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Professional Services, Inc. vs. Agana incision has been closed is at least prima facienegligence by
G.R. No. 126297. January 31, 2007. *
the operating surgeon. To put it simply, such act is
PROFESSIONAL SERVICES, INC., considered so inconsistent with due care as to raise an
petitioner, vs.NATIVIDAD and ENRIQUE AGANA, inference of negligence. There are even legions of
respondents. authorities to the effect that such act is negligence per se.
G.R. No. 126467. January 31, 2007. *
Same; Same; Same; To the mind of the Court, what was
NATIVIDAD and ENRIQUE AGANA, respondents. initially an act of negligence by Dr. Ampil has ripened into a
NATIVIDAD (Substituted by her children deliberate wrongful act of deceiving his patient.—Here, Dr.
MARCELINO AGANA III, ENRIQUE AGANA, JR., Ampil did not inform Natividad about the missing two
EMMA AGANA ANDAYA, JESUS AGANA, and pieces of gauze.Worse, he even misled her that the pain she
RAYMUND AGANA) and ENRIQUE AGANA, was experiencing was the ordinary consequence of her
petitioners, vs. JUAN FUENTES, respondent. operation. Had he been more candid, Natividad could have
G.R. No. 127590. January 31, 2007. *
taken the immediate and appropriate medical remedy to
MIGUEL AMPIL, petitioner, vs. NATIVIDAD AGANA remove the gauzes from her body. To our mind, what was
and ENRIQUE AGANA, respondents. initially an act of negligence by Dr. Ampil has ripened into
a deliberate wrongful act of deceiving his patient.
_______________ Same; Same; Same; Doctrine of Res Ipsa
Loquitur; Requisites for the Applicability of the Doctrine.—
* FIRST DIVISION.
Literally, res ipsa loquiturmeans “the thing speaks for
479
itself.” It is the rule that the fact of the occurrence of an
VOL. 513, JANUARY 31, 2007 479
injury, taken with the surrounding circumstances, may
Professional Services, Inc. vs. Agana
permit an inference or raise a presumption of negligence, or
Civil Law; Damages; Negligence; The leaving of
make out a plaintiff’s prima facie case, and present a
sponges or other foreign substances in the wound after the
question of fact for defendant to meet with an explanation.
incision has been closed is at least prima facie negligence by
Stated differently, where the thing which caused the injury,
the operating surgeon.— An operation requiring the placing
without the fault of the injured, is under the exclusive
of sponges in the incision is not complete until the sponges
control of the defendant and the injury is such that it
are properly removed, and it is settled that the leaving of
should not have occurred if he, having such control used dispense with the requirement of proof of negligence. Here,
proper care, it affords reasonable evidence, in the absence of the negligence was proven to have been committed by Dr.
explanation that the injury arose from the defendant’s want Ampil and not by Dr. Fuentes.
of care, and the burden of proof is shifted to him to establish Same; Same; Same; Professionals are considered
that he has observed due care and diligence. From the personally liable for the fault or negligence they commit in
foregoing statements of the rule, the requisites for the the discharge of their duties and their employer cannot be
applicability of the doctrine of res ipsa loquiturare: (1) the held liable for such fault or negligence.—A prominent
occurrence of an injury; (2) the thing which caused the civilist commented that professionals engaged by an
injury was under the control and management of the employer, such as physicians, dentists, and pharmacists,
defendant;(3) the occurrence was such that in the ordinary are not “employees” under this article because the manner
course of things, would in which they perform their work is not within the control
480 of the latter (employer). In other words, professionals are
4 SUPREME COURT REPORTS ANNOTATED considered personally liable for the fault or negligence they
80 commit in the discharge of their duties, and their employer
Professional Services, Inc. vs. Agana cannot be held liable for such fault or negligence. In the
not have happened if those who had control or context of the present case, “a hospital cannot be held liable
management used proper care; and (4) the absence of for the fault or negligence of a physician or surgeon in the
explanation by the defendant. Of the foregoing requisites, treatment or operation of patients.”
