CERENO

v. CA

FACTS:

At about 9:15 in the evening of 16 September 1995, Raymond S. Olavere (Raymond),
a victim of a stabbing incident, was rushed to the emergency room of the Bicol
Regional Medical Center (BRMC). There, Raymond was attended to by Nurse Balares
and Dr. Realuyo the emergency room resident physician.

Subsequently, the parents of Raymond the spouses Deogenes Olavere (Deogenes)
and Fe R. Serrano arrived at the BRMC. They were accompanied by one Andrew
Olavere, the uncle of Raymond. After extending initial medical treatment to
Raymond, Dr. Realuyo recommended that the patient undergo "emergency
exploratory laparotomy." Dr. Realuyo then requested the parents of Raymond to
procure 500 cc of type "O" blood needed for the operation. Complying with the
request, Deogenes and Andrew Olavere went to the Philippine National Red Cross to
secure the required blood.

At 10:30 P.M., Raymond was wheeled inside the operating room. During that time,
the hospital surgeons, Drs. Zafe and Cereno, were busy operating on gunshot victim
Charles Maluluy-on. Assisting them in the said operation was Dr. Rosalina Tatad (Dr.
Tatad), who was the only senior anesthesiologist on duty at BRMC that night. Dr.
Tatad also happened to be the head of Anesthesiology Department of the BRMC. Just
before the operation on Maluluy-on was finished, another emergency case involving
Lilia Aguila, a woman who was giving birth to triplets, was brought to the operating
room. At 10:59 P.M., the operation on Charles Maluluy-on was finished. By that time,
however, Dr. Tatad was already working with the obstetricians who will perform
surgery on Lilia Aguila. There being no other available anesthesiologist to assist
them, Drs. Zafe and Cereno decided to defer the operation on Raymond. Drs. Zafe
and Cereno, in the meantime, proceeded to examine Raymond and they found that
the latters blood pressure was normal and "nothing in him was significant." Dr.
Cereno reported that based on the xray result he interpreted, the fluid inside the
thoracic cavity of Raymond was minimal at around 200-300 cc.

At 11:15 P.M., Deogenes and Andrew Olavere returned to the BRMC with a bag
containing the requested 500 cc type "O" blood. They handed over the bag of blood
to Dr. Realuyo. After Dr. Tatad finished her work with the Lilia Aguila operation,
petitioners immediately started their operation on Raymond at around 12:15 A.M.
of 17 September 1995. Upon opening of Raymonds thoracic cavity, they found that
3,200 cc of blood was stocked therein. The blood was evacuated and petitioners
found a puncture at the inferior pole of the left lung. In his testimony, Dr. Cereno
stated that considering the loss of blood suffered by Raymond, he did not
immediately transfuse blood because he had to control the bleeders first.

Blood was finally transfused on Raymond at 1:40 A.M. At 1:45 A.M., while the
operation was on-going, Raymond suffered a cardiac arrest. The operation ended at
1:50 A.M. and Raymond was pronounced dead at 2:30 A.M. Raymonds death
certificate indicated that the immediate cause of death was "hypovolemic shock" or
the cessation of the functions of the organs of the body due to loss of blood.

Claiming that there was negligence on the part of those who attended to their son,
the parents of Raymond, on 25 October 1995, filed before the RTC, Branch 22, Naga
City a complaint for damages7 against Nurse Balares, Dr. Realuyo and attending
surgeons Dr. Cereno and Dr. Zafe. the case against dr realuyo and balares was
dismissed. Dr. cereno and dr zafe found guilty and ordered to pay for damages.

The trial court found petitioners negligent in not immediately conducting surgery
on Raymond. It noted that petitioners have already finished operating on Charles
Maluluy-on as early as 10:30 in the evening, and yet they only started the operation
on Raymond at around 12:15 early morning of the following day. The trial court
held that had the surgery been performed promptly, Raymond would not have lost
so much blood and, therefore, could have been saved.10 The trial court also held
that the non-availability of Dr. Tatad after the operation on Maluluy-on was not a
sufficient excuse for the petitioners to not immediately operate on Raymond. It
called attention to the testimony of Dr. Tatad herself, which disclosed the possibility
of calling a standby anesthesiologist in that situation. The trial court opined that the
petitioners could have just requested for the standby anesthesiologist from Dr.
Tatad, but they did not. Lastly, the trial court faulted petitioners for the delay in the
transfusion of blood on Raymond. On appeal, the CA in a decision dated 21 February
2005 affirmed in toto the judgment rendered by the RTC finding herein petitioners
guilty of gross negligence in the performance of their duties and awarding damages
to private respondents.

