LEGAL MEDICINE DOCTRINES AND JURISPRUDENCE

I. PHYSICIAN AND THIRD PARTY TORTFEASORS

1. DOCTRINE OF APPARENT AUTHORITY

The doctrine of apparent authority, also known as “holding out theory” or
doctrine of ostensible agency or agency by estoppel, is a means of imposing liability not
based on contract but based on principle of estoppel.
Under the doctrine of apparent authority a hospital can be held vicariously liable
for the negligent acts of a physician providing care at the hospital, regardless of whether
the physician is an independent contractor, unless the patient knows, or should have
known, that the physician is an independent contractor.

JURISPRUDENCE:

A. ROGELIO NOGALES vs. CAPITOL MEDICAL CENTER et al.

511 SCRA 223, DECEMBER 19, 2006

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. 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"). t 6:13 a.m., Corazon started to experience convulsions. At 6:22
a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract
Corazon's baby. In the process, a 1.0 x 2.5 cm. piece of cervical tissue was
allegedly torn.At 6:27 a.m., Corazon began to manifest moderate vaginal
bleeding which rapidly became profuse. Corazon died at 9:15 a.m. The cause
of death was "hemorrhage, post partum.

ISSUE:

Whether or not Capitol Medical Center is vicariously liable for the negligence
of Dr. Estrada.

HELD:

Private hospitals, hire, fire and exercise real control over their attending and
visiting "consultant" staff. The basis for holding an employer solidarily
responsible for the negligence of its employee is found in Article 2180 of the

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 Civil Code which considers a person accountable not only for his own acts
but also for those of others based on the former's responsibility under a
relationship of patria potestas.

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”.

For a hospital to be liable under the doctrine of apparent authority, a plaintiff

must show that: (1) the hospital, or its agent, acted in a manner that would
lead a reasonable person to conclude that the individual who was alleged to
be negligent was an employee or agent of the hospital; (2) where the acts of
the agent create the appearance of authority, the plaintiff must also prove that
the hospital had knowledge of and acquiesced in them; and (3) the plaintiff
acted in reliance upon the conduct of the hospital or its agent, consistent with
ordinary care and prudence. In the instant case, CMC impliedly held out Dr.
Estrada as a member of its medical staff. Through CMC's acts, CMC clothed
Dr. Estrada with apparent authority thereby leading the Spouses Nogales to
believe that Dr. Estrada was an employee or agent of CMC.

B. SAN JUAN DE DIOS HOSPITAL VS. NELSON CORTEJO

752 SCRA 379 MARCH 11, 2015

FACTS:

Edmer Cortejo (Edmer) was brought to the emergency room of San Juan de
Dios Hospital (SJDH) by his mother, Mrs. Jesusa Cortejo (Jesusa) due to
difficulty in breathing, chest pains, stomach pain, and fever. Dr. Ramoncito
Livelo (Livelo), a family doctor, initially attended to Edmer and after a few
tests had the initial impression of Bronchopneumonia. Dr. Livelo then gave
Edmer some antibiotics to lessen his fever and loosen his phlegm.

Jesusa did not know anyone from SJDH. Jesusa used her fortune card and was
referred to a Fortune Care Coordinator, who was then absent. She got assigned
to Dr. Noel Casumpang (Casumpang) who appeared to be an employee of the
hospital. Dr. Casumpang examined Edmer for the first time and merely used a
stethoscope and determined that it was Bronchopneumonia. Not satisfied, she
stated that Edmer had high fever, no colds or cough; Dr. Casumpang said that
it was normal for Bronchopneumonia. The following day early morning,
Edmer had now a fever, throat irritation and even stomach and chest pains.
Despite being known to such information, Dr. Casumpang mere inquired if
Edmer had asthma, reassured that the illness was Bronchopneumonia.

Later in the morning, Edmer began vomiting phlegm with blood streak.
Nelson Cornejo (Nelson), Edmer’s father, thus called for a doctor and Dr.

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Ruby Miranda-Sanga came to their call. Dr. Sanga examined Edmer and
found that he had a low grade non continuing fever, rashes that were not
typical of dengue fever. Dr. Ruby had told Dr. Casumpang of the symptoms.
She failed to positively diagnose the patient immediately because the blood
streak was washed by Nelson, thus she ordered the next time it occurred
Nelson should preserve the same. Upon acquiring a sample she positively
determined that it was Dengue Hemorrahgic Fever. Dr. Casumpang advised
that Edmer be bought to the ICU, to which the spouses Cortejo agreed to but
the ICU was full, thus they opted to go to Makati Medical Center. Upon
arriving it was declared that it was already at stage IV and thus irreverisible.
Edmer died.

ISSUE:

Whether or not San Juan De Dios hospital is liable for the negligence of the
doctors.

HELD:

SJDH is solidarily liable based on The Principle of Agency or Doctrine

of Apparent Authority.