the most instrumental is the “control and management of Same; Same; Same; In this jurisdiction, the nature of
the thing which caused the injury.” the relationship between the hospital and the physicians is
Same; Same; Same; Same; Res ipsa loquitur is not a rendered inconsequential in view of the pronouncement in
rule of substantive law, hence, does not per se create or Ramos vs. Court of Appeals, 321 SCRA 584 (1999), that for
constitute an independent or separate ground of liability, purposes of apportioning responsibility in medical
being a mere evidentiary rule.—In this jurisdiction, res ipsa negligence cases, an employer-employee relationship in effect
loquitur is not a rule of substantive law, hence, does not per exists between hospitals and their attending and visiting
se create or constitute an independent or separate ground of physicians.—In our shores, the nature of the relationship
liability, being a mere evidentiary rule. In other words, between the hospital and the physicians is rendered
mere invocation and application of the doctrine does not inconsequential in view of our categorical pronouncement
in Ramos v. Court of Appeals, 321 SCRA 584 (1999), that essentially one of estoppel and has been explained in this
for purposes of apportioning responsibility in manner: “The principal is bound by the acts of his agent
481 with the apparent authority which he knowingly permits
VOL. 513, JANUARY 31, 2007 48 the agent to assume, or which he holds the agent out to the
1 public as possessing. The question in every case is whether
Professional Services, Inc. vs. Agana the principal has by his voluntary act placed the agent in
medical negligence cases, an employer-employee such a situation that a person of ordinary prudence,
relationship in effect exists between hospitals and their conversant with business usages and the nature of the
attending and visiting physicians. particular business, is justified in presuming that such
Same;Same; Same; PSI’s liability is also anchored agent has authority to perform the particular act in
upon the agency principle of apparent authority or agency by question.
estoppel and the doctrine of corporate negligence.—But Same; Same; Same; In cases where it can be shown that
the Ramospronouncement is not our only basis in a hospital, by its actions, has held out a particular physician
sustaining PSI’s liability. Its liability is also anchored upon as its agent and/or employee and that a patient has accepted
the agency principle of apparent authority or agency by treatment from that physician in the reasonable belief that it
estoppel and the doctrine of corporate negligence which have is being rendered in behalf of the hospital, then the hospital
gained acceptance in the determination of a hospital’s will be liable for the physician’s negligence.—The
liability for negligent acts of health professionals. The applicability of apparent authority in the field of hospital
present case serves as a perfect platform to test the liability was upheld long time ago in Irving v. Doctor
applicability of these doctrines, thus, enriching our Hospital of Lake Worth, Inc., 415 So. 2d 55 (1982). There, it
jurisprudence. Apparent authority, or what is sometimes was explicitly stated that “there does not appear to be any
referred to as the “holding out” theory, or doctrine rational basis for excluding the concept of apparent
of ostensible agency or agency by estoppel, has its origin authority from the field of hospital liability.” Thus, in cases
from the law of agency. It imposes liability, not as the result where it can be shown that a hospital, by its actions, has
of the reality of a contractual relationship, but rather held out a particular physician as its agent and/or employee
because of the actions of a principal or an employer in and
somehow misleading the public into believing that the 482
relationship or the authority exists. The concept is 4 SUPREME COURT REPORTS ANNOTATED
82 rendered by the hospital or its employees, agents, or
Professional Services, Inc. vs. Agana servants.
that a patient has accepted treatment from that PETITION for review on certiorari of the decisions of
physician in the reasonable belief that it is being rendered the Court of Appeals.
in behalf of the hospital, then the hospital will be liable for The facts are stated in the opinion of the Court.
the physician’s negligence. Bengzon, Narciso, Cudala, Pecson, Bengzon &
Same; Same; Same; By accrediting Dr. Ampil and Dr. Jimenez for petitioner Professional Services, Inc.
Fuentes and publicly advertising their qualifications, the Enrique Agana & Associates for petitioners
hospital created the impression that they were its agents, Natividad and Enrique Agana.
authorized to perform medical or surgical services for its The Law Firm of Raymundo M. Armovit for
patients.—In this case, PSI publicly displays in the lobby of petitioner Miguel Ampil.
the Medical City Hospital the names and specializations of Agcaoili Law Offices collaborating counsel for
the physicians associated or accredited by it, including Heirs of Natividad Agana.
those of Dr. Ampil and Dr. Fuentes. We concur with the Benjamin M. Tongol for Juan Fuentes.
Court of Appeals’ conclusion that it “is now estopped from 483
passing all the blame to the physicians whose names it VOL. 513, JANUARY 31, 2007 483
proudly paraded in the public directory leading the public to Professional Services, Inc. vs. Agana
believe that it vouched for their skill and competence.”
Indeed, PSI’s act is tantamount to holding out to the public SANDOVAL-GUTIERREZ, J.:
that Medical City Hospital, through its accredited
Hospitals, having undertaken one of mankind’s most
physicians, offers quality health care services. By
important and delicate endeavors, must assume the
accrediting Dr. Ampil and Dr. Fuentes and publicly
grave responsibility of pursuing it with appropriate
advertising their qualifications, the hospital created the
care. The care and service dispensed through this high
impression that they were its agents, authorized to perform
trust, however technical, complex and esoteric its
medical or surgical services for its patients. As expected,
character may be, must meet standards of
these patients, Natividad being one of them, accepted the
responsibility commensurate with the undertaking to
services on the reasonable belief that such were being
preserve and protect the health, and indeed, the very
lives of those placed in the hospital’s keeping. 1
Assailed in these three consolidated petitions for Professional Services, Inc. vs. Agana
review on certiorari is the Court of Appeals’ On April 11, 1984, Dr. Ampil, assisted by the medical
Decision dated September 6, 1996 in CA-G.R. CV No.
