Dr. Rubi Li, Petitioner, vs.

Spouses Reynaldo and Lina Soliman, as parents/heirs of

deceased Angelica Soliman, Respondents.
G.R. No. 165279
June 7, 2011
Legal Issue: How is medical malpractice proven?
Legal Facts:
Respondents 11-year old daughter, Angelica Soliman, underwent a biopsy
of the mass located in her lower extremity at the St. Lukes Medical Center (SLMC) on
July 7, 1993 and results showed that Angelica was suffering from osteosarcoma,
osteoblastic type, (highly malignant) cancer of the bone because of that a necessity of
amputation was conducted by Dr, Tamayo on Angelicas right leg in order to remove
the tumor and to prevent the metastasis that chemotherapy was suggested by Dr.
Tamayo, which he referred to petitioner Dr. Rubi Li, a medical oncologist. The
respondent was admitted to SLMC on August 18, 1993; however, she died eleven (11)
days after the (intravenous) administration of chemotherapy first cycle. Respondents
brought their daughters body to the Philippine National Police (PNP) Crime Laboratory
at Camp Crame for post-mortem examination after the refusal of the hospital to
release the death certificate without full payment of bills. The Medico-Legal Report
showed that the cause of death as "Hypovolemic shock secondary to multiple organ
hemorrhages and Disseminated Intravascular Coagulation. The respondents filed
charges against the SLMC and physicians involve for negligence and failure to
observe the essential precautions in to prevent Angelicas untimely death. Petitioner
denied the allegation for damages as she observed best known procedures, highest
skill and knowledge in the administration of chemotherapy drugs despite all efforts the
patient died. The trial court was in favor of the petitioner and ordered to pay their
unpaid hospital bill in the amount of P139, 064.43, but the Court of Appeals reversed
the decision supporting the respondents pray.
Holding:
In this case medical malpractice is proven because the four essential elements
of such action are present based upon the doctrine of informed consent.
Reasoning:
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." Informed consent case requires the plaintiff to "point to
significant undisclosed information relating to the treatment that would alter her
decision to undergo. The physician is not expected to give the patient a short medical
education, the disclosure rule only requires of him a reasonable general explanation in
nontechnical terms.
Policy Formation:
In all sorts of medical procedures either invasive or not, medical institution
must have a certificate of competency in rendering standards of care to delicate
medical procedures before initiating a general protocol that would establish a guideline
principle in a form of proper disclosure of such procedure and presenting a consent or
waiver to their patients so that possible future medico-legal suits will be prevented.
Synthesis:
In Dr. Rubi Li, vs. Spouses Reynaldo and Lina Soliman, as parents/heirs
of deceased Angelica Soliman, Respondents, G.R. No. 165279, promulgated on June
7, 2011, the Court ruled that medical malpractice is proved base on lack/impaired
informed consent, and reasonable expert testimony subject a breach of duty causing
gross injury to its patient.
Professional Services Inc. v. Agana
Professional Services Inc. (PSI) v. Natividad and Enrique Agana
Natividad and Enrique Agana v. Juan Fuentes
Miguel Ampil v. Natividad and Enrique Agana
2007 / Sandoval-Gutierrez / Petition for review on certiorari of CA decisions
Standard of conduct > Experts > Medical professionals

FACTS
Natividad Agana was rushed to Medical City because of difficulty of bowel
movement and bloody anal discharge. Dr. Ampil diagnosed her to be suffering
from cancer of the sigmoid. Dr. Ampil performed an anterior resection surgery on
her, and finding that the malignancy spread on her left ovary, he obtained the consent
of her husband, Enrique, to permit Dr. Fuentes to perform hysterectomy on her. After
the hysterectomy, Dr. Fuentes showed his work to Dr. Ampil, who examined it and

found it in order, so he allowed Dr. Fuentes to leave the operating room. Dr. Ampil was
about to complete the procedure when the attending nurses made some remarks on
the Record of Operation: sponge count lacking 2; announced to surgeon search
done but to no avail continue for closure (two pieces of gauze were missing). A
diligent search was conducted but they could not be found. Dr. Ampil then directed
that the incision be closed.
A couple of days after, she complained of pain in her anal region, but the
doctors told her that it was just a natural consequence of the surgery. Dr. Ampil
recommended that she consult an oncologist to examine the cancerous nodes which
were not removed during the operation. After months of consultations and
examinations in the US, she was told that she was free of cancer. Weeks after coming
back, her daughter found a piece of gauze (1.5 in) protruding from her vagina, so Dr.
Ampil manually extracted this, assuring Natividad that the pains will go away. However,
the pain worsened, so she sought treatment at a hospital, where another 1.5 in piece
of gauze was found in her vagina. She underwent another surgery.
Sps. Agana filed a complaint for damages against PSI (owner of Medical City),
Dr. Ampil, and Dr. Fuentes, alleging that the latter are liable for negligence for leaving
2 pieces of gauze in Natividads body, and malpractice for concealing their acts of
negligence. Enrique Agana also filed an administrative complaint for gross
negligence and malpractice against the two doctors with the PRC (although only the
case against Dr. Fuentes was heard since Dr. Ampil was abroad). Pending the
outcome of the cases, Natividad died (now substituted by her children). RTC found
PSI and the two doctors liable for negligence and malpractice. PRC dismissed
the case against Dr. Fuentes. CA dismissed only the case against Fuentes.

