G.R. No.

118141 September 5, 1997

LEONILA GARCIA-RUEDA, petitioner, 
vs.
WILFRED L. PASCASIO, RAUL R. ARNAU, ABELARDO L. APORTADERA JR.,
Honorable CONRADO M. VASQUEZ, all of the Office of the Ombudsman; JESUS
F. GUERRERO, PORFIRIO MACARAEG, and GREGORIO A. ARIZALA, all of the
Office of the City Prosecutor, Manila, respondents.

Syllabus topic: Medical Malpractice – Elements of Liability

FACTS:

Florencio V. Rueda, husband of petitioner Leonila Garcia-Rueda, underwent surgical

operation at the UST hospital for the removal of a stone blocking his ureter. He was
attended by Dr. Domingo Antonio, Jr. who was the surgeon, while Dr. Erlinda Balatbat-
Reyes was the anaesthesiologist. Six hours after the surgery, however, Florencio died
of complications of "unknown cause," according to officials of the UST Hospital.

Not satisfied with the findings of the hospital, petitioner requested the National
Bureau of Investigation (NBI) to conduct an autopsy on her husband's body.
Consequently, the NBI ruled that Florencio's death was due to lack of care by the
attending physician in administering anaesthesia. Pursuant to its findings, the NBI
recommended that Dr. Domingo Antonio and Dr. Erlinda Balatbat-Reyes be charged for
Homicide through Reckless Imprudence before the Office of the City Prosecutor.

During the preliminary investigation, what transpired was a confounding series of

events of investigative "pingpong" who later on resolved to exonerate Dr. Reyes from
any wrongdoing. Aggrieved, petitioner filed graft charges specifically for violation of
Section 3(e) of Republic Act No. 3019 3 against Prosecutors Guerrero, Macaraeg, and
Arizala for manifest partiality in favor of Dr. Reyes before the Office of the
Ombudsman who later on dismissed the complaint. (NAINIS NA SIYA SILA NALANG
KINASUHAN NIYA)

ISSUE (with respect to medical malpractice): What constitutes medical

malpractice?

RULING: In its simplest terms, the type of lawsuit which has been called medical
malpractice or, more appropriately, medical negligence, is that type of claim which a
victim has available to him or her to redress a wrong committed by a medical
professional which has caused bodily harm.

In order to successfully pursue such a claim, a patient must prove that a health care
provider, in most cases a physician, either failed to do something which a reasonably
prudent health care provider would have done, or that he or she did something that a
reasonably prudent provider would not have done; and that that failure or action
caused injury to the patient. 

Four elements involved in medical negligence cases: duty, breach, injury and proximate
causation.

Evidently, when the victim employed the services of Dr. Antonio and Dr. Reyes, a
physician-patient relationship was created. In accepting the case, Dr. Antonio and Dr.
Reyes in effect represented that, having the needed training and skill possessed by
physicians and surgeons practicing in the same field, they will employ such training,
care and skill in the treatment of their patients. 13 They have a duty to use at least
the same level of care that any other reasonably competent doctor would use to
treat a condition under the same circumstances. 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. 14 Consequently, in the event that any injury results to the patient from
want of due care or skill during the operation, the surgeons may be held answerable in
damages for negligence. 

Moreover, in malpractice or negligence cases involving the administration of

anaesthesia, the necessity of expert testimony and the availability of the charge
of res ipsa loquitur to the plaintiff; have been applied in actions against
anaesthesiologists to hold the defendant liable for the death or injury of a patient
under excessive or improper anaesthesia. 16 Essentially, it requires two-pronged
evidence: evidence as to the recognized standards of the medical community in the
particular kind of case, and a showing that the physician in question negligently
departed from this standard in his treatment. 

Another element in medical negligence cases is causation which is divided into two
inquiries: (1) whether the doctor's actions in fact caused the harm to the patient and
(2) whether these were the proximate cause of the patient's injury. 18 Indeed here, a
causal connection is discernible from the occurrence of the victim's death after the
negligent act of the anaesthesiologist in administering the anesthesia, a fact which, if
confirmed, should warrant the filing of the appropriate criminal case. Moreover, the
NBI deduced that the attending surgeons did not conduct the necessary interview
of the patient prior to the operation. It appears that the cause of the death of the
victim could have been averted had the proper drug been applied to cope with the
symptoms of malignant hyperthermia. Also, we cannot ignore the fact that an antidote
was readily available to counteract whatever deleterious effect the anaesthesia might
produce.

WHEREFORE, in view of the foregoing, the instant petition is DISMISSED, without

prejudice to the filing of an appeal by the petitioner with the Secretary of Justice
assailing the dismissal of her criminal complaint by the respondent City Prosecutors.
G.R. No. 178763               April 21, 2009

PETER PAUL PATRICK LUCAS, FATIMA GLADYS LUCAS, ABBEYGAIL LUCAS

AND GILLIAN LUCAS, Petitioners, 
vs.
DR. PROSPERO MA. C. TUAÑO, Respondent.

Syllabus topic: Medical Malpractice – Elements of Liability

FACTS:

Sometime in August 1988, petitioner Peter Paul Patrick Lucas (Peter) contracted "sore
eyes" in his right eye. On 2 September 1988, complaining of a red right eye and swollen
eyelid.

Upon consultation with Dr. Tuaño, Peter narrated that it had been nine (9) days since
the problem with his right eye began; and that he was already taking Maxitrol to
address the problem in his eye. According to Dr. Tuaño, he performed "ocular routine
examination" on Peter’s eyes, wherein on that particular consultation, Dr. Tuaño
diagnosed that Peter was suffering from conjunctivitis 5 or "sore eyes." Dr. Tuaño then
prescribed Spersacet-C6 eye drops for Peter and told the latter to return for follow-
up after one week. 

As instructed, Peter went back to Dr. Tuaño on 9 September 1988. Upon examination,
Dr. Tuaño told Peter that the "sore eyes" in the latter’s right eye had already cleared
up and he could discontinue the Spersacet-C. However, the same eye developed
Epidemic Kerato Conjunctivitis (EKC),7 a viral infection. To address the new problem
with Peter’s right eye, Dr. Tuaño prescribed to the former a steroid-based eye drop
called Maxitrol. To recall, Peter had already been using Maxitrol prior to his consult
with Dr. Tuaño. 

On 21 September 1988, Peter saw Dr. Tuaño for a follow-up consultation. After
examining both of Peter’s eyes, Dr. Tuaño instructed the former to taper down10 the
dosage of Maxitrol, because the EKC in his right eye had already resolved. Dr. Tuaño
specifically cautioned Peter that, being a steroid, Maxitrol had to be withdrawn
gradually; otherwise, the EKC might recur.11

Complaining of feeling as if there was something in his eyes, Peter returned to Dr.
Tuaño for another check-up on 6 October 1988. Dr. Tuaño examined Peter’s eyes and
found that the right eye had once more developed EKC. So, Dr. Tuaño instructed Peter
to resume the use of Maxitrol at six (6) drops per day. 

The series of consultations and check-ups went on as Peter’s condition worsens.

On 26 November 1988, Peter returned to Dr. Tuaño’s clinic, complaining of "feeling

worse."14 It appeared that the EKC had spread to the whole of Peter’s right eye yet
again. Thus, Dr. Tuaño instructed Peter to resume the use of Maxitrol. Petitioners
averred that Peter already made mention to Dr. Tuaño during said visit of the above-
quoted warning against the prolonged use of steroids, but Dr. Tuaño supposedly
brushed aside Peter’s concern as mere paranoia, even assuring him that the former was
taking care of him (Peter).

Four months later and after the petitioner suffered from significant swelling of his righ
t eyeball, headaches, nausea and blindness on this
right eye, he sought for the opinion of another doctor,
Dr. Aquino. Dr. Aquino found that the petitioner
had been suffering from glaucoma and needed
to undergo laser surgery, lest he might suffer from total blindness.