2 staff of the Medical City Hospital, performed an
4
42062 and CA-G.R. SP No. 32198 affirming with anterior resection surgery on Natividad. He found that
modification the Decision dated March 17, 1993 of the
3 the malignancy in her sigmoid area had spread on her
Regional Trial Court (RTC), Branch 96, Quezon City left ovary, necessitating the removal of certain
in Civil Case No. Q-43322 and nullifying its Order portions of it. Thus, Dr. Ampil obtained the consent of
dated September 21, 1993. Natividad’s husband, Enrique Agana, to permit Dr.
The facts, as culled from the records, are: Juan Fuentes, respondent in G.R. No. 126467, to
On April 4, 1984, Natividad Agana was rushed to perform hysterectomy on her.
the Medical City General Hospital (Medical City After Dr. Fuentes had completed the hysterectomy,
Hospital) because of difficulty of bowel movement and Dr. Ampil took over, completed the operation and
bloody anal discharge. After a series of medical closed the incision.
examinations, Dr. Miguel Ampil, petitioner in G.R. No. However, the operation appeared to be flawed. In
127590, diagnosed her to be suffering from “cancer of the corresponding Record of Operation dated April 11,
the sigmoid.” 1984, the attending nurses entered these remarks:
“sponge count lacking 2
_______________ “announced to surgeon searched (sic) done but to no avail
continue for closure.”
Beeck v. Tucson General Hospital, 500 P. 2d 1153 (1972), citingDarling v.
On April 24, 1984, Natividad was released from the
1
well as nurses.
Civil Case No. Q-43322. They alleged that the latter
485
are liable for negligence for leaving two pieces of gauze
VOL. 513, JANUARY 31, 2007 485
inside Natividad’s body and malpractice for concealing
Professional Services, Inc. vs. Agana
their acts of negligence.
On August 31, 1984, Natividad flew back to the Meanwhile, Enrique Agana also filed with the
Philippines, still suffering from pains. Two weeks Professional Regulation Commission (PRC) an
thereafter, her daughter found a piece of gauze administrative complaint for gross negligence and
protruding from her vagina. Upon being informed malpractice against Dr. Ampil and Dr. Fuentes,
about it, Dr. Ampil proceeded to her house where he docketed as Administrative Case No. 1690. The PRC
managed to extract by hand a piece of gauze Board of Medicine heard the case only with respect to
measuring 1.5 inches in width. He then assured her Dr. Fuentes because it failed to acquire jurisdiction
that the pains would soon vanish. over Dr. Ampil who was then in the United States.
Dr. Ampil’s assurance did not come true. Instead, On February 16, 1986, pending the outcome of the
the pains intensified, prompting Natividad to seek above cases, Natividad died and was duly substituted
treatment at the Polymedic General Hospital. While by her abovenamed children (the Aganas).
confined there, Dr. Ramon Gutierrez detected the
486
presence of another foreign object in her vagina—a
486 SUPREME COURT REPORTS ANNOTATED 4. 5.Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove,
Professional Services, Inc. vs. Agana from date of filing of the complaint until full payment; and
On March 17, 1993, the RTC rendered its Decision in 5. 6.Costs of suit.
favor of the Aganas, finding PSI, Dr. Ampil and Dr.
Fuentes liable for negligence and malpractice, the SO ORDERED.”
decretal part of which reads: Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed
“WHEREFORE, judgment is hereby rendered for the plaintiffs ordering an appeal to the Court of Appeals, docketed as CA-
the defendants PROFESSIONAL SERVICES, INC., DR. MIGUEL G.R. CV No. 42062.
AMPIL and DR. JUAN FUENTES to pay to the plaintiffs, jointly and Incidentally, on April 3, 1993, the Aganas filed with
severally, except in respect of the award for exemplary damages and the the RTC a motion for a partial execution of its
interest thereon which are the liabilities of defendants Dr. Ampil and Dr. Decision, which was granted in an Order dated May
Fuentes only, as follows: 11, 1993. Thereafter, the sheriff levied upon certain
properties of Dr. Ampil and sold
1. 1.As actual damages, the following amounts: 487
VOL. 513, JANUARY 31, 2007 487
1. a.The equivalent in Philippine Currency of the total of Professional Services, Inc. vs. Agana
US$19,900.00 at the rate of P21.60-US$1.00, as them for P451,275.00 and delivered the amount to the
reimbursement of actual expenses incurred in the United Aganas.
States of America; Following their receipt of the money, the Aganas
2. b.The sum of P4,800.00 as travel taxes of plaintiffs and their entered into an agreement with PSI and Dr. Fuentes
physician daughter; to indefinitely suspend any further execution of the
3. c.The total sum of P45,802.50, representing the cost of RTC Decision. However, not long thereafter, the
hospitalization at Polymedic Hospital, medical fees, and cost of Aganas again filed a motion for an alias writ of
the saline solution; execution against the properties of PSI and Dr.
