LEGAL MEDICINE

CASE DIGESTS

1. LUTHER A. CUSTODIO* v. SANDIGANBAYAN, GR NOS. 96027-28, 2005-03-08

Criminal Procedure; Newly discovered evidence as a ground for new trial which in this case is of no merit
since it does not comply with the rules of court because the evidence was readily available at the time
before final judgment.

Facts: Petitioners were members of the military who acted as Senator Aquino’s security detail upon his
arrival in Manila from his sojourn in the United States.

They were charged, together with several other members of the military, before the Sandiganbayan for
the killing of Senator Aquino who was fatally shot as he was coming down from the aircraft of China
Airlines at the Manila International Airport. Petitioners were also indicted for the killing of Rolando Galman
who was also gunned down at the airport tarmac.

Sandiganbayan rendered a Decision acquitting all the accused, which include the petitioners.
Proceedings before the Sandiganbayan were later found by SC to be a sham trial. The SC nullified said
proceedings, as well as the judgment of acquittal, and ordered a re-trial of the cases which found the
petitioners guilty as principals o the crime of murder.

Petitioners sought legal assistance from the Chief Public Attorney who, in turn, requested the
Independent Forensic Group of the University of the Philippines to make a thorough review of the forensic
evidence in the double murder case. The petitioners now want to present the findings of the forensic
group to this Court and ask the Court to allow the re-opening of the cases and the holding of a third trial to
determine the circumstances surrounding the death of Senator Benigno Aquino, Jr. and Rolando Galman.

Petitioners invoke the following grounds for the re-opening of the case:

1. Existence of newly discovered pieces of evidence that were not available during the second
trial of the above-entitled cases which could have altered the judgment of the Sandiganbayan,
specifically:

A) Independent forensic evidence uncovering the false forensic claims that led to the
unjust conviction of the petitioners-movants.

Their report essentially concludes that it was not possible, based on the forensic study of the evidence in
the double murder case, that C1C Rogelio Moreno fired at Senator Aquino as they descended the service
stairway from the aircraft. They posit that Senator Aquino was shot while he was walking on the airport
tarmac toward the waiting AVSECOM van which was supposed to transport him from the airport to Fort
Bonifacio. This is contrary to the finding of the Sandiganbayan in the second trial that it was C1C Moreno,
the security escort positioned behind Senator Aquino, who shot the latter. The report also suggests that
the physical evidence in these cases may have been misinterpreted and manipulated to mislead the
court. Thus, petitioners assert that the decision of the Sandiganbayan should be voided as it was based
on false forensic evidence. Petitioners submit that the review by the forensic group of the physical
evidence in the double murder case constitutes newly discovered evidence which would entitle them to a
new trial under Rule 121 of the 2000 Rules of Criminal Procedure.

Issue: Are the petitioners entitled to a new trial? NO

Ruling: NO. Applying the newly discovered evidence tests, SC find that petitioners’ purported evidence
does not qualify as newly discovered evidence that would justify the re-opening of the case and the
holding of a third trial.

The report of the forensic group may not be considered as newly discovered evidence as petitioners
failed to show that it was impossible for them to secure an independent forensic study of the physical
evidence during the trial of the double murder case. It appears from their report that the forensic group
used the same physical and testimonial evidence preferred during the trial, but made their own analysis
and interpretation of said evidence. They cited the materials and methods that they used for their study,
viz:

MATERIALS AND METHODS

MATERIALS:

a. Court records of the case, especially photographs of: a) the stairway where the late Sen.
Aquino and his escorts descended; b) the part of the tarmac where the lifeless bodies of the late
Sen. Aquino and Galman fell; and c) the autopsy conducted by the NBI Medico-legal team
headed by Dr. Mu[ñ]oz; and the autopsy report of the late Sen. Benigno Aquino[,] Jr. signed by
Dr. Mu[ñ]oz and Dr. Solis;

b. The gun and live ammunitions collected at the crime scene;

c. A reference human skull photos and X-rays of the same to demonstrate wound location and
bullet trajectory;

d. The reports of interviews and statements by the convicted military escorts, and other
witnesses;

e. Re-enactment of the killing of Aquino based on the military escorts[’] version, by the military
escorts themselves in the Bilibid Prison and by volunteers at the NAIA Tarmac;

f. Various books and articles on forensic and the medico-legal field[;]

g. Results of Forensic experiments conducted in relation to the case.

METHODS:

a. Review of the forensic exhibits presented in the court;

b. Review of TSNs relevant to the forensic review;

c. Study of and research on the guns, slugs and ammunitions allegedly involved in the crime;

d. Interviews/re-enactment of the crime based on the military’s accounts, both in the Bilibid Prison
where the convicts are confined and the MIA (now NAIA) stairway and tarmac;

e. Conduct of ocular inspection and measurements on the actual crime scene (stairway and
tarmac) at the old Manila International Airport (now NAIA);
 f. Retracing the slug’s trajectory based on the autopsy reports and experts’ testimonies using an
actual human skull;

g. X-rays of the skull with the retraced trajectory based on the autopsy report and experts’
testimonies;

h. Evaluation of the presented facts and opinions of local experts in relation to accepted forensic
findings in international publications on forensic science, particularly on guns and [gunshot]
wound injuries;

i. Forensic experiments and simulations of events in relation to this case.

These materials were available to the parties during the trial and there was nothing that prevented the
petitioners from using them at the time to support their theory that it was not the military, but Rolando
Galman, who killed Senator Aquino. Petitioners, in their present motion, failed to present any new
forensic evidence that could not have been obtained by the defense at the time of the trial even with the
exercise of due diligence. If they really wanted to seek and offer the opinion of other forensic experts at
the time regarding the physical evidence gathered at the scene of the crime, there was ample opportunity
for them to do so before the case was finally submitted and decided.

The finding that the fatal bullet which killed Sen. Benigno Aquino, Jr. was directed downwards sustains
the allegation of prosecution eyewitnesses to the effect that Sen. Benigno Aquino, Jr. was shot by a
military soldier at the bridge stairs while he was being brought down from the plane. Rebecca Quijano
saw that the senator was shot by the military man who was directly behind the Senator while the Senator
and he were descending the stairs. Rebecca Quijano’s testimony in this regard is echoed by Jessie
Barcelona, Ramon Balang, Olivia Antimano, and Mario Laher, whose testimonies this Court finds likewise
as credible.

The downward trajectory of the bullet having been established, it stands to reason that the gun used in
shooting the Senator was fired from an elevation higher than that of the wound of entrance at the back of
the head of the Senator. This is consistent with the testimony of prosecution witnesses to the effect that
the actual killer of the Senator shot as he stood at the upper step of the stairs, the second or third behind
Senator Aquino, while Senator Aquino and the military soldiers bringing him were at the bridge stairs.
This is likewise consistent with the statement of Sandra Jean Burton that the shooting of Senator Aquino
occurred while the Senator was still on the bridge stairs, a conclusion derived from the fact that the fatal
shot was fired ten (10) seconds after Senator Aquino crossed the service door and was led down the
bridge stairs.

The wound of entrance having been at a higher elevation than the wound of exit, there can be no other
conclusion but that the trajectory was downward. The fatal bullet, whether it be a Smith and Wesson
Caliber .357 magnum revolver or a .45 caliber, must have traveled at a fast rate of speed and it stands to
reason that it took a straight path from the wound of entrance to the wound of exit. A hole indicating this
straight path was proven to have existed. If, as contended on cross-examination by Dr. Bienvenido
Muñoz, that the bullet was projected upwards, it ought to have exited at the roof of the head.

The report of the forensic group essentially reiterates the theory presented by the defense during the trial
of the double murder case. Clearly, the report is not newly discovered, but rather recently sought, which is
not allowed by the Rules. If at all, it only serves to discredit the version of the prosecution which had
already been weighed and assessed, and thereafter upheld by the Sandiganbayan. a new trial will only
be allowed if the new evidence is of such weight that it would probably change the judgment if admitted.
Also, new trial will not be granted if the new evidence is merely cumulative, corroborative or impeaching.