ISSUE:

Whether or not Dr. Cereno and Dr. Zafe are guilty of gross negligence in the
performance of their duties.

HELD:

No. Causation Not Proven In medical negligence cases, it is settled that the
complainant has the burden of establishing breach of duty on the part of the doctors
or surgeons. It must be proven that such breach of duty has a causal connection to
the resulting death of the patient.

A verdict in malpractice action cannot be based on speculation or conjecture.
Causation must be proven within a reasonable medical probability based upon
competent expert testimony. The parents of Raymond failed in this respect. Aside
from their failure to prove negligence on the part of the petitioners, they also failed
to prove that it was petitioners fault that caused the injury. Their cause stands on
the mere assumption that Raymonds life would have been saved had petitioner
surgeons immediately operated on him; had the blood been cross-matched
immediately and had the blood been transfused immediately.

There was, however, no proof presented that Raymonds life would have been saved
had those things been done. Those are mere assumptions and cannot guarantee
their desired result. Such cannot be made basis of a decision in this case, especially
considering that the name, reputation and career of petitioners are at stake. The
Court understands the parents grief over their sons death. That notwithstanding, it
cannot hold petitioners liable.

It was noted that Raymond, who was a victim of a stabbing incident, had multiple
wounds when brought to the hospital. Upon opening of his thoracic cavity, it was
discovered that there was gross bleeding inside the body. Thus, the need for
petitioners to control first what was causing the bleeding. Despite the situation that
evening i.e. numerous patients being brought to the hospital for emergency
treatment considering that it was the height of the Peafrancia Fiesta, it was evident
that petitioners exerted earnest efforts to save the life of Raymond.

It was just unfortunate that the loss of his life was not prevented. In the case of Dr.
Cruz v. CA, it was held that doctors are protected by a special 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 mistake of judgment"

This Court affirms the ruling of the CA that the BRMC is not an indispensible party.
The core issue as agreed upon by the parties and stated in the pre-trial order is
whether petitioners were negligent in the performance of their duties. It pertains to
acts/omissions of petitioners for which they could be held liable. The cause of action
against petitioners may be prosecuted fully and the determination of their liability
may be arrived at without impleading the hospital where they are employed. As
such, the BRMC cannot be considered an indispensible party without whom no final
determination can be had of an action.




BATIQUIN V COURT OF APPEALS

FACTS:

Mrs. Villegas submitted to Dr. Batiquin for prenatal care as the latter's private
patient sometime before September 21,1988. In the morning of September 21, 1988
Dr. Batiquin, along with other physicians and nurses, performed a caesarean
operation on Mrs. Villegas and successfully delivered the latters baby.

After leaving the hospital, Mrs. Villegas began to suffer abdominal pains and
complained of being feverish. She also gradually lost her appetite, so she consulted
Dr. Batiquin at the latter's polyclinic who prescribed for her certain medicines.
However, the pains still kept recurring. She then consulted Dr.Ma. Salud Kho. After
examining her, Dr Kho suggested that Mrs.Villegas submit to another surgery.-
When Dr. Kho opened the abdomen of Mrs. Villegas she found whitish-yellow
discharge inside, an ovarian cyst on each of the left and right ovaries which gave out
pus, dirt and pus behind the uterus, and a piece of rubber material on the right side
of the uterus, embedded on the ovarian cyst. The piece of rubber appeared to be a
part of a rubber glove.

This was the cause of all of the infection of the ovaries and consequently of all the
discomfort suffered by Mrs. Villegas. The piece of rubber allegedly found was not
presented in court, and Dr. Kho testified that she sent it to a pathologist in Cebu City
for examination. Aside from Dr. Kho's testimony, the evidence which mentioned the
piece of rubber are a Medical Certificate, a Progress Record, an Anaesthesia Record,
a Nurse's Record, and a Physician's Discharge Summary.

The trial court, however, regarded these documentary evidence as mere hearsay,
"there being no showing that the person or persons who prepared them are
deceased or unable to testify on the facts therein stated- There was also doubts as to
the whereabouts of the piece of rubber, as 2 versions arose from Dr. Khos
testimony: 1) that it was sent to the Pathologist in Cebu as testified to in Court by Dr.
Kho and (2) that Dr. Kho threw it away as told by her to Defendant. The failure of
the Plaintiffs to reconcile these two different versions served only to weaken their
claim against Defendant Batiquin. The trial court ruled in favor of the defendants.
The CA reversed the decision.

