Dr. Rubi Li,Petitioner,vs. Spouses Reynaldo and Lina Soliman, as parents/heirs of deceased Angelica Soliman,Respondents.G.R. No. 165279June 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 ofP139, 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. AganaProfessional Services Inc. (PSI) v. Natividad and Enrique AganaNatividad and Enrique Agana v. Juan FuentesMiguel Ampil v. Natividad and Enrique Agana2007 / Sandoval-Gutierrez / Petition for review on certiorari of CA decisionsStandard of conduct > Experts > Medical professionals

FACTSNatividad Agana was rushed to Medical City because of difficulty of bowel movementand bloody anal discharge. Dr. Ampil diagnosed her to be suffering fromcancer of the sigmoid. Dr. Ampil performed ananterior resection surgeryon her, and finding that the malignancy spread on her left ovary, he obtained the consent of her husband, Enrique, to permit Dr. Fuentes to performhysterectomyon 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 theattending 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 thendirected that the incision be closed.A couple of days after, she complained ofpain 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 apiece 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 acomplaint for damagesagainst PSI (owner of Medical City), Dr. Ampil, and Dr. Fuentes, alleging that the latter are liable fornegligencefor leaving 2 pieces of gauze in Natividads body, andmalpracticefor concealing their acts of negligence. Enrique Agana also filed anadministrative complaintfor 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 HOLDING1. WON CA erred in holding Dr. Ampil liable for negligence and malpractice.NO; DR. AMPIL IS GUILTY2. WON CA erred in absolving Dr. Fuentes of any liability.NO3. WON PSI may be held solidarily liable for Dr. Ampils negligence.YESRATIODR. AMPIL IS LIABLE FOR NEGLIGENCE AND MALPRACTICEHis 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 leastprima facienegligence 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 hislegal 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 diligenceTo 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 establishedcausal link:gauze pieces later extracted from patients vaginaDR. FUENTES NOT LIABLETheres 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 ofres ipsa loquitur1. Occurrence of injury2. Thing which caused injury was under thecontrol and management of the defendant [DR. FUENTES]LACKING SINCECTRL+MGT WAS WITH DR. AMPIL3. Occurrence was such that in the ordinary course of things, would not have happened if those who had control or management used proper care4. Absence of explanation by defendantUnder theCaptain of the Shiprule, theoperating surgeonis the personin 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 incisionHOSPITAL 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 ofrespondeat superior. Here are the Courts bases for sustaining PSIs liability: Ramos v. CAdoctrine on E-E relationship For purposes of apportioning responsibility in medical negligence cases, anemployer-employee relationshipin effect exists between hospitals and their attending and visiting physicians. [LABOR LESSON: power to hire, fire, power of control] Agency principle ofapparent 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. 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 ofcorporate 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 ofrespondeat superior. This provides for the duties expected [from hospitals]. In this case, PSI failed to perform the duty of exercisingreasonable 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 tooversee or supervise all persons who practice medicine within its wallsandtake an active step in fixing the negligence committed PSI also liable underNCC 2180 It failed to adduce evidence to show that it exercised thediligence of a good father of the familyin the accreditation and supervision of Dr. AmpilDr. Ninevetch Cruz v. CA and Lydia Umali1997 / Francisco / Petition for review on certiorari of a CA decisionStandard of conduct > Experts > Medical professionals

FACTSMedical malpractice suit-type of claim which a victim has available to him/her to redress a wrong committed by a medical professional which has caused bodily harm; most often brought as a civil action for damages under NCC 2176 or acriminal case under RPC 365, with which a civil action for damages is impliedly instituted.

