OUR LADY OF LOURDES HOSPITAL vs.

 SPOUSES ROMEO AND REGINA

FACTS:
Regina was scheduled for her third caesarean section (C-section). However, a week earlier
she went into active labor and was brought to petitioner hospital for an emergency C-section. She first
underwent a pre-operative physical examination by Dr. Ramos and Dr. Santos the same attending
physicians in her prior childbirths. She was found fit for anesthesia after she responded negatively to
questions about tuberculosis, rheumatic fever, and cardiac diseases. On that same day, she gave
birth to a baby boy. When her condition stabilized, she was discharged from the recovery room and
transferred to a regular hospital room.
13 hours after her operation, Regina who was then under watch by her niece, complained of
a headache, a chilly sensation, restlessness, and shortness of breath. She asked for oxygen and later
became cyanotic. After undergoing an x-ray, she was found to be suffering from pulmonary edema.
She was eventually transferred to the Intensive Care Unit, where she was hooked to a mechanical
ventilator. The impression then was that she was showing signs of amniotic fluid embolism.
When her condition still showed no improvement, Regina was transferred to the Cardinal
Santos Hospital. The doctors thereat found that she was suffering from rheumatic heart disease mitral
stenosis with mild pulmonary hypertension, which contributed to the pulmonary edema. This
development resulted in cardio-pulmonary arrest and, subsequently, brain damage. Regina lost the
use of her speech, eyesight, hearing and limbs. She was discharged, still in a vegetative state.
Respondent spouses Capanzana filed a complaint for damages against petitioner hospital,
along with co-defendants: Ramos, an obstetrician/gynecologist; Dr. Santos, an anesthesiologist; and
Jane Does, the nurses on duty stationed on the second floor of petitioner hospital.
Respondents imputed negligence to Drs. Ramos and Santos for the latter's failure to detect
the heart disease of Regina, resulting in failure not only to refer her to a cardiologist for cardiac
clearance, but also to provide the appropriate medical management before, during, and after the
operation. They further stated that the nurses were negligent for not having promptly given oxygen,
and that the hospital was equally negligent for not making available and accessible the oxygen unit
on that same hospital floor at the time.
Petitioner hospital and defendant Ballano claimed that there was no instruction to the hospital
or the staff to place Regina in a room with a standby oxygen tank. They also claimed that the nurses
on duty had promptly attended to her needs. They prayed that the complaint be dismissed, and
respondents ordered to pay unpaid medical bills.  CAIHTE
Meanwhile, defendant Dr. Ramos and Dr. Santos claimed that they have conducted a pre-
operative evaluation and Regina showed no sign or symptom of any heart problem or abnormality in
the latter's cardiovascular, respiratory, or central nervous systems.
The RTC rendered judgment, finding no negligence on the part of Dr. Ramos or Dr. Santos. It
found that the medical community's recognized standard practices in attending to a patient in
connection with a C-section had been duly observed by the doctors.
The RTC also found that the primary cause of Regina's vegetative state was amniotic fluid
embolism, an unfortunate condition that was not within the control of any doctor to anticipate or
prevent. However, it noted that it could have been prevented, or at least minimized, had there been a
timely administration of oxygen. 
On the strength of the testimony of Balad, the RTC found that negligence on the part of the
nurses contributed to the injury of Regina. It found that they failed to respond immediately when
Regina was experiencing shortness of breath. It took the nurses more or less 10 minutes after being
informed of the condition of Regina before they checked on her, called for the resident doctor, and
requested oxygen. While the trial court acknowledged that the immediate administration of oxygen
was not a guarantee that Regina's condition would improve, it gave credence to the testimony of the
expert witness. The latter opined that the delay contributed to the onset of hypoxic encephalopathy or
diffuse brain damage due to lack of oxygen in Regina's brain. The expert witness also said that had
there been a timely administration of oxygen the risk of brain damage would have been lessened, if
not avoided, and the onset of hypoxic encephalopathy reduced. The RTC therefore found the nurses
liable for contributory negligence.
On the issue of whether petitioner hospital could be held liable for the negligence of its
nurses, the RTC ruled that the hospital was able to discharge the burden of proof that it had
exercised the diligence of a good father of a family in the selection and supervision of its employees.
Consequently, only the nurses were held liable to pay damages.
 The respondents appealed and the CA rendered the assailed decision affirming the RTC
ruling with modification. The appellate court upheld the finding of the trial court that the proximate
cause of Regina's condition was a diffuse brain damage secondary to lack of oxygen in the brain.
The CA ruled that petitioner hospital should be held liable based on the doctrine of corporate
responsibility. It was found that while there was evidence to prove that petitioner hospital showed
diligence in its selection and hiring processes, there was no evidence to prove that it exercised the
required diligence in the supervision of its nurses. Also, the appellate court ruled that the non-
availability of an oxygen unit on the hospital floor, a fact that was admitted, constituted gross
negligence on the part of petitioner hospital.
Only petitioner hospital filed a Motion for Reconsideration, which the CA denied.
Hence, this petition.
ISSUE:
Whether the hospital, Dr. Santos and Dr. Ramos, and the nurses on duty should be held liable for
damages for their negligence.
RULING:
Only the nurses and the hospital are liable.