The Supreme Court held that, under the doctrine of apparent authority, a
hospital can be held vicariously liable for the negligent acts of a physician
providing care at the hospital, regardless of whether the physician is an
independent contractor, unless the patient knows, or should have known, that
the physician is an independent contractor.

The doctrine of apparent authority, a plaintiff must show that:

(1) the hospital, or its agent, acted in a manner that would lead a reasonable
person to conclude that the individual who was alleged to be negligent was an
employee or agent of the hospital; (2) where the acts of the agent create the
appearance of authority, the plaintiff must also prove that the hospital had
knowledge of and acquiesced in them; and (3) the plaintiff acted in reliance
upon the conduct of the hospital or its agent, consistent with ordinary care and
prudence. (Emphasis supplied)

The first factor focuses on the hospital’s 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. The second factor focuses on the patient's reliance. It is sometimes
characterized as an inquiry on whether the plaintiff acted in reliance upon the

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 conduct of the hospital or its agent, consistent with ordinary care and
prudence. (Citation omitted)

HOSPITAL’S MANIFESTATIONS: In this case, the court considered the act

of the hospital of holding itself out as provider of complete medical care, and
considered the hospital to have impliedly created the appearance of authority.

PATIENT’S RELIANCE: SDJH CLOTHED DR. CASUMPANG W/

APPARENTAUTHORITY
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.

Significantly, the respondent had relied on SJDH's representation of Dr.

Casumpang's authority. To recall, when Mrs. Cortejo presented her Fortune
Care card, she was initially referred to the Fortune Care coordinator, who was
then out of town. She was thereafter referred to Dr. Casumpang, who is also
accredited with Fortune Care. In both instances, SJDH through its agent failed
to advise Mrs. Cortejo that Dr. Casumpang is an independent contractor.

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, not only as an accredited member of Fortune Care, but also
as a member of its medical staff.

C. DEBORAH IRVING VS. DOCTORS HOSPITAL OF LAKE WORTH,

INC.

FACTS:

The appellant, Deborah Irving as mother and next friend of her daughter,
Jennifer Johnson, sued Gilbert R. Panzer, M.D., Doctors Hospital of Lake
Worth, Inc., and Florida Patients Compensation Fund to recover damages for
the negligence of Dr. Panzer in failing to diagnose that Jennifer Johnson was
suffering from meningitis when she was brought to the emergency room of
Doctors Hospital for treatment. Prior to trial Irving settled with Panzer and the
hospital's primary insurer paid her $100,000. The Patients Compensation Fund
was obliged to pay any damages for which the hospital was liable in excess of
$100,000. The case against the hospital was tried by jury, and resulted in a
finding of no liability because the jury agreed Panzer was not an employee of
the hospital.

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 Irving contends the judgment should be reversed because the trial court erred
1) in failing to direct a verdict for the plaintiff because there was no dispute
that Panzer was the hospital's employee and that he was negligent; and 2) in
failing to give appellant's requested instructions to the jury on the exceptions
to the independent contractor rule. From our study of the briefs and record we
conclude no error is demonstrated by the first point because a jury question
was presented. However, we conclude that reversible error was committed
when the trial court instructed the jury regarding the non-liability of an
independent contractor without including the inculpatory exceptions to that
rule that had been requested by Irving.

ISSUE:

Whether or not the hospital is vicariously liable for the negligence of its
emergency room physician.

HELD:

Yes. The doctrine of apparent authority 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.

The court establishes that a hospital which provides emergency room services
has a non-delegable duty to provide competent emergency treatment based
upon an implied contract. It is therefore clear that the plaintiff could have
pleaded a claim against the hospital for the emergency room doctor's
negligence on a non-delegable duty theory. The imposition of a non-delegable
duty to provide competent emergency room services makes sense, because a
patient in an emergency room generally has little, if any, control over who
will be the treating physician.

2. DOCTRINE OF CORPORATE NEGLIGENCE

Under the doctrine of corporate negligence, the hospital owes a direct duty to its
patients to its patients to ensure their safety and well-being while at the hospital. In
Philippine jurisdiction, this has been translated as the “duty to exercise reasonable care to
protect from harm all patients admitted into its facility for medical treatment.”
JURISPRUDENCE:
A. PROFESSIONAL SERVICES, INC. VS. NATIVIDAD AND ENRIQUE
AGANA 513 SCRA 478 JANUARY 31, 2007

FACTS:
Natividad Agana was rushed to the Medical City Hospital because of difficulty of bowel
movement and bloody anal discharge. Dr. Miguel Ampil, diagnosed her to be suffering

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from “cancer of the sigmoid.” Dr. Ampil, assisted by the medical staff 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 Natividad’s husband,
Enrique Agana, to permit Dr. Juan Fuentes, to perform hysterectomy on her.

After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over,
completed the operation and closed the incision. However, the operation appeared
to be flawed. 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.

Two weeks after Natividad returned from the United States to seek further
treatment, 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. Ampil’s 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.

