ARELLANO UNIVERSITY SCHOOL OF LAW SCHOOL OF LAW

LEGAL MEDICINE JURISPRUDENCE MEDICAL MALPRACTICE AND PHYSICAL INJURIES 1. Carillo vs. People of the Philippines G.R. No. 86890, January 21, 1994 Facts: Petitioner filed a petition for review on certiorari on the decision of the Court of Appeals affirming his conviction by the RTC of the crime of simple negligence resulting in homicide, for the death of his 13 year old patient Catherine Acosta after an appendectomy procedure conducted on the patient. Catherine Acosta, a 13 year old girl, daughter of spouses Domingo and Yolanda Acosta, complained to her father at about 10:30 o'clock in the morning of May 31, 1981 of pains in the lower part of her abdomen. Catherine was then brought to Dr. Elva Pea. Dra. Pea called for Dr. Emilio Madrid and the latter examined Catherine Acosta.

According to Dr. Madrid, his findings might be appendicitis. The appellant Dr. Emilio Madrid, a surgeon, operated on Catherine. He was assisted by appellant, Dr. Leandro Carillo, anesthesiologists. After operation, Catherine remained unconscious until noontime the next day, a neurologist examined her and she was diagnosed as comatose. Three (3) days later, Catherine died without regaining consciousness. The Court of Appeals held that Catherine had suffered from an overdose of, or an adverse reaction to, anesthesia, particularly the arbitrary administration of Nubain, a pain killer, without benefit of prior weighing of the patient's body mass, which weight determines the dosage of Nubain which can safely be given to a patient.

The Court of Appeals held that this condition triggered off a heart attack as a post-operative complication, depriving Catherine's brain of oxygen, leading to the brain's hemorrhage. The Court of Appeals identified such cardiac arrest as the immediate cause of Catherine's death. The Court of Appeals found criminal negligence on the part of petitioner Dr. Carillo and his co-accused Dr. Madrid, holding that both had failed to observe the required standard of diligence in the examination of Catherine prior to the actual administration of anesthesia; that it was "a bit rash" on the part of the accused Dr. Carillo "to have administered Nubain without first weighing Catherine"; and that it was an act of negligence on the part of both doctors when, (a) they failed to monitor Catherine's heartbeat after the operation and (b) they left the hospital immediately after reviving Catherine's heartbeat, depriving the latter of immediate and expert medical assistance when she suffered a heart attack approximately fifteen (15) to thirty (30) minutes later.

Issue: Whether or not Dr. Carillo is guilty of the crime of simple negligence resulting in homicide.

Held: Simple negligence, penalized under what is now Article 365 of the Revised Penal Code, is defined as "a mere lack of prevision in a situation where either the threatened harm is not immediate or the danger not openly visible." Put in a slightly different way, the gravamen of the offense of simple negligence is the failure to exercise the diligence necessitated or called for the situation which was not immediately life-destructive but which culminated in the present case, in the death of a human being three (3) days later. In the case at bar, we consider that the chain of circumstances above noted, namely: (1)the failure of petitioner and Dr. Madrid to appreciate the serious post-surgery condition of their patient and to monitor her condition and provide close patient care to her; (2) the summons of petitioner by Dr. Madrid and the cardiologist after the patient's heart attack on the very evening that the surgery was completed; (3) the low level of care and diligence exhibited by petitioner in failing to correct Dr. Madrid's prescription of Nubain for post-operative pain; (4) the extraordinary failure or refusal of petitioner and Dr. Madrid to inform the parents of Catherine Acosta of her true condition after surgery, in disregard of the requirements of the Code of Medical Ethics; and (5) the failure of petitioner and Dr. Madrid to prove that they had in fact exercised the necessary and appropriate degree of care and diligence to prevent the sudden decline in the condition of Catherine Acosta and her death three (3) days later, leads the Court to the conclusion, with moral certainty, that petitioner and Dr. Madrid were guilty of simple negligence resulting in homicide. 2. 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. July 5, 1996 Facts: The petitioner Dr. Batiquin was a Resident Physician at the Negros Oriental Provincial Hospital, Dumaguete City from January 9, 1978 to September 1989. And 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. The latter was submitted to a simple cesarean operation by herein petitioner to deliver her first child. 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. In the meantime, Mrs. Villegas was given a Medical Certificate by Dr. Batiquin certifying to her physical fitness to return to her work and indeed soon after she returned back to her work. But still the abdominal pains and fever kept on recurring and bothered Mrs. Villegas no end and despite the medications administered by Dr. Batiquin. When the pains become unbearable and she was rapidly losing weight she consulted Dr. Ma. Salud Kho at the Holy Child's Hospital in Dumaguete City on January 20, 1989. Dr. Kho found whitish-yellow discharge inside, an ovarian cyst on each of the left and right ovaries which gave out pus, dirt and pus behind the uterus, and a

piece of rubber materials on the right side of the uterus embedded on 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" . . . and which is also "rubber-drain like . . . . It could have been a torn section of a surgeon's gloves or could have come from other sources. And this foreign body was the cause of the infection of the ovaries and consequently of all the discomfort suffered by Mrs. Villegas after her delivery. And this prompted Mrs. Villegas to file this present case against Dr. Batiquin. The CA ruled against the petitioner, hence, this petition.

Issue: Whether or not petitioner, Dr. Batiquin should be held liable for her negligence in leaving behind the piece of rubber from Mrs. Villegas abdomen.

Held: Yes.

Dr. Batiquin is liable for negligently leaving behind a piece of rubber in private respondent Villegas' abdomen and for all the adverse effects thereof. As such, the rule of res ipsa loquitur comes to fore. This Court has had occasion to delve into the nature and operation of this doctrine: This doctrine [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 if 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." Or as Black's Law Dictionary puts it: Res ipsa loquitur. The thing speaks for itself. Rebuttable presumption or inference that defendant was negligent, which arises upon proof that [the] instrumentality causing injury was in defendant's exclusive control, and that the accident was one which ordinary does not happen in absence of negligence. Res ipsa loquitur is [a] rule of evidence whereby negligence of [the] alleged wrongdoer may be inferred from [the] mere fact that [the] accident happened provided [the] character of [the] accident and circumstances attending it lead reasonably to belief that in [the] absence of negligence it would not have occurred and that thing which caused injury is shown to have been under [the] management and control of [the] alleged wrongdoer . . . . Under [this] doctrine . . . the happening of an injury permits an inference of negligence where plaintiff produces substantial evidence that [the] injury was caused by an agency or instrumentality under [the] exclusive control and management of defendant, and that the occurrence [sic] was such that in the ordinary course of things would not happen if reasonable care had been used.

xxx xxx xxx 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 cesarean 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' body, which, needless to say, does not occur unless through the intervention of negligence. Second, since aside from the cesarean 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 cesarean 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.

As a final word, this Court reiterates its recognition of the vital role the medical profession plays in the lives of the people, and State's compelling interest to enact measures to protect the public from "the potentially deadly effects of incompetence and ignorance in those who would undertake to treat our bodies and minds for disease or trauma." Indeed, a physician is bound to serve the interest of his patients "with the greatest of solicitude, giving them always his best talent and skill." Through her tortious conduct, the petitioner endangered the life of Flotilde Villegas, in violation of her profession's rigid ethical code and in contravention of the legal standards set forth for professionals, in the general, and members of the medical profession, in particular. 3. LEONILA GARCIA-RUEDA, petitioner, vs. WILFREDO L. PASCASIO, RAUL R. ARNAU, ABELARDO L. APORTADERA JR., Honorable CONDRADO 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. G.R. No. 118141. September 5, 1997 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 husbands body. Consequently, the NBI ruled that Florencios 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.

