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G.R. No. 126297 January 31, 2007 After Dr.

Fuentes had completed the hysterectomy,


Dr. Ampil took over, completed the operation and
PROFESSIONAL SERVICES, INC., Petitioner, closed the incision.
vs.
NATIVIDAD and ENRIQUE AGANA, Respondents. However, the operation appeared to be flawed. In the
corresponding Record of Operation dated April 11,
x-----------------------x 1984, the attending nurses entered these remarks:

G.R. No. 126467 January 31, 2007 "sponge count lacking 2

NATIVIDAD (Substituted by her children "announced to surgeon searched (sic) done but to no
MARCELINO AGANA III, ENRIQUE AGANA, JR., avail continue for closure."
EMMA AGANA ANDAYA, JESUS AGANA, and
RAYMUND AGANA) and ENRIQUE On April 24, 1984, Natividad was released from the
AGANA, Petitioners, hospital. Her hospital and medical bills, including the
vs. doctors fees, amounted to P60,000.00.
JUAN FUENTES, Respondent.
After a couple of days, Natividad complained of
x- - - - - - - - - - - - - - - - - - - -- - - - x excruciating pain in her anal region. She consulted
both Dr. Ampil and Dr. Fuentes about it. They told her
G.R. No. 127590 January 31, 2007 that the pain was the natural consequence of the
surgery. Dr. Ampil then recommended that she consult
MIGUEL AMPIL, Petitioner, an oncologist to examine the cancerous nodes which
vs. were not removed during the operation.
NATIVIDAD AGANA and ENRIQUE
AGANA, Respondents. On May 9, 1984, Natividad, accompanied by her
husband, went to the United States to seek further
DECISION treatment. After four months of consultations and
laboratory examinations, Natividad was told she was
free of cancer. Hence, she was advised to return to
SANDOVAL-GUTIERREZ, J.:
the Philippines.
Hospitals, having undertaken one of mankinds most
On August 31, 1984, Natividad flew back to the
important and delicate endeavors, must assume the
Philippines, still suffering from pains. Two weeks
grave responsibility of pursuing it with appropriate
thereafter, her daughter found a piece of gauze
care. The care and service dispensed through this
protruding from her vagina. Upon being informed
high trust, however technical, complex and esoteric its
about it, Dr. Ampil proceeded to her house where he
character may be, must meet standards of
managed to extract by hand a piece of gauze
responsibility commensurate with the undertaking to
measuring 1.5 inches in width. He then assured her
preserve and protect the health, and indeed, the very
that the pains would soon vanish.
lives of those placed in the hospitals keeping.1
Dr. Ampils assurance did not come true. Instead, the
Assailed in these three consolidated petitions for
pains intensified, prompting Natividad to seek
review on certiorari is the Court of Appeals
treatment at the Polymedic General Hospital. While
Decision2 dated September 6, 1996 in CA-G.R. CV
confined there, Dr. Ramon Gutierrez detected the
No. 42062 and CA-G.R. SP No. 32198 affirming with
presence of another foreign object in her vagina -- a
modification the Decision3dated March 17, 1993 of the
foul-smelling gauze measuring 1.5 inches in width
Regional Trial Court (RTC), Branch 96, Quezon City
which badly infected her vaginal vault. A recto-vaginal
in Civil Case No. Q-43322 and nullifying its Order
fistula had formed in her reproductive organs which
dated September 21, 1993.
forced stool to excrete through the vagina. Another
surgical operation was needed to remedy the
The facts, as culled from the records, are: damage. Thus, in October 1984, Natividad underwent
another surgery.
On April 4, 1984, Natividad Agana was rushed to the
Medical City General Hospital (Medical City Hospital) On November 12, 1984, Natividad and her husband
because of difficulty of bowel movement and bloody filed with the RTC, Branch 96, Quezon City a
anal discharge. After a series of medical complaint for damages against the Professional
examinations, Dr. Miguel Ampil, petitioner in G.R. No. Services, Inc. (PSI), owner of the Medical City
127590, diagnosed her to be suffering from "cancer of Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil
the sigmoid." Case No. Q-43322. They alleged that the latter are
liable for negligence for leaving two pieces of gauze
On April 11, 1984, Dr. Ampil, assisted by the medical inside Natividads body and malpractice for
staff4 of the Medical City Hospital, performed an concealing their acts of negligence.
anterior resection surgery on Natividad. He found that
