of the tests. At
that time, only the results for the blood sugar
(BS), uric acid determination, cholesterol determination, and complete blood cou
nt (CBC) were available. Teresita s BS
count was 10.67mmol/l7 and her CBC was 109g/l.8
Based on these preparations, Dr. Felicisima proceeded with the D&C operation wit
h Dr. Fredelicto administering the

general anesthesia. The D&C operation lasted for about 10 to 15 minutes. By 3:40
p.m., Teresita was wheeled back to her
room.
A day after the operation (or on April 29, 1987), Teresita was subjected to an u
ltrasound examination as a confirmatory
procedure. The results showed that she had an enlarged uterus and myoma uteri.9
Dr. Felicisima, however, advised
Teresita that she could spend her recovery period at home. Still feeling weak, T
eresita opted for hospital confinement.
Teresita s complete laboratory examination results came only on that day (April
29, 1987). Teresita s urinalysis showed a
three plus sign (+++) indicating that the sugar in her urine was very high. She
was then placed under the care of Dr.
Amado Jorge, an internist.
By April 30, 1987, Teresita s condition had worsened. She experienced difficulty
in breathing and was rushed to the
intensive care unit. Further tests confirmed that she was suffering from Diabete
s Mellitus Type II.10 Insulin was
administered on the patient, but the medication might have arrived too late. Due
to complications induced by diabetes,
Teresita died in the morning of May 6, 1987.11

Believing that Teresita s death resulted from the negligent handling of her medi
cal needs, her family (respondents)
instituted an action for damages against Dr. Fredelicto Flores and Dr. Felicisim
a Flores (collectively referred to as the
petitioner spouses) before the RTC of Nueva Ecija.
The RTC ruled in favor of Teresita s family and awarded actual, moral, and exemp
lary damages, plus attorney s fees and
costs.12 The CA affirmed the judgment, but modified the amount of damages awarde
d and deleted the award for attorney s
fees and costs of suit.13
Through this petition for review on certiorari, the petitioner spouses -Dr. Fred
elicto (now deceased) and Dr. Felicisima
Flores - allege that the RTC and CA committed a reversible error in finding them
liable through negligence for the death of
Teresita Pineda.
ASSIGNMENT OF ERRORS
The petitioner spouses contend that they exercised due care and prudence in the
performance of their duties as medical
professionals. They had attended to the patient to the best of their abilities a
nd undertook the management of her case
based on her complaint of an on-and-off vaginal bleeding. In addition, they clai
m that nothing on record shows that the
death of Teresita could have been averted had they employed means other than wha
t they had adopted in the ministration
of the patient.
THE COURT S RULING
We do not find the petition meritorious.
The respondents claim for damages is predicated on their allegation that the de
cision of the petitioner spouses to proceed
with the D&C operation, notwithstanding Teresita s condition and the laboratory
test results, amounted to negligence. On
the other hand, the petitioner spouses contend that a D&C operation is the prope
r and accepted procedure to address
vaginal bleeding - the medical problem presented to them. Given that the patient
died after the D&C, the core issue is
whether the decision to proceed with the D&C operation was an honest mistake of
judgment or one amounting to
negligence.
Elements of a Medical Negligence Case
A medical negligence case is a type of claim to redress a wrong committed by a m
edical professional, that has caused
bodily harm to or the death of a patient. There are four elements involved in a
medical negligence case, namely: duty,
breach, injury, and proximate causation.14
Duty refers to the standard of behavior which imposes restrictions on one s cond
uct. 15 The standard in turn refers to the
amount of competence associated with the proper discharge of the profession. A p
hysician is expected to use at least the
same level of care that any other reasonably competent doctor would use under th
e same circumstances. Breach of duty
occurs when the physician fails to comply with these professional standards. If
injury results to the patient as a result of
this breach, the physician is answerable for negligence.16
As in any civil action, the burden to prove the existence of the necessary eleme
nts rests with the plaintiff.17 To successfully
pursue a claim, the plaintiff must prove by preponderance of evidence that, one,
the physician either failed to do
something which a reasonably prudent health care provider would have done, or th
at he did something that a
reasonably prudent provider would not have done; and two, the failure or action

caused injury to the patient.18 Expert

testimony is therefore essential since the factual issue of whether a physician
or surgeon has exercised the requisite degree
of skill and care in the treatment of his patient is generally a matter of exper
t opinion.19
Standard of Care and Breach of Duty
D&C is the classic gynecologic procedure for the evaluation and possible therape
utic treatment for abnormal vaginal
bleeding.20 That this is the recognized procedure is confirmed by Drs. Salvador
Nieto (Dr. Nieto) and Joselito Mercado
(Dr. Mercado), the expert witnesses presented by the respondents:
DR. NIETO: [W]hat I know among obstetricians, if there is bleeding, they perform
what we call D&C for
diagnostic purposes.

xxx xxx xxx

Q: So are you trying to tell the Court that D&C can be a diagnostic treatment?
A: Yes, sir. Any doctor knows this.21
Dr. Mercado, however, objected with respect to the time the D&C operation should
have been conducted in Teresita s case.
He opined that given the blood sugar level of Teresita, her diabetic condition s
hould have been addressed first:
Q: Why do you consider the time of performance of the D&C not appropriate?
A: Because I have read the record and I have seen the urinalysis, [there is] spi
llage in the urine, and blood sugar
was 10.67
Q: What is the significance of the spillage in the urine?
A: It is a sign that the blood sugar is very high.
Q: Does it indicate sickness?
A: 80 to 95% it means diabetes mellitus. The blood sugar was 10.67.
xxx xxx xxx
COURT: In other words, the operation conducted on the patient, your opinion, tha
t it is inappropriate?
A: The timing of [when] the D&C [was] done, based on the record, in my personal
opinion, that D&C should be
postponed a day or two.22
The petitioner spouses countered that, at the time of the operation, there was n
othing to indicate that Teresita was
afflicted with diabetes: a blood sugar level of 10.67mmol/l did not necessarily
mean that she was a diabetic considering
that this was random blood sugar;23 there were other factors that might have cau
sed Teresita s blood sugar to rise such
as the taking of blood samples during lunchtime and while patient was being give
n intra-venous dextrose.24 Furthermore,
they claim that their principal concern was to determine the cause of and to sto
p the vaginal bleeding.
The petitioner spouses contentions, in our view, miss several points. First, as
early as April 17, 1987, Teresita was already
suspected to be suffering from diabetes.25 This suspicion again arose right befo
re the D&C operation on April 28, 1987
when the laboratory result revealed Teresita s increased blood sugar level.26 Un
fortunately, the petitioner spouses did not
wait for the full medical laboratory results before proceeding with the D&C, a f
act that was never considered in the courts
below. Second, the petitioner spouses were duly advised that the patient was exp
eriencing general body weakness, loss of
appetite, frequent urination, and thirst - all of which are classic symptoms of
diabetes.27 When a patient exhibits
symptoms typical of a particular disease, these symptoms should, at the very lea
st, alert the physician of the possibility
that the patient may be afflicted with the suspected disease:
Expert testimony for the plaintiff showed that] tests should have been ordered i
mmediately on admission to the hospital in view of the symptoms presented, and t
hat failure to
recognize the existence of diabetes constitutes negligence.28
Third, the petitioner spouses cannot claim that their principal concern was the
vaginal bleeding and should not therefore
be held accountable for complications coming from other sources. This is a very
narrow and self-serving view that even
reflects on their competence.
Taken together, we find that reasonable prudence would have shown that diabetes
and its complications were foreseeable
harm that should have been taken into consideration by the petitioner spouses. I
f a patient suffers from some

disability that increases the magnitude of risk to him, that disability must be
taken into account so long
as it is or should have been known to the physician.29 And when the patient is e
xposed to an increased risk, it is
incumbent upon the physician to take commensurate and adequate precautions.
Taking into account Teresita s high blood sugar,30 Dr. Mendoza opined that the a
ttending physician should have
postponed the D&C operation in order to conduct a confirmatory test to make a co
nclusive diagnosis of diabetes and to

refer the case to an internist or diabetologist. This was corroborated by Dr. De

lfin Tan (Dr. Tan), an obstetrician and
gynecologist, who stated that the patient s diabetes should have been managed by
an internist prior to, during, and after
the operation.31
Apart from bleeding as a complication of pregnancy, vaginal bleeding is only rar
ely so heavy and life-threatening that
urgent first-aid measures are required.32 Indeed, the expert witnesses declared
that a D&C operation on a hyperglycemic
patient may be justified only when it is an emergency case - when there is profu
se vaginal bleeding. In this case, we choose
not to rely on the assertions of the petitioner spouses that there was profuse b
leeding, not only because the statements
were self-serving, but also because the petitioner spouses were inconsistent in
their testimonies. Dr. Fredelicto testified
earlier that on April 28, he personally saw the bleeding,33 but later on said th
at he did not see it and relied only on
Teresita s statement that she was bleeding.34 He went on to state that he schedu
led the D&C operation without conducting
any physical examination on the patient.
The likely story is that although Teresita experienced vaginal bleeding on April
28, it was not sufficiently profuse to
necessitate an immediate emergency D&C operation. Dr. Tan35 and Dr. Mendoza36 bo
th testified that the medical records
of Teresita failed to indicate that there was profuse vaginal bleeding. The clai
m that there was profuse vaginal bleeding
although this was not reflected in the medical records strikes us as odd since t
he main complaint is vaginal bleeding. A
medical record is the only document that maintains a long-term transcription of
patient care and as such, its maintenance
is considered a priority in hospital practice. Optimal record-keeping includes a
ll patient inter-actions. The records should
always be clear, objective, and up-to-date.37 Thus, a medical record that does n
ot indicate profuse medical bleeding speaks
loudly and clearly of what it does not contain.
That the D&C operation was conducted principally to diagnose the cause of the va
ginal bleeding further leads us to
conclude that it was merely an elective procedure, not an emergency case. In an
elective procedure, the physician must
conduct a thorough pre-operative evaluation of the patient in order to adequatel
y prepare her for the operation and
minimize possible risks and complications. The internist is responsible for gene
rating a comprehensive evaluation of all
medical problems during the pre-operative evaluation.38
The aim of pre-operative evaluation is not to screen broadly for undiagnosed dis
ease, but rather to identify and
quantify comorbidity that may impact on the operative outcome. This evaluation i
s driven by findings on history
and physical examination suggestive of organ system dysfunctionThe goal is to unc
over problem areas
that may require further investigation or be amenable to preoperative optimizati
on.
If the preoperative evaluation uncovers significant comorbidity or evidence of p
oor control of an underlying
disease process, consultation with an internist or medical specialist may be req
uired to facilitate the work-up and
direct management. In this process, communication between the surgeons and the c
onsultants is essential to
define realistic goals for this optimization process and to expedite surgical ma
nagement. 39 [Emphasis supplied.]

Significantly, the evidence strongly suggests that the pre-operative evaluation

was less than complete as the laboratory
results were fully reported only on the day following the D&C operation. Dr. Fel
icisima only secured a telephone report of
the preliminary laboratory result prior to the D&C. This preliminary report did
not include the 3+ status of sugar in the
patient s urine40 - a result highly confirmatory of diabetes.
Because the D&C was merely an elective procedure, the patient s uncontrolled hyp
erglycemia presented a far greater risk
than her on-and-off vaginal bleeding. The presence of hyperglycemia in a surgica
l patient is associated with poor clinical
outcomes, and aggressive glycemic control positively impacts on morbidity and mo
rtality. 41 Elective surgery in people with
uncontrolled diabetes should preferably be scheduled after acceptable glycemic c
ontrol has been achieved.42 According to
Dr. Mercado, this is done by administering insulin on the patient.43
The management approach in this kind of patients always includes insulin therapy
in combination with dextrose
and potassium infusion. Insulin xxx promotes glucose uptake by the muscle and fa
t cells while decreasing glucose
production by the liver xxx. The net effect is to lower blood glucose levels. 44
The prudent move is to address the patient s hyperglycemic state immediately and
promptly before any other procedure is
undertaken. In this case, there was no evidence that insulin was administered on
Teresita prior to or during the D&C
operation. Insulin was only administered two days after the operation.
As Dr. Tan testified, the patient s hyperglycemic condition should have been man
aged not only before and during the
operation, but also immediately after. Despite the possibility that Teresita was
afflicted with diabetes, the possibility was
casually ignored even in the post-operative evaluation of the patient; the conce
rn, as the petitioner spouses expressly
admitted, was limited to the complaint of vaginal bleeding. Interestingly, while
the ultrasound test confirmed that Teresita

had a myoma in her uterus, she was advised that she could be discharged a day af
ter the operation and that her recovery
could take place at home. This advice implied that a day after the operation and
even after the complete laboratory results
were submitted, the petitioner spouses still did not recognize any post-operativ
e concern that would require the
monitoring of Teresita s condition in the hospital.
The above facts, point only to one conclusion - that the petitioner spouses fail
ed, as medical professionals, to comply with
their duty to observe the standard of care to be given to hyperglycemic/diabetic
patients undergoing surgery. Whether this
breach of duty was the proximate cause of Teresita s death is a matter we shall
next determine.
Injury and Causation
As previously mentioned, the critical and clinching factor in a medical negligen
ce case is proof of the causal connection
between the negligence which the evidence established and the plaintiff s injuri
es; 45 the plaintiff must plead and prove not
only that he had been injured and defendant has been at fault, but also that the
defendant s fault caused the injury. A
verdict in a malpractice action cannot be based on speculation or conjecture. Ca
usation must be proven within a
reasonable medical probability based upon competent expert testimony.46
The respondents contend that unnecessarily subjecting Teresita to a D&C operatio
n without adequately preparing her,
aggravated her hyperglycemic state and caused her untimely demise. The death cer
tificate of Teresita lists down the
following causes of death:
Immediate cause:
Cardiorespiratory arrest
Antecedent cause:
Septicemic shock, ketoacidocis
Underlying cause:
Diabetes Mellitus II
Other significant conditions
contributing to death:
Renal Failure - Acute47
Stress, whether physical or emotional, is a factor that can aggravate diabetes;
a D&C operation is a form of physical stress.
Dr. Mendoza explained how surgical stress can aggravate the patient s hyperglyce
mia: when stress occurs, the diabetic s
body, especially the autonomic system, reacts by secreting hormones which are co
unter-regulatory; she can have
prolonged hyperglycemia which, if unchecked, could lead to death. 48 Medical lit
erature further explains that if the blood
sugar has become very high, the patient becomes comatose (diabetic coma). When t
his happens over several days, the
body uses its own fat to produce energy, and the result is high levels of waste
products (called ketones) in the blood and
urine (called diabetic ketoacidiosis, a medical emergency with a significant mor
tality).49 This was apparently what
happened in Teresita s case; in fact, after she had been referred to the interni

st Dr. Jorge, laboratory test showed that her

blood sugar level shot up to 14.0mmol/l, way above the normal blood sugar range.
Thus, between the D&C and death was
the diabetic complication that could have been prevented with the observance of
standard medical precautions. The D&C
operation and Teresita s death due to aggravated diabetic condition is therefore
sufficiently established.
The trial court and the appellate court pinned the liability for Teresita s deat
h on both the petitioner spouses and this
Court finds no reason to rule otherwise. However, we clarify that Dr. Fredelicto
s negligence is not solely the act of
ordering an "on call" D&C operation when he was mainly an anaesthesiologist who
had made a very cursory
examination of the patient s vaginal bleeding complaint. Rather, it was his fail
ure from the very start to identify and
confirm, despite the patient s complaints and his own suspicions, that diabetes
was a risk factor that should be guarded
against, and his participation in the imprudent decision to proceed with the D&C
operation despite his early suspicion and
the confirmatory early laboratory results. The latter point comes out clearly fr
om the following exchange during the trial:
Q: On what aspect did you and your wife consult [with] each other?
A: We discussed on the finding of the laboratory [results] because the hemoglobi
n was below normal, the blood
sugar was elevated, so that we have to evaluate these laboratory results - what
it means.
Q: So it was you and your wife who made the evaluation when it was phoned in?
A: Yes, sir.

Q: Did your wife, before performing D&C ask your opinion whether or not she can
proceed?
A: Yes, anyway, she asked me whether we can do D&C based on my experience.
Q: And your answer was in the positive notwithstanding the elevation of blood su
gar?
A: Yes, sir, it was both our disposition to do the D&C. [Emphasis supplied.]50
If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not
being an internist or a diabetologist (for
which reason he referred Teresita to Dr. Jorge),51 he should have likewise refra
ined from making a decision to proceed
with the D&C operation since he was niether an obstetrician nor a gynecologist.
These findings lead us to the conclusion that the decision to proceed with the D
&C operation, notwithstanding Teresita s
hyperglycemia and without adequately preparing her for the procedure, was contra
ry to the standards observed by the
medical profession. Deviation from this standard amounted to a breach of duty wh
ich resulted in the patient s death. Due
to this negligent conduct, liability must attach to the petitioner spouses.
Liability of the Hospital
In the proceedings below, UDMC was the spouses Flores co-defendant. The RTC fou
nd the hospital jointly and severally
liable with the petitioner spouses, which decision the CA affirmed. In a Resolut
ion dated August 28, 2006, this Court
however denied UDMC s petition for review on certiorari. Since UDMC s appeal has
been denied and they are not parties
to this case, we find it unnecessary to delve on the matter. Consequently, the R
TC s decision, as affirmed by the CA, stands.
Award of Damages
Both the trial and the appellate court awarded actual damages as compensation fo
r the pecuniary loss the respondents
suffered. The loss was presented in terms of the hospital bills and expenses the
respondents incurred on account of
Teresita s confinement and death. The settled rule is that a plaintiff is entitl
ed to be compensated for proven pecuniary
loss.52 This proof the respondents successfully presented. Thus, we affirm the a
ward of actual damages of P36,000.00
representing the hospital expenses the patient incurred.
In addition to the award for actual damages, the respondent heirs of Teresita ar
e likewise entitled to P50,000.00 as death
indemnity pursuant to Article 2206 of the Civil Code, which states that "the amo
unt of damages for death caused by a
xxx quasi-delict shall be at least three thousand pesos,53 even though there may
have been mitigating circumstances xxx."
This is a question of law that the CA missed in its decision and which we now de
cide in the respondents favor.
The same article allows the recovery of moral damages in case of death caused by
a quasi-delict and enumerates the
spouse, legitimate or illegitimate ascendants or descendants as the persons enti
tled thereto. Moral damages are designed
to compensate the claimant for the injury suffered, that is, for the mental angu
ish, serious anxiety, wounded feelings
which the respondents herein must have surely felt with the unexpected loss of t
heir daughter. We affirm the appellate
court s award of P400,000.00 by way of moral damages to the respondents.
We similarly affirm the grant of exemplary damages. Exemplary damages are impose
d by way of example or correction for
the public good.54 Because of the petitioner spouses negligence in subjecting T
eresita to an operation without first
recognizing and addressing her diabetic condition, the appellate court awarded e
xemplary damages to the respondents

in the amount of P100,000.00. Public policy requires such imposition to suppress

the wanton acts of an offender. 55 We
therefore affirm the CA s award as an example to the medical profession and to s
tress that the public good requires stricter
measures to avoid the repetition of the type of medical malpractice that happene
d in this case.
With the award of exemplary damages, the grant of attorney s fees is legally in
order.56 We therefore reverse the CA
decision deleting these awards, and grant the respondents the amount of P100,000
.00 as attorney s fees taking into
consideration the legal route this case has taken.
WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003 in CA G.R. CV No
. 63234 finding petitioner
spouses liable for negligent medical practice. We likewise AFFIRM the awards of
actual and compensatory damages of
P36,000.00; moral damages of P400,000.00; and exemplary damages of P100,000.00.

We MODIFY the CA Decision by additionally granting an award of P50,000.00 as dea

th indemnity and by reversing the
deletion of the award of attorney s fees and costs and restoring the award of P1
00,000.00 as attorney s fees. Costs of
litigation are adjudged against petitioner spouses.
To summarize, the following awards shall be paid to the family of the late Teres
ita Pineda:
1. The sum of P36,000.00 by way of actual and compensatory damages;
2. The sum of P50,000.00 by way of death indemnity;
3. The sum of P400,000.00 by way of moral damages;
4. The sum of P100,000.00 by way of exemplary damages;
5. The sum of P100,000.00 by way of attorney s fees; and
6. Costs.
SO ORDERED.
ARTURO D. BRION
Associate Justice
WE CONCUR:
LEONARDO A. QUISUMBING
Acting Chief Justice
Chairperson
CONCHITA CARPIO MORALES
Associate Justice
DANTE O. TINGA
Associate Justice
PRESBITERO J. VELASCO, JR.
Associate Justice
CERTIFICATION
Pursuant to Section 13, Article VIII of the Constitution, and the Division Chair
person s Attestation, it is hereby certified
that the conclusions in the above Decision were reached in consultation before t
he case was assigned to the writer of the
opinion of the Court s Division.
LEONARDO A. QUISUMBING
Acting Chief Justice
Republic of the Philippines
SUPREME COURT
Manila
FIRST DIVISION
G.R. No. 192123
March 10, 2014

DR. FERNANDO P. SOLIDUM, Petitioner,

vs.
PEOPLE OF THE PHILIPPINES, Respondent.
DECISION
BERSAMIN, J.:
This appeal is taken by a physician-anesthesiologist who has been pronounced gui
lty of reckless imprudence resulting in
serious physical injuries by the Regional Trial Court (RTC) and the Court of App
eals (CA). He had been part of the team of
anesthesiologists during the surgical pull-through operation conducted on a thre
e-year old patient born with an
imperforate anus.1
The antecedents are as follows:
Gerald Albert Gercayo (Gerald) was born on June 2, 19922 with an imperforate anu
s. Two days after his birth, Gerald
underwent colostomy, a surgical procedure to bring one end of the large intestin
e out through the abdominal wall,3
enabling him to excrete through a colostomy bag attached to the side of his body
.4
On May 17, 1995, Gerald, then three years old, was admitted at the Ospital ng Ma
ynila for a pull-through operation.5 Dr.
Leandro Resurreccion headed the surgical team, and was assisted by Dr. Joselito
Luceo, Dr. Donatella Valea and Dr.
Joseph Tibio. The anesthesiologists included Dr. Marichu Abella, Dr. Arnel Razon
and petitioner Dr. Fernando Solidum
(Dr. Solidum).6 During the operation, Gerald experienced bradycardia,7 and went
into a coma.8 His coma lasted for two
weeks,9 but he regained consciousness only after a month.10 He could no longer s
ee, hear or move.11
Agitated by her sons helpless and unexpected condition, Ma. Luz Gercayo (Luz) lod
ged a complaint for reckless
imprudence resulting in serious physical injuries with the City Prosecutors Offic
e of Manila against the attending
physicians.12
Upon a finding of probable cause, the City Prosecutors Office filed an informatio
n solely against Dr. Solidum,13 alleging:

That on or about May 17, 1995, in the City of Manila, Philippines, the said accu
sed, being then an anesthesiologist at the
Ospital ng Maynila, Malate, this City, and as such was tasked to administer the
anesthesia on three-year old baby boy
GERALD ALBERT GERCAYO, represented by his mother, MA. LUZ GERCAYO, the former ha
ving been born with an
imperforate anus [no anal opening] and was to undergo an operation for anal open
ing [pull through operation], did then
and there willfully, unlawfully and feloniously fail and neglect to use the care
and diligence as the best of his judgment
would dictate under said circumstance, by failing to monitor and regulate proper
ly the levels of anesthesia administered to
said GERALD ALBERT GERCAYO and using 100% halothane and other anesthetic medicat
ions, causing as a consequence
of his said carelessness and negligence, said GERALD ALBERT GERCAYO suffered a c
ardiac arrest and consequently a
defect called hypoxic encephalopathy meaning insufficient oxygen supply in the b
rain, thereby rendering said GERALD
ALBERT GERCAYO incapable of moving his body, seeing, speaking or hearing, to his
damage and prejudice.
Contrary to law.14
The case was initially filed in the Metropolitan Trial Court of Manila, but was
transferred to the RTC pursuant to Section 5

of Republic Act No. 8369 (The Family Courts Act of 1997),15 where it was dockete
d as Criminal Case No. 01-190889.
Judgment of the RTC
On July 19, 2004, the RTC rendered its judgment finding Dr. Solidum guilty beyon
d reasonable doubt of reckless
imprudence resulting to serious physical injuries,16 decreeing:
WHEREFORE, premises considered, the Court finds accused DR. FERNANDO P. SOLIDUM
GUILTY beyond reasonable
doubt as principal of the crime charged and is hereby sentenced to suffer the in
determinate penalty of TWO (2) MONTHS
and ONE (1) DAY of arresto mayor as minimum to ONE (1) YEAR, ONE (1) MONTH and T
EN (10) DAYS of prision
correccional as maximum and to indemnify, jointly and severally with the Ospital
ng Maynila, Dr. Anita So and Dr.
Marichu Abella, private complainant Luz Gercayo, the amount of P500,000.00 as mo
ral damages and P100,000.00 as
exemplary damages and to pay the costs.

Accordingly, the bond posted by the accused for his provisional liberty is hereb
y CANCELLED.
SO ORDERED.17
Upon motion of Dr. Anita So and Dr. Marichu Abella to reconsider their solidary
liability,18 the RTC excluded them from
solidary liability as to the damages, modifying its decision as follows:
WHEREFORE, premises considered, the Court finds accused Dr. Fernando Solidum, gu
ilty beyond reasonable doubt as
principal of the crime charged and is hereby sentenced to suffer the indetermina
te penalty of two (2) months and one (1)
day of arresto mayor as minimum to one (1) year, one (1) month and ten (10) days
of prision correccional as maximum
and to indemnify jointly and severally with Ospital ng Maynila, private complain
ant Luz Gercayo the amount of
P500,000.00 as moral damages and P100,000 as exemplary damages and to pay the co
sts.
Accordingly, the bond posted by the accused for his provisional liberty is hereb
y cancelled.19
Decision of the CA
On January 20, 2010, the CA affirmed the conviction of Dr. Solidum,20 pertinentl
y stating and ruling:
The case appears to be a textbook example of res ipsa loquitur.
xxxx
x x x [P]rior to the operation, the child was evaluated and found fit to undergo
a major operation. As noted by the OSG, the
accused himself testified that pre-operation tests were conducted to ensure that
the child could withstand the surgery.
Except for his imperforate anus, the child was healthy. The tests and other proc
edures failed to reveal that he was
suffering from any known ailment or disability that could turn into a significan
t risk. There was not a hint that the nature
of the operation itself was a causative factor in the events that finally led to
hypoxia.
In short, the lower court has been left with no reasonable hypothesis except to
attribute the accident to a failure in the
proper administration of anesthesia, the gravamen of the charge in this case. Th
e High Court elucidates in Ramos vs.
Court of Appeals 321 SCRA 584
In cases where the res ipsa loquitur is applicable, the court is permitted to fi
nd a physician negligent upon proper proof of
injury to the patient, without the aid of expert testimony, where the court from
its fund of common knowledge can
determine the proper standard of care.
Where common knowledge and experience teach that a resulting injury would not ha
ve occurred to the patient if due care
had been exercised, an inference of negligence may be drawn giving rise to an ap
plication of the doctrine of res ipsa
loquitur without medical evidence, which is ordinarily required to show not only
what occurred but how and why it
occurred. When the doctrine is appropriate, all that the patient must do is prov
e a nexus between the particular act or
omission complained of and the injury sustained while under the custody and mana
gement of the defendant without need
to produce expert medical testimony to establish the standard of care. Resort to
res ipsa loquitur is allowed because there
is no other way, under usual and ordinary conditions, by which the patient can o
btain redress for injury suffered by him.
The lower court has found that such a nexus exists between the act complained of
and the injury sustained, and in line
with the hornbook rules on evidence, we will afford the factual findings of a tr

ial court the respect they deserve in the

absence of a showing of arbitrariness or disregard of material facts that might
affect the disposition of the case. People v.
Paraiso 349 SCRA 335.
The res ipsa loquitur test has been known to be applied in criminal cases. Altho
ugh it creates a presumption of negligence,
it need not offend due process, as long as the accused is afforded the opportuni
ty to go forward with his own evidence and
prove that he has no criminal intent. It is in this light not inconsistent with
the constitutional presumption of innocence of
an accused.
IN VIEW OF THE FOREGOING, the modified decision of the lower court is affirmed.
SO ORDERED.21

