However, the operation appeared to be flawed.

In the
53 G.R. No. 126297 January 31, 2007 corresponding Record of Operation, the attending nurses entered
these remarks:
PROFESSIONAL SERVICES, INC., Petitioner,
"sponge count lacking 2
vs.
"announced to surgeon searched (sic) done but to no avail
NATIVIDAD and ENRIQUE AGANA, Respondents. continue for closure."

x-----------------------x ● Natividad was released from the hospital. After a couple of days,
Natividad complained of excruciating pain in her anal region. She
G.R. No. 126467 January 31, 2007
consulted both Dr. Ampil and Dr. Fuentes about it. They told her that
the pain was the natural consequence of the surgery. Dr. Ampil
NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE
AGANA, JR., EMMA AGANA ANDAYA, JESUS AGANA, and RAYMUND AGANA) then recommended that she consult an oncologist to examine the
and ENRIQUE AGANA, Petitioners, cancerous nodes which were not removed during the operation.

vs. ● Natividad went to the US. After four months of consultations and
laboratory examinations, Natividad was told she was free of cancer.
JUAN FUENTES, Respondent. She flew back to the Philippines, still suffering from pains. Two
weeks thereafter, her daughter found a piece of gauze protruding
x- - - - - - - - - - - - - - - - - - - -- - - - x from her vagina. Upon being informed about it, Dr. Ampil
proceeded to her house where he managed to extract by hand a
G.R. No. 127590 January 31, 2007 piece of gauze measuring 1.5 inches in width. He then assured
her that the pains would soon vanish.
MIGUEL AMPIL, Petitioner,
● The pains intensified, prompting Natividad to seek treatment at
vs.
the Polymedic General Hospital. While confined there, Dr. Ramon
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
Gutierrez detected the presence of another foreign object in her
vagina -- a foul-smelling gauze measuring 1.5 inches in width
FACTS: which badly infected her vaginal vault. A recto-vaginal fistula had
formed in her reproductive organs which forced stool to excrete
● On April 4, 1984, Natividad Agana was rushed to the Medical City through the vagina. Another surgical operation was needed to remedy
General Hospital (Medical City Hospital) because of difficulty of bowel the damage. She underwent another surgery.
movement and bloody anal discharge. After a series of medical
● Natividad and her husband filed with the RTC of Quezon City a
examinations, Dr. Miguel Ampil diagnosed her to be suffering from
complaint for damages against the Professional Services, Inc. (PSI),
"cancer of the sigmoid."
owner of the Medical City Hospital, Dr. Ampil, and Dr. Fuentes,
● On April 11, 1984, Dr. Ampil, assisted by the medical staff of the docketed as Civil Case No. Q-43322. They alleged that the latter are
Medical City Hospital, performed an anterior resection surgery on liable for negligence for leaving two pieces of gauze inside Natividad’s
Natividad. He found that the malignancy in her sigmoid area had body and malpractice for concealing their acts of negligence.
spread on her left ovary, necessitating the removal of certain portions
of it. Thus, Dr. Ampil obtained the consent of Natividad’s husband, ● Pending the outcome of the above cases, Natividad died.
Enrique Agana, to permit Dr. Juan Fuentes, to perform
hysterectomy on her. RTC: rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and
Dr. Fuentes jointly and severally liable for negligence and malpractice.
● After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took
over, completed the operation and closed the incision.
CA: except for the modification that the case against Juan Fuentes is hereby body that should be removed as part of the operation, he thereby leaves his
DISMISSED, and with the pronouncement that Dr. Miguel Ampil is liable to operation uncompleted and creates a new condition which imposes upon him
reimburse PSI whatever amount the latter will pay or had paid to the plaintiffs- the legal duty of calling the new condition to his patient’s attention, and
appellees, the decision is affirmed. endeavoring with the means he has at hand to minimize and avoid untoward
results likely to ensue therefrom.
ISSUES/RULING:
Here, Dr. Ampil did not inform Natividad about the missing two pieces of
gauze. Worse, he even misled her that the pain she was experiencing was the
1. Whether the Court of Appeals erred in holding Dr. ampil liable for
ordinary consequence of her operation. Had he been more candid, Natividad
negligence and malpractice.
could have taken the immediate and appropriate medical remedy to remove
NO. the gauzes from her body. To our mind, what was initially an act of negligence
by Dr. Ampil has ripened into a deliberate wrongful act of deceiving his patient.
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 This is a clear case of medical malpractice or more appropriately,
negligent party, thus: medical negligence. To successfully pursue this kind of case, a patient
must only prove that a health care provider either failed to do something