ISSUE:

Whether or not Dr. Batiquin is liable

HELD:

The focal point of the appeal is Dr. Khos testimony. There were inconsistencies
within her own testimony, which led to the different decision of the RTC and CA. The
CA was correct in saying that the trial court erred when it isolated the disputed
portion of Dr. Khos testimony and did not consider it with other portions of Dr.
Khos testimony.

Also, the phrase relied upon by the trial court does not negate the fact that Dr. Kho
saw a piece of rubber in private respondent Villegas' abdomen, and that she sent it
to a laboratory and then to Cebu City for examination by a pathologist. Furthermore,
Dr. Kho's knowledge of the piece of rubber could not be based on other than first
hand knowledge for, as she asserted before the trial court.



RAMOS v. Court of Appeals

FACTS:

Erlinda Ramos underwent a surgical procedure to remove stone from her gall
bladder (cholecystectomy). They hired Dr. Hosaka, a surgeon, to conduct the surgery
at the De Los Santos Medical Center (DLSMC). Hosaka assured them that he would
find a good anesthesiologist. But the operation did not go as planned, Dr. Hosaka
arrived 3 hours late for the operation, Dra. Gutierrez, the anesthesiologist botched
the administration of the anesthesia causing Erlinda to go into a coma and suffer
brain damage. The botched operation was witnessed by Herminda Cruz, sister in
law of Erlinda and Dean of College of Nursing of Capitol Medical Center.

The family of Ramos (petitioners) sued the hospital, the surgeon and the
anesthesiologist for damages. The petitioners showed expert testimony showing
that Erlinda's condition was caused by the anesthesiologist in not exercising
reasonable care in intubating Erlinda. Eyewitnesses heard the anesthesiologist
saying Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang
tiyan.

Diagnostic tests prior to surgery showed that Erlinda was robust and fit to undergo
surgery.

The RTC held that the anesthesiologist ommitted to exercise due care in intubating
the patient, the surgeon was remiss in his obligation to provide a good
anesthesiologist and for arriving 3 hours late and the hospital is liable for the
negligence of the doctors and for not cancelling the operation after the surgeon
failed to arrive on time. The surgeon, anesthesiologist and the DLSMC were all held
jointly and severally liable for damages to petitioners. The CA reversed the decision
of the Trial Court.

ISSUES:

Whether or not the private respondents were negligent and thereby caused the
comatose condition of Ramos.

HELD:

Yes, private respondents were all negligent and are solidarily liable for the damages.



RATIO:

Res ipsa loquitur a procedural or evidentiary rule which means the thing or the
transaction speaks for itself. It is a maxim for the rule that the fact of the
occurrence of an injury, taken with the surrounding circumstances, may permit an
inference or raise a presumption of negligence, or make out a plaintiffs prima facie
case, and present a question of fact for defendant to meet with an explanation,
where ordinarily in a medical malpractice case, the complaining party must present
expert testimony to prove that the attending physician was negligent.

This doctrine finds application in this case. On the day of the operation, Erlinda
Ramos already surrendered her person to the private respondents who had
complete and exclusive control over her. Apart from the gallstone problem, she was
neurologically sound and fit. Then, after the procedure, she was comatose and brain
damagedres ipsa loquitur!the thing speaks for itself!

Negligence Private respondents were not able to disprove the presumption of
negligence on their part in the care of Erlinda and their negligence was the
proximate cause of her condition. One need not be an anesthesiologist in order to
tell whether or not the intubation was a success. [res ipsa loquitur applies here]. The
Supreme Court also found that the anesthesiologist only saw Erlinda for the first
time on the day of the operation which indicates unfamiliarity with the patient and
which is an act of negligence and irresponsibility.

The head surgeon, Dr. Hosaka was also negligent. He failed to exercise the proper
authority as the captain of the ship in determining if the anesthesiologist observed
the proper protocols. Also, because he was late, he did not have time to confer with
the anesthesiologist regarding the anesthesia delivery.

The hospital failed to adduce evidence showing that it exercised the diligence of a
good father of the family in hiring and supervision of its doctors (Art. 2180). The
hospital was negligent since they are the one in control of the hiring and firing of
their consultants. While these consultants are not employees, hospitals still exert
significant controls on the selection and termination of doctors who work there
which is one of the hallmarks of an employer-employee reationship. Thus, the
hospital was allocated a share in the liability.


Damages temperate damages can and should be awarded on top of actual or
compensatory damages in instances where the injury is chronic and continuing.