In May 1990 and June 1991, Peter underwent two (2) procedures of laser
trabeculoplasty to attempt to control the high IOP of his right eye.

Claiming to have steroid-induced glaucoma 45 and blaming Dr. Tuaño for the same, Peter
instituted a civil complaint for damages against Dr. Tuaño. Petitioners averred that as
the "direct consequence of [Peter’s] prolonged use of Maxitrol, [he] suffered from
steroid induced glaucoma which caused the elevation of his intra-ocular pressure. The
elevation of the intra-ocular pressure of [Peter’s right eye] caused the impairment of
his vision which impairment is not curable and may even lead to total blindness."

RTC – dismissed the complaint for insufficiency of evidence.

CA – affirmed RTC’s decision.

ISSUE: Should Dr. Tuaño be held liable for medical malpractice?

RULING: NO.

The general rule that only questions of law may be raised on appeal in a petition for
review under Rule 45 of the Rules of Court admits of certain exceptions, including the
circumstance when the finding of fact of the Court of Appeals is premised on the
supposed absence of evidence, but is contradicted by the evidence on record. Although
petitioners may not explicitly invoke said exception, it may be gleaned from their
allegations and arguments in the instant Petition.
Petitioners’ position, in sum, is that Peter’s glaucoma is the direct result of Dr. Tuaño’s
negligence in his improper administration of the drug Maxitrol; "thus, [the latter]
should be liable for all the damages suffered and to be suffered by
[petitioners]."75 Clearly, the present controversy is a classic illustration of a medical
negligence case against a physician based on the latter’s professional negligence. In
this type of suit, the patient or his heirs, in order to prevail, is required to prove
by preponderance of evidence that the physician failed to exercise that degree of
skill, care, and learning possessed by other persons in the same profession; and
that as a proximate result of such failure, the patient or his heirs suffered
damages. 

For lack of a specific law geared towards the type of negligence committed by
members of the medical profession, such claim for damages is almost always anchored
on the alleged violation of Article 2176 of the Civil Code.

In medical negligence cases, also called medical malpractice suits, there exist a
physician-patient relationship between the doctor and the victim. But just like any
other proceeding for damages, four essential (4) elements i.e., (1) duty; (2)
breach; (3) injury; and (4) proximate causation,76 must be established by the
plaintiff/s. All the four (4) elements must co-exist in order to find the physician
negligent and, thus, liable for damages. 

When a patient engages the services of a physician, a physician-patient relationship is

generated. And in accepting a case, the physician, for all intents and purposes,
represents that he has the needed training and skill possessed by physicians and
surgeons practicing in the same field; and that he will employ such training, care, and
skill in the treatment of the patient. 77 Thus, in treating his patient, the physician has
the duty to use at least the same level of care that any other reasonably
competent physician would use to treat the condition under similar circumstances. 

This standard level of care, skill and diligence is a matter best addressed by expert
medical testimony, because the standard of care in a medical malpractice case is a
matter peculiarly within the knowledge of experts in the field.

There is breach of duty of care, skill and diligence, or the improper performance of
such duty, by the attending physician when the patient is injured in body or in
health [and this] constitutes the actionable malpractice.80 Proof of such breach must
likewise rest upon the testimony of an expert witness that the treatment accorded to
the patient failed to meet the standard level of care, skill and diligence which
physicians in the same general neighborhood and in the same general line of practice
ordinarily possess and exercise in like cases. 

Even so, proof of breach of duty on the part of the attending physician is insufficient,
for there must be a causal connection between said breach and the resulting injury
sustained by the patient. Put in another way, in order that there may be a recovery
for an injury, it must be shown that the negligence must be the proximate cause of the
injury. And the proximate cause of an injury is that cause, which, in the natural and
continuous sequence, unbroken by any efficient intervening cause, produces the injury,
and without which the result would not have occurred.

Just as with the elements of duty and breach of the same, in order to establish the
proximate cause [of the injury] by a preponderance of the evidence in a medical
malpractice action, [the patient] must similarly use expert testimony, because the
question of whether the alleged professional negligence caused [the patient’s] injury is
generally one for specialized expert knowledge beyond the ken of the average
layperson; using the specialized knowledge and training of his field, the expert’s role is
to present to the [court] a realistic assessment of the likelihood that [the physician’s]
alleged negligence caused [the patient’s] injury.

From the foregoing, it is apparent that medical negligence cases are best proved by
opinions of expert witnesses belonging in the same general neighborhood and in the
same general line of practice as defendant physician or surgeon. The deference of
courts to the expert opinion of qualified physicians [or surgeons] stems from the
former’s realization that the latter possess unusual technical skills which laymen in
most instances are incapable of intelligently evaluating; 84 hence, the indispensability of
expert testimonies.

In the case at bar, there is no question that a physician-patient relationship developed

between Dr. Tuaño and Peter when Peter went to see the doctor on 2 September 1988,
seeking a consult for the treatment of his sore eyes. 
However, as correctly pointed out by the Court of Appeals, "[t]he onus probandi was on
the patient to establish before the trial court that the physicians ignored standard
medical procedure, prescribed and administered medication with recklessness and
exhibited an absence of the competence and skills expected of general practitioners
similarly situated."86 Unfortunately, in this case, there was absolute failure on the
part of petitioners to present any expert testimony to establish: (1) the standard
of care to be implemented by competent physicians in treating the same condition as
Peter’s under similar circumstances; (2) that, in his treatment of Peter, Dr. Tuaño
failed in his duty to exercise said standard of care that any other competent physician
would use in treating the same condition as Peter’s under similar circumstances; and (3)
that the injury or damage to Peter’s right eye, i.e., his glaucoma, was the result of his
use of Maxitrol, as prescribed by Dr. Tuaño. Petitioners’ failure to prove the first
element alone is already fatal to their cause.

Absent a definitive standard of care or diligence required of Dr. Tuaño under the
circumstances, we have no means to determine whether he was able to comply with
the same in his diagnosis and treatment of Peter. This Court has no yardstick upon
which to evaluate or weigh the attendant facts of this case to be able to state with
confidence that the acts complained of, indeed, constituted negligence and, thus,
should be the subject of pecuniary reparation. In contrast, Dr. Tuaño was able to
clearly explain that what is only required of ophthalmologists, in cases such as Peter’s,
is the conduct of standard tests/procedures known as "ocular routine
examination,"88 composed of five (5) tests/procedures .

We cannot but agree with Dr. Tuaño’s assertion that when a doctor sees a patient, he
cannot determine immediately whether the latter would react adversely to the use of
steroids; all the doctor can do is map out a course of treatment recognized as correct
by the standards of the medical profession. It must be remembered that a physician is
not an insurer of the good result of treatment. The mere fact that the patient does
not get well or that a bad result occurs does not in itself indicate failure to
exercise due care.89 The result is not determinative of the performance [of the
physician] and he is not required to be infallible.

Even if we are to assume that Dr. Tuaño committed negligent acts in his treatment of
Peter’s condition, the causal connection between Dr. Tuaño’s supposed negligence and
Peter’s injury still needed to be established. The critical and clinching factor in a
medical negligence case is proof of the causal connection between the negligence
which the evidence established and the plaintiff’s injuries. The causation between
the physician’s negligence and the patient’s injury may only be established by the
presentation of proof that Peter’s glaucoma would not have occurred but for Dr.
Tuaño’s supposed negligent conduct. Once more, petitioners failed in this regard. 