ISSUE AND HOLDING

1.
WON CA erred in holding Dr. Ampil liable for negligence and
malpractice. NO; DR. AMPIL IS GUILTY
2.
WON CA erred in absolving Dr. Fuentes of any liability. NO
3.
WON PSI may be held solidarily liable for Dr. Ampils negligence. YES
RATIO
DR. AMPIL IS LIABLE FOR NEGLIGENCE AND MALPRACTICE
His arguments are without basis [did not prove that the American doctors were the
ones who put / left the gauzes; did not submit evidence to rebut the correctness of the
operation record (re: number of gauzes used); re: Dr. Fuentes alleged negligence, Dr.
Ampil examined his work and found it in order].
Leaving foreign substances in the wound after incision has been closed is
at least prima facie negligence by the operating surgeon. Even if it has been
shown that a surgeon was required to leave a sponge in his patients abdomen
because of the dangers attendant upon delay, still, it is his legal duty to inform his
patient within a reasonable time by advising her of what he had been compelled to do,
so she can seek relief from the effects of the foreign object left in her body as her
condition might permit. Whats worse in this case is that he misled her by saying that
the pain was an ordinary consequence of her operation.

Medical negligence; standard of diligence

To successfully pursue this case of medical negligence, a patient must only prove that
a health care provider either failed to do something [or did something] which a
reasonably prudent health care provider would have done [or wouldnt have done], and
that the failure or action caused injury to the patient.

Duty to remove all foreign objects from the body before closure of the
incision; if he fails to do so, it was his duty to inform the patient about it

Breach failed to remove foreign objects; failed to inform patient

Injury suffered pain that necessitated examination and another surgery

Proximate Causation breach caused this injury; could be traced from his
act of closing the incision despite information given by the attendant nurses that 2
pieces of gauze were still missing; what established causal link: gauze pieces later
extracted from patients vagina
DR. FUENTES NOT LIABLE
The res ipsa loquitur [thing speaks for itself] argument of the Aganas does not
convince the court. Mere invocation and application of this doctrine does not dispense
with the requirement of proof of negligence.

Requisites for the applicability of res ipsa loquitur

1.
Occurrence of injury
2.
Thing which caused injury was under the control and management of
the defendant [DR. FUENTES] LACKING SINCE CTRL+MGT WAS WITH
DR. AMPIL
3.
Occurrence was such that in the ordinary course of things, would not have
happened if those who had control or management used proper care
4.
Absence of explanation by defendant

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. That Dr.
Ampil discharged such role is evident from the following:

He called Dr. Fuentes to perform a hysterectomy

He examined Dr. Fuentes work and found it in order

He granted Dr. Fuentes permission to leave

He ordered the closure of the incision

HOSPITAL OWNER PSI SOLIDARILY LIABLE WITH DR. AMPIL [NCC 2180], AND
DIRECTLY LIABLE TO SPS. AGANAS [NCC 2176]
Previously, employers cannot be held liable for the fault or negligence of its
professionals. However, this doctrine has weakened since courts came to realize that
modern hospitals are taking a more active role in supplying and regulating medical
care to its patients, by employing staff of physicians, among others. Hence, there is no
reason to exempt hospitals from the universal rule of respondeat superior. Here are
the Courts bases for sustaining PSIs liability:

Ramos v. CA doctrine on E-E relationship

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, ObGyne 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.

For purposes of apportioning responsibility in medical

negligence cases, an employer-employee relationship in effect exists between
hospitals and their attending and visiting physicians. [LABOR LESSON: power
to hire, fire, power of control]
Agency principle of apparent authority / agency by estoppel

Imposes liability because of the actions of a principal or

employer in somehow misleading the public into believing that the relationship
or the authority exists [see NCC 1869]
PSI publicly displays in the Medical City lobby the names and
specializations of their physicians. Hence, PSI is now estopped from passing
all the blame to the physicians whose names it proudly paraded in the public
directory, leading the public to believe that it vouched for their skill and
competence.

o
o

o
If doctors do well, hospital profits financially, so
when negligence mars the quality of its services, the hospital should not
be allowed to escape liability for its agents acts.
Doctrine of corporate negligence / corporate responsibility

This is the judicial answer to the problem of allocating

hospitals liability for the negligent acts of health practitioners, absent facts to
support the application of respondeat superior.
This provides for the duties expected [from hospitals]. In this
case, PSI failed to perform the duty of exercising reasonable care to protect
from harm all patients admitted into its facility for medical treatment. PSI failed
to conduct an investigation of the matter reported in the note of the
count nurse, and this established PSIs part in the dark conspiracy of
silence and concealment about the gauzes.

