G.R. No.
159132 December 18, 2008 advised Editha to undergo D&C procedure which the respondents
FE CAYAO-LASAM, petitioner,
vs.
SPOUSES CLARO and EDITHA RAMOLETE, respondents.*
DECISION
AUSTRIA-MARTINEZ, J.:
Before the Court is a Petition for Review on Certiorari under Rule 45 of
the Rules of Court filed by Dr. Fe Cayao-Lasam (petitioner) seeking to
annul the Decision1 dated July 4, 2003 of the Court of Appeals (CA) in
CA-G.R. SP No. 62206.
The antecedent facts:
On July 28, 1994, respondent, three months pregnant Editha Ramolete
(Editha) was brought to the Lorma Medical Center (LMC) in San
Fernando, La Union due to vaginal bleeding. Upon advice of petitioner
relayed via telephone, Editha was admitted to the LMC on the same
day. A pelvic sonogram2 was then conducted on Editha revealing the
fetus’ weak cardiac pulsation.3 The following day, Editha’s repeat pelvic
sonogram4 showed that aside from the fetus’ weak cardiac pulsation,
no fetal movement was also appreciated. Due to persistent and
profuse vaginal bleeding, petitioner advised Editha to undergo a
Dilatation and Curettage Procedure (D&C) or "raspa."
On July 30, 1994, petitioner performed the D&C procedure. Editha was
discharged from the hospital the following day.
On September 16, 1994, Editha was once again brought at the LMC,
as she was suffering from vomiting and severe abdominal pains.
Editha was attended by Dr. Beatriz de la Cruz, Dr. Victor B. Mayo and
Dr. Juan V. Komiya. Dr. Mayo allegedly informed Editha that there was
a dead fetus in the latter’s womb. After, Editha underwent
laparotomy,5 she was found to have a massive intra-abdominal
hemorrhage and a ruptured uterus. Thus, Editha had to undergo a
procedure for hysterectomy6 and as a result, she has no more chance
to bear a child.
On November 7, 1994, Editha and her husband Claro Ramolete
(respondents) filed a Complaint7 for Gross Negligence and Malpractice
against petitioner before the Professional Regulations Commission
(PRC).
Respondents alleged that Editha’s hysterectomy was caused by
petitioner’s unmitigated negligence and professional incompetence in
conducting the D&C procedure and the petitioner’s failure to remove
the fetus inside Editha’s womb.8 Among the alleged acts of negligence
were: first, petitioner’s failure to check up, visit or administer
medication on Editha during her first day of confinement at the
LMC;9 second, petitioner recommended that a D&C procedure be
performed on Editha without conducting any internal examination prior
to the procedure;10 third, petitioner immediately suggested a D&C
procedure instead of closely monitoring the state of pregnancy of
Editha.11
In her Answer,12 petitioner denied the allegations of negligence and
incompetence with the following explanations: upon Editha’s
confirmation that she would seek admission at the LMC, petitioner
immediately called the hospital to anticipate the arrival of Editha and
ordered through the telephone the medicines Editha needed to take,
which the nurses carried out; petitioner visited Editha on the morning of
July 28, 1994 during her rounds; on July 29, 1994, she performed an
internal examination on Editha and she discovered that the latter’s
cervix was already open, thus, petitioner discussed the possible D&C
procedure, should the bleeding become more profuse; on July 30
1994, she conducted another internal examination on Editha, which
revealed that the latter’s cervix was still open; Editha persistently
complained of her vaginal bleeding and her passing out of some meaty
mass in the process of urination and bowel movement; thus, petitioner
consented to; petitioner was very vocal in the operating room about not
being able to see an abortus;13 taking the words of Editha to mean that
she was passing out some meaty mass and clotted blood, she
assumed that the abortus must have been expelled in the process of
bleeding; it was Editha who insisted that she wanted to be discharged;
petitioner agreed, but she advised Editha to return for check-up on
August 5, 1994, which the latter failed to do.
Petitioner contended that it was Editha’s gross negligence and/or
omission in insisting to be discharged on July 31, 1994 against doctor’s
advice and her unjustified failure to return for check-up as directed by
petitioner that contributed to her life-threatening condition on
September 16, 1994; that Editha’s hysterectomy was brought about by
her very abnormal pregnancy known as placenta increta, which was an
extremely rare and very unusual case of abdominal placental
implantation. Petitioner argued that whether or not a D&C procedure
was done by her or any other doctor, there would be no difference at
all because at any stage of gestation before term, the uterus would
rupture just the same.
On March 4, 1999, the Board of Medicine (the Board) of the PRC
rendered a Decision,14 exonerating petitioner from the charges filed
against her. The Board held:
Based on the findings of the doctors who conducted the
laparotomy on Editha, hers is a case of Ectopic Pregnancy
Interstitial. This type of ectopic pregnancy is one that is being
protected by the uterine muscles and manifestations may
take later than four (4) months and only attributes to two
percent (2%) of ectopic pregnancy cases.
When complainant Editha was admitted at Lorma Medical
Center on July 28, 1994 due to vaginal bleeding, an ultra-
sound was performed upon her and the result of the
Sonogram Test reveals a morbid fetus but did not specify
where the fetus was located. Obstetricians will assume that
the pregnancy is within the uterus unless so specified by the
Sonologist who conducted the ultra-sound. Respondent (Dr.
Lasam) cannot be faulted if she was not able to determine
that complainant Editha is having an ectopic pregnancy
interstitial. The D&C conducted on Editha is necessary
considering that her cervix is already open and so as to stop
the profuse bleeding. Simple curettage cannot remove a
fetus if the patient is having an ectopic pregnancy, since
ectopic pregnancy is pregnancy conceived outside the
uterus and curettage is done only within the uterus.
Therefore, a more extensive operation needed in this case of
pregnancy in order to remove the fetus.15
Feeling aggrieved, respondents went to the PRC on appeal. On
November 22, 2000, the PRC rendered a Decision16 reversing the
findings of the Board and revoking petitioner’s authority or license to
practice her profession as a physician.17
Petitioner brought the matter to the CA in a Petition for Review under
Rule 43 of the Rules of Court. Petitioner also dubbed her petition as
one for certiorari18 under Rule 65 of the Rules of Court.
In the Decision dated July 4, 2003, the CA held that the Petition for
Review under Rule 43 of the Rules of Court was an improper remedy,
as the enumeration of the quasi-judicial agencies in Rule 43 is
exclusive.19 PRC is not among the quasi-judicial bodies whose
judgment or final orders are subject of a petition for review to the CA,
thus, the petition for review of the PRC Decision, filed at the CA, was
improper. The CA further held that should the petition be treated as a
petition for certiorari under Rule 65, the same would still be dismissed
for being improper and premature. Citing Section 2620 of Republic Act
(R.A.) No. 2382 or the Medical Act of 1959, the CA held that the plain,
speedy and adequate remedy under the ordinary course of law which
petitioner should have availed herself of was to appeal to the Office of
the President.21
Hence, herein petition, assailing the decision of the CA on the following
grounds:
1. THE COURT OF APPEALS ERRED ON A QUESTION
OF LAW IN HOLDING THAT THE PROFESSIONAL
REGULATION[S] COMMISSION (PRC) WAS EXCLUDED
AMONG THE QUASI-JUDICIAL AGENCIES
CONTEMPLATED UNDER RULE 43 OF THE RULES OF
CIVIL PROCEDURE;
2. EVEN ASSUMING, ARGUENDO, THAT PRC WAS
EXCLUDED FROM THE PURVIEW OF RULE 43 OF THE
RULES OF CIVIL PROCEDURE, THE PETITIONER WAS
NOT PRECLUDED FROM FILING A PETITION FOR
CERTIORARI WHERE THE DECISION WAS ALSO
ISSUED IN EXCESS OF OR WITHOUT JURISDICTION,
OR WHERE THE DECISION WAS A PATENT NULLITY;
3. HEREIN RESPONDENTS-SPOUSES ARE NOT
ALLOWED BY LAW TO APPEAL FROM THE DECISION
OF THE BOARD OF MEDICINE TO THE PROFESSIONAL
REGULATION[S] COMMISSION;
4. THE COURT OF APPEALS COMMITTED GRAVE
ABUSE OF DISCRETION IN DENYING FOR IMPROPER
FORUM THE PETITION FOR REVIEW/PETITION FOR
CERTIORARI WITHOUT GOING OVER THE MERITS OF
THE GROUNDS RELIED UPON BY THE PETITIONER;
5. PRC’S GRAVE OMISSION TO AFFORD HEREIN
PETITONER A CHANCE TO BE HEARD ON APPEAL IS A
CLEAR VIOLATION OF HER CONSTITUTIONAL RIGHT
TO DUE PROCESS AND HAS THE EFFECT OF
RENDERING THE JUDGMENT NULL AND VOID;
6. COROLLARY TO THE FOURTH ASSIGNED ERROR,
PRC COMMITTED GRAVE ABUSE OF DISCRETION,
AMOUNTING TO LACK OF JURISDICTION, IN
ACCEPTING AND CONSIDERING THE MEMORANDUM
ON APPEAL WITHOUT PROOF OF SERVICE TO HEREIN
PETITIONER, AND IN VIOLATION OF ART. IV, SEC. 35 OF
THE RULES AND REGULATIONS GOVERNING THE
REGULATION AND PRACTICE OF PROFESSIONALS;
7. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN
REVOKING PETITIONER’S LICENSE TO PRACTICE
MEDICINE WITHOUT AN EXPERT TESTIMONY TO
SUPPORT ITS CONCLUSION AS TO THE CAUSE OF
RESPONDENT EDITHAT [SIC] RAMOLETE’S INJURY;
8. PRC COMMITTED AN EVEN GRAVER ABUSE OF
DISCRETION IN TOTALLY DISREGARDING THE FINDING
OF THE BOARD OF MEDICINE, WHICH HAD THE
NECESSARY COMPETENCE AND EXPERTISE TO
ESTABLISH THE CAUSE OF RESPONDENT EDITHA’S
INJURY, AS WELL AS THE TESTIMONY OF THE EXPERT
WITNESS AUGUSTO MANALO, M.D. ;[and]
9. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN
MAKING CONCLUSIONS OF FACTS THAT WERE NOT
ONLY UNSUPPORTED BY EVIDENCE BUT WERE
ACTUALLY CONTRARY TO EVIDENCE ON RECORD.22
The Court will first deal with the procedural issues.
Petitioner claims that the law does not allow complainants to appeal to
the PRC from the decision of the Board. She invokes Article IV,
Section 35 of the Rules and Regulations Governing the Regulation and
Practice of Professionals, which provides:
Sec. 35. The respondent may appeal the decision of the
Board within thirty days from receipt thereof to the
Commission whose decision shall be final. Complainant,
when allowed by law, may interpose an appeal from the
Decision of the Board within the same period. (Emphasis
supplied)
Petitioner asserts that a careful reading of the above law indicates that
while the respondent, as a matter of right, may appeal the Decision of
the Board to the Commission, the complainant may interpose an
appeal from the decision of the Board only when so allowed by
law.23 Petitioner cited Section 26 of Republic Act No. 2382 or "The
Medical Act of 1959," to wit:
Section 26. Appeal from judgment. The decision of the Board
of Medical Examiners (now Medical Board) shall
automatically become final thirty days after the date of its
promulgation unless the respondent, during the same period,
has appealed to the Commissioner of Civil Service (now
Professional Regulations Commission) and later to the Office
of the President of the Philippines. If the final decision is not
satisfactory, the respondent may ask for a review of the
case, or may file in court a petition for certiorari.
Petitioner posits that the reason why the Medical Act of 1959 allows
only the respondent in an administrative case to file an appeal with the
Commission while the complainant is not allowed to do so is double
jeopardy. Petitioner is of the belief that the revocation of license to
practice a profession is penal in nature.24
The Court does not agree.
For one, the principle of double jeopardy finds no application in
administrative cases. Double jeopardy attaches only: (1) upon a valid
indictment; (2) before a competent court; (3) after arraignment; (4)
when a valid plea has been entered; and (5) when the defendant was
acquitted or convicted, or the case was dismissed or otherwise
terminated without the express consent of the accused. 25 These
elements were not present in the proceedings before the Board of
Medicine, as the proceedings involved in the instant case were
administrative and not criminal in nature. The Court has already held
that double jeopardy does not lie in administrative cases.26
Moreover, Section 35 of the Rules and Regulations Governing the
Regulation and Practice of Professionals cited by petitioner was
subsequently amended to read:
Sec. 35. The complainant/respondent may appeal the
order, the resolution or the decision of the Board within thirty
(30) days from receipt thereof to the Commission whose
decision shall be final and executory. Interlocutory order
shall not be appealable to the Commission. (Amended by
Res. 174, Series of 1990).27 (Emphasis supplied)
Whatever doubt was created by the previous provision was settled with
said amendment. It is axiomatic that the right to appeal is not a natural
right or a part of due process, but a mere statutory privilege that may
be exercised only in the manner prescribed by law.28 In this case, the
clear intent of the amendment is to render the right to appeal from a
decision of the Board available to both complainants and respondents.
Such conclusion is bolstered by the fact that in 2006, the PRC issued
Resolution No. 06-342(A), or the New Rules of Procedure in
Administrative Investigations in the Professional Regulations
Commission and the Professional Regulatory Boards, which provides
for the method of appeal, to wit:
Sec. 1. Appeal; Period Non-Extendible.- The decision,
order or resolution of the Board shall be final and executory
after the lapse of fifteen (15) days from receipt of the
decision, order or resolution without an appeal being
perfected or taken by either the respondent or the
complainant. A party aggrieved by the decision, order or
resolution may file a notice of appeal from the decision,
order or resolution of the Board to the Commission
 within fifteen (15) days from receipt thereof, and serving
upon the adverse party a notice of appeal together with the
appellant’s brief or memorandum on appeal, and paying the
appeal and legal research fees. x x x29
The above-stated provision does not qualify whether only the
complainant or respondent may file an appeal; rather, the new rules
provide that "a party aggrieved" may file a notice of appeal. Thus,
either the complainant or the respondent who has been aggrieved by
the decision, order or resolution of the Board may appeal to the
Commission. It is an elementary rule that when the law speaks in clear
and categorical language, there is no need, in the absence of
legislative intent to the contrary, for any interpretation.30 Words and
phrases used in the statute should be given their plain, ordinary, and
common usage or meaning.31
Petitioner also submits that appeals from the decisions of the PRC
should be with the CA, as Rule 4332 of the Rules of Court was precisely
formulated and adopted to provide for a uniform rule of appellate
procedure for quasi-judicial agencies.33 Petitioner further contends that
a quasi-judicial body is not excluded from the purview of Rule 43 just
because it is not mentioned therein.34
On this point, the Court agrees with the petitioner.
Sec. 1, Rule 43 of the Rules of Court provides:
Section 1. Scope. - This Rule shall apply to appeals from
judgments or final orders of the Court of Tax Appeals,
and from awards, judgments, final orders or resolutions
of or authorized by any quasi-judicial agency in the
exercise of its quasi-judicial functions. Among these
agencies are the Civil Service Commission, Central Board of
Assessment Appeals, Securities and Exchange Commission,
Office of the President, Land Registration Authority, Social
Security Commission, Civil Aeronautics Board, Bureau of
Patents, Trademarks and Technology Transfer, National
Electrification Administration, Energy Regulatory Board,
National Telecommunications Commission, Department of
Agrarian Reform under Republic Act No. 6657, Government
Service Insurance System, Employees Compensation
Commission, Agricultural Inventions Board, Insurance
Commission, Philippine Atomic Energy Commission, Board
of Investments, Construction Industry Arbitration
Commission, and voluntary arbitrators authorized by law.
(Emphasis supplied)
Indeed, the PRC is not expressly mentioned as one of the agencies
which are expressly enumerated under Section 1, Rule 43 of the Rules
of Court. However, its absence from the enumeration does not, by this
fact alone, imply its exclusion from the coverage of said Rule.35 The
Rule expressly provides that it should be applied to appeals from
awards, judgments final orders or resolutions of any quasi-judicial
agency in the exercise of its quasi-judicial functions. The phrase
"among these agencies" confirms that the enumeration made in the
Rule is not exclusive to the agencies therein listed.36
Specifically, the Court, in Yang v. Court of Appeals,37 ruled
that Batas Pambansa (B.P.) Blg. 12938 conferred upon the CA
exclusive appellate jurisdiction over appeals from decisions of the
PRC. The Court held:
The law has since been changed, however, at least in the
matter of the particular court to which appeals from the
Commission should be taken. On August 14, 1981, Batas
Pambansa Bilang 129 became effective and in its Section
29, conferred on the Court of Appeals "exclusive appellate
jurisdiction over all final judgments, decisions, resolutions,
orders or awards of Regional Trial Courts and quasi-judicial
agencies, instrumentalities, boards or commissions except
those falling under the appellate jurisdiction of the Supreme
Court. x x x." In virtue of BP 129, appeals from the
Professional Regulations Commission are now
exclusively cognizable by the Court of
Appeals.39 (Emphasis supplied)
Clearly, the enactment of B.P. Blg. 129, the precursor of the present
Rules of Civil Procedure,40 lodged with the CA such jurisdiction over
the appeals of decisions made by the PRC.
Anent the substantive merits of the case, petitioner questions the PRC
decision for being without an expert testimony to support its conclusion
and to establish the cause of Editha’s injury. Petitioner avers that in
cases of medical malpractice, expert testimony is necessary to support
the conclusion as to the cause of the injury.41
Medical malpractice is a particular form of negligence which consists in
the failure of a physician or surgeon to apply to his practice of medicine
that degree of care and skill which is ordinarily employed by the
profession generally, under similar conditions, and in like surrounding
circumstances.42 In order to successfully pursue such a claim, a patient
must prove that the physician or surgeon either failed to do something
which a reasonably prudent physician or surgeon would not have done,
and that the failure or action caused injury to the patient.43
There are four elements involved in medical negligence cases: duty,
breach, injury and proximate causation.44
A physician-patient relationship was created when Editha employed
the services of the petitioner. As Editha’s physician, petitioner was
duty-bound to use at least the same level of care that any reasonably
competent doctor would use to treat a condition under the same
circumstances.45 The breach of these professional duties of skill and
care, or their improper performance by a physician surgeon, whereby
the patient is injured in body or in health, constitutes actionable
malpractice.46 As to this aspect of medical malpractice, the
determination of the reasonable level of care and the breach thereof,
expert testimony is essential.47 Further, inasmuch 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 support the conclusion as to
causation.48
In the present case, respondents did not present any expert testimony
to support their claim that petitioner failed to do something which a
reasonably prudent physician or surgeon would have done.
Petitioner, on the other hand, presented the testimony of Dr. Augusto
M. Manalo, who was clearly an expert on the subject.
Generally, to qualify as an expert witness, one must have acquired
special knowledge of the subject matter about which he or she is to
testify, either by the study of recognized authorities on the subject or by
practical experience.49
Dr. Manalo specializes in gynecology and obstetrics, authored and co-
authored various publications on the subject, and is a professor at the
University of the Philippines.50 According to him, his diagnosis of
Editha’s case was "Ectopic Pregnancy Interstitial (also referred to as
Cornual), Ruptured."51 In stating that the D&C procedure was not the
proximate cause of the rupture of Editha’s uterus resulting in her
hysterectomy, Dr. Manalo testified as follows:
Atty. Hidalgo:
Q: Doctor, we want to be clarified on this matter. The
complainant had testified here that the D&C was the
proximate cause of the rupture of the uterus. The condition
which she found herself in on the second admission. Will you
please tell us whether that is true or not?
A: Yah, I do not think so for two reasons. One, as I
have said earlier, the instrument cannot reach the site of the
pregnancy, for it to further push the pregnancy outside the
uterus. And, No. 2, I was thinking a while ago about another
 reason- well, why I don’t think so, because it is the triggering
factor for the rupture, it could have–the rupture could have
occurred much earlier, right after the D&C or a few days after
the D&C.
Q: In this particular case, doctor, the rupture occurred to
have happened minutes prior to the hysterectomy or right
upon admission on September 15, 1994 which is about 1 ½
months after the patient was discharged, after the D&C was
conducted. Would you tell us whether there is any relation at
all of the D&C and the rupture in this particular instance?
A: I don’t think so for the two reasons that I have just
mentioned- that it would not be possible for the
instrument to reach the site of pregnancy. And, No. 2, if it
is because of the D&C that rupture could have occurred
earlier.52 (Emphases supplied)
Clearly, from the testimony of the expert witness and the reasons given
by him, it is evident that the D&C procedure was not the proximate
cause of the rupture of Editha’s uterus.
During his cross-examination, Dr. Manalo testified on how he would
have addressed Editha’s condition should he be placed in a similar
circumstance as the petitioner. He stated:
Atty. Ragonton:
Q: Doctor, as a practicing OB-Gyne, when do you
consider that you have done a good, correct and ideal
dilatation and curettage procedure?
A: Well, if the patient recovers. If the patient gets well.
Because even after the procedure, even after the procedure
you may feel that you have scraped everything, the patient
stops bleeding, she feels well, I think you should still have
some reservations, and wait a little more time.
Q: If you were the OB-Gyne who performed the procedure
on patient Editha Ramolete, would it be your standard
practice to check the fetal parts or fetal tissues that were
allegedly removed?
A: From what I have removed, yes. But in this particular
case, I think it was assumed that it was part of the meaty
mass which was expelled at the time she was urinating and
flushed in the toilet. So there’s no way.
Q: There was [sic] some portions of the fetal parts that
were removed?
A: No, it was described as scanty scraping if I remember it
right–scanty.
Q: And you would not mind checking those scant or those
little parts that were removed?
A: Well, the fact that it was described means, I assume
that it was checked, ‘no. It was described as scanty and the
color also, I think was described. Because it would be very
unusual, even improbable that it would not be examined,
because when you scrape, the specimens are right there
before your eyes. It’s in front of you. You can touch it. In
fact, some of them will stick to the instrument and
therefore to peel it off from the instrument, you have to
touch them. So, automatically they are examined
closely.
Q: As a matter of fact, doctor, you also give telephone
orders to your patients through telephone?
A: Yes, yes, we do that, especially here in Manila because
you know, sometimes a doctor can also be tied-up
somewhere and if you have to wait until he arrive at a certain
place before you give the order, then it would be a lot of time
wasted. Because if you know your patient, if you have
handled your patient, some of the symptoms you can
interpret that comes with practice. And, I see no reason for
not allowing telephone orders unless it is the first time
that you will be encountering the patient. That you have
no idea what the problem is.
Q: But, doctor, do you discharge patients without seeing
them?
A: Sometimes yes, depending on how familiar I am with
the patient. We are on the question of telephone orders. I am
not saying that that is the idle [sic] thing to do, but I think the
reality of present day practice somehow justifies
telephone orders. I have patients whom I have justified and
then all of a sudden, late in the afternoon or late in the
evening, would suddenly call they have decided that they will
go home inasmuch as they anticipated that I will discharge
them the following day. So, I just call and ask our resident on
duty or the nurse to allow them to go because I have seen
that patient and I think I have full grasp of her problems. So,
that’s when I make this telephone orders. And, of course
before giving that order I ask about how she
feels.53 (Emphases supplied)
From the foregoing testimony, it is clear that the D&C procedure was
conducted in accordance with the standard practice, with the same
level of care that any reasonably competent doctor would use to treat a
condition under the same circumstances, and that there was nothing
irregular in the way the petitioner dealt with Editha.
Medical malpractice, in our jurisdiction, is often brought as a civil action
for damages under Article 217654 of the Civil Code. The defenses in an
action for damages, provided for under Article 2179 of the Civil Code
are:
Art. 2179. When the plaintiff’s own negligence was the
immediate and proximate cause of his injury, he cannot
recover damages. But if his negligence was only
contributory, the immediate and proximate cause of the
injury being the defendant’s lack of due care, the plaintiff
may recover damages, but the courts shall mitigate the
damages to be awarded.
Proximate cause has been defined as that which, in natural and
continuous sequence, unbroken by any efficient intervening cause,
produces injury, and without which the result would not have
occurred.55 An injury or damage is proximately caused by an act or a
failure to act, whenever it appears from the evidence in the case that
the act or omission played a substantial part in bringing about or
actually causing the injury or damage; and that the injury or damage
was either a direct result or a reasonably probable consequence of the
act or omission.56
In the present case, the Court notes the findings of the Board of
Medicine:
When complainant was discharged on July 31, 1994,
herein respondent advised her to return on August 4,
1994 or four (4) days after the D&C. This advise was
clear in complainant’s Discharge
Sheet. However, complainant failed to do so. This being
the case, the chain of continuity as required in order that the
doctrine of proximate cause can be validly invoked was
interrupted. Had she returned, the respondent could have
examined her thoroughly.57 x x x (Emphases supplied)
Also, in the testimony of Dr. Manalo, he stated further that assuming
that there was in fact a misdiagnosis, the same would have been
rectified if Editha followed the petitioner’s order to return for a check-up proceedings in the appeal. The same holds true in the case at bar. The
on August 4, 1994. Dr. Manalo stated: Court finds that the failure of the respondents to furnish the petitioner a
copy of the Memorandum of Appeal submitted to the PRC constitutes a
violation of due process. Thus, the proceedings before the PRC were
Granting that the obstetrician-gynecologist has been
null and void.
misled (justifiably) up to thus point that there would
have been ample opportunity to rectify the
misdiagnosis, had the patient returned, as instructed for All told, doctors are protected by a special rule of law. They are not
her follow-up evaluation. It was one and a half months guarantors of care. They are not insurers against mishaps or unusual
later that the patient sought consultation with another consequences68 specially so if the patient herself did not exercise the
doctor. The continued growth of an ectopic pregnancy, until proper diligence required to avoid the injury.
its eventual rupture, is a dynamic process. Much change in
physical findings could be expected in 1 ½ months, including
WHEREFORE, the petition is GRANTED. The assailed Decision of the
the emergence of suggestive ones.58
Court of Appeals dated July 4, 2003 in CA-GR SP No. 62206 is
hereby REVERSED and SET ASIDE. The Decision of the Board of
It is undisputed that Editha did not return for a follow-up evaluation, in Medicine dated March 4, 1999 exonerating petitioner is AFFIRMED.
defiance of the petitioner’s advise. Editha omitted the diligence No pronouncement as to costs.
required by the circumstances which could have avoided the injury.
The omission in not returning for a follow-up evaluation played a
SO ORDERED.
substantial part in bringing about Editha’s own injury. Had Editha
returned, petitioner could have conducted the proper medical tests and
procedure necessary to determine Editha’s health condition and
applied the corresponding treatment which could have prevented the
rupture of Editha’s uterus. The D&C procedure having been conducted
in accordance with the standard medical practice, it is clear that
Editha’s omission was the proximate cause of her own injury and not
merely a contributory negligence on her part.