It must be remembered that when the qualifications of a physician are admitted, as in

the instant case, there is an inevitable presumption that in proper cases, he takes the
necessary precaution and employs the best of his knowledge and skill in attending to his
clients, unless the contrary is sufficiently established
Casumpang v. Cortejo, (GR. Nos. 171127-217, 171228; Mar. 11, 2015) 

BRION, J.:

Facts:

 Mrs. Jesusa Cortejo brought her 11-year old son, Edmer Cortejo (Edmer), to the
Emergency Room of the San Juan de Dios Hospital (SJDH) because of difficulty in
breathing, chest pain, stomach pain, and fever.

 Edmer had developed a slight fever that lasted for one day; a few hours upon
discovery, she brought Edmer to their family doctor; and two hours after
administering medications, Edmer's fever had subsided. Dr. Livelo diagnosed Edmer
with "bronchopneumonia." Edmer's blood was also taken. Afterwards, Dr. Livelo gave
Edmer an antibiotic medication to lessen his fever and to loosen his phlegm.

 Mrs. Cortejo did not know any doctor at SJDH. She used her Fortune Care card.
She was thereafter assigned to Dr. Noel Casumpang (Dr. Casumpang), a pediatrician
also accredited with Fortune Care. Dr. Casumpang confirmed the initial diagnosis of
"Bronchopneumonia."

 At that moment, Mrs. Cortejo recalled entertaining doubts on the doctor's

diagnosis. She immediately advised Dr. Casumpang that Edmer had a high fever, and
had no colds or cough but Dr. Casumpang merely told her that her son's
"bloodpressure is just being active," and remarked that "that's the usual
bronchopneumonia, no colds, no phlegm."

 Still suspicious about his son's illness, Mrs. Cortejo again called Dr. Casumpang's
attention, but simply nooded. Edmer vomited "phlegm with blood streak" prompting
the respondent (Edmer's father) to request for a doctor at the nurses' station.
(Dr. Miranda), although aware failed to examine the blood specimen because the
respondent washed it away. Dr. Miranda conducted a physical check-up.

 The blood test results came, Dr. Miranda advised Edmer's parents that the blood
test results showed that Edmer was suffering from "Dengue Hemorrhagic Fever."
By request Edmar was to be transported to Makati Medical Center.

 Dr. Casumpang immediately gave the attending physician the patient's clinical
history and laboratory exam results. Upon examination, the attending physician
diagnosed "Dengue Fever Stage IV" that was already in its irreversible stage.

 Edmer died.  His Death Certificate indicated the cause of death as "Hypovolemic

Shock/hemorrhagic shock;" "Dengue Hemorrhagic Fever Stage IV."
 Believing that Edmer’s death was caused by the negligent and erroneous diagnosis
of his doctors, the respondent instituted an action for damages against SJDH, and
its attending physicians: Dr. Casumpang and Dr. Sanga

 The RTC ruled in favor of the plaintiff. The CA affirmed en toto the RTC’s ruling,
finding that SJDH and its attending physicians failed to exercise the minimum
medical care, attention, and treatment expected of an ordinary doctor under like
circumstances.

 The respondent submits that SJDH should not only be held vicariously liable for
the petitioning doctors’ negligence but also for its own negligence. He claims that
SJDH fell short of its duty of providing its patients with the necessary facilities
and equipment.

 SJDH on the other hand disclaims liability by claiming that the petitioning doctors
are not its employees but are mere consultants and independent contractors

Issue:

Whether or not the petitioner hospital is solidarily liable with the petitioning doctors

Ruling:

 We affirm the hospital’s liability not on the basis of Article 2180 of the Civil Code,
but on the basis of the doctrine of apparent authority or agency by estoppel.

 There is No Employer-Employee Relationship between SJDH and the Petitioning

Doctors. Control, which is the most crucial among the elements of EE – ER , is not
present in this case. No evidence exists showing that SJDH exercised any degree
of control over the means, methods of procedure and manner by which the
petitioning doctors conducted and performed their medical profession. SJDH did
not control their diagnosis and treatment.

 Despite the absence of employer-employee relationship between SJDH and the

petitioning doctors, SJDH is not free from liability. As a rule, hospitals are not
liable for the negligence of its independent contractors. However, it may be found
liable if the physician or independent contractor acts as an ostensible agent of the
hospital. This exception is also known as the "doctrine of apparent authority.

 Under the doctrine of apparent authority, a hospital can be held vicariously liable
for the negligent acts of a physician providing care at the hospital, regardless of
whether the physician is an independent contractor, unless the patient knows, or
should have known, that the physician is an independent contractor. The elements
of the action have been set out as follows:
 o For a hospital to be liable under the doctrine of apparent authority, a
plaintiff must show that: (1) the hospital, or its agent, acted in a manner
that would lead a reasonable person to conclude that the individual who was
alleged to be negligent was an employee or agent of the hospital; (2) where
the acts of the agent create the appearance of authority, the plaintiff must
also prove that the hospital had knowledge of and acquiesced in them; and
(3) the plaintiff acted in reliance upon the conduct of the hospital or its
agent, consistent with ordinary care and prudence.

 a hospital can be held vicariously liable for the negligent acts of a physician (or an
independent contractor) providing care at the hospital if the plaintiff can prove
these two factors: first, the hospital’s manifestations; and second, the patient’s
reliance.

o a. Hospital’s manifestations- It involves an inquiry on whether the hospital

acted in a manner that would lead a reasonable person to conclude that the
individual alleged to be negligent was an employee or agent of the hospital.
As pointed out in Nogales, the hospital need not make express
representations to the patient that the physician or independent contractor
is an employee of the hospital; representation may be general and implied.

o b. Patient’s reliance - It involves an inquiry on whether the plaintiff acted in

reliance on the conduct of the hospital or its agent, consistent with ordinary
care and prudence

 SJDH impliedly held out and clothed Dr. Casumpang with apparent authority leading
the respondent to believe that he is an employee or agent of the hospital.

 Mrs. Cortejo accepted Dr. Casumpang’s services on the reasonable belief that such
were being provided by SJDH or its employees, agents, or servants. By referring
Dr. Casumpang to care and treat for Edmer, SJDH impliedly held out Dr.
Casumpang, not only as an accredited member of Fortune Care, but also as a
member of its medical staff. SJDH cannot now disclaim liability since there is no
showing that Mrs. Cortejo or the respondent knew, or should have known, that Dr.
Casumpang is only an independent contractor of the hospital. In this case, estoppel
has already set in.
 Reyes v. Sisters of Mercy Hospital (GR. No. 130547, Oct. 3, 2000)

MENDOZA, J.:

Facts

 Petitioner, Leah Alesna Reyes, is the wife of the deceased patient, Jorge Reyes.

 On January 8, 1987, he was taken to the Mercy Community Clinic by his wife. He was
attended to by respondent Dr. Marlyn Rico, resident physician and admitting physician
on duty, who gave Jorge a physical examination and took his medical history. 

 Five days before the latter’s death, Jorge has been suffering from recurring fever
with chills. The doctors confirmed through the Widal test that Jorge has typhoid
fever. However, he did not respond to the treatment and died. The cause of his death
was “Ventricular Arrythemia Secondary to Hyperpyrexia and typhoid fever.”

 Consequently, petitioner filed the instant case for damages before the Regional Trial
Court of Cebu City, petitioners filed before the Regional Trial Court of Cebu City a
complaint for damages against respondents Sisters of Mercy, Sister Rose Palacio, Dr.
Marvie Blanes, Dr. Marlyn Rico, and nurse Josephine Pagente.

 The contention was that Jorge did not die of typhoid fever. Instead, his death was due
to the wrongful administration of chloromycetin. They contended that had respondent
doctors exercised due care and diligence, they would not have recommended and
rushed the performance of the Widal Test, hastily concluded that Jorge was suffering
from typhoid fever, and administered chloromycetin without first conducting
sufficient tests on the patient’s compatibility with said drug

 The trial court rendered its decision absolving respondents from the charges of
negligence and dismissing petitioners' action for damages. The Court of Appeals
affirmed the decision of the trial court.

