G.R. No. 126297 January 31, 2007
Fuentes had completed the hysterectomy,
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
AGANA, Respondents.
DECISION
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankinds most
important and delicate endeavors, must assume the
grave responsibility of pursuing it with appropriate
care. The care and service dispensed through this
high trust, however technical, complex and esoteric its
character may be, must meet standards of
responsibility commensurate with the undertaking to
preserve and protect the health, and indeed, the very
lives of those placed in the hospitals keeping.1
Assailed in these three consolidated petitions for
review on certiorari is the Court of Appeals
Decision2 dated September 6, 1996 in CA-G.R. CV
No. 42062 and CA-G.R. SP No. 32198 affirming with
modification the Decision3dated 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 Hospital (Medical City Hospital)
because of difficulty of bowel movement and bloody
anal discharge. After a series of medical
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 spread on her
left ovary, necessitating the removal of certain
portions of it. Thus, Dr. Ampil obtained the consent of
Natividads husband, Enrique Agana, to permit Dr.
Juan Fuentes, respondent in G.R. No. 126467, to
perform hysterectomy on her.
After Dr.
Dr. Ampil took over, completed the operation and
closed the incision.
However, the operation appeared to be flawed. In the
corresponding Record of Operation 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 medical bills, including the
doctors fees, amounted to P60,000.00.
After a couple of days, Natividad complained of
excruciating pain in her anal region. She consulted
both Dr. Ampil and Dr. Fuentes about it. They told her
that the pain was the natural consequence of the
surgery. Dr. Ampil then recommended that she consult
an oncologist to examine the cancerous nodes which
were not removed during the operation.
ENRIQUE
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 width. 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 the
presence of another foreign object in her vagina -- a
foul-smelling gauze measuring 1.5 inches in width
which badly infected her vaginal vault. A recto-vaginal
fistula had formed in her reproductive organs which
forced stool to excrete through the vagina. Another
surgical operation was needed to remedy the
damage. Thus, in October 1984, Natividad underwent
another surgery.
On November 12, 1984, Natividad and her husband
filed with the RTC, Branch 96, Quezon City a
complaint for damages against the Professional
Services, Inc. (PSI), owner of the Medical City
Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil
Case No. Q-43322. They alleged that the latter are
liable for negligence for 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 failed 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 above-named 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 defendants PROFESSIONAL
SERVICES, INC., DR. MIGUEL AMPIL and DR. JUAN
FUENTES to pay to the plaintiffs, jointly and severally,
except in respect of the award for exemplary
damages and the interest thereon which are the
liabilities of 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 rate 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
daughter;
c. The total sum of P45,802.50,
representing the cost of hospitalization
at Polymedic 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 Appeals, docketed as CA-
G.R. CV No. 42062.
Incidentally, on April 3, 1993, the Aganas filed with the
RTC a motion for a partial execution of its Decision,
which was granted in an Order dated May 11, 1993.
Thereafter, the sheriff levied upon certain 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 September 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 for injunctive relief.
On January 24, 1994, CA-G.R. SP No. 32198 was
consolidated with CA-G.R. CV No. 42062.
Meanwhile, on January 23, 1995, the PRC Board of
Medicine rendered its Decision6 in Administrative
Case No. 1690 dismissing the case against Dr.
Fuentes. The Board held that the prosecution failed to
show that Dr. Fuentes was the one who left the two
pieces of gauze inside Natividads body; and that he
concealed such fact from Natividad.
On September 6, 1996, the Court of Appeals
rendered its Decision jointly disposing 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 defendant-appellant 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 the
respondent judge dated September 21, 1993, as well
as the alias writ of execution issued pursuant thereto
are hereby NULLIFIED and SET ASIDE. The bond
posted by the petitioner in connection with the writ of
preliminary injunction issued 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 Resolution7 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 liable with Dr.
Ampil; and (3) it is not entitled to its counterclaim
against the Aganas. PSI contends that Dr. Ampil is not
its employee, but a mere consultant or independent
contractor. As such, he alone should answer for his
negligence.
In G.R. No. 126467, the Aganas maintain that the
Court of Appeals erred in finding that Dr. Fuentes is
not guilty of negligence or medical malpractice,
invoking the doctrine of res ipsa loquitur. They
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 in finding him liable for
negligence and malpractice sans evidence that he left
the two pieces of gauze in Natividads vagina. He
pointed to other probable causes, such as: (1) it was
Dr. Fuentes who used gauzes in performing the
hysterectomy; (2) the attending nurses failure to
properly count the gauzes used during surgery; and
(3) the medical intervention of the American doctors
who examined Natividad in the United States of
America.