Contributory negligence is the act or omission amounting to want of

ordinary care on the part of the person injured, which, concurring with
the defendant’s negligence, is the proximate cause of the
injury.59 Difficulty seems to be apprehended in deciding which acts of
the injured party shall be considered immediate causes of the
accident.60 Where the immediate cause of an accident resulting in an
injury is the plaintiff’s own act, which contributed to the principal
occurrence as one of its determining factors, he cannot recover
damages for the injury.61 Again, based on the evidence presented in
the present case under review, in which no negligence can be
attributed to the petitioner, the immediate cause of the accident
resulting in Editha’s injury was her own omission when she did
not return for a follow-up check up, in defiance of petitioner’s
orders. The immediate cause of Editha’s injury was her own act;
thus, she cannot recover damages from the injury.

Lastly, petitioner asserts that her right to due process was violated
because she was never informed by either respondents or by the PRC
that an appeal was pending before the PRC.62 Petitioner claims that a
verification with the records section of the PRC revealed that on April
15, 1999, respondents filed a Memorandum on Appeal before the
PRC, which did not attach the actual registry receipt but was merely
indicated therein.63

Respondents, on the other hand avers that if the original registry

receipt was not attached to the Memorandum on Appeal, PRC would
not have entertained the appeal or accepted such pleading for lack of
notice or proof of service on the other party.64 Also, the registry receipt
could not be appended to the copy furnished to petitioner’s former
counsel, because the registry receipt was already appended to the
original copy of the Memorandum of Appeal filed with PRC. 65

It is a well-settled rule that when service of notice is an issue, the rule

is that the person alleging that the notice was served must prove the
fact of service. The burden of proving notice rests upon the party
asserting its existence.66 In the present case, respondents did not
present any proof that petitioner was served a copy of the
Memorandum on Appeal. Thus, respondents were not able to satisfy
the burden of proving that they had in fact informed the petitioner of the
appeal proceedings before the PRC.