Finally, SC was not moved by petitioners’ assertion that the forensic evidence may have been
manipulated and misinterpreted during the trial of the case. Again, petitioners did not allege concrete
facts to support their crass claim. Hence, we find the same to be unfounded and purely speculative.

2. ARNEL L. AGUSTIN v. CA, GR NO. 162571, 2005-06-15

REMEDIAL LAW; EVIDENCE; DNA PATERNITY TESTING can be ordered by a competent court to be
done without infringing on the constitutional right to self-incrimination and not violative to right of privacy.

Facts: Respondents Fe Angela and her son Martin Prollamante sued Martin’s alleged biological father,
petitioner Arnel L. Agustin, for support and support pendente lite before the RTC of Quezon.

Arnel had an intimate relationship with Fe. Arnel supposedly impregnated Fe on her 34th birthday.
Despite Arnel’s insistence on abortion, Fe decided otherwise and gave birth to their child out of wedlock.
The baby’s birth certificate was purportedly signed by Arnel as the father. Arnel shouldered the pre-natal
and hospital expenses but later refused Fe’s repeated requests for Martin’s support despite his adequate
financial capacity and even suggested to have the child committed for adoption. Arnel also denied having
fathered the child.

While Fe was carrying five-month old Martin at a parking lot, Arnel sped off in his van, with the open car
door hitting Fe’s leg. Fe was diagnosed with leukemia and has, since then, been undergoing
chemotherapy. Fe and Martin sued Arnel for support.

Arnel denied having sired Martin because his affair and intimacy with Fe had allegedly ended in 1998,
long before Martin’s conception. He claimed that Fe had at least one other secret lover. Arnel admitted
that their relationship started in 1993 but "he never really fell in love with (Fe) not only because (she) had
at least one secret lover, a certain Jun, but also because she proved to be scheming and overly
demanding and possessive. As a result, theirs was a stormy on-and-off affair. What started as a romantic
liaison between two consenting adults eventually turned out to be a case of fatal attraction where (Fe)
became so obsessed with (Arnel), to the point of even entertaining the idea of marrying him, that she
resorted to various devious ways and means to alienate (him) from his wife and family.

Fe and Martin moved for the issuance of an order directing all the parties to submit themselves to DNA
paternity testing pursuant to Rule 28 of the Rules of Court.

Arnel opposed said motion by invoking his constitutional right against self-incrimination. He also moved to
dismiss the complaint for lack of cause of action, considering that his signature on the birth certificate was
a forgery and that, under the law, an illegitimate child is not entitled to support if not recognized by the
putative father. The trial court denied the motion to dismiss the complaint and ordered the parties to
submit themselves to DNA paternity testing at the expense of the applicants. The Court of Appeals
affirmed the trial court.
Issue: (1) whether a complaint for support can be converted to a petition for recognition? YES

(2) whether DNA paternity testing can be ordered in a proceeding for support without violating
petitioner’s constitutional right to privacy and right against self-incrimination? YES

Ruling: (1) The assailed resolution and order did not convert the action for support into one for
recognition but merely allowed the respondents to prove their cause of action against petitioner who had
been denying the authenticity of the documentary evidence of acknowledgement. But even if the assailed
resolution and order effectively integrated an action to compel recognition with an action for support, such
was valid and in accordance with jurisprudence. Whether or not respondent Martin is entitled to support
depends completely on the determination of filiation. A separate action will only result in a multiplicity of
suits, given how intimately related the main issues in both cases are. The declaration of filiation is entirely
appropriate to these proceedings.

(2) SC in 2001 opened the possibility of admitting DNA as evidence of parentage, as enunciated in Tijing
v. Court of Appeals:23

Parentage will still be resolved using conventional methods unless SC adopts the modern and scientific
ways available. Fortunately, we have now the facility and expertise in using DNA test for identification and
parentage testing. The University of the Philippines Natural Science Research Institute (UP-NSRI) DNA
Analysis Laboratory has now the capability to conduct DNA typing using short tandem repeat (STR)
analysis. The analysis is based on the fact that the DNA of a child/person has two (2) copies, one copy
from the mother and the other from the father. The DNA from the mother, the alleged father and child are
analyzed to establish parentage. Of course, being a novel scientific technique, the use of DNA test as
evidence is still open to challenge. Eventually, as the appropriate case comes, courts should not hesitate
to rule on the admissibility of DNA evidence. For it was said, that courts should apply the results of
science when competently obtained in aid of situations presented, since to reject said result is to deny
progress.

The first real breakthrough of DNA as admissible and authoritative evidence in Philippine jurisprudence
came in 2002 with our en banc decision in People v. Vallejo where the rape and murder victim’s DNA
samples from the bloodstained clothes of the accused were admitted in evidence.

in Tecson, et al. v. COMELEC26 where the Court en banc was faced with the issue of filiation of then
presidential candidate Fernando Poe Jr., we stated:

In case proof of filiation or paternity would be unlikely to satisfactorily establish or would be difficult to
obtain, DNA testing, which examines genetic codes obtained from body cells of the illegitimate child and
any physical residue of the long dead parent could be resorted to. A positive match would clear up filiation
or paternity. In Tijing vs. Court of Appeals, this Court has acknowledged the strong weight of DNA
testing…

Moreover, in our en banc decision in People v. Yatar,27 we affirmed the conviction of the accused for rape
with homicide, the principal evidence for which included DNA test results. SC did a lengthy discussion of
DNA, the process of DNA testing and the reasons for its admissibility in the context of our own Rules of
Evidence:
Deoxyribonucleic Acid, or DNA, is a molecule that encodes the genetic information in all living organisms.
A person’s DNA is the same in each cell and it does not change throughout a person’s lifetime; the DNA
in a person’s blood is the same as the DNA found in his saliva, sweat, bone, the root and shaft of hair,
earwax, mucus, urine, skin tissue, and vaginal and rectal cells. Most importantly, because of
polymorphisms in human genetic structure, no two individuals have the same DNA, with the notable
exception of identical twins.

xxx xxx xxx

In assessing the probative value of DNA evidence, courts should consider, inter alia, the following factors:
how the samples were collected, how they were handled, the possibility of contamination of the samples,
the procedure followed in analyzing the samples, whether proper standards and procedures were
followed in conducting the tests, and the qualification of the analyst who conducted the tests.

Significantly, SC uphelds the constitutionality of compulsory DNA testing and the admissibility of the
results thereof as evidence.

Over the years, SC has expressly excluded several kinds of object evidence taken from the person of the
accused from the realm of self-incrimination. These include photographs, hair, and other bodily
substances. SC also declared as constitutional several procedures performed on the accused such as
pregnancy tests for women accused of adultery, expulsion of morphine from one’s mouth and the tracing
of one’s foot to determine its identity with bloody footprints. Some of these procedures were, to be sure,
rather invasive and involuntary, but all of them were constitutionally sound. DNA testing and its results,
per our ruling in Yatar, are now similarly acceptable.

Petitioner’s case involves neither and, as already stated, his argument that his right against self-
incrimination is in jeopardy holds no water. His hollow invocation of his constitutional rights elicits no
sympathy here for the simple reason that they are not in any way being violated. If, in a criminal case, an
accused whose very life is at stake can be compelled to submit to DNA testing, we see no reason why, in
this civil case, petitioner herein who does not face such dire consequences cannot be ordered to do the
same.

DNA paternity testing first came to prominence in the United States, where it yielded its first official results
sometime in 1985. In the decade that followed, DNA rapidly found widespread general acceptance.
Several cases decided by various State Supreme Courts reflect the total assimilation of DNA testing into
their rules of procedure and evidence.