Lydia Umali was examined by Dr. Cruz who found amyoma[benign tumor] in her uterus, and scheduled her for ahysterectomy 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 theclinic 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 buytagamet ampules, and Rowena's sister went out to buy some. An hour later, Dr. Ercillo asked them to buybloodfor Lydia, so they did. A few hours later, the operation was finished, but later, Dr. Cruz asked the family to buyadditional blood, but there was no more type A blood available in the blood bank.A person arrived to donate bloodwhich was later transfused to Lydia. Rowena noticed that her mother wasgasping for breath--apparently, theoxygen supply had run out, so the family went out to buy oxygen. Later in the evening, she went intoshockand herblood pressure dropped. She was thentransferred to another hospitalso 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-operatedupon by Dr. Cruz and Dr. Ercillo because blood was oozing out from her incision. They summoned Dr. Angeles, Ob-Gyne head of the new hospital, but when he arrived, Lydia was already inshockandpossibly dead(BP: 0/0). Dr. Angeles told Drs. Cruz and Ercillo that there was nothing he could do.Lydia diedwhile 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 withreckless imprudence and negligence resulting in homicideof Lydia Umali. TheMunicipal Trial Court in Cities(MTCC) found Dr. Ercillo not guilty for insufficiency of evidence against her, butheld Dr. Cruz responsiblefor Umali's death.RTC and CAaffirmed MTCC.

Manifestation of negligence untidiness of clinic lack of provision of supplies the fact that the transfer was needed meant that there was something wrong in the way Dr. Cruz conducted operation no showing that pre-surgery procedure (clearance, blood typing/tests) was conductedISSUE AND HOLDINGWON the circumstances are sufficient to sustain a judgment of conviction against Dr. Cruz for reckless imprudence resulting in homicide.NO. DR. CRUZ IS ACQUITTED, BUT SHE IS STILL CIVILLY LIABLE(50K civil liability; 100k moral damages, 50k exemplary damages).

RATIOElements of reckless imprudence1. Offender does / fails to do an act2. Doing / failure to do act is voluntary3. Without malice4. Material damage results from reckless imprudence5. There is inexcusable lack of precaution, taking into consideration offender's employment, degree of intelligence, physical condition, other circumstances re: persons, time, place

Standard of careStandard of care observed by other members of the profession in good standing under similar circumstances, bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science When the physician's qualifications are admitted, there is an inevitablepresumptionthat 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 byexpert testimony.

Expert testimonyExpert testimony is essentialtoestablish standard of careof the profession, as well as that thephysician's conductin the treatment and carefalls below such standard. It is also usually necessary tosupport the conclusion as to causation. There is anabsence of any expert testimony re: standard of carein 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 theexpert opinion of qualified physiciansstems from the realization that the latter possessunusual technical skillswhich laymen are incapable of intelligently evaluating.

Burden of establishing medical negligence on plaintiffPlaintiff has the burden to establish this, and for a reasonable conclusion of negligence, there must be proof ofbreach of dutyon the part of the surgeon, as well as acausal connectionof 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, sothe 4th element of reckless imprudence is missing.The testimonies of the doctors presented by the prosecution establishhemorrhage / hemorrhagic shockas the cause of death, which may be caused by several different factors.Autopsydid 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 DigestG.R. No. 192123 : March 10, 2014

DR. FERNANDO P. SOLIDUM, Petitioner, v. PEOPLE OF THE PHILIPPINES, Respondent.

BERSAMIN, J.:

FACTS:

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.

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.

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.

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 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.

GRANTED.

Nogalesvs. Capitol Medical CenterCarpio, J.:G.R. No. 142625, Dec. 19, 2006 | 511SCRA 204

FACTS:Pregnant with her fourth child, CorazonNogales("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.

Aroundmidnightof25May1976,Corazonstartedtoexperiencemildlaborpainsprompting Corazon and Rogelio Nogales("SpousesNogales") to see Dr. Estrada at his home. After examining Corazon, Dr. Estrada advised her immediate admission to the Capitol Medical Center ("CMC").

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, RogelioNogales("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.

Accordingto theNurse'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 ifhe neededthe services ofan anesthesiologist, Dr. Estrada refused. Despite Dr. Estrada's refusal, Dr. Enriquez stayed to observe Corazons condition.

At 6:00 a.m., Corazon was transferred toDeliveryRoomNo.1oftheCMC.At6:10a.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 orderedtheinjectionoftengramsofmagnesiumsulfate. 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 forcepstoextract Corazon's baby. In the process, a 1.0 x 2.5 cm. piece of cervical tissue was allegedly torn.The babycame out in anapnic, cyanotic, weak andinjured condition.Consequently,the baby had to be intubated and resuscitated by Dr. Enriquez and Dr. Payumo.