Fuentes. On September 21, 1993, the RTC granted the
1. 2.As moral damages, the sum of P2,000,000.00; motion and issued the corresponding writ, prompting
2. 3.As exemplary damages, the sum of P300,000.00; Dr. Fuentes to file with the Court of Appeals a petition
3. 4.As attorney’s fees, the sum of P250,000.00; for certiorari and prohibition, with prayer for
preliminary injunction, docketed as CA-G.R. SP No. On September 6, 1996, the Court of Appeals rendered
32198. During its pendency, the Court of Appeals its Decision jointly disposing of CA-G.R. CV No. 42062
issued a Resolution dated October 29, 1993 granting
5 and CA-G.R. SP No. 32198, thus:
Dr. Fuentes’ prayer for injunctive relief. “WHEREFORE, except for the modification that the case against
On January 24, 1994, CA-G.R. SP No. 32198 was defendant-appellant Dr. Juan Fuentes is hereby DISMISSED, and with
consolidated with CA-G.R. CV No. 42062. the pronouncement that defendant-appellant Dr. Miguel Ampil is liable
Meanwhile, on January 23, 1995, the PRC Board of to reimburse defendant-appellant Professional Services, Inc.,
Medicine rendered its Decision in Administrative Case 6
whatever amount the latter will pay or had paid to the plaintiffs-
No. 1690 dismissing the case against Dr. Fuentes. The appellees, the decision appealed from is herebyAFFIRMED and the
Board held that the prosecution failed to show that Dr. instant appeal DISMISSED.
Fuentes was the one who left the two pieces of gauze Concomitant with the above, the petition for certiorari and
inside Natividad’s body; and that he concealed such prohibition filed by herein defendant-appellant Dr. Juan Fuentes in CA-
fact from Natividad. G.R. SP No. 32198 is hereby GRANTED and the challenged order of the
respondent judge dated September 21, 1993, as well as the alias writ of
_______________ execution issued pursuant thereto are hereby NULLIFIED and SET
ASIDE. The bond posted by the petitioner in connection with the writ of
5 The dispositive portion reads:
preliminary injunction issued by this Court on November 29, 1993 is
“WHEREFORE, let a writ of preliminary injunction be issued upon petitioner’s posting of
hereby cancelled.
bond in the amount of P20,000.00, ENJOINING public respondents from implementing the
Costs against defendants-appellants Dr. Miguel
questioned order dated September 21, 1993 and from further taking any action in Civil Case
Ampil andProfessional Services, Inc.
No. Q-43322 entitled ‘Natividad G. Agana, et al., plaintiffs, versus Professional Services, Inc.,
SO ORDERED.”
et al., defendants’ pending resolution of the instant petition.
Only Dr. Ampil filed a motion for reconsideration, but
SO ORDERED.” See Rollo, G.R. No. 126297, p. 42.
it was denied in a Resolution dated December 19,
7
488
Hence, the instant consolidated petitions.
488 SUPREME COURT REPORTS ANNOTATED
In G.R. No. 126297, PSI alleged in its petition that
Professional Services, Inc. vs. Agana
the Court of Appeals 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; doctors who examined Natividad in the United States
and (3) it is not entitled to its counterclaim against the of America.
Aganas. PSI contends that Dr. Ampil is not its For our resolution are these three vital issues: first,
employee, but a mere consultant or independent whether the Court of Appeals erred in holding Dr.
contractor. As such, he alone should answer for his Ampil liable for negligence and malpractice; second,
negligence. whether the Court of Appeals erred in absolving Dr.
Fuentes of any liability; and third, whether PSI may
_______________ be held solidarily liable for the negligence of Dr. Ampil.
I—G.R. No. 127590
Rollo of G.R. No. 127590, p. 40.
Whether the Court of Appeals Erred in Holding Dr. Ampil
7
172 F. 191; Reeves v. Lutz, 179 Mo. App. 61, 162 S.W. 280;Rayburn v. Day, 126 Or.
Court of Appeals, directly point to Dr. Ampil as the
135, 68 P. 1002, 59 A.L.R. 1062; Wynne v. Harvey, 96 Wash. 379, 165 P. 67; Harris
negligent party, thus:
v. Fall (C.C.A.), 177 F. 79,
First, it is not disputed that the surgeons used gauzes as sponges to
491
control the bleeding of the patient during the surgical operation.
