CASUMPANG v.

CORTEJO
GR. 171127, 171217, 171228. March 11, 2015

FACTS:
At about 11:30 AM, Mrs. Cortejo brought her 11-year-old son, 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. Livelo initially attended to and examined Edmer and diagnosed him
with "bronchopneumonia." Mrs. Cortejo did not know any doctor at SJDH and used her Fortune
Care card and was assigned to Dr. Casumpang, a pediatrician. At 5:30 PM, Dr. Casumpang for
the first time examined Edmer in his room and confirmed the initial diagnosis of
"Bronchopneumonia." At that moment, Mrs. Cortejo, having doubts on the diagnosis,
immediately advised Dr. Casumpang that Edmer had a high fever, and had no colds or cough
but Dr. Casumpang merely told her that "that's the usual bronchopneumonia, no colds, no
phlegm." Dr. Casumpang examined again and again Mrs. Cortejo called his attention on the
same matter, as well as chest and stomach pain and traces of blood in his sputum. Despite
these, Dr. Casumpang simply nodded and reassured Mrs. Cortejo that it is bronchopneumonia.
At around 11:30 AM that day, Edmer vomited "phlegm with blood streak", respondent
(Edmer's father) requested for a doctor. Dr. Miranda, one of the resident physicians of SJDH,
arrived and although aware of the incident, failed to examine the blood specimen. She then
conducted a physical check-up and found that Edmer had a low-grade noncontinuing fever, and
rashes that were not typical of dengue fever. At 3:00 PM, Edmer once again vomited blood, she
then examined it and noted that he was bleeding. She conducted a tourniquet test, which turned
out negative and ordered the monitoring of his blood pressure and some blood tests. At 4:40
PM, Dr. Miranda called Dr. Casumpang and told him about Edmer's condition and Dr.
Casumpang ordered several procedures done. The blood test results came and that Edmer was
suffering from "Dengue Hemorrhagic Fever." Dr. Casumpang recommended his transfer to the
ICU but since the ICU was full, respondent insisted on transferring to Makati Medical Center. Dr.
Casumpang, lastly, checked Edmer's condition, found that his blood pressure was stable.
Respondent had to hire a private ambulance because he was informed that the driver was
nowhere to be found.
Edmer, accompanied by his parents and by Dr. Casumpang, was transferred to MMC.
Dr. Casumpang immediately gave the attending physician the patient's clinical history and lab
exam results. Upon examination, the attending physician diagnosed "Dengue Fever Stage IV"
that was already in its irreversible stage. Edmer died and his Death Certificate indicated the
cause of death as "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.
Miranda (petitioners) before the RTC of Makati City.
RTC ruled in favor of the respondent and awarded actual and moral damages. It held
that petitioning doctors were negligent since in diagnosing and treating an illness, the
physician's conduct should be judged not only by what he/she saw and knew, but also by what
he/she could have reasonably seen and known. It also held SJDH solidarily liable with the
petitioning doctors for damages on the basis that, Dr. Casumpang, as consultant, is an
ostensible agent of SJDH; and Dr. Miranda, as resident physician, is an employee of SJDH; the
hospital also exercised control over her work.
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. It found petitioning doctors' failure to read even the most basic
signs of "dengue fever" expected of an ordinary doctor as medical negligence. And ruled that
the hospital's liability is based on Article 2180 of the Civil Code. That the control which the
hospital exercises over its consultants, the hospital's power to hire and terminate their services,
all fulfill the employer-employee relationship requirement under Article 2180.
ISSUES:
1. Whether or not the petitioning doctors had committed “inexcusable lack of precaution” in
diagnosing and in treating the patient;
2. Whether or not the petitioner hospital is solidarily liable with the petitioning doctors;
3. Whether or not there is a causal connection between the petitioners’ negligent
act/omission and the patient’s resulting death; and

