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Cruz vs. Court of Appeals that exp ert testimony is usually necessary to support the
conclusion as to causation.Whether or not a physician has
G.R. No. 122445. November 18, 1997. *
for while a conviction of a crime requires proof beyond The present case against petitioner is in the nature of a
reasonable doubt, only a preponderance of evidence is medical malpractice suit, which in simplest terms is the
required to establish civil liability. The petitioner is a doctor type of claim which a victim has available to him or her
in whose hands a patient puts his life and limb. For to redress a wrong committed by a medical professional
insufficiency of evidence this Court was not able to render a
which has caused bodily harm. In this jurisdiction,
2
The heirs of the deceased continue to feel the loss of their Article 365 of the Revised Penal Code 4
mother up to the present time and this Court is aware that ________________
no amount of compassion and commiseration nor words of 1 THE PHYSICIANS LIABILITY AND THE LAW ON
bereavement can suffice to assuage the sorrow felt for the NEGLIGENCE by Constantino Nuez, p. 1 citing Louis Nizer, My
loss of a loved one. Certainly, the award of moral and Life in Court, New York: Double Day & Co., 1961 in Tolentino, Jr.,
exemplary damages in favor of the heirs of Lydia Umali are MEDICINE and LAW, Proceedings of the Symposium on Current
proper in the instant case. Issues Common to Medicine and Law, U.P. Law Center, 1980.
2 Leonila Garcia-Rueda vs. Wilfred L. Pascasio, et al., G.R. No.
192
192 SUPREME COURT REPORTS ANNOTATED 118141, September 5, 1997.
3 ART. 2176. Whoever by act or omission causes damage to another,
Cruz vs. Court of Appeals there being fault or negligence, is obliged to pay for the damage done.
Such fault or negligence, if there is no pre-existing contractual relation
PETITION for review on certiorari of a decision of the between the parties, is called a quasi-delict and is governed by the
provisions of this Chapter.
Court of Appeals. 4 Art. 365. Imprudence and Negligence. Any person who, by reckless
lower than those provided in the first two paragraphs of this Trial ensued after both the petitioner and Dr. Lina
article, in which case the courts shall impose the penalty Ercillo pleaded not guilty to the above-mentioned
next lower in degree than that which should be imposed, in charge. On March 4, 1994, the Municipal Trial Court in
the period which they may deem proper to apply.
2. 2.When, by imprudence or negligence and with violation of the
Cities (MTCC) of San Pablo City rendered a decision,
Automobile Law, the death of a person shall be caused, in the dispositive portion of which is hereunder quoted as
which case the defendant shall be punished by prision follows:
correccional in its medium and the maximum periods.
WHEREFORE, the court finds the accused Dra. Lina Ercillo homicide, arising from an alleged medical malpractice,
not guilty of the offense charged for insufficiency of evidence is supported by the evidence on record.
while her co-accused Dra. Ninevetch Cruz is hereby held First the antecedent facts.
responsible for the death of Lydia Umali on March 24, 1991, On March 22, 1991, prosecution witness, Rowena
and therefore guilty under Art. 365 of the Revised Penal
Umali De Ocampo, accompanied her mother to the
Code, and she is hereby sentenced to suffer the penalty of 2
Perpetual Help Clinic and General Hospital situated in
months and 1 day imprisonment of arresto mayor with
costs.6
Balagtas Street, San Pablo City, Laguna. They arrived
________________ at the said hospital at around 4:30 in the afternoon of
the same day. Prior to March 22, 1991, Lydia was
9
Simple imprudence consists in the lack of precaution displayed in examined by the petitioner who found a myoma in 10
article shall be imposed upon the offender who fails to lend on the spot slept in the clinic on the evening of March 22, 1991 as
to the injured parties such help as may be in his hands to give. the latter was to be operated on the next day at 1:00
5 INFORMATION.
Rollo, p. 65. noticed that the clinic was untidy and the window and
195 the floor were very dusty prompting her to ask the
VOL. 282, NOVEMBER 18, 1997 195 attendant for a rag to wipe the win-
Cruz vs. Court of Appeals ________________
The petitioner appealed her conviction to the Regional 7 DECISION in Criminal Case No. 9273-SP, July 26, 1994, p. 4;
Trial Court (RTC) which affirmed in toto the decision of Rollo, p. 53.
the MTCC prompting the petitioner to file a petition for
7 8 DECISION in CA-G.R. CR No. 16388, October 24, 1995, p. 10;
review with the Court of Appeals but to no avail. Hence Rollo, p. 49.
