Legal Medicine Finals

May 27, 2018

6-7PM

F. MEDICAL NEGLIGENCE
ELEMENTS OF MEDICAL NEGLIGENCE:
DUTY – to use at least the same level of care that any other reasonably competent doctor would
use to treat a condition under the same circumstances
BREACH
INJURY
PROXIMATE CAUSE ("that cause, which, in natural and continuous sequence, unbroken by any
efficient intervening cause, produces the injury, and without which the result would not have
occurred." – Urbano vs IAC)

STANDARD OF CARE: The standard of care is that which 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

NECESSITY OF EXPERT WITNESS IN PROVIDING FOR THE STANDARD OF CARE

This Court has recognized that medical negligence cases are best proved by opinions of expert witnesses
belonging in the same general neighborhood and in the same general line of practice as defendant
physician or surgeon. (Li vs Soliman)

A layman’s evidence is not enough. The evidence required typically takes the form of testimony by other
doctors in the same or related fields of practice, and of medical literature and regulations duly proven
before the Court.

RECKLESS IMPRUDENCE
ELEMENTS OF RECKLESS IMPRUDENCE
(DR. NINEVETCH CRUZ, petitioner, vs. COURT OF APPEALS and LYDIA UMALI, G.R. No. 122445. November 18, 1997)
The elements of reckless imprudence are:
(1) That the offender does or fails to do an ACT;
(2) That the doing or the failure to do that act is VOLUNTARY;
(3) That it be without MALICE;
(4) That material damage results from the reckless IMPRUDENCE; and
(5) That there is inexcusable lack of PRECAUTION on the part of the offender, taking into
consideration his employment or occupation, degree of intelligence, physical condition, and other
circumstances regarding persons, time and place.

(DR. NINEVETCH CRUZ, petitioner, vs. COURT OF APPEALS and LYDIA UMALI, G.R. No. 122445.
November 18, 1997)

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

Lydia Umali was examined by Dr. Cruz who found a myoma [benign tumor] in her uterus, and
scheduled her for a hysterectomy operation [removal of uterus] on 23 Mar 1991.

Rowena Umali de Ocampo accompanied her mother to the hospital a day before the
operation, and they spent the night there. Rowena noticed that the clinic was untidy, so she
tried to persuade her mother not to proceed with the operation. The following day, Rowena
asked Dr. Cruz if the operation could be postponed, but Lydia told her daughter that Dr. Cruz
said that the operation must go on as scheduled.

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

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

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

Manifestation of negligence
 untidiness of clinic
 lack of provision of supplies
 the fact that the transfer was needed meant that there was something wrong in the
way Dr. Cruz conducted operation
 no showing that pre-surgery procedure (clearance, blood typing/tests) was
conducted

ISSUE
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).

RATIO
Elements of reckless imprudence
1. Offender does / fails to do an act
2. Doing / failure to do act is voluntary
3. Without malice
4. Material damage results from reckless imprudence
5. 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.

SIMPLE IMPRUDENCE
ELEMENTS OF SIMPLE IMPRUDENCE
(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.

PRESCRIPTION

Art. 1139. Actions prescribe by the mere lapse of time fixed by law. (1961)

Art. 1140. Actions to recover movables shall prescribe eight years from the time the possession thereof is
lost, unless the possessor has acquired the ownership by prescription for a less period, according to
Articles 1132, and without prejudice to the provisions of Articles 559, 1505, and 1133. (1962a)

Art. 1141. Real actions over immovables prescribe after thirty years.