the malignancy in her sigmoid area had spread on her Meanwhile, Enrique Agana also filed with the
left ovary, necessitating the removal of certain Professional Regulation Commission (PRC) an
portions of it. Thus, Dr. Ampil obtained the consent of administrative complaint for gross negligence and
Natividads husband, Enrique Agana, to permit Dr. malpractice against Dr. Ampil and Dr. Fuentes,
Juan Fuentes, respondent in G.R. No. 126467, to docketed as Administrative Case No. 1690. The PRC
perform hysterectomy on her.
Board of Medicine heard the case only with respect to Following their receipt of the money, the Aganas
Dr. Fuentes because it failed to acquire jurisdiction entered into an agreement with PSI and Dr. Fuentes
over Dr. Ampil who was then in the United States. to indefinitely suspend any further execution of the
RTC Decision. However, not long thereafter, the
On February 16, 1986, pending the outcome of the Aganas again filed a motion for an alias writ of
above cases, Natividad died and was duly substituted execution against the properties of PSI and Dr.
by her above-named children (the Aganas). Fuentes. On September 21, 1993, the RTC granted
the motion and issued the corresponding writ,
On March 17, 1993, the RTC rendered its Decision in prompting Dr. Fuentes to file with the Court of Appeals
favor of the Aganas, finding PSI, Dr. Ampil and Dr. a petition for certiorari and prohibition, with prayer for
Fuentes liable for negligence and malpractice, the preliminary injunction, docketed as CA-G.R. SP No.
decretal part of which reads: 32198. During its pendency, the Court of Appeals
issued a Resolution5 dated October 29, 1993 granting
Dr. Fuentes prayer for injunctive relief.
WHEREFORE, judgment is hereby rendered for the
plaintiffs ordering the defendants PROFESSIONAL
SERVICES, INC., DR. MIGUEL AMPIL and DR. JUAN On January 24, 1994, CA-G.R. SP No. 32198 was
FUENTES to pay to the plaintiffs, jointly and severally, consolidated with CA-G.R. CV No. 42062.
except in respect of the award for exemplary
damages and the interest thereon which are the Meanwhile, on January 23, 1995, the PRC Board of
liabilities of defendants Dr. Ampil and Dr. Fuentes Medicine rendered its Decision6 in Administrative
only, as follows: Case No. 1690 dismissing the case against Dr.
Fuentes. The Board held that the prosecution failed to
1. As actual damages, the following amounts: show that Dr. Fuentes was the one who left the two
pieces of gauze inside Natividads body; and that he
concealed such fact from Natividad.
a. The equivalent in Philippine
Currency of the total of US$19,900.00
at the rate of P21.60-US$1.00, as On September 6, 1996, the Court of Appeals
reimbursement of actual expenses rendered its Decision jointly disposing of CA-G.R. CV
incurred in the United States of No. 42062 and CA-G.R. SP No. 32198, thus:
America;
WHEREFORE, except for the modification that the
b. The sum of P4,800.00 as travel case against defendant-appellant Dr. Juan Fuentes is
taxes of plaintiffs and their physician hereby DISMISSED, and with the pronouncement that
daughter; defendant-appellant Dr. Miguel Ampil is liable to
reimburse defendant-appellant Professional Services,
Inc., whatever amount the latter will pay or had paid to
c. The total sum of P45,802.50,
the plaintiffs-appellees, the decision appealed from is
representing the cost of hospitalization
hereby AFFIRMED and the instant appeal
at Polymedic Hospital, medical fees,
DISMISSED.
and cost of the saline solution;
Concomitant with the above, the petition for certiorari
2. As moral damages, the sum of
and prohibition filed by herein defendant-appellant Dr.
P2,000,000.00;
Juan Fuentes in CA-G.R. SP No. 32198 is hereby
GRANTED and the challenged order of the
3. As exemplary damages, the sum of respondent judge dated September 21, 1993, as well
P300,000.00; as the alias writ of execution issued pursuant thereto
are hereby NULLIFIED and SET ASIDE. The bond
4. As attorneys fees, the sum of P250,000.00; posted by the petitioner in connection with the writ of
preliminary injunction issued by this Court on
5. Legal interest on items 1 (a), (b), and (c); 2; November 29, 1993 is hereby cancelled.
and 3 hereinabove, from date of filing of the
complaint until full payment; and Costs against defendants-appellants Dr. Miguel Ampil
and Professional Services, Inc.
6. Costs of suit.
SO ORDERED.
SO ORDERED.
Only Dr. Ampil filed a motion for reconsideration, but it
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed was denied in a Resolution7 dated December 19,