The foregoing considered, SC finds no grave abuse of discretion on the part of the public respondent for
upholding the orders of the trial court which both denied the petitioner’s motion to dismiss and ordered
him to submit himself for DNA testing. For too long, illegitimate children have been marginalized by
fathers who choose to deny their existence. The growing sophistication of DNA testing technology finally
provides a much needed equalizer for such ostracized and abandoned progeny. We have long believed
in the merits of DNA testing and have repeatedly expressed as much in the past. This case comes at a
perfect time when DNA testing has finally evolved into a dependable and authoritative form of evidence
gathering. We therefore take this opportunity to forcefully reiterate our stand that DNA testing is a valid
means of determining paternity.
3. PEOPLE V VALLEJO GR NO. 144656 2002-05-09

PEOPLE v. GERRICO VALLEJO Y SAMARTINO, GR No. 144656, 2002-05-09

Facts:

This is an appeal from the decision of the RTC sentencing Gerrico Vallejo y Samartino to DEATH for the
rape-slaying of a 9-year old child Daisy Diolola on July 10, 1999.

Ten (10) witnesses testified for the prosecution. (for purposes of legal med, only the mother and the
members of the medical team are included)

The victim's mother, Ma. Nida Diolola sent her 9-year old daughter Daisy Diolola to their neighbor's
house, Aimee Vallejo, the sister of accused-appellant, to help Daisy with her lessons.

An hour later, Daisy came back with accused-appellant. They were looking for a book which accused-
appellant could copy to make a drawing or a poster that Daisy would submit to her teacher.

At about 5:30 PM, Daisy was not yet home, mother, proceeded to the house of Aimee, but she was not
there.

At about 10:00 o'clock in the morning of June 11, 1999, she was informed that the dead body of her
daughter was found tied to the root of an aroma tree by the river after the "compuerta" Daisy was wearing
her pink short pants with her sleeveless shirt tied around her neck.

Ma. Nida pointed to accused-appellant Gerrico Vallejo as the probable suspect since he was with the
victim when she was last seen alive.

Dr. Antonio S. Vertido, NBI Medico-Legal Officer, testified that at about 9:00 o'clock in the evening of
July 11, 1999, he conducted a physical examination of accused-appellant. There were abrasions,
hematoma and lacerations on the accused-appellant.

At about 10:00 o'clock in the evening, Dr. Vertido went for an autopsy on the cadaver of the victim Daisy
Diolola.

"CAUSE OF DEATH: -Asphyxia by Manual Strangulation.

"GENITAL EXAMINATION: Hymen, moderately tall, thick with fresh lacerations, complete at 3:00, 6:00
and 9:00 o'clock positions, edges with blood clots."

Pet Byron Buan, Forensic Biologist of the NBI, testified that on July 12, 1999, he took blood samples
from accused-appellant in his office for laboratory examination to determine his blood type. Examinations
showed accused-appellant to belong to Group "O" but His basketball shirt; his athletic basketball short
pants; Daisy’s Hello Kitty T-shirt; pink short pants and small panty has presence of human blood showing
the reactions of the same Group "A"

NBI Forensic Biologist Pet Byron Buan took buccal swabs and hair samples from accused-appellant, as
well as buccal swabs and hair samples from the parents of the victim, namely, Ma. Nida Diolola and
ArnulfoDiolola.

Aida Viloria-Magsipoc, Forensic Chemist of the NBI, conducted DNA tests on the specimens collected
by Dr. Vertido. She testified that the vaginal swabs of the victim taken by Dr. Vertido during the autopsy
contained the DNA profiles of accused-appellant and the victim.
Issue1: Whether the bloodstains found on his garments were not proven to have been that of the victim
as the victim's blood type was not determined.

Ruling1: The contention has no merit. The examination conducted by Forensic Biologist Pet Byron Buan
of both accused-appellant's and the victim's clothing yielded bloodstains of the same blood type "A". Even
if there was no direct determination as to what blood type the victim had, it can reasonably be inferred
that the victim was blood type "A" since she sustained contused abrasions all over her body which would
necessarily produce the bloodstains on her clothing. That it was the victim's blood which predominantly
registered in the examination

Buan said during the hearing that, “it is possible when there is a huge amount of blood coming from the
victim and the suspect. It is possible. It will mix. Whichever is the dominant blood in it, it will be the one
which will register. For example, if there is more blood coming from the victim, that blood will be the one
to register, on occasions when the two blood mix.”

Issue2: Whether the method by which his bloodstained clothes were recovered is valid

Ruling2: YES. There is no showing, however, that accused-appellant was coerced or forced into
producing the garments. The accused-appellant accompanied the police to the back of the house where
dirty clothes were kept.

Indeed, that the accused-appellant voluntarily brought out the clothes sought by the police becomes more
convincing when considered together with his confessions. A consented warrantless search is an
exception to the proscription in Section 2 of Article III of the Constitution. As we have held, the consent of
the owner of the house to the search effectively removes any badge of illegality

Issue3: Whether the prosecution failed to show that all the samples submitted for DNA testing were not
contaminated, considering that these specimens were already soaked in smirchy waters before they were
submitted to the laboratory.

Ruling3: NO. According to NBI Forensic Chemist Aida MAgsipoc, it is the inadequacy of the specimens
submitted for examination, and not the possibility that the samples had been contaminated which
accounted for the negative results of their examination. But the vaginal swabs taken from the victim
yielded positive for the presence of human DNA. Upon analysis by the experts, they showed the DNA
profile of accused-appellant

She claimed that the specimens were soaked in smirchy water before they were submitted to the
laboratory. The state of the specimens prior to the DNA analysis could have hampered the preservation
of any DNA that could have been there before. So when serological methods were done on these
specimens, Mr. Byron could have taken such portion or stains that were only amenable for serological
method and were not enough for DNA analysis already. So negative results were found on the clothing
that were submitted

On the vaginal smears submitted by Dr. Vertido, the smear on the slide was very, very dry and could have
chipped off. And so upon examination, the smears geared negative results and the swabs gave positive
results, Sir.

On the hair and nails. The hair samples were cut hair. This means that the hair did not contain any root.
So any hair that is above the skin or the epidermis of one's skin would give negative results as the hair
shaft is negative for DNA. And then the nails did... not contain any subcutaneous cells that would be
amenable for DNA analysis also, Sir.
The decision of the Regional Trial Court finding accused-appellant Gerrico Vallejo y Samartino
GUILTY beyond reasonable doubt of the crime of Rape with Homicide and sentencing him to the
supreme penalty of DEATH is hereby AFFIRMED.

************** ADDITIONAL INFO ABOUT DNA*********************

DNA is an organic substance found in a person's cells which contains his or her genetic code. Except for
identical twins, each person's DNA profile is distinct and unique

When a crime is committed, material is collected from the scene of the crime or from the victim's body for
the suspect's DNA. This is the evidence sample. The evidence sample is then matched with the
reference sample taken from the suspect and the victim

The purpose of DNA testing is to ascertain whether an association exists between the evidence sample
and the reference sample. The samples collected are subjected to various chemical processes to
establish their profile

The test may yield three possible results:

1. The samples are different and therefore must have originated from different sources (exclusion).
This conclusion is absolute and requires no further analysis or discussion;
2. It is not possible to be sure, based on the results of the test, whether the samples have similar
DNA types (inconclusive). This might occur for a variety of reasons including degradation,
contamination, or failure of some aspect of the protocol. Various parts of... the analysis might
then be repeated with the same or a different sample, to obtain a more conclusive result; or
3. The samples are similar, and could have originated from the same source (inclusion)

In assessing the probative value of DNA evidence, therefore, courts should consider, among
other things, the following data: how the samples were collected, how they were handled, the
possibility of contamination of the samples, the procedure followed in analyzing the samples,
whether the proper standards and procedures were followed in conducting the tests, and the
qualification of the analyst who conducted the tests.

4. RAMOS V CA GR NO. 124354 1999-12-29

ROGELIO E. RAMOS v. CA, GR No. 124354, 1999-12-29

Facts: Plaintiff Erlinda Ramos was a 47-year old robust woman. Except for occasional complaints of
discomfort due to pains allegedly caused by the presence of a stone in her gall bladder, she was as
normal as any other woman.

She was advised to undergo an operation for the removal of a stone in her gall bladder. She underwent a
series of examinations which included blood and urine tests which indicated she was fit for surgery.