This provision is without prejudice to what is established for the acquisition of ownership and other real
rights by prescription. (1963)

Art. 1142. A mortgage action prescribes after ten years. (1964a)

Art. 1143. The following rights, among others specified elsewhere in this Code, are not extinguished by
prescription:

(1) To demand a right of way, regulated in Article 649;

(2) To bring an action to abate a public or private nuisance. (n)

Art. 1144. The following actions must be brought within ten years from the time the right of action
accrues:
(1) Upon a written contract;

(2) Upon an obligation created by law;

(3) Upon a judgment. (n)

Art. 1145. The following actions must be commenced within six years:
(1) Upon an oral contract;

(2) Upon a quasi-contract. (n)

Art. 1146. The following actions must be instituted within four years:

(1) Upon an injury to the rights of the plaintiff;

(2) Upon a quasi-delict;

However, when the action arises from or out of any act, activity, or conduct of any public officer involving
the exercise of powers or authority arising from Martial Law including the arrest, detention and/or trial of
the plaintiff, the same must be brought within one (1) year. (As amended by PD No. 1755, Dec. 24, 1980.)

Art. 1147. The following actions must be filed within one year:

(1) For forcible entry and detainer;

(2) For defamation. (n)

Art. 1148. The limitations of action mentioned in Articles 1140 to 1142, and 1144 to 1147 are without
prejudice to those specified in other parts of this Code, in the Code of Commerce, and in special laws. (n)

Art. 1149. All other actions whose periods are not fixed in this Code or in other laws must be brought
within five years from the time the right of action accrues. (n)

Art. 1150. The time for prescription for all kinds of actions, when there is no special provision which
ordains otherwise, shall be counted from the day they may be brought. (1969)

Art. 1151. The time for the prescription of actions which have for their object the enforcement of
obligations to pay principal with interest or annuity runs from the last payment of the annuity or of the
interest. (1970a)

Art. 1152. The period for prescription of actions to demand the fulfillment of obligation declared by a
judgment commences from the time the judgment became final. (1971)

Art. 1153. The period for prescription of actions to demand accounting runs from the day the persons
who should render the same cease in their functions.

The period for the action arising from the result of the accounting runs from the date when said result
was recognized by agreement of the interested parties. (1972)

Art. 1154. The period during which the obligee was prevented by a fortuitous event from enforcing his
right is not reckoned against him. (n)

Art. 1155. The prescription of actions is interrupted when they are filed before the court, when there is a
written extrajudicial demand by the creditors, and when there is any written acknowledgment of the debt
by the debtor. (1973a)

SPS. ANTONIO and ESPERANZA C. SANTOS et al. vs. JUDGE NORMANDIE B.

PIZARDO (RTC of Quezon City, Branch 101), DIONISIO M SIBAYAN, and
VIRON TRANSPORTATION COMPANY, INC.

On December 17, 1998 Dionisio M. Sibayan was convicted of Reckless

Imprudence Resulting to Multiple Homicide and Multiple Physical Injuries in
connection with a vehicle collision in April 1994 between a southbound Viron
Transit bus driven by Sibayan and a northbound Lite Ace Van, which claimed
the lives of the vans driver and three (3) of its passengers, including a two-
month old baby, and caused physical injuries to five (5) of the vans
passengers.

On October 20, 2000, petitioners filed a complaint for damages against

Sibayan, Viron Transit predicated upon the conviction in the criminal case.

Viron Transit moved to dismiss on the ground of prescription.

Petitioners opposed the motion to dismiss contending the action in this case
prescribes in ten (10) years reckoned from the finality of the judgment in the
criminal action.

RTC dismissed the complaint on the ground of prescription because the

complaint was filed more than four (4) years after the vehicular accident (Art.
1146 NCC)

CA dismissed the petition for certiorari for being the wrong remedy.

ISSUE: WON the action of petitioners has prescribed?

HELD: NO.

Section 1, Rule 111 provides that “When a criminal action is instituted, the
civil action for the recovery of civil liability is impliedly instituted with the
criminal action, unless the offended party waives the civil action, reserves his
right to institute it separately, or institutes the civil action prior to the criminal
action.”

Here, Sps. Santos et al expressly made a reservation of their right to file a

separate civil action as a result of the crime committed by Sibayan. On
account of this reservation, the municipal circuit trial court, in its decision
convicting Sibayan, did not make any pronouncement as to the latters civil
liability.