an appeal to the Court of Appeals, docketed as CA- 1996.
G.R. CV No. 42062.
Hence, the instant consolidated petitions.
Incidentally, on April 3, 1993, the Aganas filed with the
RTC a motion for a partial execution of its Decision, In G.R. No. 126297, PSI alleged in its petition that the
which was granted in an Order dated May 11, 1993. Court of Appeals erred in holding that: (1) it is
Thereafter, the sheriff levied upon certain properties estopped from raising the defense that Dr. Ampil is
of Dr. Ampil and sold them for P451,275.00 and not its employee; (2) it is solidarily liable with Dr.
delivered the amount to the Aganas. 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 lacking 2; that such anomaly was announced
negligence. to surgeon and that a search was done but to
no avail prompting Dr. Ampil to continue for
In G.R. No. 126467, the Aganas maintain that the closure x x x.
Court of Appeals erred in finding that Dr. Fuentes is
not guilty of negligence or medical malpractice, Third, after the operation, two (2) gauzes were
invoking the doctrine of res ipsa loquitur. They extracted from the same spot of the body of
contend that the pieces of gauze are prima facie Mrs. Agana where the surgery was performed.
proofs that the operating surgeons have been
negligent. An operation requiring the placing of sponges in the
incision is not complete until the sponges are properly
Finally, in G.R. No. 127590, Dr. Ampil asserts that the removed, and it is settled that the leaving of sponges
Court of Appeals erred in finding him liable for or other foreign substances in the wound after the
negligence and malpractice sans evidence that he left incision has been closed is at least prima facie
the two pieces of gauze in Natividads vagina. He negligence by the operating surgeon. 8 To put it simply,
pointed to other probable causes, such as: (1) it was such act is considered so inconsistent with due care
Dr. Fuentes who used gauzes in performing the as to raise an inference of negligence. There are even
hysterectomy; (2) the attending nurses failure to legions of authorities to the effect that such act is
properly count the gauzes used during surgery; and negligence per se.9
(3) the medical intervention of the American doctors
who examined Natividad in the United States of Of course, the Court is not blind to the reality that
America. there are times when danger to a patients life
precludes a surgeon from further searching missing
For our resolution are these three vital issues: first, sponges or foreign objects left in the body. But this
whether the Court of Appeals erred in holding Dr. does not leave him free from any obligation. Even if it
Ampil liable for negligence and malpractice; second, has been shown that a surgeon was required by the
whether the Court of Appeals erred in absolving Dr. urgent necessities of the case to leave a sponge in
Fuentes of any liability; and third, whether PSI may be his patients abdomen, because of the dangers
held solidarily liable for the negligence of Dr. Ampil. attendant upon delay, still, it is his legal duty to so
inform his patient within a reasonable time thereafter
I - G.R. No. 127590 by advising her of what he had been compelled to do.
This is in order that she might seek relief from the
Whether the Court of Appeals Erred in Holding Dr. effects of the foreign object left in her body as her
Ampil condition might permit. The ruling in Smith v.
Zeagler10 is explicit, thus:
Liable for Negligence and Malpractice.
The removal of all sponges used is part of a surgical
operation, and when a physician or surgeon fails to
Dr. Ampil, in an attempt to absolve himself, gears the
remove a sponge he has placed in his patients body
Courts attention to other possible causes of
that should be removed as part of the operation, he
Natividads detriment. He argues that the Court
thereby leaves his operation uncompleted and
should not discount either of the following
creates a new condition which imposes upon him the
possibilities: first, Dr. Fuentes left the gauzes in
legal duty of calling the new condition to his patients
Natividads body after performing hysterectomy;
attention, and endeavoring with the means he has at
second, the attending nurses erred in counting the
hand to minimize and avoid untoward results likely to
gauzes; and third, the American doctors were the
ensue therefrom.
ones who placed the gauzes in Natividads body.
Here, Dr. Ampil did not inform Natividad about the
Dr. Ampils arguments are purely conjectural and