Issue: (1) Whether or not Dr. Domingo Antonio and Dr. Erlinda Balatbat-Reyes should be charged for Homicide through Reckless Imprudence before the Office of the City Prosecutor.

(2) Whether or not a medical malpractice committed by Dr. Domingo Antonio and Dr. Erlinda Balatbat-Reyes indeed transpired.

Held:

(1) No. In this instant case, no less than the NBI pronounced after conducting an autopsy that there was indeed negligence on the part of the attending physicians in administering the anaesthesia. The fact of want of competence or diligence is evidentiary in nature, the veracity of which can best be passed upon after a full-blown trial for it is virtually impossible to ascertain the merits of a medical negligence case without extensive investigation, research, evaluation and consultations with medical experts. Clearly, the City Prosecutors are not in a competent position to pass judgment on such a technical matter, especially when there are conflicting evidence and findings. The bases of a partys accusation and defenses are better ventilated at the trial proper than at the preliminary investigation.

(2) Yes. 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. Hence, there are 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. 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. 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. 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: whether the doctors actions in fact caused the harm to the patient and whether these were the proximate cause of the patients injury. Indeed here, a causal connection is discernible from the occurrence of the victims 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. To be sure, the allegation of negligence is not entirely baseless. 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. Why these precautionary measures were disregarded must be sufficiently explained. Absent otherwise, the attending medical expert should have been held liable therein. 4. DR. NINEVETCH CRUZ, petitioner, vs. COURT OF APPEALS and LYDIA UMALI, respondents. G.R. No. 122445. November 18, 1997 Facts: On March 22, 1991, prosecution witness, Rowena Umali De Ocampo, accompanied her mother to the Perpetual Help Clinic and General Hospital situated in Balagtas Street, San Pablo City, Laguna. They arrived at the said hospital at around 4:30 in the afternoon of the same day. Prior to March 22, 1991, Lydia was examined by the petitioner who found a "myoma" in her uterus, and scheduled her for a hysterectomy operation on March 23, 1991. According to Rowena, she noticed that the clinic was untidy and the window and the floor were very dusty prompting her to ask the attendant for a rag to wipe the window and the floor with. Because of the untidy state of the clinic, Rowena tried to persuade her mother not to proceed with the operation. The following day, before her mother was wheeled into the operating room, Rowena asked the petitioner if the operation could be postponed. The petitioner called Lydia into her office and the two had a conversation. Lydia then informed Rowena that the petitioner told her that she must be operated on as scheduled. The operation nevertheless happened with these circumstances attending: a. The relatives of Umali were asked to buy tagamet ampules by Dr. Ercillo. b. They were asked to buy blood for Umali, Type A. c. When asked again to buy blood, nowhere blodd available at the Blood Bank of the Hospital. d. The condition of Umali became worse that she has to be transferred to another Hospital, San Pablo District hospital.

Upon Lydia's arrival at the San Pablo District Hospital, she was wheeled into the operating room and the petitioner and Dr. Ercillo re-operated on her because there was blood oozing from the abdominal incision. While petitioner was closing the abdominal wall, the patient died.

Thus, on March 24, 1991, Lydia Umali was pronounced dead. Her death certificate states "shock" as the immediate cause of death and "Disseminated Intravascular Coagulation (DIC)" as the antecedent cause. In convicting the petitioner, the MTCC found her to be negligent in the performance of the operation.

The RTC reiterated the abovementioned findings of the MTCC and upheld the latter's declaration of "incompetency, negligence and lack of foresight and skill of appellant (herein petitioner) in handling the subject patient before and after the operation." And likewise affirming the petitioner's conviction, the Court of Appeals echoed similar observations, thus: "x x x. While we may grant that the untidiness and filthiness of the clinic may not by itself indicate negligence, it nevertheless shows the absence of due care and supervision over her subordinate employees. Did this unsanitary condition permeate the operating room? Were the surgical instruments properly sterilized? Could the conditions in the OR have contributed to the infection of the patient? Only the petitioner could answer these, but she opted not to testify. This could only give rise to the presumption that she has nothing good to testify on her defense. Anyway, the alleged "unverified statement of the prosecution witness" remains unchallenged and unrebutted. Issue: Whether or not a physician has committed an "inexcusable lack of precaution" in the treatment of his patient is to be determined according to the standard 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. Held:

The attending physician may have committed the lack of precaution if duly proven with concrete evidence supporting such claim. But absence of the same will lead such allegations as mere hearsay. In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pacasio, et. al., this Court stated that in accepting a case, a doctor in effect represents that, having the needed training and skill possessed by physicians and surgeons practicing in the same field, he will employ such training, care and skill in the treatment of his patients. He therefore has 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. It is in this aspect of medical malpractice that expert testimony is essential to establish not only the standard of care of the profession but also that the physician's conduct in the treatment and care falls below such standard.

Further, inasmuch as the causes of the injuries involved in malpractice actions are determinable only in the light of scientific knowledge, it has been recognized that expert testimony is

usually necessary to support the conclusion as to causation. Immediately apparent from a review of the records of this case is the absence of any expert testimony on the matter of the standard of care employed by other physicians of good standing in the conduct of similar operations. The prosecution's expert witnesses in the persons of Dr. Floresto Arizala and Dr. Nieto Salvador, Jr. of the National Bureau of Investigation (NBI) only testified as to the possible cause of death but did not venture to illuminate the court on the matter of the standard of care that petitioner should have exercised. All three courts below bewail the inadequacy of the facilities of the clinic and its untidiness; the lack of provisions such as blood, oxygen, and certain medicines; the failure to subject the patient to a cardio-pulmonary test prior to the operation; the omission of any form of blood typing before transfusion; and even the subsequent transfer of Lydia to the San Pablo Hospital and the reoperation performed on her by the petitioner. But while it may be true that the circumstances pointed out by the courts below seemed beyond cavil to constitute reckless imprudence on the part of the surgeon, this conclusion is still best arrived at not through the educated surmises nor conjectures of laymen, including judges, but by the unquestionable knowledge of expert witnesses. For whether a physician or surgeon has exercised the requisite degree of skill and care in the treatment of his patient is, in the generality of cases, a matter of expert opinion. The deference of courts to the expert opinion of qualified physicians stems from its realization that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating. Expert testimony should have been offered to prove that the circumstances cited by the courts below are constitutive of conduct falling below the standard of care employed by other physicians in good standing when performing the same operation. 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. This presumption is rebuttable by expert opinion which is so sadly lacking in the case at bench.

Even granting arguendo that the inadequacy of the facilities and untidiness of the clinic; the lack of provisions; the failure to conduct pre-operation tests on the patient; and the subsequent transfer of Lydia to the San Pablo Hospital and the reoperation performed on her by the petitioner do indicate, even without expert testimony, that petitioner was recklessly imprudent in the exercise of her duties as a surgeon, no cogent proof exists that any of these circumstances caused petitioner's death. Thus, the absence of the fourth element of reckless imprudence: that the injury to the person or property was a consequence of the reckless imprudence.

In litigations involving medical negligence, the plaintiff has the burden of establishing appellant's negligence 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 casual connection of such breach and the resulting death of his patient. In Chan Lugay v. St Luke's Hospital, Inc., where the attending physician was absolved of liability for the death of the complainant's wife and newborn baby, this court held that: "In order that there may be a recovery for an injury, however, it must be shown that the 'injury for which recovery is sought must be the legitimate

consequence of the wrong done; the connection between the negligence and the injury must be a direct and natural sequence of events, unbroken by intervening efficient causes.'