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

Commission,67 in which the National Labor Relations Commission
failed to order the private respondent to furnish the petitioner a copy of
the Appeal Memorandum, the Court held that said failure deprived the
petitioner of procedural due process guaranteed by the Constitution,
which could have served as basis for the nullification of the
G.R. No. 124354 December 29, 1999
ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf
and as natural guardians of the minors, ROMMEL RAMOS, ROY
RODERICK RAMOS and RON RAYMOND RAMOS, petitioners,
vs.
COURT OF APPEALS, DELOS SANTOS MEDICAL CENTER, DR.
ORLINO HOSAKA and DRA. PERFECTA GUTIERREZ, respondents.
KAPUNAN, J.:
The Hippocratic Oath mandates physicians to give primordial
consideration to the health and welfare of their patients. If a doctor fails
to live up to this precept, he is made accountable for his acts. A
mistake, through gross negligence or incompetence or plain human
error, may spell the difference between life and death. In this sense,
the doctor plays God on his patient's fate. 1
In the case at bar, the Court is called upon to rule whether a surgeon,
an anesthesiologist and a hospital should be made liable for the
unfortunate comatose condition of a patient scheduled for
cholecystectomy. 2
Petitioners seek the reversal of the decision 3 of the Court of Appeals,
dated 29 May 1995, which overturned the decision 4 of the Regional
Trial Court, dated 30 January 1992, finding private respondents liable
for damages arising from negligence in the performance of their
professional duties towards petitioner Erlinda Ramos resulting in her
comatose condition.
The antecedent facts as summarized by the trial court are reproduced
hereunder:
Plaintiff Erlinda Ramos was, until the afternoon of
June 17, 1985, a 47-year old (Exh. "A") robust
woman (TSN, October 19, 1989, p. 10). Except for
occasional complaints of discomfort due to pains
allegedly caused by the presence of a stone in her
gall bladder (TSN, January 13, 1988, pp. 4-5), she
was as normal as any other woman. Married to
Rogelio E. Ramos, an executive of Philippine Long
Distance Telephone Company, she has three
children whose names are Rommel Ramos, Roy
Roderick Ramos and Ron Raymond Ramos (TSN,
October 19, 1989, pp. 5-6).
Because the discomforts somehow interfered with
her normal ways, she sought professional advice.
She was advised to undergo an operation for the
removal of a stone in her gall bladder (TSN,
January 13, 1988, p. 5). She underwent a series of
examinations which included blood and urine tests
(Exhs. "A" and "C") which indicated she was fit for
surgery.
Through the intercession of a mutual friend, Dr.
Buenviaje (TSN, January 13, 1988, p. 7), she and
her husband Rogelio met for the first time Dr.
Orlino Hozaka (should be Hosaka; see TSN,
February 20, 1990, p. 3), one of the defendants in
this case, on June 10, 1985. They agreed that
their date at the operating table at the DLSMC
(another defendant), would be on June 17, 1985 at
9:00 A.M.. Dr. Hosaka decided that she should
undergo a "cholecystectomy" operation after
examining the documents (findings from the
Capitol Medical Center, FEU Hospital and
DLSMC) presented to him. Rogelio E. Ramos,
however, asked Dr. Hosaka to look for a good
anesthesiologist. Dr. Hosaka, in turn, assured
Rogelio that he will get a good anesthesiologist.
Dr. Hosaka charged a fee of P16,000.00, which
was to include the anesthesiologist's fee and
which was to be paid after the operation (TSN,
October 19, 1989, pp. 14-15, 22-23, 31-33; TSN,
February 27, 1990, p. 13; and TSN, November 9,
1989, pp. 3-4, 10, 17).
A day before the scheduled date of operation, she
was admitted at one of the rooms of the DLSMC,
located along E. Rodriguez Avenue, Quezon City
(TSN, October 19,1989, p. 11).
At around 7:30 A.M. of June 17, 1985 and while
still in her room, she was prepared for the
operation by the hospital staff. Her sister-in-law,
Herminda Cruz, who was the Dean of the College
of Nursing at the Capitol Medical Center, was also
there for moral support. She reiterated her
previous request for Herminda to be with her even
during the operation. After praying, she was given
injections. Her hands were held by Herminda as
they went down from her room to the operating
room (TSN, January 13, 1988, pp. 9-11). Her
husband, Rogelio, was also with her (TSN,
October 19, 1989, p. 18). At the operating room,
Herminda saw about two or three nurses and Dr.
Perfecta Gutierrez, the other defendant, who was
to administer anesthesia. Although not a member
of the hospital staff, Herminda introduced herself
as Dean of the College of Nursing at the Capitol
Medical Center who was to provide moral support
to the patient, to them. Herminda was allowed to
stay inside the operating room.
At around 9:30 A.M., Dr. Gutierrez reached a
nearby phone to look for Dr. Hosaka who was not
yet in (TSN, January 13, 1988, pp. 11-12). Dr.
Gutierrez thereafter informed Herminda Cruz
about the prospect of a delay in the arrival of Dr.
Hosaka. Herminda then went back to the patient
who asked, "Mindy, wala pa ba ang Doctor"? The
former replied, "Huwag kang mag-alaala, darating
na iyon" (Ibid.).
Thereafter, Herminda went out of the operating
room and informed the patient's husband, Rogelio,
that the doctor was not yet around (id., p. 13).
When she returned to the operating room, the
patient told her, "Mindy, inip na inip na ako, ikuha
mo ako ng ibang Doctor." So, she went out again
and told Rogelio about what the patient said (id., p.
15). Thereafter, she returned to the operating
room.
At around 10:00 A.M., Rogelio E. Ramos was
"already dying [and] waiting for the arrival of the
doctor" even as he did his best to find somebody
who will allow him to pull out his wife from the
operating room (TSN, October 19, 1989, pp. 19-
20). He also thought of the feeling of his wife, who
was inside the operating room waiting for the
doctor to arrive (ibid.). At almost 12:00 noon, he
met Dr. Garcia who remarked that he (Dr. Garcia)
was also tired of waiting for Dr. Hosaka to arrive
(id., p. 21). While talking to Dr. Garcia at around
12:10 P.M., he came to know that Dr. Hosaka
arrived as a nurse remarked, "Nandiyan na si Dr.
Hosaka, dumating na raw." Upon hearing those
words, he went down to the lobby and waited for
the operation to be completed (id., pp. 16, 29-30).
At about 12:15 P.M., Herminda Cruz, who was
inside the operating room with the patient, heard
somebody say that "Dr. Hosaka is already here."
She then saw people inside the operating room
"moving, doing this and that, [and] preparing the
patient for the operation" (TSN, January 13, 1988,
p. 16). As she held the hand of Erlinda Ramos,
she then saw Dr. Gutierrez intubating the hapless
patient. She thereafter heard Dr. Gutierrez say,
"ang hirap ma-intubate nito, mali yata ang
pagkakapasok. O lumalaki ang tiyan" (id., p. 17).
Because of the remarks of Dra. Gutierrez, she
focused her attention on what Dr. Gutierrez was
doing. She thereafter noticed bluish discoloration
of the nailbeds of the left hand of the hapless
Erlinda even as Dr. Hosaka approached her. She
then heard Dr. Hosaka issue an order for someone
to call Dr. Calderon, another anesthesiologist (id.,
p. 19). After Dr. Calderon arrived at the operating
room, she saw this anesthesiologist trying to
intubate the patient. The patient's nailbed became
bluish and the patient was placed in a
trendelenburg position — a position where the
head of the patient is placed in a position lower
than her feet which is an indication that there is a
decrease of blood supply to the patient's brain (Id.,
pp. 19-20). Immediately thereafter, she went out of
the operating room, and she told Rogelio E.
Ramos "that something wrong was . . . happening"
(Ibid.). Dr. Calderon was then able to intubate the
patient (TSN, July 25, 1991, p. 9).
Meanwhile, Rogelio, who was outside the
operating room, saw a respiratory machine being
rushed towards the door of the operating room. He
also saw several doctors rushing towards the
operating room. When informed by Herminda Cruz
that something wrong was happening, he told her
(Herminda) to be back with the patient inside the
operating room (TSN, October 19, 1989, pp. 25-
28).
Herminda Cruz immediately rushed back, and saw
that the patient was still in trendelenburg position
(TSN, January 13, 1988, p. 20). At almost 3:00
P.M. of that fateful day, she saw the patient taken
to the Intensive Care Unit (ICU).
About two days thereafter, Rogelio E. Ramos was
able to talk to Dr. Hosaka. The latter informed the
former that something went wrong during the
intubation. Reacting to what was told to him,
Rogelio reminded the doctor that the condition of
his wife would not have happened, had he (Dr.
Hosaka) looked for a good anesthesiologist (TSN,
October 19, 1989, p. 31).
Doctors Gutierrez and Hosaka were also asked by
the hospital to explain what happened to the
patient. The doctors explained that the patient had
bronchospasm (TSN, November 15, 1990, pp. 26-
27).
Erlinda Ramos stayed at the ICU for a month.
About four months thereafter or on November 15,
1985, the patient was released from the hospital.
During the whole period of her confinement, she
incurred hospital bills amounting to P93,542.25
which is the subject of a promissory note and
affidavit of undertaking executed by Rogelio E.
Ramos in favor of DLSMC. Since that fateful
afternoon of June 17, 1985, she has been in a
comatose condition. She cannot do anything. She
cannot move any part of her body. She cannot see
or hear. She is living on mechanical means. She
suffered brain damage as a result of the absence
of oxygen in her brain for four to five minutes
(TSN, November 9, 1989, pp. 21-22). After being
discharged from the hospital, she has been
staying in their residence, still needing constant
medical attention, with her husband Rogelio
incurring a monthly expense ranging from
P8,000.00 to P10,000.00 (TSN, October 19, 1989,
pp. 32-34). She was also diagnosed to be
suffering from "diffuse cerebral parenchymal
damage" (Exh. "G"; see also TSN, December 21,
1989,
p. 6). 5
Thus, on 8 January 1986, petitioners filed a civil case 6 for damages
with the Regional Trial Court of Quezon City against herein private
respondents alleging negligence in the management and care of
Erlinda Ramos.
During the trial, both parties presented evidence as to the possible
cause of Erlinda's injury. Plaintiff presented the testimonies of Dean
Herminda Cruz and Dr. Mariano Gavino to prove that the sustained by
Erlinda was due to lack of oxygen in her brain caused by the faulty
management of her airway by private respondents during the
anesthesia phase. On the other hand, private respondents primarily
relied on the expert testimony of Dr. Eduardo Jamora, a pulmonologist,
to the effect that the cause of brain damage was Erlinda's allergic
reaction to the anesthetic agent, Thiopental Sodium (Pentothal).
After considering the evidence from both sides, the Regional Trial
Court rendered judgment in favor of petitioners, to wit:
After evaluating the evidence as shown in the
finding of facts set forth earlier, and applying the
aforecited provisions of law and jurisprudence to
the case at bar, this Court finds and so holds that
defendants are liable to plaintiffs for damages. The
defendants were guilty of, at the very least,
negligence in the performance of their duty to
plaintiff-patient Erlinda Ramos.
On the part of Dr. Perfecta Gutierrez, this Court
finds that she omitted to exercise reasonable care
in not only intubating the patient, but also in not
repeating the administration of atropine (TSN,
August 20, 1991, pp. 5-10), without due regard to
the fact that the patient was inside the operating
room for almost three (3) hours. For after she
committed a mistake in intubating [the] patient, the
patient's nailbed became bluish and the patient,
thereafter, was placed in trendelenburg position,
because of the decrease of blood supply to the
patient's brain. The evidence further shows that
the hapless patient suffered brain damage
because of the absence of oxygen in her
(patient's) brain for approximately four to five
minutes which, in turn, caused the patient to
become comatose.
On the part of Dr. Orlino Hosaka, this Court finds
that he is liable for the acts of Dr. Perfecta
Gutierrez whom he had chosen to administer
anesthesia on the patient as part of his obligation
to provide the patient a good anesthesiologist',
and for arriving for the scheduled operation almost
three (3) hours late.
On the part of DLSMC (the hospital), this Court
finds that it is liable for the acts of negligence of
the doctors in their "practice of medicine" in the
operating room. Moreover, the hospital is liable for
failing through its responsible officials, to cancel
the scheduled operation after Dr. Hosaka
inexcusably failed to arrive on time.
In having held thus, this Court rejects the defense
raised by defendants that they have acted with
 due care and prudence in rendering medical
services to plaintiff-patient. For if the patient was
properly intubated as claimed by them, the patient
would not have become comatose. And, the fact
that another anesthesiologist was called to try to
intubate the patient after her (the patient's) nailbed
turned bluish, belie their claim. Furthermore, the
defendants should have rescheduled the operation
to a later date. This, they should have done, if
defendants acted with due care and prudence as
the patient's case was an elective, not an
emergency case.
xxx xxx xxx
WHEREFORE, and in view of the foregoing,
judgment is rendered in favor of the plaintiffs and
against the defendants. Accordingly, the latter are
ordered to pay, jointly and severally, the former the
following sums of money, to wit:
1) the sum of P8,000.00 as
actual monthly expenses for
the plaintiff Erlinda Ramos
reckoned from November 15,
1985 or in the total sum of
P632,000.00 as of April 15,
1992, subject to its being
updated;
2) the sum of P100,000.00 as
reasonable attorney's fees;
3) the sum of P800,000.00 by
way of moral damages and
the further sum of
P200,000,00 by way of
exemplary damages; and,
4) the costs of the suit.
SO ORDERED. 7
Private respondents seasonably interposed an appeal to the Court of
Appeals. The appellate court rendered a Decision, dated 29 May 1995,
reversing the findings of the trial court. The decretal portion of the
decision of the appellate court reads:
WHEREFORE, for the foregoing premises the
appealed decision is hereby REVERSED, and the
complaint below against the appellants is hereby
ordered DISMISSED. The counterclaim of
appellant De Los Santos Medical Center is
GRANTED but only insofar as appellees are
hereby ordered to pay the unpaid hospital bills
amounting to P93,542.25, plus legal interest for
justice must be tempered with mercy.
SO ORDERED. 8
The decision of the Court of Appeals was received on 9 June 1995 by
petitioner Rogelio Ramos who was mistakenly addressed as "Atty.
Rogelio Ramos." No copy of the decision, however, was sent nor
received by the Coronel Law Office, then counsel on record of
petitioners. Rogelio referred the decision of the appellate court to a
new lawyer, Atty. Ligsay, only on 20 June 1995, or four (4) days before
the expiration of the reglementary period for filing a motion for
reconsideration. On the same day, Atty. Ligsay, filed with the appellate
court a motion for extension of time to file a motion for reconsideration.
The motion for reconsideration was submitted on 4 July 1995.
However, the appellate court denied the motion for extension of time in
its Resolution dated 25 July 1995. 9 Meanwhile, petitioners engaged
the services of another counsel, Atty. Sillano, to replace Atty. Ligsay.
Atty. Sillano filed on 7 August 1995 a motion to admit the motion for
reconsideration contending that the period to file the appropriate