PSI has actual / constructive knowledge of the

matter, through the report of the attending nurses + the fact that the
operation was carried on with the assistance of various hospital staff
It also breached its duties to oversee or supervise all persons
who practice medicine within its walls and take an active step in fixing the
negligence committed
PSI also liable under NCC 2180

It failed to adduce evidence to show that it exercised

the diligence of a good father of the family in the accreditation and supervision
of Dr. Ampil
Dr. Ninevetch Cruz v. CA and Lydia Umali
1997 / Francisco / Petition for review on certiorari of a CA decision
Standard of conduct > Experts > Medical professionals
o

FACTS
Medical 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.

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

conducted
ISSUE AND HOLDING
WON 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).

Manifestation of negligence
untidiness of clinic

1.
2.
3.
4.
5.

RATIO
Elements of reckless imprudence
Offender does / fails to do an act
Doing / failure to do act is voluntary
Without malice
Material damage results from reckless imprudence
There is inexcusable lack of precaution, taking into consideration offender's
employment, degree of intelligence, physical condition, other circumstances re:
persons, time, place
Standard of care
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
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 testimony
Expert 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 plaintiff
Plaintiff 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.
Dr. Solidum vs. People Digest
G.R. No. 192123 : March 10, 2014
DR. FERNANDO P. SOLIDUM, Petitioner, v. PEOPLE OF THE PHILIPPINES,
Respondent.
BERSAMIN, J.:

other person suffers injury.

The following are the elements of medical negligence: (1) the duty owed by the
physician to the patient, as created by the physician-patient relationship, to act in
accordance with the specific norms or standards established by his profession; (2) the
breach of the duty by the physician failing to act in accordance with the applicable
standard of care; (3) the causation, i.e., there must be a reasonably close and causal
connection between the negligent act or omission and the resulting injury; and (4) the
damages suffered by the patient.
Most medical malpractice cases are highly technical, therefore, witnesses with special
medical qualifications must impart the knowledge necessary to render a fair and just
verdict. In the case at bar, there were no witnesses with special medical qualifications
in anesthesia presented. Hence, it is difficult to assess whether the first three elements
of medical negligence were present.
CRIMINAL LAW: subsidiary liability pursuant to Article 103 of the Revised Penal Code
Ospital ng Maynila could not be held civilly liable because it was not a party to the
case. To hold it so would be to deny it due process of law. Furthermore, before it can
be held subsidiary liable, the conditions therefor must first be established:(1) it must be
a corporation engaged in any kind of industry; (2) defendant must be shown to be an
employee of the corporation engaged in industry for profit; and (3) defendant must be
insolvent.
Applying the conditions in the case at bar, Ospital ng Maynila cannot be held
subsidiary liable because: (1) Ospital ng Maynila, being a public hospital, was not
engaged in industry conducted for profit but purely in charitable and humanitarian
work; (2) Dr. Solidumwas not an employee of Ospital ng Maynila but a consultant; and
(3) Dr. Solidum was not insolvent.

FACTS:
GRANTED.
On June 2, 1992, Gerald Albert Gercayo (Gerald) was born with an imperforate anus.
Hence, two days after his birth, he underwentcolostomy which enabled him to excrete
through a colostomy bag attached to the side of his body.

Nogales vs. Capitol Medical Center

Carpio, J.:G.R. No. 142625, Dec . 19, 2006 | 511 S CRA 204

Three years later or on May 17, 1995, he was admitted at the Ospital ng Maynila for a
pull-through operation. The surgical team consisted of Dr. Resurreccion, Dr. Luceo, Dr.
Valea, and Dr. Tibio. The anesthesiologists included Dr. Abella, Dr. Razon and herein
Petitioner Dr. Solidum. It was during the said operation that Gerald experienced
bradycardia or an abnormally slow heart rate of less than 60 beats per minute. He
subsequently went into a coma which lasted for two weeks. When he regained
consciousness after a month, he could no longer see, hear, or move. Ma. Luz Gercayo
(Luz) lodged a complaint for reckless imprudence resulting in serious physical injuries
against the attending physicians.