The date at the operating table at the DLSMC (another defendant), would be on June 17, 1985 at 9:00
A.M.Dr. Hosaka decided that she should undergo a "cholecystectomy" operation after examining the
documents (findings from the Capitol Medical Center, FEU Hospital and DLSMC) presented to him.

Rogelio E. Ramos, however, asked Dr. Hosaka to look for a good anesthesiologist and that he will get a
good anesthesiologist.
At the operating room, Herminda, sis-in-law saw two or three nurses and Dr. Perfecta Gutierrez, the other
defendant, who was to administer anesthesia. Herminda introduced herself as Dean of the College of
Nursing at the Capitol Medical Center so she was allowed to stay inside the operating room.

At about 12:15 P.M., 3- hours later, Herminda Cruz, who was inside the operating room with the patient,
heard somebody say that "Dr. Hosaka is already here." Dr Gutierrez started intubating the hapless
patient, She thereafter heard Dr. Gutierrez say, "ang hirap ma-intubate nito, mali yata ang pagkakapasok.
O lumalaki ang tiyan"

Herminda thereafter noticed bluish discoloration of the nail beds of the left hand. She then heard Dr.
Hosaka issue an order for someone to call Dr. Calderon another anesthesiologist

After Dr. Calderon arrived at the operating room, she saw this anesthesiologist trying to intubate the
patient. The patient's nail bed became bluish and the patient was placed in a trendelenburg position done
in cases where there is a decrease of blood supply to the patient's brain

Dr. Calderon was then able to intubate the patient. At almost 3:00 P.M. of that fateful day, she saw the
patient taken to the Intensive Care Unit (ICU).

Doctors Gutierrez and Hosaka were asked by the hospital to explain what happened, so they claimed that
the patient had bronchospasm

Petitioners filed a civil case for damages against herein private respondents alleging negligence in the
management and care of Erlinda Ramos.

RTC: rendered judgment in favor of petitioners

On the part of Dr. Perfecta Gutierrez, this Court finds that she omitted to exercise reasonable care in
intubating the patient. For after she committed a mistake in intubating [the] patient, the patient's nailbed
became bluish and the patient, thereafter, was placed in trendelenburg position, because of the decrease
of blood supply to the patient's brain. The evidence further shows that the hapless patient suffered brain
damage because of the absence of oxygen in her (patient's) brain for approximately four to five minutes
which, in turn, caused the patient to become comatose.

On the part of Dr. Orlino Hosaka, this Court finds that he is liable for the acts of Dr. Perfecta Gutierrez
whom he had chosen to administer anesthesia on the patient as part of his obligation to provide the
patient a `good anesthesiologist', and for arriving for the scheduled operation almost three (3) hours late.

On the part of DLSMC (the hospital), this Court finds that it is liable for the acts of negligence of the
doctors in their `practice of medicine' in the operating room. Moreover, the hospital is liable for failing
through its responsible officials, to cancel the scheduled operation after Dr. Hosaka inexcusably failed to
arrive on time.

CA: reversing the findings of the trial court.

The appellate court likewise opined that private respondents were able to show that the brain damage
sustained by Erlinda was not caused by the alleged faulty intubation but was due to the allergic reaction
of the patient to the drug Thiopental Sodium (Pentothal), a short-acting barbiturate, as testified on by their
expert witness, Dr. Jamora.

Issues: Whether the doctrine of res ipsa loquitur is applicable

Ruling: YES. We find the doctrine of res ipsa loquitur appropriate in the case at bar. The damage
sustained by Erlinda in her brain prior to a scheduled gall bladder operation presents a case for the
application of res ipsa loquitur.

A case strikingly similar to the one before us is Voss vs. Bridwell where the Kansas Supreme
Court in applying the res ipsa loquitur. The plaintiff herein submitted himself for a mastoid
operation and delivered his person over to the care, custody and control of his physician who had
complete and exclusive control over him, but the operation was never performed.

In the present case, Erlinda submitted herself for cholecystectomy and expected a routine general
surgery to be performed on her gall bladder.

On that fateful day she delivered her person over to the care, custody and control of private respondents
who exercised complete and exclusive control over her. Erlinda was neurologically sound and, except for
a few minor discomforts, was likewise physically fit in mind and body.

However, during the administration of anesthesia she suffered irreparable damage to her brain.
Obviously, brain damage, which Erlinda sustained, is an injury which does not normally occur in the
process of a gall bladder operation.

In fact, this kind of situation does not happen in the absence of negligence of someone in the
administration of anesthesia and in the use of endotracheal tube. Normally, a person being put under
anesthesia is not rendered decerebrate as a consequence of administering such anesthesia if the proper
procedure was followed.

Furthermore, the instruments used in the administration of anesthesia, including the endotracheal tube,
were all under the exclusive control of private respondents

Erlinda could not have been guilty of contributory negligence because she was under the influence of
anesthetics which rendered her unconscious.

Considering that a sound and unaffected member of the body (the brain) is injured or destroyed while the
patient is unconscious and under the immediate and exclusive control of the physicians, we hold that a
practical administration of justice dictates the application of res ipsa loquitur.

Issues: Whether the Court of Appeals erred in finding that private respondents were not negligent

Ruling: YES.

Dra. Gutierrez - we find her negligent in the care of Erlinda during the anesthesia phase. Dra. Gutierrez
failed to properly intubate the patient.

Court of Appeals is trying to impress that Herminda (sis-in-law who witnessed) being a nurse, and
considered a layman in the process of intubation, is not competent to testify on whether or not the
intubation was a success.

Although witness Herminda is not an anesthesiologist, she can very well testify upon matters on which
she is capable of observing such as, the statements and acts of the physician and surgeon, external
appearances, and manifest conditions which are observable by any one.

This is precisely allowed under the doctrine of res ipsa loquitur where the testimony of expert witnesses is
not required. This kind of observation, we believe, does not require a medical degree to be acceptable.
Dr. Orlino Hosaka - The responsibility of respondent Dr. Orlino Hosaka as the head of the surgical
team. As the so-called "captain of the ship,” it is the surgeon's responsibility to see to it that those under
him perform their task in the proper manner.

Respondent Dr. Hosaka's negligence can be found in his failure to exercise the proper authority (as the
"captain" of the operative team) in not determining if his anesthesiologist observed proper anesthesia
protocols.

In fact, no evidence on record exists to show that respondent Dr. Hosaka verified if respondent Dra.
Gutierrez properly intubated the patient. Furthermore, it does not escape us that respondent Dr. Hosaka
had scheduled another procedure in a different hospital at the same time as Erlinda's cholecystectomy,
and was in fact over three hours late for the latter's operation. Because of this, he had little or no time to
confer with his anesthesiologist regarding the anesthesia delivery. This indicates that he was remiss in his
professional duties towards his patient. Thus, he shares equal responsibility for the events which resulted
in Erlinda's condition.

HOSPITAL - We now discuss the responsibility of the hospital in this particular incident. The unique
practice (among private hospitals) of filling up specialist staff with attending and visiting "consultants,"who
are allegedly not hospital employees, presents problems in apportioning responsibility for negligence in
medical malpractice cases.

Hospitals exercise significant control in the hiring and firing of consultants and in the conduct of their work
within the hospital premises. Doctors who apply for "consultant" slots, visiting or attending, are required to
submit proof of completion of... residency, their educational qualifications; generally, evidence of
accreditation by the appropriate board (diplomate), evidence of fellowship in most cases, and references.
These requirements are carefully scrutinized by members of the hospital administration or by a review
committee set up by the hospital who either accept or reject the application.

Private hospitals, hire, fire and exercise real control over their attending and visiting "consultant" staff.
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. In assessing whether such a relationship in fact exists, the control test 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.

Issues: Whether the alleged negligence was the proximate cause of Erlinda's comatose condition.

Ruling: YES. We are inclined to believe petitioners' stand that it was the faulty intubation which was
the proximate cause of Erlinda's comatose condition.

Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by any
efficient intervening cause, produces injury, and without which the result would not have occurred.