Predicating their claim on the judgment of conviction and their reservation to

file a separate civil action made in the criminal case, petitioners filed a
complaint for damages. Petitioners assert that by the institution of the
complaint, they seek to recover private respondents civil liability arising from
crime. Unfortunately, based on its misreading of the allegations in the
complaint, the trial court dismissed the same, declaring that petitioners cause
of action was based on quasi delict and should have been brought within four
(4) years from the time the cause of action accrued, i.e., from the time of the
accident.
CASUPANAN and CAPITULO vs. LAROYA (G.R. No. 145391. August 26, 2002)
FACTS: In a certain vehicular accident involving two parties, each one of them
may think and believe that the accident was caused by the fault of the other.
The first party, believing himself to be the aggrieved party, opted to file a
criminal case for reckless imprudence against the second party. On the other
hand, the second party, together with his operator, believing themselves to
be the real aggrieved parties, opted in turn to file a civil case for quasi-delict
against the first party who is the very private complainant in the criminal case.
When the civil case was filed, the criminal case was then at its preliminary
investigation stage. Laroya, defendant in the civil case, filed a motion to
dismiss the civil case on the ground of forum-shopping considering the
pendency of the criminal case.
The MCTC granted the motion on the ground of forum shopping and
dismissed the civil case. Casupanan and Capitulo filed a petition for certiorari
under Rule 65 before the Capas RTC assailing the MCTCs Order of dismissal.
Laroya further alleges that Casupanan and Capitulo forfeited their right to
question the order of dismissal when they failed to avail of the proper remedy
of appeal. The Capas RTC rendered judgment on December 28, 1999
dismissing the petition for certiorari for lack of merit.

ISSUES:
1. WON there is forum shopping. NO (Different causes of action, culpa
criminal and culpa aquiliana)
2. WON the proper remedy is appeal and not special civil action under Rule
65 is proper? (NO. S.C. A.C. No. 04-94. Order did not state “with prejudice”
and absence of such the same is deemed “without prejudice.”)
3. WON an accused in a pending criminal case for reckless imprudence can
validly file, simultaneously and independently, a separate civil action for
quasi-delict against the private complainant in the criminal case. (YES. Sec. 3,
Rule 111)
4. WON Casupanan and Capitulo, who are not the offended parties in the
criminal case, can file a separate civil action against the offended party in the
criminal case. (YES. Sec. 6, Rule 111)

HELD 1: NO. Forum-shopping is present when in the two or more cases

pending, there is identity of parties, rights of action and reliefs sought.
However, there is no forum-shopping in the instant case because the law and
the rules expressly allow the filing of a separate civil action which can proceed
independently of the criminal action. The two cases have different causes of
action. The criminal case is based on culpa criminal punishable under the
Revised Penal Code while the civil case is based on culpa aquiliana actionable
under Articles 2176 and 2177 of the Civil Code.
Thus, the offended party can file two separate suits for the same act or
omission. The first a criminal case where the civil action to recover civil
liability ex-delicto is deemed instituted, and the other a civil case for quasi-
delict - without violating the rule on non-forum shopping
The order of dismissal by the MCTC of Civil Case No. 2089 on the ground of
forum-shopping is erroneous.
HELD 2: NO. The MCTC did not state in its order of dismissal that the dismissal
was with prejudice. Under the Administrative Circular (No. 04-94), the order
of dismissal is without prejudice to refiling the complaint, unless the order
of dismissal expressly states it is with prejudice. Absent a declaration that
the dismissal is with prejudice, the same is deemed without prejudice. Thus,
the MCTCs dismissal, being silent on the matter, is a dismissal without
prejudice.
Section 1 of Rule 41 provides that an order dismissing an action without
prejudice is not appealable.

Thus, the remedy of the aggrieved party is to file a special civil action under
Rule 65.