CASUMPANG v. CORTEJO
G.R. No. 171127 | March 11, 2015

FACTS:

On April 22, 1988, at about 11:30 in the morning, Mrs. Cortejo brought her 11-
year old son, Edmer, to the Emergency Room of the San Juan de Dios Hospital
(SJDH) because of difficulty in breathing, chest pain, stomach pain, and fever.
Thereafter, she was referred and assigned to Dr. Casumpang, a pediatrician. At
5:30 in the afternoon of the same day, Dr. Casumpang, upon examination using
only a stethoscope, confirmed the diagnosis of Bronchopneumonia. Mrs. Cortejo
immediately advised Dr. Casumpang that Edmer had a high fever, and had no
colds or cough but Dr. Casumpang merely told her that her son's bloodpressure
is just being active and remarked that that's the usual bronchopneumonia, no
colds, no phlegm.

Dr. Casumpang next visited the following day. Mrs. Cortejo again called Dr.
Casumpang's attention and stated that Edmer had a fever, throat irritation, as
well as chest and stomach pain. Mrs. Cortejo also alerted Dr. Casumpang about
the traces of blood in Edmer's sputum. Despite these pieces of information,
however, Dr. Casumpang simply nodded and reassured Mrs. Cortejo that
Edmer's illness is bronchopneumonia.

At around 11:30 in the morning of April 23, 1988, Edmer vomited phlegm with
blood streak prompting the Edmer's father to request for a doctor. Later,
Miranda, one of the resident physicians of SJDH, arrived. She claimed that
although aware that Edmer had vomited phlegm with blood streak she failed to
examine the blood specimen. She then advised the respondent to preserve the
specimen for examination. Thereafter, Dr. Miranda conducted a check-up on
Edmer and found that Edmer had a low-grade fever and rashes.

At 3:00 in the afternoon, Edmer once again vomited blood. Dr. Miranda then
examined Edmer's sputum with blood and noted that he was bleeding.
Suspecting that he could be afflicted with dengue, Dr. Miranda conducted a
tourniquet test, which turned out to be negative. Dr. Miranda then called up Dr.
Casumpang at his clinic and told him about Edmer's condition. Upon being
informed, Dr. Casumpang ordered several procedures done. Dr. Miranda advised
Edmer's parents that the blood test results showed that Edmer was suffering
from Dengue Hemorrhagic Fever. Dr. Casumpang recommended Edmers
transfer to the ICU, but since the ICU was then full, the respondent, insisted on
transferring his son to Makati Medical Center.

 At 12:00 midnight, Edmer, accompanied by his parents and by Dr. Casumpang,
was transferred to Makati Medical Center. Upon examination, the attending
physician diagnosed Dengue Fever Stage IV that was already in its irreversible
stage. Edmer died at 4:00 in the morning of April 24, 1988. His Death Certificate
indicated the cause of death as Hypovolemic Shock/hemorrhagic shock/Dengue
Hemorrhagic Fever Stage IV.

Believing that Edmer's death was caused by the negligent and erroneous
diagnosis of his doctors, the respondent instituted an action for damages against
SJDH, and its attending physicians: Dr. Casumpang and Dr. Miranda.

Dr. Casumpang contends that he gave his patient medical treatment and care to
the best of his abilities, and within the proper standard of care required from
physicians under similar circumstances.

Dr. Miranda argued that the function of making the diagnosis and undertaking
the medical treatment devolved upon Dr. Casumpang, the doctor assigned to
Edmer. Dr. Miranda also alleged that she exercised prudence in performing her
duties as a physician, underscoring that it was her professional intervention that
led to the correct diagnosis of Dengue Hemorrhagic Fever.

SJDH, on the other hand, disclaims liability by asserting that Dr. Casumpang and
Dr. Miranda are mere independent contractors and consultants (not employees)
of the hospital; hence, Article 2180 of the Civil Code does not apply.

ISSUES:

1. W/N Casumpang had committed inexcusable lack of precaution in diagnosing
and in treating the patient

2. W/N Miranda had committed inexcusable lack of precaution in diagnosing and
in treating the patient

3. W/N Whether or not the petitioner hospital is solidarity liable with the
petitioner doctors

4. W/N or not there is a causal connection between the petitioners' negligent
act/omission and the patient's resulting death

HELD/RATIO:

1. YES, Casumpang was negligent.

Even assuming that Edmer's symptoms completely coincided with the diagnosis
of bronchopneumonia, we still find Dr. Casumpang guilty of negligence. Wrong
diagnosis is not by itself medical malpractice. Physicians are generally not liable
 for damages resulting from a bona fide error of judgment and from acting
according to acceptable medical practice standards. Nonetheless, when the
physician's erroneous diagnosis was the result of negligent conduct, it becomes
an evidence of medical malpractice.