Issue: WON the respondent doctors are negligent.

Ruling:

 The court is not persuaded that Jorge Reyes did not die of typhoid fever but of
shock undetermined, which could be due to allergic reaction or chloromycetin
overdose as the result of the autopsy testified by Dr.Vacalares.

 There is no showing that the attending physician in this case deviated from the
usual course of treatment with respect to typhoid fever. Jorge was given antibiotic
 choloromycetin and some dose of triglobe after compatibility test was made by the
doctor and found that no adverse reactions manifested which would necessitate
replacement of the medicines. Indeed, the standard contemplated is not what is
actually the average merit among all known practitioners from the best to the
worst and from the most to the least experienced, but the reasonable average
merit among the ordinarily good physicians. Here, the doctors did not depart from
the reasonable standard recommended by the experts as they in fact observed the
due care required under the circumstances.

 Respondents alleged failure to observe due care was not immediately apparent to a
layman so as to justify application of res ipsa loquitur. The court held the doctrine
of res ipsa loquitur can have no application in a suit against a physician or a surgeon
which involves the merits of a diagnosis or of a scientific treatment; The physician
or surgeon is not required at his peril to explain why any particular diagnosis was
not correct, or why any particular scientific treatment did not produce the desired
result.

 The standard contemplated is not what is actually the average merit among all
known practitioners from the best to the worst and from the most to the least
experienced, but the reasonable average merit among the ordinarily good
physicians. Here, Dr. Marlyn Rico did not depart from the reasonable standard
recommended by the experts as she in fact observed the due care required under
the circumstances. Though the Widal test is not conclusive, it remains a standard
diagnostic test for typhoid fever.

 The practice of medicine is a profession engaged in only by qualified individuals. It

is a right earned through years of education, training, and by first obtaining a
license from the state through professional board examinations. Such license may,
at any time and for cause, be revoked by the government. In addition to state
regulation, the conduct of doctors is also strictly governed by the Hippocratic
Oath, an ancient code of discipline and ethical rules which doctors have imposed
upon themselves in recognition and acceptance of their great responsibility to
society. Given these safeguards, there is no need to expressly require of doctors
the observance of “extraordinary” diligence. As it is now, the practice of medicine
is already conditioned upon the highest degree of diligence. And, as we have already
noted, the standard contemplated for doctors is simply the reasonable average
merit among ordinarily good physicians. That is reasonable diligence for doctors or,
as the Court of Appeals called it, the reasonable “skill and competence . . . that a
physician in the same or similar locality . . . should apply.”
Solidum v. People (GR. No. 192123, Mar. 10, 2014)

BERSAMIN, J.:

 Facts:

Gerald Albert Gercayo was born with an imperforate anus. Two days after his birth,
Gerald underwent colostomy. Dr. Resurreccion headed the surgical team, and was
assisted by Dr. Luceño, Dr. Valeña and Dr. Tibio. The anesthesiologists included Dr.
Abella, Dr. Razon and Dr. Fernando Solidum. During the operation, Gerald
experienced bradycardia, and went into a coma. His coma lasted for two weeks, but
he regained consciousness only after a month. He could no longer see, hear or move.

 Agitated by her son’s helpless and unexpected condition, Ma. Luz Gercayo lodged a
complaint for reckless imprudence resulting in serious physical injuries with the
City Prosecutor’s Office of Manila against the attending physicians.

 A complaint for reckless imprudence resulting in serious physical injuries was filed
by Gerald’s parents against the team of doctors. Upon a finding of probable cause,
the City Prosecutor’s Office filed an information solely against Dr. Solidum.

 The RTC rendered Dr. Solidum guilty beyond reasonable doubt of reckless
imprudence resulting in serious physical injuries and ordering her to indemnify,
jointly and severally with the Ospital ng Maynila, private complainant Luz Gercayo,
for damages. The CA affirmed the ruling of RTC and applied the doctrine of res
ipsa loquitur in the case.Issue:

Issues:

1. Whether the doctrine of res ipsa loquitur was applicable in the case.

2. Whether Dr. Solidum is liable for criminal negligence.

Ruling:

 Medical malpractice 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. 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.

 The requisites of res ipsa loquitor are: (1) the accident was of a kind that does not
ordinarily occur unless someone is negligent’ (2) the instrumentality or agency that
 caused the injury was under the exclusive control of the person charged; (3) the
injury suffered must not have been due to any voluntary action or contribution of
the person injured.

 In this case, the application of the doctrine is inappropriate. The first element is
wanting. Indeed, the patient experienced bradycardia during the operation, but
such fact alone did not prove that the negligence of any of his attending physicians,
including the anesthesiologists, had caused the injury. In fact, the
anesthesiologists attending to him had sensed in the course of the operation that
the lack of oxygen could have been trigerred by the vago-vagal reflex, prompting
them to administer atropine to the patient.

 Negligence is defined as the failure to observe for the protection of the interests
of another person that degree of care, precaution, and vigilance that the
circumstances justly demand, whereby such other person suffers injury. Reckless
imprudence, on the other hand, consists of voluntarily doing or failing to do, without
malice, an act from which material damage results by reason of an inexcusable lack
of precaution on the part of the person performing or failing to perform such act.

 In the medical profession, specific norms or standards to protect the patient

against unreasonable risk, commonly referred to as standards of care, set the
duty of the physician to act in respect of the patient. Unfortunately, no clear
definition of the duty of a particular physician in a particular case exists.
Because most medical malpractice cases are highly technical, witnesses with
special medical qualifications must provide guidance by giving the knowledge
necessary to render a fair and just verdict. As a result, the standard of
medical care of a prudent physician must be determined from expert testimony
in most cases; and in the case of a specialist (like an anesthesiologist), the
standard of care by which the specialist is judged is the care and skill
commonly possessed and exercised by similar specialists under similar
circumstances. The specialty standard of care may be higher than that
required of the general practitioner.[37]

 The standard of care is an objective standard by which the conduct of a

physician sued for negligence or malpractice may be measured, and it does not
depend, therefore, on any individual physician’s own knowledge either. In
attempting to fix a standard by which a court may determine whether the
physician has properly performed the requisite duty toward the patient, expert
medical testimony from both plaintiff and defense experts is required. The
judge, as the trier of fact, ultimately determines the standard of care, after
listening to the testimony of all medical experts.
 In this case, Dr. Solidum was criminally charged for "failing to monitor and regulate
properly the levels of anesthesia administered to said Gerald Albert Gercayo and
using 100% halothane and other anesthetic medications." However, the foregoing
circumstances, taken together, did not prove beyond reasonable doubt that Dr.
Solidum had been recklessly imprudent in administering the anesthetic agent to
Gerald. Indeed, Dr. Vertido’s findings did not preclude the probability that other
factors related to Gerald’s major operation, which could or could not necessarily be
attributed to the administration of the anesthesia, had caused the hypoxia and had
then led Gerald to experience bradycardia.
LUCAS VS TUANO

FACTS:

Herein petitioner, Peter Lucas, first consulted respondent, Dr. Tuaño, on a complaint of
soreness and redness on his right eye. The respondent, after a series of examinations,
found that the former was suffering from conjunctivitis or “sore eyes” and prescribed the
use of the Spersacet-C. However, after the petitioner’s condition seemed to have
worsened, he sought for the respondent’s second finding wherein the latter said that his
condition had progressed to Epidemic Kerato Conjunctivitis (EKC), a viral infection. The
respondent then prescribed the use of Maxitrol, a steroid-based eye drop. The
petitioner’s condition worsened overtime, yet he obediently complied with all the
prescriptions and orders of the respondent.

