G.R. No. 124354 December 29, 1999ROGELIO E. RAMOS and ERLINDA RAMOS, petitioners, vs.COURT OF APPEALS, DELOS SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and DRA. PERFECTA GUTIERREZ, respondents

FACTS:Erlinda Ramos was a robust woman except for occasional complaint of discomfort due to pains allegedly caused by the presence of the stone in her gall bladder. Because of discomfort which interfered her normal ways, she was advised to undergo an operation. However, on her scheduled gall bladder operation in the Delos Santos Medical Center, she sustained brain damage from wrongful intubation by her anesthesiologist Dra. Perfecta Gutierrez. Petitioners filed an action for damages and presented the testimony of Herminda Cruz, her sister in law, Dean of the College of Nursing in the same institution, who was in the operating room right beside her when the tragic event occurred. It was rebutted that Cruz is not competent to testify since she is not an anesthesiologist, therefore she had no expertise in the matter at hand.

ISSUE:WHETHER OR NOT EXPERT MEDICAL TESTIMONY IS NECESSARY IN DETERMINING NEGLIGENCE IN MEDICAL MALPRACTICES WHEN THE DOCTRINE OF RES IPSA LOQUITOR IS APPLICABLE

RULING:No. Although generally, expert medical testimony is relied upon in malpractice suit to prove that a physician has done a negligent act, when the doctrine of res ipsa loquitor ( “the thing speaks for itself”) is availed by the plaintiff, the need for expert testimony is dispensed with because the injury itself provides the proof of negilence. The reason is that the general rule on the necessity of expert testimony applies only to such matters clearly within the domain of medical science, and not to such matters clearly within the common knowledge of mankind which may be testified by anyone familiar with the facts. Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to whether a patient has been treated and operated upon with a reasonable degree of skill and care, However, testimonies as to the statements and acts of physicians and surgeons, external appearances and manifest conditions which are observable by anyone may be given by non-expert witnesses. Hence, in cases where res ipsa loquitor is applicable, the court is permitted to find the 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. Where common knowledge and experience teach that a resulting injury would not have occurred to the patient if due care had been exercised, an inference of negligence may be drawn giving rise to the application of the doctrine of res ipsa loquitor without medical evidence, which is ordinarily required to show not only what occurred but how and why it occurred. When the doctrine is

appropriate, all that a 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.

Dr. Ninevetch Cruz v. CA and Lydia Umali1997 / Francisco / Petition for review on certiorari of a CA decisionStandard of conduct > Experts > Medical professionals

FACTSMedical malpractice suit – type of claim which a victim has available to him/her to redress a wrong committed by a medical professional which has caused bodily harm; most often brought as a civil action for damages under NCC 2176 or a criminal case under RPC 365, with which a civil action for damages is impliedly instituted.Lydia Umali was examined by Dr. Cruz who found a myoma [benign tumor] in her uterus, and scheduled her for a hysterectomy operation [removal of uterus] on 23 Mar 1991. Rowena Umali de Ocampo accompanied her mother to the hospital a day before the operation, and they spent the night there. Rowena noticed that the clinic was untidy, so she tried to persuade her mother not to proceed with the operation. The following day, Rowena asked Dr. Cruz if the operation could be postponed, but Lydia told her daughter that Dr. Cruz said that the operation must go on as scheduled. 

While Lydia’s relatives were waiting, Dr. Ercillo (anesthesiologist) told them to buy tagamet ampules, and Rowena’s sister went out to buy some. An hour later, Dr. Ercillo asked them to buy blood for Lydia, so they did. A few hours later, the operation was finished, but later, Dr. Cruz asked the family to buy additional blood, but there was no more type A blood available in the blood bank. A person arrived to donate blood which was later transfused to Lydia. Rowena noticed that her mother was gasping for breath–apparently, the oxygen supply had run out, so the family went out to buy oxygen. Later in the evening, she went into shock and her blood pressure dropped. She was then transferred to another hospital so she could be connected to a respirator and further examined. However, this transfer was without the consent of the relatives, who only found out about it when an ambulance came to take Lydia to the other hospital.

In the new hospital, she was re-operated upon by Dr. Cruz and Dr. Ercillo because blood was oozing out from her incision. They summoned Dr. Angeles, Ob-Gyne head of the new hospital, but when he arrived, Lydia was already in shock and possibly dead (BP: 0/0). Dr. Angeles told Drs. Cruz and Ercillo that there was nothing he could do. Lydia died while Dr. Cruz was closing her abdominal wall. Immediate cause of death is shock; disseminated intravascular coagulation (DIC) as antecedent cause.

Dr. Cruz and Dr. Ercillo were charged with reckless imprudence and negligence resulting in homicide of Lydia Umali. The Municipal Trial Court in Cities (MTCC) found Dr. Ercillo not guilty for insufficiency of evidence against her, but held Dr. Cruz responsible for Umali’s death. RTC and CA affirmed MTCC.Manifestation of negligence

untidiness of clinic

lack of provision of supplies the fact that the transfer was needed meant that there was something wrong in the way Dr.