Issues: Whether or not respondent hospital is solidarily liable with respondent doctors for
petitioner's condition.

Ruling: YES
The basis for holding an employer solidarily responsible for the negligence of its employee is found in
Article 2180 of the Civil Code which considers a person accountable not only for his own acts but also for
those of others based on the former's responsibility under a relationship of patria potestas.

Such responsibility ceases when the persons or entity concerned prove that they have observed the
diligence of a good father of the family to prevent damage.

In other words, while the burden of proving negligence rests on the plaintiffs, once negligence is shown,
the burden shifts to the respondents (parent, guardian, teacher or employer) who should prove that they
observed the diligence of a good father of a family to prevent damage.

In the instant case, respondent hospital, apart from a general denial of its responsibility over respondent
physicians, failed to adduce evidence showing that it exercised the diligence of a good father of a family
in the hiring and supervision of the latter. It failed to adduce... evidence with regard to the degree of
supervision which it exercised over its physicians. In neglecting to offer such proof, or proof of a similar
nature, respondent hospital thereby failed to discharge its burden under the last paragraph of Article
2180. Having failed to do... this, respondent hospital is consequently solidarily responsible with its
physicians for Erlinda's condition.

Based on the foregoing, we hold that the Court of Appeals erred in accepting and relying on the
testimonies of the witnesses for the private respondents. Indeed, as shown by the above discussions,
private respondents were unable to rebut the presumption of negligence. Upon these disquisitions we
hold that private respondents are solidarily liable for damages under Article 2176

Principles:

Res ipsa loquitur is a Latin phrase which literally means "the thing or the transaction speaks for itself."
The phrase "res ipsa loquitur" 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 plaintiff's prima facie case, and present a question of fact for defendant to meet with an
explanation.

Where the thing which caused the injury complained of is shown to be under the... management of the
defendant or his servants and the accident is such as in ordinary course of things does not happen if
those who have its management or control use proper care, it affords reasonable evidence, in the
absence of explanation by the defendant, that the accident... arose from or was caused by the
defendant's want of care.

The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a matter of common
knowledge and experience, the very nature of certain types of occurrences may justify an inference of
negligence on the part of the person who controls the instrumentality... causing the injury in the absence
of some explanation by the defendant who is charged with negligence.

It is grounded in the superior logic of ordinary human experience and on the basis of such experience or
common knowledge, negligence may be deduced... from the mere occurrence of the accident itself.

Hence, res ipsa loquitur is applied in conjunction with the doctrine of common knowledge. Res ipsa
loquitur is not a rule of substantive law, it is considered as merely evidentiary or in the nature of a
procedural rule.
Mere invocation and application of the doctrine does not dispense with the requirement of proof of
negligence. It is simply a step in the process of such proof, permitting the plaintiff to present along with
the proof of the accident, enough of the attending circumstances to invoke the doctrine, creating an
inference or presumption of negligence, and to thereby place on the defendant the burden of going
forward with the proof.

Requisites for RES IPSA LOQUITOR

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; and
3. The possibility of contributing conduct which would make the plaintiff responsible is eliminated
In the above requisites, the fundamental element is the "control of the instrumentality" which caused the
damage.

generally, expert medical testimony is relied upon in malpractice suits to prove that a physician has done
a negligent act or that he has deviated from the standard medical procedure, when the doctrine of res
ipsa loquitur is availed by the plaintiff, the need... for expert medical testimony is dispensed with because
the injury itself provides the proof of negligence.

Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to whether a
patient... has been treated or operated upon with a reasonable degree of skill and care. However,
testimony as to the statements and acts of physicians and surgeons, external appearances, and manifest
conditions which are observable by any one may be given by non-expert... witnesses.

5. NOGALES V CAPITOL MEDICAL CENTER 511 SCRA 204 2006-12-19

Facts: Corazon Nogales was under the exclusive prenatal care of Dr. Oscar Estrada beginning on her
fourth month of pregnancy. 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.

On the Liability of the Other Respondents

a) Dr. Ely Villaflor

Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause of Corazon's bleeding and to suggest
the correct remedy to Dr. Estrada. Petitioners assert that it was Dr. Villaflor's duty to correct the error of
Nurse Dumlao in the administration of hemacel.

The Court is not persuaded. Dr. Villaflor admitted administering a lower dosage of magnesium sulfate.
However, this was after informing Dr. Estrada that Corazon was no longer in convulsion and that her
blood pressure went down to a dangerous level. At that moment, Dr. Estrada instructed Dr. Villaflor to
reduce the dosage of magnesium sulfate from 10 to 2.5 grams. Since petitioners did not dispute Dr.
Villaflor's allegation, Dr. Villaflor's defense remains uncontroverted. Dr. Villaflor's act of administering a
lower dosage of magnesium sulfate was not out of her own volition or was in contravention of Dr.
Estrada's order.

b) Dr. Rosa Uy

Dr. Rosa Uy's alleged negligence consisted of her failure (1) to call the attention of Dr. Estrada on the
incorrect dosage of magnesium sulfate administered by Dr. Villaflor; (2) to take corrective measures; and
(3) to correct Nurse Dumlao's wrong method of hemacel administration.
The Court believes Dr. Uy's claim that as a second year resident physician then at CMC, she was merely
authorized to take the clinical history and physical examination of Corazon. However, that routine internal
examination did not ipso facto make Dr. Uy liable for the errors committed by Dr. Estrada. Further,
petitioners' imputation of negligence rests on their baseless assumption that Dr. Uy was present at the
delivery room. Nothing shows that Dr. Uy participated in delivering Corazon's baby. Further, it is
unexpected from Dr. Uy, a mere resident physician at that time, to call the attention of a more
experienced specialist, if ever she was present at the delivery room.

c) Dr. Joel Enriquez

Petitioners fault Dr. Joel Enriquez also for not calling the attention of Dr. Estrada, Dr. Villaflor, and Nurse
Dumlao about their errors. Petitioners insist that Dr. Enriquez should have taken, or at least suggested,
corrective measures to rectify such errors.

The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field of expertise is definitely not
obstetrics and gynecology. As such, Dr. Enriquez was not expected to correct Dr. Estrada's errors.
Besides, there was no evidence of Dr. Enriquez's knowledge of any error committed by Dr. Estrada and
his failure to act upon such observation.

d) Dr. Perpetua Lacson

Petitioners fault Dr. Perpetua Lacson for her purported delay in the delivery of blood Corazon needed.
Petitioners claim that Dr. Lacson was remiss in her duty of supervising the blood bank staff.

As found by the trial court, there was no unreasonable delay in the delivery of blood from the time of the
request until the transfusion to Corazon. Dr. Lacson competently explained the procedure before blood
could be given to the patient. Taking into account the bleeding time, clotting time and cross-matching, Dr.
Lacson stated that it would take approximately 45-60 minutes before blood could be ready for transfusion.
Further, no evidence exists that Dr. Lacson neglected her duties as head of the blood bank.

e) Dr. Noe Espinola

Petitioners argue that Dr. Espinola should not have ordered immediate hysterectomy without determining
the underlying cause of Corazon's bleeding. Dr. Espinola should have first considered the possibility of
cervical injury, and advised a thorough examination of the cervix, instead of believing outright Dr.
Estrada's diagnosis that the cause of bleeding was uterine atony.

Dr. Espinola's order to do hysterectomy which was based on the information he received by phone is not
negligence. The Court agrees with the trial court's observation that Dr. Espinola, upon hearing such
information about Corazon's condition, believed in good faith that hysterectomy was the correct remedy.
At any rate, the hysterectomy did not push through because upon Dr. Espinola's arrival, it was already too
late. At the time, Corazon was practically dead.

f) Nurse J. Dumlao

In Moore v. Guthrie Hospital Inc., the US Court of Appeals, Fourth Circuit, held that to recover, a patient
complaining of injuries allegedly resulting when the nurse negligently injected medicine to him
intravenously instead of intramuscularly had to show that (1) an intravenous injection constituted a lack of
reasonable and ordinary care; (2) the nurse injected medicine intravenously; and (3) such injection was
the proximate cause of his injury.
In the present case, there is no evidence of Nurse Dumlao's alleged failure to follow Dr. Estrada's specific
instructions. Even assuming Nurse Dumlao defied Dr. Estrada's order, there is no showing that side-drip
administration of hemacel proximately caused Corazon's death. No evidence linking Corazon's death and
the alleged wrongful hemacel administration was introduced. Therefore, there is no basis to hold Nurse
Dumlao liable for negligence.