HELD 3: YES.
(RULE 111) SEC 3. In the cases provided in Articles 32, 33, 34 and 2176 of the
Civil Code of the Philippines, the independent civil action may be brought by
the offended party. It shall proceed independently of the criminal action and
shall require only a preponderance of evidence. In no case, however, may the
offended party recover damages twice for the same act or omission charged
in the criminal action.

HELD 4: YES.
(RULE 111, Sec. 6) Under this provision, the accused is barred from filing a
counterclaim, cross-claim or third-party complaint in the criminal case.
However, the same provision states that any cause of action which could have
been the subject (of the counterclaim, cross-claim or third-party complaint)
may be litigated in a separate civil action. The present Rule 111 mandates the
accused to file his counterclaim in a separate civil action which shall proceed
independently of the criminal action, even as the civil action of the offended
party is litigated in the criminal action.
This is only fair for two reasons.
First, the accused is prohibited from setting up any counterclaim in the civil
aspect that is deemed instituted in the criminal case. The accused is therefore
 forced to litigate separately his counterclaim against the offended party. If the
accused does not file a separate civil action for quasi-delict, the prescriptive
period may set in since the period continues to run until the civil action for
quasi-delict is filed.
Second, the accused, who is presumed innocent, has a right to invoke Article
2177 of the Civil Code, in the same way that the offended party can avail of
this remedy which is independent of the criminal action. To disallow the
accused from filing a separate civil action for quasi-delict, while refusing to
recognize his counterclaim in the criminal case, is to deny him due process of
law, access to the courts, and equal protection of the law.
Thus, the civil action based on quasi-delict filed separately by Casupanan and
Capitulo is proper.

THE DISCOVERY RULE

The discovery rule is an exception to the standard deadline. The purpose of the discovery rule is to give
victims of medical malpractice the right to file a medical malpractice lawsuit after the standard statute of
limitations expired, when they did not even know that they had a potential medical malpractice claim.

DOCTRINE OF APPARENT AUTHORITY/PRINCIPLE OF AGENCY (This doctrine can make the hospital
solidarily liable under this doctrine as an exception to the general rule.)

As a general rule, hospitals are not liable for the negligence of its independent contractors. However, it
may be found liable if the physician or independent contractor acts as an ostensible agent of the hospital.
This exception is also known as the "doctrine of apparent authority."

The US case of Gilbert v. Sycamore Municipal Hospital100 abrogated the hospitals’ immunity to vicarious
liability of independent contractor physicians. In that case, the Illinois Supreme Court held that under the
doctrine of apparent authority, hospitals could be found vicariously liable for the negligence of an
independent contractor:

Therefore, we hold that, under the doctrine of apparent authority, 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. The elements of the action have been set out as follows:

For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show that:

(1) the 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;
(2) 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
(3) the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary
care and prudence.

The doctrine was applied in Nogales v. Capitol Medical Center where this Court, through the ponencia of
Associate Justice Antonio T. Carpio, discussed the two factors in determining hospital liability as follows:

The first factor focuses on the hospital’s manifestations and is sometimes described as an 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. In this regard, the
hospital need not make express representations to the patient that the treating physician is an employee
of the hospital; rather a representation may be general and implied.

The second factor focuses on the patient's reliance. It is sometimes characterized as an inquiry on
whether the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with
ordinary care and prudence.
In sum, a hospital can be held vicariously liable for the negligent acts of a physician (or an independent
contractor) providing care at the hospital if the plaintiff can prove these two factors: first, the hospital’s
manifestations; and second, the patient’s reliance.
CONTEMPORANEOUS NEGLIGENCE

The gist of an action against a physician or surgeon for malpractice is usually negligence rather than
breach of contract. Thus the plaintiff must allege in his complaint that he was in the exercise of due care
or was free from contributory negligence at the time of the injury. Once the issue of contributory
negligence has been raised by the pleadings, the plaintiff has the burden of proving that he was in the
exercise of due care at the time. (Merrill C. Hoyt, Contributory Negligence as a Defense in Malpractice
Litigation , 44 Chi.-Kent. L. Rev. 148 (1967). Available at
http://scholarship.kentlaw.iit.edu/cklawreview/vol44/iss2/10)