First, it is not disputed that the surgeons used gauzes as sponges to control which a reasonably prudent health care provider would have done, or
the bleeding of the patient during the surgical operation. that he did something that a reasonably prudent provider would not have
done; and that failure or action caused injury to the patient. Simply put,
Second, immediately after the operation, the nurses who assisted in the the elements are duty, breach, injury and proximate causation.
surgery noted in their report that the ‘sponge count (was) lacking 2’; that such
anomaly was ‘announced to surgeon’ and that a ‘search was done but to no Dr, Ampil, as the lead surgeon, had the duty to remove all foreign objects,
avail’ prompting Dr. Ampil to ‘continue for closure’ x x x. such as gauzes, from Natividad’s body before closure of the incision.
When he failed to do so, it was his duty to inform Natividad about it. Dr.
Third, after the operation, two (2) gauzes were extracted from the same spot Ampil breached both duties. Such breach caused injury to Natividad,
of the body of Mrs. Agana where the surgery was performed.
necessitating her further examination by American doctors and another
surgery. That Dr. Ampil’s negligence is the proximate cause of
An operation requiring the placing of sponges in the incision is not
Natividad’s injury could be traced from his act of closing the incision
complete until the sponges are properly removed, and it is settled that
despite the information given by the attending nurses that two pieces of
the leaving of sponges or other foreign substances in the wound after
gauze were still missing. That they were later on extracted from
the incision has been closed is at least prima facie negligence by the
Natividad’s vagina established the causal link between Dr. Ampil’s
operating surgeon. To put it simply, such act is considered so inconsistent
negligence and the injury. And what further aggravated such injury was
with due care as to raise an inference of negligence. There are even legions
his deliberate concealment of the missing gauzes from the knowledge of
of authorities to the effect that such act is negligence per se.
Natividad and her family.
Of course, the Court is not blind to the reality that there are times when 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 leave him free from any
2. Whether the Court of Appeals erred in absolving Dr. Fuentes of any
obligation. Even if it has been shown that a surgeon was required by the
liability.
urgent necessities of the case to leave a sponge in his patient’s
abdomen, because of the dangers attendant upon delay, still, it is his NO.
legal duty to so inform his patient within a reasonable time thereafter by
advising her of what he had been compelled to do. This is in order that she The Aganas assailed the dismissal by the trial court of the case against Dr.
might seek relief from the effects of the foreign object left in her body as her Fuentes on the ground that it is contrary to the doctrine of res ipsa loquitur.
condition might permit. The ruling in Smith v. Zeagler is explicit, thus: According to them, the fact that the two pieces of gauze were left inside
Natividad’s body is a prima facie evidence of Dr. Fuentes’ negligence.
The removal of all sponges used is part of a surgical operation, and when a
physician or surgeon fails to remove a sponge he has placed in his patient’s
We are not convinced. ordering the closure of the incision. To our mind, it was this act of ordering the
closure of the incision notwithstanding that two pieces of gauze remained
Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule unaccounted for, that caused injury to Natividad’s body. Clearly, the control
that the fact of the occurrence of an injury, taken with the surrounding and management of the thing which caused the injury was in the hands of Dr.
circumstances, may permit an inference or raise a presumption of negligence, Ampil, not Dr. Fuentes.
or make out a plaintiff’s prima facie case, and present a question of fact for
defendant to meet with an explanation. Stated differently, where the thing In this jurisdiction, res ipsa loquitur is not a rule of substantive law,
which caused the injury, without the fault of the injured, is under the hence, does not per se create or constitute an independent or separate
exclusive control of the defendant and the injury is such that it should ground of liability, being a mere evidentiary rule. In other words, mere
not have occurred if he, having such control used proper care, it affords invocation and application of the doctrine does not dispense with the
reasonable evidence, in the absence of explanation that the injury arose requirement of proof of negligence. Here, the negligence was proven to
from the defendant’s want of care, and the burden of proof is shifted to have been committed by Dr. Ampil and not by Dr. Fuentes.
him to establish that he has observed due care and diligence.