9 TSN, Rowena Umali De Ocampo, November 10, 1992, pp. 5-6.
this petition for review on certiorari assailing the 10 TSN, Edna Pujanes, September 30, 1992, p. 5.
of the crime of reckless imprudence resulting in the clinic, Rowena tried to persuade her mother not to
proceed with the operation. The following day, before
14
her mother was wheeled into the operating room, get oxygen. Lydia was given the fresh supply of oxygen
Rowena asked the petitioner if the operation could be as soon as it arrived. But at around 10:00 oclock P.M.
16
postponed. The petitioner called Lydia into her office she went into shock and her blood pressure
and the two had a conversation. Lydia then informed _______________
Rowena that the petitioner told her that she must be 13 Ibid., p. 6.
operated on as scheduled. 15
14 Ibid., p. 8.
Rowena and her other relatives, namely her 15 Ibid., pp. 27-28.
and the same was brought by the attendant into the District Hospital was without the prior consent of
operating room. After the lapse of a few hours, the Rowena nor of the other relatives present who found out
petitioner informed them that the operation was about the intended transfer only when an ambulance
finished. The operating staff then went inside the arrived to take Lydia to the San Pablo District Hospital.
petitioners clinic to take their snacks. some thirty Rowena and her other relatives then boarded a tricycle
minutes after, Lydia was brought out of the operating and followed the ambulance. 18
room in a stretcher and the petitioner asked Rowena Upon Lydias arrival at the San Pablo District
and the other relatives to buy additional blood for Hospital, she was wheeled into the operating room and
Lydia. Unfortunately, they were not able to comply with the petitioner and Dr. Ercillo re-operated on her
petitioners order as there was no more type A blood because there was blood oozing from the abdominal
available in the blood bank. Thereafter, a person incision. The attending physicians summoned Dr.
19
arrived to donate blood which was later transfused to Bartolome Angeles, head of the Obstetrics and
Lydia. Rowena then noticed her mother, who was Gynecology Department of San Pablo District Hospital.
attached to an oxygen tank, gasping for breath. However, when Dr. Angeles arrived, Lydia was already
Apparently the oxygen supply had run out and in shock and possibly dead as her blood pressure was
Rowenas husband together with the driver of the already o/o. Dr. Agneles then informed petitioner and
accused had to go to the San Pablo District Hospital to Dr. Ercillo that there was nothing he could do to help
save the patient. While the petitioner was closing the
20 The patient (sic) chart which is a public document was not
abdominal wall, the patient died. Thus, on March 24,
21 presented because it is only there that we could determine
1991, at 3:00 oclock in the morning, Lydia Umali was the condition of the patient before the surgery. The court also
pronounced dead. Her death certificate states shock noticed in Exh. F-1 that the sister of the deceased wished
to postpone the operation but the patient was prevailed upon
as the immediate cause of death and Disseminated
by Dra. Cruz to proceed with the surgery. The court finds
Intravascular Coagulation (DIC) as the antecedent
that Lydia Umali died because of the negligence and
cause. 22
carelessness of the surgeon Dra. Ninevetch Cruz because of
In convicting the petitioner, the MTCC found the loss of blood during the operation of the deceased for evident
following circumstances as sufficient basis to conclude unpreparedness and for lack of skill, the reason why the
that she was indeed negligent in the performance of the patient was brought for operation at the San Pablo City
operation: District Hospital. As such, the surgeon should answer for
x x x, the clinic was untidy, there was lack of provision like such negligence. With respect to Dra. Lina Ercillo, the
blood and oxygen to prepare for any contingency that might anaesthesiologist, there is no evidence to indicate that she
happen during the operation. The manner and the fact that should be held jointly liable with Dra. Cruz who actually did
the patient was brought to the San Pablo District Hospital the operation.23
for reoperation indicates The RTC reiterated the abovementioned findings of the
_______________ MTCC and upheld the latters declaration of
17 Record of exhibits, supra. incompetency, negligence and lack of foresight and
18 TSN, supra, pp. 15-16. skill of appellant (herein petitioner) in handling the
19 Record of Exhibits, supra.
subject patient before and after the operation. And 24
conclusively show that the petitioner had not prepared for 200
any unforeseen circumstances before going into the first 200 SUPREME COURT REPORTS ANNOTATED
surgery, which was not emergency in nature, but was Cruz vs. Court of Appeals
elective or pre-scheduled; she had no ready antibiotics, no able lack of precaution on the part of the offender,
prepared blood, properly typed and cross-matched, and no taking into consideration his employment or
sufficient oxygen supply. occupation, degree of intelligence, physical condition,
Moreover, there are a lot of questions that keep nagging
and other circumstances regarding persons, time and
Us. Was the patient given any cardio-pulmonary clearance,
place.