VOL. 513, JANUARY 31, 2007 491
Second, immediately after the operation, the nurses who assisted in
Professional Services, Inc. vs. Agana
the surgery noted in their report that the ‘sponge count (was) lacking
Of course, the Court is not blind to the reality that
2’; that such anomaly was ‘announced to surgeon’ and that a
there are times when danger to a patient’s life
‘search was done but to no avail’ prompting Dr. Ampil to
precludes a surgeon from further searching missing
‘continue for closure’ x x x.
sponges or foreign objects left in the body. But this
Third, after the operation, two (2) gauzes were extracted from the
does not leave him free from any obligation. Even if it
same spot of the body of Mrs. Agana where the surgery was performed.
An operation requiring the placing of sponges in the has been shown that a surgeon was required by the
incision is not complete until the sponges are properly urgent necessities of the case to leave a sponge in his
removed, and it is settled that the leaving of sponges patient’s abdomen, because of the dangers attendant
or other foreign substances in the wound after the upon delay, still, it is his legal duty to so inform his
incision has been closed is at least prima patient within a reasonable time thereafter by advising
facie negligence by the operating surgeon. To put it 8
her of what he had been compelled to do. This is in
simply, such act is considered so inconsistent with due order that she might seek relief from the effects of the
care as to raise an inference of negligence. There are foreign object left in her body as her condition might
permit. The ruling in Smith v. Zeagler is explicit, 10
thus:
“The removal of all sponges used is part of a surgical operation, and Professional Services, Inc. vs. Agana
when a physician or surgeon fails to remove a sponge he has placed in his either failed to do something which a reasonably
patient’s body that should be removed as part of the operation, he prudent health care provider would have done, or that
thereby leaves his operation uncompleted andcreates a new condition he did something that a reasonably prudent provider
which imposes upon him the legal duty of calling the new would not have done; and that failure or action caused
condition to his patient’s attention, and endeavoring with the injury to the patient. Simply put, the elements
11
means he has at hand to minimize and avoid untoward results are duty, breach, injury and proximate causation. Dr,
likely to ensue therefrom.” Ampil, as the lead surgeon, had the duty to remove all
Here, Dr. Ampil did not inform Natividad about the foreign objects, such as gauzes, from Natividad’s body
missing two pieces of gauze. Worse, he even misled her before closure of the incision. When he failed to do so,
that the pain she was experiencing was the ordinary it was his duty to inform Natividad about it. Dr. Ampil
consequence of her operation. Had he been more breached both duties. Such breach caused injury to
candid, Natividad could have taken the immediate and Natividad, necessitating her further examination by
appropriate medical remedy to remove the gauzes from American doctors and another surgery. That Dr.
her body. To our mind, what was initially an act of Ampil’s negligence is the proximate cause of 12
negligence by Dr. Ampil has ripened into a deliberate Natividad’s injury could be traced from his act of
wrongful act of deceiving his patient. closing the incision despite the information given by the
This is a clear case of medical malpractice or more attending nurses that two pieces of gauze were still
appropriately, medical negligence. To successfully missing. That they were later on extracted from
pursue this kind of case, a patient must only prove Natividad’s vagina established the causal link between
that a health care provider Dr. Ampil’s negligence and the injury. And what
further aggravated such injury was
_______________
_______________
27 L.R.A. (N.S.) 1174; Moore v. Ivey, (Tex. Civ. App.) 264 S.W. 283; 21 R.C. L.
388. 11 Garcia-Rueda v. Pascasio, G.R. No. 118141, September 5, 1997, 278 SCRA
10 157 So. 328 Fla. (1934) 769.
492
492 SUPREME COURT REPORTS ANNOTATED
12 In the leading case of Vda. de Bataclan v. Medina, (102 Phil. 181[1957]), this Literally, res ipsa loquitur means “the thing speaks
Court laid down the following definition of proximate cause in this jurisdiction as for itself.” It is the rule that the fact of the occurrence
follows: of an injury, taken with the surrounding
[T]hat cause, which, in natural and continuous sequence unbroken by any efficient circumstances, may permit an inference or raise a
intervening cause, produces the injury and without which the result would not have occurred. presumption of negligence, or make out a
And more comprehensively, the proximate cause is that acting first and producing the injury, plaintiff’s prima facie case, and present a question of
either immediately or by setting other events in motion, all constituting a natural and fact for defendant to meet with an explanation. Stated 13
continuous chain of events, each having a close causal connection with the immediate differently, where the thing which caused the injury,
predecessor, the final event in the chain immediately effecting the injury as a natural and without the fault of the injured, is under the exclusive
probable result of the cause which first acted, under which circumstances that the person control of the defendant and the injury is such that it
responsible for the first event should, as an ordinarily prudent and intelligent person, have should not have occurred if he, having such control
reasonable ground to expect at the moment of his act or default that an injury to some person used proper care, it affords reasonable evidence, in the
might probably result therefrom. absence of explanation that the injury arose from the
493 defendant’s want of care, and the burden of proof is
VOL. 513, JANUARY 31, 2007 493 shifted to him to establish that he has observed due
Professional Services, Inc. vs. Agana care and diligence. 14
his deliberate concealment of the missing gauzes from From the foregoing statements of the rule, the
the knowledge of Natividad and her family. requisites for the applicability of the doctrine of res
II—G.R. No. 126467 ipsa loquitur are:(1) the occurrence of an injury; (2) the
Whether the Court of Appeals Erred in Absolving Dr. thing which caused the injury was under the control
Fuentes of any Liability and management of the defen-
The Aganas assailed the dismissal by the trial court of
the case against Dr. Fuentes on the ground that it is _______________
contrary to the doctrine of res ipsa loquitur. According
to them, the fact that the two pieces of gauze were left 13 Ramos v. Court of Appeals, G.R. No. 124354, December 29, 1999, 321 SCRA
Fuentes’ negligence. 14 Africa v. Caltex (Phils.) Inc., 123 Phil. 280; 16 SCRA 448 (1966).