The conduct alleged to constitute contributory negligence5 may occur during any of three time periods.
The plaintiff's acts may occur prior to, contemporaneous with (during) or after the negligent conduct of
the physician. (Ibid)

Article 2179. When the plaintiffs own negligence was the immediate and proximate cause of his injury, he
cannot recover damages. But if his negligence was only contributory, the immediate and proximate cause
of the injury being the defendants lack of due care, the plaintiff may recover damages, but the courts
shall mitigate the damages to be awarded. (NCC)

BORROWED SERVANT DOCTRINE

NOGALES VS CAPITOL MEDICAL CENTER (GR NO. 142625 DECEMBER 19, 2006)

FACTS: Pregnant with her fourth child, Corazon Nogales, who was then 37 y/o was under the exclusive
prenatal care of Dr. Oscar 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 edemas indicating preeclampsia which is a dangerous complication of
pregnancy. Around midnight of May 26, 1976, Corazon started to experience mild labor pains prompting
Corazon and Rogelio Nogales to see Dr. Estrada at his home. After examining Corazon, Dr. Estrada advised
her immediate admission to Capitol Medical Center (CMC). Upon her admission, an internal examination
was conducted upon her by a resident-physician. Based on the doctor’s sheet, around 3am, Dr. Estrada
advised for 10mg valium to be administered immediately by intramuscular injection, he later ordered the
start of intravenous administration of syntociron admixed with dextrose, 5% in lactated ringer’s solution,
at the rate of 8-10 micro-drops per minute. When asked if he needed the services of anesthesiologist, he
refused. Corazon’s bag of water ruptured spontaneously and her cervix was fully dilated and she
experienced convulsions. Dr. Estrada ordered the injection of 10g of magnesium sulfate but his assisting
Doctor, Dr. Villaflor, only administered 2.5g. She also applied low forceps to extract Corazon’s baby. In the
process, a 10 x 2.5cm piece of cervical tissue was allegedly torn. The baby came out in an apric, cyanatic
weak and injured condition. Consequently, the baby had to be intubated and resuscitated. Corazon had
professed vaginal bleeding where a blood typing was ordered and she was supposed to undergo
hysterectomy, however, upon the arrival of the doctor, she was already pronounced dead due to
hemorrhage.
ISSUE: Whether or not in the conduct of child delivery, the doctors and the respondent hospital is liable
for negligence.
HELD: Yes. In general, a hospital is not liable for the negligence of an independent contractor-physician.
There is, however an exception to this principle. The hospital may be liable if the physician is the
ostensible agent of the hospital. This exception is also known as the doctrine of apparent authority.
Under the doctrine of apparent authority, 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.
For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show that 1.) the
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; 2.) Where the acts
of the agent create the appearance of authority, the plaintiff must also prove that the hospital had
knowledge of and acquired in them; and 3.) the plaintiff acted in reliance upon the conduct of the
hospital or its agent, consistent with ordinary care and prudence.
Borrowed servant doctrine provides that once a surgeon enters the operating room and takes charge of
the acts or omissions of operating room personnel and any negligence associated with each acts or
omissions are imputable to the surgeon, while the assisting physicians and nurses may be employed by
the hospital, 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.
PROFESSIONAL SERVICES INC. VS AGANA (GR NO. 126297 JANUARY 31, 2007)
RES IPSA LOQUITOR and CAPTAIN OF THE SHIP DOCTRINE
FACTS: On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital because of
difficulty of bowel movement and bloody anal discharge. After a series of medical examinations, Dr.