Four months later and after the petitioner suffered from significant swelling of his right
eyeball, headaches, nausea and blindness on this right eye, he sought for the opinion of
another doctor, Dr. Aquino. Dr. Aquino found that the petitioner had been suffering from
glaucoma and needed to undergo laser surgery, lest he might suffer from total blindness.

After reading the literature on the use of the medicine Maxitrol, Fatima, one of the
petitioners herein and Peter Lucas’ wife, read that one of the adverse effects of
prolonged use of steroid-based eye drops could possibly be glaucoma. Peter, Fatima, and
their two children instituted a civil case for damages against herein respondent for
medical malpractice.

ISSUE:

Whether or not the petitioners amply proved that Dr. Tuaño failed to exercise diligence in
the performance of his duty as petitioner Peter Lucas’ physician.

RULING:

No. Absent a definitive standard of care or diligence required of Dr. Tuaño under the
circumstances, the Court has no yardstick upon which to evaluate the attendant facts of
the case at hand to be able to state with confidence that the acts complained of, indeed,
constituted negligence and, thus, should be the subject of pecuniary reparation.

In medical negligence cases, also called medical malpractice suits, there exist a physician-
patient relationship between the doctor and the victim.  But just like any other proceeding
for damages, four essential (4) elements i.e., (1) duty; (2) breach; (3) injury; and (4)
proximate causation, must be established by the plaintiff/s.  All the four (4) elements
must co-exist in order to find the physician negligent and, thus, liable for damages.
As the physician has the duty to use at least the same level of care as that of any other
reasonably competent physician would use in the treatment of his patient, said standard
level of care, skill and diligence must likewise be proven by expert medical testimony,
because the standard of care in a medical malpractice case is a matter peculiarly within
the knowledge of experts in the field. The same is outside the ken of the average
layperson.

There is breach of duty of care, skill and diligence, or the improper performance of such
duty, by the attending physician when the patient is injured in body or in health [and this]
constitutes the actionable malpractice. Hence, proof of breach of duty on the part of the
attending physician is insufficient. Rather, the negligence of the physician must be the
proximate cause of the injury.
CASUMPANG VS CORTEJO 

FACTS:

Mrs. Jesusa Cortejo brought her 11-year old son, Edmer Cortejo (Edmer), to the
Emergency Room of the San Juan de Dios Hospital (SJDH) because of difficulty in
breathing, chest pain, stomach pain, and fever.

Dr. Ramoncito Livelo (Dr. Livelo) initially attended to and examined Edmer. In her
testimony, Mrs. Cortejo narrated that in the morning of April 20, 1988, Edmer had
developed a slight fever that lasted for one day; a few hours upon discovery, she brought
Edmer to their family doctor; and two hours after administering medications, Edmer's
fever had subsided.

Dr. Livelo diagnosed Edmer with "bronchopneumonia." Edmer's blood was also taken.
Afterwards, Dr. Livelo gave Edmer an antibiotic medication to lessen his fever and to
loosen his phlegm.

Mrs. Cortejo did not know any doctor at SJDH. She used her Fortune Care card. She was
thereafter assigned to Dr. Noel Casumpang ( Dr. Casumpang), a pediatrician also accredited
with Fortune Care. Dr. Casumpang confirmed the initial diagnosis of " Bronchopneumonia."

At that moment, Mrs. Cortejo recalled entertaining doubts on the doctor's diagnosis. She
immediately advised Dr. Casumpang that Edmer had a high fever, and had no colds or cough
but Dr. Casumpang merely told her that her son's " bloodpressure is just being active ," and
remarked that "that's the usual bronchopneumonia, no colds, no phlegm ."

Still suspicious about his son's illness, Mrs. Cortejo again called Dr. Casumpang's attention,
but simply nooded. Edmer vomited "phlegm with blood streak" prompting the respondent
(Edmer's father) to request for a doctor at the nurses' station.

(Dr. Miranda), although aware failed to examine the blood specimen because the
respondent washed it away. Dr. Miranda conducted a physical check-up.

The blood test results came, Dr. Miranda advised Edmer's parents that the blood test
results showed that Edmer was suffering from "Dengue Hemorrhagic Fever." By request
Edmar was to be transported to Makati Medical Center.

Dr. Casumpang immediately gave the attending physician the patient's clinical history and
laboratory exam results. Upon examination, the attending physician diagnosed "Dengue
Fever Stage IV" that was already in its irreversible stage. Edmer died.  Parents Filed a
case against  SJDH and the Doctors

ISSUE(S):
W/N the accused is negligent?

RULING:

Dr. Casumpang's Negligence

a. Negligence in the Diagnosis

At the trial, Dr. Casumpang declared that a doctor's impression regarding a patient's
illness is 90% based on the physical examination, the information given by the patient or
the latter's parents, and the patient's medical history. 55 He testified that he did not
consider either dengue fever or dengue hemorrhagic fever because the patient's history
showed that Edmer had low breath and voluntary submission, and that he was up and about
playing basketball.56 He based his diagnosis of bronchopneumonia on the following
observations: "difficulty in breathing, clearing run nostril, harsh breath sound, tight air,
and sivilant sound."

We also find it strange why Dr. Casumpang did not even bother to check Edmer's throat
despite knowing that as early as 9:00 in the morning of April 23, 1988, Edmer had blood
streaks in his sputum. Neither did Dr. Casumpang order confirmatory tests to confirm
the source of bleeding. The Physician's Progress Notes 59 stated: "Blood streaks on
phlegm  can be due to bronchial irritation or congestion " which clearly showed that Dr.
Casumpang merely assumed, without confirmatory physical examination, that
bronchopneumonia caused the bleeding.

Even assuming that Edmer's symptoms completely coincided with the diagnosis of
bronchopneumonia (so that this diagnosis could not be considered "wrong"), we still find
Dr. Casumpang guilty of negligence.

First, we emphasize that we do not decide the correctness of a doctor's diagnosis, or

the accuracy of the medical findings and treatment. Our duty in medical malpractice
cases is to decide - based on the evidence adduced and expert opinion presented  -
whether a breach of duty took place.

Second, we clarify that a wrong diagnosis is not by itself medical

malpractice.  Physicians are generally not liable for damages resulting from a bona
65

fide error of judgment. Nonetheless, when the physician's erroneous diagnosis was the
result of negligent conduct (e.g., neglect of medical history, failure to order the
appropriate tests, failure to recognize symptoms ), it becomes an evidence of medical
malpractice.

Third, we also note that medicine is not an exact science; 66 and doctors, or even
specialists, are not expected to give a 100% accurate diagnosis in treating patients who
come to their clinic for consultations. Error is possible as the exercise of judgment is
called for in considering and reading the exhibited symptoms, the results of tests, and in
arriving at definitive conclusions. But in doing all these, the doctor must have acted
according to acceptable medical practice standards.

Standard of Care and Breach of Duty

A determination of whether or not the petitioning doctors met the required standard of
care involves a question of mixed fact and law; it is factual as medical negligence cases are
highly technical in nature, requiring the presentation of expert witnesses to provide
guidance to the court on matters clearly falling within the domain of medical science, and
legal, insofar as the Court, after evaluating the expert testimonies, and guided by medical
literature, learned treatises, and its fund of common knowledge, ultimately determines
whether breach of duty took place.

Whether or not Dr. Casumpang and Dr. Miranda committed a breach of duty is to be
measured by the yardstick of professional standards observed by the other members of
the medical profession in good standing under similar circumstances.49 It is in this aspect
of medical malpractice that expert testimony is essential to establish not only the
professional standards observed in the medical community, but also that the physician's
conduct in the treatment of care falls below such standard.50

In the present case, expert testimony is crucial in determining first, the standard medical
examinations, tests, and procedures that the attending physicians should have undertaken
in the diagnosis and treatment of dengue fever; and second, the dengue fever signs and
symptoms that the attending physicians should have noticed and considered.