In other words, the negligence must be the proximate cause of the injury. For, 'negligence, no matter in what it consists, cannot create a right of action unless it is the proximate cause of the injury complained of.' And 'the proximate cause of an injury is that cause, which, in natural and continuous sequence, unbroken by any efficient intervening cause, produces the injury, and without which the result would not have occurred.''' (Underscoring supplied.) The petitioner is a doctor in whose hands a patient puts his life and limb. For insufficiency of evidence this Court was not able to render a sentence of conviction but it is not blind to the reckless and imprudent manner in which the petitioner carried out her duties. A precious life has been lost and the circumstances leading thereto exacerbated the grief of those left behind. The heirs of the deceased continue to feel the loss of their mother up to the present time and this Court is aware that no amount of compassion and commiseration nor words of bereavement can suffice to assuage the sorrow felt for the loss of a loved one. Certainly, the award of moral and exemplary damages in favor of the heirs of Lydia Umali are proper in the instant case.

Hence, petitioner DR. NINEVETCH CRUZ is hereby ACQUITTED of the crime of reckless imprudence resulting in homicide but is ordered to pay the heirs of the deceased Lydia Umali the amount of FIFTY THOUSAND PESOS (P50,000.00) as civil liability, ONE HUNDRED THOUSAND PESOS (P100,000.00) as moral damages, and FIFTY THOUSAND PESOS (P50,000.00) as exemplary damages. 5. 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 December 29, 1999 Facts: Plaintiff Erlinda Ramos was, until the afternoon of June 17, 1985, a 47-year old was a robust 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. Married to Rogelio E. Ramos, an executive of Philippine Long Distance Telephone Company, she has three children whose names are Rommel Ramos, Roy Roderick Ramos and Ron Raymond Ramos. 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. She underwent a series of examinations which included blood and urine tests indicated she was fit for surgery.

Through the intercession of a mutual friend, Dr. Buenviaje, she and her husband Rogelio met for the first time Dr. Orlino Hozaka, one of the defendants in this case, on June 10, 1985. They agreed that their date at the operating table at the DLSMC (another defendant), would be on June 17, 1985 at 9:00 A.M.. Dr. Hosaka decided that she should undergo a "cholecystectomy" operation after examining the documents presented to him. Rogelio E. Ramos, however, asked Dr. Hosaka to look for a good anesthesiologist.

After the operation, unfortunately, 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, with her husband Rogelio incurring a monthly expense ranging from P8,000.00 to P10,000.00. She was also diagnosed to be suffering from "diffuse cerebral parenchymal damage".

Thus, on 8 January 1986, petitioners filed a civil case for damages with the Regional Trial Court of Quezon City against herein private respondents alleging negligence in the management and care of Erlinda Ramos. After considering the evidence from both sides, the Regional Trial Court rendered judgment in favor of petitioners. Private respondents seasonably interposed an appeal to the Court of Appeals. The appellate court rendered a Decision, dated 29 May 1995, reversing the findings of the trial court. Issue: Whether a surgeon, an anesthesiologist and a hospital should be made liable for the unfortunate comatose condition of a patient scheduled for cholecystectomy. Held:

Yes. We hold that private respondents were unable to disprove the presumption of negligence on their part in the care of Erlinda and their negligence was the proximate cause of her piteous condition.

We do not agree with the reasoning of the appellate court. Although witness Cruz is not an anesthesiologist, she can very well testify upon matters on which she is capable of observing such as, the statements and acts of the physician and surgeon, external appearances, and manifest conditions which are observable by any one. This is precisely allowed under the doctrine of res ipsa loquitur where the testimony of expert witnesses is not required. It is the accepted rule that expert testimony is not necessary for the proof of negligence in non-technical matters or those of which an ordinary person may be expected to have knowledge, or where the lack of skill or want of care is so obvious as to render expert testimony unnecessary. We take judicial notice of the fact that anesthesia procedures have become so common, that even an ordinary person can tell if it was administered properly. As such, it would not be too difficult to tell if the tube was properly inserted.

This kind of observation, we believe, does not require a medical degree to be acceptable. 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. 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. Hence, res ipsa loquitur is applied in conjunction with the doctrine of common knowledge. Established medical procedures and practices, though in constant flux are devised for the purpose of preventing complications. A physician's experience with his patients would sometimes tempt him to deviate from established community practices, and he may end a distinguished career using unorthodox methods without incident. However, when failure to follow established procedure results in the evil precisely sought to be averted by observance of the procedure and a nexus is made between the deviation and the injury or damage, the physician would necessarily be called to account for it.

In the case at bar, the failure to observe pre-operative assessment protocol which would have influenced the intubation in a salutary way was fatal to private respondents' case.

WHEREFORE, the decision and resolution of the appellate court appealed from are hereby modified so as to award in favor of petitioners, and solidarily against private respondents the following: 1) P1,352,000.00 as actual damages computed as of the date of promulgation of this decision plus a monthly payment of P8,000.00 up to the time that petitioner Erlinda Ramos expires or miraculously survives; 2) P2,000,000.00 as moral damages, 3) P1,500,000.00 as temperate damages; 4) P100,000.00 each as exemplary damages and attorney's fees; and, 5) the costs of the suit.

6. Reyes v Sisters of Mercy Hospital G.R. 130547 October 3, 2000 Facts: Petitioner Leah Alesna Reyes is the wife of the late Jorge Reyes. The other petitioners, namely, Rose Nahdja, Johnny, Lloyd, and Kristine, all surnamed Reyes, were their children. Five days before his death on January 8, 1987, Jorge had been suffering from are curring fever with chills. After he failed to get relief from some home medication he was taking, which consisted of analgesic, antipyretic, and antibiotics, he decided to see the doctor. 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. She noted that at the time of his admission, Jorge was conscious, ambulatory, oriented, coherent, and with respiratory distress. Typhoid fever was then prevalent in the locality, as the clinic had been getting from 15 to 20 cases of typhoid per month Suspecting that Jorge could be suffering from this disease, Dr. Rico ordered a Widal Test, a standard test for typhoid fever, to be