In the present case, evidence on record established that in confirming the
diagnosis of bronchopneumonia, Dr. Casumpang selectively appreciated some
and not all of the symptoms presented, and failed to promptly conduct the
appropriate tests to confirm his findings. In sum, Dr. Casumpang failed to timely
detect dengue fever, which failure, especially when reasonable prudence would
have shown that indications of dengue were evident and/or foreseeable,
constitutes negligence. Apart from failing to promptly detect dengue fever, Dr.
Casumpang also failed to promptly undertake the proper medical management
needed for this disease. Dr. Casumpang failed to measure up to the acceptable
medical standards in diagnosing and treating dengue fever.

Dr. Casumpang's claim that he exercised prudence and due diligence in handling
Edmer's case, sside from being self-serving, is not supported by competent
evidence. He failed, as a medical professional, to observe the most prudent
medical procedure under the circumstances in diagnosing and treating Edmer.

2. No, Dr. Miranda is not liable for negligence.

We find that Dr. Miranda was not independently negligent. Although she was
subject to the same standard of care applicable to attending physicians, as a
resident physician, she merely operates as a subordinate who usually refer to
the attending physician on the decision to be made and on the action to be taken.
We also believe that a finding of negligence should also depend on several
competing factors. In this case, before Dr. Miranda attended to Edmer, Dr.
Casumpang had diagnosed Edmer with bronchopneumonia. There is also
evidence supporting Dr. Miranda's claim that she extended diligent care to
Edmer. In fact, when she suspected, during Edmer's second episode of bleeding,
that Edmer could be suffering from dengue, she wasted no time in conducting
the necessary tests, and promptly notified Dr. Casumpang about the incident.
Indubitably, her medical assistance led to the finding of dengue fever. Dr.
Miranda's error was merely an honest mistake of judgment; hence, she should
not be held liable for medical negligence.

3. Yes, causal connection between the petitioners' negligence and the
patient's resulting death was established

Casumpang failed to timely diagnose Edmer with dengue fever despite the
presence of its characteristic symptoms; and as a consequence of the delayed
diagnosis, he also failed to promptly manage Edmer's illness. Had he
immediately conducted confirmatory tests, and promptly administered the
proper care and management needed for dengue fever, the risk of complications
 or even death, could have been substantially reduced. That Edmer later died of
Dengue Hemorrhagic Fever Stage IV, a severe and fatal form of dengue fever,
established the causal link between Dr. Casumpang's negligence and the injury.
The element of causation is successfully proven.

4. YES, SJDH is solidarily liable.

As a rule, hospitals are not liable for the negligence of its independent
contractors. However, it may be found liable if the physician or independent
contractor acts as an ostensible agent of the hospital. This exception is also
known as the doctrine of apparent authority.

SJDH impliedly held out and clothed Dr. Casumpang with apparent authority
leading the respondent to believe that he is an employee or agent of the hospital.
Based on the records, the respondent relied on SJDH rather than upon Dr.
Casumpang, to care and treat his son Edmer. His testimony during trial showed
that he and his wife did not know any doctors at SJDH; they also did not know
that Dr. Casumpang was an independent contractor. They brought their son to
SJDH for diagnosis because of their family doctor's referral. The referral did not
specifically point to Dr. Casumpang or even to Dr. Miranda, but to SJDH.

Mrs. Cortejo accepted Dr. Casumpang's services on the reasonable belief that
such were being provided by SJDH or its employees, agents, or servants. By
referring Dr. Casumpang to care and treat for Edmer, SJDH impliedly held out Dr.
Casumpang as a member of its medical staff. SJDH cannot now disclaim liability
since there is no showing that Mrs. Cortejo or the respondent knew, or should
have known, that Dr. Casumpang is only an independent contractor of the
hospital. In this case, estoppel has already set in.



NOGALES v. CAPITOL MEDICAL CENTER

FACTS:

Pregnant with her fourth child, Corazon Nogales (Corazon), who was then 37
years old, was under the exclusive prenatal care of Dr. Oscar Estrada (Dr. Estrada)
beginning on her fourth month of pregnancy or as early as December 1975. While
Corazon was on her last trimester of pregnancy, Dr. Estrada noted an increase in her
blood pressure and development of leg edema indicating preeclampsia, which is a
dangerous complication of pregnancy. Around midnight of 25 May 1976, Corazon
started to experience mild labor pains prompting Corazon and Rogelio Nogales
(Spouses Nogales) to see Dr. Estrada at his home. After examining Corazon, Dr.
Estrada advised her immediate admission to the Capitol Medical Center (CMC).
The following day, Corazon was admitted at 2:30 a.m. at the CMC after the staff
nurse noted the written admission request of Dr. Estrada. Upon Corazons
admission at the CMC, Rogelio Nogales (Rogelio) executed and signed the Consent
on Admission and Agreement and Admission Agreement. Corazon was then
brought to the labor room of the CMC. Corazon died at 9:15 a.m. The cause of death
was hemorrhage, post partum.