Natividad and her husband filed with the RTC a complaint for damages against
the Professional Services, Inc. (PSI), owner of the Medical City Hospital, Dr.
Ampil, and Dr. Fuentes. They alleged that the latter are liable for negligence for
leaving two pieces of gauze inside Natividad’s body and malpractice for
concealing their acts of negligence.

Pending the outcome of the above cases, Natividad died and was duly substituted
by her children (the Aganas). The RTC rendered its Decision in favor of the
Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable for negligence and
malpractice.

The Court of Appeals rendered its Decision dismissing the case against Dr.
Fuentes with Dr. Ampil liable to reimburse Professional Services, Inc., whatever
amount the latter will pay or had paid to the plaintiffs.

ISSUE:

Whether or not PSI may be held solidarily liable for the negligence of Dr. Ampil.

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HELD:

Yes, PSI is solidarily liable for the negligence of Dr. Ampil. In Ramos v. Court of
Appeals, the court held that private hospitals, hire, fire and exercise real control
over their attending and visiting ‘consultant’ staff. While ‘consultants’ are not,
technically employees, 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. The court held 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.

Its liability is anchored upon the doctrine of corporate negligence.

Under the doctrine of corporate negligence or corporate responsibility, 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.
Premised on the doctrine of corporate negligence, the trial court held that PSI is
directly liable for such breach of duty.

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.

It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the
assistance of the Medical City Hospital’s 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, 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.

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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 Dr. Ampil. In neglecting to offer such proof, PSI
failed to discharge its burden under the last paragraph of Article 2180 and,
therefore, must be adjudged solidarily liable with Dr. Ampil.

B. OUR LADY OF LOURDES HOSPITAL VS. SPOUSES ROMEO AND

REGINA CAPANZANA 821 SCRA 258 MARCH 22, 2017

FACTS:

Regina was scheduled for her third caesarean section (C-section) on 2 January
1998. However, a week earlier, on 26 December 1997, she went into active labor
and was brought to petitioner hospital for an emergency C-section. She first
underwent a preoperative physical examination by Dr. Miriam Ramos (Dr.
Ramos) and Dr. Milagros Joyce Santos, (Dr. Santos) the same attending
physicians in her prior childbirths. She was found fit for anesthesia after she
responded negatively to questions about tuberculosis, rheumatic fever, and
cardiac diseases. On that same day, she gave birth to a baby boy. When her
condition stabilized, she was discharged from the recovery room and transferred
to a regular hospital room.

At 2:30 a.m. the following day, or 13 hours after her operation, Regina who was
then under watch by her niece, Katherine L. Balad (Balad), complained of a
headache, a chilly sensation, restlessness, and shortness of breath. She asked for
oxygen and later became cyanotic. After undergoing an x-ray, she was found to
be suffering from pulmonary edema. She was eventually transferred to the
Intensive Care Unit, where she was hooked to a mechanical ventilator. The
impression then was that she was showing signs of amniotic fluid embolism.

On 2 January 1998, when her condition still showed no improvement, Regina was
transferred to the Cardinal Santos Hospital. The doctors thereat found that she
was suffering from rheumatic heart disease mitral stenosis with mild pulmonary
hypertension, which contributed to the onset of fluid in her lung tissue
(pulmonary edema). This development resulted in cardiopulmonary arrest and,
subsequently, brain damage. Regina lost the use of her speech, eyesight, hearing
and limbs. She was discharged, still in a vegetative state, on 19January 1998.

Respondent spouses Capanzana filed a complaint for damages against petitioner

hospital, along with co-defendants: Dr. Miriam Ramos, an
obstetrician/gynecologist; Dr. Milagros Joyce Santos, an anesthesiologist; and
Jane Does, the nurses on duty stationed on the second floor of petitioner hospital
on 26-27 December 1997.

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ISSUE:

Whether or not the hospital is liable.

HELD:

The court ruled that petitioner hospital should be held liable based on the doctrine
of corporate responsibility. It was found that while there was evidence to prove
that petitioner hospital showed diligence in its selection and hiring processes,
there was no evidence to prove that it exercised the required diligence in the
supervision of its nurses. Also, the appellate court ruled that the non-availability
of an oxygen unit on the hospital floor, a fact that was admitted, constituted gross
negligence on the part of petitioner hospital. The CA stressed that, as borne out by
the records, there was only one tank in the ward section of 27 beds. It said that
petitioner hospital should have devised an effective way for the staff to properly
and timely respond to a need for an oxygen tank in a situation of acute distress.

The Court has emphasized that a higher degree of caution and an exacting
standard of diligence in patient management and health care are required of a
hospital’s staff, as they deal with the lives of patients who seek urgent medical
assistance. It is incumbent upon nurses to take precautions or undertake steps to
safeguard patients under their care from any possible injury that may arise in the
course of the latter’s treatment and care.