FACTS:
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 years
old, was under the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada")
beginning on her fourth month of pregnancy or as early as December 1975. While
Corazon was on her last trimester of pregnancy, Dr. Estrada noted an increase in her
blood pressure and development of leg edema5 indicating preeclampsia, which is a
dangerous complication of pregnancy.

The RTC found Dr. Solidum guilty beyond reasonable doubt of reckless imprudence
resulting to serious physical injuries. The CA affirmed the conviction of Dr. Solidum.

Around midnight of 25 May 1976, Corazon started to experience mild labor painsprom
pting Corazon and Rogelio Nogales ("Spouses Nogales") to see Dr. Estrada at his
home. After examining Corazon, Dr. Estrada advised her immediate admission to the
Capitol Medical Center ("CMC").

ISSUES: Whether or not the doctrine of res ipsa loquitur applies in this case? Whether
the CA correctly affirmed the conviction of Dr. Solidum for criminal negligence?
HELD: The Court of Appeals decision is overruled.
TORTS: applicability of the Doctrine of Res Ipsa Loquitur
The Court held that the application the doctrine of res ipsa loquitur in the case at bar is
inappropriate. Res ipsa loquitur is literally translated as he thing or the transaction
speaks for itself.Jarcia, Jr. v. People, G.R. No. 187926 laid down that, here 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.Hence, the
requisites for the doctrine to apply are as follows: (1) the accident was of the kind that
does not ordinarily occur unless someone is negligent; (2) the instrumentality or
agency that caused the injury was under the exclusive control of the person charged;
and (3) the injury suffered must not have been due to any voluntary action or
contribution of the person injured.
Elements 2 and 3 were present in the case at bar. However, the first element was
undeniably wanting.
TORTS: elements of medical negligence
The Prosecution failed to prove the existence of the elements of reckless imprudence
beyond reasonable doubt. Gaid v. People, G.R. No. 171636 defined negligence as the
failure to observe for the protection of the interests of another person that degree of
care, precaution, and vigilance that the circumstances justly demand, whereby such

On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the staff nurse
noted the written admission request8 of Dr. Estrada. Upon Corazon's admission at the
CMC, Rogelio Nogales ("Rogelio") executed and signed the "Consent on Admission
Agreement and Admission Agreement. Corazon was then bought to the labor room
of the CMC.
Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an
internal examination of Corazon. Dr. Uy then called up Dr. Estrada to notify him of her
findings.
Based on the Doctor's Order Sheet, around 3:00 a.m., Dr. Estrada ordered for 10
mg.of valium to be administered immediately by intramuscular injection. Dr. Estrada
later ordered the start of intravenous administration of syntocinon admixed with
dextrose,5%, in lactated Ringers' solution, at the rate of eight to ten micro-drops per
minute.
According to the Nurse's Observation Notes, Dr. Joel Enriquez ("Dr. Enriquez"), an
anesthesiologist at CMC, was notified at 4:15 a.m. of Corazon's admission.
Subsequently, when asked if he needed the services of an anesthesiologist, Dr.
Estrada refused. Despite Dr. Estrada's refusal, Dr. Enriquez stayed to observe
Corazons condition.
At
6:00
a.m.,
Corazon
was
transferred
to Delivery Room No. 1 of the CMC. At 6:10a.m., Corazon's bag of water ruptured
spontaneously. At 6:12 a.m., Corazon's cervix was fully dilated. At 6:13 a.m., Corazon
started to experience convulsions.

At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfate.
However, Dr. Ely Villaflor ("Dr. Villaflor"), who was assisting Dr. Estrada, administered
only 2.5 grams of magnesium sulphate.
At 6:22 a.m. Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract
Corazon's baby. In the process, a 1.0 x 2.5 cm. piece of cervical tissue was allegedly
torn. The baby came out in an apnic, cyanotic, weak and injured
condition. Consequently, the baby had to be intubated and resuscitated by Dr.
Enriquez and Dr. Payumo.
At 6:27 a.m., Corazon began to manifest moderate vaginal bleeding which rapidly bec
ame profuse. Corazon's blood pressure dropped from 130/80 to 60/40 within five
minutes. There was continuous profuse vaginal bleeding. The assisting nurse
administered hemacel through a gauge 19 needle as a side drip to the
ongoing intravenous injection of dextrose.
At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with bottled blood.
Ittook approximately 30 minutes for the CMC laboratory, headed by Dr. Perpetua
Lacson("Dr. Lacson"), to comply with Dr. Estrada's order and deliver the blood.
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the ObstetricsGynecology Department of the CMC, was apprised of Corazon's condition by
telephone. Upon being informed that Corazon was bleeding profusely, Dr. Espinola
ordered immediate hysterectomy. Rogelio was made to sign a "Consent to
Operation."13