and (4) the absence of explanation by the defendant. before, Dr. Ampil was the lead surgeon. In other words,
Of the foregoing requisites, the most instrumental is he was the “Captain of the Ship.” That he discharged
the “control and management of the thing which such role is evident from his following
caused the injury.”
15
the instrumentality which caused the damage,” citing St. John’s Hospital and
It was duly established that Dr. Ampil was the lead
School of Nursing v. Chapman, 434 P2d 160 (1967).
surgeon during the operation of Natividad. He
Rural Educational Assn v. Bush, 42 Tenn. App. 34, 298 S.W. 2d 761 (1956).
requested the assistance of Dr. Fuentes only to
16
495
perform hysterectomy when he (Dr. Ampil) found that
VOL. 513, JANUARY 31, 2007 495
the malignancy in her sigmoid area had spread to her
Professional Services, Inc. vs. Agana
left ovary. Dr. Fuentes performed the surgery and
thereafter reported and showed his work to Dr. conduct: (1) calling Dr. Fuentes to perform a
Ampil. The latter examined it and finding everything to hysterectomy;(2) examining the work of Dr. Fuentes
be in order, allowed Dr. Fuentes to leave the operating and finding it in order; (3) granting Dr. Fuentes’
room. Dr. Ampil then resumed operating on Natividad. permission to leave; and (4)ordering the closure of the
He was about to finish the procedure when the incision. To our mind, it was this act of ordering the
attending nurses informed him that two pieces of closure of the incision notwithstanding that two pieces
gauze were missing. A “diligent search” was conducted, of gauze remained unaccounted for, that caused injury
but the misplaced gauzes were not found. Dr. Ampil to Natividad’s body. Clearly, the control and
then directed that the incision be closed. During this management of the thing which caused the injury was
entire period, Dr. Fuentes was no longer in the in the hands of Dr. Ampil, not Dr. Fuentes.
operating room and had, in fact, left the hospital. 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 Professional Services, Inc. vs. Agana
liability, being a mere evidentiary rule. In other 17 charitable past and has experienced a significant
words, mere invocation and application of the doctrine conversion from a not-for-profit health care to for-
does not dispense with the requirement of proof of profit hospital businesses. Consequently, significant
negligence. Here, the negligence was proven to have changes in health law have accompanied the business-
been committed by Dr. Ampil and not by Dr. Fuentes. related changes in the hospital industry. One
III—G.R. No. 126297 important legal change is an increase in hospital
Whether PSI Is Liable for the Negligence of Dr. Ampil liability for medical malpractice. Many courts now
The third issue necessitates a glimpse at the historical allow claims for hospital vicarious liability under the
development of hospitals and the resulting theories theories of respondeat superior, apparent authority,
concerning their liability for the negligence of ostensible authority, or agency by estoppel. 20
500
of health professionals. The present case serves as a
500 SUPREME COURT REPORTS ANNOTATED
perfect platform to test the applicability of these business usages and the nature of the particular business, is justified in
doctrines, thus, enriching our jurisprudence. presuming that such agent has authority to perform the particular act in
Apparent authority, or what is sometimes referred question. 31
to as the “holding out” theory, or doctrine of ostensible The applicability of apparent authority in the field of
agency or agency by estoppel, has its origin from the
29 hospital liability was upheld long time ago in Irving v.