6. PROFESSIONAL SERVICES, INC. V AGANA 513 SCRA 478 2007-01-31

Gr No 126297, 126467, 127590

Facts:

· April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital because of difficulty
of bowel movement and bloody anal discharge. Dr, Miguel Ampil diagnosed her to be suffering from
“cancer of the sigmoid”

· April 11, 1984, Dr. Ampil, assisted by the medical staff of the Medical City Hospital, performed an
anterior resection surgery on Natividad. He found that the malignancy in 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.

· However, the operation appeared to be flawed. In the corresponding Record of Operation dated April
11, 1984, the attending nurses entered these remarks:
o “sponge count lacking 2
o “announced to surgeon searched (sic) done but to no avail continue for closure.”

· After a couple of days, Natividad complained of excruciating pain in her anal region but was told that
the pain was the natural consequence of the surgery, and was recommended to consult an oncologist

· Natividad and husband went to US to seek further treatment. After 4 months, she was told that she
was free of cancer

· Two after her return, her daughter found a piece of gauze protruding from her vagina

· Upon being informed, Dr Ampil proceeded to her house where he managed to extract by hand a
piece of gauze measuring 1.5 inches in width; and assuring her that the pains would soon vanish but did
not come true

· The pains intensified, prompting Natividad to seek treatment at the Polymedic General Hospital.

· Dr. Ramon Gutierrez detected the presence of another foreign object in her vagina—a foul-smelling
gauze measuring 1.5 inches in width which badly infected her vaginal vault. A rectovaginal fistula had
formed in her reproductive organs which forced stool to excrete through the vagina.
· Another surgical operation was needed to remedy the damage

· Natividad and husband filed with the RTC Quezon city a complaint for damages against Professional
Service Inc, owner of the Medical City Hospital, Dr Ampil and Dr Fuentes
o Alleged that the latter are liable for negligence for leaving two pieces of gauze inside
Natividad’s body and malpractice for concealing their acts of negligence

· Enrique Agana also filed with the PRC an administrative complaint for gross negligence and
malpractice against Dr. Ampil and Dr. Fuentes
o PRC Board of Medicine heard the case only with respect to Dr Fuentes because it
failed to acquire jurisdiction over Dr Ampil who was in US

· Natividad died, pending the cases, and was duly substituted by her children

· RTC decided in favor of the Aganas, and opposing party Appealed to CA

o Dismissed case against Dr Fuentes; Dr Ampil is liable to reimburse PSI

· PRC Board of Med dismissed the case against Dr Fuentes

o Prosec failed to show that Dr Fuentes was the one who left the two pieces of gauze
inside Natividad’s body and he concealed such fact

In GR 126297, PSI alleged:

· that the CA erred in holding that:

· (1) it is estopped from raising the defense that Dr. Ampil is not its employee;

· (2) it is solidarily liable with Dr. Ampil; and

· (3) it is not entitled to its counterclaim against the Aganas. PSI contends that Dr. Ampil is not its
employee, but a mere consultant or independent contractor. As such, he alone should answer for his
negligence.

In GR 126467, Aganas maintained that CA:

· Erred in finding that Dr Fuentes is not guilty of negligence or medical malpractice, invoking the
doctrine of res ipsa loquitor

· Pieces of gauze are prima facie proofs that the operating surgeons have been negligent

In GR 127590, Dr Ampil asserts that CA

· Erred in finding him liable without evidence that he left 2 pieces of gauze
· He pointed to other probable causes, such as:
o (1) it was Dr. Fuentes who used gauzes in performing the hysterectomy;
o (2) the attending nurses’ failure to properly count the gauzes used during surgery;
o and (3) the medical intervention of the American doctors who examined Natividad in
the US

Issue #1: whether CA erred in holding Dr Ampil liable for negligence and malpractice?

Ruling #1: No.

Dr Ampil argues:

· first, Dr Fuentes left the gauzes in Natividad’s body after performing hysterectomy

· second, the attending nurses erred in counting the gauzes

· third, American doctors were the ones who placed the gauzes in her body

Court:

· Ampil’s arguments are purely conjectural and without basis

· Did not present evidence to rebut the correctness of the record of the operation
· The court is mindful that dr Ampil examined Dr Fuentes’ work and found it in order
· All major circumstances taken together directly point to Dr Ampil as the negligent party:
o First, it is not disputed that the surgeons used gauzes as sponges to control the
bleeding of the patient during the surgical operation.
o Second, immediately after the operation, the nurses who assisted in the surgery noted
in their report that the ‘sponge count (was) lacking 2’; that such anomaly was ‘announced
to surgeon’ and that a ‘search was done but to no avail’ prompting Dr. Ampil to ‘continue
for closure’ x x x.
o Third, after the operation, two (2) gauzes were extracted from the same spot of the
body of Mrs. Agana where the surgery was performed.

· 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 an inference of
negligence. There are even legions of authorities to the effect that such act is negligence per se.
· There are times when danger to a patient’s life precludes a surgeon from further searching missing
sponges or foreign objects left in the body. But this does not leave him free from any obligation.

· Even if it has been shown that a surgeon was required by the urgent necessities of the case to leave
a sponge in his patient’s abdomen, because of the dangers attendant upon delay, still, it is his legal duty
to so inform his patient within a reasonable time thereafter by advising her of what he had been
compelled to do. This is in order that she might seek relief from the effects of the foreign object left in her
body as her condition might permit.

Application:

· Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even
misled her that the pain she was experiencing was the ordinary consequence of her operation. Had he
been more candid, Natividad could have taken the immediate and appropriate medical remedy to remove
the gauzes from her body.

· To our mind, what was initially an act of negligence by Dr. Ampil has ripened into a deliberate
wrongful act of deceiving his patient.

· 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 put, 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 two 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 the missing gauzes from the knowledge of Natividad and her family

Issue #2: whether CA erred in absolving Dr Fuentes of any liability?

Ruling #2: NO.

Aganas maintained that CA:

· Erred in finding that Dr Fuentes is not guilty of negligence or medical malpractice, invoking the
doctrine of res ipsa loquitor

· Pieces of gauze are prima facie proofs that the operating surgeons have been negligent

Court: is not convinced

· res ipsa loquitur means “the thing speaks for itself.” It is 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 plaintiff’s prima facie case, and present a question of fact for defendant to meet
with an explanation.

· Stated differently, where the thing which caused the injury, without the fault of the injured, is under
the exclusive control of the defendant and the injury is such that it should not have occurred if he, having
such control used proper care, it affords reasonable evidence, in the absence of explanation that the
injury arose from the defendant’s want of care, and the burden of proof is shifted to him to establish that
he has observed due care and diligence.

· the requisites for the applicability of the doctrine of res ipsa loquitur are:
o (1) the occurrence of an injury;
o (2) the thing which caused the injury was under the control and management of the
defendant;
o (3) the occurrence was such that in the ordinary course of things, would not have
happened if those who had control or management used proper care; and
o (4) the absence of explanation by the defendant.

· Of the foregoing requisites, the most instrumental is the “control and management of the thing which
caused the injury.”

Application:

· We find the element of “control and management of the thing which caused the injury” to be wanting.
Hence, the doctrine of res ipsa loquitur will not lie.

· It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad.
o He requested the assistance of Dr. Fuentes only to perform hysterectomy when Dr.
Ampil found that the malignancy in her sigmoid area had spread to her left ovary.
o Dr. Fuentes performed the surgery and thereafter reported and showed his work to Dr.
Ampil.
· The latter examined it and finding everything to be in order, allowed Dr. Fuentes to leave the
operating room.