The Court further notes that the immediate response of the nurses was especially
imperative, since Regina herself had asked for oxygen. They should have been
prompted to respond immediately when Regina herself expressed her needs,
especially in that emergency situation when it was not easy to determine with
certainty the cause of her breathing difficulty. Indeed, even if the patient had not
asked for oxygen, the mere fact that her breathing was labored to an abnormal
degree should have impelled the nurses to immediately call the doctor and to
administer oxygen.

C. DARLING VS. CHARLESTON COMMUNITY MEMORIAL

HOSPITAL 33 Ill. 2d 326, 211 N.E. 2d 253

FACTS:

Darling (Plaintiff) was taken to the emergency room at Charleston Community

Memorial Hospital (Defendant) when he broke his leg. The attending physician,
Dr. Alexander (Defendant), set the break and put the leg in a cast. The next day,
Plaintiff’s toes turned dark and cold. The cast was removed, but much of the
tissue in the leg had become necrotic from constriction caused by the cast.
Eventually the lower leg had to be amputated. Plaintiff brought suit against
Alexander (Defendant) and Charleston (Defendant). After Plaintiff settled with
Alexander (Defendant), he tried the case against Charleston (Defendant). The

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 jury returned a verdict of $150,000.00. The court of appeals affirmed this, and the
Supreme Court of Illinois granted review on the issue of whether or not a hospital
could be held liable for the negligence of its staff.

ISSUE:

May a hospital be liable for the negligence of its staff?

HELD:

Yes. A hospital is liable for the negligence of its staff under the doctrine of
Corporate Negligence. There is no reality to the idea that a hospital provides
facilities only and does not claim to act through its staff doctors and nurses.
Modern hospitals provide facilities and much more. They employ a large staff of
doctors, nurses, administrators, and other workers, and are not hesitant to collect
fees for services performed at the hospital. A person goes to a hospital and
reasonably expects the hospital as an entity to treat him. Therefore, no legitimate
basis exists for not holding a hospital vicariously responsible for torts of its
employed staff. In this case, the jury found negligence by both Alexander
(Defendant) in the procedures he used, and the nursing staff in their follow-ups.
This was thoroughly supported by the evidence.

II. APPLICABLE TO PHYSICIAN TORTFEASORS

1. RES IPSA LOQUITUR

The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a
matter of common knowledge and experience, the very nature of certain types of
occurrences may justify an inference of negligence on the part of the person who controls
the instrumentality causing the injury in the absence of some explanation by the
defendant who is charged with negligence.

JURISPRUDENCE:

A. DR. MILAGROS L. CANTRE VS. SPS. JOHN DAVID Z. GO AND

NORA S. GO 522 SCRA 547, APRIL 27, 2007

FACTS:

Nora Go gave birth to her 4th child. Two hours later, she suffered profuse
bleeding inside her womb due to some placenta parts which were not completely
expelled after delivery. She then suffered hypovolemic shock, so her BP dropped
to 40/0. Dr. Milagros Cantre, an Ob-Gyne specialist and Nora's attending
physician, together with an assisting resident physician, performed various
medical procedures to stop the bleeding and to restore Nora's BP. While Dr.
Cantre was massaging Nora's uterus for it to contract and stop bleeding, she

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ordered a droplight to warm Nora and her baby. At that time, she was
unconscious.

While in the recovery room, Nora's husband John David noticed a fresh gaping
wound (2 1/2 x 3 1/2 in) in the inner portion of her left arm near the armpit. When
he asked the nurses about the cause of the injury, he was informed that it was due
to a burn. John David filed a request for investigation. Dr. Cantre said that what
caused the injury was the blood pressure cuff. John David brought Nora to the
NBI for a physical examination. The medico-legal said that the injury appeared to
be a burn and that a droplight when placed near the skin for about 10 minutes
could cause such burn. He dismissed the likelihood that the wound was caused by
a blood pressure cuff since the scar was not around the arm, but just on one side
of the arm. Nora's injury was referred to a plastic surgeon for skin grafting.
However, her arm would never be the same--the surgery left an unsightly scar, her
movements are restricted, and the injured arm aches at the slightest touch.

ISSUE:

Whether or not Dr. Cantre is liable for the injury suffered by Nora Go.

HELD:

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

1. Accident is of a kind which ordinarily does not occur absent someone's

negligence
o Wound not an ordinary occurrence in the act of delivering a baby;
could not have happened unless negligence set in somewhere
2. Caused by an instrumentality within defendant's exclusive control
o It doesn't matter WON the injury was caused by the droplight or by the
blood pressure cuff, since both are within the exclusive control of the
physician in charge [Dr. Cantre] under the captain of the ship doctrine
[surgeon in charge of an operation is held liable for his assistants'
negligence during the time when they are under the surgeon's control].
3. Possibility of contributing conduct which would make plaintiff responsible
is eliminated
o Wound could only be caused by something external to and outside the
control of Nora since she was unconscious while in hypervolemic
shock.