law of agency. It Doctor Hos-
_______________ _______________
29 Black’s Law Dictionary (6th Ed. 1990) 1100. The terms “ostensible agency,” 579 P2d 970 (1978). Agency by estoppel is defined as “one created by operation
“agency by estoppel,” “apparent authority,” and “holding out” tend to be used of law and established by proof of such acts of the principal as reasonably lead
interchangeably by the courts to refer to this theory of liability. See for third persons to the conclusion of its existence. Arises where principal by
instance, Baker v. Werner, 654 P2d 263 (1982) andAdamski v. Tacoma Gen. Hosp., negligence in failing to supervise agent’s affairs, allows agent to exercise powers
20 Wash App. 98, not granted to him, thus justifying others in believing the agent possesses
501 requisite authority.” Black’s, supra, p. 62. An ostensible agency is “an implied or
VOL. 513, JANUARY 31, 2007 501 presumptive agency which exists where one, either intentionally or from want of
Professional Services, Inc. vs. Agana ordinary care, induces another to believe that a third person is his agent, though
imposes liability, not as the result of the reality of a he never in fact, employed him. It is, strictly speaking, no agency at all, but is in
contractual relationship, but rather because of the reality based entirely upon estoppel.” Apparent authority refers to “the power to
actions of a principal or an employer in somehow affect the legal relations of another person by transactions with third persons,
misleading the public into believing that the professedly as agent for the other, arising from and in accordance with the other’s
relationship or the authority exists. The concept is 30
manifestations to such third persons.” Supra, p. 96.
essentially one of estoppel and has been explained in 30 Irving v. Doctors Hospital of Lake Worth, Inc., 415 So. 2d 55 (1982),
this manner: quoting Arthur v. St. Peters Hospital, 169 N.J. 575, 405 A. 2d 443 (1979).
“The principal is bound by the acts of his agent with the apparent 31 Id., citing Hudson v. C., Loan Assn., Inc. v. Horowytz, 116 N.J.L. 605, 608,
authority which he knowingly permits the agent to assume, or which he 186 A 437 (Sup. Ct. 1936).
holds the agent out to the public as possessing. The question in every 502
case is whether the principal has by his voluntary act placed the agent in 502 SUPREME COURT REPORTS ANNOTATED
such a situation that a person of ordinary prudence, conversant with Professional Services, Inc. vs. Agana
pital of Lake Worth, Inc. There, it was explicitly
32 quality health care services. By accrediting Dr. Ampil
stated that “there does not appear to be any rational and Dr. Fuentes and publicly advertising their
basis for excluding the concept of apparent authority qualifications, the hospital created the impression that
from the field of hospital liability.” Thus, in cases they were its agents, authorized to perform medical or
where it can be shown that a hospital, by its actions, surgical services for its patients. As expected, these
has held out a particular physician as its agent and/or patients, Natividad being one of them, accepted the
employee and that a patient has accepted treatment services on the reasonable belief that such were being
from that physician in the reasonable belief that it is rendered by the hospital or its employees, agents, or
being rendered in behalf of the hospital, then the servants. The trial court correctly pointed out:
hospital will be liable for the physician’s negligence.
Our jurisdiction recognizes the concept of an agency _______________
503
ART. 1869. Agency may be express, or implied from the acts of the
VOL. 513, JANUARY 31, 2007 503
principal, from his silence or lack of action, or his failure to repudiate the
Professional Services, Inc. vs. Agana
agency, knowing that another person is acting on his behalf without
“x x x regardless of the education and status in life of the patient,
authority.
he ought not be burdened with the defense of absence of
In this case, PSI publicly displays in the lobby of the
employer-employee relationship between the hospital and the
Medical City Hospital the names and specializations of
independent physician whose name and competence are
the physicians associated or accredited by it, including
certainly certified to the general public by the hospital’s act of
those of Dr. Ampil and Dr. Fuentes. We concur with
listing him and his specialty in its lobby directory, as in the case
the Court of Appeals’ conclusion that it “is now
herein. The high costs of today’s medical and health care should
estopped from passing all the blame to the physicians
at least exact on the hospital greater, if not broader, legal
whose names it proudly paraded in the public directory
responsibility for the conduct of treatment and surgery within
leading the public to believe that it vouched for their
its facility by its accredited physician or surgeon, regardless of
skill and competence.” Indeed, PSI’s act is tantamount
whether he is independent or employed.”
to holding out to the public that Medical City 33
Hospital, through its accredited physicians, offers The wisdom of the foregoing ratiocination is easy to
discern. Corporate entities, like PSI, are capable of
acting only through other individuals, such as Recent years have seen the doctrine of corporate
physicians. If these accredited physicians do their job negligence as the judicial answer to the problem of
well, the hospital succeeds in its mission of offering allocating hospital’s liability for the negligent acts of
quality medical services and thus profits financially. health practitioners, absent facts to support the
Logically, where negligence mars the quality of its application ofrespondeat superior or apparent
services, the hospital should not be allowed to escape authority. Its formulation proceeds from the judiciary’s
liability for the acts of its ostensible agents. acknowledgment that in these modern times, the duty
We now proceed to the doctrine of corporate of providing quality medical service is no longer the
negligence or corporate responsibility. sole prerogative and responsibility of the physician.
One allegation in the complaint in Civil Case No. Q- The modern hospitals have changed structure.