o It is undisputed that throughout Corazon's pregnancy, she was under the

exclusive prenatal care of Dr. Estrada. At the time of Corazon's admission at
CMC and during her delivery, it was Dr. Estrada, assisted by Dr. Villaflor, who
attended to Corazon.
o There was no showing that CMC had a part in diagnosing Corazon's condition.
o While Dr. Estrada enjoyed staff privileges at CMC, such fact alone did not
make him an employee of CMC.42 CMC merely allowed Dr.Estrada to use its
facilities43
when
Corazon
was
about
to
give
birth, which CMC considered an emergency. Considering thesecircumstances,
Dr. Estrada is not an employee of CMC, but an independent contractor
.
Question now is whether CMC is automatically exempt from liability considering that
Dr. Estrada is an independent contractor-physician.
o General Rule: Hospital is NOT liable for the negligence of an independent
contractor-physician
o Exception:
D o c t r i n e o f A p p a r e n t A u t h o r i t y
( D A A )
- a hospital can be held vicariously liable for the negligent acts of a
physician providing care at the hospital, regardless of whether the
physician is an independent contractor, unless the patient knows, or
should have known, that the physician is an independent contractor.
Elements:
a.
Hospital, or its agent, acted in a manner that would lead a
reasonable person to conclude that the individual who was
alleged to be negligent was an employee or agent of the
hospital
b.
Where the acts of the agent create the appearance
of
authority, the plaintiff must also prove that the hospital had
knowledge of and acquiesced in them ;and
c.
The plaintiff acted in reliance upon the conduct of the hospital
or its agent, consistent with ordinary care and prudence

Due to the inclement weather then, Dr. Espinola, who was fetched from his residence
by an ambulance, arrived at the CMC about an hour later or at 9:00 a.m. He examined
the patient and ordered some resuscitative measures to be administered. Despite
Dr.Espinola's efforts, Corazon died at 9:15 a.m. The cause of death was "hemorrhage,
postpartum."14
On 14 May 1980, petitioners filed a complaint for damages15 with the Regional
TrialCourt16 of Manila against CMC, Dr. Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez,
Dr.Lacson, Dr. Espinola, and a certain Nurse J. Dumlao for the death of Corazon.
Petitioners mainly contended that defendant physicians and CMC personnel were
negligent in the treatment and management of Corazon's condition. Petitioners
charged CMC with negligence in the selection and supervision of defendant physicians
and hospital staff.
ISSUES & ARGUMENTS
W/N CMC should be held liable
HOLDING & RATIO DECIDENDI
YES
The mere fact that a hospital permitted a physician to practice medicine and use its
facilities is not sufficient to render the hospital liable for the negligence of a physician
who is an independent contractor
o There is no proof that defendant physician was an employee of defenda
nt hospital or that the latter had reason to know that any acts of
malpractice would take place
B o r r o w e d S e r v a n t D o c t r i n e
once the surgeon enters the operating room and takes charge of the proceedings,
the acts or omissions of operating room personnel, and any negligence associated
with such acts or omissions, are imputable to the surgeon.
o While the assisting physicians and nurses may be employed by thehospital, or
engaged by the patient, they normally become the temporary servants or agents
of the surgeon in charge while the operation is in progress, and liability may be
imposed upon the surgeon for their negligent acts under the doctrine
of respondeat superior
A hospital is the employer, master, or principal of a physician employee,
servant, or agent, and may be held liable for the physicians negligence
While "consultants" are not, technically employees, a point which respondent hospital
asserts in denying all responsibility for the patient's condition, the control exercised,
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.
O In assessing whether such a relationship in fact exists, the c o n t r o l
t e s t is determining. Accordingly, on the basis of the foregoing, we rule that
for the purpose of allocating responsibility in medical negligence cases, an
employer-employee relationship in effect exists between hospitals and their
attending and visiting physicians.
After a thorough examination of the voluminous records of this case, the Court finds
no single evidence pointing to CMC's exercise of control over Dr.Estrada's treatment
and management of Corazon's condition.

o 2 Factors to determine liability of an independent contractor-physician:

Hospitals manifestations
Inquiry whether the hospital acted in a manner which would lead a
reasonable person to conclude that the individual who was alleged
to be negligent was an employee or agent of the hospital
Patients reliance
Inquiry on whether the plaintiff acted in reliance upon the conduct
of the hospital or its agent, consistent with ordinary care and
prudence
o Circumstances of the cases showing application of DAA:
CMC granted Dr. Estrada staff privileges
Consent forms were printed on CMC letterhead
Dr. Estradas referral of Corazons case with other physicians of CMC
gave the impression that he, as a member of the CMCs medical staff,
was collaborating with other CMC-employed specialists
Spouses Nogales took Dr. Estrada as their physician inconsideration of
his connection with a reputable hospital(CMC)
Played a significant role in the Spouses decision
WHEREFORE, CMC is found liable to pay the corresponding damages