Petitioners filed a complaint for damages with the Regional Trial Court of Manila
against CMC, Dr. Estrada, and the rest of CMC medical staff for the death of Corazon.
In their defense, CMC pointed out that Dr. Estrada was a consultant to be considered
as an independent-contractor, and that no employer-employee relationship existed
between the former and the latter.

After more than 11 years of trial, the trial court rendered judgment on 22 November
1993 finding Dr. Estrada solely liable for damages. Petitioners appealed the trial
courts 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 respondents alleged liability.

On appeal, the Court of Appeals affirmed the trial courts ruling and applied the
borrowed servant doctrine to release the liability of other medical staff. This
doctrine provides that once the surgeon enters the operating room and takes charge
of the proceedings, the acts or omissions of operating room personnel, and any
negligence associated with such acts or omissions, are imputable to the surgeon.
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.

ISSUE:

Whether CMC is vicariously liable for the negligence of Dr. Estrada as its attending
independent-contractor physician considering that facts of the instant case.

HELD:

YES.

In general, a hospital is not liable for the negligence of an independent contractor-
physician. There is, however, an exception to this principle. The hospital may be
liable if the physician is the ostensible agent of the hospital. This exception is also
known as the doctrine of apparent authority.xxx The doctrine of apparent
authority essentially involves two factors to determine the liability of an
independent-contractor physician. The first factor focuses on the hospitals
manifestations and is sometimes described as an inquiry whether the hospital acted
in a manner which would lead a reasonable person to conclude that the individual
who was alleged to be negligent was an employee or agent of the hospital. In this
regard, the hospital need not make express representations to the patient that the
treating physician is an employee of the hospital; rather a representation may be
general and implied. xxx The second factor focuses on the patients reliance. It is
sometimes characterized as an inquiry on whether the plaintiff acted in reliance
upon the conduct of the hospital or its agent, consistent with ordinary care and
prudence.

xxx

In the instant case, CMC impliedly held out Dr. Estrada as a member of its medical
staff. Through CMCs 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. The records show that the Spouses
Nogales relied upon a perceived employment relationship with CMC in accepting Dr.
Estradas services. Rogelio testified that he and his wife specifically chose Dr.
Estrada to handle Corazons delivery not only because of their friends
recommendation, but more importantly because of Dr. Estradas connection with a
reputable hospital, the [CMC]. In other words, Dr. Estradas relationship with CMC
played a significant role in the Spouses Nogales decision in accepting Dr. Estradas
services as the obstetrician-gynecologist for Corazons delivery. Moreover, as earlier
stated, there is no showing that before and during Corazons confinement at CMC,
the Spouses Nogales knew or should have known that Dr. Estrada was not an
employee of CMC. xxx CMCs defense that all it did was to extend to [Corazon] its
facilities is untenable. The Court cannot close its eyes to the reality that hospitals,
such as CMC, are in the business of treatment.

xxx

The Court finds respondent Capitol Medical Center vicariously liable for the
negligence of Dr. Oscar Estrada. The amounts of P105,000 as actual damages and
P700,000 as moral damages should each earn legal interest at the rate of six percent
(6%) per annum computed from the date of the judgment of the trial court. The
Court affirms the rest of the Decision dated 6 February 1998 and Resolution dated
21 March 2000 of the Court of Appeals in CA-G.R. CV No. 45641.



PROFESSIONAL SERVICES v. AGANA

FACTS
Natividad Agana was rushed to Medical City because of difficulty of bowel
movement and bloody anal discharge. Dr. Ampil diagnosed her to be suffering
from cancer of the sigmoid. Dr. Ampil performed an anterior resection
surgery on her, and finding that the malignancy spread on her left ovary, he
obtained the consent of her husband, Enrique, to permit Dr. Fuentes to
perform hysterectomy on her. After the hysterectomy, Dr. Fuentes showed his
work to Dr. Ampil, who examined it and found it in order, so he allowed Dr. Fuentes
to leave the operating room. Dr. Ampil was about to complete the procedure when
the attending nurses made some remarks on the Record of Operation: sponge
count lacking 2; announced to surgeon search done but to no avail continue for
closure (two pieces of gauze were missing). A diligent search was conducted but
they could not be found. Dr. Ampil then directed that the incision be closed.