Cruz conducted operation no showing that pre-surgery procedure (clearance, blood typing/tests) was conductedISSUE AND HOLDINGWON the circumstances are sufficient to sustain a judgment of conviction against Dr. Cruz for reckless imprudence resulting in homicide. NO. DR. CRUZ IS ACQUITTED, BUT SHE IS STILL CIVILLY LIABLE (50K civil liability; 100k moral damages, 50k exemplary damages).RATIOElements of reckless imprudence

1.     Offender does / fails to do an act2.     Doing / failure to do act is voluntary3.     Without malice4.     Material damage results from reckless imprudence5.     There is inexcusable lack of precaution, taking into consideration offender’s employment,

degree of intelligence, physical condition, other circumstances re: persons, time, placeStandard of careStandard of care observed by other members of the profession in good standing under similar circumstances, bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science          When the physician’s qualifications are admitted, 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 by expert testimony.Expert testimonyExpert testimony is essential to establish standard of care of the profession, as well as that the physician’s conduct in the treatment and care falls below such standard. It is also usually necessary to support the conclusion as to causation. There is an absence of any expert testimony re: standard of care in the case records. NBI doctors presented by the prosecution only testified as to the possible cause of death.     While it may be true that the circumstances pointed out by the lower courts constitute reckless imprudence, this conclusion is still best arrived not through the educated surmises nor conjectures of laymen, including judges, but by the unquestionable knowledge of expert witnesses. The deference of courts to the expert opinion of qualified physicians stems from the realization that the latter possess unusual technical skills which laymen are incapable of intelligently evaluating.Burden of establishing medical negligence on plaintiffPlaintiff has the burden to establish this, and for a reasonable conclusion of negligence, there must be proof of breach of duty on the part of the surgeon, as well as a causal connection of such breach and the resulting death of patient. Negligence cannot create a right of action unless it is the proximate cause of the injury complained of (Chan Lugay v. St. Luke’s Hospital, Inc.). In this case, no cogent proof exists that the circumstances caused Lydia’s death, so the 4th element of reckless imprudence is missing.     The testimonies of the doctors presented by the prosecution establish hemorrhage / hemorrhagic shock as the cause of death, which may be caused by several different factors. Autopsy did not reveal any untied cut blood vessel, nor was there a tie of a cut blood

vessel that became loose. The findings of the doctors do not preclude the probability that a clotting defect (DIC) caused the hemorrhage and consequently, Lydia’s death.The Court has no recourse but to rely on the expert testimonies that substantiate Dr. Cruz’ allegation that the cause of Lydia’s death was DIC, which cannot be attributed to Dr. Cruz’ fault or negligence. This probability was unrebutted during trial.

Professional Services, Inc. V. Natividad And Enrique Agana (2007)

G.R. No. 157906   November 2, 2006Lessons Applicable: Res ipsa loquitur (Torts and Damages)Laws Applicable: Art. 2176 Art. 2180  and  Art. 1869 of the Civil Code

FACTS:  April 4, 1984: Natividad Agana was rushed to the Medical City General Hospital because of

difficulty of bowel movement and bloody anal discharge. Dr. Miguel Ampil diagnosed her to be suffering from cancer of the sigmoid.

April 11, 1984: Dr. Ampil performed an anterior resection surgery on Natividad and found that the malignancy in her sigmoid area had spread on her left ovary, necessitating the removal of certain portions of it

Dr. Ampil obtained the consent of Natividad’s husband, Enrique Agana to perform hysterectomy.

After a couple of days, Natividad consulted both Dr. Ampil and Dr. Fuentes about the excruciating pain in her anal region. Dr. Ampil recommended that she consult an oncologist.

May 9, 1984: The Aganas went to the United States to seek further treatment and was told she was FREE from cancer.

August 31, 1984: Natividad's daughter found a piece of gauze protruding from her vagina. Dr. Ampil proceeded to her house and extracted by hand a piece of gauze measuring 1.5 inches in width and assuring that the pain will vanish. 

When the pain intensified, Nativided went to Polymedic General Hospital where Dr. Ramon Gutierrez  found a foul-smelling gauze measuring 1.5 inches in width which badly infected her vaginal vault which formed a recto-vaginal fistula forcign her stool to excrete through the vagina.

October 1984: Natividad underwent another surgery to remedy the damage February 16, 1986: Natividad died so she was substituted by her children

RTC: PSI solidarily liable with Dr. Ampil and Dr. Fuentes for damages for negligence and malpractice

CA: absolved Dr. Fuentes upon the same advise from the PRC Board of Medicine for failure to show that he placed the guages or concealed the fact from Natividad 

ISSUE: W/N  Dr. Fuentes may be held liable under the principle of res ipso loquitor

HELD: NO.  CA affirmed Dr. Ampil as the negligent party surgeons used gauzes as sponges to control the bleeding of the patient during the surgical

operation immediately after the operation, the nurses who assisted in the surgery noted in their report 2

sponges lacking 2 gauzes were extracted from the same spot of the body of Mrs. Agana element 3 "control and management of the thing which caused the injury" to be wanting  Dr. Fuentes performed the surgery and thereafter reported and showed his work to Dr. Ampil

who allowed Dr. Fuentes to leave the operating room Under the "Captain of the Ship" rule, the operating surgeon is the person in complete charge

of the surgery room and all personnel connected with the operation res ipsa loquitur not a rule of substantive law, hence, does not per se create or constitute an independent or

separate ground of liability, being a mere evidentiary rule mere invocation and application of the doctrine does not dispense with the requirement of

proof of negligence Art. 2176. Whoever by act or omission causes damage to another, there being fault or

negligence, is obliged to pay for the damage done. Such fault or negligence, if there is no pre-existing contractual relation between the parties, is called a quasi-delict and is governed by the provisions of this Chapter.

ART. 2180. The obligation imposed by Article 2176 is demandable not only for one’s own acts or omissions, but also for those of persons for whom one is responsible.

The owners and managers of an establishment or enterprise are likewise responsible for damages caused by their employees in the service of the branches in which the latter are employed or on the occasion of their functions.

Employers shall be liable for the damages caused by their employees and household helpers acting within the scope of their assigned tasks even though the former are not engaged in any business or industry.