For our resolution are these three vital issues: first,
whether the Court of Appeals erred in holding Dr.
Ampil liable for negligence and malpractice; second,
whether the Court of Appeals erred in absolving 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
possibilities: 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 Natividads
body. Neither did he submit evidence to rebut the
correctness of the record of operation, particularly the
number of gauzes used. As to the alleged negligence
of Dr. Fuentes, we are mindful that Dr. Ampil
examined his (Dr. Fuentes) work and found it in
order.
The glaring truth is that all the major circumstances,
taken together, as specified 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 the 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 search 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 until the sponges are properly
removed, and it is settled that the leaving of sponges
or other foreign substances in the wound after the
incision has been closed is at least prima facie
negligence by the operating surgeon. 8 To put it simply,
such act is considered so inconsistent with due care
as to raise an inference of negligence. There are even
legions of authorities to the effect that such act is
negligence per se.9
Of course, the Court is not blind to the reality that
there are times when danger 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 legal 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 permit. The ruling in Smith v.
Zeagler10 is explicit, thus:
The removal of all sponges used is part of a surgical
operation, and when a physician or surgeon fails to
remove a sponge he has placed in his patients body
that should be removed as part of the operation, 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 negligence. 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 prudent 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 objects,
such as gauzes, from Natividads body before closure
of the incision. When he failed to do so, it was his
duty to inform Natividad about it. Dr. Ampil breached
both duties. Such breach caused injury to Natividad,
necessitating her further examination by American
doctors and another surgery. That Dr. Ampils
negligence is the proximate cause 12 of Natividads
injury could be traced from his act of closing the
incision despite the information given by the attending
nurses that two pieces of gauze were still missing.
That they were later on extracted from Natividads
vagina established the causal link between Dr. Ampils
negligence and the injury. And what further
aggravated such injury was his deliberate
concealment of the missing gauzes from the
knowledge of Natividad and her family.
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. Fuentes on the ground that it is
contrary to the doctrine of res ipsa loquitur. According
to them, the fact that the two pieces of 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 presumption 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 under the exclusive control of the defendant
and the injury is such that it should not have occurred
if he, having such control used proper care, it affords
reasonable evidence, in the absence of explanation
that the injury arose from the defendants want of
care, and the burden of proof is shifted to him to
establish that he has observed due care and
diligence.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
control and management of the defendant; (3) the
occurrence was such that in the ordinary course of
things, would not have happened if those who had
control or management used proper care; and (4) the
absence of explanation by the defendant. Of the
foregoing requisites, the most instrumental is the
"control and management of the thing which caused
the injury."15
We find the element of "control and management of
the thing which caused the injury" 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 malignancy in her sigmoid area had spread to her
left ovary. Dr. Fuentes performed the surgery and
thereafter reported and showed his work to Dr. Ampil.
The latter examined it and finding everything to be in
order, allowed Dr. Fuentes to leave the operating
room. Dr. Ampil then resumed operating on Natividad.
He was about to finish the procedure when the
attending nurses informed him that two pieces of
gauze were missing. A "diligent search" was
conducted, but the misplaced gauzes were not found.
Dr. Ampil then directed that the incision be closed.
During this entire period, Dr. Fuentes 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 complete 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 such role is evident from his following
conduct: (1) calling Dr. Fuentes to perform a
hysterectomy; (2) examining the work 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 remained 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 In other
words, mere invocation and application of the doctrine
does not dispense with the requirement of proof of
negligence. 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 hospitals and the resulting theories
concerning their liability for the negligence of
physicians.
Until the mid-nineteenth century, hospitals were
generally charitable institutions, providing medical
services to the lowest classes of society, without
regard for a patients ability to pay.18 Those who could
afford medical treatment were usually treated at home
by their doctors.19 However, the days of house calls
and philanthropic health care are over. The modern
health care industry continues to distance itself from
its charitable past and has experienced a significant
conversion from a not-for-profit health care to for-
profit hospital businesses. Consequently, significant
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 vicarious liability under the
theories of respondeat superior, apparent authority,
ostensible authority, or agency by estoppel. 20
In this jurisdiction, the statute governing liability for
negligent acts is Article 2176 of the Civil Code, which
reads:
Art. 2176. Whoever by act or omission causes
damage to another, there being fault or negligence, is
obliged to pay for the damage done. Such fault or
negligence, if there is no pre-existing contractual
relation 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 liability 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 room, food, facilities for treatment and operation, and
x x
The owners and managers of an establishment or
enterprise are likewise responsible 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 household helpers acting within
the scope of their assigned tasks even though the
former are not engaged in any business or industry.