Cantre v. Sps. Go
Tags: cantre v. go, cantre v. sps. go, digest, medical negligence, ncc 2176, res ipsa
loquitur, torts

Dr. Milagros Cantre v. Sps. John David and Nora Go

2007 / Quisumbing / Petition for review on certiorari of CA decision and resolution
FACTS
Nora Go gave birth to her 4th child. Two hours later, she suffered profuse bleeding
inside her womb due to some placenta parts which were not completely expelled after
delivery. She then suffered hypovolemic shock, so her BP dropped to 40/0. Dr.
Milagros Cantre, an Ob-Gyne specialist and Nora's attending physician, together with
an assisting resident physician, performed various medical procedures to stop the
bleeding and to restore Nora's BP. While Dr. Cantre was massaging Nora's uterus for it

to contract and stop bleeding, she ordered a droplight to warm Nora and her baby. At
that time, she was unconscious.
While in the recovery room, Nora's husband John David noticed a fresh gaping
wound (2 1/2 x 3 1/2 in) in the inner portion of her left arm near the armpit. When he
asked the nurses about the cause of the injury, he was informed that it was due to a
burn. John David filed a request for investigation. Dr. Cantre said that what caused the
injury was the blood pressure cuff. John David brought Nora to the NBI for a physical
examination. The medico-legal said that the injury appeared to be a burn and that a
droplight when placed near the skin for about 10 minutes could cause such burn. He
dismissed the likelihood that the wound was caused by a blood pressure cuff since the
scar was not around the arm, but just on one side of the arm. Nora's injury was
referred to a plastic surgeon for skin grafting. However, her arm would never be the
same--the surgery left an unsightly scar, her movements are restricted, and the injured
arm aches at the slightest touch.
Sps. Go filed a complaint for damages against Dr. Cantre, the medical director, and
the hospital. In the RTC, parties have rested their respective cases, but the court
admitted additional exhibits [consist mostly of medical records produced by the
hospital during trial pursuant to a subpoena duces tecum] offered by Sps. Go, which
were not testified to by any witness. RTC ruled in favor of the spouses. CA affirmed
RTC with modification (complaint dismissed with respect to the medical director and
the hospital; only moral damages awarded).

ISSUES AND HOLDING

1.

WON the questioned additional exhibits are admissible in evidence. YES

2.

WON Dr. Cantre is liable for the injury suffered by Nora Go. YES

RATIO
Preliminary discussion
Dr. Cantre's counsel admitted the existence of the additional exhibits when they were
formally offered for admission by the RTC. In any case, given the circumstances of this
case, a ruling on Dr. Cantre's negligence may be made based on the res ipsa
loquitur doctrine even in the absence of the additional exhibits.

Wound could only be caused by something external to and

outside the control of Nora since she was unconscious while in
hypervolemic shock.

On Dr. Cantre's other arguments + what would have been her saving grace
BP cuff defense does not afford her an escape. The medical practice is
to deflate the cuff immediately after use, or else, it could cause an injury similar to what
happened to Nora. If the wound was caused by the constant taking of BP, it must have
been done so negligently as to inflict a gaping wound.

The argument that the failed plastic surgery was a measure to prevent
complication (and not intended as a cosmetic procedure) does not negate negligence
on Dr. Cantre's part.

Dr. Cantre has been Nora's ob-gyne for her past 3 deliveries, and this is
the first time that Dr. Cantre is being held liable for damages due to negligence in the
practice of her profession. She promptly took care of the wound before infection set in.
Since Nora was in a critical condition at that time, saving her life became Dr. Cantre's
elemental concern. Still, her good intentions characteristics do not justify
negligence.

NCC provisions applied

NCC 2176. Whoever by act or omission causes damage to another, there
being fault or negligence, is obliged to pay for the damage done. [...]
NCC 2217. Moral damages include physical suffering, mental anguish,
fright, serious anxiety, besmirched reputation, wounded feelings, moral shock, social
humiliation, and similar injury. Though incapable of pecuniary computation, moral
damages may be recovered if they are the proximate result of the defendant's wrongful
act or omission. [200k moral damages awarded]
RAMOS vs. COURT OF APPEALS
FACTS:
Erlinda Ramos underwent a surgical procedure to remove stone from her gall bladder
(cholecystectomy). They hired Dr. Hosaka, a surgeon, to conduct the surgery at the De
Los Santos Medical Center (DLSMC). Hosaka assured them that he would find a good
anesthesiologist. But the operation did not go as planned, Dr. Hosaka arrived 3 hours
late for the operation, Dra. Gutierrez, the anesthesiologist botched the administration
of the anesthesia causing Erlinda to go into a coma and suffer brain damage. The
botched operation was witnessed by Herminda Cruz, sister in law of Erlinda and Dean
of College of Nursing of Capitol Medical Center.