pleading on the assailed decision had not yet commenced to run as the
Division Clerk of Court of the Court of Appeals had not yet served a
copy thereof to the counsel on record. Despite this explanation, the
appellate court still denied the motion to admit the motion for
reconsideration of petitioners in its Resolution, dated 29 March 1996,
primarily on the ground that the fifteen-day (15) period for filing a
motion for reconsideration had already expired, to wit:
We said in our Resolution on July 25, 1995, that
the filing of a Motion for Reconsideration cannot
be extended; precisely, the Motion for Extension
(Rollo, p. 12) was denied. It is, on the other hand,
admitted in the latter Motion that
plaintiffs/appellees received a copy of the decision
as early as June 9, 1995. Computation wise, the
period to file a Motion for Reconsideration expired
on June 24. The Motion for Reconsideration, in
turn, was received by the Court of Appeals already
on July 4, necessarily, the 15-day period already
passed. For that alone, the latter should be
denied.
Even assuming admissibility of the Motion for the
Reconsideration, but after considering the
Comment/Opposition, the former, for lack of merit,
is hereby DENIED.
SO ORDERED. 10
A copy of the above resolution was received by Atty. Sillano on 11 April
1996. The next day, or on 12 April 1996, Atty. Sillano filed before this
Court a motion for extension of time to file the present petition
for certiorari under Rule 45. The Court granted the motion for extension
of time and gave petitioners additional thirty (30) days after the
expiration of the fifteen-day (15) period counted from the receipt of the
resolution of the Court of Appeals within which to submit the petition.
The due date fell on 27 May 1996. The petition was filed on 9 May
1996, well within the extended period given by the Court.
Petitioners assail the decision of the Court of Appeals on the following
grounds:
I
IN PUTTING MUCH RELIANCE ON THE
TESTIMONIES OF RESPONDENTS DRA.
GUTIERREZ, DRA. CALDERON AND DR.
JAMORA;
II
IN FINDING THAT THE NEGLIGENCE OF THE
RESPONDENTS DID NOT CAUSE THE
UNFORTUNATE COMATOSE CONDITION OF
PETITIONER ERLINDA RAMOS;
III
IN NOT APPLYING THE DOCTRINE OF RES
IPSA LOQUITUR. 11
Before we discuss the merits of the case, we shall first dispose of the
procedural issue on the timeliness of the petition in relation to the
motion for reconsideration filed by petitioners with the Court of
Appeals. In their
Comment, 12 private respondents contend that the petition should not
be given due course since the motion for reconsideration of the
petitioners on the decision of the Court of Appeals was validly
dismissed by the appellate court for having been filed beyond the
reglementary period. We do not agree.
A careful review of the records reveals that the reason behind the
delay in filing the motion for reconsideration is attributable to the fact
that the decision of the Court of Appeals was not sent to then counsel
on record of petitioners, the Coronel Law Office. In fact, a copy of the
decision of the appellate court was instead sent to and received by
petitioner Rogelio Ramos on 9 June 1995 wherein he was mistakenly
addressed as Atty. Rogelio Ramos. Based on the other
communications received by petitioner Rogelio Ramos, the appellate
court apparently mistook him for the counsel on record. Thus, no copy
of the decision of the counsel on record. Petitioner, not being a lawyer
and unaware of the prescriptive period for filing a motion for
reconsideration, referred the same to a legal counsel only on 20 June
1995.
It is elementary that when a party is represented by counsel, all notices
should be sent to the party's lawyer at his given address. With a few
exceptions, notice to a litigant without notice to his counsel on record is
no notice at all. In the present case, since a copy of the decision of the
appellate court was not sent to the counsel on record of petitioner,
there can be no sufficient notice to speak of. Hence, the delay in the
filing of the motion for reconsideration cannot be taken against
petitioner. Moreover, since the Court of Appeals already issued a
second Resolution, dated 29 March 1996, which superseded the
earlier resolution issued on 25 July 1995, and denied the motion for
reconsideration of petitioner, we believed that the receipt of the former
should be considered in determining the timeliness of the filing of the
present petition. Based on this, the petition before us was submitted on
time.
After resolving the foregoing procedural issue, we shall now look into
the merits of the case. For a more logical presentation of the
discussion we shall first consider the issue on the applicability of the
doctrine of res ipsa loquitur to the instant case. Thereafter, the first two
assigned errors shall be tackled in relation to the res ipsa
loquitur doctrine.
Res ipsa loquitur is a Latin phrase which literally means "the thing or
the transaction speaks for itself." The phrase "res ipsa loquitur'' 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. 13 Where the thing which caused the injury complained of
is shown to be under the management of the defendant or his servants
and the accident is such as in ordinary course of things does not
happen if those who have its management or control use proper care,
it affords reasonable evidence, in the absence of explanation by the
defendant, that the accident arose from or was caused by the
defendant's want of care. 14
The doctrine of res ipsa loquitur is simply a recognition of the postulate
that, as a matter of common knowledge and experience, the very
nature of certain types of occurrences may justify an 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. 15 It is grounded in the superior logic
of ordinary human experience and on the basis of such experience or
common knowledge, negligence may be deduced from the mere
occurrence of the accident itself. 16 Hence, res ipsa loquitur is applied
in conjunction with the doctrine of common knowledge.
However, much has been said that res ipsa loquitur is not a rule of
substantive law and, as such, does not create or constitute an
independent or separate ground of liability. 17 Instead, it is considered
as merely evidentiary or in the nature of a procedural rule. 18 It is
regarded as a mode of proof, or a mere procedural of convenience
since it furnishes a substitute for, and relieves a plaintiff of, the burden
of producing specific proof of negligence. 19 In other words, mere
invocation and application of the doctrine does not dispense with the
requirement of proof of negligence. It is simply a step in the process of
such proof, permitting the plaintiff to present along with the proof of the
accident, enough of the attending circumstances to invoke the doctrine,
creating an inference or presumption of negligence, and to thereby
place on the defendant the burden of going forward with the
proof. 20 Still, before resort to the doctrine may be allowed, the
following requisites must be satisfactorily shown:
1. The accident is of a kind
which ordinarily does not
occur in the absence of
someone's negligence;
2. It is caused by an
instrumentality within the
exclusive control of the
defendant or defendants; and
3. The possibility of
contributing conduct which
would make the plaintiff
responsible is eliminated. 21
In the above requisites, the fundamental element is the "control of
instrumentality" which caused the damage. 22 Such element of control
must be shown to be within the dominion of the defendant. In order to
have the benefit of the rule, a plaintiff, in addition to proving injury or
damage, must show a situation where it is applicable, and must
establish that the essential elements of the doctrine were present in a
particular incident. 23
Medical malpractice 24 cases do not escape the application of this
doctrine. Thus, res ipsa loquitur has been applied when the
circumstances attendant upon the harm are themselves of such a
character as to justify an inference of negligence as the cause of that
harm. 25 The application of res ipsa loquitur in medical negligence
cases presents a question of law since it is a judicial function to
determine whether a certain set of circumstances does, as a matter of
law, permit a given inference. 26
Although generally, expert medical testimony is relied upon in
malpractice suits to prove that a physician has done a negligent act or
that he has deviated from the standard medical procedure, when the
doctrine of res ipsa loquitur is availed by the plaintiff, the need for
expert medical testimony is dispensed with because the injury itself
provides the proof of negligence. 27 The reason is that the general rule
on the necessity of expert testimony applies only to such matters
clearly within the domain of medical science, and not to matters that
are within the common knowledge of mankind which may be testified to
by anyone familiar with the facts. 28 Ordinarily, only physicians and
surgeons of skill and experience are competent to testify as to whether
a patient has been treated or operated upon with a reasonable degree
of skill and care. However, testimony as to the statements and acts of
physicians and surgeons, external appearances, and manifest
conditions which are observable by any one may be given by non-
expert witnesses. 29 Hence, in cases where the res ipsa loquitur is
applicable, the court is permitted to find a physician negligent upon
proper proof of injury to the patient, without the aid of expert testimony,
where the court from its fund of common knowledge can determine the
proper standard of care. 30 Where common knowledge and experience
teach that a resulting injury would not have occurred to the patient if
due care had been exercised, an inference of negligence may be
drawn giving rise to an application of the doctrine of res ipsa
loquitur without medical evidence, which is ordinarily required to show
not only what occurred but how and why it occurred. 31 When the
doctrine is appropriate, all that the patient must do is prove a nexus
between the particular act or omission complained of and the injury
sustained while under the custody and management of the defendant
without need to produce expert medical testimony to establish the
standard of care. Resort to res ipsa loquitur is allowed because there is
no other way, under usual and ordinary conditions, by which the patient
can obtain redress for injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the
following situations: leaving of a foreign object in the body of the
patient after an operation, 32 injuries sustained on a healthy part of the
body which was not under, or in the area, of treatment, 33 removal of
the wrong part of the body when another part was circumstances are such that the true explanation
intended, 34 knocking out a tooth while a patient's jaw was under of event is more accessible to the defendants than
anesthetic for the removal of his tonsils, 35 and loss of an eye while the to the plaintiff for they had the exclusive control of
patient plaintiff was under the influence of anesthetic, during or the instrumentalities of anesthesia.
following an operation for appendicitis, 36 among others.
Upon all the facts, conditions and circumstances
Nevertheless, despite the fact that the scope of res ipsa loquitur has alleged in Count II it is held that a cause of action
been measurably enlarged, it does not automatically apply to all cases is stated under the doctrine of res ipsa loquitur. 44
of medical negligence as to mechanically shift the burden of proof to
the defendant to show that he is not guilty of the ascribed
Indeed, the principles enunciated in the aforequoted case apply with
negligence. Res ipsa loquitur is not a rigid or ordinary doctrine to be
equal force here. In the present case, Erlinda submitted herself for
perfunctorily used but a rule to be cautiously applied, depending upon
cholecystectomy and expected a routine general surgery to be
the circumstances of each case. It is generally restricted to situations in
performed on her gall bladder. On that fateful day she delivered her
malpractice cases where a layman is able to say, as a matter of
person over to the care, custody and control of private respondents
common knowledge and observation, that the consequences of
who exercised complete and exclusive control over her. At the time of
professional care were not as such as would ordinarily have followed if
submission, Erlinda was neurologically sound and, except for a few
due care had been
minor discomforts, was likewise physically fit in mind and body.
exercised. 37 A distinction must be made between the failure to secure
However, during the administration of anesthesia and prior to the
results, and the occurrence of something more unusual and not
performance of cholecystectomy she suffered irreparable damage to
ordinarily found if the service or treatment rendered followed the usual
her brain. Thus, without undergoing surgery, she went out of the
procedure of those skilled in that particular practice. It must be
operating room already decerebrate and totally incapacitated.
conceded that the doctrine of res ipsa loquitur can have no application
Obviously, brain damage, which Erlinda sustained, is an injury which
in a suit against a physician or surgeon which involves the merits of a
does not normally occur in the process of a gall bladder operation. In
diagnosis or of a scientific treatment. 38 The physician or surgeon is not
fact, this kind of situation does not in the absence of negligence of
required at his peril to explain why any particular diagnosis was not
someone in the administration of anesthesia and in the use of
correct, or why any particular scientific treatment did not produce the
endotracheal tube. Normally, a person being put under anesthesia is
desired result. 39 Thus, res ipsa loquitur is not available in a
not rendered decerebrate as a consequence of administering such
malpractice suit if the only showing is that the desired result of an
anesthesia if the proper procedure was followed. Furthermore, the
operation or treatment was not accomplished. 40 The real question,
instruments used in the administration of anesthesia, including the
therefore, is whether or not in the process of the operation any
endotracheal tube, were all under the exclusive control of private
extraordinary incident or unusual event outside of the routine
respondents, who are the physicians-in-charge. Likewise, petitioner
performance occurred which is beyond the regular scope of customary
Erlinda could not have been guilty of contributory negligence because
professional activity in such operations, which, if unexplained would
she was under the influence of anesthetics which rendered her
themselves reasonably speak to the average man as the negligent
unconscious.
cause or causes of the untoward consequence. 41 If there was such
extraneous interventions, the doctrine of res ipsa loquitur may be
utilized and the defendant is called upon to explain the matter, by Considering that a sound and unaffected member of the body (the
evidence of exculpation, if he could. 42 brain) is injured or destroyed while the patient is unconscious and
under the immediate and exclusive control of the physicians, we hold
that a practical administration of justice dictates the application of res
We find the doctrine of res ipsa loquitur appropriate in the case at bar.
ipsa loquitur. Upon these facts and under these circumstances the
As will hereinafter be explained, the damage sustained by Erlinda in
Court would be able to say, as a matter of common knowledge and
her brain prior to a scheduled gall bladder operation presents a case
observation, if negligence attended the management and care of the
for the application of res ipsa loquitur.