or at least a clearance by an internist, which are standard
requirements before a patient is subjected to surgery. Did the Whether or not a physician has committed an
petitioner determine as part of the pre-operative evaluation, inexcusable lack of precaution in the treatment of his
the bleeding parameters of the patient, such as bleeding time patient is to be determined according to the standard of
and clotting time? There is no showing that these were done. care observed by other members of the profession in
The petitioner just appears to have been in a hurry to good standing under similar circumstances bearing in
perform the operation, even as the family wanted a mind the advanced state of the profession at the time of
treatment or the present state of medical science. In 26 VOL. 282, NOVEMBER 18, 1997 201
the recent case of Leonila Garcia-Rueda v. Wilfred L. Cruz vs. Court of Appeals
Pascasio, et al., this Court stated that in accepting a
27
tions expert witnesses in the persons of Dr. Floresto
case, a doctor in effect represents that, having the Arizala and Dr. Nieto Salvador, Jr. of the National
needed training and skill possessed by physicians and Bureau of Investigation (NBI) only testified as to the
surgeons practicing in the same field, he will employ possible cause of death but did not venture to illuminate
such training, care and skill in the treatment of his the court on the matter of the standard of care that
patients. He therefore has a duty to use at least the petitioner should have exercised.
same level of care that any other reasonably competent All three courts below bewail the inadequacy of the
doctor would use to treat a condition under the same facilities of the clinic and its untidiness; the lack of
circumstances. It is in this aspect of medical provisions such as blood, oxygen, and certain medicines;
malpractice that expert testimony is essential to the failure to subject the patient to a cardio-pulmonary
establish not only the standard of care of the profession test prior to the operation; the omission of any form of
but also that the physicians conduct in the treatment blood typing before transfusion; and even the
and care falls below such standard. Further, inasmuch
28
subsequent transfer of Lydia to the San Pablo Hospital
as the causes of the injuries involved in malpractice and the reoperation performed on her by the petitioner.
actions are determinable only in the light of scientific But while it may be true that the circumstances pointed
knowledge, it has been recognized that expert out by the courts below seemed beyond cavil to
testimony is usually necessary to support the conclusion constitute reckless imprudence on the part of the
as to causation. 29
surgeon, this conclusion is still best arrived at not
Immediately apparent from a review of the records through the educated surmises nor conjectures of
of this case is the absence of any expert testimony of the laymen, including judges, but by the unquestionable
matter of the standard of care employed by other knowledge of expert witnesses. For whether a physician
physicians of good standing in the conduct of similar or surgeon has exercised the requisite degree of skill
operations. The prosecu- and care in the treatment of his patient is, in the
__________________
generality of cases, a matter of expert opinion. The30
26 MEDICINE and LAW, supra, p. 24. deference of courts to the expert opinion of qualified
27 Supra. physicians stems from its realization that the latter
28 MEDICINE and LAW, supra, p. 25; Willard vs. Hutson, 1 ALR
possess unusual technical skills which laymen in most
3d 1092, 1102 [1963]; Snyder vs. Pantaleo, 122 A. 2d 21, 23 [1956].
29 American Jurisprudence 2d, Vol. 61, p. 510.
instances are incapable of intelligently
201 evaluating. Expert testimony should have been offered
31
knowledge and skill in attending to his clients, unless Inc., where the attending physician was absolved of
34
the contrary is sufficiently established. This 32 liability for the death of the complainants wife and
________________ newborn baby, this Court held that:
In order that there may be a recovery for an injury, however,
30 Willard vs. Hutson, supra.
31 MEDICINE and LAW, supra.
it must be shown that the injury for which recovery is sought
32 Abaya, et al. vs. Favis, 3 CA Reports 450, 454-455 [1963].
must be the legitimate consequence of the wrong done; the
202 connection between the negligence and the injury must be a
202 SUPREME COURT REPORTS ANNOTATED direct and natural sequence of events, unbroken by
intervening efficient causes. In other words, the negligence
Cruz vs. Court of Appeals
must be the proximate cause of the injury. For, negligence, no
presumption is rebuttable by expert opinion which is so matter in what it consists, cannot create a right of action
sadly lacking in the case at bench. unless it is the proximate cause of the injury complained of.