performed on Jorge. Blood count, routine urinalysis, stool examination, and malarial smear were also made after about an hour, the medical technician submitted the results of the test from which Dr. Rico concluded that Jorge was positive for typhoid fever. As her shift was only up to 5:00 p.m., Dr. Rico indorsed Jorge to respondent Dr. Marvie Blanes.Dr. Marvie Blanes attended to Jorge at around six in the evening. She also took Jorges history and gave him a physical examination. Like Dr. Rico, her impression was that Jorge had typhoid fever. Antibiotics being the accepted treatment for typhoid fever, she ordered that a compatibility test with the antibiotic chloromycetin be done on Jorge. Said test was administered by nurse Josephine Pagente who also gave the patient a dose of triglobe. As she did not observe any adverse reaction by the patient to chloromycetin,Dr. Blanes ordered the first five hundred milligrams of said antibiotic to be administered on Jorge at around 9:00 p.m. A second dose was administered on Jorge about three hours later just before midnight. At around 1:00 a.m. of January 9, 1987, Dr. Blanes was called as Jorges temperature roseto 41C. The patient also experienced chills and exhibited respiratory distress, nausea, vomiting, and convulsions. Dr. Blanes put him under oxygen, used a suction machine, and administered hydrocortisone, temporarily easing the patients convulsions. When here gained consciousness, the patient was asked by Dr. Blanes whether he had a previous heart ailment or had suffered from chest pains in the past. Jorge replied he did not After about 15 minutes, however, Jorge again started to vomit, showed restlessness, and his convulsions returned. Dr. Blanes re-applied the emergency measures taken before and, in addition, valium was administered. Jorge, however, did not respond to the treatment and slipped into cyanosis, a bluish or purplish discoloration of the skin or mucous membrane due to deficient oxygenation of the blood. At around 2:00 a.m., Jorge died. He was forty years old. The cause of his death was Ventricular Arrythemia Secondary to Hyperpyrexia and typhoid fever. Issue: Whether or not petitioner is entitled to damage applying res ipsa loquitur? Held: There is a case when expert testimony may be dispensed with, and that is under the doctrine of res ipsa loquitur. 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 area, of treatment, removal of the wrong part of the body when another part was intended, knocking out a tooth while a patients jaw was under anesthetic for the removal of his tonsils, and loss of an eye while the patient was under the influence of anesthetic, during or following an operation for appendicitis, among others. Petitioners now contend that all requisites for the application of res ipsa loquitur were present, namely: (1) the accident was of a kind which does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency which caused the injury was under the exclusive control of the person in charge; and (3) the injury suffered must not have been due to any voluntary action or contribution of the person injured. The contention is without merit. We

agree with the ruling of the Court of Appeals. In the Ramos case, the question was whether a surgeon, an anesthesiologist, and a hospital should be made liable for the comatose condition of a patient scheduled for cholecystectomy. In that case, the patient was given anesthesia prior to her operation.

Noting that the patient was neurologically sound at the time of her operation, the Courtapplied the doctrine of res ipsa loquitur as mental brain damage does not normally occurin a gall blader operation in the absence of negligence of the anesthesiologist.

Taking judicial notice that anesthesia procedures had become so common that even an ordinary person could tell if it was administered properly, we allowed the testimony of a witness who was not an expert.

In this case, while it is true that the patient died just a few hours after professional medical assistance was rendered, there is really nothing unusual or extraordinary about his death. Prior to his admission, the patient already had recurring fevers and chills for five days unrelieved by the analgesic, antipyretic, and antibiotics given him by his wife. This shows that he had been suffering from a serious illness and professional medical help came too late for him. Respondents alleged failure to observe due care was not immediately apparent to a layman so as to justify application of res ipsa loquitur. The question required expert opinion on the alleged breach by respondents of the standard of care required by the circumstances. Furthermore, on the issue of the correctness of her diagnosis, no presumption of negligence can be applied to Dr. Marlyn Rico. 7. Ramos vs. CA; GR No. 124354 ; April 11, 2001 Facts: After seeking professional help, Erlinda Ramos was advised to undergo an operation for the removal of a stone in her gallbladder. She was referred to Dr. Hosaka who agreed to do the operation and was further recommended to an anaesthesiologist, Dr. Gutierrez. On the day of the scheduled operation at De Los Santos Medical Center, around 9:30 in the morning Dr. Hosaka had not yet arrived so Dr. Gutierres tried to get in touch with him by phone and informed Hermina Cruz, sister-in-law of Erlina who accompanied Erlinda to the operating room, that the operation might be delayed. Dr. Hosaka arrived around 12:20 in the afternoon, or more than three hours after the scheduled operation. Cruz, who was then still inside the operation room while still holding the hand of Erlinda saw Dr. Gutierrez trying to intubate the patient and heard Dr. Gutierrez utter and hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan. Cruz then noticed bluish discoloration of Erlindas nailbeds on her left hand. She then hear Osaka instructed someone to call another anestheologist in the name of Dr. Calderon. Dr. Calderon then attempted

to intubate the patient but still the nailbeds of the patient remained bluish thus she was placed in a trendelenburg position. At almost 3:00 in the afternoon, Cruz saw Erlinda being wheeled to the ICU and the doctors explained to Rogelio that Erlinda his wife had bronchospasm. Erlinda stayed in the ICU for a month. She was then released from the hospital after four months and since then she remained in a comatose condition and died on August 1999.

Petitioner then filed with the RTC a civil case for damages against private respondents. After due trial, RTC rendered judgment in favor of petitioners and found the respondent negiligent in the performance of their duties to Erlinda. On appeal, the CA reversed the RTCs decision and directed the petitioners to pay their unpaid medical bills. Issue: Whether Dr. Hosaka and Gutierrez were liable for negligence. Held: Dr. Hosaka's irresponsible conduct of arriving very late for the scheduled operation of petitioner Erlinda is violative, not only of his duty as a physician "to serve the interest of his patients with the greatest solicitude, giving them always his best talent and skill," but also of Article 19 of the Civil Code which requires a person, in the performance of his duties, to act with justice and give everyone his due. Dr. Gutierrez claim of lack of negligence on her part is belied by the records of the case. It has been sufficiently established that she failed to exercise the standards of care in the administration of anesthesia on a patient. Dr. Gutierrez omitted to perform a thorough preoperative evaluation on Erlinda. Further, there is no cogent reason for the Court to reverse its finding that it was the faulty intubation on Erlinda that caused her comatose condition. There is no question that Erlinda became comatose after Dr. Gutierrez performed a medical procedure on her. 8. Ruez Jr. vs. Dr. Jurado A.M. No. 2005-08-SC, December 9, 2005 (To follow by Gladys Chua) 9. ROGELIO P. NOGALES, for himself and on behalf of the minors, ROGER ANTHONY, ANGELICA,NANCY, and MICHAEL CHRISTOPHER, all surnamed NOGALES, petitioners, vs. CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR. ELY VILLAFLOR, DR. ROSA UY, DR. JOELENRIQUEZ, DR. PERPETUA LACSON, DR. NOE ESPINOLA, and NURSE J. DUMLAO, respondents. G.R. No. 142625 December 19, 2006 Facts: Corazon Nogales ("Corazon"), 37 years old pregnant with her fourth child, under the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada"). The Doctor noted an increase in her blood pressure and development of leg edema indicating preeclampsia. Corazon started to experience mild labor pains Dr. Estrada advised her immediate admission to the Capitol Medical Center ("CMC"). The staff nurse noted the written admission request of Dr. Estrada. Due to the "Consent on Admission and Agreement" and "Admission Agreement" signed by Corazons husband she was then brought to the labor room of the CMC. Corazon manifest moderate vaginal bleeding which rapidly became profusely, Dr. Espinola ordered immediate hysterectomy. Rogelio was made to sign. Consent to Operation."Due to the inclement weather, Dr. Espinola arrived an hour late. He examined the patient and ordered some resuscitative measures to be administered. Despite Dr. Espinola's efforts, Corazon died the cause of death was "hemorrhage, post partum."Petitioners filed a complaint for damages with the Regional Trial Court of Manila contending that defendant physicians and CMC personnel were negligent in the treatment and management of Corazon's condition also in the selection and supervision of defendant physicians and hospital staff. The defendant fail to file their answer to the complaint the trial court declared Dr. Estrada, Dr. Enriquez, and Nurse Dumlao in default. CMC, Dr. Villaflor, Dr. Uy, Dr. Espinola, and Dr. Lacson filed their respective answers denying and opposing the allegations in the complaint. The trial court rendered judgment finding Dr. Estrada solely liable for damages. Petitioners appealed the trial court's decision, The Court of Appeals affirmed the decision of the trial court. Petitioners filed a motion for reconsideration which was denied in its Resolution. Hence, petitioners filed a Manifestation that respondents "need no longer be notified of the petition because they are not involved in the issue raised before the [Court], regarding the liability of [CMC]." The Court of Appeals concluded that since Rogelio engaged Dr.Estrada as the attending physician of his wife, any liability for malpractice must be Dr. Estrada's sole responsibility. While it found the amount of damages fair and reasonable, the Court of Appeals held that no interest could be imposed on unliquidated claims or damages. Hence this petition. Issue: Whether or not CMC is vicariously liable for the negligence? Held: On the Liability of CMC CMC is vicariously liable for Dr. Estrada's negligence based on Article 2180 in relation to Article2176 of the Civil Code. 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. Employers shall be liable for the damages caused by their employees. The records show that Rogelio testified that he and his wife specifically chose Dr. Estrada to handle Corazon's delivery not only because of their friend's recommendation, but more importantly