x x x the hospital and the physicians is rendered
x x x inconsequential in view of our categorical
The responsibility treated of in this article shall cease
when the persons herein 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 as 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 liable for the fault or negligence
they commit in the discharge of their duties, and their
employer cannot be held liable 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 status and the very nature
of the physicians calling preclude him from being
classed as an agent or employee of a hospital,
whenever he acts in a professional capacity. 22 It has
been said that medical practice strictly involves highly
developed and specialized knowledge, 23 such that
physicians are generally free to exercise their own
skill and judgment in rendering 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 responsibility.25
The case of Schloendorff v. Society of New York
Hospital26 was then considered an 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
doctrine, hospitals are exempt from the application of
the respondeat superior principle for fault or
negligence committed by physicians in the discharge
of their profession.
However, the efficacy of the foregoing doctrine has
weakened with the significant developments in
medical care. Courts came to realize that modern
hospitals are increasingly taking active role in
supplying and regulating medical care to patients. No
longer were a hospitals functions limited to furnishing
attendants for its patients. Thus, in Bing v.
Thunig,27 the New York Court of Appeals deviated
from the Schloendorff doctrine, noting that modern
hospitals actually do far more than provide facilities
for treatment. Rather, they regularly employ, on a
salaried basis, a large staff of physicians, interns,
nurses, administrative and manual workers. They
charge patients for medical care and treatment, even
collecting for such services through legal action, if
necessary. The court then concluded that there is no
reason to exempt hospitals from the universal rule of
respondeat superior.
In our shores, the nature of the relationship between
pronouncement in Ramos v. Court of Appeals 28 that
for purposes of apportioning responsibility in medical
negligence cases, an employer-employee relationship
in effect exists between hospitals and their attending
and visiting physicians. 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 "consultants," who are allegedly
not hospital employees, presents problems in
apportioning responsibility for negligence in medical
malpractice cases. However, the difficulty is more
apparent than real.
In the first place, hospitals exercise significant control
in the hiring and firing of consultants and in the
conduct of their work within the hospital premises.
Doctors who apply for consultant slots, visiting or
attending, are required to submit proof of completion
of residency, their educational qualifications,
generally, evidence of accreditation by the appropriate
board (diplomate), evidence of fellowship in most
cases, and references. These requirements are
carefully scrutinized by members of the hospital
administration or by a review committee set up by the
hospital who either accept or reject the application. x
x x.
After a physician is accepted, either as a visiting or
attending consultant, he is normally required to attend
clinico-pathological conferences, conduct bedside
rounds for clerks, interns and residents, moderate
grand rounds and patient audits and perform other
tasks and responsibilities, for the privilege of being
able to maintain a clinic in the hospital, and/or for the
privilege of admitting patients into the hospital. In
addition to these, the physicians performance as a
specialist is generally evaluated by a peer review
committee on the basis of mortality and morbidity
statistics, and feedback from patients, nurses, interns
and residents. A consultant remiss in his duties, or a
consultant who regularly falls short of the minimum
standards acceptable to the hospital or its peer review
committee, is normally politely terminated.
In other words, private hospitals, hire, fire and
exercise real control over their attending and visiting
consultant staff. While consultants are not,
technically employees, x x x, the control exercised,
the hiring, and the right to terminate consultants all
fulfill the important hallmarks of an employer-
employee relationship, with the exception of the
payment of wages. In assessing whether such a
relationship in fact exists, the control test is
determining. Accordingly, on the basis of the
foregoing, we rule that for the purpose of allocating
responsibility in medical negligence cases, an
employer-employee relationship in effect exists
between hospitals and their attending and visiting
physicians. "
But the Ramos pronouncement is not our only basis
in sustaining PSIs liability. Its 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 health professionals. The present case serves as a
perfect platform to test the applicability of these
doctrines, thus, enriching 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 origin from the law of
agency. It imposes liability, not as the result of the
reality of a contractual relationship, but rather
because of the actions of a principal or an employer in
somehow misleading the public into believing that the
relationship or the authority exists.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 which he knowingly permits the
agent to assume, or which he holds the agent out to
the public as possessing. The question in every case
is whether the principal has by his voluntary act
placed the agent in such a situation that a person of
ordinary 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 upheld 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/or employee and that a patient has
accepted treatment from that physician in the
reasonable belief that it is being rendered in behalf of
the hospital, then the hospital will be liable for the
physicians negligence.
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, from his silence or lack of
action, or his failure to repudiate the agency, knowing
that another person is acting on his behalf without
authority.