Dr. Solidum filed a motion for reconsideration, but the CA denied his motion on
May 7, 2010.22
Hence, this appeal.
Issues
Dr. Solidum avers that:
I.
THE HONORABLE COURT OF APPEALS ERRED IN AFFIRMING THE DECISION OF THE LOWER COUR
T IN
UPHOLDING THE PETITIONERS CONVICTION FOR THE CRIME CHARGED BASED ON THE TRIAL
COURTS OPINION, AND NOT ON THE BASIS OF THE FACTS ESTABLISHED DURING THE TRIAL. A
LSO,
THERE IS A CLEAR MISAPPREHENSION OF FACTS WHICH IF CORRECTED, WILL RESULT TO THE
ACQUITTAL OF THE PETITIONER. FURTHER, THE HONORABLE COURT ERRED IN AFFIRMING THE
SAID
DECISION OF THE LOWER COURT, AS THIS BREACHES THE CRIMINAL LAW PRINCIPLE THAT TH
E
PROSECUTION MUST PROVE THE ALLEGATIONS OF THE INFORMATION BEYOND REASONABLE DOUB
T,
AND NOT ON THE BASIS OF ITS PRESUMPTIVE CONCLUSION.
II.
THE HONORABLE COURT OF APPEALS ERRED IN APPLYING THE PRINCIPLE OF RES IPSA LOQUI
TOR
(sic) WHEN THE DEFENSE WAS ABLE TO PROVE THAT THERE IS NO NEGLIGENCE ON THE PART
OF THE
PETITIONER, AND NO OVERDOSING IN THE APPLICATION OF THE ANESTHETIC AGENT BECAUSE
THERE WAS NO 100% HALOTHANE ADMINISTERED TO THE CHILD, BUT ONLY ONE (1%) PERCENT
AND
THE APPLICATION THEREOF, WAS REGULATED BY AN ANESTHESIA MACHINE. THUS, THE
APPLICATION OF THE PRINCIPLE OF RES IPSA LOQUITOR (sic) CONTRADICTED THE ESTABLI
SHED
FACTS AND THE LAW APPLICABLE IN THE CASE.
III.
THE AWARD OF MORAL DAMAGES AND EXEMPLARY DAMAGES IS NOT JUSTIFIED THERE BEING NO
NEGLIGENCE ON THE PART OF THE PETITIONER. ASSUMING THAT THE CHILD IS ENTITLED TO
FINANCIAL CONSIDERATION, IT SHOULD BE ONLY AS A FINANCIAL ASSISTANCE, BECAUSE TH
ERE WAS
NO NEGLIGENCE, AND NO OVERDOSING OF ANESTHETIC AGENT AND AS SUCH, THE AWARD IS S
O
EXCESSIVE, AND NO FACTUAL AND LEGAL BASIS.23
To simplify, the following are the issues for resolution, namely: (a) whether or
not the doctrine of res ipsa loquitur was
applicable herein; and (b) whether or not Dr. Solidum was liable for criminal ne
gligence.
Ruling
The appeal is meritorious.
Applicability of the Doctrine of Res Ipsa Loquitur
Res ipsa loquitur is literally translated as "the thing or the transaction speak
s for itself." The doctrine res ipsa loquitur
means that "where the thing which causes injury is shown to be under the managem
ent of the defendant, and the accident
is such as in the ordinary course of things does not happen if those who have th
e management use proper care, it affords
reasonable evidence, in the absence of an explanation by the defendant, that the
accident arose from want of care."24 It is
simply "a recognition of the postulate that, as a matter of common knowledge and
experience, the very nature of certain
types of occurrences may justify an inference of negligence on the part of the p
erson who controls the instrumentality
causing the injury in the absence of some explanation by the defendant who is ch
arged with negligence. It is grounded in

the superior logic of ordinary human experience and on the basis of such experie
nce or common knowledge, negligence
may be deduced from the mere occurrence of the accident itself.
Hence, res ipsa loquitur is applied in conjunction with the doctrine of common k
nowledge."25

Jarcia, Jr. v. People26 has underscored that the doctrine is not a rule of subst
antive law, but merely a mode of proof or a
mere procedural convenience. The doctrine, when applicable to the facts and circ
umstances of a given case, is not meant
to and does not dispense with the requirement of proof of culpable negligence ag
ainst the party charged. It merely
determines and regulates what shall be prima facie evidence thereof, and helps t
he plaintiff in proving a breach of the
duty. The doctrine can be invoked when and only when, under the circumstances in
volved, direct evidence is absent and
not readily available.27
The applicability of the doctrine of res ipsa loquitur in medical negligence cas
es was significantly and exhaustively
explained in Ramos v. Court of Appeals,28 where the Court said
Medical malpractice cases do not escape the application of this doctrine. Thus,
res ipsa loquitur has been applied when the
circumstances attendant upon the harm are themselves of such a character as to j
ustify an inference of negligence as the
cause of that harm. The application of res ipsa loquitur in medical negligence c
ases presents a question of law since it is a
judicial function to determine whether a certain set of circumstances does, as a
matter of law, permit a given inference.
Although generally, expert medical testimony is relied upon in malpractice suits
to prove that a physician has done a
negligent act or that he has deviated from the standard medical procedure, when
the doctrine of res ipsa loquitur is availed
by the plaintiff, the need for expert medical testimony is dispensed with becaus
e the injury itself provides the proof of
negligence. The reason is that the general rule on the necessity of expert testi
mony applies only to such matters clearly
within the domain of medical science, and not to matters that are within the com
mon knowledge of mankind which may
be testified to by anyone familiar with the facts. Ordinarily, only physicians a
nd surgeons of skill and experience are
competent to testify as to whether a patient has been treated or operated upon w
ith a reasonable degree of skill and care.
However, testimony as to the statements and acts of physicians and surgeons, ext
ernal appearances, and manifest
conditions which are observable by any one may be given by non-expert witnesses.
Hence, in cases where the res ipsa
loquitur is applicable, the court is permitted to find a physician negligent upo
n proper proof of injury to the patient,
without the aid of expert testimony, where the court from its fund of common kno
wledge can determine the proper
standard of care. Where common knowledge and experience teach that a resulting i
njury would not have occurred to the
patient if due care had been exercised, an inference of negligence may be drawn
giving rise to an application of the
doctrine of res ipsa loquitur without medical evidence, which is ordinarily requ
ired to show not only what occurred but
how and why it occurred. When the doctrine is appropriate, all that the patient
must do is prove a nexus between the
particular act or omission complained of and the injury sustained while under th
e custody and management of the
defendant without need to produce expert medical testimony to establish the stan
dard of care. Resort to res ipsa loquitur
is allowed because there is no other way, under usual and ordinary conditions, b
y which the patient can obtain redress for
injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following s

ituations: leaving of a foreign object in the

body of the patient after an operation, injuries sustained on a healthy part of
the body which was not under, or in the area,
of treatment, removal of the wrong part of the body when another part was intend
ed, knocking out a tooth while a
patients jaw was under anesthetic for the removal of his tonsils, and loss of an
eye while the patient plaintiff was under
the influence of anesthetic, during or following an operation for appendicitis,
among others.
Nevertheless, despite the fact that the scope of res ipsa loquitur has been meas
urably enlarged, it does not automatically
apply to all cases of medical negligence as to mechanically shift the burden of
proof to the defendant to show that he is not
guilty of the ascribed negligence. Res ipsa loquitur is not a rigid or ordinary
doctrine to be perfunctorily used but a rule to
be cautiously applied, depending upon the circumstances of each case. It is gene
rally restricted to situations in malpractice
cases where a layman is able to say, as a matter of common knowledge and observa
tion, that the consequences of
professional care were not as such as would ordinarily have followed if due care
had been exercised. A distinction must be
made between the failure to secure results, and the occurrence of something more
unusual and not ordinarily found if the
service or treatment rendered followed the usual procedure of those skilled in t
hat particular practice. It must be conceded
that the doctrine of res ipsa loquitur can have no application in a suit against
a physician or surgeon which involves the
merits of a diagnosis or of a scientific treatment. The physician or surgeon is
not required at his peril to explain why any
particular diagnosis was not correct, or why any particular scientific treatment
did not produce the desired result. Thus,
res ipsa loquitur is not available in a malpractice suit if the only showing is
that the desired result of an operation or
treatment was not accomplished. The real question, therefore, is whether or not
in the process of the operation any
extraordinary incident or unusual event outside of the routine performance occur
red 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 the
re was such extraneous intervention, the
doctrine of res ipsa loquitur may be utilized and the defendant is called upon t
o explain the matter, by evidence of
exculpation, if he could.

In order to allow resort to the doctrine, therefore, the following essential req
uisites must first be satisfied, to wit: (1) the
accident was of a kind that does not ordinarily occur unless someone is negligen
t; (2) the instrumentality or agency that
caused the injury was under the exclusive control of the person charged; and (3)
the injury suffered must not have been
due to any voluntary action or contribution of the person injured.29
The Court considers the application here of the doctrine of res ipsa loquitur in
appropriate. Although it should be conceded
without difficulty that the second and third elements were present, considering
that the anesthetic agent and the
instruments were exclusively within the control of Dr. Solidum, and that the pat
ient, being then unconscious during the
operation, could not have been guilty of contributory negligence, the first elem
ent was undeniably wanting. Luz delivered
Gerald to the care, custody and control of his physicians for a pull-through ope
ration. Except for the imperforate anus,
Gerald was then of sound body and mind at the time of his submission to the phys
icians. Yet, he experienced bradycardia
during the operation, causing loss of his senses and rendering him immobile. Hyp
oxia, or the insufficiency of oxygen
supply to the brain that caused the slowing of the heart rate, scientifically te
rmed as bradycardia, would not ordinarily
occur in the process of a pull-through operation, or during the administration o
f anesthesia to the patient, but such fact
alone did not prove that the negligence of any of his attending physicians, incl
uding the anesthesiologists, had caused the
injury. In fact, the anesthesiologists attending to him had sensed in the course
of the operation that the lack of oxygen
could have been triggered by the vago-vagal reflex, prompting them to administer
atropine to the patient.30
This conclusion is not unprecedented. It was similarly reached in Swanson v. Bri
gham,31 relevant portions of the decision
therein being as follows:
On January 7, 1973, Dr. Brigham admitted 15-year-old Randall Swanson to a hospit
al for the treatment of infectious
mononucleosis. The patient s symptoms had included a swollen throat and some bre
athing difficulty. Early in the morning
of January 9 the patient was restless, and at 1:30 a.m. Dr. Brigham examined the
patient. His inspection of the patient s
air passage revealed that it was in satisfactory condition. At 4:15 a.m. Dr. Bri
gham received a telephone call from the
hospital, advising him that the patient was having respiratory difficulty. The d
octor ordered that oxygen be administered
and he prepared to leave for the hospital. Ten minutes later, 4:25 a.m., the hos
pital called a second time to advise the
doctor that the patient was not responding. The doctor ordered that a medicine b
e administered, and he departed for the
hospital. When he arrived, the physician who had been on call at the hospital ha
d begun attempts to revive the patient. Dr.
Brigham joined him in the effort, but the patient died.
The doctor who performed the autopsy concluded that the patient died between 4:2
5 a.m. and 4:30 a.m. of asphyxia, as a
result of a sudden, acute closing of the air passage. He also found that the air
passage had been adequate to maintain life
up to 2 or 3 minutes prior to death. He did not know what caused the air passage
to suddenly close.
xxxx
It is a rare occurrence when someone admitted to a hospital for the treatment of
infectious mononucleosis dies of

asphyxiation. But that is not sufficient to invoke res ipsa loquitur. The fact t
hat the injury rarely occurs does not in itself
prove that the injury was probably caused by someone s negligence. Mason v. Ells
worth, 3 Wn. App. 298, 474 P.2d 909
(1970). Nor is a bad result by itself enough to warrant the application of the d
octrine. Nelson v. Murphy, 42 Wn.2d 737,
258 P.2d 472 (1953). See 2 S. Speiser, The Negligence Case Res Ipsa Loquitur 24:
10 (1972). The evidence presented is
insufficient to establish the first element necessary for application of res ips
a loquitur doctrine. The acute closing of the
patients air passage and his resultant asphyxiation took place over a very short
period of time. Under these circumstances
it would not be reasonable to infer that the physician was negligent. There was
no palpably negligent act. The common
experience of mankind does not suggest that death would not be expected without
negligence. And there is no expert
medical testimony to create an inference that negligence caused the injury.
Negligence of Dr. Solidum
In view of the inapplicability of the doctrine of res ipsa loquitur, the Court n
ext determines whether the CA correctly
affirmed the conviction of Dr. Solidum for criminal negligence.
Negligence is defined as the failure to observe for the protection of the intere
sts of another person that degree of care,
precaution, and vigilance that the circumstances justly demand, whereby such oth
er person suffers injury.32 Reckless
imprudence, on the other hand, consists of voluntarily doing or failing to do, w
ithout malice, an act from which material
damage results by reason of an inexcusable lack of precaution on the part of the
person performing or failing to perform
such act.33
Dr. Solidums conviction by the RTC was primarily based on his failure to monitor
and properly regulate the level of
anesthetic agent administered on Gerald by overdosing at 100% halothane. In affi
rming the conviction, the CA observed:

On the witness stand, Dr. Vertido made a significant turnaround. He affirmed the
findings and conclusions in his report
except for an observation which, to all intents and purposes, has become the sto
rm center of this dispute. He wanted to
correct one piece of information regarding the dosage of the anesthetic agent ad
ministered to the child. He declared that
he made a mistake in reporting a 100% halothane and said that based on the recor
ds it should have been 100% oxygen.
The records he was relying on, as he explains, are the following:
(a) the anesthesia record A portion of the chart in the record was marked as Exh
ibit 1-A and 1-B to indicate the
administration at intervals of the anesthetic agent.
(b) the clinical abstract A portion of this record that reads as follows was mar
ked Exhibit 3A. 3B
Approximately 1 hour and 45 minutes through the operation, patient was noted to
have bradycardia (CR = 70) and
ATSO4 0.2 mg was immediately administered. However, the bradycardia persisted, t
he inhalational agent was
shut off, and the patient was ventilated with 100% oxygen and another dose of AT
SO4 0.2 mg was given. However,
the patient did not respond until no cardiac rate can be auscultated and the sur
geons were immediately told to
stop the operation. The patient was put on a supine position and CPR was initiat
ed. Patient was given 1 amp of
epinephrine initially while continuously doing cardiac massage still with no car
diac rate appreciated; another
ampule of epinephrine was given and after 45 secs, patients vital signs returned
to normal. The entire
resuscitation lasted approximately 3-5 mins. The surgeons were then told to proc
eed to the closure and the childs
vital signs throughout and until the end of surgery were: BP = 110/70; CR = 116/
min and RR = 20-22 cycles/min
(on assisted ventilation).
Dr. Vertido points to the crucial passage in the clinical abstract that the pati
ent was ventilated with 100% oxygen and
another dose of ATSO4 when the bradycardia persisted, but for one reason or anot
her, he read it as 100% halothane. He
was asked to read the anesthesia record on the percentage of the dosage indicate
d, but he could only sheepishly note I
cant understand the number. There are no clues in the clinical abstract on the qu
antity of the anesthetic agent used. It
only contains the information that the anesthetic plan was to put the patient un
der general anesthesia using a
nonrebreathing system with halothane as the sole anesthetic agent and that 1 hou
r and 45 minutes after the operation
began, bradycardia occurred after which the inhalational agent was shut off and
the patient administered with 100%
oxygen. It would be apparent that the 100% oxygen that Dr. Vertido said should b
e read in lieu of 100% halothane was the
pure oxygen introduced after something went amiss in the operation and the halot
hane itself was reduced or shut off.
The key question remains what was the quantity of halothane used before bradycar
dia set in?
The implication of Dr. Vertidos admission is that there was no overdose of the an
esthetic agent, and the accused Dr.
Solidum stakes his liberty and reputation on this conclusion. He made the assura
nce that he gave his patient the utmost
medical care, never leaving the operating room except for a few minutes to answe
r the call of nature but leaving behind the
other members of his team Drs. Abella and Razon to monitor the operation. He ins

isted that he administered only a point

1% not 100% halothane, receiving corroboration from Dr. Abella whose initial MA
in the record should be enough to show
that she assisted in the operation and was therefore conversant of the things th
at happened. She revealed that they were
using a machine that closely monitored the concentration of the agent during the
operation.
But most compelling is Dr. Solidums interpretation of the anesthesia record itsel
f, as he takes the bull by the horns, so to
speak. In his affidavit, he says, reading from the record, that the quantity of
halothane used in the operation is one percent
(1%) delivered at time intervals of 15 minutes. He studiedly mentions the concen
tration of halothane as reflected in the
anesthesia record (Annex D of the complaint-affidavit) is only one percent (1%)
The numbers indicated in 15 minute
increments for halothane is an indication that only 1% halothane is being delive
red to the patient Gerard Gercayo for his
entire operation; The amount of halothane delivered in this case which is only o
ne percent cannot be summated because
halothane is constantly being rapidly eliminated by the body during the entire o
peration.
xxxx
In finding the accused guilty, despite these explanations, the RTC argued that t
he volte-face of Dr. Vertido on the question
of the dosage of the anesthetic used on the child would not really validate the
non-guilt of the anesthesiologist. Led to
agree that the halothane used was not 100% as initially believed, he was nonethe
less unaware of the implications of the
change in his testimony. The court observed that Dr. Vertido had described the c
ondition of the child as hypoxia which is
deprivation of oxygen, a diagnosis supported by the results of the CT Scan. All
the symptoms attributed to a failing central
nervous system such as stupor, loss of consciousness, decrease in heart rate, lo
ss of usual acuity and abnormal motor
function, are manifestations of this condition or syndrome. But why would there
be deprivation of oxygen if 100% oxygen
to 1% halothane was used? Ultimately, to the court, whether oxygen or halothane
was the object of mistake, the

detrimental effects of the operation are incontestable, and they can only be led
to one conclusion if the application of
anesthesia was really closely monitored, the event could not have happened.34
The Prosecution did not prove the elements of reckless imprudence beyond reasona
ble doubt because the circumstances
cited by the CA were insufficient to establish that Dr. Solidum had been guilty
of inexcusable lack of precaution in
monitoring the administration of the anesthetic agent to Gerald. The Court aptly
explained in Cruz v. Court of Appeals35
that:
Whether or not a physician has committed an "inexcusable lack of precaution" in
the treatment of his patient is to be
determined according to the standard of care observed by other members of the pr
ofession in good standing under similar
circumstances bearing in mind the advanced state of the profession at the time o
f treatment or the present state of medical
science. In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pacasio, et. a
l., this Court stated that in accepting a case, a
doctor in effect represents that, having the needed training and skill possessed
by physicians and surgeons practicing in
the same field, he will employ such training, care and skill in the treatment of
his patients. He therefore has a duty to use
at least the same level of care that any other reasonably competent doctor would
use to treat a condition under the same
circumstances. It is in this aspect of medical malpractice that expert testimony
is essential to establish not only the
standard of care of the profession but also that the physician s conduct in the
treatment and care falls below such
standard. Further, inasmuch as the causes of the injuries involved in malpractic
e actions are determinable only in the light
of scientific knowledge, it has been recognized that expert testimony is usually
necessary to support the conclusion as to
causation.
xxxx
In litigations involving medical negligence, the plaintiff has the burden of est
ablishing appellant s negligence and for a
reasonable conclusion of negligence, there must be proof of breach of duty on th
e part of the surgeon as well as a causal
connection of such breach and the resulting death of his patient. In Chan Lugay
v. St Luke s Hospital, Inc., where the
attending physician was absolved of liability for the death of the complainants w
ife and newborn baby, this Court held
that:
"In order that there may be a recovery for an injury, however, it must be shown
that the injury for which recovery is
sought must be the legitimate consequence of the wrong done; the connection betw
een the negligence and the injury must
be a direct and natural sequence of events, unbroken by intervening efficient ca
uses. In other words, the negligence must
be the proximate cause of the injury. For, negligence, no matter in what it consi
sts, cannot create a right of action unless it
is the proximate cause of the injury complained of. And the proximate cause of an
injury is that cause, which, in natural
and continuous sequence, unbroken by any efficient intervening cause, produces t
he injury, and without which the result
would not have occurred."
An action upon medical negligence whether criminal, civil or administrative call
s for the plaintiff to prove by
competent evidence each of the following four elements, namely: (a) the duty owe
d by the physician to the patient, as

created by the physician-patient relationship, to act in accordance with the spe

cific norms or standards established by his
profession; (b) the breach of the duty by the physicians failing to act in accord
ance with the applicable standard of care;
(3) the causation, i.e., there must be a reasonably close and causal connection
between the negligent act or omission and
the resulting injury; and (4) the damages suffered by the patient.36
In the medical profession, specific norms or standards to protect the patient ag
ainst unreasonable risk, commonly referred
to as standards of care, set the duty of the physician to act in respect of the
patient. Unfortunately, no clear definition of
the duty of a particular physician in a particular case exists. Because most med
ical malpractice cases are highly technical,
witnesses with special medical qualifications must provide guidance by giving th
e knowledge necessary to render a fair
and just verdict. As a result, the standard of medical care of a prudent physici
an must be determined from expert
testimony in most cases; and in the case of a specialist (like an anesthesiologi
st), the standard of care by which the
specialist is judged is the care and skill commonly possessed and exercised by s
imilar specialists under similar
circumstances. The specialty standard of care may be higher than that required o
f the general practitioner.37
The standard of care is an objective standard by which the conduct of a physicia
n sued for negligence or malpractice may
be measured, and it does not depend, therefore, on any individual physicians own
knowledge either. In attempting to fix a
standard by which a court may determine whether the physician has properly perfo
rmed the requisite duty toward the
patient, expert medical testimony from both plaintiff and defense experts is req
uired. The judge, as the trier of fact,
ultimately determines the standard of care, after listening to the testimony of
all medical experts.38

Here, the Prosecution presented no witnesses with special medical qualifications

in anesthesia to provide guidance to the
trial court on what standard of care was applicable. It would consequently be tr
uly difficult, if not impossible, to determine
whether the first three elements of a negligence and malpractice action were att
endant.
Although the Prosecution presented Dr. Benigno Sulit, Jr., an anesthesiologist h
imself who served as the Chairman of the
Committee on Ethics and Malpractice of the Philippine Society of Anesthesiologis
ts that investigated the complaint
against Dr. Solidum, his testimony mainly focused on how his Committee had condu
cted the investigation.39 Even then,
the report of his Committee was favorable to Dr. Solidum,40 to wit:
Presented for review by this committee is the case of a 3 year old male who unde
rwent a pull-thru operation and was
administered general anesthesia by a team of anesthesia residents. The patient,
at the time when the surgeons was
manipulating the recto-sigmoid and pulling it down in preparation for the anasto
mosis, had bradycardia. The
anesthesiologists, sensing that the cause thereof was the triggering of the vago
-vagal reflex, administered atropine to block
it but despite the administration of the drug in two doses, cardiac arrest ensue
d. As the records show, prompt resuscitative
measures were administered and spontaneous cardiac function re-established in le
ss than five (5) minutes and that
oxygen was continuously being administered throughout, unfortunately, as later b
ecome manifest, patient suffered
permanent irreversible brain damage.
In view of the actuations of the anaesthesiologists and the administration of an
aesthesia, the committee find that the same
were all in accordance with the universally accepted standards of medical care a
nd there is no evidence of any fault or
negligence on the part of the anaesthesiologists.
Dr. Antonio Vertido, a Senior Medico-Legal Officer of the National Bureau of Inv
estigation, was also presented as a
Prosecution witness, but his testimony concentrated on the results of the physic
al examination he had conducted on
Gerald, as borne out by the following portions of his direct examination, to wit
:
FISCAL CABARON Doctor, what do you mean by General Anesthetic Agent?
WITNESS General Anesthetic Agent is a substance used in the conduction of Anesth
esia and in this case, halothane was
used as a sole anesthetic agent.
xxxx
Q Now under paragraph two of page 1 of your report you mentioned that after one
hour and 45 minutes after the
operation, the patient experienced a bradycardia or slowing of heart rate, now a
s a doctor, would you be able to tell this
Honorable Court as to what cause of the slowing of heart rate as to Gerald Gerca
yo?
WITNESS Well honestly sir, I cannot give you the reason why there was a bradycar
dia of time because is some reason one
way or another that might caused bradycardia.
FISCAL CABARON What could be the possible reason?
A Well bradycardia can be caused by anesthetic agent itself and that is a possib
ility, were talking about possibility here.
Q What other possibility do you have in mind, doctor?
A Well, because it was an operation, anything can happen within that situation.
FISCAL CABARON Now, this representation would like to ask you about the slowing
of heart rate, now what is the

immediate cause of the slowing of the heart rate of a person?

WITNESS Well, one of the more practical reason why there is slowing of the heart
rate is when you do a vagal reflex in the
neck wherein the vagal receptors are located at the lateral part of the neck, wh
en you press that, you produce the slowing
of the heart rate that produce bradycardia.
Q I am pro[p]ounding to you another question doctor, what about the deficiency i
n the supply of oxygen by the patient,
would that also cause the slowing of the heart rate?

A Well that is a possibility sir, I mean not as slowing of the heart rate, if th
ere is a hypoxia or there is a low oxygen level in
the blood, the normal thing for the heart is to pump or to do not a bradycardia
but a to counter act the Hypoxia that is
being experienced by the patient
(sic).
xxxx
Q Now, you made mention also doctor that the use of general anesthesia using 100
% halothane and other anesthetic
medications probably were contributory to the production of hypoxia.
A Yes, sir in general sir.41
On cross-examination, Dr. Vertido expounded more specifically on his interpretat
ion of the anesthesia record and the
factors that could have caused Gerald to experience bradycardia, viz:
ATTY. COMIA I noticed in, may I see your report Doctor, page 3, will you kindly
read to this Honorable court your last
paragraph and if you will affirm that as if it is correct?
A "The use of General Anesthesia, that is using 100% Halothane probably will be
contributory to the production of
Hypoxia and - - - -"
ATTY COMIA And do you affirm the figure you mentioned in this Court Doctor?
WITNESS Based on the records, I know the - - Q 100%?
A 100% based on the records.
Q I will show you doctor a clinical record. I am a lawyer I am not a doctor but
will you kindly look at this and tell me where
is 100%, the word "one hundred" or 1-0-0, will you kindly look at this Doctor, t
his Xerox copy if you can show to this
Honorable Court and even to this representation the word "one hundred" or 1-0-0
and then call me.
xxxx
ATTY. COMIA Doctor tell this Honorable Court where is that 100, 1-0-0 and if the
re is, you just call me and even the
attention of the Presiding Judge of this Court. Okay, you read one by one.
WITNESS Well, are you only asking 100%, sir?
ATTY. COMIA Im asking you, just answer my question, did you see there 100% and 10
0 figures, tell me, yes or no?
WITNESS Im trying to look at the 100%, there is no 100% there sir.
ATTY. COMIA Okay, that was good, so you Honor please, may we request also tempor
arily, because this is just a xerox
copy presented by the fiscal, that the percentage here that the Halothane admini
stered by Dr. Solidum to the patient is 1%
only so may we request that this portion, temporarily your Honor, we are marking
this anesthesia record as our Exhibit 1
and then this 1% Halothane also be bracketed and the same be marked as our Exhib
it "1-A".
xxxx
ATTY. COMIA Doctor, my attention was called also when you said that there are so
many factors that contributed to
Hypoxia is that correct?
WITNESS Yes, sir.

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

the possibility of mistake.

We have to clarify that the acquittal of Dr. Solidum would not immediately exemp
t him from civil liability.1wphi1 But we
cannot now find and declare him civilly liable because the circumstances that ha
ve been established here do not present
the factual and legal bases for validly doing so. His acquittal did not derive o
nly from reasonable doubt. There was really
no firm and competent showing how the injury to Gerard had been caused. That mea
nt that the manner of administration
of the anesthesia by Dr. Solidum was not necessarily the cause of the hypoxia th
at caused the bradycardia experienced by

Gerard. Consequently, to adjudge Dr. Solidum civilly liable would be to speculat

e on the cause of the hypoxia. We are not
allowed to do so, for civil liability must not rest on speculation but on compet
ent evidence.
Liability of Ospital ng Maynila
Although the result now reached has resolved the issue of civil liability, we ha
ve to address the unusual decree of the RTC,
as affirmed by the CA, of expressly holding Ospital ng Maynila civilly liable jo
intly and severally with Dr. Solidum. The
decree was flawed in logic and in law.
In criminal prosecutions, the civil action for the recovery of civil liability t
hat is deemed instituted with the criminal action
refers only to that arising from the offense charged.48 It is puzzling, therefor
e, how the RTC and the CA could have
adjudged Ospital ng Maynila jointly and severally liable with Dr. Solidum for th
e damages despite the obvious fact that
Ospital ng Maynila, being an artificial entity, had not been charged along with
Dr. Solidum. The lower courts thereby acted
capriciously and whimsically, which rendered their judgment against Ospital ng M
aynila void as the product of grave
abuse of discretion amounting to lack of jurisdiction.
Not surprisingly, the flawed decree raises other material concerns that the RTC
and the CA overlooked. We deem it
important, then, to express the following observations for the instruction of th
e Bench and Bar.
For one, Ospital ng Maynila was not at all a party in the proceedings. Hence, it
s fundamental right to be heard was not
respected from the outset. The R TC and the CA should have been alert to this fu
ndamental defect. Verily, no person can
be prejudiced by a ruling rendered in an action or proceeding in which he was no
t made a party. Such a rule would enforce
the constitutional guarantee of due process of law.
Moreover, Ospital ng Maynila could be held civilly liable only when subsidiary l
iability would be properly enforceable
pursuant to Article 103 of the Revised Penal Code. But the subsidiary liability
seems far-fetched here. The conditions for
subsidiary liability to attach to Ospital ng Maynila should first be complied wi
th. Firstly, pursuant to Article 103 of the
Revised Penal Code, Ospital ng Maynila must be shown to be a corporation "engage
d in any kind of industry." The term
industry means any department or branch of art, occupation or business, especial
ly one that employs labor and capital,
and is engaged in industry.49 However, Ospital ng Maynila, being a public hospit
al, was not engaged in industry
conducted for profit but purely in charitable and humanitarian work.50 Secondly,
assuming that Ospital ng Maynila was
engaged in industry for profit, Dr. Solidum must be shown to be an employee of O
spital ng Maynila acting in the discharge
of his duties during the operation on Gerald. Yet, he definitely was not such em
ployee but a consultant of the hospital.
And, thirdly, assuming that civil liability was adjudged against Dr. Solidum as
an employee (which did not happen here),
the execution against him was unsatisfied due to his being insolvent.
WHEREFORE, the Court GRANTS the petition for review on certiorari; REVERSES AND
SETS ASIDE the decision
promulgated on January 20, 2010; ACQUITS Dr. Fernando P. Solidum of the crime of
reckless imprudence resulting to
serious physical injuries; and MAKES no pronouncement on costs of suit.
SO ORDERED.
LUCAS P. BERSAMIN

Associate Justice
WE CONCUR:
MARIA LOURDES P. A. SERENO
Chief Justice
TERESITA J. LEONARDO-DE CASTRO
Associate Justice
MARTIN S. VILLARAMA, JR.
Associate Justice
BIENVENIDO L. REYES
Associate Justice
CERTIFICATION

Pursuant to Section 13, Article VIII of the Constitution, I certify that the con
clusions in the above Decision had been
reached in consultation before the case was assigned to the writer of the opinio
n of the Court s Division.
MARIA LOURDES P. A. SERENO
Chief Justice
Republic of the Philippines
Supreme Court
Manila
THIRD DIVISION
FE CAYAO-LASAM,
Petitioner,
G.R. No. 159132
Present:
YNARES-SANTIAGO, J.,
Chairperson,
AUSTRIA-MARTINEZ,
CHICO-NAZARIO,
NACHURA, and
REYES, JJ.
- versus SPOUSES CLARO and
EDITHA RAMOLETE,
Respondents.
Promulgated:
December 18, 2008
x---------------------------------------------------------x
DECISION
AUSTRIA-MARTINEZ, J.:

Before the Court is a Petition for Review on Certiorari under Rule 45 of the Rul
es of Court filed by Dr. Fe Cayao-Lasam (petitioner)
seeking to annul the Decision69[1] dated July 4, 2003 of the Court of Appeals (C
A) in CA-G.R. SP No. 62206.
The antecedent facts:
On July 28, 1994, respondent, three months pregnant Editha Ramolete (Editha) was
brought to the Lorma Medical Center
(LMC) in San Fernando, La Union due to vaginal bleeding. Upon advice of petition
er relayed via telephone, Editha was admitted to the
LMC on the same day. A pelvic sonogram70[2] was then conducted on Editha reveali
ng the fetus weak cardiac pulsation.71[3] The
following day, Edithas repeat pelvic sonogram72[4] showed that aside from the fe
tus weak cardiac pulsation, no fetal movement was also
appreciated. Due to persistent and profuse vaginal bleeding, petitioner advised
Editha to undergo a Dilatation and Curettage Procedure
(D&C) or raspa.
On July 30, 1994, petitioner performed the D&C procedure. Editha was discharged
from the hospital the following day.
On September 16, 1994, Editha was once again brought at the LMC, as she was suff
ering from vomiting and severe abdominal
pains. Editha was attended by Dr. Beatriz de la Cruz, Dr. Victor B. Mayo and Dr.
Juan V. Komiya. Dr. Mayo allegedly informed Editha
that there was a dead fetus in the latters womb. After, Editha underwent laparot
omy,73[5] she was found to have a massive intraabdominal hemorrhage and a ruptur
ed uterus. Thus, Editha had to undergo a procedure for hysterectomy74[6] and as
a result, she has
no more chance to bear a child.
On November 7, 1994, Editha and her husband Claro Ramolete (respondents) filed a
Complaint75[7] for Gross Negligence and
Malpractice against petitioner before the Professional Regulations Commission (P
RC).