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New Civil Code provisions applied

 NCC 2176. Whoever by act or omission causes damage to another, there

being fault or negligence, is obliged to pay for the damage done. [...]
 NCC 2217. Moral damages include physical suffering, mental anguish, fright,
serious anxiety, besmirched reputation, wounded feelings, moral shock, social
humiliation, and similar injury. Though incapable of pecuniary computation,
moral damages may be recovered if they are the proximate result of the
defendant's wrongful act or omission. [200k moral damages awarded]

B. RAMOS VS. COURT OF APPEALS

321 SCRA 584 DECEMBER 29, 1999

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.
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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 plaintiff’s 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 damaged—res ipsa loquitur!—the thing speaks for itself!

C. DR. VICTORIA L. BATIQUIN AND ALLAN BATIQUIN VS. COURT

OF APPEALS 258 SCRA 334 JULY 5, 1996

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 latter’s 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.

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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 is a
Medical Certificate, a Progress Record, an Anaesthesia Record, a Nurse's Record,
and a Physician's Discharge Summary.

ISSUE:

Whether or not Dr. Batiquin is liable

HELD:

Yes. The doctrine of res ipsa loquitur as a rule of evidence is peculiar to the law
of negligence which recognizes that prima facie negligence may be established
without direct proof and furnishes a substitute for specific proof of negligence.
The rule, when applicable to the facts and circumstances of a particular case, is
not intended to and does not dispense with the requirement of proof of culpable
negligence on the party charged. It merely determines and regulates what shall be
prima facie evidence thereof and facilitates the burden of plaintiff of proving a
breach of the duty of due care. The doctrine can be invoked when and only when,
under the circumstances involved, direct evidence is absent and not readily
available. In the instant case, all the requisites for recourse to the doctrine are
present. First, the entire proceedings of the cesarean section were under the
exclusive control of Dr. Batiquin. In this light, the private respondents were bereft
of direct evidence as to the actual culprit or the exact cause of the foreign object
finding its way into private respondent Villegas' body, which, needless to say,
does not occur unless through the intervention of negligence. Second, since aside
from the cesarean section, private respondent Villegas underwent no other
operation which could have caused the offending piece of rubber to appear in her
uterus, it stands to reason that such could only have been a by-product of the
cesarean section performed by Dr. Batiquin. The petitioners, in this regard, failed
to overcome the presumption of negligence arising from resort to the doctrine of
res ipsa loquitur. Dr. Batiquin is therefore liable for negligently leaving behind a
piece of rubber in private respondent Villegas' abdomen and for all the adverse
effects thereof. The court reiterates its recognition of the vital role the medical
profession plays in the lives of the people and State's compelling interest to enact
measures to protect the public from "the potentially deadly effects of
incompetence and ignorance in those who would undertake to treat our bodies and
minds for disease or trauma. Indeed, a physician is bound to serve the interest of
his patients "with the greatest of solicitude, giving them always his best talent and
skill." Through her tortious conduct, the petitioner endangered the life of Flotilde
Villegas, in violation of her profession's rigid ethical code and in contravention of

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 the legal standards set forth for professionals, in the general and members of the
medical profession, in particular.

2. MEDICAL NEGLIGENCE or MEDICAL MALPRACTICE

Medical negligence 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 patient. A physician is
expected to use at least the same level of care that any other reasonably competent doctor
would use under the same circumstances.

JURISPRUDENCE:

A. FLORES VS. PINEDA 571 SCRA 83 NOVEMBER 8, 2008

FACTS:

Teresita Pineda consulted her town mate Dr. Fredelicto Flores regarding her
medical condition, complaining about general body weakness, loss of
appetite, frequent urination and thirst, and on-and-off vaginal bleeding. After
interviewing Teresita, Dr. Fredelicto advised her to go to United Doctors
Medical Center (UDMC) in Quezon City for a general check-up the following
week but the former did not. As for her other symptoms, he suspected that
Teresita might be suffering from diabetes and told her to continue her
medications. When her conditions persisted, she went to UDMC where Dr.
Fredelictor check-up her and ordered her admission and further indicate on
call Dilation and Curettage (D&C) operation to be performed by his wife,
Dra. Felicisima Flores, an ObGyne. Laboratory tests were done on Teresita
including internal vaginal examination, however, only the blood sugar and
CBC results came out prior to operation which indicated of diabetes. D&C
operations were still done and thereafter, Dra. Felicisima advised her that she
can go home and continue to rest at home but Teresita opted otherwise. Two
days after the operation, her condition worsened prompting further test to be
done which resulted that Teresita have diabetes melitus type II. Insulin was
administered but it might have arrived late, she died.

ISSUE:

Whether or not spouses petitioners are liable for medical negligence.