In this case, PSI publicly displays in the lobby of the
Medical City Hospital the 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 and competence." Indeed, PSIs
act is tantamount to holding out to the public that
Medical City Hospital, through its accredited
physicians, offers quality health care services. By
accrediting Dr. Ampil and Dr. Fuentes and publicly
advertising their qualifications, the hospital created
the impression that they were its agents, authorized to
perform medical or surgical services for its patients.
As expected, these patients, Natividad being one of
them, accepted the services on the reasonable belief
that such were being rendered by the hospital or its
employees, agents, or servants. The trial court
correctly pointed out:
x x x regardless of the education and status in life of
the patient, he ought not be burdened with the
defense of absence of employer-employee
relationship between the hospital and the independent
physician 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 exact on the hospital
greater, if not broader, legal responsibility for the
conduct of treatment and surgery within its facility 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.
Logically, 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 responsibility.
One allegation in the complaint in Civil Case No. Q-
43332 for negligence and malpractice 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, and medical interns who assisted Drs. Ampil
and Fuentes in the performance of their duties as
surgeons."34 Premised on the doctrine 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 answer to the problem of
allocating hospitals liability for the negligent acts of
health practitioners, absent facts to support the
application of respondeat superior or apparent
authority. Its formulation proceeds from the judiciarys
acknowledgment that in these modern times, the duty
of providing quality medical service is no longer the
sole prerogative and responsibility of the physician.
The modern hospitals have changed structure.
Hospitals now tend to organize a highly professional
medical staff whose competence and performance
need to be monitored by the hospitals commensurate
with their inherent responsibility to provide quality
medical care.35
The doctrine has its genesis in Darling v. Charleston
Community Hospital.36 There, 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
hospital.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 physicians; (3) the
overseeing or supervision of all persons who practice
medicine within its walls; and (4) the formulation,
adoption and enforcement of adequate rules and
policies that ensure quality care for its
patients.38 Thus, in Tucson Medical Center, Inc. v.
Misevich,39 it was held that a hospital, following the
doctrine of corporate responsibility, has the duty to
see that it meets the standards of responsibilities for
the care of patients. Such duty includes the proper
supervision of the members of its medical staff. And in
Bost v. Riley,40 the court concluded that a patient who
enters a hospital does so with the reasonable
expectation that it will attempt to cure him. The
hospital accordingly has the duty to make a
reasonable effort to monitor and oversee the
treatment prescribed and administered by the
physicians practicing in its premises.
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
treatment. 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 the matter reported in the nota
bene of the count nurse. Such failure established
PSIs part in the dark conspiracy of silence and
concealment 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
surgeons, and their institutions like PSIs hospital
facility, can callously turn their backs on and disregard
even a mere probability of mistake or negligence by
refusing or failing to investigate a report of such
seriousness as the one in Natividads case.
It is worthy to note that Dr. Ampil and Dr. Fuentes
operated on Natividad with the assistance of the
Medical City Hospitals staff, composed of resident
doctors, nurses, and interns. As such, it is reasonable
to conclude that PSI, as the operator of the hospital,
has actual or constructive knowledge of the
procedures carried out, particularly the report of the
attending nurses that the two pieces of gauze were
missing. 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 the 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 nurses report, to investigate
and inform Natividad regarding the missing gauzes
amounts to callous negligence. Not only did PSI
breach its duties to oversee or supervise all persons
who practice medicine within its walls, it also failed to
take an active step in fixing the negligence committed.
This renders PSI, not only vicariously liable for the
negligence of Dr. Ampil under Article 2180 of the Civil
Code, but also directly liable for its own negligence
under Article 2176. In Fridena, the Supreme Court of
Arizona held:
x x x In recent years, however, the duty of care owed
to the patient by the hospital has expanded. The
emerging trend is to hold the hospital responsible
where the hospital has failed to monitor and review
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 malpractice of a medical
practitioner because he was an independent
contractor within the hospital. The Court of Appeals
pointed out that the hospital had created a
professional staff whose competence and
performance was to be monitored and reviewed by
the governing body of the hospital, and the court held
that a hospital would be negligent where it had
knowledge or reason to believe that a doctor using
the facilities was employing a method of treatment or
care which fell below the recognized standard of care.
Subsequent to the Purcell decision, the Arizona Court
of Appeals held that a hospital 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. App. 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 performed 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 showing that
it exercised the diligence of a good father of a family
in the accreditation and supervision of the latter. In
neglecting to offer such proof, PSI failed to discharge
its burden under the last paragraph of Article 2180
cited earlier, and, therefore, 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 degree of learning, skill
and experience required by his profession. At the
same time, he must apply reasonable care and
diligence in the exercise of his skill and the application
of his knowledge, and exert his best judgment.

WHEREFORE, we DENY all the petitions and

AFFIRM the challenged Decision of the Court 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.