Respondents alleged that Edithas hysterectomy was caused by petitioners unmitiga

ted negligence and professional
incompetence in conducting the D&C procedure and the petitioners failure to remo
ve the fetus inside Edithas womb.76[8] Among the
alleged acts of negligence were: first, petitioners failure to check up, visit o
r administer medication on Editha during her first day of
confinement at the LMC;77[9] second, petitioner recommended that a D&C procedure
be performed on Editha without conducting any
internal examination prior to the procedure;78[10] third, petitioner immediately
suggested a D&C procedure instead of closely
monitoring the state of pregnancy of Editha.79[11]
In her Answer,80[12] petitioner denied the allegations of negligence and incompe
tence with the following explanations: upon
Edithas confirmation that she would seek admission at the LMC, petitioner immedi
ately called the hospital to anticipate the arrival of
Editha and ordered through the telephone the medicines Editha needed to take, wh
ich the nurses carried out; petitioner visited Editha on
the morning of July 28, 1994 during her rounds; on July 29, 1994, she performed
an internal examination on Editha and she discovered
that the latters cervix was already open, thus, petitioner discussed the possibl
e D&C procedure, should the bleeding become more profuse;
on July 30 1994, she conducted another internal examination on Editha, which rev
ealed that the latters cervix was still open; Editha
persistently complained of her vaginal bleeding and her passing out of some meat
y mass in the process of urination and bowel
movement; thus, petitioner advised Editha to undergo D&C procedure which the res
pondents consented to; petitioner was very vocal in
the operating room about not being able to see an abortus;81[13] taking the word
s of Editha to mean that she was passing out some
meaty mass and clotted blood, she assumed that the abortus must have been expell
ed in the process of bleeding; it was Editha who
insisted that she wanted to be discharged; petitioner agreed, but she advised Ed
itha to return for check-up on August 5, 1994, which the
latter failed to do.
Petitioner contended that it was Edithas gross negligence and/or omission in ins
isting to be discharged on July 31, 1994 against
doctors advice and her unjustified failure to return for check-up as directed by
petitioner that contributed to her life-threatening condition
on September 16, 1994; that Edithas hysterectomy was brought about by her very a
bnormal pregnancy known as placenta increta, which
was an extremely rare and very unusual case of abdominal placental implantation.
Petitioner argued that whether or not a D&C
procedure was done by her or any other doctor, there would be no difference at a
ll because at any stage of gestation before term, the
uterus would rupture just the same.

On March 4, 1999, the Board of Medicine (the Board) of the PRC rendered a Decisi
on,82[14] exonerating petitioner from the
charges filed against her. The Board held:
Based on the findings of the doctors who conducted the laparotomy on Editha, her
s is a case of Ectopic Pregnancy
Interstitial. This type of ectopic pregnancy is one that is being protected by t
he uterine muscles and manifestations may
take later than four (4) months and only attributes to two percent (2%) of ectop
ic pregnancy cases.
When complainant Editha was admitted at Lorma Medical Center on July 28, 1994 du
e 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 th
e uterus unless so specified by the
Sonologist who conducted the ultra-sound. Respondent (Dr. Lasam) cannot be fault
ed if she was not able to determine
that complainant Editha is having an ectopic pregnancy interstitial. The D&C con
ducted on Editha is necessary
considering that her cervix is already open and so as to stop the profuse bleedi
ng. Simple curettage cannot remove a fetus
if the patient is having an ectopic pregnancy, since ectopic pregnancy is pregna
ncy 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.83[15]
Feeling aggrieved, respondents went to the PRC on appeal. On November 22, 2000,
the PRC rendered a Decision84[16] reversing the
findings of the Board and revoking petitioners authority or license to practice
her profession as a physician.85[17]
Petitioner brought the matter to the CA in a Petition for Review under Rule 43 o
f the Rules of Court. Petitioner also dubbed her petition as
one for certiorari86[18] under Rule 65 of the Rules of Court.
In the Decision dated July 4, 2003, the CA held that the Petition for Review und
er Rule 43 of the Rules of Court was an improper remedy,
as the enumeration of the quasi-judicial agencies in Rule 43 is exclusive.87[19]
PRC is not among the quasi-judicial bodies whose
judgment or final orders are subject of a petition for review to the CA, thus, t
he petition for review of the PRC Decision, filed at the CA, was
improper. The CA further held that should the petition be treated as a petition
for certiorari under Rule 65, the same would still be
dismissed for being improper and premature. Citing Section 2688[20] of Republic
Act (R.A.) No. 2382 or the Medical Act of 1959, the CA
held that the plain, speedy and adequate remedy under the ordinary course of law
which petitioner should have availed herself of was to
appeal to the Office of the President.89[21]

Hence, herein petition, assailing the decision of the CA on the following ground
s:
1.
THE COURT OF APPEALS ERRED ON A QUESTION OF LAW IN HOLDING THAT THE
PROFESSIONAL REGULATION[S] COMMISSION (PRC) WAS EXCLUDED AMONG THE QUASIJUDICIAL
AGENCIES CONTEMPLATED UNDER RULE 43 OF THE RULES OF CIVIL PROCEDURE;
2.
EVEN ASSUMING, ARGUENDO, THAT PRC WAS EXCLUDED FROM THE PURVIEW OF
RULE 43 OF THE RULES OF CIVIL PROCEDURE, THE PETITIONER WAS NOT PRECLUDED FROM
FILING A PETITION FOR CERTIORARI WHERE THE DECISION WAS ALSO ISSUED IN EXCESS OF
OR WITHOUT JURISDICTION, OR WHERE THE DECISION WAS A PATENT NULLITY;
3.
HEREIN RESPONDENTS-SPOUSES ARE NOT ALLOWED BY LAW TO APPEAL FROM THE
DECISION OF THE BOARD OF MEDICINE TO THE PROFESSIONAL REGULATION[S] COMMISSION;
4.
THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF DISCRETION IN DENYING FOR
IMPROPER FORUM THE PETITION FOR REVIEW/PETITION FOR CERTIORARI WITHOUT GOING
OVER THE MERITS OF THE GROUNDS RELIED UPON BY THE PETITIONER;
5.
PRCS GRAVE OMISSION TO AFFORD HEREIN PETITONER A CHANCE TO BE HEARD ON
APPEAL IS A CLEAR VIOLATION OF HER CONSTITUTIONAL RIGHT TO DUE PROCESS AND HAS
THE EFFECT OF RENDERING THE JUDGMENT NULL AND VOID;
6.
COROLLARY TO THE FOURTH ASSIGNED ERROR, PRC COMMITTED GRAVE ABUSE OF
DISCRETION, AMOUNTING TO LACK OF JURISDICTION, IN ACCEPTING AND CONSIDERING THE
MEMORANDUM ON APPEAL WITHOUT PROOF OF SERVICE TO HEREIN PETITIONER, AND IN
VIOLATION OF ART. IV, SEC. 35 OF THE RULES AND REGULATIONS GOVERNING THE
REGULATION AND PRACTICE OF PROFESSIONALS;
7.
PRC COMMITTED GRAVE ABUSE OF DISCRETION IN REVOKING PETITIONERS LICENSE
TO PRACTICE MEDICINE WITHOUT AN EXPERT TESTIMONY TO SUPPORT ITS CONCLUSION AS
TO THE CAUSE OF RESPONDENT EDITHAT [SIC] RAMOLETES INJURY;
8.
PRC COMMITTED AN EVEN GRAVER ABUSE OF DISCRETION IN TOTALLY
DISREGARDING THE FINDING OF THE BOARD OF MEDICINE, WHICH HAD THE NECESSARY
COMPETENCE AND EXPERTISE TO ESTABLISH THE CAUSE OF RESPONDENT EDITHAS INJURY,
AS WELL AS THE TESTIMONY OF THE EXPERT WITNESS AUGUSTO MANALO, M.D. ;[AND]
9.
PRC COMMITTED GRAVE ABUSE OF DISCRETION IN MAKING CONCLUSIONS OF FACTS THAT
WERE NOT ONLY UNSUPPORTED BY EVIDENCE BUT WERE ACTUALLY CONTRARY TO EVIDENCE
ON RECORD.90[22]

The Court will first deal with the procedural issues.

Petitioner claims that the law does not allow complainants to appeal to the PRC
from the decision of the Board. She invokes
Article IV, Section 35 of the Rules and Regulations Governing the Regulation and
Practice of Professionals, which provides:

Sec. 35. The respondent may appeal the decision of the Board within thirty days
from receipt thereof to the Commission whose
decision shall be final. Complainant, when allowed by law, may interpose an appe
al from the Decision of the Board
within the same period. (Emphasis supplied)
Petitioner asserts that a careful reading of the above law indicates that while
the respondent, as a matter of right, may appeal the Decision
of the Board to the Commission, the complainant may interpose an appeal from the
decision of the Board only when so allowed by
law.91[23] Petitioner cited Section 26 of Republic Act No. 2382 or The Medical A
ct of 1959, to wit:
Section 26. Appeal from judgment. The decision of the Board of Medical Examiners
(now Medical Board) shall
automatically become final thirty days after the date of its promulgation unless
the respondent, during the same period,
has appealed to the Commissioner of Civil Service (now Professional Regulations
Commission) and later to the Office of
the President of the Philippines. If the final decision is not satisfactory, the
respondent may ask for a review of the case, or
may file in court a petition for certiorari.
Petitioner posits that the reason why the Medical Act of 1959 allows only the re
spondent in an administrative case to file an appeal with
the Commission while the complainant is not allowed to do so is double jeopardy.
Petitioner is of the belief that the revocation of license to
practice a profession is penal in nature.92[24]
The Court does not agree.
For one, the principle of double jeopardy finds no application in administrative
cases. Double jeopardy attaches only: (1) upon a
valid indictment; (2) before a competent court; (3) after arraignment; (4) when
a valid plea has been entered; and (5) when the defendant
was acquitted or convicted, or the case was dismissed or otherwise terminated wi
thout the express consent of the accused.93[25] These
elements were not present in the proceedings before the Board of Medicine, as th
e proceedings involved in the instant case were
administrative and not criminal in nature. The Court has already held that doubl
e jeopardy does not lie in administrative cases.94[26]
Moreover, Section 35 of the Rules and Regulations Governing the Regulation and P
ractice of Professionals cited by petitioner
was subsequently amended to read:

Sec. 35. The complainant/respondent may appeal the order, the resolution or the
decision of the Board within
thirty (30) days from receipt thereof to the Commission whose decision shall be
final and executory. Interlocutory order
shall not be appealable to the Commission. (Amended by Res. 174, Series of 1990)
.95[27] (Emphasis supplied)
Whatever doubt was created by the previous provision was settled with said amend
ment. It is axiomatic that the right to
appeal is not a natural right or a part of due process, but a mere statutory pri
vilege that may be exercised only in the
manner prescribed by law.96[28] In this case, the clear intent of the amendment
is to render the right to appeal from a
decision of the Board available to both complainants and respondents.
Such conclusion is bolstered by the fact that in 2006, the PRC issued Resolution
No. 06-342(A), or the New Rules of Procedure in
Administrative Investigations in the Professional Regulations Commission and the
Professional Regulatory Boards, which provides for
the method of appeal, to wit:
Sec. 1. Appeal; Period Non-Extendible.- The decision, order or resolution of the
Board shall be final and
executory after the lapse of fifteen (15) days from receipt of the decision, ord
er or resolution without an appeal being
perfected or taken by either the respondent or the complainant. A party aggrieve
d by the decision, order or
resolution may file a notice of appeal from the decision, order or resolution of
the Board to the
Commission within fifteen (15) days from receipt thereof, and serving upon the a
dverse party a notice of appeal
together with the appellants brief or memorandum on appeal, and paying the appea
l and legal research fees. x x x97[29]
The above-stated provision does not qualify whether only the complainant or resp
ondent may file an appeal; rather, the new rules provide
that a party aggrieved may file a notice of appeal. Thus, either the complainant
or the respondent who has been aggrieved by the decision,
order or resolution of the Board may appeal to the Commission. It is an elementa
ry rule that when the law speaks in clear and categorical
language, there is no need, in the absence of legislative intent to the contrary
, for any interpretation.98[30] Words and phrases used in the
statute should be given their plain, ordinary, and common usage or meaning.99[31
]
Petitioner also submits that appeals from the decisions of the PRC should be wit
h the CA, as Rule 43100[32] of the Rules of
Court was precisely formulated and adopted to provide for a uniform rule of appe
llate procedure for quasi-judicial agencies.101[33]

Petitioner further contends that a quasi-judicial body is not excluded from the
purview of Rule 43 just because it is not mentioned
therein.102[34]
On this point, the Court agrees with the petitioner.
Sec. 1, Rule 43 of the Rules of Court provides:
Section 1. Scope. - This Rule shall apply to appeals from judgments or final ord
ers of the Court of Tax
Appeals, and from awards, judgments, final orders or resolutions of or authorize
d by any quasijudicial agency in the exercise of its quasi-judicial functions. A
mong these agencies are the Civil Service
Commission, Central Board of Assessment Appeals, Securities and Exchange Commiss
ion, Office of the President,
Land Registration Authority, Social Security Commission, Civil Aeronautics Board
, Bureau of Patents, Trademarks and
Technology Transfer, National Electrification Administration, Energy Regulatory
Board, National Telecommunications
Commission, Department of Agrarian Reform under Republic Act No. 6657, Governmen
t Service Insurance System,
Employees Compensation Commission, Agricultural Inventions Board, Insurance Comm
ission, Philippine Atomic
Energy Commission, Board of Investments, Construction Industry Arbitration Commi
ssion, and voluntary arbitrators
authorized by law. (Emphasis supplied)
Indeed, the PRC is not expressly mentioned as one of the agencies which are expr
essly 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.103[35] The Rule expressly provides that it should be applied to appeals fr
om awards, judgments final orders or resolutions of any
quasi-judicial agency in the exercise of its quasi-judicial functions. The phras
e among these agencies confirms that the enumeration made
in the Rule is not exclusive to the agencies therein listed.104[36]
Specifically, the Court, in Yang v. Court of Appeals,105[37] ruled that Batas Pa
mbansa (B.P.) Blg. 129106[38] conferred upon
the CA exclusive appellate jurisdiction over appeals from decisions of the PRC.
The Court held:
The law has since been changed, however, at least in the matter of the particula
r court to which appeals from
the Commission should be taken. On August 14, 1981, Batas Pambansa Bilang 129 be
came effective and in its Section
29, conferred on the Court of Appeals exclusive appellate jurisdiction over all
final judgments, decisions, resolutions,
orders or awards of Regional Trial Courts and quasi-judicial agencies, instrumen
talities, boards or commissions except
those falling under the appellate jurisdiction of the Supreme Court. x x x. In v
irtue of BP 129, appeals from the

Professional Regulations Commission are now exclusively cognizable by the Court

of
Appeals.107[39] (Emphasis supplied)
Clearly, the enactment of B.P. Blg. 129, the precursor of the present Rules of C
ivil Procedure,108[40] lodged with the CA such jurisdiction
over the appeals of decisions made by the PRC.
Anent the substantive merits of the case, petitioner questions the PRC decision
for being without an expert testimony to support
its conclusion and to establish the cause of Edithas injury. Petitioner avers th
at in cases of medical malpractice, expert testimony is
necessary to support the conclusion as to the cause of the injury.109[41]
Medical malpractice is a particular form of negligence which consists in the fai
lure 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.110[42] In order to successfully pursue such a
claim, a patient must prove that the physician or
surgeon either failed to do something which a reasonably prudent physician or su
rgeon would not have done, and that the failure or
action caused injury to the patient.111[43]
There are four elements involved in medical negligence cases: duty, breach, inju
ry and proximate causation.112[44]
A physician-patient relationship was created when Editha employed the services o
f the petitioner. As Edithas physician,
petitioner was duty-bound to use at least the same level of care that any reason
ably competent doctor would use to treat a condition under
the same circumstances.113[45] The breach of these professional duties of skill
and care, or their improper performance by a physician
surgeon, whereby the patient is injured in body or in health, constitutes action
able malpractice.114[46] As to this aspect of medical

malpractice, the determination of the reasonable level of care and the breach th
ereof, expert testimony is essential.115[47] Further,
inasmuch as the causes of the injuries involved in malpractice actions are deter
minable only in the light of scientific knowledge, it has been
recognized that expert testimony is usually necessary to support the conclusion
as to causation.116[48]
In the present case, respondents did not present any expert testimony to support
their claim that petitioner failed to do
something which a reasonably prudent physician or surgeon would have done.
Petitioner, on the other hand, presented the testimony of Dr. Augusto M. Manalo,
who was clearly an expert on the subject.
Generally, to qualify as an expert witness, one must have acquired special knowl
edge of the subject matter about which he or she
is to testify, either by the study of recognized authorities on the subject or b
y practical experience.117[49]
Dr. Manalo specializes in gynecology and obstetrics, authored and co-authored va
rious publications on the subject, and is a
professor at the University of the Philippines.118[50] According to him, his dia
gnosis of Edithas case was Ectopic Pregnancy Interstitial
(also referred to as Cornual), Ruptured.119[51] In stating that the D&C procedur
e was not the proximate cause of the rupture of Edithas
uterus resulting in her hysterectomy, Dr. Manalo testified as follows:
Atty. Hidalgo:
Q:
Doctor, we want to be clarified on this matter. The complainant had testified he
re that the D&C was the
proximate cause of the rupture of the uterus. The condition which she found hers
elf in on the second
admission. Will you please tell us whether that is true or not?
A:
Yah, I do not think so for two reasons. One, as I have said earlier, the instrum
ent cannot reach the site of
the pregnancy, for it to further push the pregnancy outside the uterus. And, No.
2, I was thinking a while ago
about another reason- well, why I dont think so, because it is the triggering fa
ctor for the rupture, it could
havethe rupture could have occurred much earlier, right after the D&C or a few d
ays after the D&C.
Q:
In this particular case, doctor, the rupture occurred to have happened minutes p
rior to the hysterectomy or
right upon admission on September 15, 1994 which is about 1 months after the pat
ient was discharged, after
the D&C was conducted. Would you tell us whether there is any relation at all of
the D&C and the rupture in
this particular instance?

A:
I dont think so for the two reasons that I have just mentioned- that it would no
t be possible
for the instrument to reach the site of pregnancy. And, No. 2, if it is because
of the D&C that rupture
could have occurred earlier.120[52] (Emphases supplied)
Clearly, from the testimony of the expert witness and the reasons given by him,
it is evident that the D&C procedure was not the
proximate cause of the rupture of Edithas uterus.
During his cross-examination, Dr. Manalo testified on how he would have addresse
d Edithas condition should he be placed in a
similar circumstance as the petitioner. He stated:
Atty. Ragonton:
Q:
Doctor, as a practicing OB-Gyne, when do you consider that you have done a good,
correct and ideal dilatation
and curettage procedure?
A:
Well, if the patient recovers. If the patient gets well. Because even after the
procedure, even after the procedure
you may feel that you have scraped everything, the patient stops bleeding, she f
eels well, I think you should still
have some reservations, and wait a little more time.
Q:
A:
If you were the OB-Gyne who performed the procedure on patient Editha Ramolete,
would it be your
standard practice to check the fetal parts or fetal tissues that were allegedly
removed?
From what I have removed, yes. But in this particular case, I think it was assum
ed that it was part of the meaty
mass which was expelled at the time she was urinating and flushed in the toilet.
So theres no way.
Q:
A:
There was [sic] some portions of the fetal parts that were removed?
No, it was described as scanty scraping if I remember it rightscanty.
Q:
A:
And you would not mind checking those scant or those little parts that were remo
ved?
Well, the fact that it was described means, I assume that it was checked, no. It
was described as
scanty and the color also, I think was described. Because it would be very unusu
al, even improbable
that it would not be examined, because when you scrape, the specimens are right
there
before your eyes. Its in front of you. You can touch it. In fact, some of them w
ill stick to the
instrument and therefore to peel it off from the instrument, you have to touch t
hem. So,

automatically they are examined closely.

As a matter of fact, doctor, you also give telephone orders to your patients thr
ough telephone?
Yes, yes, we do that, especially here in Manila because you know, sometimes a do
ctor can also be tied-up
somewhere and if you have to wait until he arrive at a certain place before you
give the order, then it would be
a lot of time wasted. Because if you know your patient, if you have handled your
patient, some of the
symptoms you can interpret that comes with practice. And, I see no reason for no
t allowing telephone
orders unless it is the first time that you will be encountering the patient. Th
at you have no idea
what the problem is.
Q:
A:
Q:
A:
But, doctor, do you discharge patients without seeing them?
Sometimes yes, depending on how familiar I am with the patient. We are on the qu
estion of telephone orders.
I am not saying that that is the idle [sic] thing to do, but I think the reality
of present day practice
somehow justifies telephone orders. I have patients whom I have justified and th
en all of a sudden, late
in the afternoon or late in the evening, would suddenly call they have decided t
hat they will go home inasmuch
as they anticipated that I will discharge them the following day. So, I just cal
l and ask our resident on duty or
the nurse to allow them to go because I have seen that patient and I think I hav
e full grasp of her problems. So,
thats when I make this telephone orders. And, of course before giving that order
I ask about how she
feels.121[53] (Emphases supplied)

From the foregoing testimony, it is clear that the D&C procedure was conducted i
n accordance with the standard practice, with the same
level of care that any reasonably competent doctor would use to treat a conditio
n under the same circumstances, and that there was
nothing irregular in the way the petitioner dealt with Editha.
Medical malpractice, in our jurisdiction, is often brought as a civil action for
damages under Article 2176122[54] of the Civil
Code. The defenses in an action for damages, provided for under Article 2179 of
the Civil Code are:
Art. 2179. When the plaintiffs own negligence was the immediate and proximate ca
use of his
injury, he cannot recover damages. But if his negligence was only contributory,
the immediate and proximate
cause of the injury being the defendants lack of due care, the plaintiff may rec
over damages, but the courts shall
mitigate the damages to be awarded.
Proximate cause has been defined as that which, in natural and continuous sequen
ce, unbroken by any efficient intervening cause,
produces injury, and without which the result would not have occurred.123[55] An
injury or damage is proximately caused by an act or a
failure to act, whenever it appears from the evidence in the case that the act o
r omission played a substantial part in bringing about or
actually causing the injury or damage; and that the injury or damage was either
a direct result or a reasonably probable consequence of
the act or omission.124[56]
In the present case, the Court notes the findings of the Board of Medicine:
When complainant was discharged on July 31, 1994, herein respondent advised her
to return on
August 4, 1994 or four (4) days after the D&C. This advise was clear in complain
ants Discharge
Sheet. However, complainant failed to do so. This being the case, the chain of c
ontinuity as required in order that
the doctrine of proximate cause can be validly invoked was interrupted. Had she
returned, the respondent could
have examined her thoroughly.125[57] x x x (Emphases supplied)
Also, in the testimony of Dr. Manalo, he stated further that assuming that there
was in fact a misdiagnosis, the same would have
been rectified if Editha followed the petitioners order to return for a check-up
on August 4, 1994. Dr. Manalo stated:

Granting that the obstetrician-gynecologist has been misled (justifiably) up to

thus point
that there would have been ample opportunity to rectify the misdiagnosis, had th
e patient returned,
as instructed for her follow-up evaluation. It was one and a half months later t
hat the patient sought
consultation with another doctor. The continued growth of an ectopic pregnancy,
until its eventual rupture, is a
dynamic process. Much change in physical findings could be expected in 1 months,
including the emergence of
suggestive ones.126[58]
It is undisputed that Editha did not return for a follow-up evaluation, in defia
nce of the petitioners advise. Editha omitted the
diligence required by the circumstances which could have avoided the injury. The
omission in not returning for a follow-up evaluation
played a substantial part in bringing about Edithas own injury. Had Editha retur
ned, petitioner could have conducted the proper medical
tests and procedure necessary to determine Edithas health condition and applied
the corresponding treatment which could have
prevented the rupture of Edithas uterus. The D&C procedure having been conducted
in accordance with the standard medical practice, it
is clear that Edithas omission was the proximate cause of her own injury and not
merely a contributory negligence on her part.
Contributory negligence is the act or omission amounting to want of ordinary car
e on the part of the person injured, which,
concurring with the defendants negligence, is the proximate cause of the injury.
127[59] Difficulty seems to be apprehended in deciding
which acts of the injured party shall be considered immediate causes of the acci
dent.128[60] Where the immediate cause of an accident
resulting in an injury is the plaintiffs own act, which contributed to the princ
ipal occurrence as one of its determining factors, he cannot
recover damages for the injury.129[61] Again, based on the evidence presented in
the present case under review, in which
no negligence can be attributed to the petitioner, the immediate cause of the ac
cident resulting in Edithas injury was
her own omission when she did not return for a follow-up check up, in defiance o
f petitioners orders. The
immediate cause of Edithas injury was her own act; thus, she cannot recover dama
ges from the injury.
Lastly, petitioner asserts that her right to due process was violated because sh
e was never informed by either respondents or by
the PRC that an appeal was pending before the PRC.130[62] Petitioner claims that
a verification with the records section of the PRC
revealed that on April 15, 1999, respondents filed a Memorandum on Appeal before
the PRC, which did not attach the actual registry
receipt but was merely indicated therein.131[63]

Respondents, on the other hand avers that if the original registry receipt was n
ot attached to the Memorandum on Appeal, PRC
would not have entertained the appeal or accepted such pleading for lack of noti
ce or proof of service on the other party.132[64] Also, the
registry receipt could not be appended to the copy furnished to petitioners form
er counsel, because the registry receipt was already
appended to the original copy of the Memorandum of Appeal filed with PRC.133[65]
It is a well-settled rule that when service of notice is an issue,
hat the person alleging that the notice was served must
prove the fact of service. The burden of proving notice rests upon
erting its existence.134[66] In the present case, respondents
did not present any proof that petitioner was served a copy of the
Appeal. Thus, respondents were not able to satisfy the
burden of proving that they had in fact informed the petitioner of
oceedings before the PRC.

the rule is t
the party ass
Memorandum on
the appeal pr

In EDI-Staffbuilders International, Inc. v. National Labor Relations Commission,

135[67] in which the National Labor
Relations Commission failed to order the private respondent to furnish the petit
ioner a copy of the Appeal Memorandum, the Court held
that said failure deprived the petitioner of procedural due process guaranteed b
y the Constitution, which could have served as basis for the
nullification of the proceedings in the appeal. The same holds true in the case
at bar. The Court finds that the failure of the respondents to
furnish the petitioner a copy of the Memorandum of Appeal submitted to the PRC c
onstitutes a violation of due process. Thus, the
proceedings before the PRC were null and void.
All told, doctors are protected by a special rule of law. They are not guarantor
s of care. They are not insurers against mishaps or
unusual consequences136[68] specially so if the patient herself did not exercise
the proper diligence required to avoid the injury.
WHEREFORE, the petition is GRANTED. The assailed Decision of the Court of Appeal
s dated July 4, 2003 in CA-GR SP
No. 62206 is hereby REVERSED and SET ASIDE. The Decision of the Board of Medicin
e dated March 4, 1999 exonerating petitioner
is AFFIRMED. No pronouncement as to costs.
SO ORDERED.