missing two pieces of gauze. Worse, he even misled
without basis. Records show that he did not present
her that the pain she was experiencing was the
any evidence to prove that the American doctors were
ordinary consequence of her operation. Had he been
the ones who put or left the gauzes in Natividads
more candid, Natividad could have taken the
body. Neither did he submit evidence to rebut the
immediate and appropriate medical remedy to remove
correctness of the record of operation, particularly the
the gauzes from her body. To our mind, what was
number of gauzes used. As to the alleged negligence
initially an act of negligence by Dr. Ampil has ripened
of Dr. Fuentes, we are mindful that Dr. Ampil
into a deliberate wrongful act of deceiving his patient.
examined his (Dr. Fuentes) work and found it in
order.
This is a clear case of medical malpractice or more
appropriately, medical negligence. To successfully
The glaring truth is that all the major circumstances,
pursue this kind of case, a patient must only prove
taken together, as specified by the Court of Appeals,
that a health care provider either failed to do
directly point to Dr. Ampil as the negligent party, thus:
something which a reasonably prudent health care
provider would have done, or that he did something
First, it is not disputed that the surgeons used that a reasonably prudent provider would not have
gauzes as sponges to control the bleeding of done; and that failure or action caused injury to the
the patient during the surgical operation. patient.11 Simply put, the elements are duty, breach,
injury and proximate causation. Dr, Ampil, as the lead
Second, immediately after the operation, the surgeon, had the duty to remove all foreign objects,
nurses who assisted in the surgery noted in such as gauzes, from Natividads body before closure
their report that the sponge count (was) of the incision. When he failed to do so, it was his
duty to inform Natividad about it. Dr. Ampil breached left ovary. Dr. Fuentes performed the surgery and
both duties. Such breach caused injury to Natividad, thereafter reported and showed his work to Dr. Ampil.
necessitating her further examination by American The latter examined it and finding everything to be in
doctors and another surgery. That Dr. Ampils order, allowed Dr. Fuentes to leave the operating
negligence is the proximate cause 12 of Natividads room. Dr. Ampil then resumed operating on Natividad.
injury could be traced from his act of closing the He was about to finish the procedure when the
incision despite the information given by the attending attending nurses informed him that two pieces of
nurses that two pieces of gauze were still missing. gauze were missing. A "diligent search" was
That they were later on extracted from Natividads conducted, but the misplaced gauzes were not found.
vagina established the causal link between Dr. Ampils Dr. Ampil then directed that the incision be closed.
negligence and the injury. And what further During this entire period, Dr. Fuentes was no longer in
aggravated such injury was his deliberate the operating room and had, in fact, left the hospital.
concealment of the missing gauzes from the
knowledge of Natividad and her family. Under the "Captain of the Ship" rule, the operating
surgeon is the person in complete charge of the
II - G.R. No. 126467 surgery room and all personnel connected with the
operation. Their duty is to obey his orders. 16 As stated
Whether the Court of Appeals Erred in Absolving before, Dr. Ampil was the lead surgeon. In other
words, he was the "Captain of the Ship." That he
Dr. Fuentes of any Liability discharged such role is evident from his following
conduct: (1) calling Dr. Fuentes to perform a
hysterectomy; (2) examining the work of Dr. Fuentes
The Aganas assailed the dismissal by the trial court of
and finding it in order; (3) granting Dr. Fuentes
the case against Dr. Fuentes on the ground that it is
permission to leave; and (4) ordering the closure of
contrary to the doctrine of res ipsa loquitur. According
the incision. To our mind, it was this act of ordering
to them, the fact that the two pieces of gauze were left
the closure of the incision notwithstanding that two
inside Natividads body is a prima facie evidence of
pieces of gauze remained unaccounted for, that
Dr. Fuentes negligence.
caused injury to Natividads body. Clearly, the control
and management of the thing which caused the injury
We are not convinced. was in the hands of Dr. Ampil, not Dr. Fuentes.