patient. Moreover, the liability of the physicians and the hospital in this
case is not predicated upon an alleged failure to secure the desired
A case strikingly similar to the one before us is Voss results of an operation nor on an alleged lack of skill in the diagnosis or
vs. Bridwell, 43 where the Kansas Supreme Court in applying the res treatment as in fact no operation or treatment was ever performed on
ipsa loquitur stated: Erlinda. Thus, upon all these initial determination a case is made out
for the application of the doctrine of res ipsa loquitur.
The plaintiff herein submitted himself for a mastoid
operation and delivered his person over to the Nonetheless, in holding that res ipsa loquitur is available to the present
care, custody and control of his physician who had case we are not saying that the doctrine is applicable in any and all
complete and exclusive control over him, but the cases where injury occurs to a patient while under anesthesia, or to
operation was never performed. At the time of any and all anesthesia cases. Each case must be viewed in its own
submission he was neurologically sound and light and scrutinized in order to be within the res ipsa loquitur coverage.
physically fit in mind and body, but he suffered
irreparable damage and injury rendering him
Having in mind the applicability of the res ipsa loquitur doctrine and the
decerebrate and totally incapacitated. The injury
presumption of negligence allowed therein, the Court now comes to the
was one which does not ordinarily occur in the
issue of whether the Court of Appeals erred in finding that private
process of a mastoid operation or in the absence
respondents were not negligent in the care of Erlinda during the
of negligence in the administration of an
anesthesia phase of the operation and, if in the affirmative, whether the
anesthetic, and in the use and employment of an
alleged negligence was the proximate cause of Erlinda's comatose
endoctracheal tube. Ordinarily a person being put
condition. Corollary thereto, we shall also determine if the Court of
under anesthesia is not rendered decerebrate as a
Appeals erred in relying on the testimonies of the witnesses for the
consequence of administering such anesthesia in
private respondents.
the absence of negligence. Upon these facts and
under these circumstances a layman would be
able to say, as a matter of common knowledge In sustaining the position of private respondents, the Court of Appeals
and observation, that the consequences of relied on the testimonies of Dra. Gutierrez, Dra. Calderon and Dr.
professional treatment were not as such as would Jamora. In giving weight to the testimony of Dra. Gutierrez, the Court
ordinarily have followed if due care had been of Appeals rationalized that she was candid enough to admit that she
exercised. experienced some difficulty in the endotracheal intubation 45 of the
patient and thus, cannot be said to be covering her negligence with
falsehood. The appellate court likewise opined that private respondents
Here the plaintiff could not have been guilty of
were able to show that the brain damage sustained by Erlinda was not
contributory negligence because he was under the
caused by the alleged faulty intubation but was due to the allergic
influence of anesthetics and unconscious, and the
reaction of the patient to the drug Thiopental Sodium (Pentothal), a
short-acting barbiturate, as testified on by their expert witness, Dr.
Jamora. On the other hand, the appellate court rejected the testimony
of Dean Herminda Cruz offered in favor of petitioners that the cause of
the brain injury was traceable to the wrongful insertion of the tube since
the latter, being a nurse, was allegedly not knowledgeable in the
process of intubation. In so holding, the appellate court returned a
verdict in favor of respondents physicians and hospital and absolved
them of any liability towards Erlinda and her family.
We disagree with the findings of the Court of Appeals. We hold that
private respondents were unable to disprove the presumption of
negligence on their part in the care of Erlinda and their negligence was
the proximate cause of her piteous condition.
In the instant case, the records are helpful in furnishing not only the
logical scientific evidence of the pathogenesis of the injury but also in
providing the Court the legal nexus upon which liability is based. As will
be shown hereinafter, private respondents' own testimonies which are
reflected in the transcript of stenographic notes are replete of signposts
indicative of their negligence in the care and management of Erlinda.
With regard to Dra. Gutierrez, we find her negligent in the care of
Erlinda during the anesthesia phase. As borne by the records,
respondent Dra. Gutierrez failed to properly intubate the patient. This
fact was attested to by Prof. Herminda Cruz, Dean of the Capitol
Medical Center School of Nursing and petitioner's sister-in-law, who
was in the operating room right beside the patient when the tragic
event occurred. Witness Cruz testified to this effect:
ATTY. PAJARES:
Q: In particular, what did Dra.
Perfecta Gutierrez do, if any
on the patient?
A: In particular, I could see
that she was intubating the
patient.
Q: Do you know what
happened to that intubation
process administered by Dra.
Gutierrez?
ATTY. ALCERA:
She will be incompetent Your
Honor.
COURT:
Witness may answer if she
knows.
A: As have said, I was with
the patient, I was beside the
stretcher holding the left hand
of the patient and all of a
sudden heard some remarks
coming from Dra. Perfecta
Gutierrez herself. She was
saying "Ang hirap ma-intubate
nito, mali yata ang
pagkakapasok. O lumalaki
ang tiyan.
xxx xxx xxx
ATTY. PAJARES:
Q: From whom did you hear
those words "lumalaki ang
tiyan"?
A: From Dra. Perfecta
Gutierrez.
xxx xxx xxx
Q: After hearing the phrase
"lumalaki ang tiyan," what did
you notice on the person of
the patient?
A: I notice (sic) some bluish
discoloration on the nailbeds
of the left hand where I was
at.
Q: Where was Dr. Orlino
Ho[s]aka then at that
particular time?
A: I saw him approaching the
patient during that time.
Q: When he approached the
patient, what did he do, if
any?
A: He made an order to call
on the anesthesiologist in the
person of Dr. Calderon.
Q: Did Dr. Calderon, upon
being called, arrive inside the
operating room?
A: Yes sir.
Q: What did [s]he do, if any?
A: [S]he tried to intubate the
patient.
Q: What happened to the
patient?
A: When Dr. Calderon try (sic)
to intubate the patient, after a
while the patient's nailbed
became bluish and I saw the
patient was placed in
trendelenburg position.
xxx xxx xxx
Q: Do you know the reason
why the patient was placed in
that trendelenburg position?
A: As far as I know, when a
patient is in that position,
there is a decrease of blood
supply to the brain. 46
xxx xxx xxx
The appellate court, however, disbelieved Dean Cruz's testimony in the
trial court by declaring that:
A perusal of the standard nursing curriculum in our
country will show that intubation is not taught as
part of nursing procedures and techniques.
Indeed, we take judicial notice of the fact that
nurses do not, and cannot, intubate. Even on the
assumption that she is fully capable of determining
whether or not a patient is properly intubated,
witness Herminda Cruz, admittedly, did not peep
into the throat of the patient. (TSN, July 25, 1991,
p. 13). More importantly, there is no evidence that
she ever auscultated the patient or that she
conducted any type of examination to check if the
endotracheal tube was in its proper place, and to
determine the condition of the heart, lungs, and
other organs. Thus, witness Cruz's categorical
statements that appellant Dra. Gutierrez failed to
intubate the appellee Erlinda Ramos and that it
was Dra. Calderon who succeeded in doing so
clearly suffer from lack of sufficient factual
bases. 47
In other words, what the Court of Appeals is trying to impress is that
being a nurse, and considered a layman in the process of intubation,
witness Cruz is not competent to testify on whether or not the
intubation was a success.
We do not agree with the above reasoning of the appellate court.
Although witness Cruz is not an anesthesiologist, she can very well
testify upon matters on which she is capable of observing such as, the
statements and acts of the physician and surgeon, external
appearances, and manifest conditions which are observable by any
one. 48 This is precisely allowed under the doctrine of res ipsa
loquitur where the testimony of expert witnesses is not required. It is
the accepted rule that expert testimony is not necessary for the proof of
negligence in non-technical matters or those of which an ordinary
person may be expected to have knowledge, or where the lack of skill
or want of care is so obvious as to render expert testimony
unnecessary. 49 We take judicial notice of the fact that anesthesia
procedures have become so common, that even an ordinary person
can tell if it was administered properly. As such, it would not be too
difficult to tell if the tube was properly inserted. This kind of
observation, we believe, does not require a medical degree to be
acceptable.
At any rate, without doubt, petitioner's witness, an experienced clinical
nurse whose long experience and scholarship led to her appointment
as Dean of the Capitol Medical Center School at Nursing, was fully
capable of determining whether or not the intubation was a success.
She had extensive clinical experience starting as a staff nurse in
Chicago, Illinois; staff nurse and clinical instructor in a teaching
hospital, the FEU-NRMF; Dean of the Laguna College of Nursing in
San Pablo City; and then Dean of the Capitol Medical Center School of
Nursing. 50 Reviewing witness Cruz' statements, we find that the same
were delivered in a straightforward manner, with the kind of detail,
clarity, consistency and spontaneity which would have been difficult to
fabricate. With her clinical background as a nurse, the Court is satisfied
that she was able to demonstrate through her testimony what truly
transpired on that fateful day.
Most of all, her testimony was affirmed by no less than respondent Dra.
Gutierrez who admitted that she experienced difficulty in inserting the
tube into Erlinda's trachea, to wit:
ATTY. LIGSAY:
Q: In this particular case,
Doctora, while you were
intubating at your first attempt
(sic), you did not immediately
see the trachea?
DRA. GUTIERREZ:
A: Yes sir.
Q: Did you pull away the tube
immediately?
A: You do not pull the . . .
Q: Did you or did you not?
A: I did not pull the tube.
Q: When you said "mahirap
yata ito," what were you
referring to?
A: "Mahirap yata itong i-
intubate," that was the patient.
Q: So, you found some
difficulty in inserting the tube?
A: Yes, because of (sic) my
first attempt, I did not see right
away. 51
Curiously in the case at bar, respondent Dra. Gutierrez made the
haphazard defense that she encountered hardship in the insertion of
the tube in the trachea of Erlinda because it was positioned more
anteriorly (slightly deviated from the normal anatomy of a
person) 52 making it harder to locate and, since Erlinda is obese and
has a short neck and protruding teeth, it made intubation even more
difficult.
The argument does not convince us. If this was indeed observed,
private respondents adduced no evidence demonstrating that they
proceeded to make a thorough assessment of Erlinda's airway, prior to
the induction of anesthesia, even if this would mean postponing the
procedure. From their testimonies, it appears that the observation was
made only as an afterthought, as a means of defense.
The pre-operative evaluation of a patient prior to the administration of
anesthesia is universally observed to lessen the possibility of
anesthetic accidents. Pre-operative evaluation and preparation for
anesthesia begins when the anesthesiologist reviews the patient's
medical records and visits with the patient, traditionally, the day before
elective surgery. 53 It includes taking the patient's medical history,
review of current drug therapy, physical examination and interpretation
of laboratory data. 54 The physical examination performed by the
anesthesiologist is directed primarily toward the central nervous
system, cardiovascular system, lungs and upper airway. 55 A thorough
analysis of the patient's airway normally involves investigating the
following: cervical spine mobility, temporomandibular mobility,
prominent central incisors, diseased or artificial teeth, ability to
visualize uvula and the thyromental distance. 56 Thus, physical
characteristics of the patient's upper airway that could make tracheal
intubation difficult should be studied. 57 Where the need arises, as
when initial assessment indicates possible problems (such as the
alleged short neck and protruding teeth of Erlinda) a thorough
examination of the patient's airway would go a long way towards
decreasing patient morbidity and mortality.
In the case at bar, respondent Dra. Gutierrez admitted that she saw
Erlinda for the first time on the day of the operation itself, on 17 June
1985. Before this date, no prior consultations with, or pre-operative
evaluation of Erlinda was done by her. Until the day of the operation,
respondent Dra. Gutierrez was unaware of the physiological make-up
and needs of Erlinda. She was likewise not properly informed of the
possible difficulties she would face during the administration of
anesthesia to Erlinda. Respondent Dra. Gutierrez' act of seeing her
patient for the first time only an hour before the scheduled operative
procedure was, therefore, an act of exceptional negligence and
professional irresponsibility. The measures cautioning prudence and
vigilance in dealing with human lives lie at the core of the physician's
centuries-old Hippocratic Oath. Her failure to follow this medical
procedure is, therefore, a clear indicia of her negligence.
Respondent Dra. Gutierrez, however, attempts to gloss over this
omission by playing around with the trial court's ignorance of clinical
procedure, hoping that she could get away with it. Respondent Dra.
Gutierrez tried to muddle the difference between an elective surgery
and an emergency surgery just so her failure to perform the required
pre-operative evaluation would escape unnoticed. In her testimony she
asserted:
ATTY. LIGSAY:
Q: Would you agree, Doctor,
that it is good medical practice
to see the patient a day before
so you can introduce yourself
to establish good doctor-
patient relationship and gain
the trust and confidence of the
patient?
who advanced private respondents' theory that the oxygen deprivation
which led to anoxic encephalopathy, 60 was due to an unpredictable
drug reaction to the short-acting barbiturate. We find the theory of
private respondents unacceptable.
First of all, Dr. Jamora cannot be considered an authority in the field of
anesthesiology simply because he is not an anesthesiologist. Since Dr.
Jamora is a pulmonologist, he could not have been capable of properly
enlightening the court about anesthesia practice and procedure and
their complications. Dr. Jamora is likewise not an allergologist and
could not therefore properly advance expert opinion on allergic-
mediated processes. Moreover, he is not a pharmacologist and, as
such, could not have been capable, as an expert would, of explaining
to the court the pharmacologic and toxic effects of the supposed
culprit, Thiopental Sodium (Pentothal).
The inappropriateness and absurdity of accepting Dr. Jamora's
testimony as an expert witness in the anesthetic practice of Pentothal
administration is further supported by his own admission that he
formulated his opinions on the drug not from the practical experience
gained by a specialist or expert in the administration and use of
Sodium Pentothal on patients, but only from reading certain
references, to wit:
ATTY. LIGSAY:

DRA. GUTIERREZ: Q: In your line of expertise on

pulmonology, did you have
any occasion to use pentothal
A: As I said in my previous
as a method of management?
statement, it depends on the
operative procedure of the
anesthesiologist and in my DR. JAMORA:
case, with elective cases and
normal cardio-pulmonary
A: We do it in conjunction with
clearance like that, I usually
the anesthesiologist when
don't do it except on
they have to intubate our
emergency and on cases that
patient.
have an abnormalities
(sic). 58
Q: But not in particular when
you practice pulmonology?
However, the exact opposite is true. In an emergency procedure, there
is hardly enough time available for the fastidious demands of pre-
operative procedure so that an anesthesiologist is able to see the A: No.
patient only a few minutes before surgery, if at all. Elective procedures,
on the other hand, are operative procedures that can wait for days,
Q: In other words, your
weeks or even months. Hence, in these cases, the anesthesiologist
possesses the luxury of time to be at the patient's beside to do a knowledge about pentothal is
proper interview and clinical evaluation. There is ample time to explain based only on what you have
read from books and not by
the method of anesthesia, the drugs to be used, and their possible
hazards for purposes of informed consent. Usually, the pre-operative your own personal application
assessment is conducted at least one day before the intended surgery, of the medicine pentothal?
when the patient is relaxed and cooperative.
A: Based on my personal
Erlinda's case was elective and this was known to respondent Dra. experience also on pentothal.
Gutierrez. Thus, she had all the time to make a thorough evaluation of
Erlinda's case prior to the operation and prepare her for anesthesia. Q: How many times have you
However, she never saw the patient at the bedside. She herself used pentothal?
admitted that she had seen petitioner only in the operating room, and
only on the actual date of the cholecystectomy. She negligently failed
to take advantage of this important opportunity. As such, her attempt to A: They used it on me. I went
exculpate herself must fail. into bronchospasm during my
appendectomy.