MA. ALICIA AUSTRIA-MARTINEZ

Associate Justice
WE CONCUR:
CONSUELO YNARES-SANTIAGO
Associate Justice
Chairperson
MINITA V. CHICO-NAZARIO
ANTONIO EDUARDO B. NACHURA
Associate Justice
Associate Justice
RUBEN T. REYES
Associate Justice

ATTESTATION
I attest that the conclusions in the above Decision had been reached in consulta
tion before the case was assigned to the writer of
the opinion of the Courts Division.
CONSUELO YNARES-SANTIAGO
Associate Justice
Chairperson, Third Division
CERTIFICATION
Pursuant to Section 13, Article VIII of the Constitution, and the Division Chair
persons Attestation, it is hereby certified that the
conclusions in the above Decision had been reached in consultation before the ca
se was assigned to the writer of the opinion of the Courts
Division.
REYNATO S. PUNO

Chief Justice
Republic of the Philippines
SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 142625
December 19, 2006
ROGELIO P. NOGALES, for himself and on behalf of the minors, ROGER ANTHONY, ANGE
LICA,
NANCY, and MICHAEL CHRISTOPHER, all surnamed NOGALES, petitioners,
vs.
CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR. ELY VILLAFLOR, DR. ROSA UY, DR. J
OEL
ENRIQUEZ, DR. PERPETUA LACSON, DR. NOE ESPINOLA, and NURSE J. DUMLAO, respondent
s.
DECISION
CARPIO, J.:
The Case
This petition for review1 assails the 6 February 1998 Decision2 and 21 March 200
0 Resolution3 of the Court of Appeals in
CA-G.R. CV No. 45641. The Court of Appeals affirmed in toto the 22 November 1993
Decision4 of the Regional Trial Court
of Manila, Branch 33, finding Dr. Oscar Estrada solely liable for damages for th
e death of his patient, Corazon Nogales,
while absolving the remaining respondents of any liability. The Court of Appeals
denied petitioners motion for
reconsideration.
The Facts
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 yea
rs old, was under the exclusive prenatal
care of Dr. Oscar Estrada ("Dr. Estrada") beginning on her fourth month of pregn
ancy or as early as December 1975. While
Corazon was on her last trimester of pregnancy, Dr. Estrada noted an increase in
her blood pressure and development of
leg edema5 indicating preeclampsia,6 which is a dangerous complication of pregna
ncy.7
Around midnight of 25 May 1976, Corazon started to experience mild labor pains p
rompting 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 nur
se noted the written admission request8
of Dr. Estrada. Upon Corazon s admission at the CMC, Rogelio Nogales ("Rogelio")
executed and signed the "Consent on
Admission and Agreement"9 and "Admission Agreement."10 Corazon was then brought
to the labor room of the CMC.
Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an i
nternal examination of Corazon. Dr. Uy
then called up Dr. Estrada to notify him of her findings.
Based on the Doctor s Order Sheet,11 around 3:00 a.m., Dr. Estrada ordered for 1
0 mg. of valium to be administered
immediately by intramuscular injection. Dr. Estrada later ordered the start of i
ntravenous administration of syntocinon
admixed with dextrose, 5%, in lactated Ringers solution, at the rate of eight t

o ten micro-drops per minute.

According to the Nurse s Observation Notes, 12 Dr. Joel Enriquez ("Dr. Enriquez"
), an anesthesiologist at CMC, was
notified at 4:15 a.m. of Corazon s admission. Subsequently, when asked if he nee
ded the services of an anesthesiologist,
Dr. Estrada refused. Despite Dr. Estrada s refusal, Dr. Enriquez stayed to obser
ve Corazon s condition.

At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10
a.m., Corazon s bag of water ruptured
spontaneously. At 6:12 a.m., Corazon s cervix was fully dilated. At 6:13 a.m., C
orazon started to experience convulsions.
At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfat
e. However, Dr. Ely Villaflor ("Dr.
Villaflor"), who was assisting Dr. Estrada, administered only 2.5 grams of magne
sium sulfate.
At 6:22 a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to ext
ract 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 b
lood. It took approximately 30 minutes
for the CMC laboratory, headed by Dr. Perpetua Lacson ("Dr. Lacson"), to comply
with Dr. Estrada s order and deliver the
blood.
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-Gynecolo
gy Department of the CMC, was apprised
of Corazon s condition by telephone. Upon being informed that Corazon was bleedi
ng 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 reside
nce 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 caus
e of death was "hemorrhage, post
partum."14
On 14 May 1980, petitioners filed a complaint for damages15 with the Regional Tr
ial Court16 of Manila against CMC, Dr.
Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr. Lacson, Dr. Espinola, and a ce
rtain Nurse J. Dumlao for the death of
Corazon. Petitioners mainly contended that defendant physicians and CMC personne
l were negligent in the treatment and
management of Corazon s condition. Petitioners charged CMC with negligence in th
e selection and supervision of
defendant physicians and hospital staff.
For failing to file their answer to the complaint despite service of summons, th
e trial court declared Dr. Estrada, Dr.
Enriquez, and Nurse Dumlao in default.17 CMC, Dr. Villaflor, Dr. Uy, Dr. Espinol
a, and Dr. Lacson filed their respective
answers denying and opposing the allegations in the complaint. Subsequently, tri
al ensued.
After more than 11 years of trial, the trial court rendered judgment on 22 Novem
ber 1993 finding Dr. Estrada solely liable
for damages. The trial court ruled as follows:
The victim was under his pre-natal care, apparently, his fault began from his in
correct and inadequate
management and lack of treatment of the pre-eclamptic condition of his patient.
It is not disputed that he

misapplied the forceps in causing the delivery because it resulted in a large ce

rvical tear which had caused the
profuse bleeding which he also failed to control with the application of inadequ
ate injection of magnesium sulfate
by his assistant Dra. Ely Villaflor. Dr. Estrada even failed to notice the erron
eous administration by nurse Dumlao
of hemacel by way of side drip, instead of direct intravenous injection, and his
failure to consult a senior
obstetrician at an early stage of the problem.
On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr. Joel Enriquez, Dr.
Lacson, Dr. Espinola, nurse J.
Dumlao and CMC, the Court finds no legal justification to find them civilly liab
le.
On the part of Dra. Ely Villaflor, she was only taking orders from Dr. Estrada,
the principal physician of Corazon
Nogales. She can only make suggestions in the manner the patient maybe treated b
ut she cannot impose her will
as to do so would be to substitute her good judgment to that of Dr. Estrada. If
she failed to correctly diagnose the
true cause of the bleeding which in this case appears to be a cervical laceratio
n, it cannot be safely concluded by
the Court that Dra. Villaflor had the correct diagnosis and she failed to inform
Dr. Estrada. No evidence was
introduced to show that indeed Dra. Villaflor had discovered that there was lace
ration at the cervical area of the
patient s internal organ.

On the part of nurse Dumlao, there is no showing that when she administered the
hemacel as a side drip, she did
it on her own. If the correct procedure was directly thru the veins, it could on
ly be because this was what was
probably the orders of Dr. Estrada.
While the evidence of the plaintiffs shows that Dr. Noe Espinola, who was the Ch
ief of the Department of
Obstetrics and Gynecology who attended to the patient Mrs. Nogales, it was only
at 9:00 a.m. That he was able to
reach the hospital because of typhoon Didang (Exhibit 2). While he was able to g
ive prescription in the manner
Corazon Nogales may be treated, the prescription was based on the information gi
ven to him by phone and he
acted on the basis of facts as presented to him, believing in good faith that su
ch is the correct remedy. He was not
with Dr. Estrada when the patient was brought to the hospital at 2:30 o clock a.
m. So, whatever errors that Dr.
Estrada committed on the patient before 9:00 o clock a.m. are certainly the erro
rs of Dr. Estrada and cannot be
the mistake of Dr. Noe Espinola. His failure to come to the hospital on time was
due to fortuitous event.
On the part of Dr. Joel Enriquez, while he was present in the delivery room, it
is not incumbent upon him to call
the attention of Dr. Estrada, Dra. Villaflor and also of Nurse Dumlao on the all
eged errors committed by them.
Besides, as anesthesiologist, he has no authority to control the actuations of D
r. Estrada and Dra. Villaflor. For the
Court to assume that there were errors being committed in the presence of Dr. En
riquez would be to dwell on
conjectures and speculations.
On the civil liability of Dr. Perpetua Lacson, [s]he is a hematologist and in-ch
arge of the blood bank of the CMC.
The Court cannot accept the theory of the plaintiffs that there was delay in del
ivering the blood needed by the
patient. It was testified, that in order that this blood will be made available,
a laboratory test has to be conducted
to determine the type of blood, cross matching and other matters consistent with
medical science so, the lapse of
30 minutes maybe considered a reasonable time to do all of these things, and not
a delay as the plaintiffs would
want the Court to believe.
Admittedly, Dra. Rosa Uy is a resident physician of the Capitol Medical Center.
She was sued because of her
alleged failure to notice the incompetence and negligence of Dr. Estrada. Howeve
r, there is no evidence to support
such theory. No evidence was adduced to show that Dra. Rosa Uy as a resident phy
sician of Capitol Medical
Center, had knowledge of the mismanagement of the patient Corazon Nogales, and t
hat notwithstanding such
knowledge, she tolerated the same to happen.
In the pre-trial order, plaintiffs and CMC agreed that defendant CMC did not hav
e any hand or participation in the
selection or hiring of Dr. Estrada or his assistant Dra. Ely Villaflor as attend
ing physician[s] of the deceased. In
other words, the two (2) doctors were not employees of the hospital and therefor
e the hospital did not have
control over their professional conduct. When Mrs. Nogales was brought to the ho
spital, it was an emergency case
and defendant CMC had no choice but to admit her. Such being the case, there is
therefore no legal ground to

apply the provisions of Article 2176 and 2180 of the New Civil Code referring to
the vicarious liability of an
employer for the negligence of its employees. If ever in this case there is faul
t or negligence in the treatment of the
deceased on the part of the attending physicians who were employed by the family
of the deceased, such civil
liability should be borne by the attending physicians under the principle of "re
spondeat superior".
WHEREFORE, premises considered, judgment is hereby rendered finding defendant Dr
. Estrada of Number 13
Pitimini St. San Francisco del Monte, Quezon City civilly liable to pay plaintif
fs: 1) By way of actual damages in the
amount of P105,000.00; 2) By way of moral damages in the amount of P700,000.00;
3) Attorney s fees in the
amount of P100,000.00 and to pay the costs of suit.
For failure of the plaintiffs to adduce evidence to support its [sic] allegation
s against the other defendants, the
complaint is hereby ordered dismissed. While the Court looks with disfavor the f
iling of the present complaint
against the other defendants by the herein plaintiffs, as in a way it has caused
them personal inconvenience and
slight damage on their name and reputation, the Court cannot accepts [sic] howev
er, the theory of the remaining
defendants that plaintiffs were motivated in bad faith in the filing of this com
plaint. For this reason defendants
counterclaims are hereby ordered dismissed.
SO ORDERED.18
Petitioners appealed the trial court s decision. Petitioners claimed that aside
from Dr. Estrada, the remaining respondents
should be held equally liable for negligence. Petitioners pointed out the extent
of each respondent s alleged liability.
On 6 February 1998, the Court of Appeals affirmed the decision of the trial cour
t. 19 Petitioners filed a motion for
reconsideration which the Court of Appeals denied in its Resolution of 21 March
2000. 20

Hence, this petition.

Meanwhile, petitioners filed a Manifestation dated 12 April 2002 21 stating that
respondents Dr. Estrada, Dr. Enriquez, Dr.
Villaflor, and Nurse Dumlao "need no longer be notified of the petition because
they are absolutely not involved in the
issue raised before the [Court], regarding the liability of [CMC]."22 Petitioner
s stressed that the subject matter of this
petition is the liability of CMC for the negligence of Dr. Estrada. 23
The Court issued a Resolution dated 9 September 2002 24 dispensing with the requ
irement to submit the correct and
present addresses of respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and N
urse Dumlao. The Court stated that with
the filing of petitioners Manifestation, it should be understood that they are
claiming only against respondents CMC, Dr.
Espinola, Dr. Lacson, and Dr. Uy who have filed their respective comments. Petit
ioners are foregoing further claims
against respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao.
The Court noted that Dr. Estrada did not appeal the decision of the Court of App
eals affirming the decision of the Regional
Trial Court. Accordingly, the decision of the Court of Appeals, affirming the tr
ial court s judgment, is already final as
against Dr. Oscar Estrada.
Petitioners filed a motion for reconsideration25 of the Court s 9 September 2002
Resolution claiming that Dr. Enriquez,
Dr. Villaflor and Nurse Dumlao were notified of the petition at their counsels
last known addresses. Petitioners reiterated
their imputation of negligence on these respondents. The Court denied petitioner
s Motion for Reconsideration in its 18
February 2004 Resolution.26
The Court of Appeals Ruling
In its Decision of 6 February 1998, the Court of Appeals upheld the trial court
s ruling. The Court of Appeals rejected
petitioners view that the doctrine in Darling v. Charleston Community Memorial
Hospital 27 applies to this case.
According to the Court of Appeals, the present case differs from the Darling cas
e since Dr. Estrada is an independent
contractor-physician whereas the Darling case involved a physician and a nurse w
ho were employees of the hospital.
Citing other American cases, the Court of Appeals further held that the mere fac
t that a hospital permitted a physician to
practice medicine and use its facilities is not sufficient to render the hospita
l liable for the physician s negligence. 28 A
hospital is not responsible for the negligence of a physician who is an independ
ent contractor. 29
The Court of Appeals found the cases of Davidson v. Conole30 and Campbell v. Emm
a Laing Stevens Hospital31 applicable
to this case. Quoting Campbell, the Court of Appeals stated that where there is
no proof that defendant physician was an
employee of defendant hospital or that defendant hospital had reason to know tha
t any acts of malpractice would take
place, defendant hospital could not be held liable for its failure to intervene
in the relationship of physician-patient
between defendant physician and plaintiff.
On the liability of the other respondents, the Court of Appeals applied the "bor
rowed servant" doctrine considering that
Dr. Estrada was an independent contractor who was merely exercising hospital pri
vileges. This doctrine provides that
once the surgeon enters the operating room and takes charge of the proceedings,
the acts or omissions of operating room
personnel, and any negligence associated with such acts or omissions, are imputa

ble to the surgeon. 32 While the assisting

physicians and nurses may be employed by the hospital, or engaged by the patient
, they normally become the temporary
servants or agents of the surgeon in charge while the operation is in progress,
and liability may be imposed upon the
surgeon for their negligent acts under the doctrine of respondeat superior.33
The Court of Appeals concluded that since Rogelio engaged Dr. Estrada as the att
ending physician of his wife, any liability
for malpractice must be Dr. Estrada s sole responsibility.
While it found the amount of damages fair and reasonable, the Court of Appeals h
eld that no interest could be imposed on
unliquidated claims or damages.
The Issue
Basically, the issue in this case is whether CMC is vicariously liable for the n
egligence of Dr. Estrada. The resolution of this
issue rests, on the other hand, on the ascertainment of the relationship between
Dr. Estrada and CMC. The Court also
believes that a determination of the extent of liability of the other respondent
s is inevitable to finally and completely
dispose of the present controversy.

The Ruling of the Court

The petition is partly meritorious.
On the Liability of CMC
Dr. Estrada s negligence in handling the treatment and management of Corazon s c
ondition which ultimately resulted in
Corazon s death is no longer in issue. Dr. Estrada did not appeal the decision o
f the Court of Appeals which affirmed the
ruling of the trial court finding Dr. Estrada solely liable for damages. Accordi
ngly, the finding of the trial court on Dr.
Estrada s negligence is already final.
Petitioners maintain that CMC is vicariously liable for Dr. Estrada s negligence
based on Article 2180 in relation to Article
2176 of the Civil Code. These provisions pertinently state:
Art. 2180. The obligation imposed by article 2176 is demandable not only for one
s own acts or omissions, but also
for those of persons for whom one is responsible.
xxxx
Employers shall be liable for the damages caused by their employees and househol
d helpers acting within the
scope of their assigned tasks, even though the former are not engaged in any bus
iness or industry.
xxxx
The responsibility treated of in this article shall cease when the persons herei
n mentioned prove that they
observed all the diligence of a good father of a family to prevent damage.
Art. 2176. Whoever by act or omission causes damage to another, there being faul
t or negligence, is obliged to pay
for the damage done. Such fault or negligence, if there is no pre-existing contr
actual relation between the parties,
is called a quasi-delict and is governed by the provisions of this Chapter.
Similarly, in the United States, a hospital which is the employer, master, or pr
incipal of a physician employee, servant, or
agent, may be held liable for the physician s negligence under the doctrine of r
espondeat superior.34
In the present case, petitioners maintain that CMC, in allowing Dr. Estrada to p
ractice and admit patients at CMC, should
be liable for Dr. Estrada s malpractice. Rogelio claims that he knew Dr. Estrada
as an accredited physician of CMC, though
he discovered later that Dr. Estrada was not a salaried employee of the CMC.35 R
ogelio further claims that he was dealing
with CMC, whose primary concern was the treatment and management of his wife s c
ondition. Dr. Estrada just happened
to be the specific person he talked to representing CMC.36 Moreover, the fact th
at CMC made Rogelio sign a Consent on
Admission and Admission Agreement37 and a Consent to Operation printed on the le
tterhead of CMC indicates that CMC
considered Dr. Estrada as a member of its medical staff.
On the other hand, CMC disclaims liability by asserting that Dr. Estrada was a m
ere visiting physician and that it admitted
Corazon because her physical condition then was classified an emergency obstetri
cs case.38
CMC alleges that Dr. Estrada is an independent contractor "for whose actuations
CMC would be a total stranger." CMC
maintains that it had no control or supervision over Dr. Estrada in the exercise
of his medical profession.
The Court had the occasion to determine the relationship between a hospital and
a consultant or visiting physician and the
liability of such hospital for that physician s negligence in Ramos v. Court of
Appeals,39 to wit:
In the first place, hospitals exercise significant control in the hiring and fir

ing of consultants and in the conduct of

their work within the hospital premises. Doctors who apply for "consultant" slot
s, visiting or attending, are
required to submit proof of completion of residency, their educational qualifica
tions; generally, evidence of
accreditation by the appropriate board (diplomate), evidence of fellowship in mo
st cases, and references. These
requirements are carefully scrutinized by members of the hospital administration
or by a review committee set up
by the hospital who either accept or reject the application. This is particularl
y true with respondent hospital.

After a physician is accepted, either as a visiting or attending consultant, he

is normally required to attend clinicopathological conferences, conduct bedside
rounds for clerks, interns and residents, moderate grand rounds and
patient audits and perform other tasks and responsibilities, for the privilege o
f being able to maintain a clinic in
the hospital, and/or for the privilege of admitting patients into the hospital.
In addition to these, the physician s
performance as a specialist is generally evaluated by a peer review committee on
the basis of mortality and
morbidity statistics, and feedback from patients, nurses, interns and residents.
A consultant remiss in his duties,
or a consultant who regularly falls short of the minimum standards acceptable to
the hospital or its peer review
committee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control over the
ir attending and visiting "consultant"
staff. While "consultants" are not, technically employees, a point which respond
ent hospital
asserts in denying all responsibility for the patient s condition, the control e
xercised, the hiring,
and the right to terminate consultants all fulfill the important hallmarks of an
employer-employee
relationship, with the exception of the payment of wages. In assessing whether s
uch a relationship
in fact exists, the control test is determining. Accordingly, on the basis of th
e foregoing, we rule
that for the purpose of allocating responsibility in medical negligence cases, a
n employeremployee relationship in effect exists between hospitals and their att
ending and visiting
physicians. This being the case, the question now arises as to whether or not re
spondent hospital is solidarily
liable with respondent doctors for petitioner s condition.
The basis for holding an employer solidarily responsible for the negligence of i
ts employee is found in Article 2180
of the Civil Code which considers a person accountable not only for his own acts
but also for those of others based
on the former s responsibility under a relationship of patria potestas. x x x 40
(Emphasis supplied)
While the Court in Ramos did not expound on the control test, such test essentia
lly determines whether an employment
relationship exists between a physician and a hospital based on the exercise of
control over the physician as to details.
Specifically, the employer (or the hospital) must have the right to control both
the means and the details of the process by
which the employee (or the physician) is to accomplish his task.41
After a thorough examination of the voluminous records of this case, the Court f
inds no single evidence pointing to CMC s
exercise of control over Dr. Estrada s treatment and management of Corazon s con
dition. It is undisputed that throughout
Corazon s pregnancy, she was under the exclusive prenatal care of Dr. Estrada. A
t the time of Corazon s admission at CMC
and during her delivery, it was Dr. Estrada, assisted by Dr. Villaflor, who atte
nded to Corazon. There was no showing that
CMC had a part in diagnosing Corazon s condition. While Dr. Estrada enjoyed staf
f privileges at CMC, such fact alone did
not make him an employee of CMC.42 CMC merely allowed Dr. Estrada to use its fac
ilities43 when Corazon was about to
give birth, which CMC considered an emergency. Considering these circumstances,
Dr. Estrada is not an employee of
CMC, but an independent contractor.

The question now is whether CMC is automatically exempt from liability consideri
ng that Dr. Estrada is an independent
contractor-physician.
In general, a hospital is not liable for the negligence of an independent contra
ctor-physician. There is, however, an
exception to this principle. The hospital may be liable if the physician is the
"ostensible" agent of the hospital. 44 This
exception is also known as the "doctrine of apparent authority."45 In Gilbert v.
Sycamore Municipal Hospital,46 the
Illinois Supreme Court explained the doctrine of apparent authority in this wise
:
[U]nder the doctrine of apparent authority a hospital can be held vicariously li
able 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 co
ntractor. The elements of the
action have been set out as follows:
"For a hospital to be liable under the doctrine of apparent authority, a plainti
ff must show that: (1) the hospital, or
its agent, acted in a manner that would lead a reasonable person to conclude tha
t the individual who was alleged
to be negligent was an employee or agent of the hospital; (2) where the acts of
the agent create the appearance of
authority, the plaintiff must also prove that the hospital had knowledge of and
acquiesced in them; and (3) the
plaintiff acted in reliance upon the conduct of the hospital or its agent, consi
stent with ordinary care and
prudence."
The element of "holding out" on the part of the hospital does not require an exp
ress representation by the hospital
that the person alleged to be negligent is an employee. Rather, the element is s
atisfied if the hospital holds itself

out as a provider of emergency room care without informing the patient that the
care is provided by independent
contractors.
The element of justifiable reliance on the part of the plaintiff is satisfied if
the plaintiff relies upon the hospital to
provide complete emergency room care, rather than upon a specific physician.
The doctrine of apparent authority essentially involves two factors to determine
the liability of an independent-contractor
physician.
The first factor focuses on the hospital s manifestations and is sometimes descr
ibed as an inquiry whether the hospital
acted in a manner which would lead a reasonable person to conclude that the indi
vidual who was alleged to be negligent
was an employee or agent of the hospital.47 In this regard, the hospital need no
t make express representations
to the patient that the treating physician is an employee of the hospital; rathe
r a representation may be
general and implied.48
The doctrine of apparent authority is a species of the doctrine of estoppel. Art
icle 1431 of the Civil Code provides that
"[t]hrough estoppel, an admission or representation is rendered conclusive upon
the person making it, and cannot be
denied or disproved as against the person relying thereon." Estoppel rests on th
is rule: "Whenever a party has, by his own
declaration, act, or omission, intentionally and deliberately led another to bel
ieve a particular thing true, and to act upon
such belief, he cannot, in any litigation arising out of such declaration, act o
r omission, be permitted to falsify it."49
In the instant case, CMC impliedly held out Dr. Estrada as a member of its medic
al staff. Through CMC s acts, CMC
clothed Dr. Estrada with apparent authority thereby leading the Spouses Nogales
to believe that Dr. Estrada was an
employee or agent of CMC. CMC cannot now repudiate such authority.
First, CMC granted staff privileges to Dr. Estrada. CMC extended its medical sta
ff and facilities to Dr. Estrada. Upon Dr.
Estrada s request for Corazon s admission, CMC, through its personnel, readily a
ccommodated Corazon and updated Dr.
Estrada of her condition.
Second, CMC made Rogelio sign consent forms printed on CMC letterhead. Prior to
Corazon s admission and supposed
hysterectomy, CMC asked Rogelio to sign release forms, the contents of which rei
nforced Rogelio s belief that Dr. Estrada
was a member of CMC s medical staff.50 The Consent on Admission and Agreement ex
plicitly provides:
KNOW ALL MEN BY THESE PRESENTS:
I, Rogelio Nogales, of legal age, a resident of 1974 M. H. Del Pilar St., Malate
Mla., being the
father/mother/brother/sister/spouse/relative/ guardian/or person in custody of M
a. Corazon, and representing
his/her family, of my own volition and free will, do consent and submit said Ma.
Corazon to Dr. Oscar Estrada
(hereinafter referred to as Physician) for cure, treatment, retreatment, or emer
gency measures, that the
Physician, personally or by and through the Capitol Medical Center and/or its st
aff, may use,
adapt, or employ such means, forms or methods of cure, treatment, retreatment, o
r emergency
measures as he may see best and most expedient; that Ma. Corazon and I will comp
ly with any and
all rules, regulations, directions, and instructions of the Physician, the Capit

ol Medical Center
and/or its staff; and, that I will not hold liable or responsible and hereby wai
ve and forever discharge and hold
free the Physician, the Capitol Medical Center and/or its staff, from any and al
l claims of whatever kind of nature,
arising from directly or indirectly, or by reason of said cure, treatment, or re
treatment, or emergency measures or
intervention of said physician, the Capitol Medical Center and/or its staff.
x x x x51 (Emphasis supplied)
While the Consent to Operation pertinently reads, thus:
I, ROGELIO NOGALES, x x x, of my own volition and free will, do consent and subm
it said CORAZON NOGALES
to Hysterectomy, by the Surgical Staff and Anesthesiologists of Capitol Medical
Center and/or whatever
succeeding operations, treatment, or emergency measures as may be necessary and
most expedient; and, that I
will not hold liable or responsible and hereby waive and forever discharge and h
old free the Surgeon, his
assistants, anesthesiologists, the Capitol Medical Center and/or its staff, from
any and all claims of whatever kind
of nature, arising from directly or indirectly, or by reason of said operation o
r operations, treatment, or emergency
measures, or intervention of the Surgeon, his assistants, anesthesiologists, the
Capitol Medical Center and/or its
staff.52 (Emphasis supplied)

Without any indication in these consent forms that Dr. Estrada was an independen
t contractor-physician, the Spouses
Nogales could not have known that Dr. Estrada was an independent contractor. Sig
nificantly, no one from CMC informed
the Spouses Nogales that Dr. Estrada was an independent contractor. On the contr
ary, Dr. Atencio, who was then a
member of CMC Board of Directors, testified that Dr. Estrada was part of CMC s s
urgical staff.53
Third, Dr. Estrada s referral of Corazon s profuse vaginal bleeding to Dr. Espin
ola, who was then the Head of the
Obstetrics and Gynecology Department of CMC, gave the impression that Dr. Estrad
a as a member of CMC s medical staff
was collaborating with other CMC-employed specialists in treating Corazon.
The second factor focuses on the patient s reliance. It is sometimes characteriz
ed as an inquiry on whether the plaintiff
acted in reliance upon the conduct of the hospital or its agent, consistent with
ordinary care and prudence.54
The records show that the Spouses Nogales relied upon a perceived employment rel
ationship with CMC in accepting Dr.
Estrada s services. Rogelio testified that he and his wife specifically chose Dr
. Estrada to handle Corazon s delivery not
only because of their friend s recommendation, but more importantly because of D
r. Estrada s "connection with a
reputable hospital, the [CMC]."55 In other words, Dr. Estrada s relationship wit
h CMC played a significant role in the
Spouses Nogales decision in accepting Dr. Estrada s services as the obstetricia
n-gynecologist for Corazon s delivery.
Moreover, as earlier stated, there is no showing that before and during Corazon
s confinement at CMC, the Spouses
Nogales knew or should have known that Dr. Estrada was not an employee of CMC.
Further, the Spouses Nogales looked to CMC to provide the best medical care and
support services for Corazon s delivery.
The Court notes that prior to Corazon s fourth pregnancy, she used to give birth
inside a clinic. Considering Corazon s age
then, the Spouses Nogales decided to have their fourth child delivered at CMC, w
hich Rogelio regarded one of the best
hospitals at the time.56 This is precisely because the Spouses Nogales feared th
at Corazon might experience complications
during her delivery which would be better addressed and treated in a modern and
big hospital such as CMC. Moreover,
Rogelio s consent in Corazon s hysterectomy to be performed by a different physi
cian, namely Dr. Espinola, is a clear
indication of Rogelio s confidence in CMC s surgical staff.
CMC s defense that all it did was "to extend to [Corazon] its facilities" is unt
enable. The Court cannot close its eyes to the
reality that hospitals, such as CMC, are in the business of treatment. In this r
egard, the Court agrees with the observation
made by the Court of Appeals of North Carolina in Diggs v. Novant Health, Inc.,5
7 to wit:
"The conception that the hospital does not undertake to treat the patient, does
not undertake to act through its
doctors and nurses, but undertakes instead simply to procure them to act upon th
eir own responsibility, no longer
reflects the fact. Present day hospitals, as their manner of operation plainly d
emonstrates, do far
more than furnish facilities for treatment. They regularly employ on a salary ba
sis a large staff of
physicians, nurses and internes [sic], as well as administrative and manual work
ers, and they
charge patients for medical care and treatment, collecting for such services, if

necessary, by legal
action. Certainly, the person who avails himself of hospital facilities expect
s that the hospital will
attempt to cure him, not that its nurses or other employees will act on their ow
n responsibility." x
x x (Emphasis supplied)
Likewise unconvincing is CMC s argument that petitioners are estopped from claim
ing damages based on the Consent on
Admission and Consent to Operation. Both release forms consist of two parts. The
first part gave CMC permission to
administer to Corazon any form of recognized medical treatment which the CMC med
ical staff deemed advisable. The
second part of the documents, which may properly be described as the releasing p
art, releases CMC and its employees
"from any and all claims" arising from or by reason of the treatment and operati
on.
The documents do not expressly release CMC from liability for injury to Corazon
due to negligence during her treatment
or operation. Neither do the consent forms expressly exempt CMC from liability f
or Corazon s death due to negligence
during such treatment or operation. Such release forms, being in the nature of c
ontracts of adhesion, are construed strictly
against hospitals. Besides, a blanket release in favor of hospitals "from any an
d all claims," which includes claims due to
bad faith or gross negligence, would be contrary to public policy and thus void.
Even simple negligence is not subject to blanket release in favor of establishme
nts like hospitals but may only mitigate
liability depending on the circumstances.58 When a person needing urgent medical
attention rushes to a hospital, he
cannot bargain on equal footing with the hospital on the terms of admission and
operation. Such a person is literally at the
mercy of the hospital. There can be no clearer example of a contract of adhesion
than one arising from such a dire
situation. Thus, the release forms of CMC cannot relieve CMC from liability for
the negligent medical treatment of
Corazon.