· Dr. Ampil then resumed operating on Natividad. He was about to finish the procedure when the
attending nurses informed him that two pieces of gauze were missing. A “diligent search” was conducted,
but the misplaced gauzes were not found. Dr. Ampil then directed that the incision be closed.

· During this entire period, Dr. Fuentes was no longer in the operating room and had, in fact, left the
hospital.

· 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. Their duty is to obey his orders. As stated
before, Dr. Ampil was the lead surgeon. In other words, he was the “Captain of the Ship.” That he
discharged such role is evident from his following conduct:
o (1) calling Dr. Fuentes to perform a hysterectomy;
o (2) examining the work of Dr. Fuentes and finding it in order;
o (3) granting Dr. Fuentes’ permission to leave; and
o (4) ordering the closure of the incision.

· To our mind, it was this act of ordering the closure of the incision notwithstanding that two pieces of
gauze remained unaccounted for, that caused injury to Natividad’s body. Clearly, the control and
management of the thing which caused the injury was in the hands of Dr. Ampil, not Dr. Fuentes.

· In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not per se create or
constitute an independent or separate ground of liability, being a mere evidentiary rule.

· In other words, mere invocation and application of the doctrine does not dispense with the
requirement of proof of negligence. Here, the negligence was proven to have been committed by Dr.
Ampil and not by Dr. Fuentes.

Issue #3: Whether PSI may be held solidarily liable for negligence of Dr Ampil?

Ruling #3: YES.

· In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of the Civil Code.

· A derivative of this provision is Article 2180, the rule governing vicarious liability under the doctrine of
respondeat superior.
 o professionals engaged by an employer, such as physicians, dentists, and pharmacists,
are not “employees” under this article because the manner in which they perform their
work is not within the control of the latter (employer).

· In other words, professionals are considered personally liable for the fault or negligence they commit
in the discharge of their duties, and their employer cannot be held liable for such fault or negligence.

· In the context of the present case, “a hospital cannot be held liable for the fault or negligence of a
physician or surgeon in the treatment or operation of patients.”

· The foregoing view is grounded on the traditional notion that the professional status and the very
nature of the physician’s calling preclude him from being classed as an agent or employee of a hospital,
whenever he acts in a professional capacity.

· It has been said that medical practice strictly involves highly developed and specialized knowledge,
such that physicians are generally free to exercise their own skill and judgment in rendering medical
services sans interference.

· Hence, when a doctor practices medicine in a hospital setting, the hospital and its employees are
deemed to subserve him in his ministrations to the patient and his actions are of his own responsibility.

· The “Schloendorff doctrine” regards a physician, even if employed by a hospital, as an independent

contractor because of the skill he exercises and the lack of control exerted over his work.
o Under this doctrine, hospitals are exempt from the application of the respondeat
superior principle for fault or negligence committed by physicians in the discharge of their
profession.

· In our shores, the nature of the relationship between the hospital and the physicians is rendered
inconsequential in view of our categorical pronouncement in Ramos v. Court of Appeals that for purposes
of apportioning responsibility in medical negligence cases, an employer-employee relationship in effect
exists between hospitals and their attending and visiting physicians.

· But the Ramos pronouncement is not our only basis in sustaining PSI’s liability. Its liability is also
anchored upon the agency principle of apparent authority or agency by estoppel and the doctrine of
corporate negligence which have gained acceptance in the determination of a hospital’s liability for
negligent acts of health professionals. The present case serves as a perfect platform to test the
applicability of these doctrines, thus, enriching our jurisprudence.

Apparent authority
· referred to as the “holding out” theory, or doctrine of ostensible agency or agency by estoppel

· it imposes liability, not as the result of the reality of a contractual relationship, but rather because of
the actions of a principal or an employer in somehow misleading the public into believing that the
relationship or the authority exists

· PSI publicly displays in the lobby of the Medical City Hospital the names and specializations of the
physicians associated or accredited by it

· it “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.”

· Indeed, PSI’s act is tantamount to holding out to the public that Medical City Hospital, through its
accredited physicians, offers quality health care services.

· By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications, the hospital
created the impression that they were its agents, authorized to perform medical or surgical services for its
patients.

· As expected, these patients, Natividad being one of them, accepted the services on the reasonable
belief that such were being rendered by the hospital or its employees, agents, or servants

Corporate negligence or corporate responsibility

· The doctrine has its genesis in Darling v. Charleston Community Hospital. the Supreme Court of
Illinois held that “the jury could have found a hospital negligent, inter alia, in failing to have a sufficient
number of trained nurses attending the patient; failing to require a consultation with or examination by
members of the hospital staff; and failing to review the treatment rendered to the patient.”

· On the basis of Darling, other jurisdictions held that a hospital’s corporate negligence extends to
permitting a physician known to be incompetent to practice at the hospital.

· In the present case, it was duly established that PSI operates the Medical City Hospital for the
purpose and under the concept of providing comprehensive medical services to the public.

· Accordingly, it has the duty to exercise reasonable care to protect from harm all patients admitted into
its facility for medical treatment. Unfortunately, PSI failed to perform such duty.

· Trial court findings which the Court agrees:

o PSI’s liability is traceable to its failure to conduct an investigation of the matter reported
in the nota bene of the count nurse. Such failure established PSI’s part in the dark
conspiracy of silence and concealment about the gauzes.

Application:
· the failure of PSI, despite the attending nurses’ report, to investigate and inform Natividad regarding
the missing gauzes amounts to callous negligence.

· Not only did PSI breach its duties to oversee or supervise all persons who practice medicine within its
walls, it also failed to take an active step in fixing the negligence committed.

· This renders PSI, not only vicariously liable for the negligence of Dr. Ampil under Article 2180 of the
Civil Code, but also directly liable for its own negligence under Article 2176.

Liability:

· Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for damages, let it be
emphasized that PSI, apart from a general denial of its responsibility, failed to adduce evidence showing
that it exercised the diligence of a good father of a family in the accreditation and supervision of the latter.

· In neglecting to offer such proof, PSI failed to discharge its burden under the last paragraph of Article
2180 cited earlier, and, therefore, must be adjudged solidarily liable with Dr. Ampil. Moreover, as we have
discussed, PSI is also directly liable to the Aganas.

One final word. Once a physician undertakes the treatment and care of a patient, the law imposes on him
certain obligations. In order to escape liability, he must possess that reasonable degree of learning, skill
and experience required by his profession. he must apply reasonable care and diligence in the exercise
of his skill and the application of his knowledge, and exert his best judgment.

Wherefore, we deny all petitions and affirm challenged decision of the CA

7. ORLANDO GARCIA V SALVADOR GR NO. 168512 20017-03-20

Facts:

Ranida Salvador worked as a trainee in the accounting department of Limay Bulk Handling Terminal. As
a prerequisite for regular employment, she underwent a medical exam at the Community Diagnostic
Center (CDC). Garcia, a medical technologist, conducted the HBs Ag (Hepatitis B Surface Antigen) test
and issued the test result indicating that Ranida was “HBs Ag: Reactive.” The result bore the name and
signature of Garcia as examiner and the rubber stamp signature of Bu Castro as pathologist.

When Ranida submitted the result to company physician Dr. Sto. Domingo, the latter told her that the result
indicated that she is suffering from Hepatitis B, a liver disease. Based on the the doctor’s medical report,
the company terminated Ranida’s employment for failing the physical exam.
When she informed her father Ramon, he suffered a heart attack and was confined at Bataan Doctors
Hospital. During her father’s confinement, she had another HBs Ag test at the same hospital. The result
indicated that she is non-reactive. She informed Sto. Domingo but was told that the test by the CDC was
more reliable because it used the Micro-Elisa Method.

She went back to CDC for confirmatory testing and the Anti-HBs test conducted on her had a Negative
result. She also had another test at the hospital using the Micro-Elisa Method and the result indicated that
she was non-reactive.