Backgrounder
The Hippocratic Oath mandates physicians to give primordial consideration to their
patients' well-being, and if a doctor fails to live up to this precept, he is accountable for
his acts. This notwithstanding, courts face a unique restraint in adjudicating
medical negligence cases because physicians are not guarantors of care,
and they never set out to intentionally cause injury to their
patients. HOWEVER, intent is immaterial in these cases because where
negligence exists and is proven, it automatically gives the injured a right to
reparation for the damage caused.

Res ipsa loquitur x Medical negligence cases

In medical negligence cases, 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.
Accident is of a kind which ordinarily does not occur absent
someone's negligence

2.

Wound not an ordinary occurrence in the act of delivering a

baby; could not have happened unless negligence set in somewhere

The family of Ramos (petitioners) sued the hospital, the surgeon and the
anesthesiologist for damages. The petitioners showed expert testimony showing that
Erlinda's condition was caused by the anesthesiologist in not exercising reasonable
care in intubating Erlinda. Eyewitnesses heard the anesthesiologist saying Ang
hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan.

Diagnostic tests prior to surgery showed that Erlinda was robust and fit to undergo
surgery.
The RTC held that the anesthesiologist ommitted to exercise due care in intubating the
patient, the surgeon was remiss in his obligation to provide a good anesthesiologist
and for arriving 3 hours late and the hospital is liable for the negligence of the doctors
and for not cancelling the operation after the surgeon failed to arrive on time. The
surgeon, anesthesiologist and the DLSMC were all held jointly and severally liable for
damages to petitioners. The CA reversed the decision of the Trial Court.
ISSUES: Whether or not the private respondents were negligent and thereby caused
the comatose condition of Ramos.
HELD:

Caused by an instrumentality within defendant's exclusive control

Yes, private respondents were all negligent and are solidarily liable for the damages.

It doesn't matter WON the injury was caused by the droplight

or by the blood pressure cuff, since both are within the exclusive control of
the physician in charge [Dr. Cantre] under the captain of the ship doctrine
[surgeon in charge of an operation is held liable for his assistants'
negligence during the time when they are under the surgeon's control].

RATIO:

3.
Possibility of contributing conduct which would make plaintiff
responsible is eliminated

Res ipsa loquitur a procedural or evidentiary rule which means the thing or the
transaction speaks for itself. It is a maxim for the rule that the fact of the occurrence of
an injury, taken with the surrounding circumstances, may permit an inference or raise a
presumption of negligence, or make out a plaintiffs prima facie case, and present a
question of fact for defendant to meet with an explanation, where ordinarily in a

medical malpractice case, the complaining party must present expert testimony to
prove that the attending physician was negligent.

This doctrine finds application in this case. On the day of the operation, Erlinda Ramos
already surrendered her person to the private respondents who had complete and
exclusive control over her. Apart from the gallstone problem, she was neurologically
sound and fit. Then, after the procedure, she was comatose and brain damagedres
ipsa loquitur!the thing speaks for itself!

Negligence Private respondents were not able to disprove the presumption of

negligence on their part in the care of Erlinda and their negligence was the proximate
cause of her condition. One need not be an anesthesiologist in order to tell whether or
not the intubation was a success. [res ipsa loquitur applies here]. The Supreme Court
also found that the anesthesiologist only saw Erlinda for the first time on the day of the
operation which indicates unfamiliarity with the patient and which is an act of
negligence and irresponsibility.

The head surgeon, Dr. Hosaka was also negligent. He failed to exercise the proper
authority as the captain of the ship in determining if the anesthesiologist observed
the proper protocols. Also, because he was late, he did not have time to confer with
the anesthesiologist regarding the anesthesia delivery.

The hospital failed to adduce evidence showing that it exercised the diligence of a
good father of the family in hiring and supervision of its doctors (Art. 2180). The
hospital was negligent since they are the one in control of the hiring and firing of their
consultants. While these consultants are not employees, hospitals still exert
significant controls on the selection and termination of doctors who work there which is
one of the hallmarks of an employer-employee reationship. Thus, the hospital was
allocated a share in the liability.