On the Liability of the Other Respondents

Despite this Court s pronouncement in its 9 September 200259 Resolution that the
filing of petitioners Manifestation
confined petitioners claim only against CMC, Dr. Espinola, Dr. Lacson, and Dr.
Uy, who have filed their comments, the
Court deems it proper to resolve the individual liability of the remaining respo
ndents to put an end finally to this more
than two-decade old controversy.
a) Dr. Ely Villaflor
Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause of Corazon
s bleeding and to suggest the correct remedy
to Dr. Estrada.60 Petitioners assert that it was Dr. Villaflor s duty to correct
the error of Nurse Dumlao in the
administration of hemacel.
The Court is not persuaded. Dr. Villaflor admitted administering a lower dosage
of magnesium sulfate. However, this was
after informing Dr. Estrada that Corazon was no longer in convulsion and that he
r blood pressure went down to a
dangerous level.61 At that moment, Dr. Estrada instructed Dr. Villaflor to reduc
e the dosage of magnesium sulfate from 10
to 2.5 grams. Since petitioners did not dispute Dr. Villaflor s allegation, Dr.
Villaflor s defense remains uncontroverted. Dr.
Villaflor s act of administering a lower dosage of magnesium sulfate was not out
of her own volition or was in
contravention of Dr. Estrada s order.
b) Dr. Rosa Uy
Dr. Rosa Uy s alleged negligence consisted of her failure (1) to call the attent
ion of Dr. Estrada on the incorrect dosage of
magnesium sulfate administered by Dr. Villaflor; (2) to take corrective measures
; and (3) to correct Nurse Dumlao s wrong
method of hemacel administration.
The Court believes Dr. Uy s claim that as a second year resident physician then
at CMC, she was merely authorized to take
the clinical history and physical examination of Corazon.62 However, that routin
e internal examination did not ipso facto
make Dr. Uy liable for the errors committed by Dr. Estrada. Further, petitioners
imputation of negligence rests on their
baseless assumption that Dr. Uy was present at the delivery room. Nothing shows
that Dr. Uy participated in delivering
Corazon s baby. Further, it is unexpected from Dr. Uy, a mere resident physician
at that time, to call the attention of a
more experienced specialist, if ever she was present at the delivery room.
c) Dr. Joel Enriquez
Petitioners fault Dr. Joel Enriquez also for not calling the attention of Dr. Es
trada, Dr. Villaflor, and Nurse Dumlao about
their errors.63 Petitioners insist that Dr. Enriquez should have taken, or at le
ast suggested, corrective measures to rectify
such errors.
The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field of e
xpertise is definitely not obstetrics and
gynecology. As such, Dr. Enriquez was not expected to correct Dr. Estrada s erro
rs. Besides, there was no evidence of Dr.
Enriquez s knowledge of any error committed by Dr. Estrada and his failure to ac
t upon such observation.
d) Dr. Perpetua Lacson
Petitioners fault Dr. Perpetua Lacson for her purported delay in the delivery of
blood Corazon needed. 64 Petitioners claim
that Dr. Lacson was remiss in her duty of supervising the blood bank staff.
As found by the trial court, there was no unreasonable delay in the delivery of
blood from the time of the request until the

transfusion to Corazon. Dr. Lacson competently explained the procedure before bl

ood could be given to the patient. 65
Taking into account the bleeding time, clotting time and cross-matching, Dr. Lac
son stated that it would take
approximately 45-60 minutes before blood could be ready for transfusion.66 Furth
er, no evidence exists that Dr. Lacson
neglected her duties as head of the blood bank.
e) Dr. Noe Espinola
Petitioners argue that Dr. Espinola should not have ordered immediate hysterecto
my without determining the underlying
cause of Corazon s bleeding. Dr. Espinola should have first considered the possi
bility of cervical injury, and advised a

thorough examination of the cervix, instead of believing outright Dr. Estrada s

diagnosis that the cause of bleeding was
uterine atony.
Dr. Espinola s order to do hysterectomy which was based on the information he re
ceived by phone is not negligence. The
Court agrees with the trial court s observation that Dr. Espinola, upon hearing
such information about Corazon s
condition, believed in good faith that hysterectomy was the correct remedy. At a
ny rate, the hysterectomy did not push
through because upon Dr. Espinola s arrival, it was already too late. At the tim
e, Corazon was practically dead.
f) Nurse J. Dumlao
In Moore v. Guthrie Hospital Inc.,67 the US Court of Appeals, Fourth Circuit, he
ld that to recover, a patient complaining of
injuries allegedly resulting when the nurse negligently injected medicine to him
intravenously instead of intramuscularly
had to show that (1) an intravenous injection constituted a lack of reasonable a
nd ordinary care; (2) the nurse injected
medicine intravenously; and (3) such injection was the proximate cause of his in
jury.
In the present case, there is no evidence of Nurse Dumlao s alleged failure to f
ollow Dr. Estrada s specific instructions.
Even assuming Nurse Dumlao defied Dr. Estrada s order, there is no showing that
side-drip administration of hemacel
proximately caused Corazon s death. No evidence linking Corazon s death and the
alleged wrongful hemacel
administration was introduced. Therefore, there is no basis to hold Nurse Dumlao
liable for negligence.
On the Award of Interest on Damages
The award of interest on damages is proper and allowed under Article 2211 of the
Civil Code, which states that in crimes
and quasi-delicts, interest as a part of the damages may, in a proper case, be a
djudicated in the discretion of the court. 68
WHEREFORE, the Court PARTLY GRANTS the petition. The Court finds respondent Capi
tol 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%) pe
r annum computed from the date of the
judgment of the trial court. The Court affirms the rest of the Decision dated 6
February 1998 and Resolution dated 21
March 2000 of the Court of Appeals in CA-G.R. CV No. 45641.
SO ORDERED.
Quisumbing, J., Chairperson, Carpio Morales, Tinga, and Velasco, Jr., JJ., concu
r.
SECOND DIVISION
DR. MILAGROS L. CANTRE,
G.R. No. 160889
Petitioner,
Present:
QUISUMBING, J., Chairperson,
CARPIO,
- versus CARPIO MORALES,

TINGA, and
VELASCO, JR., JJ.
SPS. JOHN DAVID Z. GO and NORA S. GO,
Promulgated:
Respondents.
April 27, 2007
x------------------------------------------------x
DECISION
QUISUMBING, J.:
For review on certiorari are the Decision137[1] dated October 3, 2002 and Resolu
tion138[2] dated November 19,
2003 of the Court of Appeals in CA-G.R. CV No. 58184, which affirmed with modifi
cation the Decision139[3] dated
March 3, 1997 of the Regional Trial Court of Quezon City, Branch 98, in Civil Ca
se No. Q-93-16562.
The facts, culled from the records, are as follows:
Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and Gynecology a
t the Dr. Jesus Delgado Memorial
Hospital. She was the attending physician of respondent Nora S. Go, who was admi
tted at the said hospital on April 19,
1992.
At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy.
However, at around 3:30 a.m., Nora
suffered profuse bleeding inside her womb due to some parts of the placenta whic
h were not completely expelled from her
womb after delivery. Consequently, Nora suffered hypovolemic shock, resulting in
a drop in her blood pressure to 40 over
0. Petitioner and the assisting resident physician performed various medical pro
cedures to stop the bleeding and to

restore Noras blood pressure. Her blood pressure was frequently monitored with t
he 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.140[4] Nora remained unconscious until she recovered.
While in the recovery room, her husband, respondent John David Z. Go noticed a f
resh 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.141[5] He asked the nurses
what caused the injury. He was informed it was a burn. Forthwith, on April 22, 1
992, John David filed a request for
investigation.142[6] In response, Dr. Rainerio S. Abad, the medical director of
the hospital, called petitioner and the
assisting resident physician to explain what happened. Petitioner said the blood
pressure cuff caused the injury.
On May 7, 1992, John David brought Nora to the National Bureau of Investigation
for a physical examination,
which was conducted by medico-legal officer Dr. Floresto Arizala, Jr.143[7] The
medico-legal officer later testified that
Noras injury appeared to be a burn and that a droplight when placed near the ski
n for about 10 minutes could cause such
burn.144[8] He dismissed the likelihood that the wound was caused by a blood pre
ssure cuff as the scar was not around
the arm, but just on one side of the arm.145[9]
On May 22, 1992, Noras injury was referred to a plastic surgeon at the Dr. Jesus
Delgado Memorial Hospital for
skin grafting.146[10] Her wound was covered with skin sourced from her abdomen,
which consequently bore a scar as
well. About a year after, on April 30, 1993, scar revision had to be performed a
t the same hospital.147[11] The surgical
operation left a healed linear scar in Noras left arm about three inches in leng
th, the thickest portion rising about onefourth (1/4) of an inch from the surfac
e of the skin. The costs of the skin grafting and the scar revision were shoulde
red by
the hospital.148[12]

Unfortunately, Noras arm would never be the same. Aside from the unsightly mark,
the pain in her left arm
remains. When sleeping, she has to cradle her wounded arm. Her movements now are
also restricted. Her children cannot
play with the left side of her body as they might accidentally bump the injured
arm, which aches at the slightest touch.
Thus, on June 21, 1993, respondent spouses filed a complaint149[13] for damages
against petitioner, Dr. Abad,
and the hospital. Finding in favor of respondent spouses, the trial court decree
d:
In view of the foregoing consideration, judgment is hereby rendered in favor of
the plaintiffs and
against the defendants, directing the latters, (sic) jointly and severally
(a)
to pay the sum of Five Hundred Thousand Pesos (P500,000.00) in moral damages;
(b)
to pay the sum of One Hundred Fifty Thousand Pesos (P150,000.00) exemplary damag
es;
(c)
to pay the sum of Eighty Thousand Pesos (P80,000.00) nominal damages;
(d)
to pay Fifty Thousand Pesos (P50,000.00) for and as attorneys fees; and
(e)
to pay Six Thousand Pesos (P6,000.00) litigation expenses.
SO ORDERED.150[14]
Petitioner, Dr. Abad, and the hospital all appealed to the Court of Appeals, whi
ch affirmed with modification the
trial court decision, thus:
WHEREFORE, in view of all the foregoing, and finding no reversible error in the
appealed
Decision dated March 3, 1997 of Branch 98 of the Regional Trial Court of Quezon
City in Civil Case No. Q93-16562, the same is hereby AFFIRMED, with the followin
g MODIFICATIONS:
1.
2.
3.
Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay plaintiffs-ap
pellees
John David Go and Nora S. Go the sum of P200,000.00 as moral damages;
Deleting the award [of] exemplary damages, attorneys fees and expenses of litiga
tion;
Dismissing the complaint with respect to defendants-appellants Dr. Rainerio S. A
bad and
Delgado Clinic, Inc.;

4.
Dismissing the counterclaims of defendants-appellants for lack of merit; and
5.
Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay the costs.
SO ORDERED.151[15]

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

WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF DISCRETION WHEN,
CONTRARY TO THE MEDICAL PURPOSES OF COSMETIC SURGERY, IT RULED THAT THE
COSMETIC SURGERY MADE THE SCARS EVEN MORE UGLY AND DECLARED THE COSMETIC
SURGERY A FAILURE;
VIII.
WHETHER OR NOT THE LOWER COURT GRAVELY ABUSE OF (SIC) DISCRETION WHEN,
CONTRARY TO RESPONDENTS CONTRARY TESTIMONIES AND THE ABSENCE OF ANY
TESTIMONY, IT RULED THAT THEY ARE ENTITLED TO DAMAGES AND WHICH WAS UPHELD,
ALTHOUGH MODIFIED, BY THE COURT OF APPEALS LIKEWISE ABUSING ITS
DISCRETION.152[16]
Petitioner contends that additional documentary exhibits not testified to by any
witness are inadmissible in
evidence because they deprived her of her constitutional right to confront the w
itnesses 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 test
imony of the medico-legal officer who never
saw the original injury before plastic surgery was performed. Finally, petitione
r stresses that plastic surgery was not
intended to restore respondents injury to its original state but rather to preve
nt further complication.
Respondents, however, counter that the genuineness and
tional documentary exhibits
were duly admitted by petitioners counsel. Respondents
s blood pressure cuff theory is highly
improbable, being unprecedented in medical history and
itely caused by the droplight. At any
rate, they argue, even if the injury was brought about
f, petitioner was still negligent in her duties
as Noras attending physician.

due execution of the addi

point out that petitioner
that the injury was defin
by the blood pressure cuf

Simply put, the threshold issues for resolution are: (1) Are the questioned addi
tional exhibits admissible in
evidence? (2) Is petitioner liable for the injury suffered by respondent Nora Go
? Thereafter, the inquiry is whether the
appellate court committed grave abuse of discretion in its assailed issuances.
As to the first issue, we agree with the Court of Appeals that said exhibits are
admissible in evidence. We note that
the questioned exhibits consist mostly of Noras medical records, which were prod
uced by the hospital during trial
pursuant to a subpoena duces tecum. Petitioners counsel admitted the existence o
f the same when they were formally
offered for admission by the trial court. In any case, given the particular circ
umstances of this case, a ruling on the
negligence of petitioner may be made based on the res ipsa loquitur doctrine eve
n in the absence of such additional
exhibits.

Petitioners contention that the medico-legal officer who conducted Noras physica
l examination never saw her
original injury before plastic surgery was performed is without basis and contra
dicted by the records. Records show that
the medico-legal officer conducted the physical examination on May 7, 1992, whil
e the skin grafting and the scar revision
were performed on Nora on May 22, 1992 and April 30, 1993, respectively.
Coming now to the substantive matter, is petitioner liable for the injury suffer
ed by respondent Nora Go?
The Hippocratic Oath mandates physicians to give primordial consideration to the
well-being of their patients. If a
doctor fails to live up to this precept, he is accountable for his acts. This no
twithstanding, courts face a unique restraint in
adjudicating medical negligence cases because physicians are not guarantors of c
are and, they never set out to
intentionally cause injury to their patients. However, intent is immaterial in n
egligence cases because where negligence
exists and is proven, it automatically gives the injured a right to reparation f
or the damage caused.153[17]
In cases involving medical negligence, the doctrine of res ipsa loquitur allows
the mere existence of an injury to
justify a presumption of negligence on the part of the person who controls the i
nstrument 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 some
ones 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.154[18]
As to the first requirement, the gaping wound on Noras arm is certainly not an o
rdinary occurrence in the act of
delivering a baby, far removed as the arm is from the organs involved in the pro
cess 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 u
nder the captain of the ship doctrine. This
doctrine holds the surgeon in charge of an operation liable for the negligence o
f his assistants during the time when those
assistants are under the surgeons control.155[19] In this particular case, it ca
n be logically inferred that petitioner, the
senior consultant in charge during the delivery of Noras baby, exercised control
over the assistants assigned to both the
use of the droplight and the taking of Noras blood pressure. Hence, the use of t
he droplight and the blood pressure cuff is
also within petitioners exclusive control.
Third, the gaping wound on Noras left arm, by its very nature and considering he
r condition, could only be caused
by something external to her and outside her control as she was unconscious whil
e in hypovolemic shock. Hence, Nora
could not, by any stretch of the imagination, have contributed to her own injury
.
Petitioners defense that Noras wound was caused not by the droplight but by the
constant taking of her blood
pressure, even if the latter was necessary given her condition, does not absolve
her from liability. As testified to by the
medico-legal officer, Dr. Arizala, Jr., the medical practice is to deflate the b
lood pressure cuff immediately after each use.
Otherwise, the inflated band can cause injury to the patient similar to what cou
ld have happened in this case. Thus, if
Noras wound was caused by the blood pressure cuff, then the taking of Noras bloo
d pressure must have been done so
negligently as to have inflicted a gaping wound on her arm,156[20] for which pet
itioner cannot escape liability under the
captain of the ship doctrine.
Further, petitioners argument that the failed plastic surgery was not intended a
s a cosmetic procedure, but rather
as a measure to prevent complication does not help her case. It does not negate
negligence on her part.
Based on the foregoing, the presumption that petitioner was negligent in the exe
rcise of her profession stands
unrebutted. In this connection, the Civil Code provides:
ART. 2176. Whoever by act or omission causes damage to another, there being faul
t or negligence,
is obliged to pay for the damage done.
ART. 2217. Moral damages include physical suffering, mental anguish, fright, ser
ious anxiety,
besmirched reputation, wounded feelings, moral shock, social humiliation, and si
milar injury. Though

incapable of pecuniary computation, moral damages may be recovered if they are t

he proximate result of
the defendants wrongful act or omission.
Clearly, under the law, petitioner is obliged to pay Nora for moral damages suff
ered by the latter as a proximate
result of petitioners negligence.
We note, however, that petitioner has served well as Noras obstetrician for her
past three successful deliveries.
This is the first time petitioner is being held liable for damages due to neglig
ence in the practice of her profession. The fact
that petitioner promptly took care of Noras wound before infection and other com
plications set in is also indicative of
petitioners good intentions. We also take note of the fact that Nora was sufferi
ng from a critical condition when the injury
happened, such that saving her life became petitioners elemental concern. Noneth
eless, it should be stressed that all these
could not justify negligence on the part of petitioner.
Hence, considering the specific circumstances in the instant case, we find no gr
ave abuse of discretion in the
assailed decision and resolution of the Court of Appeals. Further, we rule that
the Court of Appeals award of Two Hundred
Thousand Pesos (P200,000) as moral damages in favor of respondents and against p
etitioner is just and
equitable.157[21]
WHEREFORE, the petition is DENIED. The Decision dated October 3, 2002 and Resolu
tion dated November
19, 2003 of the Court of Appeals in CA-G.R. CV No. 58184 are AFFIRMED.
No pronouncement as to costs.
SO ORDERED.
LEONARDO A. QUISUMBING
Associate Justice
WE CONCUR:
ANTONIO T. CARPIO
Associate Justice

CONCHITA CARPIO MORALES

DANTE O. TINGA
Associate Justice
Associate Justice
PRESBITERO J. VELASCO, JR.
Associate Justice
ATTESTATION
I attest that the conclusions in the above Decision had been reached in consulta
tion before
the case was assigned to the writer of the opinion of the Courts Division.
LEONARDO A. QUISUMBING
Associate Justice
Chairperson
CERTIFICATION
Pursuant to Section 13, Article VIII of the Constitution, and the Division Chair
persons
Attestation, I certify that the conclusions in the above Decision had been reach
ed in consultation
before the case was assigned to the writer of the opinion of the Courts Division
.
REYNATO S. PUNO
Chief Justice
Republic of the Philippines
SUPREME COURT
Manila
FIRST DIVISION

G.R. No. 124354 December 29, 1999

ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural guardians
of the minors,
ROMMEL RAMOS, ROY RODERICK RAMOS and RON RAYMOND RAMOS, petitioners,
vs.
COURT OF APPEALS, DELOS SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and DRA. PERFEC
TA
GUTIERREZ, respondents.
KAPUNAN, J.:
The Hippocratic Oath mandates physicians to give primordial consideration to the
health and welfare of their patients. If a
doctor fails to live up to this precept, he is made accountable for his acts. A
mistake, through gross negligence or
incompetence or plain human error, may spell the difference between life and dea
th. In this sense, the doctor plays God on
his patient s fate. 1
In the case at bar, the Court is called upon to rule whether a surgeon, an anest
hesiologist and a hospital should be made
liable for the unfortunate comatose condition of a patient scheduled for cholecy
stectomy. 2
Petitioners seek the reversal of the decision 3 of the Court of Appeals, dated 2
9 May 1995, which overturned the decision 4
of the Regional Trial Court, dated 30 January 1992, finding private respondents
liable for damages arising from negligence
in the performance of their professional duties towards petitioner Erlinda Ramos
resulting in her comatose condition.
The antecedent facts as summarized by the trial court are reproduced hereunder:
Plaintiff Erlinda Ramos was, until the afternoon of June 17, 1985, a 47-year old
(Exh. "A") robust woman
(TSN, October 19, 1989, p. 10). Except for occasional complaints of discomfort d
ue to pains allegedly
caused by the presence of a stone in her gall bladder (TSN, January 13, 1988, pp
. 4-5), she was as normal
as any other woman. Married to Rogelio E. Ramos, an executive of Philippine Long
Distance Telephone
Company, she has three children whose names are Rommel Ramos, Roy Roderick Ramos
and Ron
Raymond Ramos (TSN, October 19, 1989, pp. 5-6).
Because the discomforts somehow interfered with her normal ways, she sought prof
essional advice. She
was advised to undergo an operation for the removal of a stone in her gall bladd
er (TSN, January 13,
1988, p. 5). She underwent a series of examinations which included blood and uri
ne tests (Exhs. "A" and
"C") which indicated she was fit for surgery.
Through the intercession of a mutual friend, Dr. Buenviaje (TSN, January 13, 198
8, p. 7), she and her
husband Rogelio met for the first time Dr. Orlino Hozaka (should be Hosaka; see
TSN, February 20, 1990,
p. 3), one of the defendants in this case, on June 10, 1985. They agreed that th
eir date at the operating
table at the DLSMC (another defendant), would be on June 17, 1985 at 9:00 A.M..
Dr. Hosaka decided
that she should undergo a "cholecystectomy" operation after examining the docume
nts (findings from the
Capitol Medical Center, FEU Hospital and DLSMC) presented to him. Rogelio E. Ram
os, however, asked
Dr. Hosaka to look for a good anesthesiologist. Dr. Hosaka, in turn, assured Rog
elio that he will get a good

anesthesiologist. Dr. Hosaka charged a fee of P16,000.00, which was to include t

he anesthesiologist s fee
and which was to be paid after the operation (TSN, October 19, 1989, pp. 14-15,
22-23, 31-33; TSN,
February 27, 1990, p. 13; and TSN, November 9, 1989, pp. 3-4, 10, 17).
A day before the scheduled date of operation, she was admitted at one of the roo
ms of the DLSMC, located
along E. Rodriguez Avenue, Quezon City (TSN, October 19,1989, p. 11).
At around 7:30 A.M. of June 17, 1985 and while still in her room, she was prepar
ed for the operation by
the hospital staff. Her sister-in-law, Herminda Cruz, who was the Dean of the Co
llege of Nursing at the
Capitol Medical Center, was also there for moral support. She reiterated her pre
vious request for
Herminda to be with her even during the operation. After praying, she was given
injections. Her hands
were held by Herminda as they went down from her room to the operating room (TSN
, January 13, 1988,
pp. 9-11). Her husband, Rogelio, was also with her (TSN, October 19, 1989, p. 18
). At the operating room,

Herminda saw about two or three nurses and Dr. Perfecta Gutierrez, the other def
endant, who was to
administer anesthesia. Although not a member of the hospital staff, Herminda int
roduced herself as Dean
of the College of Nursing at the Capitol Medical Center who was to provide moral
support to the patient,
to them. Herminda was allowed to stay inside the operating room.
At around 9:30 A.M., Dr. Gutierrez reached a nearby phone to look for Dr. Hosaka
who was not yet in
(TSN, January 13, 1988, pp. 11-12). Dr. Gutierrez thereafter informed Herminda C
ruz about the prospect
of a delay in the arrival of Dr. Hosaka. Herminda then went back to the patient
who asked, "Mindy, wala
pa ba ang Doctor"? The former replied, "Huwag kang mag-alaala, darating na iyon"
(Ibid.).
Thereafter, Herminda went out of the operating room and informed the patient s h
usband, Rogelio, that
the doctor was not yet around (id., p. 13). When she returned to the operating r
oom, the patient told her,
"Mindy, inip na inip na ako, ikuha mo ako ng ibang Doctor." So, she went out aga
in and told Rogelio
about what the patient said (id., p. 15). Thereafter, she returned to the operat
ing room.
At around 10:00 A.M., Rogelio E. Ramos was "already dying [and] waiting for the
arrival of the doctor"
even as he did his best to find somebody who will allow him to pull out his wife
from the operating room
(TSN, October 19, 1989, pp. 19-20). He also thought of the feeling of his wife,
who was inside the
operating room waiting for the doctor to arrive (ibid.). At almost 12:00 noon, h
e met Dr. Garcia who
remarked that he (Dr. Garcia) was also tired of waiting for Dr. Hosaka to arrive
(id., p. 21). While talking
to Dr. Garcia at around 12:10 P.M., he came to know that Dr. Hosaka arrived as a
nurse remarked,
"Nandiyan na si Dr. Hosaka, dumating na raw." Upon hearing those words, he went
down to the lobby
and waited for the operation to be completed (id., pp. 16, 29-30).
At about 12:15 P.M., Herminda Cruz, who was inside the operating room with the p
atient, heard
somebody say that "Dr. Hosaka is already here." She then saw people inside the o
perating room "moving,
doing this and that, [and] preparing the patient for the operation" (TSN, Januar
y 13, 1988, p. 16). As she
held the hand of Erlinda Ramos, she then saw Dr. Gutierrez intubating the haples
s patient. She thereafter
heard Dr. Gutierrez say, "ang hirap ma-intubate nito, mali yata ang pagkakapasok
. O lumalaki ang tiyan"
(id., p. 17). Because of the remarks of Dra. Gutierrez, she focused her attentio
n on what Dr. Gutierrez was
doing. She thereafter noticed bluish discoloration of the nailbeds of the left h
and of the hapless Erlinda
even as Dr. Hosaka approached her. She then heard Dr. Hosaka issue an order for
someone to call Dr.
Calderon, another anesthesiologist (id., p. 19). After Dr. Calderon arrived at t
he operating room, she saw
this anesthesiologist trying to intubate the patient. The patient s nailbed beca
me bluish and the patient
was placed in a trendelenburg position a position where the head of the patient
is placed in a position

lower than her feet which is an indication that there is a decrease of blood sup
ply to the patient s brain
(Id., pp. 19-20). Immediately thereafter, she went out of the operating room, an
d she told Rogelio E.
Ramos "that something wrong was . . . happening" (Ibid.). Dr. Calderon was then
able to intubate the
patient (TSN, July 25, 1991, p. 9).
Meanwhile, Rogelio, who was outside the operating room, saw a respiratory machin
e being rushed
towards the door of the operating room. He also saw several doctors rushing towa
rds the operating room.
When informed by Herminda Cruz that something wrong was happening, he told her (
Herminda) to be
back with the patient inside the operating room (TSN, October 19, 1989, pp. 25-2
8).
Herminda Cruz immediately rushed back, and saw that the patient was still in tre
ndelenburg position
(TSN, January 13, 1988, p. 20). At almost 3:00 P.M. of that fateful day, she saw
the patient taken to the
Intensive Care Unit (ICU).
About two days thereafter, Rogelio E. Ramos was able to talk to Dr. Hosaka. The
latter informed the
former that something went wrong during the intubation. Reacting to what was tol
d to him, Rogelio
reminded the doctor that the condition of his wife would not have happened, had
he (Dr. Hosaka) looked
for a good anesthesiologist (TSN, October 19, 1989, p. 31).
Doctors Gutierrez and Hosaka were also asked by the hospital to explain what hap
pened to the patient.
The doctors explained that the patient had bronchospasm (TSN, November 15, 1990,
pp. 26-27).
Erlinda Ramos stayed at the ICU for a month. About four months thereafter or on
November 15, 1985, the
patient was released from the hospital.