Miguel Ampil diagnosed her to be suffering from Cancer of the sigmoid. On April 11, 1984, Dr. Ampil
assisted by the medical staff of the Medical City Hospital performed an Anterior resection surgery on
Natividad. He found that the malignancy on her sigmoid area had spread on her left ovary, necessitating
the removal of certain portions of it. Thus, Dr. Ampil obtained the consent of Natividad’s husband,
Enrique Agana, to permit Dr. Juan Fuentes to perform hysterectomy on her. After Dr. Fuentes had
completed the hysterectomy, Dr. Ampil took over, completed the operation and closed the incision after
searching for the missing 2 gauzes as indicated by the assisting nurses but failed to locate it. After a
couple of days, Natividad complained of excruciating pains in her anal region but Dr. Ampil said it is a
natural consequence of the operation/surgery and recommended that she consult an oncologist to
examine the cancerous nodes which were not removed during the operation. Natividad and her husband
went to the US to seek further treatment and she was declared free from cancer. A piece of gauze
portruding from Natividad’s vagina was found by her daughter which was then removed by hand by Dr.
Ampil and assured that the pains will vanished. However, it didn’t. The pains intensified prompting
Natividad to seek treatment at the Polymedic General Hospital. While confined there, Dr. Ramon
Guttierez detected the presence of another foreign object in her vagina – a foul smelling gauze measuring
1.5 inches in width which badly infected her vagina. A recto-vaginal fistula had forced stool to excrete
through her vagina. Another surgical operation was needed to remedy the damage.
ISSUE: Whether or not Dr. Ampil and Fuentes are liable for medical malpractice and the PSI for damages
due to the negligence of the said doctors.
HELD: Yes. No. Yes. An operation requiring the placing of sponges in the incision is not complete until the
sponges are properly removed and it is settled that the leaving of sponges or other foreign substances in
the wound after the incision has been closed is at least prima facie negligence by the operating surgeon.
To put it simply, such act is considered so inconsistent with due care as to raise inference of negligence.
There are even legions of authorities to the effect that such act is negligence per se.
This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully
pursue this kind of case, a patient must only prove that a health care provider either failed to do
something which a reasonably prudent health care provider would have done, or that he did something
that a reasonably prudent provider would not have done; and that failure or action caused injury to the
patient. Simply puts the elements are duty, breach, injury, and proximate causation. Dr. Ampil, as the
lead surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividad’s body before
closure of the incision. When he failed to do so, it was his duty to inform Natividad about it. Dr. Ampil
breached both duties. Such breach caused injury to Natividad, necessitating her further examination by
American doctors and another surgery. That Dr. Ampil’s negligence is the proximate cause of Natividad’s
injury could be traced from his act of closing the incision despite the information given by the attending
nurses that 2 pieces of gauze were still missing. That they were later on extracted from Natividad’s vagina
established the causal link between Dr. Ampil’s negligence and the injury. And what further aggravated
such injury was his deliberate concealment of this missing gauzes from the knowledge of Natividad and
her family.
The requisites for the applicability of the doctrine of RES IPSA LIQUITOR are:
1. The accident is of a kind which ordinarily does not occur in the absence of someone’s negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or defendants;
3. The possibility of contributing conduct which would make the plaintiff responsible is eliminated.