A couple of days after, she complained of pain in her anal region, but the
doctors told her that it was just a natural consequence of the surgery. Dr. Ampil
recommended that she consult an oncologist to examine the cancerous nodes which
were not removed during the operation. After months of consultations and
examinations in the US, she was told that she was free of cancer. Weeks after coming
back, her daughter found a piece of gauze (1.5 in) protruding from her vagina, so Dr.
Ampil manually extracted this, assuring Natividad that the pains will go away.
However, the pain worsened, so she sought treatment at a hospital, where another
1.5 in piece of gauze was found in her vagina. She underwent another surgery.

Sps. Agana filed a complaint for damages against PSI (owner of Medical City),
Dr. Ampil, and Dr. Fuentes, alleging that the latter are liable for negligence for
leaving 2 pieces of gauze in Natividads body, and malpractice for concealing their
acts of negligence. Enrique Agana also filed an administrative complaint for gross
negligence and malpractice against the two doctors with the PRC (although only the
case against Dr. Fuentes was heard since Dr. Ampil was abroad). Pending the
outcome of the cases, Natividad died (now substituted by her children). RTC found
PSI and the two doctors liable for negligence and malpractice. PRC dismissed
the case against Dr. Fuentes. CA dismissed only the case against Fuentes.


ISSUE AND HOLDING
1. WON CA erred in holding Dr. Ampil liable for negligence and malpractice. NO;
DR. AMPIL IS GUILTY
2. WON CA erred in absolving Dr. Fuentes of any liability. NO
3. WON PSI may be held solidarily liable for Dr. Ampils negligence. YES

RATIO

DR. AMPIL IS LIABLE FOR NEGLIGENCE AND MALPRACTICE
His arguments are without basis [did not prove that the American doctors were the
ones who put / left the gauzes; did not submit evidence to rebut the correctness of
the operation record (re: number of gauzes used); re: Dr. Fuentes alleged
negligence, Dr. Ampil examined his work and found it in order].

Leaving foreign substances in the wound after incision has been closed is
at least prima facie negligence by the operating surgeon. Even if it has been
 shown that a surgeon was required to leave a sponge in his patients abdomen
because of the dangers attendant upon delay, still, it is his legal duty to inform his
patient within a reasonable time by advising her of what he had been compelled to do,
so she can seek relief from the effects of the foreign object left in her body as her
condition might permit. Whats worse in this case is that he misled her by saying
that the pain was an ordinary consequence of her operation.


Medical negligence; standard of diligence

To successfully pursue this case of medical negligence, a patient must only prove
that a health care provider either failed to do something [or did something] which a
reasonably prudent health care provider would have done [or wouldnt have done],
and that the failure or action caused injury to the patient.
Duty to remove all foreign objects from the body before closure of the incision; if
he fails to do so, it was his duty to inform the patient about it
Breach failed to remove foreign objects; failed to inform patient
Injury suffered pain that necessitated examination and another surgery
Proximate Causation breach caused this injury; could be traced from his act of
closing the incision despite information given by the attendant nurses that 2
pieces of gauze were still missing; what established causal link: gauze pieces later
extracted from patients vagina

DR. FUENTES NOT LIABLE

The res ipsa loquitur [thing speaks for itself] argument of the Aganas does not
convince the court. Mere invocation and application of this doctrine does not
dispense with the requirement of proof of negligence.

Requisites for the applicability of res ipsa loquitur
1. Occurrence of injury
2. Thing which caused injury was under the control and management of the
defendant [DR. FUENTES] LACKING SINCE CTRL+MGT WAS WITH DR.
AMPIL
3. Occurrence was such that in the ordinary course of things, would not have
happened if those who had control or management used proper care
4. Absence of explanation by defendant
Under the Captain of the Ship rule, the operating surgeon is the person in complete
charge of the surgery room and all personnel connected with the operation. That Dr.
Ampil discharged such role is evident from the following:

He called Dr. Fuentes to perform a hysterectomy
He examined Dr. Fuentes work and found it in order
He granted Dr. Fuentes permission to leave
He ordered the closure of the incision
 HOSPITAL OWNER PSI SOLIDARILY LIABLE WITH DR. AMPIL [NCC 2180], AND
DIRECTLY LIABLE TO SPS. AGANAS [NCC 2176]