During the whole period of her confinement, she incurred hospital bills amountin
g to P93,542.25 which is
the subject of a promissory note and affidavit of undertaking executed by Rogeli
o E. Ramos in favor of
DLSMC. Since that fateful afternoon of June 17, 1985, she has been in a comatose
condition. She cannot
do anything. She cannot move any part of her body. She cannot see or hear. She i
s living on mechanical
means. She suffered brain damage as a result of the absence of oxygen in her bra
in for four to five minutes
(TSN, November 9, 1989, pp. 21-22). After being discharged from the hospital, sh
e has been staying in
their residence, still needing constant medical attention, with her husband Roge
lio incurring a monthly
expense ranging from P8,000.00 to P10,000.00 (TSN, October 19, 1989, pp. 32-34).
She was also
diagnosed to be suffering from "diffuse cerebral parenchymal damage" (Exh. "G";
see also TSN, December
21, 1989,
p. 6). 5
Thus, on 8 January 1986, petitioners filed a civil case 6 for damages with the R
egional Trial Court of Quezon City against
herein private respondents alleging negligence in the management and care of Erl
inda Ramos.
During the trial, both parties presented evidence as to the possible cause of Er
linda s injury. Plaintiff presented the
testimonies of Dean Herminda Cruz and Dr. Mariano Gavino to prove that the susta
ined by Erlinda was due to lack of
oxygen in her brain caused by the faulty management of her airway by private res
pondents during the anesthesia phase.
On the other hand, private respondents primarily relied on the expert testimony
of Dr. Eduardo Jamora, a pulmonologist,
to the effect that the cause of brain damage was Erlinda s allergic reaction to
the anesthetic agent, Thiopental Sodium
(Pentothal).
After considering the evidence from both sides, the Regional Trial Court rendere
d judgment in favor of petitioners, to wit:
After evaluating the evidence as shown in the finding of facts set forth earlier
, and applying the aforecited
provisions of law and jurisprudence to the case at bar, this Court finds and so
holds that defendants are
liable to plaintiffs for damages. The defendants were guilty of, at the very lea
st, negligence in the
performance of their duty to plaintiff-patient Erlinda Ramos.
On the part of Dr. Perfecta Gutierrez, this Court finds that she omitted to exer
cise reasonable care in not
only intubating the patient, but also in not repeating the administration of atr
opine (TSN, August 20,
1991, pp. 5-10), without due regard to the fact that the patient was inside the
operating room for almost
three (3) hours. For after she committed a mistake in intubating [the] patient,
the patient s nailbed
became bluish and the patient, thereafter, was placed in trendelenburg position,
because of the decrease
of blood supply to the patient s brain. The evidence further shows that the hapl
ess patient suffered brain
damage because of the absence of oxygen in her (patient s) brain for approximate
ly four to five minutes
which, in turn, caused the patient to become comatose.
On the part of Dr. Orlino Hosaka, this Court finds that he is liable for the act

s of Dr. Perfecta Gutierrez

whom he had chosen to administer anesthesia on the patient as part of his obliga
tion to provide the
patient a good anesthesiologist , and for arriving for the scheduled operation a
lmost three (3) hours late.
On the part of DLSMC (the hospital), this Court finds that it is liable for the
acts of negligence of the
doctors in their "practice of medicine" in the operating room. Moreover, the hos
pital is liable for failing
through its responsible officials, to cancel the scheduled operation after Dr. H
osaka inexcusably failed to
arrive on time.
In having held thus, this Court rejects the defense raised by defendants that th
ey have acted with due care
and prudence in rendering medical services to plaintiff-patient. For if the pati
ent was properly intubated
as claimed by them, the patient would not have become comatose. And, the fact th
at another
anesthesiologist was called to try to intubate the patient after her (the patien
t s) nailbed turned bluish,
belie their claim. Furthermore, the defendants should have rescheduled the opera
tion to a later date. This,
they should have done, if defendants acted with due care and prudence as the pat
ient s case was an
elective, not an emergency case.
xxx xxx xxx
WHEREFORE, and in view of the foregoing, judgment is rendered in favor of the pl
aintiffs and against
the defendants. Accordingly, the latter are ordered to pay, jointly and severall
y, the former the following
sums of money, to wit:

1) the sum of P8,000.00 as actual monthly expenses for the plaintiff Erlinda Ram
os
reckoned from November 15, 1985 or in the total sum of P632,000.00 as of April 1
5,
1992, subject to its being updated;
2) the sum of P100,000.00 as reasonable attorney s fees;
3) the sum of P800,000.00 by way of moral damages and the further sum of
P200,000,00 by way of exemplary damages; and,
4) the costs of the suit.
SO ORDERED. 7
Private respondents seasonably interposed an appeal to the Court of Appeals. The
appellate court rendered a Decision,
dated 29 May 1995, reversing the findings of the trial court. The decretal porti
on of the decision of the appellate court
reads:
WHEREFORE, for the foregoing premises the appealed decision is hereby REVERSED,
and the complaint
below against the appellants is hereby ordered DISMISSED. The counterclaim of ap
pellant De Los Santos
Medical Center is GRANTED but only insofar as appellees are hereby ordered to pa
y the unpaid hospital
bills amounting to P93,542.25, plus legal interest for justice must be tempered
with mercy.
SO ORDERED. 8
The decision of the Court of Appeals was received on 9 June 1995 by petitioner R
ogelio Ramos who was mistakenly
addressed as "Atty. Rogelio Ramos." No copy of the decision, however, was sent n
or received by the Coronel Law Office,
then counsel on record of petitioners. Rogelio referred the decision of the appe
llate court to a new lawyer, Atty. Ligsay,
only on 20 June 1995, or four (4) days before the expiration of the reglementary
period for filing a motion for
reconsideration. On the same day, Atty. Ligsay, filed with the appellate court a
motion for extension of time to file a
motion for reconsideration. The motion for reconsideration was submitted on 4 Ju
ly 1995. However, the appellate court
denied the motion for extension of time in its Resolution dated 25 July 1995. 9
Meanwhile, petitioners engaged the
services of another counsel, Atty. Sillano, to replace Atty. Ligsay. Atty. Silla
no filed on 7 August 1995 a motion to admit the
motion for reconsideration contending that the period to file the appropriate pl
eading on the assailed decision had not yet
commenced to run as the Division Clerk of Court of the Court of Appeals had not
yet served a copy thereof to the counsel
on record. Despite this explanation, the appellate court still denied the motion
to admit the motion for reconsideration of
petitioners in its Resolution, dated 29 March 1996, primarily on the ground that
the fifteen-day (15) period for filing a
motion for reconsideration had already expired, to wit:
We said in our Resolution on July 25, 1995, that the filing of a Motion for Reco
nsideration cannot be
extended; precisely, the Motion for Extension (Rollo, p. 12) was denied. It is,
on the other hand, admitted
in the latter Motion that plaintiffs/appellees received a copy of the decision a
s early as June 9, 1995.
Computation wise, the period to file a Motion for Reconsideration expired on Jun
e 24. The Motion for
Reconsideration, in turn, was received by the Court of Appeals already on July 4
, necessarily, the 15-day
period already passed. For that alone, the latter should be denied.

Even assuming admissibility of the Motion for the Reconsideration, but after con
sidering the
Comment/Opposition, the former, for lack of merit, is hereby DENIED.
SO ORDERED. 10
A copy of the above resolution was received by Atty. Sillano on 11 April 1996. T
he next day, or on 12 April 1996, Atty.
Sillano filed before this Court a motion for extension of time to file the prese
nt petition for certiorari under Rule 45. The
Court granted the motion for extension of time and gave petitioners additional t
hirty (30) days after the expiration of the
fifteen-day (15) period counted from the receipt of the resolution of the Court
of Appeals within which to submit the
petition. The due date fell on 27 May 1996. The petition was filed on 9 May 1996
, well within the extended period given by
the Court.
Petitioners assail the decision of the Court of Appeals on the following grounds
:
I

IN PUTTING MUCH RELIANCE ON THE TESTIMONIES OF RESPONDENTS DRA. GUTIERREZ, DRA.

CALDERON AND DR. JAMORA;
II
IN FINDING THAT THE NEGLIGENCE OF THE RESPONDENTS DID NOT CAUSE THE
UNFORTUNATE COMATOSE CONDITION OF PETITIONER ERLINDA RAMOS;
III
IN NOT APPLYING THE DOCTRINE OF RES IPSA LOQUITUR. 11
Before we discuss the merits of the case, we shall first dispose of the procedur
al issue on the timeliness of the petition in
relation to the motion for reconsideration filed by petitioners with the Court o
f Appeals. In their
Comment, 12 private respondents contend that the petition should not be given du
e course since the motion for
reconsideration of the petitioners on the decision of the Court of Appeals was v
alidly dismissed by the appellate court for
having been filed beyond the reglementary period. We do not agree.
A careful review of the records reveals that the reason behind the delay in fili
ng the motion for reconsideration is
attributable to the fact that the decision of the Court of Appeals was not sent
to then counsel on record of petitioners, the
Coronel Law Office. In fact, a copy of the decision of the appellate court was i
nstead sent to and received by petitioner
Rogelio Ramos on 9 June 1995 wherein he was mistakenly addressed as Atty. Rogeli
o Ramos. Based on the other
communications received by petitioner Rogelio Ramos, the appellate court apparen
tly mistook him for the counsel on
record. Thus, no copy of the decision of the counsel on record. Petitioner, not
being a lawyer and unaware of the
prescriptive period for filing a motion for reconsideration, referred the same t
o a legal counsel only on 20 June 1995.
It is elementary that when a party is represented by counsel, all notices should
be sent to the party s lawyer at his given
address. With a few exceptions, notice to a litigant without notice to his couns
el on record is no notice at all. In the present
case, since a copy of the decision of the appellate court was not sent to the co
unsel on record of petitioner, there can be no
sufficient notice to speak of. Hence, the delay in the filing of the motion for
reconsideration cannot be taken against
petitioner. Moreover, since the Court of Appeals already issued a second Resolut
ion, dated 29 March 1996, which
superseded the earlier resolution issued on 25 July 1995, and denied the motion
for reconsideration of petitioner, we
believed that the receipt of the former should be considered in determining the
timeliness of the filing of the present
petition. Based on this, the petition before us was submitted on time.
After resolving the foregoing procedural issue, we shall now look into the merit
s of the case. For a more logical
presentation of the discussion we shall first consider the issue on the applicab
ility of the doctrine of res ipsa loquitur to
the instant case. Thereafter, the first two assigned errors shall be tackled in
relation to the res ipsa loquitur doctrine.
Res ipsa loquitur is a Latin phrase which literally means "the thing or the tran
saction speaks for itself." The phrase "res
ipsa loquitur is a maxim for the rule that the fact of the occurrence of an in
jury, taken with the surrounding
circumstances, may permit an inference or raise a presumption of negligence, or
make out a plaintiff s prima facie case,
and present a question of fact for defendant to meet with an explanation. 13 Whe
re the thing which caused the injury
complained of is shown to be under the management of the defendant or his servan

ts and the accident is such as in

ordinary course of things does not happen if those who have its management or co
ntrol use proper care, it affords
reasonable evidence, in the absence of explanation by the defendant, that the ac
cident arose from or was caused by the
defendant s want of care. 14
The doctrine of res ipsa loquitur is simply a recognition of the postulate that,
as a matter of common knowledge and
experience, the very nature of certain types of occurrences may justify an infer
ence of negligence on the part of the person
who controls the instrumentality causing the injury in the absence of some expla
nation by the defendant who is charged
with negligence. 15 It is grounded in the superior logic of ordinary human exper
ience and on the basis of such experience
or common knowledge, negligence may be deduced from the mere occurrence of the a
ccident itself. 16 Hence, res ipsa
loquitur is applied in conjunction with the doctrine of common knowledge.
However, much has been said that res ipsa loquitur is not a rule of substantive
law and, as such, does not create or
constitute an independent or separate ground of liability. 17 Instead, it is con
sidered as merely evidentiary or in the nature
of a procedural rule. 18 It is regarded as a mode of proof, or a mere procedural
of convenience since it furnishes a
substitute for, and relieves a plaintiff of, the burden of producing specific pr
oof of negligence. 19 In other words, mere
invocation and application of the doctrine does not dispense with the requiremen
t of proof of negligence. It is simply a

step in the process of such proof, permitting the plaintiff to present along wit
h the proof of the accident, enough of the
attending circumstances to invoke the doctrine, creating an inference or presump
tion of negligence, and to thereby place
on the defendant the burden of going forward with the proof. 20 Still, before re
sort to the doctrine may be allowed, the
following requisites must be satisfactorily shown:
1. The accident is of a kind which ordinarily does not occur in the absence of s
omeone s
negligence;
2. It is caused by an instrumentality within the exclusive control of the defend
ant or
defendants; and
3. The possibility of contributing conduct which would make the plaintiff respon
sible is
eliminated. 21
In the above requisites, the fundamental element is the "control of instrumental
ity" which caused the damage. 22 Such
element of control must be shown to be within the dominion of the defendant. In
order to have the benefit of the rule, a
plaintiff, in addition to proving injury or damage, must show a situation where
it is applicable, and must establish that the
essential elements of the doctrine were present in a particular incident. 23
Medical malpractice 24 cases do not escape the application of this doctrine. Thu
s, res ipsa loquitur has been applied when
the circumstances attendant upon the harm are themselves of such a character as
to justify an inference of negligence as
the cause of that harm. 25 The application of res ipsa loquitur in medical negli
gence cases presents a question of law since
it is a judicial function to determine whether a certain set of circumstances do
es, as a matter of law, permit a given
inference. 26
Although generally, expert medical testimony is relied upon in malpractice suits
to prove that a physician has done a
negligent act or that he has deviated from the standard medical procedure, when
the doctrine of res ipsa loquitur is
availed by the plaintiff, the need for expert medical testimony is dispensed wit
h because the injury itself provides the proof
of negligence. 27 The reason is that the general rule on the necessity of expert
testimony applies only to such matters
clearly within the domain of medical science, and not to matters that are within
the common knowledge of mankind which
may be testified to by anyone familiar with the facts. 28 Ordinarily, only physi
cians and surgeons of skill and experience
are competent to testify as to whether a patient has been treated or operated up
on with a reasonable degree of skill and
care. However, testimony as to the statements and acts of physicians and surgeon
s, external appearances, and manifest
conditions which are observable by any one may be given by non-expert witnesses.
29 Hence, in cases where the res ipsa
loquitur is applicable, the court is permitted to find a physician negligent upo
n proper proof of injury to the patient,
without the aid of expert testimony, where the court from its fund of common kno
wledge can determine the proper
standard of care. 30 Where common knowledge and experience teach that a resultin
g injury would not have occurred to
the patient if due care had been exercised, an inference of negligence may be dr
awn giving rise to an application of the
doctrine of res ipsa loquitur without medical evidence, which is ordinarily requ
ired to show not only what occurred but

how and why it occurred. 31 When the doctrine is appropriate, all that the patie
nt must do is prove a nexus between the
particular act or omission complained of and the injury sustained while under th
e custody and management of the
defendant without need to produce expert medical testimony to establish the stan
dard of care. Resort to res ipsa loquitur
is allowed because there is no other way, under usual and ordinary conditions, b
y which the patient can obtain redress for
injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following s
ituations: leaving of a foreign object in the
body of the patient after an operation, 32 injuries sustained on a healthy part
of the body which was not under, or in the
area, of treatment, 33 removal of the wrong part of the body when another part w
as intended, 34 knocking out a tooth while
a patient s jaw was under anesthetic for the removal of his tonsils, 35 and loss
of an eye while the patient plaintiff was
under the influence of anesthetic, during or following an operation for appendic
itis, 36 among others.
Nevertheless, despite the fact that the scope of res ipsa loquitur has been meas
urably enlarged, it does not automatically
apply to all cases of medical negligence as to mechanically shift the burden of
proof to the defendant to show that he is not
guilty of the ascribed negligence. Res ipsa loquitur is not a rigid or ordinary
doctrine to be perfunctorily used but a rule to
be cautiously applied, depending upon the circumstances of each case. It is gene
rally restricted to situations in malpractice
cases where a layman is able to say, as a matter of common knowledge and observa
tion, that the consequences of
professional care were not as such as would ordinarily have followed if due care
had been
exercised. 37 A distinction must be made between the failure to secure results,
and the occurrence of something more
unusual and not ordinarily found if the service or treatment rendered followed t
he usual procedure of those skilled in that
particular practice. It must be conceded that the doctrine of res ipsa loquitur
can have no application in a suit against a
physician or surgeon which involves the merits of a diagnosis or of a scientific
treatment. 38 The physician or surgeon is

not required at his peril to explain why any particular diagnosis was not correc
t, or why any particular scientific treatment
did not produce the desired result. 39 Thus, res ipsa loquitur is not available
in a malpractice suit if the only showing is
that the desired result of an operation or treatment was not accomplished. 40 Th
e real question, therefore, is whether or
not in the process of the operation any extraordinary incident or unusual event
outside of the routine performance
occurred which is beyond the regular scope of customary professional activity in
such operations, which, if unexplained
would themselves reasonably speak to the average man as the negligent cause or c
auses of the untoward consequence. 41 If
there was such extraneous interventions, the doctrine of res ipsa loquitur may b
e utilized and the defendant is called upon
to explain the matter, by evidence of exculpation, if he could. 42
We find the doctrine of res ipsa loquitur appropriate in the case at bar. As wil
l hereinafter be explained, the damage
sustained by Erlinda in her brain prior to a scheduled gall bladder operation pr
esents a case for the application of res ipsa
loquitur.
A case strikingly similar to the one before us is Voss vs. Bridwell, 43 where th
e Kansas Supreme Court in applying the res
ipsa loquitur stated:
The plaintiff herein submitted himself for a mastoid operation and delivered his
person over to the care,
custody and control of his physician who had complete and exclusive control over
him, but the operation
was never performed. At the time of submission he was neurologically sound and p
hysically fit in mind
and body, but he suffered irreparable damage and injury rendering him decerebrat
e and totally
incapacitated. The injury was one which does not ordinarily occur in the process
of a mastoid operation or
in the absence of negligence in the administration of an anesthetic, and in the
use and employment of an
endoctracheal tube. Ordinarily a person being put under anesthesia is not render
ed decerebrate as a
consequence of administering such anesthesia in the absence of negligence. Upon
these facts and under
these circumstances a layman would be able to say, as a matter of common knowled
ge and observation,
that the consequences of professional treatment were not as such as would ordina
rily have followed if due
care had been exercised.
Here the plaintiff could not have been guilty of contributory negligence because
he was under the
influence of anesthetics and unconscious, and the circumstances are such that th
e true explanation of
event is more accessible to the defendants than to the plaintiff for they had th
e exclusive control of the
instrumentalities of anesthesia.
Upon all the facts, conditions and circumstances alleged in Count II it is held
that a cause of action is
stated under the doctrine of res ipsa loquitur. 44
Indeed, the principles enunciated in the aforequoted case apply with equal force
here. In the present case, Erlinda
submitted herself for cholecystectomy and expected a routine general surgery to
be performed on her gall bladder. On that
fateful day she delivered her person over to the care, custody and control of pr
ivate respondents who exercised complete

and exclusive control over her. At the time of submission, Erlinda was neurologi
cally sound and, except for a few minor
discomforts, was likewise physically fit in mind and body. However, during the a
dministration of anesthesia and prior to
the performance of cholecystectomy she suffered irreparable damage to her brain.
Thus, without undergoing surgery, she
went out of the operating room already decerebrate and totally incapacitated. Ob
viously, brain damage, which Erlinda
sustained, is an injury which does not normally occur in the process of a gall b
ladder operation. In fact, this kind of
situation does not in the absence of negligence of someone in the administration
of anesthesia and in the use of
endotracheal tube. Normally, a person being put under anesthesia is not rendered
decerebrate as a consequence of
administering such anesthesia if the proper procedure was followed. Furthermore,
the instruments used in the
administration of anesthesia, including the endotracheal tube, were all under th
e exclusive control of private respondents,
who are the physicians-in-charge. Likewise, petitioner Erlinda could not have be
en guilty of contributory negligence
because she was under the influence of anesthetics which rendered her unconsciou
s.
Considering that a sound and unaffected member of the body (the brain) is injure
d or destroyed while the patient is
unconscious and under the immediate and exclusive control of the physicians, we
hold that a practical administration of
justice dictates the application of res ipsa loquitur. Upon these facts and unde
r these circumstances the Court would be
able to say, as a matter of common knowledge and observation, if negligence atte
nded the management and care of the
patient. Moreover, the liability of the physicians and the hospital in this case
is not predicated upon an alleged failure to
secure the desired results of an operation nor on an alleged lack of skill in th
e diagnosis or treatment as in fact no
operation or treatment was ever performed on Erlinda. Thus, upon all these initi
al determination a case is made out for
the application of the doctrine of res ipsa loquitur.

Nonetheless, in holding that res ipsa loquitur is available to the present case
we are not saying that the doctrine is
applicable in any and all cases where injury occurs to a patient while under ane
sthesia, or to any and all anesthesia cases.
Each case must be viewed in its own light and scrutinized in order to be within
the res ipsa loquitur coverage.
Having in mind the applicability of the res ipsa loquitur doctrine and the presu
mption of negligence allowed therein, the
Court now comes to the issue of whether the Court of Appeals erred in finding th
at private respondents were not negligent
in the care of Erlinda during the anesthesia phase of the operation and, if in t
he affirmative, whether the alleged
negligence was the proximate cause of Erlinda s comatose condition. Corollary th
ereto, we shall also determine if the
Court of Appeals erred in relying on the testimonies of the witnesses for the pr
ivate respondents.
In sustaining the position of private respondents, the Court of Appeals relied o
n the testimonies of Dra. Gutierrez, Dra.
Calderon and Dr. Jamora. In giving weight to the testimony of Dra. Gutierrez, th
e Court of Appeals rationalized that she
was candid enough to admit that she experienced some difficulty in the endotrach
eal intubation 45 of the patient and thus,
cannot be said to be covering her negligence with falsehood. The appellate court
likewise opined that private respondents
were able to show that the brain damage sustained by Erlinda was not caused by t
he alleged faulty intubation but was due
to the allergic reaction of the patient to the drug Thiopental Sodium (Pentothal
), a short-acting barbiturate, as testified on
by their expert witness, Dr. Jamora. On the other hand, the appellate court reje
cted the testimony of Dean Herminda Cruz
offered in favor of petitioners that the cause of the brain injury was traceable
to the wrongful insertion of the tube since
the latter, being a nurse, was allegedly not knowledgeable in the process of int
ubation. In so holding, the appellate court
returned a verdict in favor of respondents physicians and hospital and absolved
them of any liability towards Erlinda and
her family.
We disagree with the findings of the Court of Appeals. We hold that private resp
ondents were unable to disprove the
presumption of negligence on their part in the care of Erlinda and their neglige
nce was the proximate cause of her piteous
condition.
In the instant case, the records are helpful in furnishing not only the logical
scientific evidence of the pathogenesis of the
injury but also in providing the Court the legal nexus upon which liability is b
ased. As will be shown hereinafter, private
respondents own testimonies which are reflected in the transcript of stenograph
ic notes are replete of signposts indicative
of their negligence in the care and management of Erlinda.
With regard to Dra. Gutierrez, we find her negligent in the care of Erlinda duri
ng the anesthesia phase. As borne by the
records, respondent Dra. Gutierrez failed to properly intubate the patient. This
fact was attested to by Prof. Herminda
Cruz, Dean of the Capitol Medical Center School of Nursing and petitioner s sist
er-in-law, who was in the operating room
right beside the patient when the tragic event occurred. Witness Cruz testified
to this effect:
ATTY. PAJARES:
Q: In particular, what did Dra. Perfecta Gutierrez do, if any on the patient?
A: In particular, I could see that she was intubating the patient.

Q: Do you know what happened to that intubation process administered by Dra.

Gutierrez?
ATTY. ALCERA:
She will be incompetent Your Honor.
COURT:
Witness may answer if she knows.
A: As have said, I was with the patient, I was beside the stretcher holding the
left hand of
the patient and all of a sudden heard some remarks coming from Dra. Perfecta Gut
ierrez
herself. She was saying "Ang hirap ma-intubate nito, mali yata ang pagkakapasok.
O
lumalaki ang tiyan.
xxx xxx xxx

ATTY. PAJARES:
Q: From whom did you hear those words "lumalaki ang tiyan"?
A: From Dra. Perfecta Gutierrez.
xxx xxx xxx
Q: After hearing the phrase "lumalaki ang tiyan," what did you notice on the per
son of the
patient?
A: I notice (sic) some bluish discoloration on the nailbeds of the left hand whe
re I was at.
Q: Where was Dr. Orlino Ho[s]aka then at that particular time?
A: I saw him approaching the patient during that time.
Q: When he approached the patient, what did he do, if any?
A: He made an order to call on the anesthesiologist in the person of Dr. Caldero
n.
Q: Did Dr. Calderon, upon being called, arrive inside the operating room?
A: Yes sir.
Q: What did [s]he do, if any?
A: [S]he tried to intubate the patient.
Q: What happened to the patient?
A: When Dr. Calderon try (sic) to intubate the patient, after a while the patien
t s nailbed
became bluish and I saw the patient was placed in trendelenburg position.
xxx xxx xxx
Q: Do you know the reason why the patient was placed in that trendelenburg posit
ion?
A: As far as I know, when a patient is in that position, there is a decrease of
blood supply
to the brain. 46
xxx xxx xxx
The appellate court, however, disbelieved Dean Cruz s testimony in the trial cou
rt by declaring that:
A perusal of the standard nursing curriculum in our country will show that intub
ation is not taught as part
of nursing procedures and techniques. Indeed, we take judicial notice of the fac
t that nurses do not, and
cannot, intubate. Even on the assumption that she is fully capable of determinin
g whether or not a patient
is properly intubated, witness Herminda Cruz, admittedly, did not peep into the
throat of the patient.
(TSN, July 25, 1991, p. 13). More importantly, there is no evidence that she eve
r auscultated the patient or
that she conducted any type of examination to check if the endotracheal tube was
in its proper place, and
to determine the condition of the heart, lungs, and other organs. Thus, witness
Cruz s categorical
statements that appellant Dra. Gutierrez failed to intubate the appellee Erlinda
Ramos and that it was
Dra. Calderon who succeeded in doing so clearly suffer from lack of sufficient f
actual bases. 47
In other words, what the Court of Appeals is trying to impress is that being a n
urse, and considered a layman in the
process of intubation, witness Cruz is not competent to testify on whether or no
t the intubation was a success.