In the present case, evidence on record established that in confirming the diagnosis of
bronchopneumonia, Dr. Casumpang selectively appreciated some and not all of the
symptoms presented, and failed to promptly conduct the appropriate tests to confirm his
findings. In sum, Dr. Casumpang failed to timely detect dengue fever, which
failure, especially when reasonable prudence would have shown that indications of dengue
were evident and/or foreseeable, constitutes negligence.

a. Negligence in the Treatment and Management of Dengue

Apart from failing to promptly detect dengue fever, Dr. Casumpang also failed to
promptly undertake the proper medical management needed for this disease.

As Dr. Jaudian opined, the standard medical procedure once the patient had exhibited the
classic symptoms of dengue fever should have been: oxygen inhalation, use of analgesic,
and infusion of fluids or dextrose ;67 and once the patient had twice vomited fresh blood,
the doctor should have ordered: blood transfusion, monitoring of the patient every 30
minutes, hemostatic to stop bleeding, and oxygen if there is difficulty in breathing .68

Dr. Casumpang failed to measure up to these standards. The evidence strongly suggests
that he ordered a transfusion of platelet concentrate instead of blood transfusion. The
tourniquet test was only conducted after Edmer's second episode of bleeding, and the
medical management (as reflected in the records) did not include antibiotic therapy and
complete physical examination.
ALANO vs MAGUD-LUGMAO

Facts:

Plaintiff-appellee Zenaida Magud-Logmao is the mother of deceased Arnelito Logmao.

Defendant-appellant Dr. Filoteo Alano is the Executive Director of the National Kidney
Institute (NKI).

Arnelito Logmao was admitted to East Avenue Medical Center (EAMC), then the NKI, when
he fell from an overpass and suffered a severe head injury. At the EAMC, the name
Arnelito Logmao was recorded as Angelito Lugmoso, and was followed by the NKI.
Attempts to locate his family at the time failed. When he was pronounced brain dead, Dr.
Alano issued a memorandum to Logmao's doctor stating that if despite all reasonable
attempts to find his family, they could not be found, then in accordance with the
provisions of Republic Act No. 349 as amended and P.D. 856, permission and/or authority
is hereby given to the Department of Surgery to retrieve and remove the kidneys,
pancreas, liver and heart of the said deceased patient and to transplant the said organs to
any compatible patient who maybe in need of said organs to live and survive.

A certification was issued by the Medico-Legal Officer of the NBI that such conditions
have been complied with. The organs were removed and transplanted to other patients.

The NKI issued a press statement on the success of the transplants. Aida Doromal, a
cousin of plaintiff, heard the news aired on television that the donor was an eighteen (18)
year old boy whose remains were still at the funerary. As the name of the donor sounded
like Arnelito Logmao, Aida informed plaintiff of the news report.

It appears that Arlen Logmao, a brother of Arnelito, reported to the police that the
latter did not return home after seeing a movie, and that the relatives of Arnelito were
likewise informed that the latter was missing. Upon receiving the news from Aida, plaintiff
Zenaida and her other children went to the funerary where they found Arnelito.

Plaintiff Zenaida filed with the court a quo a complaint for damages against the doctors
who handled Arnelito, alleging that defendants conspired to remove the organs of Arnelito
while the latter was still alive and that they concealed his true identity. The court a quo
rendered judgment finding only Dr. Filoteo Alano liable for damages to plaintiff and
dismissing the complaint against the other defendants for lack of legal basis. The CA
affirmed the decision.
ISSUE:

whether plaintiff Zenaida's sufferings were brought about by Dr Alano's alleged

negligence in granting authorization for the removal or retrieval of the internal organs of
Zenaida’s son who had been declared brain dead.

RULING:

A careful reading of Dr Alano's memorandum shows that he instructed his subordinates to

"make certain" that "all reasonable efforts" are exerted to locate the patient's next of
kin, even enumerating ways in which to ensure that notices of the death of the patient
would reach said relatives. It also clearly stated that permission or authorization to
retrieve and remove the internal organs of the deceased was being given ONLY IF the
provisions of the applicable law had been complied with. Such instructions reveal that Dr
Alano acted prudently by directing his subordinates to exhaust all reasonable means of
locating the relatives of the deceased. He could not have made his directives any clearer.
He even specifically mentioned that permission is only being granted IF the Department of
Surgery has complied with all the requirements of the law. Verily, Dr Alano could not have
been faulted for having full confidence in the ability of the doctors in the Department of
Surgery to comprehend the instructions, obeying all his directives, and acting only in
accordance with the requirements of the law.

Furthermore, the doctors and personnel of NKI disseminated notices of the death of
Zenaida's son to the media and sought the assistance of the appropriate police authorities
even before Dr. Alano issued the Memorandum. Prior to performing the procedure for
retrieval of the deceased's internal organs, the doctors concerned also the sought the
opinion and approval of the Medico-Legal Officer of the NBI.

Thus, Dr. Alano employed reasonable means to disseminate notifications intended to reach
the relatives of the deceased. The only question that remains pertains to the sufficiency
of time allowed for notices to reach the relatives of the deceased.

If Zenaida failed to immediately receive notice of her son's death because the notices did
not properly state the name or identity of the deceased, fault cannot be laid at Dr.
Alano's door. The trial and appellate courts found that it was the EAMC, who had the
opportunity to ascertain the name of the deceased, who recorded the wrong information
regarding the deceased's identity to NKI. The NKI could not have obtained the
information about his name from the patient, because as found by the lower courts, the
deceased was already unconscious by the time he was brought to the NKI.

Ultimately, it is respondent Zenaida’s failure to adduce adequate evidence that doomed

this case."[i]n civil cases, it is a basic rule that the party making allegations has the burden
of proving them by a preponderance of evidence. The parties must rely on the strength of
their own evidence and not upon the weakness of the defense offered by their
opponent." (See Otero v. Tan) Here, there is to proof that the period of around 24 hours
from the time notices were disseminated cannot be considered as reasonable under the
circumstances. They failed to present any expert witness to prove that given the medical
technology and knowledge at that time (1980's), the doctors could or should have waited
longer before harvesting the internal organs for transplantation.

Verily, the Court cannot, in conscience, agree with the lower court. Finding petitioner Dr
Alano liable for damages is improper. It should be emphasized that the internal organs of
the deceased were removed only after he had been declared brain dead; thus, the
emotional pain suffered by Zenaida due to the death of her son cannot in any way be
attributed to petitioner. Neither can the Court find evidence on record to show that r
Zenaida 's emotional suffering at the sight of the pitiful state in which she found her
son's lifeless body be categorically attributed to Dr. Alano's conduct.
SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA FLORES, Petitioners,
versus SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO, and FLORENCIO,
CANDIDA, MARTA, GODOFREDO, BALTAZAR and LUCENA, all surnamed PINEDA,
as heirs of the deceased TERESITA S. PINEDA, and UNITED DOCTORS MEDICAL
CENTER, INC., Respondents.

G.R. No. 158996 | 2008-11-14

FACTS:

 Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto.
Domingo, Nueva Ecija. She consulted on April 17, 1987 her townmate, Dr. Fredelicto
Flores, regarding her medical condition. She complained of general body weakness,
loss of appetite, frequent urination and thirst, and on-and-off vaginal bleeding. Dr.
Fredelicto initially interviewed the patient and asked for the history of her monthly
period to analyze the probable cause of the vaginal bleeding. He advised her to
return the following week or to go to the United Doctors Medical Center (UDMC) in
Quezon City for a general check-up. As for her other symptoms, he suspected that
Teresita might be suffering from diabetes and told her to continue her
medications.