In order to successfully pursue a claim in a medical negligence case, the plaintiff must prove
that a health professional either failed to do something which a reasonably prudent health
professional would have or have not done; and that the action or omission caused injury to the
patient. Proceeding from this guideline, the plaintiff must show the following elements by a
preponderance of evidence: duty of the health professional, breach of that duty, injury of the
patient, and proximate causation between the breach and the injury. Meanwhile, in fixing a
standard by which a court may determine whether the physician properly performed the requisite duty
toward the patient, expert medical testimonies from both plaintiff and defense are resorted to.
In this case, the expert testimony of witness for the respondent Dr. Godfrey Robeniol, a
neurosurgeon, provided that the best time to treat hypoxic encephalopathy is at the time of its
occurrence; i.e., when the patient is experiencing difficulty in breathing and showing signs of cardiac
arrest.
To recall, the records, including petitioner's Nurses' Notes, indisputably show that Regina
complained of difficulty in breathing before eventually showing signs of cyanosis.  Had they done so,
proper oxygenation could have been restored and other interventions performed without wasting
valuable time. That such high degree of care and responsiveness was needed cannot be
overemphasized — considering that according to expert medical evidence in the records, it takes only
five minutes of oxygen deprivation for irreversible brain damage to set in. Indeed, the Court has
emphasized that a higher degree of caution and an exacting standard of diligence in patient
management and health care are required of a hospital's staff, as they deal with the lives of
patients who seek urgent medical assistance. It is incumbent upon nurses to take precautions or
undertake steps to safeguard patients under their care from any possible injury that may arise in the
course of the latter's treatment and care.
The Court further notes that the immediate response of the nurses was especially imperative,
since Regina herself had asked for oxygen. They should have been prompted to respond immediately
when Regina herself expressed her needs, especially in that emergency situation when it was not
easy to determine with certainty the cause of her breathing difficulty. Indeed, even if the patient had
not asked for oxygen, the mere fact that her breathing was labored to an abnormal degree should
have impelled the nurses to immediately call the doctor and to administer oxygen. ETHIDa
In this regard, both courts found that there was a delay in the administration of oxygen to the
patient, caused by the delayed response of the nurses of petitioner hospital. They committed a
breach of their duty to respond immediately to the needs of Regina, considering her
precarious situation and her physical manifestations of oxygen deprivation.
Taken together, the above instances of delay convinced the courts below, as well as this
Court, that there was a breach of duty on the part of the hospital's nurses. The CA therefore
correctly affirmed the finding of the trial court that the nurses responded late, and that Regina was
already cyanotic when she was referred to the resident doctor.
Regina suffered from brain damage, particularly hypoxic encephalopathy, which is caused by
lack of oxygen in the brain. The testimonies of Dr. Dizon and Dr. Robeniol proved this fact. And the
proximate cause of the brain damage was the delay in responding to Regina's call for help and
for oxygen.
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. 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. It is the dominant,
moving or producing cause.
Applying the above definition to the facts in the present case, the omission of the nurses —
their failure to check on Regina and to refer her to the resident doctor and, thereafter, to immediately
provide oxygen — was clearly the proximate cause that led to the brain damage suffered by the
patient. As the trial court and the CA both held, had the nurses promptly responded, oxygen would
have been immediately administered to her and the risk of brain damage lessened, if not avoided.
For the negligence of its nurses, petitioner is thus liable under Article 2180 in relation to
Article 2176 of the Civil Code. Under Article 2180, an employer like petitioner hospital may be held
liable for the negligence of its employees based on its responsibility under a relationship of patria
potestas.  The liability of the employer under this provision is "direct and immediate; it is not
conditioned upon a prior recourse against the negligent employee or a prior showing of the insolvency
of that employee."  The employer may only be relieved of responsibility upon a showing that it
exercised the diligence of a good father of a family in the selection and supervision of its employees.
The rule is that once negligence of the employee is shown, the burden is on the employer to
overcome the presumption of negligence on the latter's part by proving observance of the required
diligence.  IDSTE
In the instant case, there is no dispute that petitioner was the employer of the nurses who
have been found to be negligent in the performance of their duties. This fact has never been in issue.
Hence, petitioner had the burden of showing that it exercised the diligence of a good father of a family
not only in the selection of the negligent nurses, but also in their supervision.
After a careful review of the records, the preponderance of evidence supports the finding of
the CA that the hospital failed to discharge its burden of proving due diligence in the supervision of its
nurses and is therefore liable for their negligence. It must be emphasized that even though it proved
due diligence in the selection of its nurses, the hospital was able to dispose of only half the burden it
must overcome.
Indeed, the formulation of a supervisory hierarchy, company rules and regulations, and
disciplinary measures upon employees in case of breach, is indispensable. However, to prove due
diligence in the supervision of employees, it is not enough for an employer such as petitioner to
emptily invoke the existence of such a formulation. What is more important is the actual
implementation and monitoring of consistent compliance with the rules. Understandably, this actual
implementation and monitoring should be the constant concern of the employer, acting through
dependable supervisors who should regularly report on their supervisory functions. Thus, there must
be proof of diligence in the actual supervision of the employees' work. 
In the present case, there is no proof of actual supervision of the employees' work or actual
implementation and monitoring of consistent compliance with the rules.