Literally, res ipsa loquitur means "the thing speaks for In this jurisdiction, res ipsa loquitur is not a rule of
itself." It is the rule that the fact of the occurrence of substantive law, hence, does not per se create or
an injury, taken with the surrounding circumstances, constitute an independent or separate ground of
may permit an inference or raise a presumption of liability, being a mere evidentiary rule. 17 In other
negligence, or make out a plaintiffs prima facie case, words, mere invocation and application of the doctrine
and present a question of fact for defendant to meet does not dispense with the requirement of proof of
with an explanation.13 Stated differently, where the negligence. Here, the negligence was proven to have
thing which caused the injury, without the fault of the been committed by Dr. Ampil and not by Dr. Fuentes.
injured, is under the exclusive control of the defendant
and the injury is such that it should not have occurred
III - G.R. No. 126297
if he, having such control used proper care, it affords
reasonable evidence, in the absence of explanation
that the injury arose from the defendants want of Whether PSI Is Liable for the Negligence of Dr. Ampil
care, and the burden of proof is shifted to him to
establish that he has observed due care and The third issue necessitates a glimpse at the historical
diligence.14 development of hospitals and the resulting theories
concerning their liability for the negligence of
From the foregoing statements of the rule, the physicians.
requisites for the applicability of the doctrine of res
ipsa loquitur are: (1) the occurrence of an injury; (2) Until the mid-nineteenth century, hospitals were
the thing which caused the injury was under the generally charitable institutions, providing medical
control and management of the defendant; (3) the services to the lowest classes of society, without
occurrence was such that in the ordinary course of regard for a patients ability to pay.18 Those who could
things, would not have happened if those who had afford medical treatment were usually treated at home
control or management used proper care; and (4) the by their doctors.19 However, the days of house calls
absence of explanation by the defendant. Of the and philanthropic health care are over. The modern
foregoing requisites, the most instrumental is the health care industry continues to distance itself from
"control and management of the thing which caused its charitable past and has experienced a significant
the injury."15 conversion from a not-for-profit health care to for-
profit hospital businesses. Consequently, significant
We find the element of "control and management of changes in health law have accompanied the
the thing which caused the injury" to be wanting. business-related changes in the hospital industry.
Hence, the doctrine of res ipsa loquitur will not lie. One important legal change is an increase in hospital
liability for medical malpractice. Many courts now
allow claims for hospital vicarious liability under the
It was duly established that Dr. Ampil was the lead
theories of respondeat superior, apparent authority,
surgeon during the operation of Natividad. He
ostensible authority, or agency by estoppel. 20
requested the assistance of Dr. Fuentes only to
perform hysterectomy when he (Dr. Ampil) found that
the malignancy in her sigmoid area had spread to her
In this jurisdiction, the statute governing liability for ministrations to the patient and his actions are of his
negligent acts is Article 2176 of the Civil Code, which own responsibility.25
reads:
The case of Schloendorff v. Society of New York
Art. 2176. Whoever by act or omission causes Hospital26 was then considered an authority for this
damage to another, there being fault or negligence, is view. The "Schloendorff doctrine" regards a physician,
obliged to pay for the damage done. Such fault or even if employed by a hospital, as an independent
negligence, if there is no pre-existing contractual contractor because of the skill he exercises and the
relation between the parties, is called a quasi-delict lack of control exerted over his work. Under this
and is governed by the provisions of this Chapter. doctrine, hospitals are exempt from the application of
the respondeat superior principle for fault or
A derivative of this provision is Article 2180, the rule negligence committed by physicians in the discharge
governing vicarious liability under the doctrine of of their profession.
respondeat superior, thus:
However, the efficacy of the foregoing doctrine has
ART. 2180. The obligation imposed by Article 2176 is weakened with the significant developments in
demandable not only for ones own acts or omissions, medical care. Courts came to realize that modern
but also for those of persons for whom one is hospitals are increasingly taking active role in
responsible. supplying and regulating medical care to patients. No
longer were a hospitals functions limited to furnishing
x x x x room, food, facilities for treatment and operation, and
x x attendants for its patients. Thus, in Bing v.
Thunig,27 the New York Court of Appeals deviated
from the Schloendorff doctrine, noting that modern
The owners and managers of an establishment or
hospitals actually do far more than provide facilities
enterprise are likewise responsible for damages
for treatment. Rather, they regularly employ, on a
caused by their employees in the service of the
salaried basis, a large staff of physicians, interns,
branches in which the latter are employed or on the
nurses, administrative and manual workers. They
occasion of their functions.
charge patients for medical care and treatment, even
collecting for such services through legal action, if
Employers shall be liable for the damages caused by necessary. The court then concluded that there is no
their employees and household helpers acting within reason to exempt hospitals from the universal rule of
the scope of their assigned tasks even though the respondeat superior.
former are not engaged in any business or industry.
In our shores, the nature of the relationship between
x x x the hospital and the physicians is rendered
x x x inconsequential in view of our categorical
pronouncement in Ramos v. Court of Appeals 28 that
The responsibility treated of in this article shall cease for purposes of apportioning responsibility in medical
when the persons herein mentioned prove that they negligence cases, an employer-employee relationship
observed all the diligence of a good father of a family in effect exists between hospitals and their attending
to prevent damage. and visiting physicians. This Court held:

A prominent civilist commented that professionals "We now discuss the responsibility of the hospital in
engaged by an employer, such as physicians, this particular incident. The unique practice (among
dentists, and pharmacists, are not "employees" under private hospitals) of filling up specialist staff with
this article because the manner in which they perform attending and visiting "consultants," who are allegedly
their work is not within the control of the latter not hospital employees, presents problems in
(employer). In other words, professionals are apportioning responsibility for negligence in medical
considered personally liable for the fault or negligence malpractice cases. However, the difficulty is more
they commit in the discharge of their duties, and their apparent than real.
employer cannot be held liable for such fault or
negligence. In the context of the present case, "a In the first place, hospitals exercise significant control
hospital cannot be held liable for the fault or in the hiring and firing of consultants and in the
negligence of a physician or surgeon in the treatment conduct of their work within the hospital premises.
or operation of patients."21 Doctors who apply for consultant slots, visiting or
attending, are required to submit proof of completion
The foregoing view is grounded on the traditional of residency, their educational qualifications,
notion that the professional status and the very nature generally, evidence of accreditation by the appropriate
of the physicians calling preclude him from being board (diplomate), evidence of fellowship in most
classed as an agent or employee of a hospital, cases, and references. These requirements are
whenever he acts in a professional capacity. 22 It has carefully scrutinized by members of the hospital
been said that medical practice strictly involves highly administration or by a review committee set up by the
developed and specialized knowledge, 23 such that hospital who either accept or reject the application. x
physicians are generally free to exercise their own x x.
skill and judgment in rendering medical services sans
interference.24 Hence, when a doctor practices After a physician is accepted, either as a visiting or
medicine in a hospital setting, the hospital and its attending consultant, he is normally required to attend
employees are deemed to subserve him in his clinico-pathological conferences, conduct bedside
rounds for clerks, interns and residents, moderate
grand rounds and patient audits and perform other actions, has held out a particular physician as its
tasks and responsibilities, for the privilege of being agent and/or employee and that a patient has
able to maintain a clinic in the hospital, and/or for the accepted treatment from that physician in the
privilege of admitting patients into the hospital. In reasonable belief that it is being rendered in behalf of
addition to these, the physicians performance as a the hospital, then the hospital will be liable for the
specialist is generally evaluated by a peer review physicians negligence.
committee on the basis of mortality and morbidity
statistics, and feedback from patients, nurses, interns Our jurisdiction recognizes the concept of an agency
and residents. A consultant remiss in his duties, or a by implication or estoppel. Article 1869 of the Civil
consultant who regularly falls short of the minimum Code reads:
standards acceptable to the hospital or its peer review
committee, is normally politely terminated. ART. 1869. Agency may be express, or implied from
the acts of the principal, from his silence or lack of
In other words, private hospitals, hire, fire and action, or his failure to repudiate the agency, knowing
exercise real control over their attending and visiting that another person is acting on his behalf without
consultant staff. While consultants are not, authority.
technically employees, x x x, the control exercised,
the hiring, and the right to terminate consultants all In this case, PSI publicly displays in the lobby of the
fulfill the important hallmarks of an employer- Medical City Hospital the names and specializations
employee relationship, with the exception of the of the physicians associated or accredited by it,
payment of wages. In assessing whether such a including those of Dr. Ampil and Dr. Fuentes. We
relationship in fact exists, the control test is concur with the Court of Appeals conclusion that it "is
determining. Accordingly, on the basis of the now estopped from passing all the blame to the
foregoing, we rule that for the purpose of allocating physicians whose names it proudly paraded in the
responsibility in medical negligence cases, an public directory leading the public to believe that it
employer-employee relationship in effect exists vouched for their skill and competence." Indeed, PSIs
between hospitals and their attending and visiting act is tantamount to holding out to the public that
physicians. " Medical City Hospital, through its accredited
physicians, offers quality health care services. By
But the Ramos pronouncement is not our only basis accrediting Dr. Ampil and Dr. Fuentes and publicly
in sustaining PSIs liability. Its liability is also anchored advertising their qualifications, the hospital created
upon the agency principle of apparent authority or the impression that they were its agents, authorized to
agency by estoppel and the doctrine of corporate perform medical or surgical services for its patients.
negligence which have gained acceptance in the As expected, these patients, Natividad being one of
determination of a hospitals liability for negligent acts them, accepted the services on the reasonable belief
of health professionals. The present case serves as a that such were being rendered by the hospital or its
perfect platform to test the applicability of these employees, agents, or servants. The trial court
doctrines, thus, enriching our jurisprudence. correctly pointed out:

Apparent authority, or what is sometimes referred to x x x regardless of the education and status in life of
as the "holding the patient, he ought not be burdened with the
defense of absence of employer-employee
out" theory, or doctrine of ostensible agency or relationship between the hospital and the independent
agency by estoppel,29 has its origin from the law of physician whose name and competence are certainly
agency. It imposes liability, not as the result of the certified to the general public by the hospitals act of
reality of a contractual relationship, but rather listing him and his specialty in its lobby directory, as in
because of the actions of a principal or an employer in the case herein. The high costs of todays medical
somehow misleading the public into believing that the and health care should at least exact on the hospital
relationship or the authority exists.30 The concept is greater, if not broader, legal responsibility for the
essentially one of estoppel and has been explained in conduct of treatment and surgery within its facility by
this manner: its accredited physician or surgeon, regardless of
whether he is independent or employed." 33
"The principal is bound by the acts of his agent with
the apparent authority which he knowingly permits the The wisdom of the foregoing ratiocination is easy to
agent to assume, or which he holds the agent out to discern. Corporate entities, like PSI, are capable of
the public as possessing. The question in every case acting only through other individuals, such as
is whether the principal has by his voluntary act physicians. If these accredited physicians do their job
placed the agent in such a situation that a person of well, the hospital succeeds in its mission of offering
ordinary prudence, conversant with business usages quality medical services and thus profits financially.
and the nature of the particular business, is justified in Logically, where negligence mars the quality of its
presuming that such agent has authority to perform services, the hospital should not be allowed to escape
the particular act in question.31 liability for the acts of its ostensible agents.