 Teresita did not return the next week as advised. However, when her condition
persisted, she went to further consult Dr. Flores at his UDMC clinic. When Dr.
Fredelicto arrived, he did a routine check-up and ordered Teresita's admission to
the hospital. In the admission slip, he directed the hospital staff to prepare the
patient for an "on call" D&C operation to be performed by his wife, Dr. Felicisima
Flores (Dr. Felicisima). Dr. Felicisima proceeded with the D&C operation with Dr.
Fredelicto administering the general anesthesia. The D&C operation lasted for
about 10 to 15 minutes. By 3:40 p.m., Teresita was wheeled back to her room.

 Days after the operation, Teresita's condition had worsened. She experienced
difficulty in breathing and was rushed to the intensive care unit. Further tests
confirmed that she was suffering from Diabetes Mellitus Type II.[10] Insulin was
administered on the patient, but the medication might have arrived too late. Due to
complications induced by diabetes, Teresita died in the morning of May 6, 1987.

 Believing that Teresita's death resulted from the negligent handling of her medical
needs, her family (respondents) instituted an action for damages against Dr.
Fredelicto Flores and Dr. Felicisima Flores (collectively referred to as the
petitioner spouses) before the RTC of Nueva Ecija.
  RTC – ordered Dr. and Dra. Fredelicto A. Flores and the United Doctors Medical
Center, Inc. to jointly and severally pay the heirs of Teresita Pineda

 CA – affirmed the RTC. Hence, this appeal.

 The petitioner spouses contend that they exercised due care and prudence in the
performance of their duties as medical professionals. They had attended to the
patient to the best of their abilities and undertook the management of her case
based on her complaint of an on-and-off vaginal bleeding. In addition, they claim
that nothing on record shows that the death of Teresita could have been averted
had they employed means other than what they had adopted in the ministration of
the patient.

ISSUE: W/N the spouses-petitioners are liable for medical negligence?

HELD: YES.

 [Who has the burden of proof?] As in any civil action, the burden to prove the
existence of the necessary elements rests with the plaintiff.[17] To successfully
pursue a claim, the plaintiff must prove by preponderance of evidence that, one, the
physician either failed to do something which a reasonably prudent health care
provider would have done, or that he did something that a reasonably prudent
provider would not have done; and two, the failure or action caused injury to the
patient.[18] Expert testimony is therefore essential since the factual issue of
whether a physician or surgeon has exercised the requisite degree of skill and care
in the treatment of his patient is generally a matter of expert opinion.

 As early as April 17, 1987, Teresita was already suspected to be suffering from
diabetes.[25] This suspicion again arose right before the D&C operation on April
28, 1987 when the laboratory result revealed Teresita's increased blood sugar
level.[26] Unfortunately, the petitioner spouses did not wait for the full medical
laboratory results before proceeding with the D&C, a fact that was never
considered in the courts below. Second, the petitioner spouses were duly advised
that the patient was experiencing general body weakness, loss of appetite, frequent
urination, and thirst - all of which are classic symptoms of diabetes.[27] When a
patient exhibits symptoms typical of a particular disease, these symptoms should,
at the very least, alert the physician of the possibility that the patient may be
afflicted with the suspected disease.
 Taken together, we find that reasonable prudence would have shown that diabetes
and its complications were foreseeable harm that should have been taken into
consideration by the petitioner spouses. If a patient suffers from some disability
that increases the magnitude of risk to him, that disability must be taken into
account so long as it is or should have been known to the physician. And when the
patient is exposed to an increased risk, it is incumbent upon the physician to take
commensurate and adequate precautions.

 Taking into account Teresita's high blood sugar,[30] Dr. Mendoza opined that the
attending physician should have postponed the D&C operation in order to conduct a
confirmatory test to make a conclusive diagnosis of diabetes and to refer the case
to an internist or diabetologist. This was corroborated by Dr. Delfin Tan (Dr. Tan),
an obstetrician and gynecologist, who stated that the patient's diabetes should
have been managed by an internist prior to, during, and after the operation. The
prudent move is to address the patient's hyperglycemic state immediately and
promptly before any other procedure is undertaken. In this case, there was no
evidence that insulin was administered on Teresita prior to or during the D&C
operation. Insulin was only administered two days after the operation.

 The above facts, point only to one conclusion - that the petitioner spouses failed, as
medical professionals, to comply with their duty to observe the standard of care to
be given to hyperglycemic/diabetic patients undergoing surgery. The decision to
proceed with the D&C operation, notwithstanding Teresita's hyperglycemia and
without adequately preparing her for the procedure, was contrary to the standards
observed by the medical profession. Deviation from this standard amounted to a
breach of duty which resulted in the patient's death. Due to this negligent conduct,
liability must attach to the petitioner spouses.


DR. VICTORIA L. BATIQUIN and ALLAN BATIQUIN, petitioners, vs.
COURT OF APPEALS, SPOUSES QUEDO D. ACOGIDO and FLOTILDE G. VILLEGAS,
respondents.

G.R. No. 118231 | 1996-07-05

FACTS:

 Dr. Batiquin was a Resident Physician at the Negros Oriental Provincial Hospital,
Dumaguete City. Mrs. Villegas is a married woman who submitted to Dr. Batiquin for
prenatal care as the latter's private patient sometime before September 21, 1988.

 In the morning of September 21, 1988 Dr. Batiquin, with the assistance of Dr. Doris
Teresita Sy who was also a Resident Physician at the same Hospital, C.I. and O.R.
Nurse Arlene Diones and some student nurses performed a simple caesarean
section on Mrs. Villegas at the Negros Oriental Provincial Hospital and after 45
minutes Mrs. Villegas delivered her first child, Rachel Acogido.

 Soon after leaving the Hospital Mrs. Villegas began to suffer abdominal pains and
complained of being feverish. She also gradually lost her appetite, so she consulted
Dr. Batiquin at the latter's polyclinic who prescribed for her certain medicines. The
abdominal pains and fever kept on recurring and bothered Mrs. Villegas no end
despite the medications administered by Dr. Batiquin. When the pains became
unbearable and she was rapidly losing weight she consulted Dr. Ma. Salud Kho at the
Holy Child's Hospital in Dumaguete City.

 When Dr. Ma. Salud Kho examined Mrs. Villegas at the Holy Child's Hospital, she
felt an abdominal mass one finger below the umbilicus which she suspected to be
either a tumor of the uterus or an ovarian cyst, either of which could be cancerous.
She had an x-ray taken of Mrs. Villegas' chest, abdomen and kidney. When Mrs.
Villegas was submitted to another surgery, Dr. Kho found a piece of rubber material
on the right side of the uterus embedded on [sic] the ovarian cyst, 2 inches by 3/4
inch in size. This piece of rubber material which Dr. Kho described as a "foreign
body" looked like a piece of a "rubber glove".

 RTC – not liable; the piece of rubber allegedly found near private respondent
Flotilde Villegas's uterus was not presented in court

 CA – reversed RTC. Hence, this appeal.

ISSUE: W/N RIL is applicable in the instance case.

HELD: YES.

 Res ipsa loquitur is stated thus: "Where the thing which causes injury is shown to
be under the management of the defendant, and the accident is such as in the
ordinary course of things does not happen in those who have the management use
proper care, it affords reasonable evidence, in the absence of an explanation by the
defendant, that the accident arose from want of care."

 The doctrine of [r]es ipsa loquitur as a rule of evidence is peculiar to the law of
negligence which recognizes that prima facie negligence may be established without
direct proof and furnishes a substitute for specific proof of negligence. The
doctrine is not a rule of substantive law, but merely a mode of proof or a mere
procedural convenience. The rule, when applicable to the facts and circumstances of
a particular case, is not intended to and does not dispense with the requirement of
proof of culpable negligence on the party charged. It merely determines and
regulates what shall be prima facie evidence thereof and facilitates the burden of
plaintiff of proving a breach of the duty of due care. The doctrine can be invoked
when and only when, under the circumstances involved, direct evidence is absent
and not readily available.