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HELD:

Yes. A medical negligence case is a type of claim to redress a wrong

committed by a medical professional, that caused a bodily harm to or the
death of a patient. There are four elements involved in a medical negligence
case, namely: duty, breach, injury, and proximate cause. 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 case that any other reasonably competent doctor would use
under the same circumstances. Breach of duty occurs when the physician fails
to comply with those professional standards. If injury results to the patient as
a result of this breach, the physician is answerable for negligence. If a patient
suffers from some disability that increases the magnitude of risk to him, that
disability must be taken into account as long as it is or should have been
known to the physician. Stress, whether physical or emotional, is a factor that
can aggravate diabetes; a D&C operation is a form of physical stress. Dr.
Mendoza explained how surgical stress can aggravate the patient’s
hyperglycemia: when stress occurs, the diabetic’s body, especially the
autonomic system, reacts by secreting hormones which are counterregulatory;
she can have prolonged hyperglycemia which, if unchecked, could lead to
death. Medical lecture further explains that if the blood sugar has become
very high, the patient becomes comatose (diabetic coma). When this happens
over several days, the body uses its own fats to produce energy, and the result
is high level of waste products in the blood and urine. These findings lead us
to the conclusion that the decision to proceed with the D&C operation
notwithstanding Teresita’s hyperglycemia and without adequately preparing
her for the procedure, was contrary to the standards observed by the medical
profession. Deviation from this standard amounted to a breach of duty which
resulted in the patient’s death. Due to this negligent conduct, liability must
attach to the petitioner spouses.

B. CAYAO-LASAM VS. SPOUSES RAMOLETE

574 SCRA 439 December 18, 2002

FACTS:

On July 28, 1994, respondent Editha Ramolete, who was 3 months

pregnant, was brought to Lorma Medical Center (LMC) in San Fernando,
La Union due to vaginal bleeding. Upon advise of petitioner related via
telephone, Editha was admitted to the LMC on the same day. A pelvic

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sonogram was then conducted on Editha revealing the fetus’ weak cardiac
pulsation. The following day, the pelvic sonogram showed that aside from
the fetus’ weak cardiac pulsation, no fetal movement was also appreciated.
Due to persistent and profuse vaginal bleeding, petitioner advised her to
undergo a D&C procedure. She was discharged the following day. On
September 16, 1994, Editha was once gain brought at the LMC, as she was
suffering from vomiting and severe abdominal pains. Editha was attended
by Drs. Dela Cruz, Mayo and Komiya. Dr. Mayo allegedly informed
Editha that there was a dead fetus in the latter’s womb, after Editha went
laparectomy, she was found to have massive intra abdominal hemorrhage
and ruptured uterus. Thus, she had to go hysterectomy and as a result no
more chance to bear a child.

ISSUE:

Whether or not petitioner is liable for medical malpractice.

HELD:

No. Medical malpractice is a particular form of negligence which consists

in the failure of a physician or a surgeon to apply in his practice of
medicine that degree of care and skill which is ordinarily employed by the
profession generally under similar conditions and in like surrounding
circumstances. In order to successfully pursue such a claim, a patient must
either prove that the physician or surgeon failed to do something which a
reasonably prudent physician or surgeon would have done, or that the
physician or surgeon performed something which a reasonably prudent
physician or surgeon would not have done, and that such failure or action
caused injury to the patient. There are four elements involved in medical
negligence cases: duty, breach, injury, and proximate cause. The breach
of the professional duties of skill and care, or their improper performance
by a physician surgeon, whereby the patient is injured in body or in health,
constitutes actionable malpractice. Further, in as much as the causes of the
injuries involved in malpractice actions are determinable only in the light
of scientific knowledge, it has been recognized that expert testimony is
usually necessary to suspect the conclusion as to causation. However, in
this case, it was undisputedly established that Editha did not return for
follow-up evaluation, in defiance of the petitioner’s advice. This is, as
found out, is the proximate cause of the injury she sustained.

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C. PETER PAUL PATRICK LUCAS VS DR. PROSPERO MA. C .
TUANO 586 SCRA 173 APRIL 21, 2009

FACTS:

Herein petitioner, Peter Lucas, first consulted respondent, Dr. Tuaño, on a

complaint of soreness and redness on his right eye. The respondent, after a
series of examinations, found that the former was suffering from
conjunctivitis or “sore eyes” and prescribed the use of the Spersacet-C.
However, after the petitioner’s condition seemed to have worsened, he
sought for the respondent’s second finding wherein the latter said that his
condition had progressed to Epidemic Kerato Conjunctivitis (EKC), a viral
infection. The respondent then prescribed the use of Maxitrol, a
steroidbased eye drop. The petitioner’s condition worsened overtime, yet
he obediently complied with all the prescriptions and orders of the
respondent. Four months later and after the petitioner suffered from
significant swelling of his right eyeball, headaches, nausea and blindness
on this right eye, he sought for the opinion of another doctor, Dr. Aquino.
Dr. Aquino found that the petitioner had been suffering from glaucoma
and needed to undergo laser surgery, lest he might suffer from total
blindness. After reading the literature on the use of the medicine Maxitrol,
Fatima, one of the petitioners herein and Peter Lucas’ wife, read that one
of the adverse effects of prolonged use of steroid-based eye drops could
possibly be glaucoma. Claiming to have steroid-induced glaucoma and
blaming Dr. Tuano for the same, Peter, Fatima, and their two children
instituted a civil case for damages against herein respondent for medical
malpractice.