The applicability of apparent authority in the field of We now proceed to the doctrine of corporate
hospital liability was upheld long time ago in Irving v. negligence or corporate responsibility.
Doctor Hospital of Lake Worth, Inc. 32 There, it was
explicitly stated that "there does not appear to be any One allegation in the complaint in Civil Case No. Q-
rational basis for excluding the concept of apparent 43332 for negligence and malpractice is that PSI as
authority from the field of hospital liability." Thus, in owner, operator and manager of Medical City
cases where it can be shown that a hospital, by its Hospital, "did not perform the necessary supervision
nor exercise diligent efforts in the supervision of Drs. x x x PSIs liability is traceable to its failure to conduct
Ampil and Fuentes and its nursing staff, resident an investigation of the matter reported in the nota
doctors, and medical interns who assisted Drs. Ampil bene of the count nurse. Such failure established
and Fuentes in the performance of their duties as PSIs part in the dark conspiracy of silence and
surgeons."34 Premised on the doctrine of corporate concealment about the gauzes. Ethical
negligence, the trial court held that PSI is directly considerations, if not also legal, dictated the holding
liable for such breach of duty. of an immediate inquiry into the events, if not for the
benefit of the patient to whom the duty is primarily
We agree with the trial court. owed, then in the interest of arriving at the truth. The
Court cannot accept that the medical and the healing
Recent years have seen the doctrine of corporate professions, through their members like defendant
negligence as the judicial answer to the problem of surgeons, and their institutions like PSIs hospital
allocating hospitals liability for the negligent acts of facility, can callously turn their backs on and disregard
health practitioners, absent facts to support the even a mere probability of mistake or negligence by
application of respondeat superior or apparent refusing or failing to investigate a report of such
authority. Its formulation proceeds from the judiciarys seriousness as the one in Natividads case.
acknowledgment that in these modern times, the duty
of providing quality medical service is no longer the It is worthy to note that Dr. Ampil and Dr. Fuentes
sole prerogative and responsibility of the physician. operated on Natividad with the assistance of the
The modern hospitals have changed structure. Medical City Hospitals staff, composed of resident
Hospitals now tend to organize a highly professional doctors, nurses, and interns. As such, it is reasonable
medical staff whose competence and performance to conclude that PSI, as the operator of the hospital,
need to be monitored by the hospitals commensurate has actual or constructive knowledge of the
with their inherent responsibility to provide quality procedures carried out, particularly the report of the
medical care.35 attending nurses that the two pieces of gauze were
missing. In Fridena v. Evans,41 it was held that a
The doctrine has its genesis in Darling v. Charleston corporation is bound by the knowledge acquired by or
Community Hospital.36 There, the Supreme Court of notice given to its agents or officers within the scope
Illinois held that "the jury could have found a hospital of their authority and in reference to a matter to which
negligent, inter alia, in failing to have a sufficient their authority extends. This means that the
number of trained nurses attending the patient; failing knowledge of any of the staff of Medical City Hospital
to require a consultation with or examination by constitutes knowledge of PSI. Now, the failure of PSI,
members of the hospital staff; and failing to review the despite the attending nurses report, to investigate
treatment rendered to the patient." On the basis of and inform Natividad regarding the missing gauzes
Darling, other jurisdictions held that a hospitals amounts to callous negligence. Not only did PSI
corporate negligence extends to permitting a breach its duties to oversee or supervise all persons
physician known to be incompetent to practice at the who practice medicine within its walls, it also failed to
hospital.37 With the passage of time, more duties were take an active step in fixing the negligence committed.
expected from hospitals, among them: (1) the use of This renders PSI, not only vicariously liable for the
reasonable care in the maintenance of safe and negligence of Dr. Ampil under Article 2180 of the Civil
adequate facilities and equipment; (2) the selection Code, but also directly liable for its own negligence
and retention of competent physicians; (3) the under Article 2176. In Fridena, the Supreme Court of
overseeing or supervision of all persons who practice Arizona held:
medicine within its walls; and (4) the formulation,
adoption and enforcement of adequate rules and x x x In recent years, however, the duty of care owed
policies that ensure quality care for its to the patient by the hospital has expanded. The
patients.38 Thus, in Tucson Medical Center, Inc. v. emerging trend is to hold the hospital responsible
Misevich,39 it was held that a hospital, following the where the hospital has failed to monitor and review
doctrine of corporate responsibility, has the duty to medical services being provided within its walls. See
see that it meets the standards of responsibilities for Kahn Hospital Malpractice Prevention, 27 De Paul .
the care of patients. Such duty includes the proper Rev. 23 (1977).
supervision of the members of its medical staff. And in
Bost v. Riley,40 the court concluded that a patient who Among the cases indicative of the emerging trend is
enters a hospital does so with the reasonable Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335
expectation that it will attempt to cure him. The (1972). In Purcell, the hospital argued that it could not
hospital accordingly has the duty to make a be held liable for the malpractice of a medical
reasonable effort to monitor and oversee the practitioner because he was an independent
treatment prescribed and administered by the contractor within the hospital. The Court of Appeals
physicians practicing in its premises. pointed out that the hospital had created a
professional staff whose competence and
In the present case, it was duly established that PSI performance was to be monitored and reviewed by
operates the Medical City Hospital for the purpose the governing body of the hospital, and the court held
and under the concept of providing comprehensive that a hospital would be negligent where it had
medical services to the public. Accordingly, it has the knowledge or reason to believe that a doctor using
duty to exercise reasonable care to protect from harm the facilities was employing a method of treatment or
all patients admitted into its facility for medical care which fell below the recognized standard of care.
treatment. Unfortunately, PSI failed to perform such
duty. The findings of the trial court are convincing, Subsequent to the Purcell decision, the Arizona Court
thus: of Appeals held that a hospital has certain inherent
responsibilities regarding the quality of medical care
furnished to patients within its walls and it must meet
the standards of responsibility commensurate with
this undertaking. Beeck v. Tucson General Hospital,
18 Ariz. App. 165, 500 P. 2d 1153 (1972). This court
has confirmed the rulings of the Court of Appeals that
a hospital has the duty of supervising the competence
of the doctors on its staff. x x x.

x x x x x x

In the amended complaint, the plaintiffs did plead that


the operation was performed at the hospital with its
knowledge, aid, and assistance, and that the
negligence of the defendants was the proximate
cause of the patients injuries. We find that such
general allegations of negligence, along with the
evidence produced at the trial of this case, are
sufficient to support the hospitals liability based on
the theory of negligent supervision."

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. At the
same time, 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 the petitions and


AFFIRM the challenged Decision of the Court of
Appeals in CA-G.R. CV No. 42062 and CA-G.R. SP
No. 32198.

Costs against petitioners PSI and Dr. Miguel Ampil.

SO ORDERED.