At6:27a.m.,Corazonbegantomanifestmoderatevaginalbleedingwhichrapidlybecame 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 ongoingintravenous injection of dextrose.

At 7:45 a.m., Dr. Estradaordered 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"),headoftheObstetrics-GynecologyDepartment of the CMC, was apprised of Corazon's condition by telephone. Upon beinginformed that Corazon was bleeding profusely, Dr. Espinola ordered immediate hysterectomy. Rogelio was made to sign a "Consent to Operation."13

Due to the inclement weather then, Dr. Espinola, who was fetched from his residence byan 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 & ARGUMENTSW/N CMC should be held liable

HOLDING & RATIO DECIDENDIYESThe merefact thata hospital permitted aphysician topractice medicine anduse its facilities is not sufficient to render the hospital liable for the negligence of a physician who is an independent contractoroThereisnoproofthatdefendantphysicianwasanemployeeofdefendant hospital or that the latter had reason to know that any acts of malpractice would take place

Borrowed Servant Doctrine 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.oWhiletheassistingphysiciansandnursesmaybeemployedbythehospital, 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 ofrespondeat superiorA hospital is the employer, master, orprincipal of a physician employee, servant, or agent, and may be held liable for the physicians negligenceWhile"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 control testis 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 thoroughexamination of the voluminous recordsof 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 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.oTherewasno showingthatCMChad apartin diagnosing Corazon's condition.o While Dr. Estrada enjoyed staff privileges atCMC, such factalone 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,whichCMCconsideredanemergency.Consideringthesecircumstances, 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-physiciano Exception: Doctrine of Apparent Authority (DAA)- 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 hospitalb. Wheretheactsoftheagentcreatetheappearance of authority, the plaintiff must also prove that the hospital had knowledge of and acquiesced in them ;andc. The plaintiffactedin relianceupon theconductofthe hospital or its agent, consistent with ordinarycare and prudence

o 2 Factors to determine liability of an independent contractor-physician: Hospitals manifestationsInquiry whether the hospital acted in a mannerwhichwouldleada reasonablepersontoconclude that the individual who was alleged to be negligentwas an employee or agent of the hospital Patients relianceInquiry 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 topay the corresponding damages

Cantre v. Sps. GoTags: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 Go2007 / Quisumbing / Petition for review on certiorari of CA decision and resolutionFACTSNora 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 subpoenaduces 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 HOLDING1. WON the questioned additional exhibits are admissible in evidence.YES2. WON Dr. Cantre is liable for the injury suffered by Nora Go.YESRATIOPreliminary discussionDr. 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 theres ipsa loquiturdoctrine even in the absence of the additional exhibits.

BackgrounderThe 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 casesbecausephysicians are not guarantors of care, andthey never set out to intentionally cause injury to their patients.HOWEVER,intent is immaterialin these cases becausewhere negligence exists and is proven, it automatically gives the injured a right to reparation for the damage caused.

Res ipsa loquitur x Medical negligence casesInmedical negligence cases, the doctrine ofres ipsa loquiturallows themere 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 followingrequisitesconcur:1. Accident is of a kind whichordinarily does not occur absent someone's negligence Wound not an ordinary occurrence in the act of delivering a baby; could not have happened unless negligence set in somewhere2. Caused by aninstrumentality withindefendant's exclusive control 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 thecaptain of the shipdoctrine [surgeon in charge of an operation is held liable for his assistants' negligence during the time when they are under the surgeon's control].3. Possibility of contributing conductwhich would make plaintiff responsible iseliminated 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,hergood 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 APPEALSFACTS: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.

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

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 X-ray 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 resipsa loquitorthe RTC found petitioners to be guilty of simple negligence. The decision was affirmedin totoby 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 ofres ipsa loquiturmeans- "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 ofres ipsa loquiturare:(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 ofres ipsa loquituras a rule of evidence is unusual to the law of negligence which recognizes thatprima facienegligence 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 applysince 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 werenotunder 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 adutyto 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.