ISSUE:

Whether or not Dr. Tuano is liable of medical negligence.

HELD:

No, petitioners failed to prove by preponderance of evidence that Dr.

Tuano was negligent in his treatment of Peter’s condition. In medical
negligence cases, also called medical malpractice suits, there exist a
physician-patient relationship between the doctor and the victim. But just
like any other proceeding for damages, four essential (4) elements i.e., (1)
duty; (2) breach; (3) injury; and (4) proximate causation, must be
established by the plaintiff/s. All the four (4) elements must co-exist in
order to find the physician negligent and, thus, liable for damages. As the
physician has the duty to use at least the same level of care as that of any

18
 other reasonably competent physician would use in the treatment of his
patient, said standard level of care, skill and diligence must likewise be
proven by expert medical testimony, because the standard of care in a
medical malpractice case is a matter peculiarly within the knowledge of
experts in the field. The same is outside the ken of the average layperson.
There is breach of duty of care, skill and diligence, or the improper
performance of such duty, by the attending physician when the patient is
injured in body or in health [and this] constitutes the actionable
malpractice. Hence, proof of breach of duty on the part of the attending
physician is insufficient. Rather, the negligence of the physician must be
the proximate cause of the injury.

III. APPLICABLE TO BOTH PATIENT AND PHYSICIAN TORTFEASORS

1. CONTRIBUTORY NEGLIGENCE

Contributory negligence is the act or omission amounting to want of ordinary care

on the part of the person injured, which, concurring with the defendant’s negligence, is
the proximate cause of the injury.

JURISPRUDENCE:

A. Kahlon v. Vancouver Coastal Health Authority, 2009 BCSC 922 (CanLII).

FACTS:

In 1999, Shawn Kahlon sought help from his doctor for on-going lower
back pain. The physician ordered a CT Scan, and the radiologist, who saw
some abnormalities in the results wanted Kahlon to come for a followup
scan with contrast dye.

But Kahlon, a 32 year-old teacher at the time, never returned – which had
devastating consequences he had a spinal tuberculosis that was about to
migrate to his brain. The disease left him completely incapacitated,
paralyzed on one side of his body and requiring a fulltime care.

The first set of films from the CT scan were filed by a clerk before being
fully reported and weren’t found until a year later when Kahlon was taken
to Vancouver General Hospital where he was finally diagnosed.

ISSUE:

Whether or not the plaintiff is guilty of contributory negligence.

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 HELD:

Yes. The plaintiff did not return for that scan and subsequently became
seriously ill with an infection leading to a brain injury. Although the
plaintiff told his family physician that he did not return for the follow-up
CT with contrast because he did not want dye injected into his body, the
court found that he likely simply procrastinated, relying on the working
diagnosis of the physicians that he had a benign disc or muscle
problem.Finding that his misunderstanding of the cause of his back pain
was in part a consequence of his own actions in failing to follow-up as he
had been instructed, the court determined that the plaintiff should bear
some liability for the outcome. The court noted that a patient’s
understanding of his condition and of the potential risks of not following
up were relevant contex-tual factors to be considered in determining his
contribution to the injury, and assessed the plaintiff’s contributory
negligence at 30%.

B. ZHANG VS. KAN

FACTS:

Zhang involved an action by the plaintiff against her physician for a

negligence resulting in the birth of a child with Down’s Syndrome. The
plaintiff was 37 years old when she became pregnant. After consulting with
her physician in Hong Kong, the plaintiff was informed that on account of her
age she was at a heightened risk of delivering a child with Down’s Syndrome.
Following this consultation, the plaintiff travelled to Vancouver to consult
with the defendant regarding his pregnancy. During this meeting, the plaintiff
requested an amniocentesis. The defendant incorrectly stated that it was “too
late” to have a test. Several months later, the plaintiff delivered a child with
Down’s syndrome.

ISSUE:

Whether or not the plaintiff is responsible for contributory negligence.

HELD:

The British Columbia Supreme Court found the defendant was negligent in
informing the plaintiff that an amniocentesis was not available. Evidence
presented during the trial revealed that the defendant could have ordered
amniocentesis in an expedited fashion. The court noted that this procedure
would have alerted the plaintiff to the fact that the fetus had Down’s

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syndrome, and would have afforded her the opportunity to terminate the
pregnancy.

Notwithstanding, the finding of the negligence on the part of the defendant,

the court also found that the plaintiff was partially responsible for her failure
for her failure to have an amniocentesis during her pregnancy. The court noted
that the plaintiff was a “sophisticated and experienced businesswoman” who
had conducted research on amniocentesis.