Having established that respondent Dra. Gutierrez failed to perform

pre-operative evaluation of the patient which, in turn, resulted to a Q: And because they have
wrongful intubation, we now determine if the faulty intubation is truly used it on you and on account
the proximate cause of Erlinda's comatose condition. of your own personal
experience you feel that you
can testify on pentothal here
Private respondents repeatedly hammered the view that the cerebral with medical authority?
anoxia which led to Erlinda's coma was due to
bronchospasm 59 mediated by her allergic response to the drug,
Thiopental Sodium, introduced into her system. Towards this end, they A: No. That is why I used
presented Dr. Jamora, a Fellow of the Philippine College of Physicians references to support my
and Diplomate of the Philippine Specialty Board of Internal Medicine, claims. 61
An anesthetic accident caused by a rare drug-induced bronchospasm
properly falls within the fields of anesthesia, internal medicine-allergy,
and clinical pharmacology. The resulting anoxic encephalopathy
belongs to the field of neurology. While admittedly, many
bronchospastic-mediated pulmonary diseases are within the expertise
of pulmonary medicine, Dr. Jamora's field, the anesthetic drug-
induced, allergic mediated bronchospasm alleged in this case is within
the disciplines of anesthesiology, allergology and pharmacology. On
the basis of the foregoing transcript, in which the pulmonologist himself
admitted that he could not testify about the drug with medical authority,
it is clear that the appellate court erred in giving weight to Dr. Jamora's
testimony as an expert in the administration of Thiopental Sodium.
The provision in the rules of evidence 62 regarding expert witnesses
states:
Sec. 49. Opinion of expert witness. — The opinion
of a witness on a matter requiring special
knowledge, skill, experience or training which he is
shown to possess, may be received in evidence.
Generally, to qualify as an expert witness, one must have acquired
special knowledge of the subject matter about which he or she is to
testify, either by the study of recognized authorities on the subject or by
practical experience. 63 Clearly, Dr. Jamora does not qualify as an
expert witness based on the above standard since he lacks the
necessary knowledge, skill, and training in the field of anesthesiology.
Oddly, apart from submitting testimony from a specialist in the wrong
field, private respondents' intentionally avoided providing testimony by
competent and independent experts in the proper areas.
Moreover, private respondents' theory, that Thiopental Sodium may
have produced Erlinda's coma by triggering an allergic mediated
response, has no support in evidence. No evidence of stridor, skin
reactions, or wheezing — some of the more common accompanying
signs of an allergic reaction — appears on record. No laboratory data
were ever presented to the court.
In any case, private respondents themselves admit that Thiopental
induced, allergic-mediated bronchospasm happens only very rarely. If
courts were to accept private respondents' hypothesis without
supporting medical proof, and against the weight of available evidence,
then every anesthetic accident would be an act of God. Evidently, the
Thiopental-allergy theory vigorously asserted by private respondents
was a mere afterthought. Such an explanation was advanced in order
to advanced in order to absolve them of any and all responsibility for
the patient's condition.
In view of the evidence at hand, we are inclined to believe petitioners'
stand that it was the faulty intubation which was the proximate cause of
Erlinda's comatose condition.
Proximate cause has been defined as that which, in natural and
continuous sequence, unbroken by any efficient intervening cause,
produces injury, and without which the result would not have
occurred. 64 An injury or damage is proximately caused by an act or a
failure to act, whenever it appears from the evidence in the case, that
the act or omission played a substantial part in bringing about or
actually causing the injury or damage; and that the injury or damage
was either a direct result or a reasonably probable consequence of the
act or omission. 65 It is the dominant, moving or producing cause.
Applying the above definition in relation to the evidence at hand, faulty
intubation is undeniably the proximate cause which triggered the chain
of events leading to Erlinda's brain damage and, ultimately, her
comatosed condition.
Private respondents themselves admitted in their testimony that the
first intubation was a failure. This fact was likewise observed by
witness Cruz when she heard respondent Dra. Gutierrez remarked,
"Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki
ang tiyan." Thereafter, witness Cruz noticed abdominal distention on
the body of Erlinda. The development of abdominal distention, together
with respiratory embarrassment indicates that the endotracheal tube
entered the esophagus instead of the respiratory tree. In other words,
instead of the intended endotracheal intubation what actually took
place was an esophageal intubation. During intubation, such distention
indicates that air has entered the gastrointestinal tract through the
esophagus instead of the lungs through the trachea. Entry into the
esophagus would certainly cause some delay in oxygen delivery into
the lungs as the tube which carries oxygen is in the wrong place. That
abdominal distention had been observed during the first intubation
suggests that the length of time utilized in inserting the endotracheal
tube (up to the time the tube was withdrawn for the second attempt)
was fairly significant. Due to the delay in the delivery of oxygen in her
lungs Erlinda showed signs of cyanosis. 66 As stated in the testimony of
Dr. Hosaka, the lack of oxygen became apparent only after he noticed
that the nailbeds of Erlinda were already blue. 67 However, private
respondents contend that a second intubation was executed on Erlinda
and this one was successfully done. We do not think so. No evidence
exists on record, beyond private respondents' bare claims, which
supports the contention that the second intubation was successful.
Assuming that the endotracheal tube finally found its way into the
proper orifice of the trachea, the same gave no guarantee of oxygen
delivery, the hallmark of a successful intubation. In fact, cyanosis was
again observed immediately after the second intubation. Proceeding
from this event (cyanosis), it could not be claimed, as private
respondents insist, that the second intubation was accomplished. Even
granting that the tube was successfully inserted during the second
attempt, it was obviously too late. As aptly explained by the trial court,
Erlinda already suffered brain damage as a result of the inadequate
oxygenation of her brain for about four to five minutes. 68
The above conclusion is not without basis. Scientific studies point out
that intubation problems are responsible for one-third (1/3) of deaths
and serious injuries associated with anesthesia. 69 Nevertheless,
ninety-eight percent (98%) or the vast majority of difficult intubations
may be anticipated by performing a thorough evaluation of the patient's
airway prior to the operation. 70 As stated beforehand, respondent Dra.
Gutierrez failed to observe the proper pre-operative protocol which
could have prevented this unfortunate incident. Had appropriate
diligence and reasonable care been used in the pre-operative
evaluation, respondent physician could have been much more
prepared to meet the contingency brought about by the perceived
anatomic variations in the patient's neck and oral area, defects which
would have been easily overcome by a prior knowledge of those
variations together with a change in technique. 71 In other words, an
experienced anesthesiologist, adequately alerted by a thorough pre-
operative evaluation, would have had little difficulty going around the
short neck and protruding teeth. 72 Having failed to observe common
medical standards in pre-operative management and intubation,
respondent Dra. Gutierrez' negligence resulted in cerebral anoxia and
eventual coma of Erlinda.
We now determine the responsibility of respondent Dr. Orlino Hosaka
as the head of the surgical team. As the so-called "captain of the
ship," 73 it is the surgeon's responsibility to see to it that those under
him perform their task in the proper manner. Respondent Dr. Hosaka's
negligence can be found in his failure to exercise the proper authority
(as the "captain" of the operative team) in not determining if his
anesthesiologist observed proper anesthesia protocols. In fact, no
evidence on record exists to show that respondent Dr. Hosaka verified
if respondent Dra. Gutierrez properly intubated the patient.
Furthermore, it does not escape us that respondent Dr. Hosaka had
scheduled another procedure in a different hospital at the same time as
Erlinda's cholecystectomy, and was in fact over three hours late for the
latter's operation. Because of this, he had little or no time to confer with
his anesthesiologist regarding the anesthesia delivery. This indicates
that he was remiss in his professional duties towards his patient. Thus,
he shares equal responsibility for the events which resulted in Erlinda's
condition.
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," 74 who are
allegedly not hospital employees, presents problems in apportioning
responsibility for negligence in medical malpractice cases. However,
the difficulty is only 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. 75 This is
particularly true with respondent hospital.
After a physician is accepted, either as a visiting or attending
consultant, he is normally required to attend 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 physician's performance as a specialist is
generally evaluated by a peer review committee on the basis of
mortality and morbidity statistics, and feedback from patients, nurses,
interns and residents. A consultant remiss in his duties, or a consultant
who regularly falls short of the minimum standards acceptable to the
hospital or its peer review committee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control
over their attending and visiting "consultant" staff. While "consultants"
are not, technically employees, a point which respondent hospital
asserts in denying all responsibility for the patient's condition, the
control exercised, the hiring, and the right to terminate consultants all
fulfill the important hallmarks of an employer-employee relationship,
with the exception of the 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. This being the case, the question now arises as to
whether or not respondent hospital is solidarily liable with respondent
doctors for petitioner's condition. 76
The basis for holding an employer solidarily responsible for the
negligence of its employee is found in Article 2180 of the Civil Code
which considers a person accountable not only for his own acts but
also for those of others based on the former's responsibility under a
relationship of patria potestas. 77 Such responsibility ceases when the
persons or entity concerned prove that they have observed the
diligence of a good father of the family to prevent damage. 78 In other
words, while the burden of proving negligence rests on the plaintiffs,
once negligence is shown, the burden shifts to the respondents
(parent, guardian, teacher or employer) who should prove that they
observed the diligence of a good father of a family to prevent damage.
In the instant case, respondent hospital, apart from a general denial of
its responsibility over respondent physicians, failed to adduce evidence
showing that it exercised the diligence of a good father of a family in
the hiring and supervision of the latter. It failed to adduce evidence with
regard to the degree of supervision which it exercised over its
physicians. In neglecting to offer such proof, or proof of a similar
nature, respondent hospital thereby failed to discharge its burden
under the last paragraph of Article 2180. Having failed to do this,
respondent hospital is consequently solidarily responsible with its
physicians for Erlinda's condition.
Based on the foregoing, we hold that the Court of Appeals erred in
accepting and relying on the testimonies of the witnesses for the
private respondents. Indeed, as shown by the above discussions,
private respondents were unable to rebut the presumption of
negligence. Upon these disquisitions we hold that private respondents
are solidarily liable for damages under Article 2176 79 of the Civil Code.
We now come to the amount of damages due petitioners. The trial
court awarded a total of P632,000.00 pesos (should be P616,000.00)
in compensatory damages to the plaintiff, "subject to its being updated"
covering the period from 15 November 1985 up to 15 April 1992, based
on monthly expenses for the care of the patient estimated at
P8,000.00.
At current levels, the P8000/monthly amount established by the trial
court at the time of its decision would be grossly inadequate to cover
the actual costs of home-based care for a comatose individual. The
calculated amount was not even arrived at by looking at the actual cost
of proper hospice care for the patient. What it reflected were the actual
expenses incurred and proved by the petitioners after they were forced
to bring home the patient to avoid mounting hospital bills.
And yet ideally, a comatose patient should remain in a hospital or be
transferred to a hospice specializing in the care of the chronically ill for
the purpose of providing a proper milieu adequate to meet minimum
standards of care. In the instant case for instance, Erlinda has to be
constantly turned from side to side to prevent bedsores and hypostatic
pneumonia. Feeding is done by nasogastric tube. Food preparation
should be normally made by a dietitian to provide her with the correct
daily caloric requirements and vitamin supplements. Furthermore, she
has to be seen on a regular basis by a physical therapist to avoid
muscle atrophy, and by a pulmonary therapist to prevent the
accumulation of secretions which can lead to respiratory complications.
Given these considerations, the amount of actual damages
recoverable in suits arising from negligence should at least reflect the
correct minimum cost of proper care, not the cost of the care the family
is usually compelled to undertake at home to avoid bankruptcy.
However, the provisions of the Civil Code on actual or compensatory
damages present us with some difficulties.
Well-settled is the rule that actual damages which may be claimed by
the plaintiff are those suffered by him as he has duly proved. The Civil
Code provides:
Art. 2199. — Except as provided by law or by
stipulation, one is entitled to an adequate
compensation only for such pecuniary loss
suffered by him as he has duly proved. Such
compensation is referred to as actual or
compensatory damages.
Our rules on actual or compensatory damages generally assume that
at the time of litigation, the injury suffered as a consequence of an act
of negligence has been completed and that the cost can be liquidated.
However, these provisions neglect to take into account those
situations, as in this case, where the resulting injury might be
continuing and possible future complications directly arising from the
injury, while certain to occur, are difficult to predict.
In these cases, the amount of damages which should be awarded, if
they are to adequately and correctly respond to the injury caused,
should be one which compensates for pecuniary loss incurred and
proved, up to the time of trial; and one which would meet pecuniary
loss certain to be suffered but which could not, from the nature of the
case, be made with certainty. 80 In other words, temperate damages
can and should be awarded on top of actual or compensatory damages
in instances where the injury is chronic and continuing. And because of
the unique nature of such cases, no incompatibility arises when both
actual and temperate damages are provided for. The reason is that
these damages cover two distinct phases.
As it would not be equitable — and certainly not in the best interests of
the administration of justice — for the victim in such cases to
constantly come before the courts and invoke their aid in seeking
adjustments to the compensatory damages previously awarded —
temperate damages are appropriate. The amount given as temperate
damages, though to a certain extent speculative, should take into
account the cost of proper care.
In the instant case, petitioners were able to provide only home-based
nursing care for a comatose patient who has remained in that condition
for over a decade. Having premised our award for compensatory
damages on the amount provided by petitioners at the onset of
litigation, it would be now much more in step with the interests of
justice if the value awarded for temperate damages would allow
petitioners to provide optimal care for their loved one in a facility which
generally specializes in such care. They should not be compelled by
dire circumstances to provide substandard care at home without the
aid of professionals, for anything less would be grossly inadequate.
Under the circumstances, an award of P1,500,000.00 in temperate
damages would therefore be reasonable. 81
In Valenzuela vs. Court of Appeals, 82 this Court was confronted with a
situation where the injury suffered by the plaintiff would have led to
expenses which were difficult to estimate because while they would
have been a direct result of the injury (amputation), and were certain to
be incurred by the plaintiff, they were likely to arise only in the future.
We awarded P1,000,000.00 in moral damages in that case.
Describing the nature of the injury, the Court therein stated:
We recognized, in Valenzuela that a discussion of the victim's actual
injury would not even scratch the surface of the resulting moral
damage because it would be highly speculative to estimate the amount
of emotional and moral pain, psychological damage and injury suffered
by the victim or those actually affected by the victim's condition. 84 The
husband and the children, all petitioners in this case, will have to live
with the day to day uncertainty of the patient's illness, knowing any
hope of recovery is close to nil. They have fashioned their daily lives
around the nursing care of petitioner, altering their long term goals to
take into account their life with a comatose patient. They, not the
respondents, are charged with the moral responsibility of the care of
the victim. The family's moral injury and suffering in this case is clearly
a real one. For the foregoing reasons, an award of P2,000,000.00 in
moral damages would be appropriate.

As a result of the accident, Ma. Lourdes Finally, by way of example, exemplary damages in the amount of
Valenzuela underwent a traumatic amputation of P100,000.00 are hereby awarded. Considering the length and nature
her left lower extremity at the distal left thigh just of the instant suit we are of the opinion that attorney's fees valued at
above the knee. Because of this, Valenzuela will P100,000.00 are likewise proper.
forever be deprived of the full ambulatory functions
of her left extremity, even with the use of state of
Our courts face unique difficulty in adjudicating medical negligence
the art prosthetic technology. Well beyond the
cases because physicians are not insurers of life and, they rarely set
period of hospitalization (which was paid for by Li),
out to intentionally cause injury or death to their patients. However,
she will be required to undergo adjustments in her
intent is immaterial in negligence cases because where negligence
prosthetic devise due to the shrinkage of the
exists and is proven, the same automatically gives the injured a right to
stump from the process of healing.
reparation for the damage caused.