because of Dr.Estrada's "connection with a reputable hospital, to provide the best medical care and support services for Corazon's delivery. On the Liability of the other Respondents There was no evidence showing that the other respondents are liable for negligent act. The records show that all are acting with good faith.

On the Award of interest on Damages The award of interest on damages is proper and allowed under Article 2211 of the Civil Code, which states that in crimes and quasi-delicts, interest as a part of the damages may, in a proper case, be adjudicated in the discretion of the court. The Court partly grants the petition finds respondent Capitol Medical Center vicariously liable for the negligence of Dr. Oscar Estrada. The actual damages and moral damages should each earn legal interest at the rate of six percent (6%) per annum computed from the date of the judgment of the trial court. 10. PROFESSIONAL SERVICES, INC. VS. NATIVIDAD and ENRIQUE AGANA G.R. no. 126297 January 31, 2007 NATIVIDAD and ENRIQUE AGANAVS JUAN FUENTES G.R. no. 127590 January 31, 2007 Facts: Natividad Agana was rushed to the Medical City Hospital Dr. Miguel Ampil diagnosed her to be suffering from cancer of the sigmoid . Dr. Ampil performed the surgery and found the malignancy in her sigmoid necessitating the removal. Dr. Juan Fuentes performs hysterectomy Dr. Ampil took over, completed the operation and closed the incision. The attending nurse entered the remarks that the sponge count lacking 2. Since nowhere to be found the surgeon avail to continue closure. After a couple of days, Natividad complained of excruciating pain she consulted both the doctors about it but they told that it was natural consequence of the surgery. Dr. Ampil. Natividad, went to the United States after four months of consultation and laboratory examinations, she was free of cancer. Natividad flew back to the Philippines, still suffering from pains, her daughter found gauze protruding from her Vagina. Then after the pain intensified, prompting Natividad to seek treatment. Dr. Ramon Gutierez detected the presence of another foreign object in her vagina a foul-smelling gauze which badly infected her vaginal vault. Natividad underwent another surgery to remedy the damage. Natividad and her husband filed with the RTC, Quezon City a complaint for damages against the Professional Services, Inc. (PSI), owner of the Medical City Hospital, Dr. Ampil, and Dr. Fuentes. Enrique Agana also filed with the Professional Regulation Commission (PRC) an administrative complaint for gross negligence and malpractice against Dr. Ampil and Dr. Fuentes. The PRC Board of Medicine heard the case but it failed to acquire jurisdiction over Dr. Ampil who was then in the United States. The case was pending; Natividad died and was duly substituted by her above-named children (the Aganas).

RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable for negligence and malpractice, ordering the defendants PROFESSIONAL SERVICES, INC., Dr Miguel Ampil and Dr. Juan Fuentes to pay to the plaintiffs, jointly and severally, except in respect of the award for exemplary damages and the interest thereon which are the liabilities of defendants Dr. Ampil and Dr. Fuentes. Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals, Aganas filed with the RTC a motion for a partial execution of its Decision. Aganas again filed a motion for an alias writ of execution against the properties of PSI and Dr. Fuentes. RTC granted the motion and issued the corresponding writ, prompting Dr. Fuentes to file with the Court of Appeals a petition for certiorari and prohibition, with prayer for preliminary injunction. During its pendency, the Court of Appeals issued a Resolution granting Dr. Fuentes prayer for injunctive relief. PRC Board of Medicine rendered its Decision in Administrative Case dismissing the case against Dr. Fuentes. The prosecution failed to show that Dr. Fuentes was the one who left the two pieces of gauze inside Natividads body. The Court of Appeals rendered its Decision Dr.Miguel Ampil is liable to reimburse defendant-appellant Professional Services, Inc., whatever amount the latter will pay or had paid to the plaintiffs-appellees. Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolution Aganas maintain that the Court of Appeals erred in finding that Dr. Fuentes is not guilty of negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. Dr. Ampilasserts that the Court of Appeals erred in finding him liable for negligence and malpractice. Issues: (1) Whether the Court of Appeals erred in holding Dr. Ampil liable for negligence and malpractice (2) Whether the Court of Appeals erred in absolving Dr. Fuentes of any liability (3) Whether PSI may be held solidarily liable for the negligence of Dr. Ampil. Held: (1) Dr. Ampil is liable for Negligence and Malpractice, an attempt to absolve himself, gears the Courts attention to other possible causes of Natividads detriment. His arguments are purely conjectural and without basis. He did not present any evidence to prove that the American doctors were the ones who put or left the gauzes in

(2) Natividads body. Neither submit evidence to rebut the correctness of the record of operation, particularly the (3) number of gauzes used. As to the alleged negligence of Dr. Fuentes, we are mindful that Dr. Ampil examined his (Dr.Fuentes) work and found it in order. (2) The court is not convinced, that the Court of Appeals Erred in Absolving Dr. Fuentes of any Liability. It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He requested the assistance of Dr. Fuentes only to perform hysterectomy when he(Dr. Ampil) found that the malignancy in her sigmoid area had spread to her left ovary. Dr. Fuentes performed the surgery and thereafter reported and showed his work to Dr. Ampil. The latter examined it and finding everything to be in order, allowed Dr. Fuentes to leave the operating room. Dr. Ampil then resumed operating on Natividad. He was about to finish the procedure when the attending nurses informed him that two pieces of gauze were missing. A"diligent search" was conducted, but the misplaced gauzes were not found. Dr. Ampil then directed that the incision be closed. During this entire period, Dr. Fuentes was no longer in the operating room and had, in fact, left the hospital. (3) The issue of whether PSI is solidarily liable with Dr. Ampil for damages, that PSI, failed to adduce evidence showing that it exercised the diligence of a good father of a family in the accreditation and supervision of the latter. Moreover PSI is also directly liable to the Aganas. When a doctor practices medicine in a hospital setting, the hospital and its employees are deemed to sub serve him in his ministrations to the patient and his actions are of his own responsibility. The nature of the relationship between the hospital and the physicians is an employer-employee relationship the hospitals exercise significant control in the hiring and firing of consultants and in the conduct of their work within the hospital premises. Doctors who apply for consultant slots, are required to submit proof of completion of residency, their educational qualifications, evidence of accreditation by the appropriate board (diplomate), evidence of fellowship in most cases, and references. These requirements in other words, private hospitals, hire, fire and exercise real control over their attending and visiting consultant staff.

The hiring, and the right to terminate consultants all fulfill the important hallmarks of an employer-employee relationship, with the exception of the payment of wages. PSI publicly displays in the lobby of the Medical City Hospital the names and specializations of the physicians associated or accredited by it, including those of Dr. Ampil and Dr. Fuentes. PSI failed to discharge its burden under the last paragraph of Article 2180 cited must be adjudged solidarily liable with Dr. Ampil.

