Flores vs.

Pineda; Torts- medical malpractice

07/01/20131 Comment
G.R. No. 158996

November 14, 2008

Facts:
Teresita Pineda consulted Dr. Fredelicto Flores, regarding her medical condi
tion. She complained of general body weakness, loss of appetite, frequent urinat
ion and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto initially interv
iewed the patient and asked for the history of her monthly period to analyze the
probable cause of the vaginal bleeding and subsequently advised her to return t
he following week or to go to the United Doctors Medical Center (UDMC) in Quezon
City for a general check-up.
Teresita did not return the next week as advised. However, when her conditio
n persisted, she went to further consult Dr. Flores at his UDMC clinic in Quezon
City. Dr. Fredelicto did a routine check-up and ordered Teresita's admission to
the hospital. In the admission slip, he directed the hospital staff to prepare
the patient for an "on call" D&C operation to be performed by his wife, Dr. Feli
cisima Flores, despite his suspicion that Teresita was suffering from diabetis.
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 a
nd Dr. Fredelicto, conferred on the patient's medical condition, while the resid
ent physician and the medical intern gave Dr. Felicisima their own briefings. Sh
e also interviewed and conducted an internal vaginal examination of the patient
which lasted for about 15 minutes. Dr. Felicisima thereafter called up the labor
atory for the results of the tests. At that time, only the results for the blood
sugar (BS), uric acid determination, cholesterol determination, and complete bl
ood count (CBC) were available. The preliminary laboratory results indicated tha
t the blood sugar of the victim was high.
After the operation, Teresita's condition had worsened. She experienced diff
iculty in breathing and was rushed to the intensive care unit. Further tests con
firmed that she was suffering from Diabetes Mellitus Type II. Insulin was admini
stered on the patient, but the medication might have arrived too late. Due to co
mplications induced by diabetes, Teresita died in. Believing that it was neglige
nce of petitioners that caused the death of Teresita, respondents filed a medica
l negligence case. The trial court and the CA rule in their favor.
Issue:
Whether or not petitioners were negligent.
Ruling:
Yes, however it is proper that a discussion of the meaning and elements of m
edical negligence must be made before proceeding to the ruling on to the issue.
A medical negligence case is a type of claim to redress a wrong committed by
a medical professional, that has caused bodily harm to or the death of a patien
t. There are four elements involved in a medical negligence case, namely: duty,
breach, injury, and proximate causation.
However, the burden of proof lies on the plaintiff, thus he must prove that:
(1) the physician either failed to do something which a reasonably prudent heal
th care provider would have done, or that he did something that a reasonably pru
dent provider would not have done; and (2) the failure or action caused injury t
o the patient. Expert testimony is therefore essential since the factual issue o
f 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 expert opinion.
The elements of medical negligence:

Duty refers to the standard of behavior which imposes restrictions on one's

conduct. The standard in turn refers to the amount of competence associated with
the proper discharge of the profession. A physician is expected to use at least
the same level of care that any other reasonably competent doctor would use und
er the same circumstances. Breach of duty occurs when the physician fails to com
ply with these professional standards. If injury results to the patient as a res
ult of this breach, the physician is answerable for negligence.
Breach of Duty
There was a breach of duty in this case since the urinary results shows that
the blood sugar of the victim was high, indicative of diabetes. And under these
circumstances according to expert witnesses, "the attending physician should ha
ve postponed the D&C operation in order to conduct a confirmatory test to make a
conclusive diagnosis of diabetes and to refer the case to an internist or diabe
tologist. This was corroborated by Dr. Delfin Tan (Dr. Tan), an obstetrician and
gynecologist, who stated that the patient's diabetes should have been managed b
y an internist prior to, during, and after the operation."
Moreover, petitioners contention that they are concerned with the vaginal bl
eeding of the victim does not ablsolve them of liability. This, contention adds
the court, does not warrant absolution but rather reflects the petitioners incom
petence! Expert witnesses testified that vaginal bleeding is only rarely so heav
y and life-threatening that urgent first-aid measures are required. Thus, D&C op
eration on a hyperglycemic patient may be justified only when it is an emergency
case - when there is profuse vaginal bleeding.
In this case, the court choose not to rely on the assertions of the petition
er spouses that there was profuse bleeding, not only because the statements were
self-serving, but also because the petitioner spouses were inconsistent in thei
r testimonies. Dr. Fredelicto testified earlier, he personally saw the bleeding,
but later on said that he did not see it and relied only on Teresita's statemen
t that she was bleeding. He went on to state that he scheduled the D&C operation
without conducting any physical examination on the patient. These acts of petit
ioners are indicia of breach of their duties as physicians.
Casual Connection of the Injury and Breach of Duty
It must be noted that a verdict in a malpractice action cannot be based on s
peculation or conjecture. Causation must be proven within a reasonable medical p
robability based upon competent expert testimony.
The acts of petitioners in proceeding the D & C operation without adequately
preparing the victim is the logical cause of the latter's death. Relying on expe
rt testimonies and reliable medical literatures, explained the court: "stress, w
hether physical or emotional, is a factor that can aggravate diabetes; a D&C ope
ration is a form of physical stress. Dr. Mendoza explained how surgical stress c
an aggravate the patient's hyperglycemia: when stress occurs, the diabetic's bod
y, especially the autonomic system, reacts by secreting hormones which are count
er-regulatory; she can have prolonged hyperglycemia which, if unchecked, could l
ead to death. Medical literature further explains that if the blood sugar has be
come very high, the patient becomes comatose (diabetic coma). When this happens
over several days, the body uses its own fat to produce energy, and the result i
s high levels of waste products (called ketones) in the blood and urine (called
diabetic ketoacidiosis, a medical emergency with a significant mortality). This
was apparently what happened in Teresita's case; in fact, after she had been ref
erred to the internist Dr. Jorge, laboratory test showed that her blood sugar le
vel 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 Teres
ita's death due to aggravated diabetic condition is therefore sufficiently estab
lished."

Petitioners were guilty of negligence. Their negligence is not solely the ac

t of ordering an "on call" D&C operation when he was mainly an anesthesiologist
who had made a very cursory examination of the patient's vaginal bleeding compla
int. Rather, it was his failure from the very start to identify and confirm, des
pite the patient's complaints and his own suspicions, that diabetes was a risk f
actor that should be guarded against, and his participation in the imprudent dec
ision to proceed with the D&C operation despite his early suspicion and the conf
irmatory early laboratory results. Ergo, they are liable for damages.