 In the instant case, all the requisites for recourse to the doctrine are present.
First, the entire proceedings of the caesarean section were under the exclusive
control of Dr. Batiquin. In this light, the private respondents were bereft of direct
evidence as to the actual culprit or the exact cause of the foreign object finding
its way into private respondent Villegas's body, which, needless to say, does not
occur unless through the intersection of negligence. Second, since aside from the
caesarean section, private respondent Villegas underwent no other operation which
could have caused the offending piece of rubber to appear in her uterus, it stands
to reason that such could only have been a by-product of the caesarean section
performed by Dr. Batiquin. The petitioners, in this regard, failed to overcome the
presumption of negligence arising from resort to the doctrine of res ipsa loquitur.
Dr. Batiquin is therefore liable for negligently leaving behind a piece of rubber in
private respondent Villegas's abdomen and for all the adverse effects thereof.
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.

G.R. No. 124354 | 1999-12-29

FACTS:

 Plaintiff Erlinda Ramos was a 47-year old woman. Except for occasional complaints
of discomfort due to pains allegedly caused by the presence of a stone in her gall
bladder, she was as normal as any other woman. 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

 Dr. Orlino Hozaka decided that she should undergo a "cholecystectomy" operation,
to which Erlinda agreed. During the operation, the anesthesiologist (Dr. Gutierez)
was 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

 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.

 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. After being
discharged from the hospital, she has been staying in their residence, still needing
constant medical attention. Petitioners filed a civil case[6] for damages with the
Regional Trial Court of Quezon City.

 RTC - liable for damages arising from negligence in the performance of their
professional duties towards petitioner Erlinda Ramos resulting in her comatose
condition

 CA – reversed RTC. Hence, this appeal.

  Petitioners contend that the doctrine of res ipsa loquitor must apply in this case.

ISSUE: W/N RIL is applicable in this case.

HELD: YES.

 We find the doctrine of res ipsa loquitur appropriate in the case at bar. As will
hereinafter be explained, the damage sustained by Erlinda in her brain prior to a
scheduled gall bladder operation presents a case for the application of res ipsa
loquitur.

 In the present case, Erlinda submitted herself for cholecystectomy and expected a

routine general surgery to be performed on her gall bladder. On that fateful day
she delivered her person over to the care, custody and control of private
respondents who exercised complete and exclusive control over her. At the time of
submission, Erlinda was neurologically sound and, except for a few minor
discomforts, was likewise physically fit in mind and body. However, during the
administration of anesthesia and prior to the performance of cholecystectomy she
suffered irreparable damage to her brain. Thus, without undergoing surgery, she
went out of the operating room already decerebrate and totally incapacitated.
Obviously, brain damage, which Erlinda sustained, is an injury which does not
normally occur in the process of a gall bladder operation. In fact, this kind of
situation does not happen in the absence of negligence of someone in the
administration of anesthesia and in the use of endotracheal tube. Normally, a
person being put under anesthesia is not rendered decerebrate as a consequence of
administering such anesthesia if the proper procedure was followed. Furthermore,
the instruments used in the administration of anesthesia, including the
endotracheal tube, were all under the exclusive control of private respondents, who
are the physicians-in-charge. Likewise, petitioner Erlinda could not have been guilty
of contributory negligence because she was under the influence of anesthetics
which rendered her unconscious.

 Considering that a sound and unaffected member of the body (the 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 ipsa loquitur. Upon these facts and under
these circumstances the Court would be able to say, as a matter of common
knowledge and observation, if negligence attended the management and care of the
 patient. Moreover, the liability of the physicians and the hospital in this case is not
predicated upon an alleged failure to secure the desired results of an operation nor
on an alleged lack of skill in the diagnosis or treatment as in fact no operation or
treatment was ever performed on Erlinda. Thus, upon all these initial determination
a case is made out for the application of the doctrine of res ipsa loquitur.

PRINCIPLES:

 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
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.

 REQUISITES: 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.

 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.

 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. 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. 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,
 injuries sustained on a healthy part of the body which was not under, or in the
[32]

area, of treatment,[33] removal of the wrong part of the body when another part was
intended,[34] knocking out a tooth while a patient’s jaw was under anesthetic for
the removal of his tonsils,[35] and loss of an eye while the patient plaintiff was under
the influence of anesthetic, during or following an operation for appendicitis,
[36]
 among others.

 It must be conceded that the doctrine of res ipsa loquitur can have no application in
a suit against a physician or surgeon which involves the merits of a diagnosis or of a
scientific treatment. The physician or surgeon is not required at his peril to explain
why any particular diagnosis was not correct, or why any particular scientific
treatment did not produce the desired result.
DR. JAIME T. CRUZ, PETITIONER, VS. FELICISIMO V. AGAS, JR.,
RESPONDENT.

G.R. No. 204095 | 2015-06-15

FACTS:

 Dr. Cruz alleged, among others, that sometime in May 2003, he engaged the
services of St. Luke's Medical Center (SLMC) for a medical check-up; that after
being admitted in SLMC on May 28, 2003, he underwent stool, urine, blood, and
other body fluid tests conducted by the employees and doctors of the said
hospital; that on May 29, 2003, he was sent to the Gastro-Enterology Department
for a scheduled gastroscopy and colonoscopy; that because the specialist assigned
to perform the procedure was nowhere to be found, he gave the colonoscopy results
to the attending female anesthesiologist for the information and consideration of
the assigned specialist; that, thereafter, he was sedated and the endoscopic
examination was carried out; that when he regained consciousness, he felt that
something went wrong during the procedure because he felt dizzy, had cold clammy
perspiration and experienced breathing difficulty; that he could not stand or sit
upright because he felt so exhausted and so much pain in his abdomen; that when he
was about to urinate in the comfort room, he collapsed; that he tried to consult the
specialist who performed the colonoscopy but he was nowhere to be found; and that
his cardiologist, Dra. Agnes Del Rosario, was able to observe his critical condition
and immediately referred him to the surgical department which suspected that he
had hemorrhage in his abdomen and advised him to undergo an emergency surgical
operation.

 Dr. Cruz further averred that he agreed to the operation and upon waking up at the
ICU on May 30, 2003, he found out that the doctors did an exploratory laparatomy
because of the internal bleeding; that he learned that the doctors cut a portion of
the left side of his colon measuring 6-8 inches because it had a partial tear of the
colonic wall which caused the internal bleeding; that despite the painkillers, he was
under tremendous pain in the incision area during his recovery period in the ICU and
had fever; and that he had intravenous tubes attached to his arms, subclavian
artery on the left part of his chest and a nasogastric tube through his nose.

 Dr. Cruz then filed a Complaint-Affidavit[5] for Serious Physical Injuries through

Reckless Imprudence and Medical Malpractice against Dr. Agas.

 OCP – dismissed; DOJ – dismissed; CA – dismissed. Hence, this appeal.

ISSUE: W/N RIL is applicable in this case.

HELD: NO.

 In this case, the Court agrees with Dr. Agas that his purported negligence in
performing the colonoscopy on Dr. Cruz was not immediately apparent to a layman
to justify the application of res ipsa loquitur doctrine.

 Dr. Agas was able to establish that the internal bleeding sustained by Dr. Cruz was
due to the abnormal condition and configuration of his sigmoid colon which was
beyond his control considering that the said condition could not be detected before
a colonoscopic procedure. Dr. Agas adequately explained that no clinical findings,
laboratory tests, or diagnostic imaging, such as x-rays, ultrasound or computed
tomography (CT) scan of the abdomen, could have detected this condition prior to
an endoscopic procedure.