These adjustments entail costs, prosthetic

replacements and months of physical and
occupational rehabilitation and therapy. During the
lifetime, the prosthetic devise will have to be
replaced and readjusted to changes in the size of
her lower limb effected by the biological changes
of middle-age, menopause and aging. Assuming
she reaches menopause, for example, the
prosthetic will have to be adjusted to respond to
the changes in bone resulting from a precipitate
decrease in calcium levels observed in the bones
of all post-menopausal women. In other words, the
damage done to her would not only be permanent
and lasting, it would also be permanently changing
and adjusting to the physiologic changes which
her body would normally undergo through the
years. The replacements, changes, and
adjustments will require corresponding adjustive
physical and occupational therapy. All of these
adjustments, it has been documented, are painful.
xxx xxx xxx
Established medical procedures and practices, though in constant flux
are devised for the purpose of preventing complications. A physician's
experience with his patients would sometimes tempt him to deviate
from established community practices, and he may end a distinguished
career using unorthodox methods without incident. However, when
failure to follow established procedure results in the evil precisely
sought to be averted by observance of the procedure and a nexus is
made between the deviation and the injury or damage, the physician
would necessarily be called to account for it. In the case at bar, the
failure to observe pre-operative assessment protocol which would have
influenced the intubation in a salutary way was fatal to private
respondents' case.
WHEREFORE, the decision and resolution of the appellate court
appealed from are hereby modified so as to award in favor of
petitioners, and solidarily against private respondents the following: 1)
P1,352,000.00 as actual damages computed as of the date of
promulgation of this decision plus a monthly payment of P8,000.00 up
to the time that petitioner Erlinda Ramos expires or miraculously
survives; 2) P2,000,000.00 as moral damages, 3) P1,500,000.00 as
temperate damages; 4) P100,000.00 each as exemplary damages and
attorney's fees; and, 5) the costs of the suit.

A prosthetic devise, however technologically

SO ORDERED.
advanced, will only allow a reasonable amount of
functional restoration of the motor functions of the
lower limb. The sensory functions are forever lost.
The resultant anxiety, sleeplessness,
psychological injury, mental and physical pain are
inestimable. 83

The injury suffered by Erlinda as a consequence of private

respondents' negligence is certainly much more serious than the
amputation in the Valenzuela case.

Petitioner Erlinda Ramos was in her mid-forties when the incident

occurred. She has been in a comatose state for over fourteen years
now. The burden of care has so far been heroically shouldered by her
husband and children, who, in the intervening years have been
deprived of the love of a wife and a mother.

Meanwhile, the actual physical, emotional and financial cost of the care
of petitioner would be virtually impossible to quantify. Even the
temperate damages herein awarded would be inadequate if petitioner's
condition remains unchanged for the next ten years.
G.R. No. 126297 January 31, 2007
PROFESSIONAL SERVICES, INC., Petitioner,
vs.
NATIVIDAD and ENRIQUE AGANA, Respondents.
x-----------------------x
G.R. No. 126467 January 31, 2007
NATIVIDAD (Substituted by her children MARCELINO AGANA III,
ENRIQUE AGANA, JR., EMMA AGANA ANDAYA, JESUS AGANA,
and RAYMUND AGANA) and ENRIQUE AGANA, Petitioners,
vs.
JUAN FUENTES, Respondent.
x- - - - - - - - - - - - - - - - - - - -- - - - x
G.R. No. 127590 January 31, 2007
MIGUEL AMPIL, Petitioner,
vs.
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
DECISION
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankind’s 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 hospital’s 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 Decision3 dated March 17, 1993 of the Regional Trial Court (RTC),
Branch 96, Quezon City in Civil Case No. Q-43322 and nullifying its
Order dated September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the Medical City
General 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 Natividad’s husband,
Enrique Agana, to permit Dr. Juan Fuentes, respondent in G.R. No.
126467, to perform hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took
over, completed the operation and closed the incision.
However, the operation appeared to be flawed. In the corresponding
Record of 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.
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. 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. 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 Natividad’s 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 attorney’s 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 Natividad’s 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 Natividad’s 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 Court’s attention
to other possible causes of Natividad’s detriment. He argues that the
Court should not discount either of the following possibilities: first, Dr.
Fuentes left the gauzes in Natividad’s 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 Natividad’s body.
Dr. Ampil’s 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
Natividad’s 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 Whether the Court of Appeals Erred in Absolving
sponges to control the bleeding of the patient during the
surgical operation.
Dr. Fuentes of any Liability

Second, immediately after the operation, the nurses who

The Aganas assailed the dismissal by the trial court of the case against
assisted in the surgery noted in their report that the ‘sponge
Dr. Fuentes on the ground that it is contrary to the doctrine of res ipsa
count (was) lacking 2’; that such anomaly was ‘announced to
loquitur. According to them, the fact that the two pieces of gauze were
surgeon’ and that a ‘search was done but to no avail’
left inside Natividad’s body is a prima facie evidence of Dr. Fuentes’
prompting Dr. Ampil to ‘continue for closure’ x x x.
negligence.

Third, after the operation, two (2) gauzes were extracted

We are not convinced.
from the same spot of the body of Mrs. Agana where the
surgery was performed.
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
An operation requiring the placing of sponges in the incision is not
surrounding circumstances, may permit an inference or raise a
complete until the sponges are properly removed, and it is settled that
presumption of negligence, or make out a plaintiff’s prima facie case,
the leaving of sponges or other foreign substances in the wound after
and present a question of fact for defendant to meet with an
the incision has been closed is at least prima facie negligence by the
explanation.13 Stated differently, where the thing which caused the
operating surgeon.8 To put it simply, such act is considered so
injury, without the fault of the injured, is under the exclusive control of
inconsistent with due care as to raise an inference of negligence.
the defendant and the injury is such that it should not have occurred if
There are even legions of authorities to the effect that such act is
he, having such control used proper care, it affords reasonable
negligence per se.9
evidence, in the absence of explanation that the injury arose from the
defendant’s want of care, and the burden of proof is shifted to him to
Of course, the Court is not blind to the reality that there are times when establish that he has observed due care and diligence.14
danger to a patient’s life precludes a surgeon from further searching
missing sponges or foreign objects left in the body. But this does not
From the foregoing statements of the rule, the requisites for the
leave him free from any obligation. Even if it has been shown that a
applicability of the doctrine of res ipsa loquitur are: (1) the occurrence
surgeon was required by the urgent necessities of the case to leave a
of an injury; (2) the thing which caused the injury was under the control
sponge in his patient’s abdomen, because of the dangers attendant
and management of the defendant; (3) the occurrence was such that in
upon delay, still, it is his legal duty to so inform his patient within a
the ordinary course of things, would not have happened if those who
reasonable time thereafter by advising her of what he had been
had control or management used proper care; and (4) the absence of
compelled to do. This is in order that she might seek relief from the
explanation by the defendant. Of the foregoing requisites, the most
effects of the foreign object left in her body as her condition might
instrumental is the "control and management of the thing which caused
permit. The ruling in Smith v. Zeagler10 is explicit, thus:
the injury."15

The removal of all sponges used is part of a surgical operation, and

We find the element of "control and management of the thing which
when a physician or surgeon fails to remove a sponge he has placed in
caused the injury" to be wanting. Hence, the doctrine of res ipsa
his patient’s body that should be removed as part of the operation, he
loquitur will not lie.
thereby leaves his operation uncompleted and creates a new condition
which imposes upon him the legal duty of calling the new condition to
his patient’s attention, and endeavoring with the means he has at hand It was duly established that Dr. Ampil was the lead surgeon during the
to minimize and avoid untoward results likely to ensue therefrom. 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.
Here, Dr. Ampil did not inform Natividad about the missing two pieces
Fuentes performed the surgery and thereafter reported and showed his
of gauze. Worse, he even misled her that the pain she was
work to Dr. Ampil. The latter examined it and finding everything to be in
experiencing was the ordinary consequence of her operation. Had he
order, allowed Dr. Fuentes to leave the operating room. Dr. Ampil then
been more candid, Natividad could have taken the immediate and
resumed operating on Natividad. He was about to finish the procedure
appropriate medical remedy to remove the gauzes from her body. To
when the attending nurses informed him that two pieces of gauze were
our mind, what was initially an act of negligence by Dr. Ampil has
missing. A "diligent search" was conducted, but the misplaced gauzes
ripened into a deliberate wrongful act of deceiving his patient.
were not found. Dr. Ampil then directed that the incision be closed.
During this entire period, Dr. Fuentes was no longer in the operating
This is a clear case of medical malpractice or more appropriately, room and had, in fact, left the hospital.
medical negligence. To successfully pursue this kind of case, a patient
must only prove that a health care provider either failed to do
Under the "Captain of the Ship" rule, the operating surgeon is the
something which a reasonably prudent health care provider would
person in complete charge of the surgery room and all personnel
have done, or that he did something that a reasonably prudent provider
connected with the operation. Their duty is to obey his orders. 16 As
would not have done; and that failure or action caused injury to the
stated before, Dr. Ampil was the lead surgeon. In other words, he was
patient.11 Simply put, the elements are duty, breach, injury and
the "Captain of the Ship." That he discharged such role is evident from
proximate causation. Dr, Ampil, as the lead surgeon, had the duty to
his following conduct: (1) calling Dr. Fuentes to perform a
remove all foreign objects, such as gauzes, from Natividad’s body
hysterectomy; (2) examining the work of Dr. Fuentes and finding it in
before closure of the incision. When he failed to do so, it was his duty
order; (3) granting Dr. Fuentes’ permission to leave; and (4) ordering
to inform Natividad about it. Dr. Ampil breached both duties. Such
the closure of the incision. To our mind, it was this act of ordering the
breach caused injury to Natividad, necessitating her further
closure of the incision notwithstanding that two pieces of gauze
examination by American doctors and another surgery. That Dr.
remained unaccounted for, that caused injury to Natividad’s body.
Ampil’s negligence is the proximate cause12 of Natividad’s injury could
Clearly, the control and management of the thing which caused the
be traced from his act of closing the incision despite the information
injury was in the hands of Dr. Ampil, not Dr. Fuentes.
given by the attending nurses that two pieces of gauze were still
missing. That they were later on extracted from Natividad’s vagina
established the causal link between Dr. Ampil’s negligence and the In this jurisdiction, res ipsa loquitur is not a rule of substantive law,
injury. And what further aggravated such injury was his deliberate hence, does not per se create or constitute an independent or separate
concealment of the missing gauzes from the knowledge of Natividad ground of liability, being a mere evidentiary rule.17 In other words, mere
and her family. 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.
II - G.R. No. 126467
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 patient’s 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 one’s own acts or omissions, but also for those of persons for
whom one is responsible.
x x x x x x
The owners and managers of an establishment or enterprise are
likewise 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 x x x and references. These requirements are carefully scrutinized by
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 physician’s 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 hospital’s
functions limited to furnishing room, food, facilities for treatment and
operation, and attendants for its patients. Thus, in Bing v. Thunig,27 the
New York Court of 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 the hospital and
the physicians is rendered inconsequential in view of our categorical
pronouncement in Ramos v. Court of Appeals28 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,
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 physician’s performance as a specialist is
generally evaluated by a peer review committee on the basis of
mortality and morbidity statistics, and feedback from patients, nurses,
interns and residents. A consultant remiss in his duties, or a consultant
who regularly falls short of the minimum standards acceptable to the
hospital or its peer review committee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control
over 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 PSI’s
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
hospital’s 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 physician’s
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, PSI’s 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 hospital’s act of listing him and his specialty in its
lobby directory, as in the case herein. The high costs of today’s
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 hospital’s 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 judiciary’s 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 hospital’s 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 PSI’s liability is traceable to its failure to conduct an investigation exercised the diligence of a good father of a family in the accreditation
of the matter reported in the nota bene of the count nurse. Such failure and supervision of the latter. In neglecting to offer such proof, PSI
established PSI’s part in the dark conspiracy of silence and failed to discharge its burden under the last paragraph of Article 2180
concealment about the gauzes. Ethical considerations, if not also legal, cited earlier, and, therefore, must be adjudged solidarily liable with Dr.
dictated the holding of an immediate inquiry into the events, if not for Ampil. Moreover, as we have discussed, PSI is also directly liable to
the benefit of the patient to whom the duty is primarily owed, then in the Aganas.
the interest of arriving at the truth. The Court cannot accept that the
medical and the healing professions, through their members like
One final word. Once a physician undertakes the treatment and care of
defendant surgeons, and their institutions like PSI’s hospital facility,
a patient, the law imposes on him certain obligations. In order to
can callously turn their backs on and disregard even a mere probability
escape liability, he must possess that reasonable degree of learning,
of mistake or negligence by refusing or failing to investigate a report of
skill and experience required by his profession. At the same time, he
such seriousness as the one in Natividad’s case.
must apply reasonable care and diligence in the exercise of his skill
and the application of his knowledge, and exert his best judgment.
It is worthy to note that Dr. Ampil and Dr. Fuentes operated on
Natividad with the assistance of the Medical City Hospital’s staff,
WHEREFORE, we DENY all the petitions and AFFIRM the challenged
composed of resident doctors, nurses, and interns. As such, it is
Decision of the Court of Appeals in CA-G.R. CV No. 42062 and CA-
reasonable to conclude that PSI, as the operator of the hospital, has
G.R. SP No. 32198.
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 Costs against petitioners PSI and Dr. Miguel Ampil.
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
SO ORDERED.
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 patient’s 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 hospital’s 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