From the foregoing statements of the rule, the requisites for the applicability
of the doctrine of res ipsa loquitur are: (1) the occurrence of an injury; 3. Whether PSI Is Liable for the negligence of Dr. Ampil.
(2) the thing which caused the injury was under the control and
management of the defendant; (3) the occurrence was such that in the YES.
ordinary course of things, would not have happened if those who had
control or management used proper care; and (4) the absence of In this jurisdiction, the statute governing liability for negligent acts is Article
explanation by the defendant. Of the foregoing requisites, the most 2176 of the Civil Code, which reads:
instrumental is the "control and management of the thing which caused
the injury." 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
We find the element of "control and management of the thing which caused governed by the provisions of this Chapter.
the injury" to be wanting. Hence, the doctrine of res ipsa loquitur will not lie.
A derivative of this provision is Article 2180, the rule governing vicarious
It was duly established that Dr. Ampil was the lead surgeon during the liability under the doctrine of respondeat superior, thus:
operation of Natividad. He requested the assistance of Dr. Fuentes only to
perform hysterectomy when he (Dr. Ampil) found that the malignancy in her ART. 2180. The obligation imposed by Article 2176 is demandable not only for one’s
sigmoid area had spread to her left ovary. Dr. Fuentes performed the surgery own acts or omissions, but also for those of persons for whom one is responsible.
and thereafter reported and showed his work to Dr. Ampil. The latter examined x x x x x x
it and finding everything to be in order, allowed Dr. Fuentes to leave the
operating room. Dr. Ampil then resumed operating on Natividad. He was about The owners and managers of an establishment or enterprise are likewise responsible
to finish the procedure when the attending nurses informed him that two pieces for damages caused by their employees in the service of the branches in which the
of gauze were missing. A "diligent search" was conducted, but the misplaced latter are employed or on the occasion of their functions.
gauzes were not found. Dr. Ampil then directed that the incision be closed.
Employers shall be liable for the damages caused by their employees and household
During this entire period, Dr. Fuentes was no longer in the operating room and helpers acting within the scope of their assigned tasks even though the former are not
had, in fact, left the hospital. engaged in any business or industry.

Under the "Captain of the Ship" rule, the operating surgeon is the person x x x x x x
in complete charge of the surgery room and all personnel connected with
the operation. Their duty is to obey his orders. As stated before, Dr. Ampil 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
was the lead surgeon. In other words, he was the "Captain of the Ship." prevent damage.
That he discharged such role is evident from his following conduct: (1) calling
Dr. Fuentes to perform a hysterectomy; (2) examining the work of Dr. Fuentes
and finding it in order; (3) granting Dr. Fuentes’ permission to leave; and (4)
In our shores, the nature of the relationship between the hospital and the The applicability of apparent authority in the field of hospital liability was
physicians is rendered inconsequential in view of our categorical upheld long time ago in Irving v. Doctor Hospital of Lake Worth, Inc. There, it
pronouncement in Ramos v. Court of Appeals that for purposes of was explicitly stated that "there does not appear to be any rational basis for
apportioning responsibility in medical negligence cases, an employer- excluding the concept of apparent authority from the field of hospital liability."
employee relationship in effect exists between hospitals and their Thus, in cases where it can be shown that a hospital, by its actions, has
attending and visiting physicians. This Court held: held out a particular physician as its agent and/or employee and that a
patient has accepted treatment from that physician in the reasonable
"We now discuss the responsibility of the hospital in this particular incident. belief that it is being rendered in behalf of the hospital, then the hospital
The unique practice (among private hospitals) of filling up specialist staff with will be liable for the physician’s negligence.
attending and visiting "consultants," who are allegedly not hospital employees,
presents problems in apportioning responsibility for negligence in medical Our jurisdiction recognizes the concept of an agency by implication or
malpractice cases. However, the difficulty is more apparent than real.
estoppel. Article 1869 of the Civil Code reads:
Private hospitals, hire, fire and exercise real control over their attending ART. 1869. Agency may be express, or implied from the acts of the principal, from his
and visiting ‘consultant’ staff. While ‘consultants’ are not, technically silence or lack of action, or his failure to repudiate the agency, knowing that another
employees, x x x, the control exercised, the hiring, and the right to person is acting on his behalf without authority.
terminate consultants all fulfill the important hallmarks of an employer-
employee relationship, with the exception of the payment of wages. In In this case, PSI publicly displays in the lobby of the Medical City
assessing whether such a relationship in fact exists, the control test is Hospital the names and specializations of the physicians associated or
determining. Accordingly, on the basis of the foregoing, we rule that for the accredited by it, including those of Dr. Ampil and Dr. Fuentes. We concur
purpose of allocating responsibility in medical negligence cases, an employer- with the Court of Appeals’ conclusion that it "is now estopped from
employee relationship in effect exists between hospitals and their attending passing all the blame to the physicians whose names it proudly paraded
and visiting physicians. " 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
But the Ramos pronouncement is not our only basis in sustaining PSI’s to the public that Medical City Hospital, through its accredited physicians,
liability. Its liability is also anchored upon the agency principle of offers quality health care services. By accrediting Dr. Ampil and Dr. Fuentes
apparent authority or agency by estoppel and the doctrine of corporate and publicly advertising their qualifications, the hospital created the
negligence which have gained acceptance in the determination of a impression that they were its agents, authorized to perform medical or
hospital’s liability for negligent acts of health professionals. The present surgical services for its patients. As expected, these patients, Natividad
case serves as a perfect platform to test the applicability of these doctrines, being one of them, accepted the services on the reasonable belief that such
thus, enriching our jurisprudence. were being rendered by the hospital or its employees, agents, or servants.