Damages temperate damages can and should be awarded on top of actual or

compensatory damages in instances where the injury is chronic and continuing.
Jarcia vs. People; torts- medical malpractice
Facts:
Private complainant Belinda Santiago lodged a complaint with the National Bureau
of Investigation against the petitioners, Dr. Emmanuel Jarcia, Jr. and Dr. Marilou
Bastan, for their alleged neglect of professional duty which caused her son, Roy
Alfonso Santiago, to suffer serious physical injuries.
Upon investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was
rushed to the Manila Doctors Hospital for an emergency medical treatment; that an Xray of the victims ankle was ordered; that the X-ray result showed no fracture as read
by Dr. Jarcia; that Dr. Bastan entered the emergency room and, after conducting her
own examination of the victim, informed Mrs. Santiago that since it was only the ankle
that was hit, there was no need to examine the upper leg. despite Mrs. Santiago's
protest the doctors did not examine the upper portion of the leg of Roy. that eleven (11)
days later, Roy Jr. developed fever, swelling of the right leg and misalignment of the
right foot; that Mrs. Santiago brought him back to the hospital; and that the X-ray
revealed a right mid-tibial fracture and a linear hairline fracture in the shaft of the bone.
After trial and applying the doctrine of res ipsa loquitor the RTC found petitioners to
be guilty of simple negligence. The decision was affirmed in toto by the CA.
Issues:
(1) Whether or not res ipsa loquitor is applicable in this case.
(2) Whether of not the petitioner physicians are negligent, hence liable for
damages.
Ruling:
As to the first issue: This doctrine of res ipsa loquitur means- "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." The
requisites for the application of the doctrine of res ipsa loquitur are:
(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.
However, the doctrine of res ipsa loquitur as a rule of evidence is unusual 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. Ergo,
the doctrine can be invoked when and only when, under the circumstances involved,
direct evidence is absent and not readily available.
Relative to the case, res ipsa loquitor does not apply since the circumstances that
caused patient Roy Jr.s injury and the series of tests that were supposed to be
undergone by him to determine the extent of the injury suffered were notunder the
exclusive control of Drs. Jarcia and Bastan. It was established that they are mere
residents of the Manila Doctors Hospital at that time who attended to the victim at the
emergency room. While it may be true that the circumstances pointed out by the
courts below seem doubtless to constitute reckless imprudence on the part of the
petitioners, this conclusion is still best achieved, not through the scholarly assumptions
of a layman like the patients mother, but by the unquestionable knowledge of expert
witness/es. As to whether the petitioners have exercised the requisite degree of skill
and care in treating patient Roy, Jr. is generally a matter of expert opinion.
As to the second issue: Petitioners were negligent in their obligation. It was
proven that a thorough examination was not performed on Roy Jr since as residents
on duty at the emergency room, Dr. Jarcia and Dr. Bastan were expected to know the
medical protocol in treating leg fractures and in attending to victims of car accidents.
Thus, simple negligence is resent if: (1) that there is lack of precaution on the part of
the offender, and (2) that the damage impending to be caused is not immediate or the
danger is not clearly manifest.
Dr. Jarcia and Dr. Bastan, explained the court, cannot pass on the liability to the taxi
driver who hit the victim. It may be true that the actual, direct, immediate, and
proximate cause of the injury (fracture of the leg bone or tibia) of Roy Jr. was the
vehicular accident when he was hit by a taxi. The petitioners, however, cannot simply
invoke such fact alone to excuse themselves from any liability. If this would be so,
doctors would have a ready defense should they fail to do their job in attending to
victims of hit-and-run, maltreatment, and other crimes of violence in which the actual,
direct, immediate, and proximate cause of the injury is indubitably the act of the
perpetrator/s.
In failing to perform an extensive medical examination to determine the extent of
Roy Jr.s injuries, Dr. Jarcia and Dr. Bastan were remiss of their duties as members of
the medical profession. Assuming for the sake of argument that they did not have the
capacity to make such thorough evaluation at that stage, they should have referred the
patient to another doctor with sufficient training and experience instead of assuring him
and his mother that everything was all right.
Moreover, the contention of petitioners that they cannot be held liable since Roy is
not their patient, since they are not the attending physicians but merely requested by
the ER does not hold water.
Physician-patient relationship exists when a patient engages the services of a
physician, a physician-patient relationship is generated. And in accepting a case, the
physician, for all intents and purposes, represents that he has the needed training and
skill possessed by physicians and surgeons practicing in the same field; and that he
will employ such training, care, and skill in the treatment of the patient. Thus, in
treating his patient, a physician is under a duty to exercise that degree of care, skill
and diligence which physicians in the same general neighborhood and in the same
general line of practice ordinarily possess and exercise in like cases. Stated otherwise,
the physician has the obligation to use at least the same level of care that any other
reasonably competent physician would use to treat the condition under similar
circumstances.
There is a physician-patient relationship in this case since the petitioner obliged
themselves and examined the victim, and later assured the mother that everything was
fine and that they could go home. Their assurance that everything is fine deprived the
victim of seeking medical help.
Petitioners were absolved in the criminal charge for the reason that a reasonable
doubt existed but the are liable for damages. There is no direct evidence proving that it
was their negligence that caused the suffering of Roy.