Even granting arguendo that the inadequacy of the And the proximate cause of an injury is that cause, which,
facilities and untidiness of the clinic; the lack of in natural and continuous sequence, unbroken by any
provisions; the failure to conduct pre-operation tests on efficient intervening cause, produces the injury, and without
the patient; and the subsequent transfer of Lydia to the which the result would not have occurred. (Italics 35
_________________
as well as the other record.
ATTY. PASCUAL: 44TSN, Dr. Bu C. Castro, supra, pp. 13-15.
Precisely based on this examination. 45 Padilla vs. Court of Appeals, 129 SCRA 558, 565 [1984]; People
vs. Jalandoni,131 SCRA 454 [1984].
ATTY. MALVEDA: 210
Not finding, there was no finding made. 210 SUPREME COURT REPORTS ANNOTATED
COURT: Cruz vs. Court of Appeals
He is only reading the record. The petitioner is a doctor in whose hands a patient puts
ATTY. PASCUAL: his life and limb. For insufficiency of evidence this
Yes, sir. Court was not able to render a sentence of conviction
A. No, sir, there is no fault on the part of the but it is not blind to the reckless and imprudent manner
surgeon, sir. 44
in which the petitioner carried out her duties. A
This Court has no recourse but to rely on the expert precious life has been lost and the circumstances
testimonies rendered by both prosecution and defense leading thereto exacerbated the grief of those left
witnesses that substantiate rather than contradict behind. The heirs of the deceased continue to feel the
petitioners allegation that the cause of Lydias death loss of their mother up to the present time and this 46
was DIC which, as attested to by an expert witness, Court is aware that no amount of compassion and
cannot be attributed to the petitioners fault or commiseration nor words of bereavement can suffice to
negligence. The probability that Lydias death was assuage the sorrow felt for the loss of a loved one.
caused by DIC was unrebutted during trial and has Certainly, the award of moral and exemplary damages
engendered in the mind of this Court a reasonable doubt in favor of the heirs of Lydia Umali are proper in the
as to the petitioners guilt. Thus, her acquittal of the instant case.
crime of reckless imprudence resulting in homicide. WHEREFORE, premises considered, petitioner DR.
While we condole with the family of Lydia Umali, our NINEVETCH CRUZ is hereby ACQUITTED of the
crime of reckless imprudence resulting in homicide but Narvasa (C.J., Chairman), On leave.
is ordered to pay the heirs of the deceased Lydia Umali Petitioner acquitted but ordered to pay moral and
the amount of FIFTY THOUSAND PESOS (P50,000.00) exemplary damages.
as civil liability, ONE HUNDRED THOUSAND PESOS Notes.The supposed medical evaluation made by
(P100,000.00) as moral damages, and FIFTY appellant or his counsel, without showing their
THOUSAND PESOS (P50,000.00) as exemplary competence in the field of medicine, must give way to
damages. the expert testimony of the examining physician.
Let a copy of this decision be furnished to the (People vs. Pelones, 230 SCRA 379 [1994])
Professional Regulation Commission (PRC) for The fact of want of competence or diligence is
appropriate action. evidentiary in nature, the veracity of which can best be
__________________ passed upon after a full-blown trial for it is virtually
46
impossible to ascertain the merits of a medical
Q. When you came to know that your mother was already negligence case without extensive investigation,
dead there in the operating room of the San Pablo District research, evaluation and consultations with medical
Hospital, how did you feel being the daughter? expertsclearly, the City Prosecutors are not in a
A. I was crying and crying hysterically. And I asked why it competent position to pass judgment on such a technical
happened to my mother, sir. matter, especially when there are conflicting evidence
Q. And up to the present time do you still feel about the loss and findings. (Garcia-Rueda vs. Pascasio, 278 SCRA
of your mother? 769[1997])
A. Yes, sir. o0o
Q. How about your sister and brother?
A. Same with me, sir. 212
Q. Estimated to money value, how much I cost you and your Copyright 2016 Central Book Supply, Inc. All rights
sister and brotherthe lost of your mother? reserved.
A. There is no equivalent, sir. (TSN, Rowena Umali De
Ocampo, supra, p. 18.)
211
VOL. 282, NOVEMBER 18, 1997 211
Cruz vs. Court of Appeals
SO ORDERED.
Romero, Melo and Panganiban, JJ., concur.