RULING:
1. We find that Dr. Casumpang, as Edmer's attending physician was guilty of breach
of duty. We do not find Dr. Miranda liable.
The claim for damages is based on the petitioning doctors' negligence in
diagnosing and treating the deceased Edmer, the child of the respondent. It is a medical
malpractice suit, an action available to victims to redress a wrong committed by medical
professionals who caused bodily harm to, or the death of, a patient. To successfully
pursue a medical malpractice suit, the plaintiff must prove that the doctor either failed to
do what a reasonably prudent doctor would have done or did what a reasonably prudent
doctor would not have done; and the act or omission had caused injury to the patient.
The patient's heir/s bears the burden of proving his/her cause of action.
The elements of medical negligence are: (1) duty; (2) breach; (3) injury; and
(4) proximate causation. Duty refers to the standard of behavior that imposes
restrictions on one's conduct. It requires proof of professional relationship between the
physician and the patient. Breach of duty occurs when the doctor fails to comply with,
or improperly performs his duties under professional standards. If the patient, as a result
of the breach of duty, is injured in body or in health, actionable malpractice is
committed, entitling the patient to damages. To successfully claim damages, the patient
must lastly prove the causal relation between the negligence and the injury. The injury
or damage is proximately caused by the physician's negligence when it appears, based
on the evidence and the expert testimony, that the negligence played an integral part in
causing the injury or damage, and that the injury or damage was either a direct result, or
a reasonably probable consequence of the physician's negligence.
In the present case, expert testimony is crucial in determining the standard
medical examinations, tests, and procedures that the attending physicians should have
undertaken in the diagnosis and treatment of dengue fever and the dengue fever signs
and symptoms that the attending physicians should have noticed and considered. It has
been established that 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. Apart from failing to promptly
detect dengue fever, Dr. Casumpang also failed to promptly undertake the proper
medical management needed for this disease.
In considering the case of Dr. Miranda, the junior resident physician who was on-
duty at the time of Edmer's confinement, we see the need to draw distinctions between
the responsibilities and corresponding liability of Dr. Casumpang, as the attending
physician, and that of Dr. Miranda. In his testimony, Dr. Pasion declared that resident
physician’s function under the supervision of attending physicians or of the hospital's
teaching staff. Under this arrangement, residents operate merely as subordinates who
usually defer to the attending physician on the decision to be made and on the action to
 be taken. The attending physician, on the other hand, is primarily responsible for
managing the resident's exercise of duties.
Based on her statements we find that Dr. Miranda was not entirely faultless. In
addition, considering the diagnosis previously made by two doctors, and the
uncontroverted fact that the burden of final diagnosis pertains to the attending physician
(Dr. Casumpang), we believe that Dr. Miranda's error was merely an honest mistake of
judgment influenced in no small measure by her status in the hospital hierarchy; hence,
she should not be held liable for medical negligence.

2. SJDH is solidarily liable based on the doctrine of apparent authority and not Art.
2180 of the Civil Code.
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." 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.
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.
Respondent relied on SJDH, to care and treat his son Edmer since he and his wife did
not know any doctors nor did they know that Dr. Casumpang was an independent
contractor. When Mrs. Cortejo presented her Fortune Care card, she was referred to Dr.
Casumpang. She 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 the spouses
Cortejo knew, or should have known, that Dr. Casumpang is only an independent
contractor of the hospital. In this case, estoppel has already set in.

3. YES. The causation between Dr. Casumpang’s negligence and the injury was
adequately proven.
Dr. Jaudian's testimony strongly suggests that due to Dr. Casumpang's failure to
timely diagnose Edmer with dengue, the latter was not immediately given the proper
treatment. As in any fatal diseases, it requires immediate medical attention. With the
correct and timely diagnosis, coupled with the proper medical management, dengue
fever is not a life-threatening disease and could easily be cured. Hence, the survival of
the patient is directly related to early and proper management of the illness.
Dr. Casumpang failed to timely diagnose Edmer with dengue fever despite the
presence of its characteristic symptoms; and as a consequence of the delayed
diagnosis, he also failed to promptly manage Edmer's illness. Had he immediately
conducted confirmatory tests and promptly administered the proper care and
management needed for dengue fever, the risk of complications or even death, could
have been substantially reduced.