We do not agree with the above reasoning of the appellate court. Although witnes
s Cruz is not an anesthesiologist, she can
very well testify upon matters on which she is capable of observing such as, the
statements and acts of the physician and
surgeon, external appearances, and manifest conditions which are observable by a
ny one. 48 This is precisely allowed
under the doctrine of res ipsa loquitur where the testimony of expert witnesses
is not required. It is the accepted rule that
expert testimony is not necessary for the proof of negligence in non-technical m
atters or those of which an ordinary
person may be expected to have knowledge, or where the lack of skill or want of
care is so obvious as to render expert
testimony unnecessary. 49 We take judicial notice of the fact that anesthesia pr
ocedures have become so common, that
even an ordinary person can tell if it was administered properly. As such, it wo
uld not be too difficult to tell if the tube was
properly inserted. This kind of observation, we believe, does not require a medi
cal degree to be acceptable.
At any rate, without doubt, petitioner s witness, an experienced clinical nurse
whose long experience and scholarship led
to her appointment as Dean of the Capitol Medical Center School at Nursing, was
fully capable of determining whether or
not the intubation was a success. She had extensive clinical experience starting
as a staff nurse in Chicago, Illinois; staff
nurse and clinical instructor in a teaching hospital, the FEU-NRMF; Dean of the
Laguna College of Nursing in San Pablo
City; and then Dean of the Capitol Medical Center School of Nursing. 50 Reviewin
g witness Cruz statements, we find that
the same were delivered in a straightforward manner, with the kind of detail, cl
arity, consistency and spontaneity which
would have been difficult to fabricate. With her clinical background as a nurse,
the Court is satisfied that she was able to
demonstrate through her testimony what truly transpired on that fateful day.
Most of all, her testimony was affirmed by no less than respondent Dra. Gutierre
z who admitted that she experienced
difficulty in inserting the tube into Erlinda s trachea, to wit:
ATTY. LIGSAY:
Q: In this particular case, Doctora, while you were intubating at your first att
empt (sic),
you did not immediately see the trachea?
DRA. GUTIERREZ:
A: Yes sir.
Q: Did you pull away the tube immediately?
A: You do not pull the . . .
Q: Did you or did you not?
A: I did not pull the tube.
Q: When you said "mahirap yata ito," what were you referring to?
A: "Mahirap yata itong i-intubate," that was the patient.
Q: So, you found some difficulty in inserting the tube?
A: Yes, because of (sic) my first attempt, I did not see right away. 51
Curiously in the case at bar, respondent Dra. Gutierrez made the haphazard defen
se that she encountered hardship in the
insertion of the tube in the trachea of Erlinda because it was positioned more a
nteriorly (slightly deviated from the normal
anatomy of a person) 52 making it harder to locate and, since Erlinda is obese a
nd has a short neck and protruding teeth, it
made intubation even more difficult.
The argument does not convince us. If this was indeed observed, private responde
nts adduced no evidence demonstrating
that they proceeded to make a thorough assessment of Erlinda s airway, prior to

the induction of anesthesia, even if this

would mean postponing the procedure. From their testimonies, it appears that the
observation was made only as an
afterthought, as a means of defense.
The pre-operative evaluation of a patient prior to the administration of anesthe
sia is universally observed to lessen the
possibility of anesthetic accidents. Pre-operative evaluation and preparation fo
r anesthesia begins when the

anesthesiologist reviews the patient s medical records and visits with the patie
nt, traditionally, the day before elective
surgery. 53 It includes taking the patient s medical history, review of current
drug therapy, physical examination and
interpretation of laboratory data. 54 The physical examination performed by the
anesthesiologist is directed primarily
toward the central nervous system, cardiovascular system, lungs and upper airway
. 55 A thorough analysis of the patient s
airway normally involves investigating the following: cervical spine mobility, t
emporomandibular mobility, prominent
central incisors, diseased or artificial teeth, ability to visualize uvula and t
he thyromental distance. 56 Thus, physical
characteristics of the patient s upper airway that could make tracheal intubatio
n difficult should be studied. 57 Where the
need arises, as when initial assessment indicates possible problems (such as the
alleged short neck and protruding teeth of
Erlinda) a thorough examination of the patient s airway would go a long way towa
rds decreasing patient morbidity and
mortality.
In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda for
the first time on the day of the operation
itself, on 17 June 1985. Before this date, no prior consultations with, or pre-o
perative evaluation of Erlinda was done by
her. Until the day of the operation, respondent Dra. Gutierrez was unaware of th
e physiological make-up and needs of
Erlinda. She was likewise not properly informed of the possible difficulties she
would face during the administration of
anesthesia to Erlinda. Respondent Dra. Gutierrez act of seeing her patient for
the first time only an hour before the
scheduled operative procedure was, therefore, an act of exceptional negligence a
nd professional irresponsibility. The
measures cautioning prudence and vigilance in dealing with human lives lie at th
e core of the physician s centuries-old
Hippocratic Oath. Her failure to follow this medical procedure is, therefore, a
clear indicia of her negligence.
Respondent Dra. Gutierrez, however, attempts to gloss over this omission by play
ing around with the trial court s
ignorance of clinical procedure, hoping that she could get away with it. Respond
ent Dra. Gutierrez tried to muddle the
difference between an elective surgery and an emergency surgery just so her fail
ure to perform the required pre-operative
evaluation would escape unnoticed. In her testimony she asserted:
ATTY. LIGSAY:
Q: Would you agree, Doctor, that it is good medical practice to see the patient
a day
before so you can introduce yourself to establish good doctor-patient relationsh
ip and
gain the trust and confidence of the patient?
DRA. GUTIERREZ:
A: As I said in my previous statement, it depends on the operative procedure of
the
anesthesiologist and in my case, with elective cases and normal cardio-pulmonary
clearance like that, I usually don t do it except on emergency and on cases that
have an
abnormalities (sic). 58
However, the exact opposite is true. In an emergency procedure, there is hardly
enough time available for the fastidious
demands of pre-operative procedure so that an anesthesiologist is able to see th
e patient only a few minutes before
surgery, if at all. Elective procedures, on the other hand, are operative proced

ures that can wait for days, weeks or even

months. Hence, in these cases, the anesthesiologist possesses the luxury of time
to be at the patient s beside to do a proper
interview and clinical evaluation. There is ample time to explain the method of
anesthesia, the drugs to be used, and their
possible hazards for purposes of informed consent. Usually, the pre-operative as
sessment is conducted at least one day
before the intended surgery, when the patient is relaxed and cooperative.
Erlinda s case was elective and this was known to respondent Dra. Gutierrez. Thu
s, she had all the time to make a
thorough evaluation of Erlinda s case prior to the operation and prepare her for
anesthesia. However, she never saw the
patient at the bedside. She herself admitted that she had seen petitioner only i
n the operating room, and only on the actual
date of the cholecystectomy. She negligently failed to take advantage of this im
portant opportunity. As such, her attempt
to exculpate herself must fail.
Having established that respondent Dra. Gutierrez failed to perform pre-operativ
e evaluation of the patient which, in turn,
resulted to a wrongful intubation, we now determine if the faulty intubation is
truly the proximate cause of Erlinda s
comatose condition.
Private respondents repeatedly hammered the view that the cerebral anoxia which
led to Erlinda s coma was due to
bronchospasm 59 mediated by her allergic response to the drug, Thiopental Sodium
, introduced into her system. Towards
this end, they presented Dr. Jamora, a Fellow of the Philippine College of Physi
cians and Diplomate of the Philippine
Specialty Board of Internal Medicine, who advanced private respondents theory t
hat the oxygen deprivation which led to

anoxic encephalopathy, 60 was due to an unpredictable drug reaction to the short

-acting barbiturate. We find the theory of
private respondents unacceptable.
First of all, Dr. Jamora cannot be considered an authority in the field of anest
hesiology simply because he is not an
anesthesiologist. Since Dr. Jamora is a pulmonologist, he could not have been ca
pable of properly enlightening the court
about anesthesia practice and procedure and their complications. Dr. Jamora is l
ikewise not an allergologist and could not
therefore properly advance expert opinion on allergic-mediated processes. Moreov
er, he is not a pharmacologist and, as
such, could not have been capable, as an expert would, of explaining to the cour
t the pharmacologic and toxic effects of the
supposed culprit, Thiopental Sodium (Pentothal).
The inappropriateness and absurdity of accepting Dr. Jamora s testimony as an ex
pert witness in the anesthetic practice of
Pentothal administration is further supported by his own admission that he formu
lated his opinions on the drug not from
the practical experience gained by a specialist or expert in the administration
and use of Sodium Pentothal on patients, but
only from reading certain references, to wit:
ATTY. LIGSAY:
Q: In your line of expertise on pulmonology, did you have any occasion to use pe
ntothal
as a method of management?
DR. JAMORA:
A: We do it in conjunction with the anesthesiologist when they have to intubate
our
patient.
Q: But not in particular when you practice pulmonology?
A: No.
Q: In other words, your knowledge about pentothal is based only on what you have
read
from books and not by your own personal application of the medicine pentothal?
A: Based on my personal experience also on pentothal.
Q: How many times have you used pentothal?
A: They used it on me. I went into bronchospasm during my appendectomy.
Q: And because they have used it on you and on account of your own personal expe
rience
you feel that you can testify on pentothal here with medical authority?
A: No. That is why I used references to support my claims. 61
An anesthetic accident caused by a rare drug-induced bronchospasm properly falls
within the fields of anesthesia, internal
medicine-allergy, and clinical pharmacology. The resulting anoxic encephalopathy
belongs to the field of neurology. While
admittedly, many bronchospastic-mediated pulmonary diseases are within the exper
tise of pulmonary medicine, Dr.
Jamora s field, the anesthetic drug-induced, allergic mediated bronchospasm alle
ged in this case is within the disciplines
of anesthesiology, allergology and pharmacology. On the basis of the foregoing t
ranscript, in which the pulmonologist
himself admitted that he could not testify about the drug with medical authority
, it is clear that the appellate court erred in
giving weight to Dr. Jamora s testimony as an expert in the administration of Th
iopental Sodium.
The provision in the rules of evidence 62 regarding expert witnesses states:
Sec. 49. Opinion of expert witness. The opinion of a witness on a matter requiri
ng special knowledge,
skill, experience or training which he is shown to possess, may be received in e
vidence.

Generally, to qualify as an expert witness, one must have acquired special knowl
edge of the subject matter about which he
or she is to testify, either by the study of recognized authorities on the subje
ct or by practical experience. 63 Clearly, Dr.
Jamora does not qualify as an expert witness based on the above standard since h
e lacks the necessary knowledge, skill,

and training in the field of anesthesiology. Oddly, apart from submitting testim
ony from a specialist in the wrong field,
private respondents intentionally avoided providing testimony by competent and
independent experts in the proper
areas.
Moreover, private respondents theory, that Thiopental Sodium may have produced
Erlinda s coma by triggering an
allergic mediated response, has no support in evidence. No evidence of stridor,
skin reactions, or wheezing some of the
more common accompanying signs of an allergic reaction appears on record. No lab
oratory data were ever presented to
the court.
In any case, private respondents themselves admit that Thiopental induced, aller
gic-mediated bronchospasm happens
only very rarely. If courts were to accept private respondents hypothesis witho
ut supporting medical proof, and against
the weight of available evidence, then every anesthetic accident would be an act
of God. Evidently, the Thiopental-allergy
theory vigorously asserted by private respondents was a mere afterthought. Such
an explanation was advanced in order to
advanced in order to absolve them of any and all responsibility for the patient
s condition.
In view of the evidence at hand, we are inclined to believe petitioners stand t
hat it was the faulty intubation which was the
proximate cause of Erlinda s comatose condition.
Proximate cause has been defined as that which, in natural and continuous sequen
ce, unbroken by any efficient
intervening cause, produces injury, and without which the result would not have
occurred. 64 An injury or damage is
proximately caused by an act or a failure to act, whenever it appears from the e
vidence in the case, that the act or omission
played a substantial part in bringing about or actually causing the injury or da
mage; and that the injury or damage was
either a direct result or a reasonably probable consequence of the act or omissi
on. 65 It is the dominant, moving or
producing cause.
Applying the above definition in relation to the evidence at hand, faulty intuba
tion is undeniably the proximate cause
which triggered the chain of events leading to Erlinda s brain damage and, ultim
ately, her comatosed condition.
Private respondents themselves admitted in their testimony that the first intuba
tion was a failure. This fact was likewise
observed by witness Cruz when she heard respondent Dra. Gutierrez remarked, "Ang
hirap ma-intubate nito, mali yata
ang pagkakapasok. O lumalaki ang tiyan." Thereafter, witness Cruz noticed abdomi
nal distention on the body of Erlinda.
The development of abdominal distention, together with respiratory embarrassment
indicates that the endotracheal tube
entered the esophagus instead of the respiratory tree. In other words, instead o
f the intended endotracheal intubation
what actually took place was an esophageal intubation. During intubation, such d
istention indicates that air has entered
the gastrointestinal tract through the esophagus instead of the lungs through th
e trachea. Entry into the esophagus would
certainly cause some delay in oxygen delivery into the lungs as the tube which c
arries oxygen is in the wrong place. That
abdominal distention had been observed during the first intubation suggests that
the length of time utilized in inserting
the endotracheal tube (up to the time the tube was withdrawn for the second atte
mpt) was fairly significant. Due to the

delay in the delivery of oxygen in her lungs Erlinda showed signs of cyanosis. 6
6 As stated in the testimony of Dr. Hosaka,
the lack of oxygen became apparent only after he noticed that the nailbeds of Er
linda were already blue. 67 However,
private respondents contend that a second intubation was executed on Erlinda and
this one was successfully done. We do
not think so. No evidence exists on record, beyond private respondents bare cla
ims, which supports the contention that
the second intubation was successful. Assuming that the endotracheal tube finall
y found its way into the proper orifice of
the trachea, the same gave no guarantee of oxygen delivery, the hallmark of a su
ccessful intubation. In fact, cyanosis was
again observed immediately after the second intubation. Proceeding from this eve
nt (cyanosis), it could not be claimed, as
private respondents insist, that the second intubation was accomplished. Even gr
anting that the tube was successfully
inserted during the second attempt, it was obviously too late. As aptly explaine
d by the trial court, Erlinda already suffered
brain damage as a result of the inadequate oxygenation of her brain for about fo
ur to five minutes. 68
The above conclusion is not without basis. Scientific studies point out that int
ubation problems are responsible for onethird (1/3) of deaths and serious injuri
es associated with anesthesia. 69 Nevertheless, ninety-eight percent (98%) or th
e
vast majority of difficult intubations may be anticipated by performing a thorou
gh evaluation of the patient s airway prior
to the operation. 70 As stated beforehand, respondent Dra. Gutierrez failed to o
bserve the proper pre-operative protocol
which could have prevented this unfortunate incident. Had appropriate diligence
and reasonable care been used in the
pre-operative evaluation, respondent physician could have been much more prepare
d to meet the contingency brought
about by the perceived anatomic variations in the patient s neck and oral area,
defects which would have been easily
overcome by a prior knowledge of those variations together with a change in tech
nique. 71 In other words, an experienced
anesthesiologist, adequately alerted by a thorough pre-operative evaluation, wou
ld have had little difficulty going around
the short neck and protruding teeth. 72 Having failed to observe common medical
standards in pre-operative management
and intubation, respondent Dra. Gutierrez negligence resulted in cerebral anoxi
a and eventual coma of Erlinda.

We now determine the responsibility of respondent Dr. Orlino Hosaka as the head
of the surgical team. As the so-called
"captain of the ship," 73 it is the surgeon s responsibility to see to it that t
hose under him perform their task in the proper
manner. Respondent Dr. Hosaka s negligence can be found in his failure to exerci
se the proper authority (as the "captain"
of the operative team) in not determining if his anesthesiologist observed prope
r anesthesia protocols. In fact, no evidence
on record exists to show that respondent Dr. Hosaka verified if respondent Dra.
Gutierrez properly intubated the patient.
Furthermore, it does not escape us that respondent Dr. Hosaka had scheduled anot
her procedure in a different hospital at
the same time as Erlinda s cholecystectomy, and was in fact over three hours lat
e for the latter s operation. Because of this,
he had little or no time to confer with his anesthesiologist regarding the anest
hesia delivery. This indicates that he was
remiss in his professional duties towards his patient. Thus, he shares equal res
ponsibility for the events which resulted in
Erlinda s condition.
We now discuss the responsibility of the hospital in this particular incident. T
he unique practice (among private hospitals)
of filling up specialist staff with attending and visiting "consultants," 74 who
are allegedly not hospital employees, presents
problems in apportioning responsibility for negligence in medical malpractice ca
ses. However, the difficulty is only more
apparent than real.
In the first place, hospitals exercise significant control in the hiring and fir
ing of consultants and in the conduct of their
work within the hospital premises. Doctors who apply for "consultant" slots, vis
iting or attending, are required to submit
proof of completion of residency, their educational qualifications; generally, e
vidence of accreditation by the appropriate
board (diplomate), evidence of fellowship in most cases, and references. These r
equirements are carefully scrutinized by
members of the hospital administration or by a review committee set up by the ho
spital who either accept or reject the
application. 75 This is particularly true with respondent hospital.
After a physician is accepted, either as a visiting or attending consultant, he
is normally required to attend clinicopathological conferences, conduct bedside
rounds for clerks, interns and residents, moderate grand rounds and patient
audits and perform other tasks and responsibilities, for the privilege of being
able to maintain a clinic in the hospital,
and/or for the privilege of admitting patients into the hospital. In addition to
these, the physician s performance as a
specialist is generally evaluated by a peer review committee on the basis of mor
tality and morbidity statistics, and
feedback from patients, nurses, interns and residents. A consultant remiss in hi
s duties, or a consultant who regularly falls
short of the minimum standards acceptable to the hospital or its peer review com
mittee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control over the
ir attending and visiting "consultant" staff.
While "consultants" are not, technically employees, a point which respondent hos
pital 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 paymen
t of wages. In assessing whether such a
relationship in fact exists, the control test is determining. Accordingly, on th
e basis of the foregoing, we rule that for the

purpose of allocating responsibility in medical negligence cases, an employer-em

ployee relationship in effect exists
between hospitals and their attending and visiting physicians. This being the ca
se, the question now arises as to whether
or not respondent hospital is solidarily liable with respondent doctors for peti
tioner s condition. 76
The basis for holding an employer solidarily responsible for the negligence of i
ts employee is found in Article 2180 of the
Civil Code which considers a person accountable not only for his own acts but al
so for those of others based on the
former s responsibility under a relationship of patria potestas. 77 Such respons
ibility ceases when the persons or entity
concerned prove that they have observed the diligence of a good father of the fa
mily to prevent damage. 78 In other words,
while the burden of proving negligence rests on the plaintiffs, once negligence
is shown, the burden shifts to the
respondents (parent, guardian, teacher or employer) who should prove that they o
bserved the diligence of a good father of
a family to prevent damage.
In the instant case, respondent hospital, apart from a general denial of its res
ponsibility over respondent physicians, failed
to adduce evidence showing that it exercised the diligence of a good father of a
family in the hiring and supervision of the
latter. It failed to adduce evidence with regard to the degree of supervision wh
ich it exercised over its physicians. In
neglecting to offer such proof, or proof of a similar nature, respondent hospita
l thereby failed to discharge its burden
under the last paragraph of Article 2180. Having failed to do this, respondent h
ospital is consequently solidarily
responsible with its physicians for Erlinda s condition.
Based on the foregoing, we hold that the Court of Appeals erred in accepting and
relying on the testimonies of the
witnesses for the private respondents. Indeed, as shown by the above discussions
, private respondents were unable to
rebut the presumption of negligence. Upon these disquisitions we hold that priva
te respondents are solidarily liable for
damages under Article 2176 79 of the Civil Code.

We now come to the amount of damages due petitioners. The trial court awarded a
total of P632,000.00 pesos (should be
P616,000.00) in compensatory damages to the plaintiff, "subject to its being upd
ated" covering the period from 15
November 1985 up to 15 April 1992, based on monthly expenses for the care of the
patient estimated at P8,000.00.
At current levels, the P8000/monthly amount established by the trial court at th
e time of its decision would be grossly
inadequate to cover the actual costs of home-based care for a comatose individua
l. The calculated amount was not even
arrived at by looking at the actual cost of proper hospice care for the patient.
What it reflected were the actual expenses
incurred and proved by the petitioners after they were forced to bring home the
patient to avoid mounting hospital bills.
And yet ideally, a comatose patient should remain in a hospital or be transferre
d to a hospice specializing in the care of the
chronically ill for the purpose of providing a proper milieu adequate to meet mi
nimum standards of care. In the instant
case for instance, Erlinda has to be constantly turned from side to side to prev
ent bedsores and hypostatic pneumonia.
Feeding is done by nasogastric tube. Food preparation should be normally made by
a dietitian to provide her with the
correct daily caloric requirements and vitamin supplements. Furthermore, she has
to be seen on a regular basis by a
physical therapist to avoid muscle atrophy, and by a pulmonary therapist to prev
ent the accumulation of secretions which
can lead to respiratory complications.
Given these considerations, the amount of actual damages recoverable in suits ar
ising from negligence should at least
reflect the correct minimum cost of proper care, not the cost of the care the fa
mily is usually compelled to undertake at
home to avoid bankruptcy. However, the provisions of the Civil Code on actual or
compensatory damages present us with
some difficulties.
Well-settled is the rule that actual damages which may be claimed by the plainti
ff are those suffered by him as he has duly
proved. The Civil Code provides:
Art. 2199. Except as provided by law or by stipulation, one is entitled to an ad
equate compensation only
for such pecuniary loss suffered by him as he has duly proved. Such compensation
is referred to as actual
or compensatory damages.
Our rules on actual or compensatory damages generally assume that at the time of
litigation, the injury suffered as a
consequence of an act of negligence has been completed and that the cost can be
liquidated. However, these provisions
neglect to take into account those situations, as in this case, where the result
ing injury might be continuing and possible
future complications directly arising from the injury, while certain to occur, a
re difficult to predict.
In these cases, the amount of damages which should be awarded, if they are to ad
equately and correctly respond to the
injury caused, should be one which compensates for pecuniary loss incurred and p
roved, up to the time of trial; and one
which would meet pecuniary loss certain to be suffered but which could not, from
the nature of the case, be made with
certainty. 80 In other words, temperate damages can and should be awarded on top
of actual or compensatory damages in
instances where the injury is chronic and continuing. And because of the unique
nature of such cases, no incompatibility

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

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

As a result of the accident, Ma. Lourdes Valenzuela underwent a traumatic amputa
tion of her left lower
extremity at the distal left thigh just above the knee. Because of this, Valenzu
ela will forever be deprived of
the full ambulatory functions of her left extremity, even with the use of state
of the art prosthetic
technology. Well beyond the period of hospitalization (which was paid for by Li)
, she will be required to
undergo adjustments in her prosthetic devise due to the shrinkage of the stump f
rom the process of
healing.
These adjustments entail costs, prosthetic replacements and months of physical a
nd occupational
rehabilitation and therapy. During the lifetime, the prosthetic devise will have
to be replaced and
readjusted to changes in the size of her lower limb effected by the biological c
hanges of middle-age,
menopause and aging. Assuming she reaches menopause, for example, the prosthetic
will have to be
adjusted to respond to the changes in bone resulting from a precipitate decrease
in calcium levels
observed in the bones of all post-menopausal women. In other words, the damage d
one to her would not
only be permanent and lasting, it would also be permanently changing and adjusti
ng to the physiologic
changes which her body would normally undergo through the years. The replacement
s, changes, and
adjustments will require corresponding adjustive physical and occupational thera
py. All of these
adjustments, it has been documented, are painful.
xxx xxx xxx
A prosthetic devise, however technologically advanced, will only allow a reasona
ble amount of functional
restoration of the motor functions of the lower limb. The sensory functions are
forever lost. The resultant
anxiety, sleeplessness, psychological injury, mental and physical pain are inest
imable. 83
The injury suffered by Erlinda as a consequence of private respondents negligen
ce is certainly much more serious than
the amputation in the Valenzuela case.
Petitioner Erlinda Ramos was in her mid-forties when the incident occurred. She
has been in a comatose state for over
fourteen years now. The burden of care has so far been heroically shouldered by
her husband and children, who, in the
intervening years have been deprived of the love of a wife and a mother.
Meanwhile, the actual physical, emotional and financial cost of the care of peti
tioner would be virtually impossible to
quantify. Even the temperate damages herein awarded would be inadequate if petit
ioner s condition remains unchanged
for the next ten years.
We recognized, in Valenzuela that a discussion of the victim s actual injury wou
ld not even scratch the surface of the
resulting moral damage because it would be highly speculative to estimate the am
ount of emotional and moral pain,
psychological damage and injury suffered by the victim or those actually affecte
d by the victim s condition. 84 The husband
and the children, all petitioners in this case, will have to live with the day t
o day uncertainty of the patient s illness,
knowing any hope of recovery is close to nil. They have fashioned their daily li

ves around the nursing care of petitioner,

altering their long term goals to take into account their life with a comatose p
atient. They, not the respondents, are
charged with the moral responsibility of the care of the victim. The family s mo
ral injury and suffering in this case is
clearly a real one. For the foregoing reasons, an award of P2,000,000.00 in mora
l damages would be appropriate.
Finally, by way of example, exemplary damages in the amount of P100,000.00 are h
ereby awarded. Considering the
length and nature of the instant suit we are of the opinion that attorney s fees
valued at P100,000.00 are likewise proper.
Our courts face unique difficulty in adjudicating medical negligence cases becau
se physicians are not insurers of life and,
they rarely set out to intentionally cause injury or death to their patients. Ho
wever, intent is immaterial in negligence
cases because where negligence exists and is proven, the same automatically give
s the injured a right to reparation for the
damage caused.
Established medical procedures and practices, though in constant flux are devise
d for the purpose of preventing
complications. A physician s experience with his patients would sometimes tempt
him to deviate from established
community practices, and he may end a distinguished career using unorthodox meth
ods without incident. However, when
failure to follow established procedure results in the evil precisely sought to
be averted by observance of the procedure and
a nexus is made between the deviation and the injury or damage, the physician wo
uld necessarily be called to account for

it. In the case at bar, the failure to observe pre-operative assessment protocol
which would have influenced the intubation
in a salutary way was fatal to private respondents case.
WHEREFORE, the decision and resolution of the appellate court appealed from are
hereby modified so as to award in
favor of petitioners, and solidarily against private respondents the following:
1) P1,352,000.00 as actual damages
computed as of the date of promulgation of this decision plus a monthly payment
of P8,000.00 up to the time that
petitioner Erlinda Ramos expires or miraculously survives; 2) P2,000,000.00 as m
oral damages, 3) P1,500,000.00 as
temperate damages; 4) P100,000.00 each as exemplary damages and attorney s fees;
and, 5) the costs of the suit.
SO ORDERED.
Davide, Jr., C.J., Puno, Pardo and Ynares-Santiago, JJ., concur.
Republic of the Philippines
Supreme Court
Manila
THIRD DIVISION
DR. EMMANUEL JARCIA, JR. and DR.
MARILOU BASTAN,
G.R. No. 187926
Petitioners,
Present:
CARPIO,* J.,
PERALTA,** Acting Chairperson,
ABAD,
- versus PEREZ,*** and
MENDOZA, JJ.

Promulgated:
PEOPLE OF THE PHILIPPINES,
Respondent.
February 15, 2012
x -------------------------------------------------------------------------------------- x
DECISION
MENDOZA, J.:
Even early on, patients have consigned their lives to the skill of their doctors
. Time and again, it
can be said that the most important goal of the medical profession is the preser
vation of life and health
of the people. Corollarily, when a physician departs from his sacred duty and en
dangers instead the life
of his patient, he must be made liable for the resulting injury. This Court, as
this case would show,
cannot and will not let the act go unpunished.158[1]
This is a petition for review under Rule 45 of the Rules of Court challenging th
e August 29, 2008 Decision159[2]
of the Court of Appeals (CA), and its May 19, 2009 Resolution160[3] in CA-G.R. C
R No. 29559, dismissing the appeal and
affirming in toto the June 14, 2005 Decision161[4] of the Regional Trial Court,
Branch 43, Manila (RTC), finding the
accused guilty beyond reasonable doubt of simple imprudence resulting to serious
physical injuries.

THE FACTS
Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of
Investigation (NBI) against the
petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou Bastan (Dr. B
astan), for their alleged neglect of
professional duty which caused her son, Roy Alfonso Santiago (Roy Jr.), to suffe
r serious physical injuries. Upon
investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was rush
ed to the Manila Doctors Hospital for an
emergency medical treatment; that an X-ray of the victims ankle was ordered; tha
t the X-ray result showed no fracture as
read by Dr. Jarcia; that Dr. Bastan entered the emergency room (ER) and, after c
onducting her own examination of the
victim, informed Mrs. Santiago that since it was only the ankle that was hit, th
ere was no need to examine the upper leg;
that eleven (11) days later, Roy Jr. developed fever, swelling of the right leg
and misalignment of the right foot; that Mrs.
Santiago brought him back to the hospital; and that the X-ray revealed a right m
id-tibial fracture and a linear hairline
fracture in the shaft of the bone.
The NBI indorsed the matter to the Office of the City Prosecutor of Manila for p
reliminary investigation. Probable
cause was found and a criminal case for reckless imprudence resulting to serious
physical injuries, was filed against Dr.
Jarcia, Dr. Bastan and Dr. Pamittan,162[5] before the RTC, docketed as Criminal
Case No. 01-196646.
On June 14, 2005, the RTC found the petitioners guilty beyond reasonable doubt o
f the crime of Simple Imprudence
Resulting to Serious Physical Injuries. The decretal portion of the RTC decision
reads:
WHEREFORE, premises considered, the Court finds accused DR. EMMANUEL JARCIA, JR.
and DR.
MARILOU BASTAN GUILTY beyond reasonable doubt of the crime of SIMPLE IMPRUDENCE
RESULTING TO SERIOUS PHYSICAL INJURIES and are hereby sentenced to suffer the pe
nalty of ONE (1)
MONTH and ONE (1) DAY to TWO (2) MONTHS and to indemnify MRS. BELINDA SANTIAGO t
he
amount of 3,850.00 representing medical expenses without subsidiary imprisonment
in case of insolvency
and to pay the costs.
It appearing that Dr. Pamittan has not been apprehended nor voluntarily surrende
red despite warrant issued
for her arrest, let warrant be issued for her arrest and the case against her be
ARCHIVED, to be reinstated
upon her apprehension.
SO ORDERED.163[6]

The RTC explained:

After a thorough and in depth evaluation of the evidence adduced by the prosecut
ion and the
defense, this court finds that the evidence of the prosecution is the more credi
ble, concrete and sufficient
to create that moral certainty in the mind of the Court that accused herein [are
] criminally responsible.
The Court believes that accused are negligent when both failed to exercise the n
ecessary and reasonable
prudence in ascertaining the extent of injury of Alfonso Santiago, Jr.
However, the negligence exhibited by the two
ence of a
reckless nature but merely amounts to simple
sts in the lack of
precaution displayed in those cases in which
s not the immediate nor
the danger clearly manifest. The elements of

doctors does not approximate neglig

imprudence. Simple imprudence consi
the damage impending to be caused i
simple imprudence are as follows.