11. DR. MILAGROS L. CANTRE, Petitioner, vs. SPS. JOHN DAVID Z. GO and NORA S. GO, Respondents. Facts: At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy. However, at around 3:30 a.m., Nora suffered profuse bleeding inside her womb due to some parts of the placenta which were not completely expelled from her womb after delivery. Consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood pressure to "40" over "0." Petitioner and the assisting resident physician performed various medical procedures to stop the bleeding and to restore Noras blood pressure. Her blood pressure was frequently monitored with the use of a sphygmomanometer. While petitioner was massaging Noras uterus for it to contract and stop bleeding, she ordered a droplight to warm Nora and her baby.

Nora remained unconscious until she recovered. While in the recovery room, her husband, respondent John David Z. Go noticed a fresh gaping wound two and a half (2 ) by three and a half (3 ) inches in the inner portion of her left arm, close to the armpit.He asked the nurses what caused the injury. He was informed it was a burn. Respondent spouses filed a complaint for damages against petitioner, Dr. Abad, and the hospital. Issue: Is petitioner liable for the injury suffered by respondent Nora Go?? Held:

The Court ruled In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere existence of an injury to justify a presumption of negligence on the part of the person who controls the instrument causing the injury, provided that the following requisites concur: 1. The accident is of a kind which ordinarily does not occur in the absence of someones 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.

As to the first requirement, the gaping wound on Noras arm is certainly not an ordinary occurrence in the act of delivering a baby, far removed as the arm is from the organs involved in the process of giving birth. Such injury could not have happened unless negligence had set in somewhere. Second, whether the injury was caused by the droplight or by the blood pressure cuff is of no moment. Both instruments are deemed within the exclusive control of the physician in charge under the "captain of the ship" doctrine. This doctrine holds the surgeon in charge of an operation liable for the negligence of his assistants during the time when those assistants are under the surgeons control.

Use of the droplight and the blood pressure cuff is also within petitioners exclusive control. Third, the gaping wound on Noras left arm, by its very nature and considering her condition, could only be caused by something external to her and outside her control as she was unconscious while in hypovolemic shock. Hence, Nora could not, by any stretch of the imagination, have contributed to her own injury. 12. ILAO-ORETA vs. RONQUILLOGR G.R. No. 172406 October 17, 2007 Facts: Despite several years of marriage, Spouses Ronquillo is still childless. They consulted Dr. Concepcion Ilao-Oreta, an obstetrician gynecologist-consultant at St. Lukes and Chief of the Reproductive Endocrinology and Infertility Section. Eva Marie agreed to undergo alaparoscopic procedure where a laparoscope would be inserted through her abdominal wall to get a direct view of her internal reproductive organ in order to determine the real cause of her infertility. The procedure was scheduled on April 5, 1999 at 2 pm. Dr. Ilao-Oreta did not arrive at the schedules time and no prior notice of its cancellation was received by the Ronquillos. Dr. Ilao-Oreta was on her honeymoon in Hawaii. She estimated that she would arrive in Manila in the early morning of April5. However, she failed to consider the time difference between Hawaii and Philippines. Ronquillos filed a complaint against Dr. Ilao-Oreta and St. Lukes for breach of professional and service contract and for damages. RTC: awarded Eva Marie only actual damages upon finding that the doctors failure to arrive on time was not intentional CA: found Dr. Ilao-Oreta grossly negligent Issue: WON Dr. Ilao-Oreta was grossly negligent in not arriving on time for the scheduled laparoscopy Held: Records show that Dr- Ilao-Oreta left an admitting order with her secretary for one of the spouses to pick up, apprised Eva Marie of the necessary preparations for the procedure and instructed the hospital staff to perform pre-operative treatments before leaving for Hawaii. These acts reflect an earnest intention to perform the procedure on the day and time scheduled. On realizing that she missed the scheduled procedure, Dr. Ilao Oreta, upon arrival in Manila, immediately called the hospital and asked the nurses about Eva Marie. She also wanted to call the Ronquillos but she didnt have their number at that time. So the next morning, she went to

her office to get the Ronquillos contact number, which is written on Eva Maries chart, and called them right away. Noel admitted that indeed Dr. Ilao-Oreta called him up after she arrived in Manila. Although Dr. Ilao-Oretas act is not grossly negligent, she was negligent when she scheduled to perform professional service at 2 pm without considering the time difference between Philippines and Hawaii. Having travelled to the US, where she obtained a fellowship in Reproductive Endocrinology and Infertility, more than twice, she should have been mindful of said difference. The procedure to be conducted on Eva Marie was only elective in nature thus the situation did not present any clear and apparent harm or injury that even a careless person may perceive. According to the SC, it bears noting that when Dr. Ilao-Oreta was scheduling the date of her performance of the procedure, she had just gotten married and was preparing for her honeymoon. It is common knowledge that excitement attends its preparations. Her negligence could then be partly attributed to human frailty which rules out its characterization as gross.

13. SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA FLORES, petitioners, vs. 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.

Facts: 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. 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. They went to United Doctors Medical Center (UDMC) in Quezon City. Teresita was taken to the operating room. It was only then that she met Dr. Felicisima, an obstetrician and gynecologist. Upon Teresita's complete laboratory examination results came only on that day . Teresita's urinalysis showed a three plus sign (+++) indicating that the sugar in her urine was very high. She was then placed under the care of Dr. Amado Jorge, an internist. 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. Insulin was administered on the patient, but the medication might have arrived too late. Due to complications induced by diabetes, Teresita died. 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.

Issue: Whether the said doctors can be held liable for negligence?

Held: A medical negligence case is a type of claim to redress a wrong committed by a medical professional, that has caused bodily harm to or the death of a patient. There are four elements involved in a medical negligence case, namely: duty, breach, injury, and proximate causation. We clarify that Dr. Fredelicto's negligence is not solely the act of ordering an "on call" D&C operation when he was mainly ananaesthesiologist who had made a very cursory examination of the patient's vaginal bleeding complaint. Rather, it was his failure from the very start to identify and confirm, despite the patient's complaints and his own suspicions, that diabetes was a risk factor that should be guarded against, and his participation in the imprudent decision to proceed with the D&C operation despite his early suspicion and the confirmatory early laboratory results.

If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not being an internist or a diabetologist (for which reason he referred Teresita to Dr. Jorge), he should have likewise refrained from making a decision to proceed with the D&C operation since he was niether an obstetrician nor a gynecologist.