She submitted both results to the Executive Officer of the company who requested her to undergo another
similar test before her re-employment would be considered. The CDC conducted another test which
indicated a Negative result. The Med-Tech OIC of CDC issued a certification correcting the initial result and
explaining that the examining med tech Garcia interpreted the delayed reaction as positive or negative.

The company rehired Ranida. She then filed a complaint for damages against Garcia and an unknown
pathologist of CDC. She claimed that because of the erroneous interpretation of the results of the
examination, she lost her job and suffered serious mental anxiety, trauma, sleepless nights, while Ramon
was hospitalized and lost business opportunities. In an amended complaint, she named Castro as the
“unknown pathologist.”

Garcia denied the allegations of gross negligence and incompetence and reiterated the scientific
explanation for the “false positive” result of the first HBs Ag tests in a letter to the respondents.

Castro claimed that as pathologist, he rarely went to CDC and only when a case was referred to him; that
he did not examine Ranida; and that the test results bore only his rubber-stamp signature.

RTC dismissed the complaint because the respondent failed to present sufficient evidence to prove the
liability of Garcia and Castro. CA reversed the RTC’s ruling and found Garcia liable for damages for
negligently issuing an erroneous HBs Ag result. The appellate court exonerated Castro for lack of
participation thereof.

Issue: Whether or not Garcia was negligent in issuing the incorrect HBsAg test result and thus
liable for damages

Ruling: YES.

Negligence is the failure to observe for the protection of the interest of another person that degree of care,
precaution and vigilance which the circumstance justly demands, whereby such other person suffers injury.
For health care providers, the test of the existence of negligence is: did the health care provider either fail
to do something which a reasonably prudent health care provider would have done, or that he or she did
something that a reasonably prudent health care provider would not have done; and that failure or action
caused injury to the patient; if yes, then he is guilty of negligence.

Thus, the elements of actionable conduct are: 1) duty, 2) breach, 3) injury, and 4) proximate causation.

All the elements are present in the case at bar.

Owners and operators of clinical laboratories have the duty to comply with statutes, as well as rules and
regulations, purposely promulgated to protect and promote the health of the people by preventing the
operation of substandard, improperly managed and inadequately supported clinical laboratories and by
improving the quality of performance of clinical laboratory examinations. Their business is impressed with
public interest, as such, high standards of performance are expected from them.

In fine, violation of a statutory duty is negligence. Where the law imposes upon a person the duty to do
something, his omission or non-performance will render him liable to whoever may be injured thereby.

From provisions RA 4688, otherwise known as the The Clinical Laboratory Law, it is clear that a clinical
laboratory must be administered, directed and supervised by a licensed physician authorized by the Sec.
of Health, like a pathologist who is specially trained in methods of laboratory medicine; that the medical
technologist must be under the supervision of the pathologist or licensed physician; and that the results of
any examination may be released only to the requesting physician or his authorized representative upon
the direction of the laboratory pathologist.

These rules are intended for the protection of the public by preventing performance of substandard clinical
examinations by laboratories whose personnel are not properly supervised. The public demands no less
than an effective and efficient performance of clinical laboratory examinations through compliance with the
quality standards set by laws and regulations.

We find that petitioner Garcia failed to comply with these standards. First: CDC is not administered, directed
and supervised by a licensed physician as required by law. Second: Garcia conducted the HBs Ag test of
respondent Ranida without the supervision of defendant-appellee Castro. Third: The HBs Ag test result
was released to Ranida without the authorization of defendant-appellee Castro.

Garcia may not have intended to cause the consequence which followed after the release of the test result.
However, his failure to comply with the laws and rules promulgated and issued for the protection of public
safety and interest is failure to observe that care which a reasonably prudent health care provider would
observe. Thus, his act or omission constitutes a breach of duty.

Indubitably, Ranida suffered injury as a direct consequence of Garcia’s failure to comply with the mandate
of the laws and rules aforequoted. She was terminated from the service for failing the physical examination;
suffered anxiety because of the diagnosis; and was compelled to undergo several more tests. All these
could have been avoided had the proper safeguards been scrupulously followed in conducting the clinical
examination and releasing the clinical report.

Art. 20, NCC provides the legal basis for the award of damages to a party who suffers damage whenever
one commits an act in violation of some legal provision. This was incorporated by the Code Commission to
provide relief to a person who suffers damages because another has violated some legal provision.

8. REYES V SISTERS OF MERCY HOSPITAL 396 PHIL 87 2000-10-03

Facts:
Petitioner, Leah Alesna Reyes, is the wife of the deceased patient, Jorge Reyes. Five days before the
latter’s death, Jorge has been suffering from recurring fever with chills. The doctors confirmed through the
Widal test that Jorge has typhoid fever. However, he did not respond to the treatment and died. The cause
of his death was “Ventricular Arrythemia Secondary to Hyperpyrexia and typhoid fever.” Consequently,
petitioner filed the instant case for damages before the Regional Trial Court of Cebu City, which dismissed
the case and was affirmed by the Court of Appeals.

The contention was that Jorge did not die of typhoid fever. Instead, his death was due to the wrongful
administration of chloromycetin. They contended that had respondent doctors exercised due care and
diligence, they would not have recommended and rushed the performance of the Widal Test, which hastily
concluded that Jorge was suffering from typhoid fever, and administered chloromycetin without first
conducting sufficient tests on the patient’s compatibility with said drug.

Issues: 1. Whether or not the doctrine of Res Ipsa Loquitor applies in this case.

2. Whether or not extraordinary diligence should be required in medical practice.

3. Whether or not Sisters of Mercy Hospital is liable for the death of Jorge Reyes.

Ruling# 1(Res Ipsa Loquitor)

NO. In this case, while it is true that the patient died just a few hours after professional medical assistance
was rendered, there is really nothing unusual or extraordinary about his death. Prior to his admission, the
patient already had recurring fevers and chills for five days unrelieved by the analgesic, antipyretic, and
antibiotics given him by his wife. This shows that he had been suffering from a serious illness and
professional medical help came too late for him.

It must be conceded that the doctrine of res ipsa loquitur can have no application in a suit against a
physician or a surgeon which involves the merits of a diagnosis or of a scientific treatment. The physician
or surgeon is not required at his peril to explain why any particular diagnosis was not correct, or why any
particular scientific treatment did not produce the desired result.

Ruling# 2(extraordinary diligence)

NO. The practice of medicine is a profession engaged in only by qualified individuals.1âwphi1 It is a right
earned through years of education, training, and by first obtaining a license from the state through
professional board examinations. Such license may, at any time and for cause, be revoked by the
government. In addition to state regulation, the conduct of doctors is also strictly governed by the
Hippocratic Oath, an ancient code of discipline and ethical rules which doctors have imposed upon
themselves in recognition and acceptance of their great responsibility to society.

Given these safeguards, there is no need to expressly require of doctors the observance of "extraordinary"
diligence. As it is now, the practice of medicine is already conditioned upon the highest degree of diligence.
And, as we have already noted, the standard contemplated for doctors is simply the reasonable average
merit among ordinarily good physicians. That is reasonable diligence for doctors or, as the Court of Appeals
called it, the reasonable "skill and competence . . . that a physician in the same or similar locality . . . should
apply."
Ruling# 3

NO. There is no showing that the attending physician in this case deviated from the usual course of
treatment with respect to typhoid fever. Jorge was given antibiotic choloromycetin and some dose of triglobe
after compatibility test was made by the doctor and found that no adverse reactions manifested which would
necessitate replacement of the medicines. Indeed, the standard contemplated is not what is actually the
average merit among all known practitioners from the best to the worst and from the most to the least
experienced, but the reasonable average merit among the ordinarily good physicians. Here, the doctors did
not depart from the reasonable standard recommended by the experts as they in fact observed the due
care required under the circumstances.

In Medical Negligence cases, it is incumbent upon the plaintiff to establish that the usual procedure in
treating the illness is not followed by the doctor. Failure to prove this, the doctor is not liable. Physicians
are not insurers of the success of every procedure undertaken and if the procedure was shown to be
properly done but did not work, they cannot be faulted for such result.