43332 for negligence and malpractice is that PSI as Hospitals now tend to organize a highly professional
owner, operator and manager of Medical City Hospital, medical staff whose competence and performance need
“did not perform the necessary supervision nor exercise to be monitored by the hospitals commensurate with
diligent efforts in the supervision of Drs. Ampil and their inherent responsibility to provide quality medical
Fuentes and its nursing staff, resident doctors, and care.
35
medical interns who assisted Drs. Ampil and Fuentes The doctrine has its genesis in Darling v.
in the performance of their duties as Charleston Community Hospital. There, the Supreme
36
504
hospital. With the passage of time, more duties were
37
Supra at footnote 1.
thus:
36
37 Corleto v. Hospital, 138 N.J. Super. 302, 350 A. 2d 534 (Super. Ct. Law
x x x PSI’s liability is traceable to its failure to conduct an
Div.1975); Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972); Hospital
investigation of the matter reported in the nota bene of the count
Authority v. Joiner, 229 Ga. 140,189 S.E. 2d 412 (1972).
nurse. Such failure established PSI’s part in the dark conspiracy
505
of silence and concealment about the gauzes. Ethical
VOL. 513, JANUARY 31, 2007 505
considerations, if not also legal, dictated the holding of an immediate
Professional Services, Inc. vs. Agana
inquiry into the events, if not for the benefit of the patient to whom the
and policies that ensure quality care for its
duty is primarily owed, then in the interest of arriving at the truth. The
patients. Thus, in Tucson Medical Center, Inc. v.
38
Court cannot accept that the medical and the healing professions,
Misevich, it was held that a hospital, following the
39
507
any of the staff of Medical City Hospital constitutes
VOL. 513, JANUARY 31, 2007 507
knowledge of PSI. Now, the failure of PSI, despite the
Professional Services, Inc. vs. Agana
attending nurses’ report, to investigate and inform
and performance was to be monitored and reviewed by the
Natividad regarding the missing gauzes amounts to
governing body of the hospital, and the court held that a hospital
callous negligence. Not only did PSI breach its duties
would be negligent where it had knowledge or reason to believe
to oversee or supervise all persons who practice
that a doctor using the facilities was employing a method of
medicine within its walls, it also failed to take an
treatment or care which fell below the recognized standard of
active step in fixing the negligence committed. This
care.
renders PSI, not only vicariously liable for the
Subsequent to the Purcell decision, the Arizona Court of
negligence of Dr. Ampil under Article 2180 of the Civil
Appeals held that a hospital has certain inherent responsibilities
Code, but alsodirectly liable for its own negligence
regarding the quality of medical care furnished to patients
within its walls and it must meet the standards of responsibility must possess that reasonable degree of learning, skill
commensurate with this undertaking. Beeck v. Tucson General and experience required by
Hospital, 18 Ariz. App. 165, 500 P. 2d 1153 (1972). This court has 508
confirmed the rulings of the Court of Appeals that a hospital has the duty 508 SUPREME COURT REPORTS ANNOTATED
of supervising the competence of the doctors on its staff. x x x. Professional Services, Inc. vs. Agana
xxx xxx his profession. At the same time, he must apply
In the amended complaint, the plaintiffs did plead that the operation reasonable care and diligence in the exercise of his
was performed at the hospital with its knowledge, aid, and assistance, skill and the application of his knowledge, and exert
and that the negligence of the defendants was the proximate cause of the his best judgment.
patient’s injuries. We find that such general allegations of WHEREFORE, we DENY all the petitions and
negligence, along with the evidence produced at the trial of this AFFIRM the challenged Decision of the Court of
case, are sufficient to support the hospital’s liability based on the Appeals in CA-G.R. CV No. 42062 and CA-G.R. SP No.
theory of negligent supervision.” 32198.
Anent the corollary issue of whether PSI is solidarily Costs against petitioners PSI and Dr. Miguel Ampil.
liable with Dr. Ampil for damages, let it be emphasized SO ORDERED.
that PSI, apart from a general denial of its Puno (C.J., Chairperson), Corona and Azcuna,
responsibility, failed to adduce evidence showing that JJ., concur.
it exercised the diligence of a good father of a family in Garcia, J., No part.
the accreditation and supervision of the latter. In Petitions denied, challenged CA decision in CA-G.R.
neglecting to offer such proof, PSI failed to discharge No. CV No. 42062 and CA-G.R. SP No. 32198 affirmed.
its burden under the last paragraph of Article 2180 Note.—Under the Captain-of-the-Ship Doctrine, a
cited earlier, and, therefore, must be adjudged surgeon is likened to a captain of the ship in that it is
solidarily liable with Dr. Ampil. Moreover, as we have his duty to control everything going on in the
discussed, PSI is also directly liable to the Aganas. operating room. (Ramos vs. Court of Appeals, 380
One final word. Once a physician undertakes the SCRA 467 [2002])
treatment and care of a patient, the law imposes on
him certain obligations. In order to escape liability, he ——o0o——