Previously, employers cannot be held liable for the fault or negligence of its
professionals. However, this doctrine has weakened since courts came to realize
that modern hospitals are taking a more active role in supplying and regulating
medical care to its patients, by employing staff of physicians, among others.
Hence, there is no reason to exempt hospitals from the universal rule of respondeat
superior. Here are the Courts bases for sustaining PSIs liability:

Ramos v. CA doctrine on E-E relationship
o For purposes of apportioning responsibility in medical negligence cases,
an employer-employee relationship in effect exists between hospitals and their
attending and visiting physicians. [LABOR LESSON: power to hire, fire, power of
control]

Agency principle of apparent authority / agency by estoppel

o Imposes liability because of the actions of a principal or employer in somehow
misleading the public into believing that the relationship or the authority exists
[see NCC 1869]
o PSI publicly displays in the Medical City lobby the names and specializations of
their physicians. Hence, PSI is now estopped from passing all the blame to the
physicians whose names it proudly paraded in the public directory, leading the
public to believe that it vouched for their skill and competence.

If doctors do well, hospital profits financially, so when negligence mars the

quality of its services, the hospital should not be allowed to escape liability
for its agents acts.

Doctrine of corporate negligence / corporate responsibility

o This is the judicial answer to the problem of allocating hospitals liability for the
negligent acts of health practitioners, absent facts to support the application
of respondeat superior.
o This provides for the duties expected [from hospitals]. In this case, PSI failed to
perform the duty of exercising reasonable care to protect from harm all
patients admitted into its facility for medical treatment. PSI failed to conduct
an investigation of the matter reported in the note of the count nurse, and
this established PSIs part in the dark conspiracy of silence and
concealment about the gauzes.

PSI has actual / constructive knowledge of the matter, through the report of
the attending nurses + the fact that the operation was carried on with the
assistance of various hospital staff
 o It also breached its duties to oversee or supervise all persons who practice
medicine within its walls and take an active step in fixing the negligence
committed

PSI also liable under NCC 2180

o It failed to adduce evidence to show that it exercised the diligence of a good
father of the family in the accreditation and supervision of Dr. Ampil


DR. CANTRE v. GO

FACTS:

Petitioner Dr. Milagros L. Cantre is a specialist in obstetrics and gynecology at the

Dr. Jesus Delgado memorial Hospital. She was the attending physician of respondent
Nora Go, who was admitted at the said hospital on April 19, 1992. At 1:30am of
April 20, 1992, Nora gave birth to her fourth child, a baby boy. However, at around
3:30am Nora suffered profuse bleeding insider her womb due to some parts of the
placenta were not completely expelled from her womb after delivery consequently,
Nora suffered hypovolemic shock, resulting in a drop in her blood pressure to 40/0.
Petitioner said the assisting resident physician performed various medical
procedures to stop the bleeding and to restore Noras blood pressure. Her blood
pressure was frequently monitored with the use of a sphygmamometer. While
petitioner was massaging Noras uterus for it to contract and stop bleeding, she
ordered a drop light to warm Nora and her baby.

Nora remained unconscious until she recovered. While in the recovery room, her
husband, respondent John David Z. Go noticed a fresh gasping wound 2 1/2 x 3
1/2 in the inner portion of her left arm, close to the armpit. He asked the nurses
what caused the injury. He was informed, it was a burn. An investigation was filed
by Noras husband and found out from the petitioner that it was caused by the blood
pressure cuff, however, this was contrary to the findings from a medico-legal report
which stated that it was indeed a burn and that a drop light when placed near a skin
for about 10mins could cause such burn. Nora was referred to a plastic surgeon
from the hospital and skin grafting was done on her and scar revision but both still
left a mark on Noras arm compelling the respondent spouse to file a complaint for
damages against petitioner.

ISSUE:

Whether or not petitioner is liable for the injury referred by Nora.

HELD:

Yes. The Hippocratic oath mandates physicians to give primordial consideration to

the well-being of their patients. If a doctor fails to live up to his precept, he is
accountable for his acts. This is notwithstanding, courts face a unique restraint in
adjudicating medical negligence cases because physicians are not guardians of care
and they never set out to intentionally cause injury to their patients. However,
intent is immaterial in negligence cases because where negligence exist and is
proven, it automatically gives the injured a right to reparation for the damage
caused.

In cases, involving medical negligence, the doctrine of res ipsa liquitor allows the
mere existence of an injury to justify a presumption of negligence on the part of the
person who controls the instrument causing the injury, provided that the following
requisites concur:

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

All of these three requisites were present in the case at bar.

Under the the captain of the ship doctrine, the surgeon in charge of the operation is
liable for the negligence of his assistants during the time when those are under the
surgeons control.