These findings lead us to the conclusion that 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 14. FE CAYAO-LASAM, PETITIONER, VS. SPOUSES CLARO AND EDITHA RAMOLETE, RESPONDENTS. Facts: On July 28, 1994, respondent, three months pregnant Editha Ramolete (Editha) was brought to the Lorma Medical Center (LMC) in San Fernando, La Union due to vaginal bleeding. Upon advice of petitioner relayed via telephone, Editha was admitted to the LMC on the same day. A pelvic sonogram was then conducted on Editha revealing the fetus' weak cardiac pulsation. The following day, Editha's repeat pelvic sonogram

showed that aside from the fetus' weak cardiac pulsation, no fetal movement was also appreciated. Due to persistent and profuse vaginal bleeding, petitioner advised Editha to undergo a Dilatation and Curettage Procedure (D&C) or "raspa." Petitioner performed the D&C procedure. Editha was discharged from the hospital the following day. Editha was once again brought at the LMC, as she was suffering from vomiting and severe abdominal pains. Editha was attended by Dr. Beatriz de la Cruz, Dr. Victor B. Mayo and Dr. Juan V. Komiya. Dr. Mayo allegedly informed Editha that there was a dead fetus in the latter's womb. After, Editha underwent laparotomy, she was found to have a massive intra-abdominal hemorrhage and a ruptured uterus. Thus, Editha had to undergo a procedure for hysterectomy and as a result, she has no more chance to bear a child. Editha and her husband Claro Ramolete (respondents) filed a Complaint for Gross Negligence and Malpractice against petitioner before the Professional Regulations Commission (PRC). Petitioner contended that it was Editha's gross negligence and/or omission in insisting to be discharged on such day against doctor's advice and her unjustified failure to return for check-up as directed by petitioner that contributed to her life-threatening condition on September 16, 1994; that Editha's hysterectomy was brought about by her very abnormal pregnancy known as placenta increta, which was an extremely rare and very unusual case of abdominal placental implantation. On March 4, 1999, the Board of Medicine (the Board) of the PRC rendered a Decision, exonerating petitioner from the charges filed against her. On appeal, the PRC rendered a Decision reversing the findings of the Board and revoking petitioner's authority or license to practice her profession as a physician. Hence, this petition. Issue: Whether the petitioner is liable for malpractice? Held: When complainant was discharged on July 31, 1994, herein respondent advised her to return on August 4, 1994 or four (4) days after the D&C. This advise was clear in complainant's Discharge Sheet. However, complainant failed to do so. This being the case, the chain of continuity as required in order that the doctrine of proximate cause can be validly invoked was interrupted. Had she returned, the respondent could have examined her thoroughly. No negligence can be attributed to the petitioner, the immediate cause of the accident resulting in Editha's injury was her own omission when she did not return for a follow-up check up, in defiance of petitioner's orders. The immediate cause of Editha's injury was her own act; thus, she cannot recover damages from the injury.

The Decision of the Board of Medicine dated March 4, 1999 exonerating petitioner is AFFIRMED. 15. PETER PAUL PATRICK LUCAS, FATIMA GLADYS LUCAS, ABBEYGAIL LUCAS AND GILLIAN LUCAS, Petitioners, vs. DR. PROSPERO MA. C. TUAO, Facts: Petitioner Peter Paul Patrick Lucas (Peter) contracted "sore eyes" in his right eye. Upon consultation with Dr. Tuao, 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. Dr. Tuao diagnosed that Peter was suffering from conjunctivitisor "sore eyes." Dr. Tuao then prescribed Spersacet-C eye drops for Peter and told the latter to return for follow-up after one week. As instructed, Peter went back to Dr. Tua. Upon examination, Dr. Tuao told Peter that the "sore eyes" in the latters right eye had already cleared up and he could discontinue the Spersacet-C. However, the same eye developed Epidemic Kerato Conjunctivitis (EKC),a viral infection. To address the new problem with Peters right eye, Dr. Tuao prescribed to the former a steroid-based eye drop called Maxitrol, a dosage of six (6) drops per day.

To recall, Peter had already been using Maxitrol prior to his consult with Dr. Tuao. Peter saw Dr. Tuao for a follow-up consultation. After examining both of Peters eyes, Dr. Tuao instructed the former to taper down the dosage of Maxitrol, because the EKC in his right eye had already resolved. Dr. Tuao specifically cautioned Peter that, being a steroid, Maxitrol had to be withdrawn gradually; otherwise, the EKC might recur.

Complaining of feeling as if there was something in his eyes, Peter returned to Dr. Tuao for another check-up on . Dr. Tuao examined Peters eyes and found that the right eye had once more developed EKC. So, Dr. Tuao instructed Peter to resume the use of Maxitrol at six (6) drops per day. Several days later, Peter went to see Dr. Tuao at his clinic, alleging severe eye pain, feeling as if his eyes were about to "pop-out," a headache and blurred vision. Dr. Tuao examined Peters eyes and discovered that the EKC was again present in his right eye. As a result, Dr. Tuao told Peter to resume the maximum dosage of Blephamide.

Dr. Tuao saw Peter once more at the formers clinic. Dr. Tuaos examination showed that only the periphery of Peters right eye was positive for EKC; hence, Dr. Tuao prescribed a lower dosage of Blephamide.

Upon waking in the morning of 13 December 1988, Peter had no vision in his right eye. Fatima observed that Peters right eye appeared to be bloody and swollen.Thus, spouses Peter and Fatima rushed to the clinic of Dr. Tuao. Peter reported to Dr. Tuao that he had been suffering from constant headache in the afternoon and blurring of vision.

A civil complaint for damages against Dr. Tuao on the ground of Dr. Tuaos grossly negligent conduct in prescribing to Peter the medicine Maxitrol for a period of three (3) months,

without monitoring Peters IOP, as required in cases of prolonged use of said medicine, and notwithstanding Peters constant complaint of intense eye pain while using the same.

Issue: Whether Dr. Tuano was negligent?

Held: Absent a definitive standard of care or diligence required of Dr. Tuao 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.

Herein, the burden of proof was clearly upon petitioners, as plaintiffs in the lower court, to establish their case by a preponderance of evidence showing a reasonable connection between Dr. Tuaos alleged breach of duty and the damage sustained by Peters right eye. This, they did not do. In reality, petitioners complaint for damages is merely anchored on a statement in the literature of Maxitrol identifying the risks of its use, and the purported comment of Dr. Agulto another doctor not presented as witness before the RTC concerning the prolonged use of Maxitrol for the treatment of EKC.

It seems basic that what constitutes proper medical treatment is a medical question that should have been presented to experts. If no standard is established through expert medical witnesses, then courts have no standard by which to gauge the basic issue of breach thereof by the physician or surgeon. The RTC and Court of Appeals, and even this Court, could not be expected to determine on its own what medical technique should have been utilized for a certain disease or injury. Absent expert medical opinion, the courts would be dangerously engaging in speculations. 16. PSI vs AGANA Facts: Natividad Agana was rushed to the Medical City Hospital Dr. Miguel Ampil diagnosed her to be suffering from cancer of the sigmoid. Dr. Ampil performed the surgery and found the malignancy in her sigmoid necessitating the removal. Dr. Juan Fuentes performs hysterectomyDr. Ampil took over, completed the operation and closed the incision. The attending nurse entered the remarks that the sponge count lacking Since nowhere to be found the surge on avail to continue closure. After a couple of days, Natividad complained of excruciating pain she consulted both the doctors about it but they told that it was natural consequence of the surgery. Dr. Ampil Natividad, went to the United States after four months of consultation and laboratory examinations, she was free of cancer. Natividad flew back to the Philippines, still suffering from pains, her daughter found gauze protruding from

her Vagina. Then after the pain intensified, prompting Natividad to seek treatment. Dr. Ramon Gutierez detected the presence of another foreign object in her vagina a foul-smelling gauze which badly infected her vaginal vault.