C. RUPERT VS. TOTH

FACTS:

The physician treated the plaintiff for a condition he believed to be nasal

polyps. During the surgery, it was determined that the plaintiff did not suffer
from nasal polyps, but actually inverting papilloma in the nasal cavity. The
plaintiff was subsequently released, but was instructed that a CT scan is
necessary to discern the precise nature and scope of the disease. Accordingly,
the plaintiff was asked to book a follow up visit with his doctor. Evidence at
the trial revealed that the physician had not discussed with the plaintiff the
consequences of failing to have a further surgery. The CT scan was
conducted and another physician partially conveyed the result to the plaintiff.
This second physician instructed the plaintiff to arrange a further consultation
with the defendant-physician. Evidence also revealed that the defendant
flagged the plaintiff’s CT results and instructed his staff to arrange an
appointment with the plaintiff. Unfortunately, neither the plaintiff nor the
defendant ever scheduled this appointment. Three years later, the plaintiff
presented at his doctor’s office with debilitating headaches. A second CT scan
was ordered which showed a destructive lesion caused by the papilloma. The
patient suffered a seizure a few days later and was hospitalized for four
months until his death.

ISSUE:

Whether or not the plaintiff is partially responsible for contributory negligence

for not following the instructions of the physician.

HELD:

Yes. Here, the patient failed to arrange post-operative consultations, despite

the fact that he was clearly instructed to do so by more than one health care
practitioner.

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 LAST CLEAR CHANCE DOCTRINE

The doctrine of Last Clear Chance may be defined as a reasoning process used in
analyzing the facts of an accident situation in which the following elements are
present:

1. The plaintiff has been negligent, and as a result, he is in the position of danger
of which he is wholly unaware, or from which he cannot escape by the
exercise of ordinary care.
2. The defendant has knowledge that the plaintiff is in a position of danger, and
knows, or in the exercise of ordinary care should know, that the plaintiff
cannot escape from his position of danger.
3. The defendant has the last clear chance to avoid the occurrence by the
exercise of ordinary care, and fails to exercise that care; the plaintiff being
injured as a proximate result of the defendant’s subsequent and final
negligence.

The last clear chance doctrine, also known as the humanitarian doctrine, permits
patients to recover despite their own negligence if their health care provider had the last
clear opportunity to avoid the harm and failed to do so.

A physician who has the last clear chance of avoiding damage or injury to his
patient but negligently fails to do so is liable.

IV. APPLICABLE TO PHYSICIAN AND CO-PHYSICIAN TORTFEASORS

1. DOCTRINE OF RESPONDEAT SUPERIOR

The doctrine which holds an employer or principal liable for the employee's or
agent's wrongful acts committed within the scope of the employment or agency. The
vicarious liability of an employer is well-entrenched in our jurisdiction as it is founded on
public policy that is: a deliberate allocation of risk of losses caused by torts of employees
and that in holding an employer strictly liable, he is given the greatest incentive to be
careful in the selection, instruction and supervision of his servants, and to take every
precaution to see that the enterprise is conducted safely.

As applied to healthcare industry, the general rule is that a physician is

“responsible for an injury done to a patient through the want of proper skill and care in
his assistant, apprentice, agent, or employee.”

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 2. BORROWED SERVANT DOCTRINE

It is a doctrine in American medical malpractice law which imputes liability in a

surgeon for the negligence committed by operating room personnel regardless of the
identity of the employer of the latter.

The “borrowed servant” rule holds that a “servant directed or permitted by his
master to perform services for another may become servant of such other in performing
the services.

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.

3. CAPTAIN OF THE SHIP DOCTRINE

The “Captain-of-the-Ship” doctrine is defined as “the doctrine imposing liability

on a surgeon for the actions of assistants who are under the surgeon's control but who are
employees of the hospital, not the surgeon.

The doctrine was coined in McConnel v. Williams, 361 Pa. 355, 65 A.2d 243, 246
(1949), in which the Supreme Court of Pennsylvania ruled that, "it can readily be
understood that in the course of an operation in the operating room of a hospital, and until
the surgeon leaves that room at the conclusion of the operation... he is in the same
complete charge of those who are present and assisting him as in the captain of a ship
over all on board, and that such supreme control is indeed essential in view of the high
degree of protection to which an anesthetized, unconscious patient is entitled..."

4. DOCTRINE OF FORSEEABILITY

The doctrine of foreseeability is the basis of tortuous liability. The true basis of
foreseeability is that men should be charged only with that knowledge or notice of what a
reasonable or ordinarily prudent person would have foreseen. The law recognizes that
the conduct of a reasonable man varies with the situation with which s/he is confronted.
Thus, when a person has no reason to suspect a danger, s/he is not required to look for it.
Nor can a person be charged with a failure to observe or anticipate danger when, in
similar circumstances, an ordinarily prudent man would not have done so.

A physician cannot be held liable for negligence if the injury sustained by the
patient is on account of unforeseen conditions.

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SUBMITTED TO:

FISCAL MARIELMIRA HERRERA

SUBMITTED BY:

KRISTINE S. BONDOC-CARASI

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