Of the foregoing, the most instrumental is the “Control and management of the thing which caused the
injury.”
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.
The knowledge of any of the staff of Medical City constitutes knowledge of PSI.
The doctrine of corporate responsibility, has the duty to see that it meets the standards of
responsibilities for the care of patients. Such duty includes the proper supervision of the members of its
medical staff. The hospital accordingly has the duty to make a reasonable effort to monitor and oversee
the treatment prescribed and administered by the physician practicing in its premises.
 G. EXPERT WITNESS

CRITERIA IN QUALIFYING AS AN EXPERT WITNESS

The competence of an expert witness is a matter for the trial court to decide upon in the exercise of its
discretion. The test of qualification is necessarily a relative one, depending upon the subject matter of
the investigation, and the fitness of the expert witness. In our jurisdiction, the criterion remains to be the
expert witness’ special knowledge experience and practical training that qualify him/her to explain highly
technical medical matters to the Court.

In Ramos v. Court of Appeals, the Court found the expert witness, who is a pulmonologist, not qualified to
testify on the field of anesthesiology. Similarly, in Cereno v. Court of Appeals, a 2012 case involving
medical negligence, the Court excluded the testimony of an expert witness whose specialty was
anesthesiology, and concluded that an anesthesiologist cannot be considered an expert in the field of
surgery or even in surgical practices and diagnosis.

A close scrutiny of Ramos and Cereno reveals that the Court primarily based the witnesses’
disqualification to testify as an expert on their incapacity to shed light on the standard of care that must
be observed by the defendant-physicians. That the expert witnesses’ specialties do not match the
physicians’ practice area only constituted, at most, one of the considerations that should not be taken out
of context. After all, the sole function of a medical expert witness, regardless of his/her specialty, is to
afford assistance to the courts on medical matters, and to explain the medical facts in issue.

Furthermore, there was no reasonable indication in Ramos and Cereno that the expert witnesses possess
a sufficient familiarity with the standard of care applicable to the physicians’ specialties. US jurisprudence
on medical malpractice demonstrated the trial courts’ wide latitude of discretion in allowing a specialist
from another field to testify against a defendant specialist.

In Brown v. Sims, a neurosurgeon was found competent to give expert testimony regarding a
gynecologist's standard of pre-surgical care. In that case, the court held that since negligence was not
predicated on the gynecologist’s negligent performance of the operation, but primarily on the claim that
the pre-operative histories and physicals were inadequate, the neurosurgeon was competent to testify as
an expert.

Frost v. Mayo Clinic also allowed an orthopedic surgeon to testify against a neurologist in a medical
malpractice action. The court considered that the orthopedic surgeon’s opinion on the "immediate need
for decompression" need not come from a specialist in neurosurgery. The court held that:
It is well established that "the testimony of a qualified medical doctor cannot be excluded simply because
he is not a specialist x x x." The matter of "x x x training and specialization of the witness goes to the
weight rather than admissibility x x x."

It did not appear to the court that a medical doctor had to be a specialist in neurosurgery to express the
opinions permitted to be expressed by plaintiffs’ doctors, e.g., the immediate need for a decompression
in the light of certain neurological deficits in a post-laminectomy patient. As stated above, there was no
issue as to the proper execution of the neurosurgery. The medical testimony supported plaintiffs’ theory
of negligence and causation.

In another case, the court declared that it is the specialist’s knowledge of the requisite subject matter,
rather than his/her specialty that determines his/her qualification to testify.

Also in Evans v. Ohanesian, the court set a guideline in qualifying an expert witness:

To qualify a witness as a medical expert, it must be shown that the witness

(1) has the required professional knowledge, learning and skill of the subject under inquiry sufficient to
qualify him to speak with authority on the subject; and
(2) is familiar with the standard required of a physician under similar circumstances; where a witness has
disclosed sufficient knowledge of the subject to entitle his opinion to go to the jury, the question of the
degree of his knowledge goes more to the weight of the evidence than to its admissibility.
xxxx
Nor is it critical whether a medical expert is a general practitioner or a specialist so long as he exhibits
knowledge of the subject. Where a duly licensed and practicing physician has gained knowledge of the
standard of care applicable to a specialty in which he is not directly engaged but as to which he has an
opinion based on education, experience, observation, or association with that specialty, his opinion is
competent.

Finally, Brown v. Mladineo adhered to the principle that the witness’ familiarity, and not the classification
by title or specialty, which should control issues regarding the expert witness’ qualifications:
The general rule as to expert testimony in medical malpractice actions is that "a specialist in a particular
branch within a profession will not be required." Most courts allow a doctor to testify if they are satisfied
of his familiarity with the standards of a specialty, though he may not practice the specialty himself. One
court explained that "it is the scope of the witness’ knowledge and not the artificial classification by title
that should govern the threshold question of admissibility. (Casumpang vs Cortejo G.R. No. 171127
March 11, 2015)