Apparent authority, or what is sometimes referred to as the "holding out" The wisdom of the foregoing ratiocination is easy to discern. Corporate
theory, or doctrine of ostensible agency or agency by estoppel, has its entities, like PSI, are capable of acting only through other individuals,
origin from the law of agency. It imposes liability, not as the result of the such as physicians. If these accredited physicians do their job well, the
reality of a contractual relationship, but rather because of the actions of hospital succeeds in its mission of offering quality medical services and thus
a principal or an employer in somehow misleading the public into profits financially. Logically, where negligence mars the quality of its services,
believing that the relationship or the authority exists. The concept is the hospital should not be allowed to escape liability for the acts of its
essentially one of estoppel and has been explained in this manner: ostensible agents.

"The principal is bound by the acts of his agent with the apparent We now proceed to the doctrine of corporate negligence or corporate
authority which he knowingly permits the agent to assume, or which he responsibility.
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 One allegation in the complaint for negligence and malpractice is that PSI as
a situation that a person of ordinary prudence, conversant with business owner, operator and manager of Medical City Hospital, "did not perform the
usages and the nature of the particular business, is justified in presuming that necessary supervision nor exercise diligent efforts in the supervision of Drs.
such agent has authority to perform the particular act in question.31 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 PSI’s hospital facility, can callously turn their backs on and disregard even a mere
probability of mistake or negligence by refusing or failing to investigate a report of such
surgeons." Premised on the doctrine of corporate negligence, the trial court seriousness as the one in Natividad’s case.
held that PSI is directly liable for such breach of duty. We agree with the trial
court. It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad
with the assistance of the Medical City Hospital’s staff, composed of
Recent years have seen the doctrine of corporate negligence as the judicial resident doctors, nurses, and interns. As such, it is reasonable to
answer to the problem of allocating hospital’s liability for the negligent acts of conclude that PSI, as the operator of the hospital, has actual or
health practitioners, absent facts to support the application of respondeat constructive knowledge of the procedures carried out, particularly the
superior or apparent authority. report of the attending nurses that the two pieces of gauze were missing.
In Fridena v. Evans, it was held that a corporation is bound by the knowledge
The doctrine has its genesis in Darling v. Charleston Community Hospital.
acquired by or notice given to its agents or officers within the scope of their
There, the Supreme Court of Illinois held that "the jury could have found a authority and in reference to a matter to which their authority extends. This
hospital negligent, inter alia, in failing to have a sufficient number of trained means that the knowledge of any of the staff of Medical City Hospital
nurses attending the patient; failing to require a consultation with or
constitutes knowledge of PSI. Now, the failure of PSI, despite the
examination by members of the hospital staff; and failing to review the
attending nurses’ report, to investigate and inform Natividad regarding
treatment rendered to the patient." On the basis of Darling, other jurisdictions
the missing gauzes amounts to callous negligence. Not only did PSI
held that a hospital’s corporate negligence extends to permitting a
breach its duties to oversee or supervise all persons who practice
physician known to be incompetent to practice at the hospital. With the
medicine within its walls, it also failed to take an active step in fixing the
passage of time, more duties were expected from hospitals, among them: (1) negligence committed. This renders PSI, not only vicariously liable for
the use of reasonable care in the maintenance of safe and adequate facilities
the negligence of Dr. Ampil under Article 2180 of the Civil Code, but also
and equipment; (2) the selection and retention of competent physicians; (3)
directly liable for its own negligence under Article 2176.
the overseeing or supervision of all persons who practice medicine within its
walls; and (4) the formulation, adoption and enforcement of adequate rules One final word. Once a physician undertakes the treatment and care of a
and policies that ensure quality care for its patients.38 Thus, in Tucson Medical patient, the law imposes on him certain obligations. In order to escape liability,
Center, Inc. v. Misevich, it was held that a hospital, following the doctrine he must possess that reasonable degree of learning, skill and experience
of corporate responsibility, has the duty to see that it meets the required by his profession. At the same time, he must apply reasonable care
standards of responsibilities for the care of patients. Such duty includes and diligence in the exercise of his skill and the application of his knowledge,
the proper supervision of the members of its medical staff. And in Bost v. and exert his best judgment.
Riley, 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 of the matter