1.
2.
that there is lack of precaution on the part of the offender; and
that the damage impending to be caused is not immediate of the danger is not
clearly manifest.
Considering all the evidence on record, The Court finds the accused guilty for s
imple imprudence
resulting to physical injuries. Under Article 365 of the Revised Penal Code, the
penalty provided for is
arresto mayor in its minimum period.164[7]
Dissatisfied, the petitioners appealed to the CA.
As earlier stated, the CA affirmed the RTC decision in toto. The August 29, 2008
Decision of the CA pertinently reads:
This Court holds concurrently and finds the foregoing circumstances sufficient t
o sustain a
judgment of conviction against the accused-appellants for the crime of simple im
prudence resulting in
serious physical injuries. The elements of imprudence are: (1) that the offender
does or fails to do an act;
(2) that the doing or the failure to do that act is voluntary; (3) that it be wi
thout malice; (4) that material
damage results from the imprudence; and (5) that there is inexcusable lack of pr
ecaution on the part of
the offender, taking into consideration his employment or occupation, degree of
intelligence, physical
condition, and other circumstances regarding persons, time and place.
Whether or not Dr. Jarcia and Dr. Bastan had committed an inexcusable lack of pr
ecaution in the
treatment of their patient is to be determined according to the standard of care
observed by other
members of the profession in good standing under similar circumstances, bearing
in mind the advanced

state of the profession at the time of treatment or the present state of medical
science. In the case of
Leonila Garcia-Rueda v. Pascasio, the Supreme Court stated that, in accepting a
case, a doctor in effect
represents that, having the needed training and skill possessed by physicians an
d surgeons practicing in
the same field, he will employ such training, care and skill in the treatment of
his patients. He therefore
has a duty to use at least the same level of care that any other reasonably comp
etent doctor would use to
treat a condition under the same circumstances.
In litigations involving medical negligence, the plaintiff has the burden of est
ablishing accusedappellants negligence, and for a reasonable conclusion of negli
gence, there must be proof of breach of
duty on the part of the physician as well as a causal connection of such breach
and the resulting injury of
his patient. The connection between the negligence and the injury must be a dire
ct and natural sequence
of events, unbroken by intervening efficient causes. In other words, the neglige
nce must be the proximate
cause of the injury. Negligence, no matter in what it consists, cannot create a
right of action unless it is the
proximate cause of the injury complained of. The proximate cause of an injury is
that cause which, in
natural and continuous sequence, unbroken by any efficient intervening cause, pr
oduces the injury and
without which the result would not have occurred.
In the case at bench, the accused-appellants questioned the imputation against t
hem and argued
that there is no causal connection between their failure to diagnose the fractur
e and the injury sustained
by Roy.
We are not convinced.
The prosecution is however after the cause which prolonged the pain and sufferin
g of Roy and not
on the failure of the accused-appellants to correctly diagnose the extent of the
injury sustained by Roy.
For a more logical presentation of the discussion, we shall first consider the a
pplicability of the
doctrine of res ipsa loquitur to the instant case. Res ipsa loquitur is a Latin
phrase which literally means
the thing or the transaction speaks for itself. The doctrine of res ipsa loquitu
r is simply a recognition of
the postulate that, as a matter of common knowledge and experience, the very nat
ure of certain types of
occurrences may justify an inference of negligence on the part of the person who
controls the
instrumentality causing the injury in the absence of some explanation by the acc
used-appellant who is
charged with negligence. It is grounded in the superior logic of ordinary human
experience and, on the
basis of such experience or common knowledge, negligence may be deduced from the
mere occurrence of
the accident itself. Hence, res ipsa loquitur is applied in conjunction with the
doctrine of common

knowledge.
The specific acts of negligence was narrated by Mrs. Santiago who accompanied he
r son during
the latters ordeal at the hospital. She testified as follows:
Fiscal Formoso:

Q:
Now, he is an intern did you not consult the doctors, Dr. Jarcia or Dra. Pamitta
n
to confirm whether you should go home or not?
A:
Dra. Pamittan was inside the cubicle of the nurses and I asked her, you let us g
o
home and you dont even clean the wounds of my son.
Q:
And what did she [tell] you?
A:
They told me they will call a resident doctor, sir.
xxx
xxx
xxx
Q:
Was there a resident doctor [who] came?
A:
Yes, Sir. Dra. Bastan arrived.
Q:
Did you tell her what you want on you to be done?
A:
Yes, sir.
Q:
What did you [tell] her?
A:
I told her, sir, while she was cleaning the wounds of my son, are you not going
to
x-ray up to the knee because my son was complaining pain from his ankle up to
the middle part of the right leg.
Q:
And what did she tell you?
A:
According to Dra. Bastan, there is no need to x-ray because it was the ankle par

t
that was run over.
Q:
What did you do or tell her?
A:
I told her, sir, why is it that they did not examine[x] the whole leg. They just
lifted
the pants of my son.
Q:
So you mean to say there was no treatment made at all?
A:
None, sir.
xxx
A:
xxx
xxx
I just listened to them, sir. And I just asked if I will still return my son.

xxx
xxx
xxx
Q:
And you were present when they were called?
A:
Yes, sir.
Q:
And what was discussed then by Sis. Retoria?
A:
When they were there they admitted that they have mistakes, sir.
Still, before resort to the doctrine may be allowed, the following requisites mu
st be satisfactorily shown:
1.
The accident is of a kind which ordinarily does not occur in the absence of some
ones
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 respon
sible is
eliminated.
In the above requisites, the fundamental element is the control of the instrumen
tality which
caused the damage. Such element of control must be shown to be within the domini
on of the accusedappellants. In order to have the benefit of the rule, a plainti
ff, in addition to proving injury or damage,
must show a situation where it is applicable and must establish that the essenti
al elements of the doctrine
were present in a particular incident. The early treatment of the leg of Roy wou
ld have lessen his suffering
if not entirely relieve him from the fracture. A boy of tender age whose leg was
hit by a vehicle would
engender a well-founded belief that his condition may worsen without proper medi
cal attention. As junior
residents who only practice general surgery and without specialization with the
case consulted before
them, they should have referred the matter to a specialist. This omission alone
constitutes simple
imprudence on their part. When Mrs. Santiago insisted on having another x-ray of
her child on the upper

part of his leg, they refused to do so. The mother would not have asked them if
they had no exclusive
control or prerogative to request an x-ray test. Such is a fact because a radiol
ogist would only conduct the
x-ray test upon request of a physician.
The testimony of Mrs. Santiago was corroborated by a bone specialist Dr. Tacata.
He further
testified based on his personal knowledge, and not as an expert, as he examined
himself the child Roy. He
testified as follows:

Fiscal Macapagal:
Q:
And was that the correct respon[se] to the medical problem that was presented to
Dr. Jarcia and Dra. Bastan?
A:
I would say at that stage, yes. Because they have presented the patient and the
history. At sabi nila, nadaanan lang po ito. And then, considering their year of
residency they are still junior residents, and they are not also orthopedic
residents but general surgery residents, its entirely different thing. Because i
f you
are an orthopedic resident, I am not trying to saybut if I were an orthopedic
resident, there would be more precise and accurate decision compare to a general
surgery resident in so far as involved.
Q:
You mean to say there is no supervisor attending the emergency room?
A:
At the emergency room, at the Manila Doctors Hospital, the supervisor there is a
consultant that usually comes from a family medicine. They see where a certain
patient have to go and then if they cannot manage it, they refer it to the
consultant on duty. Now at that time, I dont [know] why they dont.Because at
that time, I think, it is the decision. Since the x-rays.
Ordinarily, only physicians and surgeons of skill and experience are competent t
o testify as to
whether a patient has been treated or operated upon with a reasonable degree of
skill and care. However,
testimony as to the statements and acts of physicians, external appearances, and
manifest conditions
which are observable by any one may be given by non-expert witnesses. Hence, in
cases where the res ipsa
loquitur is applicable, the court is permitted to find a physician negligent upo
n proper proof of injury to
the patient, without the aid of expert testimony, where the court from its fund
of common knowledge can
determine the proper standard of care. Where common knowledge and experience tea
ch that a resulting
injury would not have occurred to the patient if due care had been exercised, an
inference of negligence
may be drawn giving rise to an application of the doctrine of res ipsa loquitur
without medical evidence,
which is ordinarily required to show not only what occurred but how and why it o
ccurred. In the case at
bench, we give credence to the testimony of Mrs. Santiago by applying the doctri
ne of res ipsa loquitur.
Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used b
ut a rule to be
cautiously applied, depending upon the circumstances of each case. It is general
ly restricted to situations
in malpractice cases where a layman is able to say, as a matter of common knowle
dge and observation,
that the consequences of professional care were not as such as would ordinarily

have followed if due care

had been exercised. A distinction must be made between the failure to secure res
ults and the occurrence
of something more unusual and not ordinarily found if the service or treatment r
endered followed the
usual procedure of those skilled in that particular practice. The latter circums
tance is the primordial issue
that confronted this Court and we find application of the doctrine of res ipsa l
oquitur to be in order.
WHEREFORE, in view of the foregoing, the appeal in this case is hereby DISMISSED
and the
assailed decision of the trial court finding accused-appellants guilty beyond re
asonable doubt of simple
imprudence resulting in serious physical injuries is hereby AFFIRMED in toto.

SO ORDERED.165[8]
The petitioners filed a motion for reconsideration, but it was denied by the CA
in its May 19, 2009 Resolution.
Hence, this petition.
The petitioners pray for the reversal of the decision of both the RTC and the CA
anchored on the following
GROUNDS1. IN AFFIRMING ACCUSED-PETITIONERS CONVICTION, THE COURT OF APPEALS
ERRED IN NOT HOLDING THAT THE ACTUAL, DIRECT, IMMEDIATE, AND PROXIMATE
CAUSE OF THE PHYSICAL INJURY OF THE PATIENT (FRACTURE OF THE LEG BONE OR
TIBIA), WHICH REQUIRED MEDICAL ATTENDANCE FOR MORE THAN THIRTY (30) DAYS
AND INCAPACITATED HIM FROM PERFORMING HIS CUSTOMARY DUTY DURING THE
SAME PERIOD OF TIME, WAS THE VEHICULAR ACCIDENT WHERE THE PATIENTS RIGHT
LEG WAS HIT BY A TAXI, NOT THE FAILURE OF THE ACCUSED-PETITIONERS TO SUBJECT
THE PATIENTS WHOLE LEG TO AN X-RAY EXAMINATION.
2. THE COURT OF APPEALS ERRED IN DISREGARDING ESTABLISHED FACTS CLEARLY
NEGATING PETITIONERS ALLEGED NEGLIGENCE OR IMPRUDENCE. SIGNIFICANTLY,
THE COURT OF APPEALS UNJUSTIFIABLY DISREGARDED THE OPINION OF THE
PROSECUTIONS EXPERT WITNESS, DR. CIRILO TACATA, THAT PETITIONERS WERE NOT
GUILTY OF NEGLIGENCE OR IMPRUDENCE COMPLAINED OF.
3. THE COURT OF APPEALS ERRED IN HOLDING THAT THE FAILURE OF PETITIONERS
TO SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY EXAMINATION PROLONGED THE
PAIN AND SUFFERING OF THE PATIENT, SUCH CONCLUSION BEING UNSUPPORTED BY,
AND EVEN CONTRARY TO, THE EVIDENCE ON RECORD.
4. ASSUMING ARGUENDO THAT THE PATIENT EXPERIENCED PROLONGED PAIN AND
SUFFERING, THE COURT OF APPEALS ERRED IN NOT HOLDING THAT THE ALLEGED
PAIN AND SUFFERING WERE DUE TO THE UNJUSTIFIED FAILURE OF THE PATIENTS
MOTHER, A NURSE HERSELF, TO IMMEDIATELY BRING THE PATIENT BACK TO THE
HOSPITAL, AS ADVISED BY THE PETITIONERS, AFTER HE COMPLAINED OF SEVERE PAIN
IN HIS RIGHT LEG WHEN HE REACHED HOME AFTER HE WAS SEEN BY PETITIONERS AT
THE HOSPITAL. THUS, THE PATIENTS ALLEGED INJURY (PROLONGED PAIN AND
SUFFERING) WAS DUE TO HIS OWN MOTHERS ACT OR OMISSION.
5. THE COURT OF APPEALS ERRED IN NOT HOLDING THAT NO PHYSICIAN-PATIENT
RELATIONSHIP EXISTED BETWEEN PETITIONERS AND PATIENT ALFONSO SANTIAGO,

JR., PETITIONERS NOT BEING THE LATTERS ATTENDING PHYSICIAN AS THEY WERE
MERELY REQUESTED BY THE EMERGENCY ROOM (ER) NURSE TO SEE THE PATIENT
WHILE THEY WERE PASSING BY THE ER FOR THEIR LUNCH.
6. THE COURT OF APPEALS GRAVELY ERRED IN NOT ACQUITTING ACCUSEDPETITIONERS OF TH
E CRIME CHARGED.166[9]
The foregoing can be synthesized into two basic issues: [1] whether or not the d
octrine of res ipsa loquitur is
applicable in this case; and [2] whether or not the petitioners are liable for c
riminal negligence.
THE COURTS RULING
The CA is correct in finding that there was negligence on the part of the petiti
oners. After a perusal of the records,
however, the Court is not convinced that the petitioners are guilty of criminal
negligence complained of. The Court is also
of the view that the CA erred in applying the doctrine of res ipsa loquitur in t
his particular case.
As to the Application of
The Doctrine of Res Ipsa Loquitur
This doctrine of res ipsa loquitur means "Where the thing which causes injury is
shown to be under the
management of the defendant, and the accident is such as in the ordinary course
of things does not happen if those who
have the management use proper care, it affords reasonable evidence, in the abse
nce of an explanation by the defendant,
that the accident arose from want of care." The Black s Law Dictionary defines t
he said doctrine. Thus:
The thing speaks for itself. Rebuttable presumption or inference that defendant
was negligent,
which arises upon proof that the instrumentality causing injury was in defendant
s exclusive control, and
that the accident was one which ordinarily does not happen in absence of neglige
nce. Res ipsa loquitur is
a rule of evidence whereby negligence of the alleged wrongdoer may be inferred f
rom the mere fact that
the accident happened provided the character of the accident and circumstances a
ttending it lead
reasonably to belief that in the absence of negligence it would not have occurre
d and that thing which
caused injury is shown to have been under the management and control of the alle
ged wrongdoer. Under
this doctrine, the happening of an injury permits an inference of negligence whe
re plaintiff produces
substantial evidence that the injury was caused by an agency or instrumentality
under the exclusive
control and management of defendant, and that the occurrence was such that in th
e ordinary course of
things would not happen if reasonable care had been used.167[10]

The doctrine of res ipsa loquitur as a rule of evidence is unusual to the law of
negligence which recognizes that
prima facie negligence may be established without direct proof and furnishes a s
ubstitute for specific proof of negligence.
The doctrine, however, is not a rule of substantive law, but merely a mode of pr
oof or a mere procedural convenience. The
rule, when applicable to the facts and circumstances of a given case, is not mea
nt to and does not dispense with the
requirement of proof of culpable negligence on the party charged. It merely dete
rmines and regulates what shall be prima
facie evidence thereof and helps the plaintiff in proving a breach of the duty.
The doctrine can be invoked when and only
when, under the circumstances involved, direct evidence is absent and not readil
y available.168[11]
The requisites for the application of the doctrine of res ipsa loquitur are: (1)
the accident was of a kind which does
not ordinarily occur unless someone is negligent; (2) the instrumentality or age
ncy which caused the injury was under the
exclusive control of the person in charge; and (3) the injury suffered must not
have been due to any voluntary action or
contribution of the person injured.169[12]
In this case, the circumstances that caused patient Roy Jr.s injury and the seri
es of tests that were supposed to be
undergone by him to determine the extent of the injury suffered were not under t
he exclusive control of Drs. Jarcia and
Bastan. It was established that they are mere residents of the Manila Doctors Ho
spital at that time who attended to the
victim at the emergency room.170[13] While it may be true that the circumstances
pointed out by the courts below seem
doubtless to constitute reckless imprudence on the part of the petitioners, this
conclusion is still best achieved, not
through the scholarly assumptions of a layman like the patients mother, but by t
he unquestionable knowledge of expert
witness/es. As to whether the petitioners have exercised the requisite degree of
skill and care in treating patient Roy, Jr. is
generally a matter of expert opinion.
As to Dr. Jarcia and
Dr. Bastans negligence
The totality of the evidence on record clearly points to the negligence of the p
etitioners. At the risk of being
repetitious, the Court, however, is not satisfied that Dr. Jarcia and Dr. Bastan
are criminally negligent in this case.
Negligence is defined as the failure to observe for the protection of the intere
sts of another person that degree of
care, precaution, and vigilance which the circumstances justly demand, whereby s
uch other person suffers injury.171[14]

Reckless imprudence consists of voluntarily doing or failing to do, without mali

ce, an act from which material
damage results by reason of an inexcusable lack of precaution on the part of the
person performing or failing to perform
such act.172[15]
The elements of simple negligence are: (1) that there is lack of precaution on t
he part of the offender, and (2) that
the damage impending to be caused is not immediate or the danger is not clearly
manifest.173[16]
In this case, the Court is not convinced with moral certainty that the petitione
rs are guilty of reckless imprudence
or simple negligence. The elements thereof were not proved by the prosecution be
yond reasonable doubt.
The testimony of Dr. Cirilo R. Tacata (Dr. Tacata), a specialist in pediatric or
thopedic, although pointing to some
medical procedures that could have been done by Dr. Jarcia and Dr. Bastan, as ph
ysicians on duty, was not clear as to
whether the injuries suffered by patient Roy Jr. were indeed aggravated by the p
etitioners judgment call and their
diagnosis or appreciation of the condition of the victim at the time they assess
ed him. Thus:
Q:
A:
Will you please tell us, for the record, doctor, what is your specialization?
At present I am the chairman department of orthopedic in UP-PGH and I had specia
l training in
pediatric orthopedic for two (2) years.
Q:
A:
In June 1998, doctor, what was your position and what was your specialization at
that time?
Since 1980, I have been specialist in pediatric orthopedic.
Q:
When Alfonso Santiago, Jr. was brought to you by his mother, what did you do by
way of physicians
as first step?
As usual, I examined the patient physically and, at that time as I have said, th
e patient could not
walk so I [began] to suspect that probably he sustained a fracture as a result o
f a vehicular accident.
So I examined the patient at that time, the involved leg, I dont know if that is
left or right, the
involved leg then was swollen and the patient could not walk, so I requested for
the x-ray of [the]
lower leg.
A:
Q:
A:
What part of the leg, doctor, did you request to be examined?
If we refer for an x-ray, usually, we suspect a fracture whether in approximal,

middle
or lebistal tinial, we usually x-ray the entire extremity.
Q:
A:
And what was the result?
Well, I can say that it was a spiral fracture of the mid-tibial, it is the bigge
r bone of the leg.
Q:
A:
And when you say spiral, doctor, how long was this fracture?
When we say spiral, it is a sort of letter S, the length was about six (6) to ei
ght (8) centimeters.
Q:
Mid-tibial, will you please point to us, doctor, where the tibial is?
(Witness pointing to his lower leg)
The tibial is here, there are two bones here, the bigger one is the tibial and t
he smaller one is the
fibula. The bigger one is the one that get fractured.
A:

Q:
A:
And in the course of your examination of Alfonso Santiago, Jr. did you ask for t
he history of such
injury?
Yes, actually, that was a routine part of our examination that once a patient co
mes in, before we
actually examine the patient, we request for a detailed history. If it is an acc
ident, then, we request
for the exact mechanism of injuries.
Q:
A:
And as far as you can recall, Doctor, what was the history of that injury that w
as told to you?
The patient was sideswiped, I dont know if it is a car, but it is a vehicular ac
cident.
Q:
A:
Who did you interview?
The mother.
Q:
A:
How about the child himself, Alfonso Santiago, Jr.?
Normally, we do not interview the child because, usually, at his age, the answer
s are not accurate.
So, it was the mother that I interviewed.
Q:
A:
And were you informed also of his early medication that was administered on Alfo
nso Santiago, Jr.?
No, not actually medication. I was informed that this patient was seen initially
at the emergency
room by the two (2) physicians that you just mentioned, Dr. Jarcia and Dra. Bast
an, that time who
happened to be my residents who were [on] duty at the emergency room.
xxxx
A:
At the emergency room, at the Manila Doctors Hospital, the supervisor there is a
consultant that
usually comes from a family medicine. They see where a certain patient have to g
o and then if they
cannot manage it, they refer it to the consultant on duty. Now at that time, I d
ont why they dont
Because at that time, I think, it is the decision. Since the x-rays
xxx
Q:
A:

You also said, Doctor, that Dr. Jarcia and Dra. Bastan are not even an orthopedi
c specialist.
They are general surgeon residents. You have to man[x] the emergency room,
including neurology, orthopedic, general surgery, they see everything at the
emergency room.
xxxx
Q:
A:
But if initially, Alfonso Santiago, Jr. and his case was presented to you at the
emergency room, you would have subjected the entire foot to x-ray even if the hi
story
that was given to Dr. Jarcia and Dra. Bastan is the same?
I could not directly say yes, because it would still depend on my examination, w
e
cannot subject the whole body for x-ray if we think that the damaged was only th
e leg.
Q:
A:
Not the entire body but the entire leg?
I think, if my examination requires it, I would.
Q:
A:
So, you would conduct first an examination?
Yes, sir.
Q:
And do you think that with that examination that you would have conducted you
would discover the necessity subjecting the entire foot for x-ray?
It is also possible but according to them, the foot and the ankle were swollen a
nd not
the leg, which sometimes normally happens that the actual fractured bone do not
get
swollen.
A:
xxxx
Q:
A:
Doctor, if you know that the patient sustained a fracture on the ankle and on th
e foot
and the history that was told to you is the region that was hit is the region of
the foot,
will the doctor subject the entire leg for x-ray?
I am an orthopedic surgeon, you have to subject an x-ray of the leg. Because you
have
to consider the kind of fracture that the patient sustained would you say the ex
act

mechanism of injury. For example spiral, paikot yung bale nya, so it was possibl
e that
the leg was run over, the patient fell, and it got twisted. Thats why the leg se
ems to be
fractured.174[17] [Emphases supplied]
It can be gleaned from the testimony of Dr. Tacata that a thorough examination w
as not performed on Roy Jr. As
residents on duty at the emergency room, Dr. Jarcia and Dr. Bastan were expected
to know the medical protocol in
treating leg fractures and in attending to victims of car accidents. There was,
however, no precise evidence and scientific
explanation pointing to the fact that the delay in the application of the cast t
o the patients fractured leg because of failure
to immediately diagnose the specific injury of the patient, prolonged the pain o
f the child or aggravated his condition or
even caused further complications. Any person may opine that had patient Roy Jr.
been treated properly and given the
extensive X-ray examination, the extent and severity of the injury, spiral fract
ure of the mid-tibial part or the bigger bone
of the leg, could have been detected early on and the prolonged pain and sufferi
ng of Roy Jr. could have been prevented.
But still, that opinion, even how logical it may seem would not, and could not,
be enough basis to hold one criminally
liable; thus, a reasonable doubt as to the petitioners guilt.
Although the Court sympathizes with the plight of the mother and the child in th
is case, the Court is bound by the
dictates of justice which hold inviolable the right of the accused to be presume
d innocent until proven guilty beyond
reasonable doubt. The Court, nevertheless, finds the petitioners civilly liable
for their failure to sufficiently attend to Roy
Jr.s medical needs when the latter was rushed to the ER, for while a criminal co
nviction requires proof beyond reasonable
doubt, only a preponderance of evidence is required to establish civil liability
. Taken into account also was the fact that
there was no bad faith on their part.
Dr. Jarcia and Dr. Bastan cannot pass on the liability to the taxi driver who hi
t the victim. It may be true that the
actual, direct, immediate, and proximate cause of the injury (fracture of the le
g bone or tibia) of Roy Jr. was the vehicular
accident when he was hit by a taxi. The petitioners, however, cannot simply invo
ke such fact alone to excuse themselves
from any liability. If this would be so, doctors would have a ready defense shou
ld they fail to do their job in attending to
victims of hit-and-run, maltreatment, and other crimes of violence in which the
actual, direct, immediate, and proximate
cause of the injury is indubitably the act of the perpetrator/s.
In failing to perform an extensive medical examination to determine the extent o
f Roy Jr.s injuries, Dr. Jarcia and
Dr. Bastan were remiss of their duties as members of the medical profession. Ass
uming for the sake of argument that they
did not have the capacity to make such thorough evaluation at that stage, they s
hould have referred the patient to another
doctor with sufficient training and experience instead of assuring him and his m
other that everything was all right.
This Court cannot also stamp its imprimatur on the petitioners contention that n
o physician-patient relationship
existed between them and patient Roy Jr., since they were not his attending phys
icians at that time. They claim that they
were merely requested by the ER nurse to see the patient while they were passing
by the ER for their lunch. Firstly, this

issue was never raised during the trial at the RTC or even before the CA. The pe
titioners, therefore, raise the want of
doctor-patient relationship for the first time on appeal with this Court. It has
been settled that issues raised for the first
time on appeal cannot be considered because a party is not permitted to change h
is theory on appeal. To allow him to do
so is unfair to the other party and offensive to the rules of fair play, justice
and due process.175[18] Stated differently,

basic considerations of due process dictate that theories, issues and arguments
not brought to the attention of the trial
court need not be, and ordinarily will not be, considered by a reviewing court.1
76[19]
Assuming again for the sake of argument that the petitioners may still raise thi
s issue of no physicianpatient
relationship, the Court finds and so holds that there was a physicianpatient rel
ationship in this case.
In the case of Lucas v. Tuao,177[20] the Court wrote that [w]hen a patient engag
es the services of a physician, a
physician-patient relationship is generated. And in accepting a case, the physic
ian, for all intents and purposes, represents
that he has the needed training and skill possessed by physicians and surgeons p
racticing in the same field; and that he
will employ such training, care, and skill in the treatment of the patient. Thus
, in treating his patient, a physician is under
a duty to exercise that degree of care, skill and diligence which physicians in
the same general neighborhood and in the
same general line of practice ordinarily possess and exercise in like cases. Sta
ted otherwise, the physician has the
obligation to use at least the same level of care that any other reasonably comp
etent physician would use to treat the
condition under similar circumstances.
Indubitably, a physician-patient relationship exists between the petitioners and
patient Roy Jr. Notably, the latter
and his mother went to the ER for an immediate medical attention. The petitioner
s allegedly passed by and were
requested to attend to the victim (contrary to the testimony of Dr. Tacata that
they were, at that time, residents on duty
at the ER).178[21] They obliged and examined the victim, and later assured the m
other that everything was fine and that
they could go home. Clearly, a physician-patient relationship was established be
tween the petitioners and the patient Roy
Jr.
To repeat for clarity and emphasis, if these doctors knew from the start that th
ey were not in the position to attend
to Roy Jr., a vehicular accident victim, with the degree of diligence and commit
ment expected of every doctor in a case like
this, they should have not made a baseless assurance that everything was all rig
ht. By doing so, they deprived Roy Jr. of
adequate medical attention that placed him in a more dangerous situation than he
was already in. What petitioners should
have done, and could have done, was to refer Roy Jr. to another doctor who could
competently and thoroughly examine
his injuries.
All told, the petitioners were, indeed, negligent but only civilly, and not crim
inally, liable as the facts show.
Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in
the Philippines states:

A physician should attend to his patients faithfully and conscientiously. He sho

uld secure for
them all possible benefits that may depend upon his professional skill and care.
As the sole tribunal to
adjudge the physicians failure to fulfill his obligation to his patients is, in
most cases, his own conscience,
violation of this rule on his part is discreditable and inexcusable.179[22]
Established medical procedures and practices, though in constant instability, ar
e devised for the purpose of
preventing complications. In this case, the petitioners failed to observe the mo
st prudent medical procedure under the
circumstances to prevent the complications suffered by a child of tender age.
As to the Award of
Damages
While no criminal negligence was found in the petitioners failure to administer
the necessary medical attention to
Roy Jr., the Court holds them civilly liable for the resulting damages to their
patient. While it was the taxi driver who ran
over the foot or leg of Roy Jr., their negligence was doubtless contributory.
It appears undisputed that the amount of 3,850.00, as expenses incurred by patien
t Roy Jr., was adequately
supported by receipts. The Court, therefore, finds the petitioners liable to pay
this amount by way of actual damages.
The Court is aware that no amount of compassion can suffice to ease the sorrow f
elt by the family of the child at
that time. Certainly, the award of moral and exemplary damages in favor of Roy J
r. in the amount of 100,000.00 and
50,000.00, respectively, is proper in this case.
It is settled that moral damages are not punitive in nature, but are designed to
compensate and alleviate in some
way the physical suffering, mental anguish, fright, serious anxiety, besmirched
reputation, wounded feelings, moral shock,
social humiliation, and similar injury unjustly inflicted on a person. Intended
for the restoration of the psychological or
emotional status quo ante, the award of moral damages is designed to compensate
emotional injury suffered, not to
impose a penalty on the wrongdoer.180[23]

The Court, likewise, finds the petitioners also liable for exemplary damages in
the said amount. Article 2229 of the
Civil Code provides that exemplary damages may be imposed by way of example or c
orrection for the public good.
WHEREFORE, the petition is PARTLY GRANTED. The Decision of the Court of Appeals
dated August 29,
2008 is REVERSED and SET ASIDE. A new judgment is entered ACQUITTING Dr. Emmanue
l Jarcia, Jr. and Dr.
Marilou Bastan of the crime of reckless imprudence resulting to serious physical
injuries but declaring them civilly liable
in the amounts of:
(1)
(2)
(3)
(4)

3,850.00 as actual damages;

100,000.00 as moral damages;
50,000.00 as exemplary damages; and
Costs of the suit.

with interest at the rate of 6% per annum from the date of the filing of the Inf
ormation. The rate shall be 12% interest per
annum from the finality of judgment until fully paid.
SO ORDERED.
JOSE CATRAL MENDOZA
Associate Justice
WE CONCUR:

ANTONIO T. CARPIO
Associate Justice
DIOSDADO M. PERALTA
ROBERTO A. ABAD
Associate Justice
Associate Justice
Acting Chairperson
JOSE PORTUGAL PEREZ
Associate Justice
ATTESTATION
I attest that the conclusions in the above Decision had been reached in consulta
tion before the case was assigned
to the writer of the opinion of the Courts Division.
DIOSDADO M. PERALTA
Associate Justice
Acting Chairperson, Third Division
CERTIFICATION

Pursuant to Section 13, Article VIII of the Constitution and the Division Acting
Chairpersons Attestation, I certify
that the conclusions in the above Decision had been reached in consultation befo
re the case was assigned to the writer of
the opinion of the Courts Division.
RENATO C. CORONA
Chief Justice