Natividad underwent another surgery to remedy the damage. Natividad and her husband filed with the RTC, Quezon City a complaint for damages against the Professional Services, Inc. (PSI), owner of the Medical City Hospital, Dr. Ampil, andDr. Fuentes. Enrique Agana also filed with the Professional Regulation Commission (PRC) an administrative complaint for gross negligence and malpractice against Dr. Ampil and Dr.Fuentes. The PRC Board of Medicine heard the case but it failed to acquire jurisdiction over Dr.Ampil who was then in the United States. The case was pending; Natividad died and was duly substituted by her above-named children (the Aganas). RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable for negligence and malpractice,ordering the defendants PROFESSIONAL SERVICES, INC., Dr Miguel Ampil and Dr. JuanFuentes to pay to the plaintiffs, jointly and severally, except in respect of the award for exemplary damages and the interest thereon which are the liabilities of defendants Dr. Ampiland Dr. Fuentes.Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals,Aganas filed with the RTC a motion for a partial execution of its Decision. Aganas again filed a motion for an alias writ of execution against the properties of PSI and Dr. Fuentes. RTC granted the motion and issued the corresponding writ, prompting Dr. Fuentes to file with the Court of Appeals a petition for certiorari and prohibition, with prayer for preliminary injunction. During its pendency, the Court of Appeals issued a Resolution granting Dr. Fuentes prayer for injunctive relief. PRC Board of Medicine rendered its Decision in Administrative Case dismissing thecase against Dr. Fuentes. The prosecution failed to show that Dr. Fuentes was the one who leftthe two pieces of gauze inside Natividads body. The Court of Appeals rendered its Decision Dr.Miguel Ampil is liable to reimburse defendant-appellant Professional Services, Inc., whatever amount the latter will pay or had paid to the plaintiffs-appellees. Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolution Aganas maintain that the Court of Appeals erred in finding that Dr. Fuentes is not guiltyof negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. Dr. Ampilasserts that the Court of Appeals erred in finding him liable for negligence and malpractice. Issues: (1) Whether the Court of Appeals erred in holding Dr. Ampil liable for negligence and malpractice (2) Whether the Court of Appeals erred in absolving Dr. Fuentes of any liability Held:

Dr. Ampil is liable for Negligence and Malpractice, an attempt to absolve himself, gears the Courts attention to other possible causes of Natividads detriment. His arguments are purely conjectural and without basis. He did not present any evidence to prove that the American doctors were the ones who put or left the gauzes in Natividads body. Neither submit evidenceto rebut the correctness of the record of operation, particularly the number of gauzes used. Asto the alleged negligence of Dr. Fuentes, we are mindful that Dr. Ampil examined his (Dr.Fuentes) work and found it in order. The court is not convinced, that the Court of Appeals Erred in Absolving Dr. Fuentes of anyLiability. It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He requested the assistance of Dr. Fuentes only to perform hysterectomy when he(Dr. Ampil) found that the malignancy in her sigmoid area had spread to her left ovary. Dr.Fuentes performed the surgery and thereafter reported and showed his work to Dr. Ampil. Thelatter examined it and finding everything to be in order, allowed Dr. Fuentes to leave theoperating room. Dr. Ampil then resumed operating on Natividad. He was about to finish theprocedure when the attending nurses informed him that two pieces of gauze were missing.

A"diligent search" was conducted, but the misplaced gauzes were not found. Dr. Ampil then directed that the incision be closed. During this entire period, Dr. Fuentes was no longer in the operating room and had, in fact, left the hospital.

17. Dr Li vs Sps Soliman Facts: This case involved the death of Angelica Soliman, respondents 11-year old daughter. Previously, Angelica was diagnosed withosteosarcoma, osteoblastic type, a highly malignant cancer of the [thigh] bone. To remove the tumor, her right leg was amputated. And to eliminate any remaining cancer cells and minimize the chances of recurrence and prevent the disease from spreading to other parts of her body (metastasis), she subsequently underwent chemotherapy. The chemotherapy was administered by petitioner Dr. Rubi Li, an oncologist at St. Lukes Medical Center (SLMC) upon consent by her parents, herein respondents. Angelica died just eleven days after the administration of the first cycle of the chemotherapy regimen. The parents of the child thereafter sued the doctor for damages before the RTC, charging the latter (along with other doctors and the SLMC itself) with negligence in causing Angelicas untimely demise. It was specifically averred in the complaint that the doctor assured the parents that Angelica would recover in view of 95% chance of healing with chemotherapy (Magiging normal na ang anak nyo basta ma-chemo. 95% ang healing), and when asked regarding the side effects, petitioner mentioned only slight vomiting, hair loss and weakness (Magsusuka ng kaunti. Malulugas ang buhok. Manghihina). The parents thus claimed that they would not have given their consent to chemotherapy had the doctor not falsely assured them of its side effects. The trial court however dismissed the case. It found that the doctor was not liable for damages as she observed the best known procedures and employed her highest skill and knowledge in the administration of chemotherapy drugs on Angelica [though] despite all efforts said patient died. The parents appealed to the Court of Appeals (CA). While concurring with the trial courts finding that there was no negligence committed by the petitioner in the administration of chemotherapy treatment to Angelica, the CA found that the doctor failed to fully explain to the parents of the patient all the known side effects of chemotherapy. The CA thus adjudged the doctor liable for damages. The doctor then appealed to the Supreme Court (SC), raising the following issue: Under the facts, can she be held liable [of failing] to fully disclose serious side effects of chemotherapy to the parents of her patient despite the absence of finding that she was negligent in administering the said treatment.

Issue: Whether or not there is malpractice Held: As indicated above, Justice Villarama ruled that there are four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed consent: (1) the physician had a duty to disclose material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to treatment she otherwise would not have consented to; and (4) plaintiff was injured by the proposed treatment. The gravamen in an informed consent case requires the plaintiff to point to significant undisclosed information relating to the treatment which would have altered her decision to undergo it. There was adequate disclosure of material risk inherent in the chemotherapy procedure performed with the consent of Angelicas parents. [The parents] could not have been unaware in the course of initial treatment and amputation of Angelicas lower extremity, that her immune system was already weak on account of the malignant tumor in her knee. When [the doctor] informed the [parents] beforehand of the side effects of chemotherapy[,] which includes lowered counts of white and red blood cells, decrease in blood platelets, possible kidney or heart damage and skin darkening, there is reasonable expectation on the part of the doctor that the parents understood very well that the severity of these side effects will not be the same for all patients undergoing the procedure.

As a physician, petitioner can reasonably expect the parents to have considered the variables in the recommended treatment for their daughter afflicted with a life-threatening illness. On the other hand, it is difficult to give credence to respondents claim that petitioner told them of 95% chance of recovery for their daughter, as it was unlikely for doctors like petitioner who were dealing with grave conditions such as cancer to have falsely assured patients of chemotherapys success rate. Besides, informed consent laws in other countries generally require only a reasonable explanation of potential harms, so specific disclosures such as statistical data, may not be legally necessary. The element of ethical duty to disclose material risks in the proposed medical treatment cannot thus be reduced to one simplistic formula applicable in all instances. Further, in a medical malpractice action based on lack of informed consent, the plaintiff must prove both the duty and the breach of that duty through expert testimony. Such expert testimony must show the customary standard of care of physicians in the same practice as that of the defendant doctor. In this case, the testimony of Dr. Balmaceda [witness for the girls parents] who is not an oncologist but a Medical Specialist of the DOHs Operational and Management Services charged with receiving complaints against hospitals, does not qualify as expert testimony to establish the standard of care in obtaining consent for chemotherapy treatment. In the absence of expert testimony in this regard, the Court felt hesitant defining the scope of mandatory disclosure in cases of malpractice based on lack of informed consent, much less set a standard of disclosure that, even in foreign jurisdictions, has been noted to be an evolving one. 18. Dr Jarcia vs Bastan Facts: Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of Investigation (NBI) against the petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou Bastan (Dr. Bastan), for their alleged neglect